Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use

Postpartum contraception in Australia: opportunities for increasing access in the primary care setting

In Australia, 20% of pregnancies occur within the first year after birth and most are unintended. Both unintended pregnancies and short interpregnancy intervals (<12-18months) can have adverse effects on maternal, infant, and child health. Access to postpartum contraception reduces the risk of unintended pregnancies and short interpregnancy intervals, and supports women in pregnancy planning and birth spacing. In this forum article, we describe how postpartum contraception is currently provided in Australia and highlight opportunities for improving access in the primary care setting.

Knowledge about unintended pregnancy shortly after childbirth: An issue of ineffective counseling or adherence?

BACKGROUND

Being aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period is often overlooked but remains a significant contributor to unintended pregnancies and may lead to maternal and neonatal comorbidities. Exploring the extent of awareness and associated factors could help tailor more interventions toward reducing the rates of short-interval unplanned pregnancies.

OBJECTIVE

This study explores the extent to which Ghanaian women are aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period and its associated factors.

DESIGN

A cross-sectional study was conducted using the 2017 Ghana Maternal Health Survey. The women participants were sampled using a two-stage cluster sampling design.

METHODS

We analyzed the 2017 Ghana Maternal Health Survey data of 8815 women who had given birth and received both antenatal care and postnatal checks after delivery in health facilities (private and public) and responded to questions on being aware of short interpregnancy intervals. A multivariable survey logistic regression was used for the analysis.

RESULTS

Of the 8815 women, approximately 62% of women who received both antenatal care and postnatal examinations before discharge reported being aware of short interpregnancy intervals. Postnatal examination before discharge but not antenatal care was associated with a higher awareness of short interpregnancy intervals. Women who received a postnatal examination were more aware of short interpregnancy intervals than their counterparts (adjusted odds ratio = 1.29, 95% confidence interval: 1.03-1.61). Also, awareness of short interpregnancy intervals increased with age, education, knowledge of the fertile period, contraceptive use, and delivery via cesarean section.

CONCLUSION

Over a decade following the initiation of Ghana's free maternal health policy, there remains a significant gap in the awareness of short interpregnancy intervals, even among women who received both antenatal pregnancy care and postnatal examinations before discharge. The unawareness of the short interpregnancy interval observed in approximately 38% of women raises concerns about the effectiveness of counseling or education provided during antenatal care and immediate post-partum care regarding birth spacing, contraceptive use, the timing of resumption of sexual activity, and the extent to which women adhere to such guidance.

A nomogram to predict the risk of scar pregnancy after caesarean section

The aim of this study was to identify the high-risk factors for caesarean scar pregnancy (CSP) and establish a nomogram to predict the risk of caesarean scar pregnancy in pregnant women with a history of caesarean section. Among 1273 pregnant women with a history of caesarean section, 70% of the patients (892 patients, training sample) were randomly selected for analysis, and a prediction model was generated. The remaining patients (381 patients, validation sample) were validated for the model. Four high-risk factors for CSP were established, including: parity, number of previous abortions, uterus position, and early vaginal bleeding. The area under the curve of the nomogram for the training set was 0.867 and that for the validation set was 0.881, indicating good performance. Calibration curves for predicting CSP showed good calibrations. Decision curve analyses showed good application prospects for the model. Our results show that our nomogram for predicting CSP risks can be a practical tool to help in the early identification of CSP.Impact StatementWhat is already known on this subject? The high-risk factors for "caesarean scar pregnancy", An simple nomogram could be constructed to predict the risk of the disease through these high-risk factors.What do the results of this study add? This study can quickly predict whether the patient is a high-risk group for uterine scar pregnancy based on the patient's previous pregnancy, early vaginal bleeding and uterine position.What are the implications of these findings for clinical practice and/or further research? Caesarean scar pregnancy was secondary Long-term complications after caesarean section that with a high risk of pregnancy. In this study, we established a nomogram based on the number of cases of CSP and a control group with a history of caesarean section delivery at term, The high-risk factors were assigned a certain risk value in the early stage, if the woman contains more high-risk factors, the higher the risk of developing CSP, it should be highly valued in the early stage, and the rate of visiting a doctor should be increased.

Understanding Progestins: From Basics to Clinical Applicability

Progestin is a term used to describe a synthetic progestogen. The activity and potency of synthetic progestins are mostly evaluated via parameters associated with their endometrial effects, which are related to their interactions with progesterone, estrogen, androgen, glucocorticoid, and mineralocorticoid receptors. The chemical structure of progestins is the key to understanding their interactions with these receptors and predicting the other effects associated with these drugs. Due to their endometrial effect, progestins are used for different gynecological conditions, such as endometriosis, contraception, hormonal replacement therapy, and artificial reproduction techniques. This review is focused on improving our knowledge of progestins (from their history and biochemical effects related to their chemical structures to clinical applications in gynecological conditions) in order to improve clinical practice.

Patient acceptability, continuation and complication rates with immediate postpartum levonorgestrel intrauterine device insertion at caesarean section and vaginal birth

BACKGROUND

Immediate postpartum long-acting reversible contraception (LARC) has been shown to reduce unintended pregnancy but uptake of this type of contraception in Australia is low compared to European counterparts.

AIMS

To assess self-reported continuation rates, complications and satisfaction in patients having immediate postpartum hormonal intrauterine device (IUD) inserted at caesarean section (CS) or after vaginal birth (VB).

MATERIALS AND METHODS

Retrospective cohort study of all patients with immediate postpartum hormonal IUD insertion over three years at a tertiary maternity service. Primary outcomes were patient satisfaction, continuation and expulsion rates. Secondary outcomes were reason for discontinuation, patient-reported complications, attendance for postpartum check with a general practitioner (GP) and rate of unplanned pregnancy. Simple descriptive statistics were used to analyse the data.

RESULTS

One hundred and ninety-three women had a hormonal IUD inserted and 143 consented to involvement (CS n = 79; VB n = 64). Six and 12 months continuation rates for CS were 60.8% and 54.4%, and VB were 46.9% and 39.1%. The most common reasons for removal were: pain (34.5%), heavy or irregular bleeding (25.9%) and partial expulsion (24.1%). Expulsion was more likely after VB (34.1%) than CS (10.1%), (odds ratio 2.72; 95% CI 1.07-6.90; P = 0.036). There were 60.8% of women post-CS and 56.3% of women post-VB who were satisfied with their decision to have immediate postpartum insertion and most women attended routine postpartum follow-up with their GP (89.5%).

CONCLUSION

Immediate postpartum hormonal IUD insertion in this cohort is associated with higher rates of expulsion and lower satisfaction rates compared to those documented in the literature for delayed postpartum insertion cohorts.

Reproductive Women’s Knowledge on Possibility of Pregnancy after Birth but before Resumption of Menstruation and Its Associated Factors in Ethiopia: A Population-Based Study Using the 2016 Ethiopian Demographic Health Survey

Introduction

Worldwide, specifically in developing countries, women believe that a woman cannot become pregnant unless she sees her first postpartum menstruation. Due to this knowledge gap, most women did not use any contraceptives till their 1^st postpartum menstruation. Hence, about 44% of women were susceptible to unintended pregnancy in the postpartum period. Assessing women knowledge on possibility of pregnancy after giving birth but before returning of menses and its associated factors will help to increase women's recognition on the issue and for early commencement of appropriate postpartum family planning methods to reduce burden of unintended pregnancy.

Objective

To assess the level of knowledge on possibility of pregnancy after giving birth but before returning of menses and its associated factors among reproductive women in Ethiopia.

Methods

A secondary data analysis using the 2016 Ethiopian Demographic Health Survey was employed. Samples were selected using two-stage stratified sampling technique. Descriptive statistics and logistic regressions were used. Adjusted odds ratio (AOR) with 95% confidence interval was used to interpret associations, and a significant association was declared at a p value of <0.05.

Result

A total of 15,683 reproductive women aged from 15 to 49 years were included. Of them, about 53% did not know that a woman can get pregnant after giving birth but before resumption of her menstruation. Age being 35 years and above (AOR = 1.50; 95%CI = 1.34, 1.67), educational status of secondary and above (AOR = 1.18; 95%CI = 1.06, 1.32), being ever married (AOR = 1.67; 95%CI = 1.47, 1.89), knowledge of any family planning method (AOR = 1.81; 95%CI = 1.52, 2.16), getting counseling on family planning methods (AOR = 1.41; 95%CI = 1.28, 1.55), and being knowledgeable on their ovulatory cycle (AOR = 1.68; 95%CI = 1.55, 1.82) were found to be significantly associated with being knowledgeable on the issue.

Conclusion

Reproductive women's level of knowledge on the possibility of pregnancy after giving birth but before returning of menses was low. Factors associated with being knowledgeable on the issue were identified. Therefore, strategies should be developed to increase their level of knowledge for reducing unintended pregnancy and its complications by integrating family planning counseling with infant immunization services.

The Effectiveness of Postpartum IUD Compared to Interval IUD in ‘Aisyiyah Hospital Klaten

BACKGROUND: Postpartum IUD (PPIUD) insertion is performed 10 min after the placenta is born until 48 h postpartum, interval method is installed after 4 weeks postpartum. The use of this contraception will provide a distance between pregnancies not to be too close. AIM: To assess the effectiveness of PPIUD and the interval on complaints and complications in acceptors. METHODOLOGY: This study used a cross-sectional design. The subjects were women who gave birth vaginally and cesarean section at the ‘Aisyiyah Hospital Klaten with PPIUD and interval acceptors installed. Complaint data obtained through history taking, complications obtained from ultrasound, inspeculo examination, and vaginal swab. Data were analyzed by univariate, bivariate, and multivariate analysis. RESULTS: One hundred and twenty-nine subjects consisted of 82 (63.6%) PPIUD and 47 (36.4%) interval. On ultrasound examination, 126 (97.7%) subjects had no abnormalities, two (1.6%) had abnormalities, and one (0.8%) found ovarian cysts. On inspeculo examination, 89 (69.0%) subjects found no erotion, and 40 (31.0%) did not find abnormalities. Vaginal swab examination showed that 119 (92.2%) subjects had pathogenic bacteria, ten (7.8%) were normal. The fungus was positive in 75 (58.1%) subjects, and no fungus was in 54 (41.9%), while in NGO, positive was 18 (14.0%) subjects, and negative was 111 (86.0%). There was a significant relationship that the type of IUD insertion had husband’s complaints (p = 0.021), the erosion incidence (p = 0.011), the presence/absence of threads (p = 0.01), and the presence of fungus (0.00). PPIUD is more effective than interval IUD. CONCLUSION: PPIUD is more effective in terms of the lack of complaints from the husband, the incidence of erosion, the presence or absence of threads, and found of fungus on the vaginal swab than interval IUD.

Study on the use practices and knowledges of French practitioners about the use of intra-uterine devices in early post-partum contraception in France

OBJECTIVES

Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France.

METHODS

A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum.

RESULTS

four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow.

CONCLUSION

insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice.

Feasibility, acceptability and sustainability of postpartum contraceptive implant provision by midwives in NSW public hospitals

BACKGROUND

Repeat pregnancy in the first year after a birth is common. Many of these conceptions are unintended and may be prevented by providing access to contraception in the immediate postpartum period. Midwives in the hospital setting could potentially play a greater role in improving postnatal contraception information and provision.

AIM

We sought to implement and examine the success of a program training hospital-based midwives in immediate postpartum implant insertion.

METHODS

This mixed methods study in two hospitals in New South Wales sought to explore the feasibility, acceptability and sustainability of a program that provided competency-based implant insertion training for midwives. The study documented training completion, implant insertion numbers and experience, and conducted end of study interviews with midwives and stakeholders.

FINDINGS

Twenty-seven midwives undertook training and inserted 265 implants during the study period. Interviews with 13 midwives and 11 stakeholders concluded the program to be feasible and acceptable with midwives reporting high satisfaction from their involvement. All interviewees felt that midwives were well placed to insert implants, and reported that challenges around workload and opportunities for practice were generally manageable. It was recognised that sustainability of the program would require supportive policy and regular insertion opportunities.

CONCLUSIONS

Midwives successfully upskilled in implant insertions and there was widespread support for the program with expectations it would be sustained. Provision of contraceptive information and implant insertion by midwives in the immediate postpartum period is likely to increase contraceptive choice and access for women and contribute to reducing rapid repeat pregnancies.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Implementing Immediate Postpartum Long-Acting Reversible Contraception Programs

OBJECTIVE

To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program.

METHODS

This was a qualitative study. We interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. Data were analyzed using directed qualitative content analysis principles. We used the Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. We compared this guide to hospitals' implementation experiences.

RESULTS

At the completion of the study, LARC was available for immediate postpartum placement at 7 of 10 study hospitals. Participants identified common themes for the implementation experience: team member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Participants expressed a need for anticipatory guidance throughout the process. Key first steps to immediate postpartum LARC program implementation were identifying project champions, creating an implementation team that included all relevant departments, obtaining financial reassurance, and ensuring hospital administration awareness of the project. Potential barriers included lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork. Although the implementation guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not all hospitals required every step to succeed.

CONCLUSION

Hospital teams report that implementing immediate postpartum LARC programs involves multiple departments and a number of important steps to consider. A stage-based approach to implementation, and a standardized guide detailing these steps, may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting.

Intrauterine Device Perforation

Intrauterine devices (IUDs) have had a controversial history but are regarded as a safe, effective form of contraception for all women. IUDs have many benefits, but at the same time, risks and complications may occur in a small percentage of women. The case study first presents a patient with an IUD that perforated the uterus and then offers a discussion of the risks and benefits of IUD contraception.

Randomized Controlled Trial of Home-Based Hormonal Contraceptive Dispensing for Women At Risk of Unintended Pregnancy

CONTEXT

Women frequently experience barriers to obtaining effective contraceptives from clinic-based providers. Allowing nurses to dispense hormonal methods during home visits may be a way to reduce barriers and improve -effective contraceptive use.

METHODS

Between 2009 and 2013, a sample of 337 low-income, pregnant clients of a nurse home-visit program in Washington State were randomly selected to receive either usual care or enhanced care in which nurses were permitted to provide hormonal contraceptives postpartum. Participants were surveyed at baseline and every three months postpartum for up to two years. Longitudinal Poisson mixed-effects regression analysis was used to examine group differences in gaps in effective contraceptive use, and survival analysis was used to examine time until a subsequent pregnancy.

RESULTS

Compared with usual care participants, enhanced care participants had an average of 9.6 fewer days not covered by effective contraceptive use during the 90 days following a first birth (52.6 vs. 62.2). By six months postpartum, 50% of usual care participants and 39% of enhanced care participants were using a long-acting reversible contraceptive (LARC). In analyses excluding LARC use, enhanced care participants had an average of 14.2 fewer days not covered by effective contraceptive use 0-3 months postpartum (65.0 vs. 79.2) and 15.7 fewer uncovered days 4-6 months postpartum (39.2 vs. 54.9).

CONCLUSION

Home dispensing of hormonal contraceptives may improve women's postpartum contraceptive use and should be explored as an intervention in communities where contraceptives are not easily accessible.

Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals

BACKGROUND

Women in the postpartum period need effective contraception. Unintended pregnancies soon after childbirth may lead to abortion or short inter-pregnancy intervals associated with adverse outcomes. Using databases for a 6-month period (September 2013-February 2014) we examined the proportion of women attending for abortion in Edinburgh, Scotland who had given birth in the preceding 12 months, and the proportion of women giving birth in this region after an inter-pregnancy interval of 12 months or less. We also surveyed 250 women prior to discharge from the same maternity service about their contraceptive intentions.

RESULTS

Some 75/1175 (6.4%) attending for abortion had given birth within the preceding 12 months and 332/4713 (7.0%) postpartum women gave birth following an inter-pregnancy interval of 12 months or less. When considering parous women, percentages were 13.3% and 13.9%, respectively. The majority (n=237, 96.7%) of postpartum women were not planning another pregnancy within the year but only a minority (n=32, 12.8%) were planning on using long-acting reversible contraception (LARC), namely the implant or intrauterine device. However, 42.8% (n=107) indicated that if the implant or intrauterine contraception could be inserted before they left hospital then they would choose these methods (p<0.0001).

DISCUSSION

Almost one in thirteen women in our population presenting for abortion or giving birth has conceived within 1 year of giving birth. Provision of LARC immediately postpartum appears to be an attractive option to mothers, and could be an important strategy to prevent unintended pregnancy and short inter-pregnancy intervals.

Post Abortion Contraception

A safe induced abortion has no impact on future fertility. Ovulation may resume as early as 8 days after the abortion. There is no difference in return to fertility after medical or surgical abortion. Most women resume sexual activity soon after an abortion. Contraceptive counseling and provision should therefore be an integrated part of the abortion services to help women avoid another unintended pregnancy and risk, in many cases an unsafe, abortion. Long-acting reversible contraceptive methods that includes implants and intrauterine contraception have been shown to be the most effective contraceptive methods to help women prevent unintended pregnancy following an abortion. However, starting any method is better than starting no method at all. This Special Report will give a short guide to available methods and when they can be started after an induced abortion.

A randomised clinical trial to assess satisfaction with the levonorgestrel- releasing intrauterine system inserted at caesarean section compared to postpartum placement

Background

Insertion of levonorgestrel‐releasing intrauterine system (LNG‐IUS) at caesarean section (CS) provides contraception prior to resumption of ovulation or sexual activity. Patient satisfaction with insertion at CS has not previously been studied.

Aims

The aim of this study was to compare patient satisfaction with LNG‐IUS inserted at the time of lower uterine segment CS to six weeks postpartum.

Materials and Methods

Open‐label randomised controlled trial. Women booked for elective CS were randomised to LNG‐IUS insertion either at the time of CS (study group) or at six weeks postpartum (control group). The primary outcome measure was patient satisfaction. Outcomes were measured at six weeks, three months and six months postpartum.

Results

Forty‐eight women were randomised into two treatment groups. Twenty‐five women were randomised to have LNG‐IUS inserted at the time of CS, 23 of whom had the planned intervention and two had the LNG‐IUS inserted postpartum. Twenty‐three women were randomised to the control group, four of whom withdrew prior to treatment. The 44 remaining women contributed to data analysis. Patient satisfaction was high and similar in both groups. At six months postpartum, 90.5% of the study group were very satisfied or somewhat satisfied compared with 88.2% of the control group.

Conclusions

Patient satisfaction is high with LNG‐IUS insertion at CS and not different to that with delayed insertion. LNG‐IUS insertion may be an option for women who find postpartum contraception difficult to access.