Urgent need to change clinical practices about postpartum contraception

In the United States, maternal mortality and unintended pregnancy rates are increasing. There are growing disparities in maternal health between indigent, minority women and Caucasian women of higher socioeconomic status. Family planning has long been viewed as a solution to these problems. As reliance on permanent contraception has diminished, timely access to highly effective contraceptive methods, namely long acting reversible contraceptives, which includes the contraceptive hormonal implant and intrauterine device- has become even more important. For women in the United States and abroad, the time of delivery is the one reliable opportunity for women to receive medical care. Consistently, research has shown that providing contraception in the immediate postpartum period is safe, effective, feasible and cost effective. However, misperceptions, lack of supplies, and reimbursement issues combine to defeat attempts to provide the most effective methods of contraception during that hospitalization. We believe that it is time to tackle the problem of unintended and rapid repeat pregnancy using an evidence-based, patient-centered paradigm and to eradicate systemic barriers blocking access to contraceptive methods during hospital stay. This editorial will outline some of the more compelling evidence supporting this move and will provide insights from successful programs.

Postpartum intrauterine device contraception: A review

AIM： To review the safety （infection, perforation） and efficacy （expulsion, continuation rates, pregnancy） of intrauterine device （IUD） insertion in the postpartum period. METHODS： MEDLINE, PubMed and Google Scholar were searched for randomized controlled trials and prospective cohort studies of IUD insertions at different times during the postpartum period. Time of insertion during the postpartum period was documented speci-fically, immediate post placenta period （within 10 min）, early post placenta period （10 min to 72 h）, and de-layed/interval period （greater than 6 wk）. Other study variables included mode of delivery, vaginal vs cesarean, manual vs use of ring forceps to insert the IUD. RESULTS： IUD insertion in the immediate postpartum （within 10 min of placental delivery）, early postpartum （10 min up to 72 h） and Interval/Delayed （6 wk onward） were found to be safe and effcacious. Expulsion rates were found to be highest in the immediate postpartum groups ranging from 14% to 27%. Immediate post placental insertion found to have expulsion rates that ranged from 3.6% to 16.2%. Expulsion rate was significantly higher after insertion following vaginal vs cesarean delivery. The rates of infection, perforation and unplanned pregnancy following postpartum IUD insertion are low. Method of insertion such as with ring forceps, by hand, or another placement method unique to the type of IUD did not show any signifcant difference in expulsion rates. Uterine perforations are highest in the delayed/interval IUD insertion groups.Breastfeeding duration and infant development are not affected by delayed/interval insertion of the non-hormonal （copper） IUD or the Levonorgestrel IUD. Timing of the Levonorgestrel IUD insertion may affect breastfeeding. CONCLUSION： IUD insertion is safe and efficacious during the immediate postpartum, early postpartum and delayed postpartum periods. Expulsion rates are highest after vaginal delivery and when inserted during the immediate postpartum period. IUD associated infection rates were not increased by insertion during the postpartum period over interval insertion rates. There is no evidence that breastfeeding is negatively affected by postpartum insertion of copper or hormone-secreting IUD. Although perforation rates were higher when inserted after lactation was initiated. Randomized controlled trials are needed to further elucidate the consequence of lactation on postpartum insertion. Despite the concerns regarding expulsion, perforation and breastfeeding, current evidence indicates that a favorable risk beneft ratio in support of postpartum IUD insertion. This may be particularly relevant for women for whom barriers exist in achieving desired pregnancy spacing.