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Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States
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GENERAL GYNECOLOGY
Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States Maura K. Whiteman, PhD; Shanna Cox, MSPH; Naomi K. Tepper, MD, MPH; Kathryn M. Curtis, PhD; Denise J. Jamieson, MD, MPH; Ana Penman-Aguilar, PhD; Polly A. Marchbanks, PhD OBJECTIVE: The purpose of this study was to estimate US rates of post-
partum intrauterine device (IUD) insertion and postpartum tubal sterilization. STUDY DESIGN: Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes. RESULTS: Estimated rates of postpartum IUD insertion and postpartum
tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of
tubal sterilizations occurred among women who were ⱕ24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43– 6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97–2.11). CONCLUSION: Among US postpartum women, IUD insertion occurs
considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern. Key words: intrauterine device, postpartum period, tubal sterilization, United States
Cite this article as: Whiteman MK, Cox S, Tepper NK, et al. Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States. Am J Obstet Gynecol 2012;206:127.e1-7.
U
se of effective contraception in the postpartum period is an essential strategy to both prevent unintended pregnancies and ensure optimal birth spacing. Nonetheless, among women who were surveyed at 2-9 months after delivery in 12 states and New York City from 2004-2006, only 62% of the women reported using effective contraceptive methods, with failure rates of ⬍10% under typical use (hormonal methods, male or female sterilization, or intrauterine devices [IUDs]).1 The initiation of contraception before hospital discharge after delivery is a potentially practical and cost-effective strategy to in-
From the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Received April 25, 2011; revised July 1, 2011; accepted Aug. 4, 2011. The authors report no conflict of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Reprints not available from the authors. 0002-9378/$36.00 Published by Mosby, Inc. doi: 10.1016/j.ajog.2011.08.004
crease effective postpartum contraceptive use, given that the women are already within the health care system and motivation for contraception may be high. Tubal sterilization and both types of IUDs that are available in the United States (the copper IUD and the levonorgestrelreleasing IUD) are all highly effective contraceptive methods that may be initiated safely in the immediate postpartum period before hospital discharge, regardless of breastfeeding status.2 IUDs are similar to tubal sterilization in their effectiveness3 but are also easily reversible. IUDs can be inserted any time in the postpartum period;2 immediate postplacental insertion is associated with lower expulsion rates than delayed postpartum insertion (up to 72 hours after delivery)4 but is associated with slightly higher expulsion rates than interval insertion (unrelated to pregnancy).4-6 Among all US women of reproductive age, usage of the IUD has increased but remains low; it was used by 2% of contraceptive users in 2002 and by 5.5% in 2006-2008.7 To date, little information exists regarding the rate of postpartum IUD insertion or factors that are associated with undergoing the procedure in the United States. Additionally, recent information regarding postpartum tubal
sterilization is limited.8,9 The objectives of our study were to estimate national rates of postpartum IUD insertion and tubal sterilization procedures and to describe recent trends in these rates, to examine whether maternal or hospital characteristics are associated with the likelihood of undergoing these procedures, and to compare the characteristics of women who undergo postpartum IUD insertion with those who undergo postpartum sterilization. This information will provide baseline rates to monitor future trends and may facilitate the development of targeted interventions or programs to increase the use of effective postpartum contraception that may be provided during delivery hospitalization.
M ATERIALS AND METHODS We used data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) for 2001–2008.10 The Healthcare Cost and Utilization Project is a family of health care databases developed through a federalstate-industry partnership sponsored by the Agency for Healthcare Research and Quality in which state partners contribute data. The NIS is the largest all-payer inpa-
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tient care database in the United States and contains data on 7-8 million hospital stays from approximately 1000 hospitals per year from 2001-2008, which approximates a 20% stratified sample of US hospitals. The sampling frame for the NIS changes annually; in 2001 the NIS included 33 states and in 2008 the NIS included 42 states. Each record includes a discharge weight to account for these differences and to allow for national estimates. The design of the NIS is described in detail elsewhere.10 Briefly, the NIS is a stratified probability sample of community hospitals in the United States that is based on a sampling frame using 5 strata: geographic region (Northeast, Midwest, West, and South), hospital size (based on number of beds), location (urban or rural), teaching status, and control (public, voluntary, or, proprietary). The universe of US community hospitals includes all those hospitals that were open during any part of the calendar year and were designated as community hospitals in the American Hospital Association Annual Survey of Hospitals.11 The American Hospital Association defines community hospitals as all nonfederal shortterm (average length of stay ⬍30 days) general and specialty hospitals that are accessible by the general public. Data are retained for 100% of discharges for each sampled hospital. In the NIS, inpatientstay records include information on patient characteristics, medical diagnoses, and surgical procedures. The NIS also contains hospital-level data from the American Hospital Association Annual Survey of Hospitals, which includes hospital geographic region, location, and hospital teaching status. We restricted our analysis to deliveryrelated discharge records that were identified with the use of the Diagnosis-Related Groups codes for vaginal birth and for cesarean delivery or International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) procedure codes for cesarean delivery. IUD insertions were identified by the presence of ICD-9-CM diagnosis code V25.1 or ICD-9-CM procedure code 69.7. Tubal sterilizations were identified by the presence of ICD-9-CM procedure codes 66.2-66.3 or ICD-9-CM diagnosis 127.e2
code V25.2 in conjunction with ICD9-CM procedure codes 65.6, 66.5, 66.63, or 66.97. We excluded records if they contained codes for hysterectomy or if they contained codes for both IUD insertion and tubal sterilization; the excluded records comprised ⬍1% of all deliveryrelated discharge records. Discharge records with comorbidities were identified by the Healthcare Cost and Utilization Project’s Comorbidity Software; comorbidities that were considered included heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders. Because there is no patient identifier in the NIS, the unit of analysis typically is considered to be the hospital discharge record because a patient can be admitted multiple times. However, because this analysis involved long-acting and permanent methods of contraception, we assume that each hospitalization represents 1 woman. Nonetheless, it is possible that some women underwent ⬎1 postpartum procedure (eg, IUD insertion and tubal sterilization) that was associated with different deliveries during the 8-year study period. SAS– callable SUDAAN software (version 9.2; Research Triangle Institute, Research Triangle Park, NC) was used to account for the complex sampling design in the NIS. Rates of postpartum IUD insertion and tubal sterilization were calculated per 10,000 deliveries. We considered estimates to be reportable if they were based on ⬎10 unweighted cases and had a relative standard error ⬍30%. To obtain reportable estimates for postpartum IUD insertions, years for all trend analyses were combined into 2-year intervals. We used the SUDAAN procedure PROC RATIO to test for linear and quadratic trends in rates over the study period. Trends in postpartum tubal sterilization rates were assessed overall and within subgroups of interest that were defined by age, geographic region, and delivery mode. The small number of postpartum IUD insertions was insufficient to examine trends in rates within subgroups. Race was not examined be-
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www.AJOG.org cause a large proportion of records did not have race information. We used the SUDAAN procedure PROC MULTILOG to construct a polytomous logistic regression model using data for 2001-2008 to assess factors that were associated with postpartum IUD insertion or postpartum tubal sterilization vs neither procedure. A 3-level nominal outcome was used in the model (postpartum IUD insertion, postpartum tubal sterilization, and neither postpartum IUD insertion nor tubal sterilization [Referent]) to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A separate logistic regression model was constructed to compare the characteristics of women who underwent postpartum IUD insertion with those of women who underwent postpartum tubal sterilization. Because the NIS data are publicly available and do not contain personal identifiers, the Centers for Disease Control and Prevention determined that this project did not require human subject research review.
R ESULTS During 2001-2008, the estimated rate of IUD insertions that were performed during delivery hospitalizations in the United States was 0.27 per 10,000 deliveries; by contrast, the rate of postpartum tubal sterilization was 770.67 per 10,000 deliveries. The rate of postpartum IUD insertion increased linearly from 0.10 per 10,000 deliveries in 2001-2002 to 0.55 per 10,000 deliveries in 2007-2008 (P for trend, ⬍ .001; Figure). A quadratic trend was detected in the rate of postpartum tubal sterilization over the time period (P for trend, ⬍ .01); the rate increased from 753.95 per 10,000 deliveries in 2001-2002 to 804.40 per 10,000 deliveries in 2005-2006 and then decreased to 743.58 per 10,000 deliveries in 2007-2008. Over the study period, linear and quadratic trends (P for trend, ⬍ .01) were detected in the rate of postpartum tubal sterilization for women ⱕ24 years old; the rate was stable from 2001-2002 to 2005-2006 (340.39-332.74 per 10,000 deliveries) and then decreased to 288.66 per 10,000 deliveries in 2007-2008 (data not shown). A quadratic trend (P for trend, ⬍ .05) was detected in the rate of
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www.AJOG.org postpartum tubal sterilization for women 25-29 years old and 30-34 years old; rates increased from 2001-2002 to 2005-2006 then declined in 2007-2008. Additionally, a linear trend (P for trend, ⬍ .001) was detected in the rate of postpartum tubal sterilization among those women who had vaginal deliveries; the rate decreased from 431.97 per 10,000 deliveries in 2001-2002 to 316.24 per 10,000 deliveries in 2007-2008. A quadratic trend (P for trend, ⬍ .05) was detected in the rate of postpartum tubal sterilization for women who underwent cesarean delivery; rates increased from 2001-2002 to 2005-2006 then declined in 2007-2008. There were no trends detected in the rate of postpartum tubal sterilization by geographic region. Among all delivery hospitalizations in our sample, we assessed factors that were associated with undergoing postpartum IUD insertion or postpartum tubal sterilization vs neither procedure (Table 1). The likelihood of undergoing postpartum IUD insertion did not vary by age, delivery mode, primary payer, hospital location, or geographic region. Women with at least 1 comorbidity were more likely than those without comorbidities to undergo postpartum IUD insertion (adjusted OR, 1.42; 95% CI, 1.04 –1.94). Women who delivered at teaching hospitals were 3 times as likely to undergo postpartum IUD insertion compared with those who delivered at nonteaching hospitals (adjusted OR, 3.02; 95% CI, 1.43– 6.37). The rate of postpartum tubal sterilization increased with increasing age (Table 1). Postpartum tubal sterilization was more likely among women with cesarean delivery vs vaginal delivery (adjusted OR, 4.56; 95% CI, 4.42– 4.70), with at least 1 comorbidity vs no comorbidities (adjusted OR, 1.15; 95% CI, 1.13–1.17), and with public or other source of primary payment vs private insurance (adjusted OR, 2.04; 95% CI, 1.97–2.11). Women who delivered in the Midwest, South, or West were more likely to undergo postpartum tubal sterilization compared with those who delivered in the Northeast. Additionally, women were less likely to undergo postpartum tubal sterilization if they delivered in an urban
Research
FIGURE
Trends in postpartum IUD insertion and postpartum tubal sterilization
Trends in A, postpartum intrauterine device (IUD) insertion and B, postpartum tubal sterilization procedures, Nationwide Inpatient Sample 2001-2002 to 2007-2008. Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
hospital vs a rural hospital and in a teaching hospital vs a nonteaching hospital. We compared the characteristics of women who underwent postpartum IUD insertion with those of women who underwent postpartum tubal sterilization (Table 2). Women who underwent postpartum IUD insertion tended to be younger than those who underwent postpartum tubal sterilization. The average age of women who underwent IUD insertion was 27.4 years, compared with 30.9 years among women who underwent tubal sterilization (P ⬍ .001, t test) and over one-third of women who underwent postpartum IUD insertion (35.0%) were ⱕ24 years old, compared with 14.9% of those who underwent postpartum tubal sterilization. After adjustment for potential confounders, those women who were ⱕ24 years old were ⬎5-times more likely to undergo IUD insertion than tubal sterilization (OR, 5.54; 95% CI, 3.33–9.23). Women who delivered at teaching hospitals were more likely to undergo IUD insertion vs tubal sterilization than those who delivered at nonteaching hospitals; women who underwent cesarean delivery were less likely to undergo IUD insertion vs tubal sterilization. Compared with women who delivered in the Northeast, those in the South were less likely to undergo IUD insertion vs tubal sterilization. Comorbidity status, primary payer, and hospital location were not associated statistically significantly
with undergoing IUD insertion vs tubal sterilization.
C OMMENT The American College of Obstetricians and Gynecologists recently stated that the immediate postpartum period is a particularly favorable time for IUD insertion.12 Although we found that the rate of postpartum IUD insertion in the United States increased from 2001-2002 to 2007-2008, it remains a rare practice and occurs at a rate markedly lower than that of postpartum tubal sterilization. These findings suggest that postpartum IUD insertion is underutilized, particularly for some subgroups. We found that age was not associated with the likelihood of postpartum IUD insertion; in contrast, the likelihood of postpartum tubal sterilization increased with increasing age, which is consistent with previous reports.13 Among women choosing either postpartum IUD insertion or postpartum tubal sterilization, we found that younger women were more likely than older women to undergo IUD insertion rather than tubal sterilization. However, both the proportion of postpartum tubal sterilizations that were performed among women ⱕ29 years old (42.4%) and the large difference between the rates of postpartum IUD insertion and postpartum tubal sterilization among younger women were no-
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TABLE 1
Association of maternal and hospital characteristics with postpartum IUD insertion and postpartum tubal sterilization IUD insertion Variable
Rate ⴞ SE
a
Tubal sterilization b
Odds ratio
95% CI
Rate ⴞ SEa
Odds ratiob
95% CI
Age, y
.......................................................................................................................................................................................................................................................................................................................................................................
ⱕ24
0.27 ⫾ 0.04
0.84
0.51–1.37
325.99 ⫾ 4.32
0.14
0.14–0.15
25-29
0.27 ⫾ 0.04
0.92
0.56–1.52
782.98 ⫾ 9.79
0.45
0.44–0.45
30-34
0.28 ⫾ 0.06
1.02
0.69–1.51
978.22 ⫾ 13.85
0.62
0.62–0.63
ⱖ35
0.27 ⫾ 0.06
1.00
Reference
1498.03 ⫾ 19.20
1.00
Reference
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Delivery mode
.......................................................................................................................................................................................................................................................................................................................................................................
Vaginal
0.27 ⫾ 0.04
1.00
Reference
383.53 ⫾ 6.99
1.00
Reference
Cesarean
0.29 ⫾ 0.06
1.23
0.82–1.85
1677.81 ⫾ 13.96
4.56
4.42–4.70
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ c
Any comorbidity
.......................................................................................................................................................................................................................................................................................................................................................................
No
0.25 ⫾ 0.03
1.00
Reference
719.80 ⫾ 7.53
1.00
Reference
Yes
0.39 ⫾ 0.08
1.42
1.04–1.94
1050.37 ⫾ 12.22
1.15
1.13–1.17
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Primary payer
.......................................................................................................................................................................................................................................................................................................................................................................
Private
0.23 ⫾ 0.05
1.00
Reference
686.66 ⫾ 7.45
1.00
Reference
Public/other
0.32 ⫾ 0.06
1.56
0.89–2.76
866.92 ⫾ 11.23
2.04
1.97–2.11
....................................................................................................................................................................................................................................................................................................................................................................... d ................................................................................................................................................................................................................................................................................................................................................................................
Hospital location
.......................................................................................................................................................................................................................................................................................................................................................................
Rural
0.15 ⫾ 0.04
1.00
Reference
1070.31 ⫾ 13.51
1.00
Reference
Urban
0.29 ⫾ 0.04
1.04
0.46–2.32
729.45 ⫾ 8.86
0.59
0.57–0.62
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Hospital teaching status
.......................................................................................................................................................................................................................................................................................................................................................................
Nonteaching
0.14 ⫾ 0.04
1.00
Reference
834.69 ⫾ 8.77
1.00
Reference
Teaching
0.43 ⫾ 0.07
3.02
1.43–6.37
695.54 ⫾ 14.14
0.87
0.83–0.92
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Geographic region
.......................................................................................................................................................................................................................................................................................................................................................................
Northeast
0.31 ⫾ 0.07
1.00
Reference
569.90 ⫾ 13.57
1.00
Reference
Midwest
0.28 ⫾ 0.08
1.02
0.48–2.18
653.98 ⫾ 15.33
1.33
1.23–1.44
South
0.23 ⫾ 0.07
0.95
0.45–2.00
987.97 ⫾ 15.46
1.89
1.76–2.02
West
0.31 ⫾ 0.07
1.36
0.67–2.75
682.58 ⫾ 13.35
1.27
1.18–1.36
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; IUD, intrauterine device. a
Per 10,000 deliveries; b Comparing odds of intrauterine device insertion (or tubal sterilization) to odds of neither intrauterine device insertion nor tubal sterilization; adjusted for all other variables in the Table; c Includes heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders; d Includes self-pay and no charge.
Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
table, given the previously reported higher rates of poststerilization regret among younger women. A US cohort study reported that the 14-year cumulative probability of regret was 20.3% among women ⱕ30 years old at the time of sterilization but was only 5.9% among women ⬎30 years old.14 As a result of concerns over regret among young women who undergo sterilizations, the World Health Organization recommends that “Young women, like all women, should be counseled about the permanency of sterilization and the 127.e4
availability of alternative, long-term, highly effective methods.”15 The rate of postpartum tubal sterilization did decline among younger women over the time period of our study, which perhaps reflects an increase in the use and promotion of longacting reversible methods of contraception. Nonetheless, our results suggest that postpartum IUD insertion is likely underutilized among younger women, particularly those who request sterilization. Several additional factors in our study were associated with the likelihood of
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undergoing postpartum IUD insertion or tubal sterilization. Women who delivered at teaching hospitals were more likely to undergo IUD insertion and less likely to undergo postpartum tubal sterilization than those who delivered at nonteaching hospitals. This could be a reflection of multiple factors that include patient population and preferences, provider training in postpartum IUD insertion at teaching institutions, or advocacy for the increased use of the IUD as a method of contraception, as reported at
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TABLE 2
Comparison of characteristics among women undergoing postpartum IUD insertion vs postpartum tubal sterilization
Variable
IUD insertion (n ⴝ 920)
Tubal sterilization (n ⴝ 2,584,420)
Weighted estimate, n
Weighted estimate, n
%
IUD insertion vs tubal sterilization Odds ratioa
%
95% CI
Age, y
.......................................................................................................................................................................................................................................................................................................................................................................
ⱕ24
322
35.0
384,533
14.9
5.54
3.33–9.23
25-29
245
26.6
710,216
27.5
1.94
1.17–3.22
30-34
222
24.2
767,894
29.7
1.60
1.07–2.37
ⱖ35
131
14.2
721,778
27.9
1.00
Reference
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Delivery mode
.......................................................................................................................................................................................................................................................................................................................................................................
Vaginal
628
68.3
901,449
34.9
1.00
Reference
Cesarean
292
31.7
1,682,971
65.1
0.27
0.18–0.40
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ b
Any comorbidity
.......................................................................................................................................................................................................................................................................................................................................................................
No
717
78.0
2,042,302
79.0
1.00
Reference
Yes
202
22.0
542,118
21.0
1.16
0.85–1.59
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Primary payer
.......................................................................................................................................................................................................................................................................................................................................................................
Private
415
45.2
1,230,130
47.7
1.00
Reference
Public/other
504
54.8
1,349,387
52.3
0.71
0.42–1.20
....................................................................................................................................................................................................................................................................................................................................................................... c ................................................................................................................................................................................................................................................................................................................................................................................
Hospital location
.......................................................................................................................................................................................................................................................................................................................................................................
Rural
62
6.7
432,013
16.7
1.00
Reference
Urban
854
93.3
2,149,975
83.3
1.90
0.85–4.28
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Hospital teaching status
.......................................................................................................................................................................................................................................................................................................................................................................
Nonteaching
254
27.8
1,506,879
58.4
1.00
Reference
Teaching
661
72.2
1,075,110
41.6
3.35
1.60–7.01
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Geographic region
.......................................................................................................................................................................................................................................................................................................................................................................
Northeast
173
18.8
317,719
12.3
1.00
Reference
Midwest
200
South
291
21.7
474,180
18.4
0.69
0.31–1.51
31.6
1,226,037
47.4
0.43
0.20–0.91
West
256
27.8
566,485
21.9
0.96
0.48–1.90
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; IUD, intrauterine device. a
Adjusted for all other variables in the Table; b Includes heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders; c Includes self-pay and no charge.
Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
some university health centers.16 In our study, women with at least 1 comorbidity were more likely than those without comorbidities to undergo postpartum IUD insertion and were also more likely to undergo postpartum tubal sterilization. This may reflect a desire among women with comorbidities or their providers for highly effective postpartum contraception to avoid the potential maternal and/or infant health risks associ-
ated with some comorbidities that may accompany future pregnancies. Several additional factors were associated with the likelihood of undergoing postpartum tubal sterilization. Women with cesarean deliveries were more likely to undergo postpartum tubal sterilization than those with vaginal deliveries, which is consistent with a previous study that found that women who undergo vaginal deliveries were less likely than
those who undergo cesarean deliveries to receive a desired postpartum tubal sterilization.17 The authors speculate that this may reflect a lack of motivation on the part of the provider or patient for another procedure or system-related barriers, such as the unavailability of operating rooms; staff availability may be another barrier. We also found that women with public or other nonprivate sources of primary
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payment were more likely than those with private insurance to undergo postpartum tubal sterilization. Other investigators have found that Medicaid was the expected payer for a higher proportion of postpartum tubal sterilizations than of outpatient interval tubal sterilizations8 and that women with no or public insurance were more likely to have undergone tubal sterilization (postpartum or interval) compared with women with private insurance.18 These findings may be explained, in part, by the constraints of pregnancyrelated Medicaid coverage, which is extended to 60 days after delivery; some states have obtained approval to continue Medicaid coverage of family planning services for women who would otherwise lose Medicaid coverage after delivery, with eligibility generally lasting for 2 years.19 Given these constraints in coverage, women who are covered by Medicaid may have an incentive to obtain a permanent form of contraception while they have coverage, rather than rely on other methods that necessitate ongoing supplies or provider visits.18 We were limited in this analysis by several factors that are inherent in hospital discharge data. Our data depend on the accuracy of the procedures and diagnoses that are listed on the hospital discharge summary. Some diagnosis codes that we examined to define the presence or absence of comorbidities, such as those for obesity or hypertension, may have poor sensitivity.20 It is also possible that IUD insertion may be more likely to be under-coded than tubal sterilization, which can involve operating room time and additional staff and equipment. By relying on ICD-9 codes, we were unable to differentiate between the copper IUD and the levonorgestrel-releasing IUD. In addition, we had no information on other contraceptive methods that women may have initiated during delivery hospitalization, such as injectables or oral contraceptives. We also lacked information on some factors that may influence postpartum contraceptive choice such as parity, marital status, breastfeeding, previous contraceptive history, or contraindications to specific contraceptive methods. Additionally, we were unable to examine race or 127.e6
ethnicity, because this information was missing in a large proportion of records. Our study represents the first reported rates of postpartum IUD insertion in the United States and demonstrates that, although rates have increased, postpartum IUD insertion is performed very rarely and, even in recent years, occurs at a rate that is ⬎1000 times lower than that of postpartum tubal sterilization. These findings point to the need to consider postpartum IUD insertion as a contraceptive option among postpartum women, particularly those who are at high-risk for poststerilization regret or who are unlikely to return for postpartum visits. Although both the IUD and tubal sterilization are safe, highly effective, and user-independent methods that may be initiated immediately after delivery, the IUD is easily reversible, does not involve an additional surgical procedure, and may be more costeffective, particularly for women who are at high risk for poststerilization regret and who may pursue expensive attempts at reversal or the use of assisted reproductive technologies. Although cost-effectiveness analyses have not been conducted specifically for postpartum women, in general, both the copper IUD and the levonorgestrel-releasing IUD are more cost-effective than tubal sterilization.21 Despite the advantages of postpartum IUD insertion, there are some potential trade-offs. Immediate postpartum insertion is associated with a higher rate of expulsion than with interval insertion4-6; however, many women who desire an IUD do not return for interval insertion,5,16 and for many women, the benefit of providing highly effective contraception before hospital discharge may outweigh the increased expulsion risk. There are also challenges related to the provision of postpartum IUDs that include insurance coverage, reimbursement policies, and the need to ensure availability of both trained staff and necessary supplies. Additionally, many providers erroneously believe that immediately postpartum women are not suitable IUD candidates.22 Ultimately, to maximize impact on unintended pregnancy rates in the United States, a full range of postpartum contraceptive options should be offered, and barriers to highly effective
American Journal of Obstetrics & Gynecology FEBRUARY 2012
www.AJOG.org postpartum contraceptive methods, such f as the IUD, should be minimized. REFERENCES 1. Contraceptive use among postpartum women: 12 states and New York City, 20042006. MMWR Morb Mortal Wkly Rep 2009;58:821-6. 2. Centers for Disease Control and Prevention. US medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th ed. MMWR Recomm Rep 2010;59:1-86. 3. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404. 4. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009;80:327-36. 5. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010;116: 1079-87. 6. Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010;5 7. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. National Center for Health Statistics. Vital Health Stat 23 2010; 29:1-44. 8. MacKay AP, Kieke BA Jr, Koonin LM, Beattie K. Tubal sterilization in the United States, 19941996. Fam Plann Perspect 2001;33:161-5. 9. Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010; 94:1-6. 10. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP); 2001-2008; Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed July 28, 2010. 11. American Hospital Association (AHA) Hospital Statistics. Chicago, IL: Health Forum LLC, an affiliate of the American Hospital Association. 1995:6-2001 12. American College of Obstetrics and Gynecology. Practice bulletin no. 121: long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2011;118: 184-96. 13. Placek PJ, Taffel SM, Smith JC, Maze JM. Postpartum sterilization in cesarean section and non-cesarean section deliveries: United States, 1970-75. Am J Public Health 1981;71: 1258-61. 14. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999;93:889-95. 15. Curtis KM, Mohllajee AP, Peterson HB. Re-
www.AJOG.org gret following female sterilization at a young age: a systematic review. Contraception 2006; 73:205-10. 16. Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception 2005;72:426-9. 17. Zite N, Wuellner S, Gilliam M. Failure to obtain desired postpartum sterilization: risk and predictors. Obstet Gynecol 2005;105: 794-9.
General Gynecology 18. Borrero S, Schwarz EB, Reeves MF, Bost JE, Creinin MD, Ibrahim SA. Race, insurance status, and tubal sterilization. Obstet Gynecol 2007;109:94-100. 19. The Alan Guttmacher Institute. State Medicaid family planning eligibility expansions. State policies in brief, Sept. 1, 2010. 20. Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM. Accuracy of obstetric diagnoses and procedures in hospital dis-
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charge data. Am J Obstet Gynecol 2006;194: 992-1001. 21. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception 2009;79:5-14. 22. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111:1359-6.
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GENERAL GYNECOLOGY
Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States Maura K. Whiteman, PhD; Shanna Cox, MSPH; Naomi K. Tepper, MD, MPH; Kathryn M. Curtis, PhD; Denise J. Jamieson, MD, MPH; Ana Penman-Aguilar, PhD; Polly A. Marchbanks, PhD OBJECTIVE: The purpose of this study was to estimate US rates of post-
partum intrauterine device (IUD) insertion and postpartum tubal sterilization. STUDY DESIGN: Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes. RESULTS: Estimated rates of postpartum IUD insertion and postpartum
tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of
tubal sterilizations occurred among women who were ⱕ24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43– 6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97–2.11). CONCLUSION: Among US postpartum women, IUD insertion occurs
considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern. Key words: intrauterine device, postpartum period, tubal sterilization, United States
Cite this article as: Whiteman MK, Cox S, Tepper NK, et al. Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States. Am J Obstet Gynecol 2012;206:127.e1-7.
U
se of effective contraception in the postpartum period is an essential strategy to both prevent unintended pregnancies and ensure optimal birth spacing. Nonetheless, among women who were surveyed at 2-9 months after delivery in 12 states and New York City from 2004-2006, only 62% of the women reported using effective contraceptive methods, with failure rates of ⬍10% under typical use (hormonal methods, male or female sterilization, or intrauterine devices [IUDs]).1 The initiation of contraception before hospital discharge after delivery is a potentially practical and cost-effective strategy to in-
From the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Received April 25, 2011; revised July 1, 2011; accepted Aug. 4, 2011. The authors report no conflict of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Reprints not available from the authors. 0002-9378/$36.00 Published by Mosby, Inc. doi: 10.1016/j.ajog.2011.08.004
crease effective postpartum contraceptive use, given that the women are already within the health care system and motivation for contraception may be high. Tubal sterilization and both types of IUDs that are available in the United States (the copper IUD and the levonorgestrelreleasing IUD) are all highly effective contraceptive methods that may be initiated safely in the immediate postpartum period before hospital discharge, regardless of breastfeeding status.2 IUDs are similar to tubal sterilization in their effectiveness3 but are also easily reversible. IUDs can be inserted any time in the postpartum period;2 immediate postplacental insertion is associated with lower expulsion rates than delayed postpartum insertion (up to 72 hours after delivery)4 but is associated with slightly higher expulsion rates than interval insertion (unrelated to pregnancy).4-6 Among all US women of reproductive age, usage of the IUD has increased but remains low; it was used by 2% of contraceptive users in 2002 and by 5.5% in 2006-2008.7 To date, little information exists regarding the rate of postpartum IUD insertion or factors that are associated with undergoing the procedure in the United States. Additionally, recent information regarding postpartum tubal
sterilization is limited.8,9 The objectives of our study were to estimate national rates of postpartum IUD insertion and tubal sterilization procedures and to describe recent trends in these rates, to examine whether maternal or hospital characteristics are associated with the likelihood of undergoing these procedures, and to compare the characteristics of women who undergo postpartum IUD insertion with those who undergo postpartum sterilization. This information will provide baseline rates to monitor future trends and may facilitate the development of targeted interventions or programs to increase the use of effective postpartum contraception that may be provided during delivery hospitalization.
M ATERIALS AND METHODS We used data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) for 2001–2008.10 The Healthcare Cost and Utilization Project is a family of health care databases developed through a federalstate-industry partnership sponsored by the Agency for Healthcare Research and Quality in which state partners contribute data. The NIS is the largest all-payer inpa-
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tient care database in the United States and contains data on 7-8 million hospital stays from approximately 1000 hospitals per year from 2001-2008, which approximates a 20% stratified sample of US hospitals. The sampling frame for the NIS changes annually; in 2001 the NIS included 33 states and in 2008 the NIS included 42 states. Each record includes a discharge weight to account for these differences and to allow for national estimates. The design of the NIS is described in detail elsewhere.10 Briefly, the NIS is a stratified probability sample of community hospitals in the United States that is based on a sampling frame using 5 strata: geographic region (Northeast, Midwest, West, and South), hospital size (based on number of beds), location (urban or rural), teaching status, and control (public, voluntary, or, proprietary). The universe of US community hospitals includes all those hospitals that were open during any part of the calendar year and were designated as community hospitals in the American Hospital Association Annual Survey of Hospitals.11 The American Hospital Association defines community hospitals as all nonfederal shortterm (average length of stay ⬍30 days) general and specialty hospitals that are accessible by the general public. Data are retained for 100% of discharges for each sampled hospital. In the NIS, inpatientstay records include information on patient characteristics, medical diagnoses, and surgical procedures. The NIS also contains hospital-level data from the American Hospital Association Annual Survey of Hospitals, which includes hospital geographic region, location, and hospital teaching status. We restricted our analysis to deliveryrelated discharge records that were identified with the use of the Diagnosis-Related Groups codes for vaginal birth and for cesarean delivery or International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM) procedure codes for cesarean delivery. IUD insertions were identified by the presence of ICD-9-CM diagnosis code V25.1 or ICD-9-CM procedure code 69.7. Tubal sterilizations were identified by the presence of ICD-9-CM procedure codes 66.2-66.3 or ICD-9-CM diagnosis 127.e2
code V25.2 in conjunction with ICD9-CM procedure codes 65.6, 66.5, 66.63, or 66.97. We excluded records if they contained codes for hysterectomy or if they contained codes for both IUD insertion and tubal sterilization; the excluded records comprised ⬍1% of all deliveryrelated discharge records. Discharge records with comorbidities were identified by the Healthcare Cost and Utilization Project’s Comorbidity Software; comorbidities that were considered included heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders. Because there is no patient identifier in the NIS, the unit of analysis typically is considered to be the hospital discharge record because a patient can be admitted multiple times. However, because this analysis involved long-acting and permanent methods of contraception, we assume that each hospitalization represents 1 woman. Nonetheless, it is possible that some women underwent ⬎1 postpartum procedure (eg, IUD insertion and tubal sterilization) that was associated with different deliveries during the 8-year study period. SAS– callable SUDAAN software (version 9.2; Research Triangle Institute, Research Triangle Park, NC) was used to account for the complex sampling design in the NIS. Rates of postpartum IUD insertion and tubal sterilization were calculated per 10,000 deliveries. We considered estimates to be reportable if they were based on ⬎10 unweighted cases and had a relative standard error ⬍30%. To obtain reportable estimates for postpartum IUD insertions, years for all trend analyses were combined into 2-year intervals. We used the SUDAAN procedure PROC RATIO to test for linear and quadratic trends in rates over the study period. Trends in postpartum tubal sterilization rates were assessed overall and within subgroups of interest that were defined by age, geographic region, and delivery mode. The small number of postpartum IUD insertions was insufficient to examine trends in rates within subgroups. Race was not examined be-
American Journal of Obstetrics & Gynecology FEBRUARY 2012
www.AJOG.org cause a large proportion of records did not have race information. We used the SUDAAN procedure PROC MULTILOG to construct a polytomous logistic regression model using data for 2001-2008 to assess factors that were associated with postpartum IUD insertion or postpartum tubal sterilization vs neither procedure. A 3-level nominal outcome was used in the model (postpartum IUD insertion, postpartum tubal sterilization, and neither postpartum IUD insertion nor tubal sterilization [Referent]) to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A separate logistic regression model was constructed to compare the characteristics of women who underwent postpartum IUD insertion with those of women who underwent postpartum tubal sterilization. Because the NIS data are publicly available and do not contain personal identifiers, the Centers for Disease Control and Prevention determined that this project did not require human subject research review.
R ESULTS During 2001-2008, the estimated rate of IUD insertions that were performed during delivery hospitalizations in the United States was 0.27 per 10,000 deliveries; by contrast, the rate of postpartum tubal sterilization was 770.67 per 10,000 deliveries. The rate of postpartum IUD insertion increased linearly from 0.10 per 10,000 deliveries in 2001-2002 to 0.55 per 10,000 deliveries in 2007-2008 (P for trend, ⬍ .001; Figure). A quadratic trend was detected in the rate of postpartum tubal sterilization over the time period (P for trend, ⬍ .01); the rate increased from 753.95 per 10,000 deliveries in 2001-2002 to 804.40 per 10,000 deliveries in 2005-2006 and then decreased to 743.58 per 10,000 deliveries in 2007-2008. Over the study period, linear and quadratic trends (P for trend, ⬍ .01) were detected in the rate of postpartum tubal sterilization for women ⱕ24 years old; the rate was stable from 2001-2002 to 2005-2006 (340.39-332.74 per 10,000 deliveries) and then decreased to 288.66 per 10,000 deliveries in 2007-2008 (data not shown). A quadratic trend (P for trend, ⬍ .05) was detected in the rate of
General Gynecology
www.AJOG.org postpartum tubal sterilization for women 25-29 years old and 30-34 years old; rates increased from 2001-2002 to 2005-2006 then declined in 2007-2008. Additionally, a linear trend (P for trend, ⬍ .001) was detected in the rate of postpartum tubal sterilization among those women who had vaginal deliveries; the rate decreased from 431.97 per 10,000 deliveries in 2001-2002 to 316.24 per 10,000 deliveries in 2007-2008. A quadratic trend (P for trend, ⬍ .05) was detected in the rate of postpartum tubal sterilization for women who underwent cesarean delivery; rates increased from 2001-2002 to 2005-2006 then declined in 2007-2008. There were no trends detected in the rate of postpartum tubal sterilization by geographic region. Among all delivery hospitalizations in our sample, we assessed factors that were associated with undergoing postpartum IUD insertion or postpartum tubal sterilization vs neither procedure (Table 1). The likelihood of undergoing postpartum IUD insertion did not vary by age, delivery mode, primary payer, hospital location, or geographic region. Women with at least 1 comorbidity were more likely than those without comorbidities to undergo postpartum IUD insertion (adjusted OR, 1.42; 95% CI, 1.04 –1.94). Women who delivered at teaching hospitals were 3 times as likely to undergo postpartum IUD insertion compared with those who delivered at nonteaching hospitals (adjusted OR, 3.02; 95% CI, 1.43– 6.37). The rate of postpartum tubal sterilization increased with increasing age (Table 1). Postpartum tubal sterilization was more likely among women with cesarean delivery vs vaginal delivery (adjusted OR, 4.56; 95% CI, 4.42– 4.70), with at least 1 comorbidity vs no comorbidities (adjusted OR, 1.15; 95% CI, 1.13–1.17), and with public or other source of primary payment vs private insurance (adjusted OR, 2.04; 95% CI, 1.97–2.11). Women who delivered in the Midwest, South, or West were more likely to undergo postpartum tubal sterilization compared with those who delivered in the Northeast. Additionally, women were less likely to undergo postpartum tubal sterilization if they delivered in an urban
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FIGURE
Trends in postpartum IUD insertion and postpartum tubal sterilization
Trends in A, postpartum intrauterine device (IUD) insertion and B, postpartum tubal sterilization procedures, Nationwide Inpatient Sample 2001-2002 to 2007-2008. Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
hospital vs a rural hospital and in a teaching hospital vs a nonteaching hospital. We compared the characteristics of women who underwent postpartum IUD insertion with those of women who underwent postpartum tubal sterilization (Table 2). Women who underwent postpartum IUD insertion tended to be younger than those who underwent postpartum tubal sterilization. The average age of women who underwent IUD insertion was 27.4 years, compared with 30.9 years among women who underwent tubal sterilization (P ⬍ .001, t test) and over one-third of women who underwent postpartum IUD insertion (35.0%) were ⱕ24 years old, compared with 14.9% of those who underwent postpartum tubal sterilization. After adjustment for potential confounders, those women who were ⱕ24 years old were ⬎5-times more likely to undergo IUD insertion than tubal sterilization (OR, 5.54; 95% CI, 3.33–9.23). Women who delivered at teaching hospitals were more likely to undergo IUD insertion vs tubal sterilization than those who delivered at nonteaching hospitals; women who underwent cesarean delivery were less likely to undergo IUD insertion vs tubal sterilization. Compared with women who delivered in the Northeast, those in the South were less likely to undergo IUD insertion vs tubal sterilization. Comorbidity status, primary payer, and hospital location were not associated statistically significantly
with undergoing IUD insertion vs tubal sterilization.
C OMMENT The American College of Obstetricians and Gynecologists recently stated that the immediate postpartum period is a particularly favorable time for IUD insertion.12 Although we found that the rate of postpartum IUD insertion in the United States increased from 2001-2002 to 2007-2008, it remains a rare practice and occurs at a rate markedly lower than that of postpartum tubal sterilization. These findings suggest that postpartum IUD insertion is underutilized, particularly for some subgroups. We found that age was not associated with the likelihood of postpartum IUD insertion; in contrast, the likelihood of postpartum tubal sterilization increased with increasing age, which is consistent with previous reports.13 Among women choosing either postpartum IUD insertion or postpartum tubal sterilization, we found that younger women were more likely than older women to undergo IUD insertion rather than tubal sterilization. However, both the proportion of postpartum tubal sterilizations that were performed among women ⱕ29 years old (42.4%) and the large difference between the rates of postpartum IUD insertion and postpartum tubal sterilization among younger women were no-
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TABLE 1
Association of maternal and hospital characteristics with postpartum IUD insertion and postpartum tubal sterilization IUD insertion Variable
Rate ⴞ SE
a
Tubal sterilization b
Odds ratio
95% CI
Rate ⴞ SEa
Odds ratiob
95% CI
Age, y
.......................................................................................................................................................................................................................................................................................................................................................................
ⱕ24
0.27 ⫾ 0.04
0.84
0.51–1.37
325.99 ⫾ 4.32
0.14
0.14–0.15
25-29
0.27 ⫾ 0.04
0.92
0.56–1.52
782.98 ⫾ 9.79
0.45
0.44–0.45
30-34
0.28 ⫾ 0.06
1.02
0.69–1.51
978.22 ⫾ 13.85
0.62
0.62–0.63
ⱖ35
0.27 ⫾ 0.06
1.00
Reference
1498.03 ⫾ 19.20
1.00
Reference
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Delivery mode
.......................................................................................................................................................................................................................................................................................................................................................................
Vaginal
0.27 ⫾ 0.04
1.00
Reference
383.53 ⫾ 6.99
1.00
Reference
Cesarean
0.29 ⫾ 0.06
1.23
0.82–1.85
1677.81 ⫾ 13.96
4.56
4.42–4.70
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ c
Any comorbidity
.......................................................................................................................................................................................................................................................................................................................................................................
No
0.25 ⫾ 0.03
1.00
Reference
719.80 ⫾ 7.53
1.00
Reference
Yes
0.39 ⫾ 0.08
1.42
1.04–1.94
1050.37 ⫾ 12.22
1.15
1.13–1.17
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Primary payer
.......................................................................................................................................................................................................................................................................................................................................................................
Private
0.23 ⫾ 0.05
1.00
Reference
686.66 ⫾ 7.45
1.00
Reference
Public/other
0.32 ⫾ 0.06
1.56
0.89–2.76
866.92 ⫾ 11.23
2.04
1.97–2.11
....................................................................................................................................................................................................................................................................................................................................................................... d ................................................................................................................................................................................................................................................................................................................................................................................
Hospital location
.......................................................................................................................................................................................................................................................................................................................................................................
Rural
0.15 ⫾ 0.04
1.00
Reference
1070.31 ⫾ 13.51
1.00
Reference
Urban
0.29 ⫾ 0.04
1.04
0.46–2.32
729.45 ⫾ 8.86
0.59
0.57–0.62
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Hospital teaching status
.......................................................................................................................................................................................................................................................................................................................................................................
Nonteaching
0.14 ⫾ 0.04
1.00
Reference
834.69 ⫾ 8.77
1.00
Reference
Teaching
0.43 ⫾ 0.07
3.02
1.43–6.37
695.54 ⫾ 14.14
0.87
0.83–0.92
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Geographic region
.......................................................................................................................................................................................................................................................................................................................................................................
Northeast
0.31 ⫾ 0.07
1.00
Reference
569.90 ⫾ 13.57
1.00
Reference
Midwest
0.28 ⫾ 0.08
1.02
0.48–2.18
653.98 ⫾ 15.33
1.33
1.23–1.44
South
0.23 ⫾ 0.07
0.95
0.45–2.00
987.97 ⫾ 15.46
1.89
1.76–2.02
West
0.31 ⫾ 0.07
1.36
0.67–2.75
682.58 ⫾ 13.35
1.27
1.18–1.36
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; IUD, intrauterine device. a
Per 10,000 deliveries; b Comparing odds of intrauterine device insertion (or tubal sterilization) to odds of neither intrauterine device insertion nor tubal sterilization; adjusted for all other variables in the Table; c Includes heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders; d Includes self-pay and no charge.
Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
table, given the previously reported higher rates of poststerilization regret among younger women. A US cohort study reported that the 14-year cumulative probability of regret was 20.3% among women ⱕ30 years old at the time of sterilization but was only 5.9% among women ⬎30 years old.14 As a result of concerns over regret among young women who undergo sterilizations, the World Health Organization recommends that “Young women, like all women, should be counseled about the permanency of sterilization and the 127.e4
availability of alternative, long-term, highly effective methods.”15 The rate of postpartum tubal sterilization did decline among younger women over the time period of our study, which perhaps reflects an increase in the use and promotion of longacting reversible methods of contraception. Nonetheless, our results suggest that postpartum IUD insertion is likely underutilized among younger women, particularly those who request sterilization. Several additional factors in our study were associated with the likelihood of
American Journal of Obstetrics & Gynecology FEBRUARY 2012
undergoing postpartum IUD insertion or tubal sterilization. Women who delivered at teaching hospitals were more likely to undergo IUD insertion and less likely to undergo postpartum tubal sterilization than those who delivered at nonteaching hospitals. This could be a reflection of multiple factors that include patient population and preferences, provider training in postpartum IUD insertion at teaching institutions, or advocacy for the increased use of the IUD as a method of contraception, as reported at
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TABLE 2
Comparison of characteristics among women undergoing postpartum IUD insertion vs postpartum tubal sterilization
Variable
IUD insertion (n ⴝ 920)
Tubal sterilization (n ⴝ 2,584,420)
Weighted estimate, n
Weighted estimate, n
%
IUD insertion vs tubal sterilization Odds ratioa
%
95% CI
Age, y
.......................................................................................................................................................................................................................................................................................................................................................................
ⱕ24
322
35.0
384,533
14.9
5.54
3.33–9.23
25-29
245
26.6
710,216
27.5
1.94
1.17–3.22
30-34
222
24.2
767,894
29.7
1.60
1.07–2.37
ⱖ35
131
14.2
721,778
27.9
1.00
Reference
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Delivery mode
.......................................................................................................................................................................................................................................................................................................................................................................
Vaginal
628
68.3
901,449
34.9
1.00
Reference
Cesarean
292
31.7
1,682,971
65.1
0.27
0.18–0.40
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ b
Any comorbidity
.......................................................................................................................................................................................................................................................................................................................................................................
No
717
78.0
2,042,302
79.0
1.00
Reference
Yes
202
22.0
542,118
21.0
1.16
0.85–1.59
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Primary payer
.......................................................................................................................................................................................................................................................................................................................................................................
Private
415
45.2
1,230,130
47.7
1.00
Reference
Public/other
504
54.8
1,349,387
52.3
0.71
0.42–1.20
....................................................................................................................................................................................................................................................................................................................................................................... c ................................................................................................................................................................................................................................................................................................................................................................................
Hospital location
.......................................................................................................................................................................................................................................................................................................................................................................
Rural
62
6.7
432,013
16.7
1.00
Reference
Urban
854
93.3
2,149,975
83.3
1.90
0.85–4.28
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Hospital teaching status
.......................................................................................................................................................................................................................................................................................................................................................................
Nonteaching
254
27.8
1,506,879
58.4
1.00
Reference
Teaching
661
72.2
1,075,110
41.6
3.35
1.60–7.01
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Geographic region
.......................................................................................................................................................................................................................................................................................................................................................................
Northeast
173
18.8
317,719
12.3
1.00
Reference
Midwest
200
South
291
21.7
474,180
18.4
0.69
0.31–1.51
31.6
1,226,037
47.4
0.43
0.20–0.91
West
256
27.8
566,485
21.9
0.96
0.48–1.90
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; IUD, intrauterine device. a
Adjusted for all other variables in the Table; b Includes heart disease, hypertension, diabetes mellitus, HIV/AIDS, chronic lung disease, thyroid disorders, cancer, obesity, anemia, neurologic disorders, renal failure, liver disorders, rheumatoid arthritis/collagen vascular diseases, and coagulation disorders; c Includes self-pay and no charge.
Whiteman. Postpartum IUD insertion and postpartum tubal sterilization. Am J Obstet Gynecol 2012.
some university health centers.16 In our study, women with at least 1 comorbidity were more likely than those without comorbidities to undergo postpartum IUD insertion and were also more likely to undergo postpartum tubal sterilization. This may reflect a desire among women with comorbidities or their providers for highly effective postpartum contraception to avoid the potential maternal and/or infant health risks associ-
ated with some comorbidities that may accompany future pregnancies. Several additional factors were associated with the likelihood of undergoing postpartum tubal sterilization. Women with cesarean deliveries were more likely to undergo postpartum tubal sterilization than those with vaginal deliveries, which is consistent with a previous study that found that women who undergo vaginal deliveries were less likely than
those who undergo cesarean deliveries to receive a desired postpartum tubal sterilization.17 The authors speculate that this may reflect a lack of motivation on the part of the provider or patient for another procedure or system-related barriers, such as the unavailability of operating rooms; staff availability may be another barrier. We also found that women with public or other nonprivate sources of primary
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payment were more likely than those with private insurance to undergo postpartum tubal sterilization. Other investigators have found that Medicaid was the expected payer for a higher proportion of postpartum tubal sterilizations than of outpatient interval tubal sterilizations8 and that women with no or public insurance were more likely to have undergone tubal sterilization (postpartum or interval) compared with women with private insurance.18 These findings may be explained, in part, by the constraints of pregnancyrelated Medicaid coverage, which is extended to 60 days after delivery; some states have obtained approval to continue Medicaid coverage of family planning services for women who would otherwise lose Medicaid coverage after delivery, with eligibility generally lasting for 2 years.19 Given these constraints in coverage, women who are covered by Medicaid may have an incentive to obtain a permanent form of contraception while they have coverage, rather than rely on other methods that necessitate ongoing supplies or provider visits.18 We were limited in this analysis by several factors that are inherent in hospital discharge data. Our data depend on the accuracy of the procedures and diagnoses that are listed on the hospital discharge summary. Some diagnosis codes that we examined to define the presence or absence of comorbidities, such as those for obesity or hypertension, may have poor sensitivity.20 It is also possible that IUD insertion may be more likely to be under-coded than tubal sterilization, which can involve operating room time and additional staff and equipment. By relying on ICD-9 codes, we were unable to differentiate between the copper IUD and the levonorgestrel-releasing IUD. In addition, we had no information on other contraceptive methods that women may have initiated during delivery hospitalization, such as injectables or oral contraceptives. We also lacked information on some factors that may influence postpartum contraceptive choice such as parity, marital status, breastfeeding, previous contraceptive history, or contraindications to specific contraceptive methods. Additionally, we were unable to examine race or 127.e6
ethnicity, because this information was missing in a large proportion of records. Our study represents the first reported rates of postpartum IUD insertion in the United States and demonstrates that, although rates have increased, postpartum IUD insertion is performed very rarely and, even in recent years, occurs at a rate that is ⬎1000 times lower than that of postpartum tubal sterilization. These findings point to the need to consider postpartum IUD insertion as a contraceptive option among postpartum women, particularly those who are at high-risk for poststerilization regret or who are unlikely to return for postpartum visits. Although both the IUD and tubal sterilization are safe, highly effective, and user-independent methods that may be initiated immediately after delivery, the IUD is easily reversible, does not involve an additional surgical procedure, and may be more costeffective, particularly for women who are at high risk for poststerilization regret and who may pursue expensive attempts at reversal or the use of assisted reproductive technologies. Although cost-effectiveness analyses have not been conducted specifically for postpartum women, in general, both the copper IUD and the levonorgestrel-releasing IUD are more cost-effective than tubal sterilization.21 Despite the advantages of postpartum IUD insertion, there are some potential trade-offs. Immediate postpartum insertion is associated with a higher rate of expulsion than with interval insertion4-6; however, many women who desire an IUD do not return for interval insertion,5,16 and for many women, the benefit of providing highly effective contraception before hospital discharge may outweigh the increased expulsion risk. There are also challenges related to the provision of postpartum IUDs that include insurance coverage, reimbursement policies, and the need to ensure availability of both trained staff and necessary supplies. Additionally, many providers erroneously believe that immediately postpartum women are not suitable IUD candidates.22 Ultimately, to maximize impact on unintended pregnancy rates in the United States, a full range of postpartum contraceptive options should be offered, and barriers to highly effective
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www.AJOG.org postpartum contraceptive methods, such f as the IUD, should be minimized. REFERENCES 1. Contraceptive use among postpartum women: 12 states and New York City, 20042006. MMWR Morb Mortal Wkly Rep 2009;58:821-6. 2. Centers for Disease Control and Prevention. US medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th ed. MMWR Recomm Rep 2010;59:1-86. 3. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404. 4. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009;80:327-36. 5. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010;116: 1079-87. 6. Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010;5 7. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. National Center for Health Statistics. Vital Health Stat 23 2010; 29:1-44. 8. MacKay AP, Kieke BA Jr, Koonin LM, Beattie K. Tubal sterilization in the United States, 19941996. Fam Plann Perspect 2001;33:161-5. 9. Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010; 94:1-6. 10. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP); 2001-2008; Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed July 28, 2010. 11. American Hospital Association (AHA) Hospital Statistics. Chicago, IL: Health Forum LLC, an affiliate of the American Hospital Association. 1995:6-2001 12. American College of Obstetrics and Gynecology. Practice bulletin no. 121: long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2011;118: 184-96. 13. Placek PJ, Taffel SM, Smith JC, Maze JM. Postpartum sterilization in cesarean section and non-cesarean section deliveries: United States, 1970-75. Am J Public Health 1981;71: 1258-61. 14. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999;93:889-95. 15. Curtis KM, Mohllajee AP, Peterson HB. Re-
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