Contraceptive Placement at Delivery Trumps Delayed Placement

Troy Brown, RN

June 11, 2015

The placement of long-acting reversible contraceptives at the time of delivery prevents pregnancy more effectively than delaying placement until 6 weeks postpartum, according to two new studies published online June 5 and in the July issue of Obstetrics & Gynecology.

"Delaying the initiation of effective contraception until the postpartum visit puts some women at risk for rapid, repeat, and unintended pregnancy," write Erika E. Levi, MD, MPH, from the Division of Family Planning and Global Health, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, and colleagues in the first study. "Women who intend to use an intrauterine device (IUD) for postpartum contraception are often unable to return for a postpartum visit and never receive an IUD," they add.

The researchers compared IUD use at 6 months postpartum among women who underwent IUD placement at the time of cesarean delivery (intracesarean placement) and women who planned to have an IUD placed 6 or more weeks postpartum (interval placement). The researchers randomly assigned women who were undergoing a cesarean delivery and who wanted an IUD to the two groups.

The study included 112 women with similar baseline characteristics (56 in each group). At 6 months postpartum, 48 women in the intracesarean placement group and 50 women in the interval placement group were available for evaluation. A larger proportion of those in the intracesarean group were using the IUD (40/48 [83%]) compared with those in the interval group (32/50 [64%]; relative risk 1.3; 95% confidence interval, 1.02 - 1.66).

Among the 56 women initially assigned to the interval placement group, 22 (39%) never received an IUD: 14 (25%) did not return for IUD placement, five (9%) declined IUD placement, and three (5%) experienced a failed IUD placement.

"The American College of Obstetricians and Gynecologists supports the practice of immediate postplacental IUD placement, and expert consensus supports aligning practice and reimbursement incentives to promote immediate postpartum initiation of [long-acting reversible contraceptive] methods," the authors conclude.

"The fact is, a woman simply cannot continue to use an IUD that she never got, and numerous reports indicate that many women do not return for postpartum care or interval postpartum IUD insertion, despite expressing interest and plans to do so during prenatal care or at delivery," Paul D. Blumenthal, MD, MPH, from the Department of Obstetrics and Gynecology, Stanford University of Medicine, California, and Lisa M. Goldthwaite, MD, from the Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, write in a related editorial.

"The serendipity of postpartum IUD use is compelling and applies to the post–cesarean delivery scenario as it does after vaginal delivery: 1) both the provider and the patient are in the same place at the same time, avoiding the need for a separate visit for contraception initiation; 2) access to the uterine cavity is facilitated by the hysterotomy, just as the open cervix facilitates access in the post–vaginal delivery setting; 3) the insertion process is highly expeditious, commonly requiring less than 30 seconds for actual deployment, and adding no appreciable cost or duration to the primary delivery procedure; and 4) fewer accessories (eg, speculum, sound, tenaculum, light source) are required," Dr Blumenthal and Dr Goldthwaite explain.

Modeling Study Favors Etonogestrel Implant at Delivery

In the second study, Aileen M. Gariepy, MD, MPH, from the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, and colleagues compare the cost-effectiveness of immediate (before hospital discharge after childbirth) and delayed (6 weeks) postpartum etonogestrel implant insertion in preventing unintended pregnancy.

The researchers developed a decision-analytic model to study a hypothetical population of women desiring a contraceptive implant after childbirth, with a timeframe for analysis from childbirth to 1 year postpartum.

They incorporated implant insertion and removal, loss to follow-up at the postpartum visit, use of alternative contraceptive methods, and contraceptive failure into the model.

They calculated the incremental cost of immediate placement for each pregnancy prevented during the first year after childbirth and cost savings associated with pregnancies that were prevented, and performed one-way sensitivity analyses.

Immediate placement is associated with higher expected cost than delayed placement ($1091 per patient compared with $650 per patient) but is more effective for pregnancy prevention (expected pregnancy rate, 2.4% and 21.6%, respectively).

The resulting incremental cost-effectiveness ratio is $2304 per pregnancy prevented. After factoring in medical costs of unintended pregnancies that could be prevented, the researchers expect immediate insertion to save $1263 per patient.

"[I]mmediate postpartum insertion of the contraceptive implant is expected to be cost-effective compared with delayed insertion and to result in a decrease in unintended pregnancy and net savings for the health care system in the long run," Dr Gariepy and colleagues conclude. "Effort should be made to offer the contraceptive implant in the immediate postpartum period to all women who desire it and do not have contraindications."

Dr Gariepy is a Nexplanon trainer for Merck & Co. The other authors and editorialists have disclosed no relevant financial relationships.

Obstet Gynecol. Published online June 5, 2015. Levi abstract, Gariepy abstract, Editorial extract

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