Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial

Prenatal Contraceptive Counseling

Pregnancy care should include open discussions with patients about their ideal family size and pregnancy spacing. With these patient-voiced goals in mind, clinicians should review contraceptive tools to meet these goals, including special considerations after birth. For patients that desire contraception, it is important to prioritize the provision of their chosen method as soon as safely possible and desired after birth.

Breastfeeding and Hormonal Contraception: A Scoping Review of Clinical Guidelines, Professional Association Recommendations, and the Literature

Background: Postpartum contraceptive use can help prevent short-interval pregnancies, which have been associated with adverse neonatal and maternal health outcomes. Many contraceptive methods are safe for postpartum use, but patients and providers may be confused as to what impact hormonal contraception has on lactation. We performed a scoping review of the most recent U.S.-based guidelines regarding hormonal contraception on lactation to provide synthesis and recommendations to aid providers in counseling their patients. Methods: We conducted a scoping review by identifying the most recent clinical recommendations and guidelines from the Centers for Disease Control and Prevention (CDC) and three maternal and child health professional associations (American College of Obstetricians and Gynecologists [ACOG], Society for Maternal-Fetal Medicine [SMFM], and Academy of Breastfeeding Medicine [ABM]). We also reviewed the citations in these guidelines used in their development. We then conducted an updated literature review to capture studies published since the most recent systematic reviews were conducted. Results: We reviewed 1 clinical guideline from the CDC and 2 systematic reviews cited in its references, 6 professional association recommendations, and 28 publications identified through the updated literature review. Progestin-only contraceptive methods continue to demonstrate safety in breastfeeding patients, while low-quality evidence supports concerns of decreased milk supply with combined hormonal contraception. Discussion: Organizations should consider updating counseling recommendations regarding progestin-only contraceptives and lactation. Further research is needed to examine new contraceptive methods as well as the effect of hormonal contraception on lactation in the setting of preterm birth.

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.

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.

Lactogenesis and breastfeeding after immediate vs delayed birth-hospitalization insertion of etonogestrel contraceptive implant: a noninferiority trial

BACKGROUND

Initiating a progestin-based contraceptive before the drop in progesterone required to start lactogenesis stage II could theoretically affect lactation. Previous studies have shown that initiating progestin-based contraception in the postnatal period before birth-hospitalization discharge has no detrimental effects on breastfeeding initiation or continuation compared with outpatient interval initiation. However, there are currently no breastfeeding data on the impact of initiating the etonogestrel contraceptive implant in the early postnatal period immediately in the delivery room.

OBJECTIVE

This study examined the effect of delivery room vs delayed birth-hospitalization contraceptive etonogestrel implant insertion on breastfeeding outcomes.

STUDY DESIGN

This was a noninferiority randomized controlled trial to determine if time to lactogenesis stage II (initiation of copious milk secretion) differs by timing of etonogestrel implant insertion during the birth-hospitalization. We randomly assigned pregnant people to insertion at 0 to 2 hours (delivery room) vs 24 to 48 hours (delayed) postdelivery. Participants intended to breastfeed, desired a contraceptive implant for postpartum contraception, were fluent in English or Spanish, and had no allergy or contraindication to the etonogestrel implant. We collected demographic information and breastfeeding intentions at enrollment. Onset of lactogenesis stage II was assessed daily using a validated tool. The noninferiority margin for the mean difference in time to lactogenesis stage II was defined as 12 hours in a per-protocol analysis. Additional electronic surveys collected data on breastfeeding and contraceptive continuation at 2 and 4 weeks, and 3, 6, and 12 months.

RESULTS

We enrolled and randomized 95 participants; 77 participants were included in the modified intention-to-treat analysis (n=38 in the delivery room group and n=39 in the delayed group) after excluding 18 because of withdrawing consent, changing contraceptive or breastfeeding plans, or failing to provide primary outcome data. A total of 69 participants were included in the as-treated analysis (n=35 delivery room, n=34 delayed); 8 participants who received the etonogestrel implant outside the protocol windows were excluded, and 2 participants from the delivery room group received the etonogestrel implant at 24 to 48 hours and were analyzed with the delayed group. Participants were similar between groups in age, gestational age, and previous breastfeeding experience. Delivery room insertion was noninferior to delayed birth-hospitalization insertion in time to lactogenesis stage II (delivery room [mean±standard deviation], 65±25 hours; delayed, 73±61 hours; mean difference, -9 hours; 95% confidence interval, -27 to 10). Onset of lactogenesis stage II by postpartum day 3 was not significantly different between the groups. Lactation failure occurred in 5.5% (n=2) participants in the delayed group. Ongoing breastfeeding rates did not differ between the groups, with decreasing rates of any/exclusive breastfeeding over the first postpartum year. Most people continued to use the implant at 12 months, which did not differ by group.

CONCLUSION

Delivery room insertion of the contraceptive etonogestrel implant does not delay the onset of lactogenesis when compared with initiation later in the birth-hospitalization and therefore should be offered routinely as part of person-centered postpartum contraceptive counseling, regardless of breastfeeding intentions.

Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception

BACKGROUND

Long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants, are highly effective, reversible methods of contraception. Providing LARC methods during the postpartum period is important to support contraceptive choice, and to prevent unintended pregnancy and short interpregnancy intervals. Delaying offering contraception to postpartum people until the first comprehensive postpartum visit, traditionally at around six weeks postpartum, may put some postpartum people at risk of unintended pregnancy, either due to loss to follow-up or because of initiation of sexual intercourse prior to receiving contraception. Therefore, immediate provision of highly effective contraception, prior to discharge from hospital, has the potential to improve contraceptive use and prevent unintended pregnancies and short interpregnancy intervals.

OBJECTIVES

To compare the initiation rate, utilization rates (at six months and 12 months after delivery), effectiveness, and adverse effects of immediate versus delayed postpartum insertion of implants and IUDs for contraception.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE for eligible studies up to December 2020. We examined review articles and contacted investigators. We checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant and IUDs for contraception.

DATA COLLECTION AND ANALYSIS

Two review authors (JS, SK) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL, SA or PP). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel or inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

In this updated review, 16 studies met the inclusion criteria; five were studies of contraceptive implants (715 participants) and 11 were studies of IUDs (1894 participants). We identified 12 ongoing studies. We applied GRADE judgements to our results; the overall certainty of the evidence for each outcome ranged from moderate to very low, with the main limitations being risk of bias, inconsistency, and imprecision. Contraceptive implants Immediate insertion probably improves the initiation rate for contraceptive implants compared with delayed insertion (RR 1.48, 95% CI 1.11 to 1.98; 5 studies, 715 participants; I2 = 95%; moderate-certainty evidence). We are uncertain if there was a difference between the two groups for the utilization rate of contraceptive implants at six months after delivery (RR 1.16, 95% CI 0.90 to 1.50; 3 studies, 330 participants; I2 = 89%; very low-certainty evidence) or at 12 months after insertion (RR 0.98, 95% CI 0.93 to 1.04; 2 studies, 164 participants; I2 = 0%; very low-certainty evidence). People who received an immediate postpartum contraceptive implant insertion may have had a higher mean number of days of prolonged vaginal bleeding within six weeks postpartum (mean difference (MD) 2.98 days, 95% CI -2.71 to 8.66; 2 studies, 420 participants; I2 = 91%; low-certainty evidence) and a higher rate of other adverse effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; 1 study, 215 participants; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups for prolonged bleeding at six months after delivery (RR 1.19, 95% CI 0.29 to 4.94; 2 studies, 252 participants; I2 = 0%; very low-certainty evidence). There may be little or no difference between the two groups for rates of unintended pregnancy at six months (RR 0.20, 95% CI 0.01 to 4.08; one study, 205 participants; low-certainty evidence). We are uncertain whether there was a difference in rates of unintended pregnancy at 12 months postpartum (RR 1.82, 95% CI 0.38 to 8.71; 1 study, 64 participants; very low-certainty evidence). There may be little or no difference between the two groups for any breastfeeding rates at six months (RR 0.97, 95% CI 0.92 to 1.01; 2 studies, 225 participants; I2 = 48%; low-certainty evidence). IUDs Immediate insertion of IUDs probably improves the initiation rate compared with delayed insertion, regardless of type of IUD (RR 1.27, 95% CI 1.07 to 1.51; 10 studies, 1894 participants; I2 = 98%; moderate-certainty evidence). However, people who received an immediate postpartum IUD insertion may have had a higher expulsion rate at six months after delivery (RR 4.55, 95% CI 2.52 to 8.19; 8 studies, 1206 participants; I2 = 31%; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups in the utilization of IUDs at six months after insertion (RR 1.02, 95% CI 0.65 to 1.62; 6 studies, 971 participants; I2 = 96%; very low-certainty evidence) or at 12 months after insertion (RR 0.86, 95% CI 0.5 to 1.47; 3 studies, 796 participants; I2 = 92%; very low-certainty evidence). Immediate IUDs insertion may reduce unintended pregnancy at 12 months (RR 0.26, 95% CI 0.17 to 0.41; 1 study, 1000 participants; low-certainty evidence). We are uncertain whether there was difference in any breastfeeding rates at six months in people receiving progestin-releasing IUDs (RR 0.90, 95% CI 0.63 to 1.30; 5 studies, 435 participants; I2 = 54%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that immediate postpartum insertion improves the initiation rate of both contraceptive implants and IUDs by the first postpartum visit compared to delayed insertion. However, it is not clear whether that there are differences in utilization rates at six and 12 months postpartum. We are uncertain whether there is any difference in the unintended pregnancy rate at 12 months. Provision of progestin-releasing implants and IUDs immediately postpartum may have little or no negative impact on breastfeeding. However, the expulsion rate of IUDs and prolonged vaginal bleeding associated with immediate implants appears to be higher.

Risk factors for self‐reported insufficient milk during the first 6 months of life: A systematic review

The objective of this systematic review was to identify multifactorial risk factors for self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub‐Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high‐income countries, 30 from upper‐middle‐income, 10 from low‐middle‐income countries, and one study was conducted in a high‐income and an upper‐middle‐income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in‐hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self‐efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby‐Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Socioeconomic and demographic factors indicative of lower economic status increased the risk of self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL).

Timely breastfeeding (BF) initiation and avoidance of in‐hospital commercial milk formula (CMF) supplementation are likely to reduce the prevalence of SRIM and DOL.

BF counselling designed to prevent SRIM and DOL needs to strengthen maternal BF self‐efficacy, maternal understanding of baby behaviours such as fussiness and maternal wellbeing.

Research is needed to better understand how the risk of DOL and SRIM increases with primiparity, caesarean sections, maternal overweight/obesity, and poor overall maternal health.

Intervention studies specifically designed to reduce the risk of SRIM and DOL are urgently needed in low‐ and middle‐income countries.

Breastfeeding and contraception counseling: a qualitative study

BACKGROUND

The objectives of this qualitative study were to better understand women's experiences regarding contraceptive choice, breastfeeding intentions and the relationship between the two. Women are routinely presented with counseling on breastfeeding and contraception throughout their prenatal and postpartum care, but little is published on patients' own priorities, desires and experiences of this peripartum counseling. This article aims to address this gap in the literature.

METHODS

Semi-structured interviews were conducted with patients in the immediate postpartum period. The interview guide explored: 1) timing and content of contraceptive counseling; 2) breastfeeding goals and expectations; 3) reasons for contraceptive choices; and 4) recommendations for counseling. Interview transcripts were coded to identify themes and analyzed.

RESULTS

Twenty interviews were conducted. The participants were reflective of our patient population in the Bronx, with ninety percent using Medicaid for insurance and fifteen percent concerned about food security in the past month, well-validated questions reflective of poverty and socioeconomic status. Three themes emerged from the interviews: (1) using contraception was described as a selfish decision by the mother without benefit to the newborn; (2) women felt pressure to breastfeed and saw the inability to breastfeed as a personal failure; and (3) medical providers were viewed as more trustworthy when it came to information regarding breastfeeding as opposed to contraceptive options, where decisions relied on anecdotes from friends or family.

CONCLUSIONS

Most decision-making regarding breastfeeding and contraception relied on the personal experiences of the participants and their friends and family. A clear need for support for women who are unable to breastfeed and education about the benefits of contraception for the newborn was identified.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.

Comparison of levonorgestrel level and creamatocrit in milk following immediate versus delayed postpartum placement of the levonorgestrel IUD

BACKGROUND

Breastfeeding and postpartum contraception critically influence infant and maternal health outcomes. In this pilot study, we explore the effects of timing and duration of postpartum levonorgestrel exposure on milk lipid and levonorgestrel content to establish baseline data for future research.

METHODS

This sub-study recruited a balanced convenience sample from 259 participants enrolled in a parent randomized controlled trial comparing immediate to delayed (4-8 weeks) postpartum levonorgestrel IUD placement. All planned to breastfeed, self-selected for sub-study participation, and provided the first sample at 4-8 weeks postpartum (before IUD placement for the delayed group) and the second four weeks later. We used the Wilcoxon rank sum (inter-group) and signed rank (intra-group) tests to compare milk lipid content (creamatocrit) and levonorgestrel levels between groups and time points.

RESULTS

We recruited 15 participants from the immediate group and 17 from the delayed group with 10 and 12, respectively, providing both early and late samples. Initially, median levonorgestrel concentration of the immediate group (n = 10) (32.5 pg/mL, IQR: 24.8, 59.4) exceeded that of the delayed group (n = 12) (17.5 pg/mL, IQR: 0.0, 25.8) (p = 0.01). Four weeks later, the values aligned: 26.2 pg/mL (IQR: 20.3, 37.3) vs. 28.0 pg/mL (IQR: 25.2, 40.8). Creamatocrits were similar between both groups and timepoints.

CONCLUSIONS

Immediate postpartum levonorgestrel IUD placement results in steady, low levels of levonorgestrel in milk without apparent effects on lipid content. These findings provide initial support for the safety of immediate postpartum levonorgestrel IUD initiation, though the study was not powered to detect noninferiority between groups.

TRIAL REGISTRATION

This randomized controlled trial was registered with ClinicalTrials.gov (Registry No. NCT01990703) on November 21, 2013.

Postplacental Insertion of Levonorgestrel Intrauterine System Versus Copper Intrauterine Device: A Prospective Study

Purpose

To compare between postplacental insertion of levonorgestrel intrauterine system versus copper intrauterine device regarding expulsion rates, patient satisfaction, complications, and continuation rates.

Methods

This prospective observational study was conducted on 1100 participants divided in to two groups: group (1) CU-IUD group and group (2) LNG-IUS group where women were assigned for postplacental insertion of either CU-IUD or LNG-IUS, respectively. Follow-up at 6 weeks, 3 and 6 months postpartum and data were collected and analyzed to evaluate outcomes.

Results

No statistical difference between both groups regarding patients' characteristics, the overall expulsion rate was higher in LNS-IUS group than CU-IUD group; 77 patients (14%) and 50 patients (9%), respectively, (P value < 0.05), odds ratio: 1.63 at CI: (1.12-2.37). No significant difference between the two groups regarding pain intensity, perforation, abnormal uterine bleeding, and clinical endometritis (P > 0.05). Overall satisfaction rate at six months was 478(87%) in the CU-IUD group and 472(85.8%) in the LNS-IUS group (P value > 0.05), odds ratio: 1.1 at CI: (0.78-1.55). Continuation rate at s6 months was comparable between the two groups 485 (88.2%) and 480 (87.3%) in CU-IUD group and LNS-IUS group respectively, (P value < 0.05), odds ratio: 1.09 at CI: (0.76-1.56).

Conclusion

The rate of expulsion of LNG-IUS is higher than copper IUD when inserted postplacental, yet the continuation and acceptability rates were comparable between the two groups.

The age of LARC: making sexual citizens on the frontiers of technoscientific healthism

Routinely positioned as the 'first-line option' for contraceptive choice-making, long-acting reversible contraception (LARC) promotion efforts have come under critical scrutiny by reproductive justice advocates for the extent to which public health actors' preference for LARC devices may override potential users' ability to freely (not) choose to use contraception among an array of options. We identify LARC promotion discourse as constituting 'The Age of LARC': multifarious strategies for producing responsible sexual citizens whose health behaviours are empowered via a LARC-only approach to contraceptive use. We suggest that immediate postpartum LARC insertion policies, which have proliferated in the U.S. since 2012, exemplify the new era of LARC hegemony, in which urgency, efficiency, cost-effectiveness, and outcomes dominate both health policy and clinical practice around these contraceptive technologies. By following these efforts to facilitate access to and use of immediate postpartum LARC, we find a discourse on sexual citizenship that paradoxically constructs sexual health freedom through the use of a single class of contraceptive technologies.

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

OBJECTIVES

To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.

STUDY ELIGIBILITY CRITERIA

We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.

STUDY APPRAISAL AND SYNTHESIS METHODS

We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.

RESULTS

We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65).

CONCLUSION

Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation

Introduction

Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter‐pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model.

Material and methods

Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow‐up was conducted in‐person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion‐related variables.

Results

Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re‐insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%.

Conclusions

Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re‐insertion and therefore longer‐term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

METHODS OF STUDY SELECTION

We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

TABULATION, INTEGRATION, AND RESULTS

We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A.

CONCLUSION

Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

Priorities for Contraception and Lactation Among Breast Pump-Dependent Mothers of Premature Infants in the Neonatal Intensive Care Unit

Objective: Determine the knowledge and priorities for postpartum contraception and lactation in mothers of premature infants. Design: Twenty-five mothers of premature infants (mean gestational age = 29.9 weeks) hospitalized in a tertiary neonatal intensive care unit (NICU) participated in a multi-methods study using a multiple-choice contraceptive survey and qualitative interview in the first 2 weeks postpartum. Data were analyzed using content analysis and descriptive statistics. Results: Although 60% of mothers planned to use contraception, all questioned the timing of postpartum contraceptive counseling while recovering from a traumatic birth and coping with the critical health status of the infant. All mothers prioritized providing mothers' own milk (MOM) over the use of early hormonal contraception because they did not want to "take any risks" with their milk. They had limited knowledge of risks for repeat preterm birth (e.g., prior preterm birth: n = 13, 52%; multiple birth: n = 9, 36%; no knowledge: n = 3, 12%); only two mothers (0.08%) were counseled about the risks of a short interpregnancy interval. Conclusion: The context of the infants' NICU admission and the mother's desire to "do what is best for the baby" by prioritizing MOM should be integrated into postpartum contraceptive counseling for this population.

Postpartum hormonal contraception in breastfeeding women

PURPOSE OF REVIEW

To provide an overview of recent research and guidelines regarding contraception and breastfeeding.

RECENT FINDINGS

Recent studies assessed lactogenesis, breastfeeding rates, and milk supply concerns in patients starting postpartum hormonal contraception. One study showed a small but statistically significant increase in milk supply concerns between users and nonusers of postpartum hormonal contraception. Mean time to lactogenesis and breastfeeding rates were similar between patients with immediate and delayed insertion of the levonorgestrel (LNG) implant in one study and the LNG intrauterine device (IUD) in another study. Two studies assessed nursing knowledge and attitudes toward postpartum contraception in breastfeeding women, showing that postpartum nurses had incorrect knowledge of contraceptive safety in this patient population. Both studies demonstrated persistent erroneous beliefs that depot medroxyprogesterone acetate (DMPA) adversely affects breastfeeding. In postpartum patients intending to breastfeed, more than half intended to initiate contraception within 6 weeks postpartum and few indicated effect on breastfeeding as a factor in their decision.

SUMMARY

There are no significant differences in lactogenesis, breastfeeding, and infant growth parameters between immediate postpartum (IPP) and delayed insertion of LNG implants and IUDs. Labor and delivery and postpartum nurses have persistent erroneous beliefs that DMPA negatively affects breastfeeding. Patients desire to use contraception postpartum but prenatal counseling rates and practices are of variable content and quality.

Immediate Postpartum Contraception: Intrauterine Device Insertion

Insertion of an intrauterine device (IUD) in the immediate postpartum period is a safe, evidence-based form of contraception appropriate for most women. Despite the higher risk of expulsion as compared with interval insertion, the benefits of insertion in the immediate postpartum period are significant and include improved rates of contraception continuance and reduced instances of short interval birth. Through shared decision making, midwives and other clinicians can assist women in clarifying their reproductive goals and understanding of contraceptive options, including this method. In response to identified gaps in knowledge and insertion technique among midwives, this article provides an overview of immediate postpartum IUD insertion, risks and benefits, and eligibility criteria and describes preinsertion, insertion, and postinsertion care.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications

Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. 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. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).

The Lactational Effects of Contraceptive Hormones: an Evaluation (LECHE) Study

OBJECTIVE

To estimate the proportion of women for whom use of hormonal contraception was associated with reporting a decreased breast milk supply.

STUDY DESIGN

The Lactational Effects of Contraceptive Hormones: an Evaluation ("LECHE") Study was an anonymous, internet-based, exploratory, cross-sectional survey of postpartum women using approximately 70 questions. Women were eligible to participate in the survey if they were 18 years or older, had a singleton infant between 3 and 9 months of age, had breastfed this infant for any amount of time and could read English. The survey included questions about breastfeeding, reproductive health, demographic characteristics and the timing of postpartum events.

RESULTS

A total of 3971 participants clicked on the survey. Our final study population included 2922 participants. Overall, 1201 (41%) reported having had milk supply concerns at some point in the first 12 weeks postpartum. The median time from birth until milk supply concerns was 3 weeks (IQR 1-7). Eight hundred fifty-two women (29%) started hormonal contraception in the first 12 weeks postpartum. Fifteen percent (127/852) of women reported new or additional milk supply concerns after starting hormonal contraception. Reported milk supply concerns were higher for women who used hormonal contraception than those who did not (44% vs. 40%; p=.05) Adjusted hazard ratios (HRs) assessing the association between contraceptive use and time to milk supply concerns were not statistically significant (HR 1.18, 95% confidence interval 0.94-1.47 for any type of hormonal contraception).

CONCLUSIONS

This study found a slightly increased proportion of reported milk supply concerns among women who started hormonal contraception.

IMPLICATIONS

It is important for caregivers in the postpartum period to recognize the potential for multiple factors, including initiation of hormonal contraception, to affect breastfeeding. Patient-centered counseling can help elicit women's values and preferences regarding breastfeeding and pregnancy prevention.

Placement of Levonorgestrel Intrauterine Device at the Time of Cesarean Delivery and the Effect on Breastfeeding Duration

Objectives: Studies have shown that immediate postpartum initiation of long-acting reversible contraception (LARC) methods leads to increased utilization of LARC and prevention of unintended pregnancies. It is unclear if immediate postpartum levonorgestrel-releasing intrauterine device (LNG-IUD) insertion has an effect on breastfeeding success. Study Design: This study was a secondary analysis of a randomized trial that compared intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean IUD placement with women who planned for interval IUD placement at 6 or more weeks postpartum. This parallel, 1:1, nonblinded randomized trial was conducted between March 2012 and June 2014 at the University of North Carolina Women's Hospital. We recruited pregnant women aged 18-45 years who were undergoing a cesarean delivery and desired an IUD for contraception postpartum. Results: We received breastfeeding information from 63 women who desired to use a LNG-IUD. A proportion analysis demonstrated that there was no difference in the proportion of women breastfeeding at any of the three time points, 6, 12, and 24 weeks, following placement. This remained true after adjusting for age, parity, and ethnicity. Conclusion: This study adds to the existing body of evidence that shows that most women are able to successfully breastfeed after immediate postpartum LNG-IUD placement. Women should be encouraged to breastfeed, and the desire to breastfeed should not preclude the initiation of a postplacental IUD. This study provides reassurance that immediate postpartum LNG-IUD placement does not adversely affect breastfeeding; however, more high-quality data are needed on the impact of hormonal IUDs on breastfeeding outcomes.

Hormonal contraception, breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.

The effect of immediate postpartum levonorgestrel contraceptive implant use on breastfeeding and infant growth: a randomized controlled trial

OBJECTIVE

This study assessed whether immediate postpartum insertion of levonorgestrel contraceptive implants is associated with a difference in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 and 6 months postpartum compared to delayed insertion at 6 to 8 weeks postpartum.

STUDY DESIGN

We conducted a randomized trial of women in Uganda who desired contraceptive implants postpartum. We randomly assigned participants to receive either immediate (within 5 days of delivery) or delayed (6 to 8 weeks postpartum) insertion of a two-rod levonorgestrel contraceptive implant system. This is a prespecified secondary analysis evaluating breastfeeding outcomes. The primary outcome of this secondary analysis was change in infant weight; infants were weighed and measured at birth and 6 months. We used a validated questionnaire to assess onset of lactogenesis daily in person while participants were in the hospital, and then daily by phone after they left the hospital, until lactogenesis was documented. We used interviewer-administered questionnaires to assess breastfeeding continuation and concerns at 3 months and 6 months postpartum.

RESULTS

Among the 96 women randomized to the immediate group and the 87 women to the delayed group, the mean change in infant weight from birth to 6 months was similar between groups: 4632 g in the immediate group and 4407 g in the delayed group (p=.26). Among the 97 women who had not experienced lactogenesis prior to randomization, the median time to onset of lactogenesis did not differ significantly between the immediate and delayed groups (65 h versus 63 h; p=.84). Similar proportions of women in the immediate and delayed groups reported exclusive breastfeeding at 3 months (74% versus 71%; p=.74) and 6 months (48% versus 52%; p=.58).

CONCLUSION

We found no association between the timing of postpartum initiation of levonorgestrel contraceptive implants and change in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 or 6 months postpartum.

IMPLICATIONS

This study provides evidence that immediate postpartum initiation of contraception implants does not have a deleterious effect on infant growth or initiation or continuation of breastfeeding.

Postpartum intrauterine devices: clinical and programmatic review

The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.