Immediate postpartum LARC for women at high risk for medical complications

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Summary of Recommendations

Introduction

Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Medically complex women are at increased risk for unintended pregnancy compared to a healthy cohort, and for these women, an unintended pregnancy in the setting of poor disease control could increase risk of adverse pregnancy outcomes, disease progression, fetal compromise, or long-term childhood health issues. The postpartum period is an especially vulnerable time, as 70% of pregnancies that occur within 1 year of delivery are unplanned. Interpregnancy intervals shorter than 6 months are associated with increased risks of preterm birth, low birth weight, and small for gestational age infants.

Despite the need for pregnancy planning, medically complex women face many barriers to contraceptive use. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. 

LARC methods include hormonal and nonhormonal intrauterine devices (IUDs) as well as subdermal contraceptive implants. In the United States, the levonorgestrel intrauterine system (IUS) is available in several commercial preparations (Liletta, Mirena, Kyleena, and Skyla), and the nonhormonal copper IUD is commercially available as Paragard. The etonogestrel implant is commercially known as Nexplanon.

1 | What is the role of contraception in the care of high-risk women? 

The interconception period is a time that allows for optimization of maternal health. Contraception facilitates adequate birth spacing to achieve this goal. This is particularly important for women with comorbid conditions or who have had a complication during pregnancy. The most effective way to prevent an unintended pregnancy is through consistent and correct use of contraception.

2 | What is the role of LARC in reproductive planning in medically complex women?  

The American College of Obstetricians and Gynecologists (ACOG) recommends that LARC methods be offered to all appropriate candidates. LARC methods have low failure rates, similar to those of sterilization, making them appealing to women for whom future pregnancy is not recommended or when sterilization is not an option. For medically complex women, LARC methods provide the benefit of allowing a pregnancy to occur in a well-planned and highly supervised medical setting for women in whom an unplanned pregnancy would pose a high medical risk. The long-acting nature of LARC allows women to optimize chronic health conditions prior to conception, but LARC methods remain easily reversible when pregnancy is desired. LARC methods do not contain estrogen, making them safe options for women with a history of medical conditions, such as thromboembolic disease, for whom estrogen is contraindicated. 

3 | What is immediate postpartum LARC?  

Immediate postpartum placement is defined as insertion of an IUD after placental delivery following a vaginal or cesarean delivery and insertion of an implant at any time during the delivery hospitalization.

4 | When should providers discuss immediate postpartum contraception?

Contraceptive counseling should begin early in pregnancy, be individualized, include a balanced discussion about the risks and benefits of all contraceptive methods, and use shared decision-making. Incorporating contraceptive counseling into prenatal care can contribute substantially to a woman’s health long after pregnancy. This should be an ongoing discussion during the prenatal period, as complications can develop during pregnancy that may have an impact on contraceptive counseling.

5 | What are the benefits of immediate postpartum LARC insertion?   

LARC is a safe, convenient, and effective option for postpartum contraception that can be placed immediately after delivery. It provides immediate contraception without breastfeeding interference and avoids the discomfort related to later IUD insertion. Compared with short-acting methods, use of immediate postpartum LARC results in increased short-term contraceptive use, similar or increased long-term contraceptive use, and decreased prevalence of short interpregnancy intervals and rates of unintended pregnancy. Compared with other interval insertions of LARC methods, immediate postpartum placement is associated with high patient satisfaction and acceptability, increased method continuation, and superior cost-effectiveness. 

6 | Which LARC methods are appropriate for women at high risk for complications?  

Obstetric care providers can use the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) to counsel medically complex women on individualized, efficacious, and evidence-based contraceptive options. 

The US MEC also makes recommendations specific to the immediate postpartum period, and LARC methods are category 1 or 2 for most conditions. With few exceptions, immediate postpartum LARC is an option regardless of medical complexity. A summary chart of the USMEC for contraceptive use is available on the US Centers for Disease Control and Prevention website as well as in an app for smartphones and tablets (“Contraception”).

7 | What are the contraindications to immediate postpartum LARC? 

The few contraindications to immediate postpartum LARC placement are similar to those for interval LARC placement and are listed in the US MEC. Clinical recommendations and medical contraindications to LARC in the US MEC also apply to the immediate postpartum period. 

8 | What are the risks of immediate postpartum IUD placement?

Most risks are similar between immediate postpartum IUD insertion and insertion at other times, with the exception of expulsion, which has a higher risk. Expulsion rates of 2%, 10%, and 25% have been reported with immediate postpartum placement compared with expulsion rates of 2% with 6-week postpartum IUD placement. The expulsion risk may influence LARC choice for some women. Although immediate postpartum IUD placement has higher expulsion rates than interval placement, the benefits of immediate placement appear to outweigh the drawbacks. A review of seven studies shows that even with higher expulsion rates, women who had immediate postpartum IUD placement were more likely to continue to use the IUD at 6 months than those who had an IUD inserted at another time.

9 | What is the technique for immediate postpartum LARC placement?  

Several techniques of immediate postpartum LARC placement following vaginal and cesarean delivery are described, using either a ring or Kelly placental forceps, manual insertion with the operator’s hand, or the manufacturer’s inserter. ACOG suggests that providers receive formal training to enable appropriate immediate postpartum IUD placement after cesarean and vaginal deliveries. LARC method-specific training opportunities are available on the ACOG website.

The technique for immediate postpartum contraceptive implant insertion is the same used in other settings and at other times. Insertion can be achieved in the labor and delivery unit or in the postpartum unit. The US Food and Drug Administration requires that obstetric care providers receive training provided by the manufacturer.

10 | Does immediate postpartum LARC placement inhibit breastfeeding?  

Although there is theoretical concern that the progestogens in the hormonal IUS and contraceptive implant could impair the onset of lactogenesis in women receiving immediate postpartum LARC, no reduction in breastfeeding has been observed in randomized trials. Women considering immediate postpartum hormonal LARC should be counseled about the theoretical risk of reduction in breastfeeding, but that the preponderance of the evidence has not shown a negative effect on actual breastfeeding outcomes.

11 | What is “early postpartum” LARC placement?  

Early postpartum LARC placement is defined as LARC insertion shortly after hospital discharge and within the first few weeks postpartum. The expulsion rate for early postpartum LARC placement is consistent with that for interval insertion and lower than that for immediate postpartum placement. In environments where immediate inpatient placement of postpartum LARC is not possible, a program of early postpartum placement has similar benefits and could provide similar reductions in unplanned and close-interval pregnancy. 

12 | What is the maternal-fetal medicine (MFM) subspecialist’s role in implementing immediate postpartum LARC programs?    

MFM subspecialists are uniquely positioned to promote immediate postpartum LARC placement because of their frequent and in-depth contact with high-risk and medically complex women during pregnancy and the postpartum period. Pregnancy is a time of high motivation for contraception; this is especially true for women with complicated pregnancies who are receiving regular counseling about the maternal and fetal risks to their current and future pregnancies. Obstetric care providers can also advocate for their patients on both an individual and system-wide level.

13 | How should patients be counseled about immediate postpartum LARC?  

Counseling should be patient-centered and provided in a shared decision-making framework, should avoid coercion, and should include the option for sterilization as well as short-acting methods. This is particularly important for low-income women and women of color, who may be more susceptible to coercion and reproductive injustice. For women who want a future pregnancy, LARC should be encouraged as an option because of its superior efficacy and longer therapeutic window. It is important to explain IUD expulsion rates and to have a plan for contraceptive management, should expulsion occur.

Anticipatory guidance about side effects such as vaginal bleeding can also be provided. Obstetric care providers can use their familiarity with their patients’ health histories to help patients choose a contraceptive method that is compatible with their medical restrictions. Evidence-based contraceptive educational tools can be used by providers to assist in counseling women. 

14 | What are the barriers to immediate postpartum LARC placement?  

Health-care system issues are the primary barrier to widespread immediate postpartum LARC use. Coordinated programs involving cooperation among providers, administration, billing, and pharmacy services are not widespread. In some religiously affiliated hospitals, immediate postpartum LARC placement may be specifically prohibited. Lack of awareness or misperceptions among MFM subspecialists and general obstetricians can impede immediate postpartum LARC placement. Insurance coverage and payment difficulties are persistent obstacles to implementation of immediate postpartum LARC placement programs and are often the result of misinformation regarding LARC clinical effects. Although Medicaid reimbursement for LARC is increasing, inpatient billing processes remain unclear for many hospitals and are not well aligned with systems for absorbing the up-front cost of the devices. Insurance coverage of IUD reinsertion in cases of postpartum expulsion and access to and coverage for removal services are also concerns for both women and obstetric care providers.

15 | What steps can be used to increase access to immediate postpartum LARC?  

Obstetric care providers can encourage development of dedicated LARC placement teams to facilitate LARC access in both inpatient and outpatient settings. Dedicated LARC placement teams can counsel women and place LARC, provide estimates of demand and inventory stocking needs, and appropriately bill for services. Expanding the range of health care professionals, such as nurses or midwives, who are trained to counsel women and to insert LARC devices could reduce the burden on physicians. ACOG’s Postpartum Contraceptive Access Initiative provides technical assistance, resources, and free onsite training to support dedicated LARC placement teams. 

Obstetric care providers can advocate for their patients on both an individual and system-wide level. Support from MFM subspecialists and family planning experts could encourage hospital systems to develop guidelines for integrating immediate postpartum LARC into best practices that provide a policy framework for these services. Educating hospital administration about the safety, acceptability, and cost-effectiveness of immediate postpartum LARC can improve the likelihood of institutional support for a placement program. 

Counseling high-risk women about postpartum contraceptive options may not be prioritized during management of a complicated pregnancy. LARC and other postpartum contraceptive methods may not be addressed because of lack of knowledge, lack of time, or the perception by referring or MFM subspecialist providers that it is not their role. However, discussing postpartum contraceptive options early and often can increase awareness of the role of immediate postpartum contraception in improving health outcomes and reducing unplanned and close-interval pregnancy.