Contraception in the postpartum period: immediate options for long-acting success.

Abstract

The postpartum period can be an ideal time to help a woman initiate contraception. Initiation of contraception in the immediate postpartum period is an important public health intervention. Shortened birth intervals (births spaced less than 2 years apart) are associated with significant maternal [1] and perinatal [2] morbidity. However, 33.1% of pregnancies in the USA are conceived within 18 months of a previous birth [3]. Successful initiation and continuation of postpartum contraception can decrease unintended pregnancy rates and improve maternal and child health outcomes. During pregnancy and the postpartum period, many women have access to medical care who otherwise would not. The inpatient admission for childbirth is a convenient opportunity for providers and patients to navigate contraceptive options together, particularly when the discussion has been raised in the antepartum period. There are pressing reasons to consider immediate postpartum contraception. After delivery, return to fertility can be rapid, with resumption of ovulation averaging 45 days, and occurring as early as 3 weeks postpartum in nonlactating women [4]. Delaying contraceptive initiation until several weeks postpartum places women at risk for unintended pregnancy. A range of contraceptive methods may be appropriate for women postpartum, and discussion should begin with the most effective options. Long-acting reversible contraceptive (LARC) methods, including the etonogestrel contraceptive implant and intrauterine devices, offer contraceptive efficacy and ease of user compliance. They combine cost– effectiveness with the benefit of being the most effective methods available. Immediate postpartum LARC placement has emerged as a safe and evidence-based practice. The US Medical Eligibility Criteria for Contraceptive Use supports immediate postplacental IUD insertion following cesarean section and vaginal delivery, and contraceptive implant insertion prior to hospital discharge, in lactating and nonlactating women [5]. Guidelines from the American College of Obstetricians and Gynecologists support the postpartum period as a particularly favorable time to initiate LARC [6]. And, from a public health standpoint, LARC has been found to be an important intervention to help women achieve optimal birth spacing and decrease rates of unplanned pregnancy [7–9]. Despite evidence supporting provision of immediate postpartum LARC, provider misinformation persists. A recent survey of 3000 members of the American Congress of Obstetricians and Gynecologists fellows found that only 11% of providers recognize the safety of postplacental IUD insertions [10]. Further, institutional and health policy barriers often limit immediate postpartum LARC provision. This contributes to wide variation in postpartum LARC use and availability [11]. Recognizing the potential public health impact of immediate postpartum LARC provision, several states have changed their funding practices to improve reimbursement for LARC initiation prior to hospital discharge [12]. Supporting this, despite the high initial cost associated with Contraception in the postpartum period: immediate options for long-acting success