ACOG Urges Immediate Postpartum LARCs

Norra MacReady

August 01, 2016

Obstetric care providers should offer new mothers the option of receiving long-acting reversible contraception (LARC) immediately after delivery or before hospital discharge, according to a committee opinion published by the American College of Obstetricians and Gynecologists.

"LARC is the most effective form of reversible contraception," with effectiveness rates greater than 99%, the authors write in the committee opinion, published in the August issue of Obstetrics & Gynecology.

"The success of LARC in reducing unintended pregnancy and abortion rates could be extended if initiated immediately postpartum, with additional effect on reduction of unintended and short-interval pregnancy."

The authors, members of the Committee on Obstetric Practice, recommend that discussions about LARC start during prenatal appointments.

"We encourage maternity providers to begin discussions about postpartum contraception prior to delivery to ensure women have the time and information they need to select the best method for them, which may be immediate postpartum LARC for many women," Ann Borders, MD, MPH, clinical assistant professor, NorthShore Medical Group, Evanston, Illinois, and one of the authors of the opinion, said in a college news release.

The widespread use of LARC immediately postpartum has been hindered by inconsistencies in reimbursement for LARC devices and services, the authors write. Some state Medicaid programs began covering immediate postpartum LARC in 2012, and currently more than 12 state Medicaid programs reimburse for it apart from the global fee for delivery. The Center for Medicare & Medicaid Services is now examining approaches to enhance the use of LARC, including a state-by-state overview of reimbursement policies and procedures.

Forms of LARC include the levonorgestrel intrauterine device (IUD), copper IUD, and contraceptive implants. These methods are "safe and highly effective for most females, including adolescents," and have few contraindications, the committee writes. They may be placed while the woman is still in the delivery room.

Using LARC immediately postpartum may help prevent short-interval pregnancies, defined as pregnancy within 1 year of delivery. Short-interval pregnancies "are an independent risk factor for preterm delivery and adverse neonatal outcomes," and at least 70% of them are unintended, the authors write.

The immediate postpartum period also is a good time to provide LARC because it ensures the woman is not pregnant. In addition, "many women, including those at highest risk of short interpregnancy intervals, have low postpartum visit follow-up rates."

Drawbacks associated with immediate postpartum insertion of an IUD include expulsion rates of 10% to 27%, which is higher than the rates associated with insertion after 6 weeks postpartum (interval insertion) or postabortion insertion. The authors recommend that any prenatal discussion of LARC include the increased expulsion risk, with counseling on how patients can recognize signs and symptoms of expulsion, along with a comparison of the risks and benefits associated with immediate postpartum vs interval IUD insertion.

"Although levonorgestrel IUD labeling recommends insertion after uterine involution and expulsion rates are higher with immediate postpartum IUD insertion, many women experience barriers to interval LARC placement, such that the advantages of immediate placement outweigh the disadvantages," the authors write.

Contraceptive implants are not associated with any specific postpartum risks, except for a "theoretical concern" that exogenous progesterone might interfere with milk production. Most of the evidence has not shown a negative effect on initiating or continuing breast-feeding associated with immediate postpartum use of LARC.

Intrauterine infection, postpartum hemorrhage, and puerperal sepsis are contraindications to immediate postpartum IUD insertion. "The contraceptive implant does not have any additional contraindications or risks associated with placement in the immediate postpartum period."

The committee also recommends that systems be in place for providing LARC during the comprehensive postpartum examination to women who want it but did not receive LARC immediately postpartum, and that clinicians and institutions develop the capability "to support immediate LARC placement after vaginal and cesarean births." They also urge obstetric care providers to advocate for appropriate reimbursement for immediate postpartum LARC insertion.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;128:422-423. Abstract

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