Patients' Experiences with an Immediate Postpartum Long-Acting Reversible Contraception Program

Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review

BACKGROUND

Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden.

METHODS

This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included.

RESULTS

133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare.

CONCLUSIONS

PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.

Changes in postpartum contraception utilization rates during the early stage of the COVID-19 pandemic

BACKGROUND

The first wave of the COVID-19 pandemic was associated with restricted access to reproductive care including delayed abortion and female sterilization procedures, in addition to altered maternity care experiences. Given high rates of unintended and short-interval pregnancies in the United States in general and negative obstetric outcomes specifically associated with COVID-19, access to all effective pregnancy prevention methods during the pandemic was crucial.

OBJECTIVES

To investigate changes in contraception utilization rates prior to delivery discharge, at outpatient postpartum visits, and at 10 weeks' postpartum, at the largest healthcare system in Central Massachusetts, during the first wave of the COVID-19 pandemic (15 March to 15 May 2020), compared to the same period in 2019.

DESIGN

Retrospective cohort review.

METHODS

Compared perinatal individuals (n = 495) who received prenatal care and delivered at UMass Memorial Medical Center from mid-March to mid-May in both 2019 (non-pandemic) and 2020 (COVID-19 pandemic). Receipt of contraception prior to delivery discharge and at outpatient postpartum visit was estimated and compared between the two time periods using the Chi-square test for categorical variables (or Fisher's exact test when cell counts were < 5) and Student's t-test for continuous variables. Multivariable logistic regression was performed to adjust for confounders.

RESULTS

The proportion of individuals who used long-acting reversible contraception before delivery discharge was 4% in 2019 and 13% in 2020 (p = 0.01). Modes of outpatient postpartum visit contraception did not vary from 2019 to 2020, (p = 0.06). Overall, there were no differences in contraception utilization rates at 10 weeks' postpartum from 2019 to 2020, (p = 0.50).

CONCLUSION

Compared to a year prior, immediate postpartum long-acting reversible contraception use increased during the first wave of the COVID-19 pandemic, while overall contraception use at 10 weeks' postpartum remained unchanged. The evaluation of contraceptive use during the most restrictive time of COVID-19 pandemic can help identify opportunities to increase access to effective contraception, such as the immediate postpartum period prior to hospital discharge.

Patient characteristics of contraception and sterilization selection at vaginal delivery

Objective

To examine patient characteristics among those who selected the long-acting reversible contraception (LARC) and surgical sterilization methods at vaginal delivery.

Design

Retrospective cohort study.

Setting

The National Inpatient Sample.

Patients

A total of 8,013,785 vaginal deliveries from October 2016 to December 2019.

Interventions

Exposure assignment per LARC (subdermal contraceptive implant [implants] or intrauterine device [IUD]) or surgical sterilization (bilateral salpingectomy [BS] or bilateral tubal ligation [BTL]) type.

Main Outcome Measures

Utilization trends of LARC or surgical sterilization, assessed with linear segmented regression with log-transformation, and differences in patient characteristics per the exposure strata (implants vs. IUD in the LARC group and BS or BTL in the surgical sterilization group), assessed using the multivariate binary logistic regression model.

Results

In a comparison between LARC and surgical sterilization, surgical sterilization use decreased from 1.90% to 1.55% (18.4% relative decrease), whereas LARC use increased from 0.35% to 1.02% (191% relative increase). In the LARC group, implant use (from 0.12% to 0.50%) increased more compared with IUD use (from 0.22% to 0.52%): relative increase, 317% vs. 136%. In the surgical sterilization group, BTL use decreased from 0.66% to 0.18% (72.7% relative decrease), whereas BS use was statistically unchanged (from 1.24% to 1.37%). In a multivariate analysis, recent year remained an independent characteristic for implant use in the LARC group and BS use in the surgical sterilization group. Moreover, in both LARC and surgical sterilization strata, procedure choices significantly differed on the basis of patient, pregnancy, hospital, and delivery factors.

Conclusions

Immediate postpartum contraception choice has evolved in recent years in the United States with an increasing demand for the LARC methods with implants at the time of vaginal delivery.

Satisfaction, Resignation, and Dissatisfaction with Long-Acting Reversible Contraception among Low-Income Postpartum Texans

INTRODUCTION

Prior longitudinal studies of long-acting reversible contraception (LARC) satisfaction and continuation guaranteed their participants access to LARC removal. Under real-world conditions, LARC users who wish to discontinue may experience barriers to LARC removal.

METHODS

A prospective cohort study recruited 1,700 postpartum Texans without private insurance from 8 hospitals in 6 cities. Our analysis included the 418 respondents who initiated LARC in the 24 months after childbirth. A content analysis of open-ended survey responses identified three categories of LARC users: satisfied, resigned, and dissatisfied. Satisfied LARC users were using their method of choice. Resigned users were using LARC as an alternative method when their preferred method was inaccessible. Dissatisfied users were unhappy with LARC. Multinomial logistic regression models identified risk factors for resignation and dissatisfaction. Cox proportional hazards models assessed differences in LARC discontinuation by satisfaction and sociodemographic characteristics.

RESULTS

Participants completed 1,505 surveys while using LARC. LARC users were satisfied in 83.46% of survey responses, resigned in 5.25%, and dissatisfied in 11.30%. Resignation was more likely if respondents were uninsured or wanted sterilization at the time of childbirth. The risk of dissatisfaction increased with time using LARC and was higher among uninsured respondents. U.S.-born Hispanic LARC users were more likely than foreign-born Hispanic LARC users to be dissatisfied and less likely to discontinue when dissatisfied. Dissatisfaction-but not resignation-predicted discontinuation. Cost, lack of insurance, and difficulty obtaining an appointment were frequent barriers to LARC removal.

CONCLUSIONS

Most postpartum LARC users were satisfied, but users who wished to discontinue frequently encountered barriers.

Obtaining buy-in for immediate postpartum long-acting reversible contraception programs in Texas hospitals: A qualitative study

OBJECTIVE

To understand the specific ways in which champions lead efforts to obtain and sustain buy-in for immediate postpartum long-acting reversible contraception (LARC) programs.

METHODS

We conducted a qualitative study with 60 semistructured interviews at 3 teaching hospitals in Texas with physicians, nurses, administrators and other staff who participated in the implementation of immediate postpartum LARC. Physicians self-identified as champions and identified other champion physicians and administrators. Two researchers analyzed and coded interview transcripts for content and themes.

RESULTS

We found that champions draw on institutional knowledge and relationships to build awareness and support for immediate postpartum LARC implementation. To obtain buy-in, champions needed to demonstrate financial sustainability, engage key stakeholders from multiple departments, and obtain nurse buy-in. Champions also created buy-in by communicating goals for the service that focused on expanding reproductive autonomy, improving maternal health, and improving access to postpartum contraception. Some staff, especially nurses, identified reasons for the program that run counter to reproductive justice principles: reducing birth rates, poverty, and/or unplanned pregnancy among young women and high-parity women. Respondents at 2 hospitals noted that not all women had equitable access to immediate postpartum LARC.

CONCLUSION

Physician and non-physician champions must secure long-term support across multiple hospital departments to successfully implement an immediate postpartum LARC program. For programs to equitably serve all women in need of postpartum contraceptive care, champions and other program leaders need to implement strategies to address access issues. They should also explicitly focus on reproductive justice principles during program introduction and training.

IMPLICATIONS

Successfully implementing immediate postpartum long-acting reversible contraception programs requires champions with institutional networking connections, administrative and nursing support, and clearly communicated goals. Champions need to address access issues and focus on reproductive justice principles during program introduction and training to equitably serve all women in need of postpartum contraceptive care.

Using the Social-Ecological Model to Understand the Current Perspective of Contraceptive Use in the United States: A Narrative Literature Review

Contraceptive use is deemed one of the 10 greatest public health achievements of the 20th century because its benefits are universally acknowledged as a cornerstone for reducing global maternal morbidity and mortality. However, although the adoption of the Affordable Care Act in the United States (US) enhanced access to preventive health services, as well as increased contraceptive use, a considerable proportion of reproductive-aged women still have unmet reproductive health needs. Current data indicates gaps in contraceptive use patterns in the US, particularly among low-income women and those from racial/ethnic and gender minority subgroups, necessitating further investigation using an ecological approach. This narrative literature review aims to investigate the current perspective of contraceptive use in the US using the social-ecological model (SEM). Based on SEM levels, barriers to contraceptive use entail the following levels: individual (e.g., misbelief about the side effects of contraceptives), interpersonal (e.g., influence of family and friends), institutional (e.g., lack of training on how to use different types of contraceptives), community (e.g., societal stigma and shame), and policy (e.g., restrictive federal and states policies). Access to contraceptives for women is a system-level issue that necessitates consideration for multilevel strategies by key stakeholders to improve contraceptive uptake among vulnerable populations.

Use of postpartum contraception during coronavirus disease 2019 (COVID-19): A retrospective cohort study

OBJECTIVE

To assess how use of postpartum contraception (PPC) changed during the COVID-19 public health emergency.

METHODS

Billing and coding data from a single urban institution (n = 1797) were used to compare use of PPC in patients who delivered from March to June 2020 (COVID Cohort, n = 927) and from March to June 2019 (Comparison Cohort, n = 895). χ2 and multivariable logistic regression models assessed relationships between cohorts, use of contraception, and interactions with postpartum visits and race/ethnicity.

RESULTS

In the COVID Cohort, 585 women (64%) attended postpartum visits (n = 488, 83.4%, via telemedicine) compared to 660 (74.7%, in-person) in the Comparison Cohort (P < 0.01). Total use of PPC remained similar: 30.4% (n = 261) in the COVID Cohort and 29.6% (n = 278) in the Comparison Cohort (P = 0.69). Compared to in-person visits in the Comparison Cohort, telemedicine visits in the COVID Cohort had similar odds of insertion of long-acting reversible contraception (LARC) (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.78-1.6), but higher odds of inpatient insertion (aOR 6.4, 95% CI 1.7-24.9). Black patients compared to white patients were more likely to initiate inpatient LARC (aOR 7.29, 95% CI 1.81-29.4) compared to the Comparison Cohort (aOR 3.63, 95% CI 0.29-46.19).

CONCLUSION

Use of PPC remained similar during COVID-19 with a decrease of in-person postpartum visits, new adoption of postpartum telemedicine visits, and an increase in inpatient insertion of LARC with higher odds of inpatient placement among black patients.