Patterns of postpartum depot medroxyprogesterone administration among low-income mothers

Breastfeeding Perceptions and Behavior Among Postpartum Women Initiating Different Hormonally Systemic Contraceptive Methods

BACKGROUND

There continues to be controversy regarding the simultaneous encouragement of both breastfeeding and immediate postpartum contraception.

RESEARCH AIM

To explore postpartum women's perspectives about breastfeeding and their breastfeeding behaviors, while using one of three different hormonally systemic contraceptive methods immediately postpartum over a 6 month period of time.

METHODS

This was a retrospective, longitudinal, three group comparative, secondary analysis of a prospective cohort study (N = 471) of immediate postpartum contraception. Breastfeeding, for this study, was defined as providing any human milk to the infant. Participants who chose one of three different hormonally systemic forms of contraception immediately postpartum (a long-acting hormonal reversible contraceptive (n = 200), depot medroxyprogesterone acetate 150 mg (n = 98), or a non-hormonal method (n = 173)) were compared at hospital discharge, 6 weeks, 3 months, and 6 months postpartum. The primary outcome was any breastfeeding at 6 months. Secondary outcomes included any and exclusive breastfeeding, concerns about breastfeeding while using contraception, and reasons for breastfeeding discontinuation.

RESULTS

There was no significant difference in the rate of any breastfeeding between the two hormonal and the non-hormonal contraceptive groups at 6 months postpartum (long-acting hormonal 20.1%, non-hormonal 21.7%, depot medroxyprogesterone acetate 13.9%, p = .77, 0.28, respectively). The number of participants who reported stopping breastfeeding due to decreased milk supply was not significantly different between any groups at all time points (total number who discontinued at 6 months postpartum was long-acting hormonal 24.7%, non-hormonal 25.1%, depot medroxyprogesterone acetate 19.3%, p = .30).

CONCLUSIONS

Breastfeeding perspectives and behavioral outcomes over the first 6 months postpartum were not influenced by participants chosen form of immediate postpartum contraception.

Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants

Objective: This study examined the effect of postpartum administration of depo medroxyprogesterone acetate (DMPA) on milk production, time to onset of secretory activation, lactation duration, and infant consumption of mother's own milk (MOM) in mothers of preterm very low-birth-weight (VLBW) infants. Materials and Methods: We conducted a secondary analysis of data from mothers who delivered infants weighing ≤1,500 g and at ≤32 weeks' gestation. The volume of milk produced was measured on days 1-7, 14, and 21 by weighing all expressed milk on an electronic scale. Time to secretory activation was determined through self-report of a feeling of breast fullness. Information on lactation duration and the percent of feeds consisting of MOM consumed by infants was obtained from the medical records. Results: Mothers who received postpartum DMPA were more likely to be African American (72.4% versus 31.4%; p = 0.0006), unemployed (65.5% versus 44.5%; p = 0.027), and Medicaid eligible (89.7% versus 67.2%; p = 0.019). There were no differences in daily milk production between mothers who received DMPA before hospital discharge (n = 29) compared with those who did not (n = 141). When mothers who reached secretory activation before receiving DMPA were removed from analysis, receiving DMPA was associated with a later onset of secretory activation (103.7 versus 88.6 hours; p = 0.028). There were no statistically significant differences between the study groups in lactation duration or infant MOM consumption. Conclusions: DMPA, when administered postpartum to mothers of preterm VLBW infants, delayed secretory activation, but had no detrimental effect on milk production or lactation duration. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01892085.

Is provision of contraception at discharge following delivery associated with postpartum visit attendance?

OBJECTIVES

We examined whether provision of contraception at discharge following delivery was associated with lower rates of postpartum visit (PPV) attendance.

METHODS

We conducted a retrospective cohort study of women who received pregnancy care at a Midwestern medical center in 2013. Attendance at the postpartum visit was compared for women with sterilization, contraception initiated prior to discharge (depot medroxyprogesterone acetate or etonogestrel implant), hormonal contraception prescription, or no contraception provided at postpartum discharge. Poisson regression models with robust standard errors were used to estimate the relative risk of postpartum visit attendance controlling for age, race, and parity, insurance status, and histories of both depression and drug abuse.

RESULTS

Of the 1015 women who met inclusion criteria, 55% had been prescribed contraception, had initiated contraception prior to discharge, or were sterilized at the time of discharge following delivery. After adjustment for confounders, there was no association between receiving contraception and PPV attendance (relative risk for prescribed contraception = 1.09 [95% CI 0.85, 1.39], for contraception initiated prior to discharge = 0.83 [95% CI 0.67, 1.03], for sterilization = 0.86 [95% CI 0.63, 1.17] compared to no contraception).

CONCLUSIONS

We found no evidence that prescribing or administering contraception post-delivery was associated with lower rates of return for postpartum follow up.

IMPLICATIONS

This single site study suggests that providing effective contraception at discharge following delivery does not appear to impact PPV attendance.

Variation in Postpartum Use of Most and Moderately Effective Contraceptive Methods Among Louisiana Women

BACKGROUND

Women experiencing unintended and short-interval pregnancies are at increased risk for adverse outcomes. Nationally, researchers report disparities in women's use of effective contraceptive methods based on demographic, cultural, financial and system-level factors. Despite 58% of Louisiana births being unplanned, researchers have not reported on these relationships in Louisiana.

METHODS

We used Louisiana Pregnancy Risk Assessment Monitoring System data from 2015 to 2018. Among postpartum women who were not abstinent, pregnant, or trying to become pregnant, we estimated use of five categories of effective contraception versus no effective method. We used multivariable multinomial logistic regression to investigate the association between effective contraceptive use and race/ethnicity, postpartum insurance and education.

RESULTS

Among Louisiana postpartum women who were not abstinent, pregnant, or trying to become pregnant, 35.4% were not using effective contraception. Women with public insurance had greater odds of using long-acting reversible contraception than women with private insurance (adjusted odds ratio [AOR] 1.55; 95% confidence interval [CI] 1.11-2.16). Compared to women with a bachelor's or higher, women with less than high school (AOR 2.09; CI 1.22-3.56), high school (AOR 3.11; CI 2.01-4.82) or some college education (AOR 2.48; CI 1.64-3.75) had greater odds of using permanent contraception. Black (AOR 3.83; CI 2.66-5.54) and Hispanic (AOR 3.85; CI 2.09-7.11) women, women with less than high school (AOR 6.79; CI 2.72-16.94), high school (AOR 7.26; CI 3.06-17.21) and some college (AOR 7.22; CI 3.14-16.60), and women with public insurance (AOR 1.91; CI 1.28-2.87) had greater odds of using injectable contraception.

DISCUSSION

Results showed variation in effective contraceptive method use by race/ethnicity, insurance and education. These findings highlight the need for state-level research into the individual, provider, and policy-level factors that influence women's contraceptive choices.

Venous Thromboembolism Among Women Initiating Depot Medroxyprogesterone Acetate Immediately Postpartum

OBJECTIVE

To estimate the absolute and relative risk of venous thromboembolism (VTE) among women who initiate depot medroxyprogesterone acetate (DMPA) immediately postpartum compared with those who do not initiate hormonal contraception.

METHODS

The IBM MarketScan Commercial Claims and Encounters databases were used to identify delivery hospitalizations among women aged 15-44 years during 2005 through 2014. Diagnosis, procedure, and drug codes were used to identify contraception, VTE, and potential confounding chronic or pregnancy-related conditions. Women who initiated DMPA during days 0 through 7 postpartum were compared with women who did not initiate hormonal contraception during days 0 through 7 postpartum. Women were followed from date of delivery through 12 weeks postpartum for the occurrence of VTE, with censoring at hormonal contraception initiation or prescription, hysterectomy, sterilization, or inpatient death. The incidence rate of VTE and 95% CIs were calculated within each group and the incidence rate ratio was calculated comparing the two groups.

RESULTS

The unadjusted VTE incidence rate through 12 weeks postpartum was 0.42/10,000 women-days in the immediate postpartum DMPA group (34 events among 11,159 women contributing 805,999 days of follow-up) and 0.15/10,000 women-days in the control group (3,107 events among 3,102,011 women contributing 206,180,811 days of follow-up). The incidence rate ratio for VTE was 2.87 (95% CI 2.05-4.03) among women in the immediate postpartum DMPA group compared with women in the control group, adjusting for age alone. After adjusting for age and pregnancy-related and chronic conditions, the adjusted incidence rate ratio for VTE was 1.94 (95% CI 1.38-2.72) among women in the immediate postpartum DMPA group compared with women in the control group.

CONCLUSION

Initiation of DMPA immediately postpartum is associated with a low incidence but an increased relative risk of VTE compared with nonuse of hormonal contraception.

Postpartum family planning utilization in Burundi and Rwanda: a comparative analysis of population based cross-sectional data

Introduction

Promotion of modern family planning is a major policy action for Africa to harness the demographic dividend. Family planning is an important public health intervention for maternal and child health.

Methods

Analysis was based on data from Demographic and Health Surveys conducted in 2010 on samples of women from Burundi (3396) and Rwanda (4670). Descriptive and multivariate logistic regression analyses to examine the contribution and comparison of the various predictors of uptake of modern contraceptives during the postpartum period (PPFP) in the two countries were carried out using STATA statistical software.

Results

Descriptive findings show only 20% of the samples of women in Burundi used while more than half of the women (51%) were using PPFP. Utilization of PPFP was significantly associated with primary (OR = 1.3, 95% CI = 1.1-1.6) and higher education (OR = 2.2, 95% CI = 1.6-3.1) in Burundi. Similarly in Rwanda increased use of PPFP in primary was (OR = 1.4, 95% CI = 1.2-1.6) while secondary education (OR = 1.6, 95% CI = 1.2-2.1). Protestant women were less likely to use PPFP in both Burundi (OR = 0.75, 95% CI = 0.6-0.9) and Rwanda (OR = 0.69, 95% CI = 0.6-0.8). Other significant variables in the regression models of both countries included wealth status, age of woman, number of living children and exposure to media. Professional birth delivery assistance was significant only in Rwanda.

Conclusion

Enhancing postpartum contraceptive use should target women with low education, low wealth status, and that the media has an important role to play in this transformation. Policies and programs must be put in place to ensure that the rural urban differences are eradicated.

Association of Postpartum Predischarge Depot-Medroxyprogesterone Acetate with In-Hospital Breastfeeding Initiation

OBJECTIVE

The primary aim of this study was to examine the association between postpartum predischarge depot-medroxyprogesterone acetate (ppDMPA) and in-hospital breastfeeding initiation, and the secondary exploratory aim was to determine if any racial disparities are associated with ppDMPA receipt or its relationship to breastfeeding initiation.

MATERIALS AND METHODS

We conducted a cross-sectional retrospective chart review of maternal and newborn records at a large urban academic medical center. Variables extracted included in-hospital feeding choice, obstetrical and sociodemographic variables, infant characteristics, and ppDMPA receipt. The association of ppDMPA and maternal-child characteristics with breastfeeding initiation was examined using logistic regression analysis.

RESULTS

Among singleton live births of 919 mother-infant pairs (76.5% African American [AA]), 67% initiated breastfeeding (34% exclusive and 33% mixed) and 31.4% received ppDMPA. Breastfeeding rates differed significantly between AA (60.7%) and non-AA mothers (86.6%), and ppDMPA also differed significantly between AA (37.6%) and non-AA mothers (11.6%). Adjusting for other independent predictors, mothers who received ppDMPA were 1.5 times more likely not to initiate breastfeeding if AA, and 5.2 times more likely not to initiate breastfeeding if non-AA.

CONCLUSIONS

ppDMPA receipt was independently associated with decreased rates of breastfeeding initiation. Although more AA mothers received ppDMPA than non-AA, the association of ppDMPA with breastfeeding noninitiation was stronger in non-AA than in AA mothers. Future research should examine this question prospectively to ascertain if there is a cause-effect relationship and should address both physiological effects and social perceptions.

Women's experiences after Planned Parenthood's exclusion from a family planning program in Texas

OBJECTIVE

We assessed the impact on depot medroxyprogesterone continuation when a large care provider was banned from a state-funded family planning program.

STUDY DESIGN

We used three methods to assess the effect of the ban: (a) In a records review, we compared how many state program participants returned to two Planned Parenthood affiliates for a scheduled dose of depot medroxyprogesterone acetate (DMPA) immediately after the ban; (b) We conducted phone interviews with 224 former Planned Parenthood patients about DMPA use and access to contraception immediately after the ban; (c) We compared current contraceptive method of our interviewees to that of comparable DMPA users in the National Survey of Family Growth 2006-2010 (NSFG).

RESULTS

(a) Fewer program clients returned for DMPA at a large urban Planned Parenthood, compared to a remotely located affiliate (14.4%, vs. 64.8%), reflecting different levels of access to alternative providers in the two cities. (b) Among program participants who went elsewhere for the injection, only 56.8% obtained it at no cost and on time. More than one in five women missed a dose because of barriers, most commonly due to difficulty finding a provider. (c) Compared to NSFG participants, our interviewees used less effective methods of contraception, even more than a year after the ban went into effect.

CONCLUSIONS

Injectable contraception use was disrupted during the rollout of the state-funded family planning program. Women living in a remote area of Texas encountered more barriers.

IMPLICATIONS

Requiring low-income family planning patients to switch healthcare providers has adverse consequences.

Prenatal contraceptive counseling and method provision after childbirth

Postpartum contraception is undergoing major changes, not only in timing, but also in content. Failure to provide immediate postpartum contraception contributes to the problems of unintended pregnancies and rapid repeat pregnancy because often the highest-risk women do not return for postpartum care. If they do attend that visit, they have often lost the insurance coverage that would enable them to use the most effective forms of birth control. Most of the issues surrounding early initiation of progestin-only methods and breastfeeding have been favorably resolved. In some cases, insurance coverage for delivery has been expanded to cover the costs of providing intrauterine devices and implants before the woman is discharged home. All of these new opportunities shift the burden of counseling about postpartum contraception onto the shoulders of the prenatal care provider. This article provides information about the advantages and disadvantages of providing immediate postpartum contraception with each of the eligible methods so clinicians can provide the needed counseling both during pregnancy and during hospitalization for delivery. It also provides guidance for initiation of bridging contraception, if needed, to initiate a method for a woman later in the postpartum period.

Use of depot medroxyprogesterone acetate and prevalent leiomyoma in young African American women

STUDY QUESTION

Is use of depot medroxyprogesterone acetate (DMPA) a risk factor for or a protective factor against prevalent uterine leiomyoma?

SUMMARY ANSWER

Ever use of DMPA was associated with a decreased risk (adjusted risk ratio (RR): 0.8, 95% confidence interval (CI): 0.6, 0.9) of prevalent leiomyoma in young African American women.

WHAT IS KNOWN ALREADY

Although progesterone is associated with growth of leiomyoma, previous epidemiological studies have shown a protective association for DMPA use. These previous studies may have been biased by studying clinically diagnosed leiomyoma (DMPA may mask symptoms thus delaying diagnoses).

STUDY DESIGN, SIZE, DURATION

Cross sectional analysis of baseline data from a cohort study of 1696 African American women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Community-based recruitment (e.g. letters, flyers, radio and TV announcements) were used to enroll African American women between 23 and 34 years old without a previous diagnosis of leiomyoma in the Metropolitan Detroit area. Extensive questionnaire data were used to determine DMPA use and screening ultrasound detected the presence of leiomyoma ≥0.5 cm in diameter. Relative risks with adjustment for covariates were calculated for the presence of leiomyoma based on ever use of DMPA as well as duration and recency of use.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 1696 volunteers who enrolled, 43% had used DMPA. Leiomyoma were detected in 17% of those who had ever used DMPA compared with 26% of those who had never used DMPA. The reduction in prevalence remained after adjustment for potential confounders and was highest among women who had used DMPA for more than 4 years (adjusted RR: 0.5, 95% CI: 0.3, 0.8). The reduction in risk was seen for women whose most recent use was up to 8 years prior to study enrollment.

LIMITATIONS, REASONS FOR CAUTION

The use of cross-sectional data means that the timing of initial fibroid development is not known, so the temporality of the association is uncertain. However in this sample of young women, most fibroids were small, suggesting that DMPA exposure may have occurred before leiomyoma development.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings are in agreement with previous epidemiological studies, but protected from the bias inherent in the use of clinically diagnosed leiomyoma. Although further studies will be needed to elucidate the mechanism, use of DMPA as a contraceptive appears to provide long lasting protection against uterine leiomyoma.

STUDY FUNDING/COMPETING INTERESTS

No competing interests. This research was supported in part by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences, and in part by funds allocated for health research by the American Recovery and Reinvestment Act.

TRIAL REGISTRATION NUMBER

N/A.

Predictors of modern contraceptive use during the postpartum period among women in Uganda: a population-based cross sectional study

BACKGROUND

The rationale for promotion of family planning (FP) to delay conception after a recent birth is a best practice that can lead to optimal maternal and child health outcomes. Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa. However, little is known about how pregnant women arrive at their decisions to adopt PPFP.

METHODS

We used 3298 women of reproductive ages 15-49 from the 2011 UDHS dataset, who had a birth in the 5 years preceding the survey. We then applied both descriptive analyses comprising Pearson's chi-square test and later a binary logistic regression model to analyze the relative contribution of the various predictors of uptake of modern contraceptives during the postpartum period.

RESULTS

More than a quarter (28%) of the women used modern family planning during the postpartum period in Uganda. PPFP was significantly associated with primary or higher education (OR=1.96; 95% CI=1.43-2.68; OR=2.73; 95% CI=1.88-3.97 respectively); richest wealth status (OR=2.64; 95% CI=1.81-3.86); protestant religion (OR=1.27; 95% CI=1.05-1.54) and age of woman (OR=0.97, 95% CI=0.95-0.99). In addition, PPFP was associated with number of surviving children (OR=1.09; 95 % CI=1.03-1.16); exposure to media (OR=1.30; 95% CI=1.05-1.61); skilled birth attendance (OR=1.39; 95% CI=1.12-1.17); and 1-2 days timing of post-delivery care (OR=1.68; 95% CI=1.14-2.47).

CONCLUSIONS

Increasing reproductive health education and information among postpartum women especially those who are disadvantaged, those with no education and the poor would significantly improve PPFP in Uganda.

ABM Clinical Protocol #13: Contraception During Breastfeeding, Revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.