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PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm

Ambivalence

Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

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The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

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Update on Emergency Contraception

Contraceptivetechnology.com New and Improved

Postpartum Contraception: Now, Not Later
September 2015

 

A revolution. That is what we may be seeing in postpartum services, and in particular postpartum contraceptive services. Why are we even worried about contraception during hospitalization? Don’t women qualify for IUDs and implants as outpatients when they return for postpartum care? Don’t the product labels for all the IUDs and the implants specifically say that method initiation should be delayed? Won’t the progestogens in most of the methods reduce milk letdown and interfere with breastfeeding success?

The call for expanded use of implants and intrauterine devices has been heard from all fronts, from ACOG[1] to the AAP.[2] Experience from the CHOICE study has provided clear evidence that implants and IUD are significantly superior to the more traditional modern methods (pills, patches, rings, injections) by showing that the traditional methods have 20 times higher failure rates.[3]  The currently available IUDs have demonstrated high efficacy, low expulsion rates and high continuation rates for both nulliparous and parous women.[4],[5],[6]

In the background, a second, quieter call has been taking place—designed to replace older ideas about when postpartum care should take place and what services should be provided at that visit.[7] This call is a revolution, one in which it has been increasingly recognized that initiation of birth control during hospitalization for delivery is safe,[8] effective, cost effective[9] and important to reducing unintended pregnancy and rapid repeat pregnancy rates.6,[10],[11],[12],[13]  Continuation rates at 6 and 12 months for implants placed postpartum are high, 96.9% and 86.3%; those for IUDs are 86.3-87.6% and 76.3%.[14] Over the last few years, at least 15 Medicaid programs have made regulatory changes that enable reimbursement for both the device (IUD or implant) and its placement procedure as part of the delivery hospitalization charges without diminishing the amount of reimbursement awarded for obstetrical services. Historically, it has been the lack of a reimbursement source for early placement that deterred the practice.[15]

What is the rush; why not wait until first postpartum visit the way we have always done for IUDs and implants?

Because it does not seem to be working for many women. First, women are at risk for pregnancy long before 6 weeks postpartum. Traditionally, it has been assumed that women would not resume sexual activity until their doctors gave them the okay at their 6-week postpartum visit. In the real world, this fails on many levels. Ovulation is known to resume within 25 days postpartum for nonbreastfeeding women.[16],[17]  Many couples are not abstinent for the requested 6 weeks.[18] Interestingly, in a recent analysis of data collected from women with unintended pregnancies who admitted not using contraception at the time of conception, the most common reason given for nonuse of contraception was the belief that the woman could not get pregnant; being postpartum was identified as a significant risk factor for the woman to believe she could not get pregnant at that time.[19]

Second, many women do not get their methods as planned in the postpartum timeframe.  Up to 35% of postpartum women do not return at all for any postpartum care.[20],[21]  And even if they do return, their contraceptive needs may not be addressed. In a large Medicaid database study, only 41% of women had evidence of a claim for any contraception made within 90 days of delivery.[22]  Only a fraction of the women who desire to use implants or IUDs receive them at that 6 week postpartum visit, often due to logistic challenges.20,[23]  In fact, a Texas study showed that less than half of the women desiring implants or IUDs were able to initiate their desired method within 6 months (let alone 6 weeks!) of delivery.23

Why is early initiation of IUDs and implants off-label?

Product labeling must reflect the practices that were followed during clinical trials. Without a complete new FDA review of new evidence, the only labeling changes that are permitted are those that add more restrictions. Typically, Phase III clinical trials are conducted in family planning clinics, where patients usually first present for care 4-6 weeks after delivery. Therefore, immediate postpartum initiation must be off-label. Other authoritative sources must be consulted to validate the practice. In this case, the authoritative sources are impressive. The US MEC endorses immediate postplacental placement of IUDs and implant placement during delivery hospitalization. Concerns about specific risks associated with early placement have been studied extensively.[24]  Special techniques that are needed for IUD placement immediately postpartum require additional trainings, but those skills are easily mastered.[25] Expulsion rates of IUDs are not significantly elevated when IUDs are placed transabdominally at the time of elective C/section.[26],[27],[28],[29],[30],[31]  However, expulsion rates are elevated (20-25%) when IUDs are placed within 10 minutes of delivery of the placenta.21,[32],[33],[34],[35],[36],[37]  The increased risk of expulsion must be balanced against the benefits of increased access.

Postpartum placement of contraceptive implants is much less complicated or controversial and is associated with high continuation rates.[38],[39] Informed consent does not have to be obtained before hospitalization; there is ample time after delivery for the new mother to consider her options and have her questions answered. The technique for placement is as easy in the hospital as it is in the office; no special techniques or instruments are needed. No special preparations are needed during labor. Placement complication rates remain low. In contrast to IUDs, the expulsion risk with implants placed postpartum are the same as those placed the 6-week postpartum visit. Labeling mentions concerns about the possibility of increased risk of venous thromboembolism with contraceptive hormones. However, even though the immediate postpartum period is a time of highest risk for VTE,[40] it is estrogen, not progestin, that is responsible for thrombotic changes induced by hormonal contraceptives.[41]

Won’t hormonal methods adversely affect breastfeeding success?

Since it is the rapid drop in circulating levels of progesterone which follows delivery of the placenta that enables breastmilk production, concerns are often raised that progesterone-containing contraceptives would diminish milk production, and lead increased risks for failure to breastfeed or premature cessation of breastfeeding.

Studies of DMPA injections have in general provided reassuring data.[42],[43]  A systemic review of all studies of progestin-only methods found no adverse effects on multiple measures of breastfeeding performance up to 12 months.[44] Studies of ENG implants placed early have demonstrated no adverse impacts on breastfeeding or infant growth.[45],[46]

The levonorgestrel IUDs placed immediately following placental delivery do not adversely affect successful breastfeeding.[47]

Now What?

This is a time of significant opportunity. The medical facts are well documented. Initiation of implants and IUDs during delivery hospitalization can reduce unintended pregnancy and is safe and cost-effective. Implementation is the next challenge. States that have not updated their Medicaid reimbursement policies need to be urged to do so promptly. Private insurance companies need to expand their benefits package to insure that all women have timely access to the most effective methods. Clinicians need to re-consider how counselling about contraceptive can be integrated into routine prenatal care. Labor and delivery staff need new policies and training. Most important, women need to be made aware of this new opportunity for them to get streamlined access to the most effective methods of birth control.

 Anita L. Nelson, MD, Professor of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center

—Crystal M. Goldsmith, MD, MSc, Physician, Kaiser Permanente

References

 

[1].  American College of Obstetricians and Gynecologists Committee on Gynecologic Practice; Long-Acting Reversible Contraception Working Group. ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2009;114(6):1434-8.

[2].  Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-56.

[3].  Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120(6):1291-7.

[4].  Nelson AL. Postpartum contraception: a new frontier (again). J Womens Health (Larchmt). 2014;23(3):193-4.

[5].  Eisenberg DL, Schreiber CA, Turok DK, Teal SB, Westhoff CL, Creinin MD; ACCESS IUS Investigators. Three-year efficacy and safety of a new 52-mg levonorgestrel-releasing intrauterine system. Contraception. 2015;92(1):10-6.

[6].  Teal SB. Postpartum contraception: optimizing interpregnancy intervals. Contraception. 2014;89(6):487-8.

[7].  Speroff L, Mishell DR Jr. The postpartum visit: it’s time for a change in order to optimally initiate contraception. Contraception. 2008;78(2):90-8.

[8].  Mwalwanda CS, Black KI. Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use. Aust N Z J Obstet Gynaecol. 2013;53(4):331-7.

[9].  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;211(1):24.e1-7.

[10].  Committee on Health Care for Underserved Women. Committee opinion no. 530: access to postpartum sterilization. Obstet Gynecol. 2012;120(1):212-5.

[11].  Washington CI, Jamshidi R, Thung SF, Nayeri UA, Caughey AB, Werner EF. Timing of postpartum intrauterine device placement: a cost-effectiveness analysis. Fertil Steril. 2015;103(1):131-7.

[12].  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;211(1):24.e1-7.

[13].  Trussell J, et al. Contraceptive Technololgy, 20th edition. New York, NY. Arden Media. 2011:45-75.

[14].  Aiken AR, Aiken CE, Trussell J, Guthrie KA. Immediate postpartum provision of highly effective reversible contraception. BJOG. 2015;122(8):1050-1.

[15].  Aiken AR, Creinin MD, Kaunitz AM, Nelson AL, Trussell J. Global fee prohibits postpartum provision of the most effective reversible contraceptives. Contraception. 2014;90(5):466-7.

[16].   Gray RH, Campbell OM, Apelo R, Eslami SS, Zacur H, Ramos RM, Gehret JC, Labbok MH. Risk of ovulation during lactation. Lancet. 1990;335(8680):25-9.

[17].  Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657-62.

[18].  Kelly LS, Sheeder J, Stevens-Simon C. Why lightning strikes twice: postpartum resumption of sexual activity during adolescence. J Pediatr Adolesc Gynecol. 2005;18(5):327-35.

[19].  Mosher W, Jones J, Abma J. Nonuse of contraception among women at risk of unintended pregnancy in the United States. Contraception. 2015;92(2):170-6.

[20].  Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception. 2005;72(6):426-9.

[21].  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.

[22].  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.

[23].  Potter JE, Hopkins K, Aiken AR, Hubert C, Stevenson AJ, White K, Grossman D. Unmet demand for highly effective postpartum contraception in Texas. Contraception. 2014;90(5):488-95.

[24].  Centers for Disease Control and Prevention (CDC). U.S. Selected Practice recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep. 2013;62(RR-05):1-60. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm

[25].  Jatlaoui TC, Marcus M, Jamieson DJ, Goedken P, Cwiak C. Postplacental intrauterine device insertion at a teaching hospital. Contraception. 2014;89(6):528-33.

[26].  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. 2014;89(6):534-9.

[27].  Chi IC, Zhou SW, Balogh S, NG K. Post-cesarean section insertion of intrauterine devices. Am J Public Health. 1984;74(11):1281-2.

[28].  Nelson AL, Chen S, Eden R. Intraoperative placement of the Copper T-380 intrauterine devices in women undergoing elective cesarean delivery: a pilot study. Contraception. 2009;80(1):81-3.

[29].  Lester F, Kakaire O, Byamugisha J, Averbach S, Fortin J, Maurer R, Goldberg A. Intracesarean insertion of the Copper T380A versus 6 weeks postcesarean: a randomized clinical trial. Contraception. 2015;91(3):198-203.

[30].  Levi E, Cantillo E, Ades V, Banks E, Murthy A. Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study. Contraception. 2012;86(2):102-5.

[31].  Lester F, Kakaire O, Byamugisha J, Averbach S, Fortin J, Maurer R, Goldberg A. Intracesarean insertion of the Copper T380A versus 6 weeks postcesarean: a randomized clinical trial. Contraception. 2015;91(3):198-203.

[32].  Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009;80(4):327-36.

[33].  Ero?lu K, Akkuzu G, Vural G, Dilbaz B, Akin A, Ta?kin L, Haberal A. 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.

[34].  Thiery M, Van Kets H, Van der Pas H. Immediate post-placental IUD insertion: the expulsion problem. Contraception. 1985;31(4):331-49.

[35].  Xu JX, Connell C, Chi IC. Immediate postpartum intrauterine device insertion–a report on the Chinese experience. Adv Contracept. 1992;8(4):281-90.

[36].  Celen S, Möröy P, Sucak A, Aktulay A, Dani?man N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception. 2004;69(4):279-82.

[37].  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. doi: 10.1002/14651858.CD003036.pub2.

[38].  Wilson S, Tennant C, Sammel MD, Schreiber C. Immediate postpartum etonogestrel implant: a contraception option with long-term continuation. Contraception. 2014;90(3):259-64.

[39].  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.

[40].  Reid R; Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guideline. No. 252, December 2010. Oral contraceptives and the risk of venous thromboembolism: an update. J Obstet Gynaecol Can. 2010;32(12):1192-204.

[41].  Jackson E, Curtis KM, Gaffield ME. Risk of venous thromboembolism during the postpartum period: a systematic review. Obstet Gynecol. 2011;117(3):691-703.

[42].  Halderman LD, Nelson AL. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am J Obstet Gynecol. 2002;186(6):1250-6.

[43].  Hannon PR, Duggan AK, Serwint JR, Vogelhut JW, Witter F, DeAngelis C. The influence of medroxyprogesterone on the duration of breast-feeding in mothers in an urban community. Arch Pediatr Adolesc Med. 1997;151(5):490-6.

[44].  Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception. 2010;82(1):17-37.

[45].  Guiloff E, Ibarra-Polo A, Zañartu J, Toscanini C, Mischler TW, Gómez-Rogers C. Effect of contraception on lactation. Am J Obstet Gynecol. 1974;118(1):42-5.

[46].  Brito MB, Ferriani RA, Quintana SM, Yazlle ME, Silva de Sá MF, Vieira CS. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80(6):519-26.

[47].  Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration. Contraception. 2011;84(5):499-504.