Postpartum etonogestrel-releasing implants and depression

The authors of the retrospective study in the Journal of Pediatric and Adolescent Gynecology noted that, although recent systematic reviews have failed to show a clear link between hormonal contraception and postpartum depression, “many clinicians remain hesitant to use progestins in the immediate postpartum period.”

The study enrolled 497 patients (median age 19, range 13 to 22) who were attending the Colorado Adolescent Maternity Program (CAMP) and delivered at the University of Colorado Hospital in Aurora between January 2013 and December 2016. Overall, 86% of participants were primiparous, 50% Latina, 24% black and 16% white.

Of the study cohort, 34% (n = 169) initiated an ENG implant within the first 14 days postpartum (the intervention group), whereas the remaining 66% (n = 328) chose other birth control methods, including no contraception (the control group).

Both groups had similar baseline characteristics, other than for an increased rate of preterm births in the intervention group: 19.4% vs. 12.1% (P = 0.03).

Prenatally, 14% of the entire cohort had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) score: 11.5% in the intervention group vs. vs. 15.4% in the control group (P = 0.25). The investigators also compared rates of positive Edinburgh Postpartum Depression Scales (EPDS) (scores ≥ 10) in the two groups.

At 6 weeks postpartum, 7.6% of the cohort had a positive postpartum depression screen, although this rate was significantly lower in the intervention group than in the control group: 4.1% vs. 9.5% (P = 0.04).

“Retrospective review allowed us to analyze EPDS scores that were free from response bias,” wrote the authors. “When making contraception decisions, our subjects were not influenced by a focus of postpartum depression as a primary outcome.”

Nonetheless, the authors said the reason for a lower rate of positive postpartum screens in AYA immediate postpartum implant users is unclear.

In addition, the study has several limitations, including the inability to adjust for baseline depression scores because a different scale was used prenatally and postnatally: CES-D and EPDS, respectively.

In addition, many subjects were excluded from the study, mainly due to not having a 6-week postpartum visit, which was the study’s only time point for EPDS scores.

A “prospective design could follow subjects more longitudinally to provide additional information about long-term depression outcomes,” wrote the investigators.

Meanwhile, despite the variance in positive postpartum depression between implant users and those who used other forms of contraception, the authors said providers should continue to encourage AYA to choose whichever highly-effective contraceptive method they prefer for postpartum use.

The authors also advocate further research of the multifactorial etiology of postpartum depression and in the psychosocial factors that influence contraceptive decision-making.

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Since hormonal contraception was introduced in the 1960s, the risks and benefits of the drugs have been the topic of considerable debate.

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Reference

1. Drake E, Grush K, Sheeder J, Tocce K. The association between immediate postpartum etonogestrel implants and positive postpartum depression screens in adolescents and young adults. J Pediatr Adolesc Gynecol. Published online June 11, 2020. doi:10.1016/j.jpag.2020.05.010