- Email: [email protected]
Postpartum contraception: optimizing interpregnancy intervals
Contraception 89 (2014) 487 – 488
Editorial
Postpartum contraception: optimizing interpregnancy intervals In this issue of Contraception, several research groups present new information on factors influencing the delivery and uptake of postpartum contraception. Singh et al. report on patient-level factors in postpartum contraceptive choices in New Mexico, and Mody et al. examine the utilization of postpartum contraception by women in Mumbai [1,2]. Huang et al. describe an intervention to increase postpartum contraceptive use among rural-to-urban migrants in Shanghai and discuss patient characteristics associated with method choice [3]. Jatlaoui et al. report on postplacental intrauterine device (IUD) insertion by residents after vaginal delivery, and Whitaker presents a randomized controlled trial of postplacental IUD insertion after cesarean delivery [4,5]. Why this focus on contraception for women who recently delivered? The postpartum period is one of intense emotional, physical and social change for a woman and her family. Women often experience postpartum changes in physiology, body image, fertility risk, sexual and relationship behavior, desire for future fertility and tolerance for an unintended pregnancy. All of these factors may change the appropriateness of a patient's prior contraceptive. Because the postpartum period can be so chaotic for women and their partners, delay in initiating effective contraception is common. In studies across multiple societies, approximately half of postpartum women resumed sexual intercourse within 6 weeks of delivery, regardless of mode of delivery or lactation. Nonbreastfeeding women begin to ovulate around 4 weeks postpartum, and most ovulate before the first menses occur [6]. This frequent lag between resumption of intercourse and initiation of contraception often leads to pregnancy and a shorter-than-recommended interpregnancy interval (IPI), which is strongly associated with negative maternal, child and social health outcomes. Because of the risk of these bad outcomes, an interval of 18 months between a delivery and subsequent conception is recommended; however, 33.1% of US pregnancies are conceived less than 18 months after a prior birth [7]. Thiel de Bocanegra et al. recently examined records of 117,644 Medicaid recipients in California and found that only 41% had a contraceptive claim within 90 days of giving birth [8]. Just 13% of women received contraception at the first postpartum visit, and these women were significantly more likely to have an adequate IPI. Even among women who were seen more than once in the 90 days postpartum, 33% had no http://dx.doi.org/10.1016/j.contraception.2014.04.013 0010-7824/© 2014 Elsevier Inc. All rights reserved.
contraceptive claims. In a separate report, the authors noted that 55% of these postpartum women adopted Tier 2, userdependent methods, such as oral contraceptive pills, patch or vaginal ring and had a mean contraceptive coverage of only 6 months. Women who started long-acting Tier 1 methods such as IUDs or implants represented 7% of the cohort and had a higher mean coverage of almost 11 months [9]. Improved birth spacing can be a key benefit use of longacting reversible contraception (LARC), but delay to initiation can still be problematic. In a study of postpartum adolescents desiring LARC, Tocce et al. found that even in a teen-focused clinic emphasizing contraceptive care, only a fraction of the patients received their implants within 2 weeks or IUDs within 8 weeks and over half of IUD recipients had resumed sexual intercourse prior to IUD placement [10]. Immediate postplacental IUD placement has been shown to result in high contraceptive use rates at 6 and 12 months postpartum [11,12], and subdermal implants prior to hospital discharge have been shown to reduce rapid repeat pregnancy (birth interval of less than 24 months) [13]. The main technical issue with postplacental IUD placement appears to be a higher risk of expulsion. Jatlaoui et al. report an expulsion rate of 20%, similar to others [11,14,15], when IUDs were placed by residents, but did not find a relationship with year of training. In this study, the majority of IUDs placed were the levonorgestrel intrauterine system (LNG-IUS) and the technique included use of the inserter and abdominal ultrasound guidance. Most studies on postplacental IUDs in the literature have used copperbearing devices. Whitaker et al. examined placement of the LNG-IUS at the time of cesarean delivery versus placement at 6 weeks postpartum [5]. They found evidence of increased expulsion and an association between expulsion and provider experience, but the study did not have enough power to achieve statistical significance. Further work on best placement techniques is clearly needed. The greatest barrier to hospital-based postpartum contraceptive initiation is reimbursement. Typically, reimbursement for prenatal, delivery and postpartum care is bundled into a global fee to the facility and to the obstetrical provider, and all costs are deducted from this amount. Since hospitals are not separately reimbursed for providing LARC or for the cost of the devices, there is a strong disincentive to providing
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Editorial / Contraception 89 (2014) 487–488
the services in the inpatient setting. Two studies have evaluated the cost-effectiveness of immediate postpartum LARC. Rodriguez et al. modeled a program offering postpartum IUDs to recent immigrants covered by Emergency Medicaid in Oregon and found that such a program would save US$3 for every dollar spent [16]. Likewise, Han et al. evaluated a cohort of adolescent mothers in Colorado who were offered immediate postpartum implant insertion and found cost–savings of US$0.78, US$3.54 and US$6.50 per dollar spent at 12, 24 and 36 months postpartum [17]. In March 2012, the South Carolina Medicaid program became the first to reimburse for inpatient postpartum IUD and implant placement. New Mexico and Colorado followed suit in the fall of 2013. At this writing, both California and New York are poised to implement similar programs. The success of immediate postpartum LARC programs will depend on effective contraceptive counseling during prenatal care visits. The third trimester, with its frequent visits over an 8-week period, provides ample opportunity for contraceptive information and counseling, especially regarding desired timing of next pregnancy, introduction to some of the most effective methods and clarification of any misconceptions. The rates of contraceptive initiation prior to resumption of intercourse indicate room for quality improvement by providers during all phases of the pregnancy. This includes helping the patient commit to a contraceptive plan antenatally, providing immediate postpartum contraceptives in-hospital if this is an option and making contraceptive initiation a higher priority at the first postpartum visit. Finally, not all patients desire LARC, and even if many more states initiate reimbursement for inpatient LARC placement, implementation strategies may be challenging outside of teaching hospitals. Improvement of outpatient postpartum services should not be neglected. Huang et al. discuss a novel program in Shanghai which overcame administrative, cost and access issues to achieve a dramatic reduction in rapid repeat pregnancy among migrant women. Mody et al. evaluated using infant immunization visits to identify women who had not yet reinitiated contraception. The articles in this issue will help providers understand factors related to contraceptive choices and alternative arenas for delivery of postpartum contraceptive care, ultimately allowing more women to realize the best number and spacing of children for their own families. Stephanie B. Teal University of Colorado, School of Medicine Dept. of Obstetrics and Gynecology 12631 E. 17th Ave Box B-198-2 Aurora, CO 80045, United States E-mail address: [email protected]
References [1] Mody SK, Nair S, Dasgupta A, Raj A, Donta B, Saggurti N, et al. Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India. Contraception 2014 (in this issue). [2] Singh RH, Rogers RG, Leeman L, Borders N, Highfill J, Espey E. Postpartum contraceptive choices among ethnically diverse women in New Mexico. Contraception 2014 (in this issue). [3] Huang Y, Merkatz R, Zhu H, Roberts K, Sitruk-Ware R, Cheng L, et al. Contraception 2014 (in this issue). [4] Jatlaoui TC, Marcus M, Jamieson DJ, Goedken P, Cwiak C. Postplacental intrauterine device insertion at a teaching hospital. Contraception 2013 (in this issue). [5] Whitaker AK, Endres LK, Mistretta SQ, Gilliam ML. Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial. Contraception 2013 (in this issue). [6] Speroff L, Mishell Jr DR. The postpartum visit: it's time for a change in order to optimally initiate contraception. Contraception 2008;78(2):90-8. [7] U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople.gov/ 2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 [Accessed 4/24/2014]. [8] Thiel de Bocanegra H, Chang R, Menz M, Howell M, Darney P. Postpartum contraception in publicly-funded programs and interpregnancy intervals. Obstet Gynecol 2013;122(2 Pt 1):296-303. [9] Thiel de Bocanegra H, Chang R, Howell M, Darney P. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2014;210(4):311.e1-8. [10] Tocce K, Sheeder J, Python J, Teal SB. Long acting reversible contraception in postpartum adolescents: early initiation of etonogestrel implant is superior to IUDs in the outpatient setting. J Pediatr Adolesc Gynecol 2012;25(1):59-63. [11] 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(5):1079-87. [12] Celen S, Moroy P, Sucak A, Aktulay A, Danisman N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception 2004;69(4):279-82. [13] Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012;206(6):481.e1-7. [14] Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010(5):CD003036. [15] Eroglu K, Akkuzu G, Vural G, Dilbaz B, Akin A, Taskin L, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. Contraception 2006;74(5):376-81. [16] Rodriguez MI, Caughey AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception 2010;81(4):304-8. [17] Han L, Teal SB, Sheeder J, Tocce K. Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective? Am J Obstet Gynecol 2014 (in press).
Editorial
Postpartum contraception: optimizing interpregnancy intervals In this issue of Contraception, several research groups present new information on factors influencing the delivery and uptake of postpartum contraception. Singh et al. report on patient-level factors in postpartum contraceptive choices in New Mexico, and Mody et al. examine the utilization of postpartum contraception by women in Mumbai [1,2]. Huang et al. describe an intervention to increase postpartum contraceptive use among rural-to-urban migrants in Shanghai and discuss patient characteristics associated with method choice [3]. Jatlaoui et al. report on postplacental intrauterine device (IUD) insertion by residents after vaginal delivery, and Whitaker presents a randomized controlled trial of postplacental IUD insertion after cesarean delivery [4,5]. Why this focus on contraception for women who recently delivered? The postpartum period is one of intense emotional, physical and social change for a woman and her family. Women often experience postpartum changes in physiology, body image, fertility risk, sexual and relationship behavior, desire for future fertility and tolerance for an unintended pregnancy. All of these factors may change the appropriateness of a patient's prior contraceptive. Because the postpartum period can be so chaotic for women and their partners, delay in initiating effective contraception is common. In studies across multiple societies, approximately half of postpartum women resumed sexual intercourse within 6 weeks of delivery, regardless of mode of delivery or lactation. Nonbreastfeeding women begin to ovulate around 4 weeks postpartum, and most ovulate before the first menses occur [6]. This frequent lag between resumption of intercourse and initiation of contraception often leads to pregnancy and a shorter-than-recommended interpregnancy interval (IPI), which is strongly associated with negative maternal, child and social health outcomes. Because of the risk of these bad outcomes, an interval of 18 months between a delivery and subsequent conception is recommended; however, 33.1% of US pregnancies are conceived less than 18 months after a prior birth [7]. Thiel de Bocanegra et al. recently examined records of 117,644 Medicaid recipients in California and found that only 41% had a contraceptive claim within 90 days of giving birth [8]. Just 13% of women received contraception at the first postpartum visit, and these women were significantly more likely to have an adequate IPI. Even among women who were seen more than once in the 90 days postpartum, 33% had no http://dx.doi.org/10.1016/j.contraception.2014.04.013 0010-7824/© 2014 Elsevier Inc. All rights reserved.
contraceptive claims. In a separate report, the authors noted that 55% of these postpartum women adopted Tier 2, userdependent methods, such as oral contraceptive pills, patch or vaginal ring and had a mean contraceptive coverage of only 6 months. Women who started long-acting Tier 1 methods such as IUDs or implants represented 7% of the cohort and had a higher mean coverage of almost 11 months [9]. Improved birth spacing can be a key benefit use of longacting reversible contraception (LARC), but delay to initiation can still be problematic. In a study of postpartum adolescents desiring LARC, Tocce et al. found that even in a teen-focused clinic emphasizing contraceptive care, only a fraction of the patients received their implants within 2 weeks or IUDs within 8 weeks and over half of IUD recipients had resumed sexual intercourse prior to IUD placement [10]. Immediate postplacental IUD placement has been shown to result in high contraceptive use rates at 6 and 12 months postpartum [11,12], and subdermal implants prior to hospital discharge have been shown to reduce rapid repeat pregnancy (birth interval of less than 24 months) [13]. The main technical issue with postplacental IUD placement appears to be a higher risk of expulsion. Jatlaoui et al. report an expulsion rate of 20%, similar to others [11,14,15], when IUDs were placed by residents, but did not find a relationship with year of training. In this study, the majority of IUDs placed were the levonorgestrel intrauterine system (LNG-IUS) and the technique included use of the inserter and abdominal ultrasound guidance. Most studies on postplacental IUDs in the literature have used copperbearing devices. Whitaker et al. examined placement of the LNG-IUS at the time of cesarean delivery versus placement at 6 weeks postpartum [5]. They found evidence of increased expulsion and an association between expulsion and provider experience, but the study did not have enough power to achieve statistical significance. Further work on best placement techniques is clearly needed. The greatest barrier to hospital-based postpartum contraceptive initiation is reimbursement. Typically, reimbursement for prenatal, delivery and postpartum care is bundled into a global fee to the facility and to the obstetrical provider, and all costs are deducted from this amount. Since hospitals are not separately reimbursed for providing LARC or for the cost of the devices, there is a strong disincentive to providing
488
Editorial / Contraception 89 (2014) 487–488
the services in the inpatient setting. Two studies have evaluated the cost-effectiveness of immediate postpartum LARC. Rodriguez et al. modeled a program offering postpartum IUDs to recent immigrants covered by Emergency Medicaid in Oregon and found that such a program would save US$3 for every dollar spent [16]. Likewise, Han et al. evaluated a cohort of adolescent mothers in Colorado who were offered immediate postpartum implant insertion and found cost–savings of US$0.78, US$3.54 and US$6.50 per dollar spent at 12, 24 and 36 months postpartum [17]. In March 2012, the South Carolina Medicaid program became the first to reimburse for inpatient postpartum IUD and implant placement. New Mexico and Colorado followed suit in the fall of 2013. At this writing, both California and New York are poised to implement similar programs. The success of immediate postpartum LARC programs will depend on effective contraceptive counseling during prenatal care visits. The third trimester, with its frequent visits over an 8-week period, provides ample opportunity for contraceptive information and counseling, especially regarding desired timing of next pregnancy, introduction to some of the most effective methods and clarification of any misconceptions. The rates of contraceptive initiation prior to resumption of intercourse indicate room for quality improvement by providers during all phases of the pregnancy. This includes helping the patient commit to a contraceptive plan antenatally, providing immediate postpartum contraceptives in-hospital if this is an option and making contraceptive initiation a higher priority at the first postpartum visit. Finally, not all patients desire LARC, and even if many more states initiate reimbursement for inpatient LARC placement, implementation strategies may be challenging outside of teaching hospitals. Improvement of outpatient postpartum services should not be neglected. Huang et al. discuss a novel program in Shanghai which overcame administrative, cost and access issues to achieve a dramatic reduction in rapid repeat pregnancy among migrant women. Mody et al. evaluated using infant immunization visits to identify women who had not yet reinitiated contraception. The articles in this issue will help providers understand factors related to contraceptive choices and alternative arenas for delivery of postpartum contraceptive care, ultimately allowing more women to realize the best number and spacing of children for their own families. Stephanie B. Teal University of Colorado, School of Medicine Dept. of Obstetrics and Gynecology 12631 E. 17th Ave Box B-198-2 Aurora, CO 80045, United States E-mail address: [email protected]
References [1] Mody SK, Nair S, Dasgupta A, Raj A, Donta B, Saggurti N, et al. Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India. Contraception 2014 (in this issue). [2] Singh RH, Rogers RG, Leeman L, Borders N, Highfill J, Espey E. Postpartum contraceptive choices among ethnically diverse women in New Mexico. Contraception 2014 (in this issue). [3] Huang Y, Merkatz R, Zhu H, Roberts K, Sitruk-Ware R, Cheng L, et al. Contraception 2014 (in this issue). [4] Jatlaoui TC, Marcus M, Jamieson DJ, Goedken P, Cwiak C. Postplacental intrauterine device insertion at a teaching hospital. Contraception 2013 (in this issue). [5] Whitaker AK, Endres LK, Mistretta SQ, Gilliam ML. Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial. Contraception 2013 (in this issue). [6] Speroff L, Mishell Jr DR. The postpartum visit: it's time for a change in order to optimally initiate contraception. Contraception 2008;78(2):90-8. [7] U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at http://www.healthypeople.gov/ 2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 [Accessed 4/24/2014]. [8] Thiel de Bocanegra H, Chang R, Menz M, Howell M, Darney P. Postpartum contraception in publicly-funded programs and interpregnancy intervals. Obstet Gynecol 2013;122(2 Pt 1):296-303. [9] Thiel de Bocanegra H, Chang R, Howell M, Darney P. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2014;210(4):311.e1-8. [10] Tocce K, Sheeder J, Python J, Teal SB. Long acting reversible contraception in postpartum adolescents: early initiation of etonogestrel implant is superior to IUDs in the outpatient setting. J Pediatr Adolesc Gynecol 2012;25(1):59-63. [11] 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(5):1079-87. [12] Celen S, Moroy P, Sucak A, Aktulay A, Danisman N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception 2004;69(4):279-82. [13] Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012;206(6):481.e1-7. [14] Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010(5):CD003036. [15] Eroglu K, Akkuzu G, Vural G, Dilbaz B, Akin A, Taskin L, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. Contraception 2006;74(5):376-81. [16] Rodriguez MI, Caughey AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception 2010;81(4):304-8. [17] Han L, Teal SB, Sheeder J, Tocce K. Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective? Am J Obstet Gynecol 2014 (in press).