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Galvin AM, Bergh RE, Walters ST, Lewis MA, Thompson EL. Exploring Postpartum Pregnancy Prevention Behaviors Among Women Experiencing Homelessness: A Mixed-Methods Analysis. J Midwifery Womens Health 2025; 70:77-87. [PMID: 39916670 DOI: 10.1111/jmwh.13657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/02/2024] [Indexed: 05/08/2025]
Abstract
INTRODUCTION Women experiencing homelessness are at higher risk of unintended pregnancy than women who are stably housed and may have unique reasons for not engaging in postpartum pregnancy prevention. This sequential explanatory mixed-methods study aimed to examine reasons women experiencing homelessness may not engage in pregnancy prevention during the postpartum period. METHODS Quantitative 2016-2019 Pregnancy Risk Assessment Monitoring System data regarding postpartum pregnancy prevention among recently pregnant women experiencing homelessness and women stably housed (n = 99,138) were analyzed with complex survey-weighted bivariate analysis. Primary outcomes included whether women engaged in postpartum contraception and key reasons for not engaging in postpartum contraception. Qualitative data from semistructured interviews with north Texas women (n = 12) recently pregnant and homeless were coded and thematically analyzed. Findings were triangulated using a woman-centered conceptual framework that facilitates meeting reproductive goals. RESULTS Women experiencing homelessness reported several statistically significant (P < .05) reasons for not using postpartum pregnancy prevention: currently pregnant, currently abstinent, cannot afford contraception, and partner not liking contraception. Key themes from interviews were related to internal factors (eg, perceived risk of pregnancy is high, current situation not good for having children); external factors (eg, my partner wants to have another child); perceptions of pregnancy (eg, children would be joyful, I want to get pregnant soon after I get housing), and salience of planning (eg, doesn't matter if we plan). DISCUSSION Findings highlight several key reasons for not engaging in postpartum pregnancy prevention among women experiencing homelessness. Findings lay the groundwork for interventions seeking to support individualized and evolving sexual and reproductive health goals within the context of needed housing and family resources.
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Affiliation(s)
- Annalynn M Galvin
- Department of Research, Cizik School of Nursing, University of Texas Health Science Center Houston, Houston, Texas
| | - Rebecca E Bergh
- Department of Research, Cizik School of Nursing, University of Texas Health Science Center Houston, Houston, Texas
| | - Scott T Walters
- Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Melissa A Lewis
- Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Erika L Thompson
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas
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Yin A, Zhou X, Qian X, Zhang L, Wang X, Yang H, Song Y, Jin L, Li M, Jiang H. Integrating a Postpartum Contraception Intervention in the Maternal and Child Health Care System of China: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2450635. [PMID: 39671197 PMCID: PMC11645651 DOI: 10.1001/jamanetworkopen.2024.50635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 10/22/2024] [Indexed: 12/14/2024] Open
Abstract
Importance The interpregnancy intervals are suboptimal worldwide, and women lack access to high-quality postpartum contraceptive services in China. Objective To evaluate the effectiveness of integrating postpartum contraceptive interventions into the existing maternal and child health care (MCH) system. Design, Setting, and Participants This cluster randomized trial randomly allocated 13 communities in Minhang District in Shanghai, China, to the intervention or the control group. Data were collected between September 2020 and February 2023. Eligible participants included women who registered their pregnancy in community health centers and were followed up to 1 year post partum. Data analysis was conducted from April 2023 to May 2024. Interventions Participants in the intervention group received postpartum contraception consultations, online educational videos, a 45-minute class, health prescriptions, and educational pamphlets at 5 stages in alignment with the MCH system of China. The control group received routine MCH services. Main Outcomes and Measures The primary outcome was incidence of unintended pregnancy within 1 year after childbirth. The secondary outcomes included knowledge level of postpartum contraception, utilization rate of reliable long-acting reversible contraception (LARC), and incidence of induced abortion. Results A total of 1279 participants (698 in intervention from 7 clusters and 581 in control from 6 clusters) were recruited, and 995 (521 older than 30 years [40.7%]; 539 intervention [54.2%] and 456 control [45.8%]) completed the trial. The incidence of unintended pregnancy, LARC utilization, and induced abortion within 1 year after childbirth was 1.5% (8 participants), 3.2% (17 participants), and 0.6% (3 participants), respectively, in the intervention group, and 3.9% (18 participants), 1.1% (5 participants), and 2.0% (9 participants), respectively, in the control group. Participants in the intervention group were significantly less likely to experience unintended pregnancy (adjusted odds ratio [aOR], 0.33; 95% CI, 0.16-0.70), had a higher rate of LARC utilization (aOR, 2.47; 95% CI, 1.02-5.98), and a lower rate of induced abortion due to unintended pregnancy (aOR, 0.30; 95% CI, 0.09-0.99). The postpartum contraception knowledge level in the intervention group was substantially higher than the control group (β = 24.20; 95% CI, 20.92-27.47). Conclusions and Relevance This cluster randomized clinical trial demonstrated the designed postpartum contraceptive interventions were effective in reducing unintended pregnancy and induced abortion and increasing postpartum contraception knowledge and LARC utilization among women at 1-year post partum. Trial Registration Chictr.org.cn Identifier: ChiCTR2000034603.
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Affiliation(s)
- AnXin Yin
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - XiaoYan Zhou
- Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Xu Qian
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - Lei Zhang
- Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - XiuRui Wang
- Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - HuiBin Yang
- Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - YuHan Song
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - LongMei Jin
- Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Mu Li
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Hong Jiang
- School of Public Health, National Health Commission Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
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Perkins E, Federspiel J, Bhattacharya D, de Los Reyes S. The association of insertion methods on immediate postpartum intrauterine device expulsion rates: A retrospective cohort study. Contraception 2024; 139:110532. [PMID: 38945350 PMCID: PMC11464192 DOI: 10.1016/j.contraception.2024.110532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To evaluate the method of immediate postpartum IUD (ppIUD) insertion (manual versus ring forceps) and expulsion rate within 6-week postpartum. STUDY DESIGN We performed a retrospective cohort study of patients who had a singleton vaginal delivery and an immediate ppIUD inserted at Rush University from January 2014 to September 2023. The primary outcome was rate of expulsion within 6-week postpartum. We compared the rate of expulsion by method of insertion, either using a manual technique versus using ring forceps. We performed univariable analysis for the association between baseline maternal characteristics and the primary outcome and we performed multivariable logistic regression to determine the independent association of the method of insertion and the primary outcome. RESULTS Two hundred nineteen patients met eligibility with 117 immediate ppIUDs inserted manually and 102 inserted with ring forceps. Baseline maternal demographics were similar across study groups. After adjusting for factors selected a priori (estimated blood loss, body mass index, gestational age at delivery, nulliparity, type of IUD), use of ring forceps was more likely to result in expulsion compared to manual insertion (30.4% vs 16.2% respectively; adjusted OR 2.49, 95% confidence interval 1.28-4.90). CONCLUSION In this retrospective analysis, insertion of immediate ppIUD with ring forceps was independently associated with an increased rate of expulsion within 6 weeks postpartum when compared to manual insertion. IMPLICATIONS In this setting, ring forceps was associated with high rates of immediate postpartum IUD expulsion compared to manual technique. Studies disagree, suggesting need for additional work.
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Affiliation(s)
- Elena Perkins
- Rush University Medical Center, Department of Obstetrics and Gynecology, Chicago, IL, United States.
| | - Jerome Federspiel
- Duke University School of Medicine, Department of Obstetrics and Gynecology, Department of Population Health Sciences, Department of Medicine, Durham, NC, United States
| | | | - Samantha de Los Reyes
- Rush University Medical Center, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Chicago, IL, United States
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Dahl CM, Turok D, Heuser CC, Sanders J, Elliott S, Pangasa M. Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape. Am J Obstet Gynecol 2024; 230:226-234. [PMID: 37536485 DOI: 10.1016/j.ajog.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023]
Abstract
The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.
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Affiliation(s)
- Carly M Dahl
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT.
| | - David Turok
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Cara C Heuser
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT; Department of Obstetrics and Gynecology, Intermountain Health, Salt Lake City UT
| | - Jessica Sanders
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Sarah Elliott
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
| | - Misha Pangasa
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City UT
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Singh R, Botfield JR. Postpartum contraception in Australia: opportunities for increasing access in the primary care setting. Aust J Prim Health 2024; 30:NULL. [PMID: 37879299 DOI: 10.1071/py23101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Rhea Singh
- SPHERE NHMRC Centre of Research Excellence, Monash University, Melbourne, Vic., Australia; and
| | - Jessica R Botfield
- SPHERE NHMRC Centre of Research Excellence, Monash University, Melbourne, Vic., Australia; and
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Thaxton L, Hofler LG. Prenatal Contraceptive Counseling. Obstet Gynecol Clin North Am 2023; 50:509-523. [PMID: 37500213 DOI: 10.1016/j.ogc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Lauren Thaxton
- Department of Women's Health, Dell Medical School, University of Texas, 2508 Greenlawn Parkway, Austin, TX 78757, USA
| | - Lisa G Hofler
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, 1 University of New Mexico, MSC10 5580, Albuquerque, NM 87131, USA.
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van Gastel D, Antheunis ML, Tenfelde K, van de Graaf DL, Geerts M, Nieboer TE, Bongers MY. Social Support Among Women With Potential Essure-Related Complaints: Analysis of Facebook Group Content. JMIR Form Res 2023; 7:e32592. [PMID: 37535412 PMCID: PMC10436114 DOI: 10.2196/32592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 03/01/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Social support groups are an important resource for people to cope with problems. Previous studies have reported the different types of support in these groups, but little is known about the type of reactions that sharing of personal experiences induce among members. It is important to know how and to what extent members of support groups influence each other regarding the consumption of medical care. We researched this in a web-based Facebook group of women sterilized with Essure. Essure was a device intended for permanent contraception. From 2015 onward, women treated with Essure for tubal occlusion raised safety concerns and numerous complaints. OBJECTIVE This study aimed to evaluate the use of social support in a Facebook community named "Essure problemen Nederland" (EPN; in English, "Essure problems in the Netherlands"). METHODS All posts in the closed Facebook group EPN between March 8 and May 8, 2018, were included. In total, 3491 Facebook posts were analyzed using a modified version of the Social Support Behavior Codes framework created by Cutrona and Suhr in 1992. Posts were abstracted and aggregated into a database. Two investigators evaluated the posts, developed a modified version of the Social Support Behavior Codes framework, and applied the codes to the collected data. RESULTS We found that 92% of messages contained a form of social support. In 68.8% of posts, social support was provided, and in 31.2% of posts, social support was received. Informational and emotional support was the most frequently used form of provided social support (40.6% and 55.5%, respectively). The same distribution was seen with received social support: informational support in 81.5% and emotional support in 17.4% of cases. Our analysis showed a strong correlation between providing or receiving social support and the main form of social support (P<.001). In a total of only 74 (2.2%) cases, women advised each other to seek medical care. CONCLUSIONS The main purpose of women in the EPN Facebook group was to provide and receive informational or emotional support or both.
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Affiliation(s)
| | - Marjolijn L Antheunis
- Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, Netherlands
| | - Kim Tenfelde
- Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, Netherlands
| | | | - Marieke Geerts
- Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, Netherlands
| | | | - Marlies Y Bongers
- Research School GROW, University Maastricht, Maastricht, Netherlands
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Jin L, Yin A, Zhang X, Jiang H, Zhou L, Zhou X, Wang X, Qian X. Integrating contraceptive services into existing perinatal care: protocol for a community-based cluster randomised controlled trial in Shanghai, China. BMJ Open 2023; 13:e066146. [PMID: 36944458 PMCID: PMC10032403 DOI: 10.1136/bmjopen-2022-066146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Postpartum contraception is essential to preventing unintended pregnancies and short interpregnancy intervals. The first year after childbirth is a critical period with a high risk of unintended pregnancy and induced abortion. However, the postpartum contraceptive services are weak in China's existing maternal and child healthcare system. We propose to evaluate the effects of integrating postpartum contraceptive services into the existing perinatal care system via a cluster randomised controlled trial. METHODS AND ANALYSIS This cluster randomised controlled trial involves all 13 communities of Minhang District, Shanghai, China. Communities will be randomly allocated, seven in the intervention group and six in the control group. One thousand and three hundred women, 100 women in each community, will be recruited in the study. Women assigned to the intervention group will receive postpartum contraceptive education and counselling during pregnancy, childbirth hospitalisation, postpartum home visits and the 42-day postpartum clinic check-up. Women in the control group will receive routine antenatal and postpartum care. Participants will be recruited in the first trimester during pregnancy and followed up to 1 year postpartum. The primary outcome is the incidence of unintended pregnancy within 1 year after childbirth. ETHICS AND DISSEMINATION The trial received ethical approval from the Ethics Committee of Shanghai Minhang District Maternal and Child Health Care Hospital (#[2020]KS-02, #[2020]KS-05, #[2020]KS-05-EX). Results will be published in academic journals and disseminated in multiple formats for the health professionals and the public. TRIAL REGISTRATION NUMBER ChiCTR2000034603.
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Affiliation(s)
- Longmei Jin
- Department of Woman Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Anxin Yin
- School of Public Health, Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - Xiaohua Zhang
- Department of Woman Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Hong Jiang
- School of Public Health, Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - Lu Zhou
- School of Public Health, Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
| | - Xiaoyan Zhou
- Department of Woman Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Xiurui Wang
- Department of Woman Health Care, Minhang District Maternal and Child Health Hospital, Shanghai, China
| | - Xu Qian
- School of Public Health, Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China
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Averbach S, Kully G, Hinz E, Dey A, Berkley H, Hildebrand M, Vaida F, Haider S, Hofler LG. Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial. JAMA 2023; 329:910-917. [PMID: 36943214 PMCID: PMC10031390 DOI: 10.1001/jama.2023.1936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/05/2023] [Indexed: 03/22/2023]
Abstract
Importance The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. Objective To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. Design, Setting, and Participants In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Interventions Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. Main Outcomes and Measures The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Results Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Conclusions and Relevance Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. Trial Registration ClinicalTrials.gov Identifier: NCT03462758.
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Affiliation(s)
- Sarah Averbach
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Gennifer Kully
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Erica Hinz
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of Illinois at Chicago
| | - Arnab Dey
- Center on Gender Equity and Health, University of California, San Diego, La Jolla
| | - Holly Berkley
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center, San Diego, California
| | - Marisa Hildebrand
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Complex Family Planning, University of California, San Diego, La Jolla
| | - Florin Vaida
- School of Public Health, Division of Biostatistics, University of California, San Diego, La Jolla
| | - Sadia Haider
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of Chicago, Chicago, Illinois
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, Rush University, Chicago, Illinois
| | - Lisa G. Hofler
- Department of Obstetrics and Gynecology, Division of Complex Family Planning, University of New Mexico, Albuquerque
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Krans EE, Chen BA, Rothenberger SD, Bogen DL, Jones K, Turocy MJ, Klocke LC, Schwarz EB. Increasing access to immediate postpartum contraceptive implants: a prospective clinical trial among patients with opioid use disorder. EUR J CONTRACEP REPR 2022; 27:478-485. [PMID: 36062524 PMCID: PMC9795857 DOI: 10.1080/13625187.2022.2114791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/30/2022] [Accepted: 08/14/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the effects of increased access to immediate postpartum contraceptive implants (IPI) on repeat pregnancy and contraceptive use rates among patients with opioid use disorder (OUD). MATERIALS AND METHODS Between 2016 and 2018, 194 postpartum patients with OUD were offered the option of IPI placement at an institution with limited immediate postpartum long-acting reversible contraception availability and followed for one-year postpartum. Differences in pregnancy rates between participants who did and did not choose IPI were examined using logistic regression with inverse probability of treatment weighting from propensity scores accounting for differences between the two groups. RESULTS Among 194 participants, 96 (49.5%) chose an IPI and 98 (50.5%) chose an alternative method or no contraception (non-IPI). Among IPI participants, 76 (80.9%) continued to use their implant at one-year postpartum. Overall, 19 participants had a repeat pregnancy and 11 (57.9%) were unintended. In multivariable analyses, repeat pregnancy was more likely among those who did not choose IPI (OR 9.90; 95% CI 3.58-27.03) than those who did. Participants with OUD and who used alcohol (11.66; 1.38, 98.20) or cocaine (2.72; 1.23, 5.99) during pregnancy were more likely to choose IPI. Participants who were married (0.28; 0.09, 0.89), engaged in OUD treatment prior to pregnancy (0.48; 0.25, 0.93), and happier when they found out about their pregnancy (0.87; 0.77, 0.98) were less likely to choose IPI. CONCLUSION Offering patients with OUD the option of IPI is associated with high utilisation and continuation rates, and low rates of repeat pregnancy within one-year postpartum.
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Affiliation(s)
- Elizabeth E Krans
- Magee-Womens Research Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions, Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Beatrice A Chen
- Magee-Womens Research Institute, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Scott D Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelley Jones
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Mary J Turocy
- Department of Family Medicine, Stanford University, Stanford, CA, USA
| | - Leah C Klocke
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Eleanor B Schwarz
- Center for Healthcare Policy and Research, Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
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Kaszubinski S. Placement of long-acting reversible contraception for minors who are mothers should not require parental consent. JOURNAL OF MEDICAL ETHICS 2022; 48:857-860. [PMID: 34261805 DOI: 10.1136/medethics-2020-106225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/02/2021] [Indexed: 06/13/2023]
Abstract
Decreasing unintended teenage pregnancy, especially repeat teenage pregnancy, is an important public health goal. Unfortunately, legal barriers in the USA impede this goal as all minors are unable to consent for birth control in 24 states, and only 10 of those states allow consent after the minor has given birth according to state statutory law. Placement of long-acting reversible contraception (LARC) is one of the most effective methods of preventing rapid repeat pregnancies. However, restrictions are placed on adolescents who may not have the option of parental consent if the parents are unwilling, or not present, to give consent. A predicament arises when healthcare professionals are willing to place the contraceptive for the patient, but cannot due to the restrictions and guidelines outlined by each state. Even though these adolescents are legally viewed as minors, adolescent mothers should be able to consent to the placement of LARC. Notably, adolescents have the legal ability to give consent for the healthcare of their child starting in the prenatal period. I argue that this ability should be extended to include adolescent consent for their own healthcare. Additionally, the procedure to place LARC is relatively low risk and highly effective, which is an opportune situation to allow minors to consent. Allowing adolescents to consent to LARC after delivery is a simple and effective way to decrease rapid repeat pregnancy rates in the USA.
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Sothornwit J, Kaewrudee S, Lumbiganon P, Pattanittum P, Averbach SH. Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception. Cochrane Database Syst Rev 2022; 10:CD011913. [PMID: 36302159 PMCID: PMC9612833 DOI: 10.1002/14651858.cd011913.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Jen Sothornwit
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Srinaree Kaewrudee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Porjai Pattanittum
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Sarah H Averbach
- OB/GYN and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
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Sothornwit J, Lumbiganon P, Saranrittichai K, Sangkomkamhang U, Singhdaeng T, Jampathong N. Barriers and Facilitators to Implementing Immediate Postpartum Contraceptive Implant Programs: A Formative Implementation Research. Int J Womens Health 2022; 14:945-956. [PMID: 35924095 PMCID: PMC9341331 DOI: 10.2147/ijwh.s370012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Abstract
Objective This study sought to identify the factors that act as barriers and facilitators to developing and implementing Immediate postpartum (IPP) insertion of contraceptive implants service according to the Consolidated Framework for Implementation Research (CFIR). Methods We conducted in-depth interviews and focus group discussions to explore IPP contraceptive implantation programs implemented in community, regional, and university hospitals in Thailand. The CFIR was used to guide the data collection and analyses. Results All CFIR domains were found to have an impact on planning and implementation. Out of 38 constructs, nine were identified as either barriers or facilitators, and four were determined to be both. Barriers included an insufficient training budget, lack of policy to support non-teenagers, disconnect among organizations, and lack of knowledge on the part of the clients. Facilitators included the relative advantage of implants over other contraceptive methods, reimbursement policy, laws that promote teenage autonomy, setting IPP implants as a key performance indicator (KPI), identifying project champions, and educating clients through antenatal counseling or multimedia intervention. Conclusion Barriers and facilitators to the successful implementation of an IPP contraceptive implant program were identified. In order to successfully implement this service, modifiable barriers should be overcome and facilitators should be strengthened. Strategies tailored to the local context should be developed to ensure the sustainability of the program. Educating clients is crucial and need both hospital- and community interventions.
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Affiliation(s)
- Jen Sothornwit
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Correspondence: Jen Sothornwit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, Email
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kesinee Saranrittichai
- Department of Health Behavior and Health Promotion, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | | | - Thanyarat Singhdaeng
- Department of Obstetrics and Gynecology, Nam Phong Hospital, Khon Kaen, Thailand
| | - Nampet Jampathong
- Cochrane Thailand, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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14
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Reed SD, Zhou X, Ichikawa L, Gatz JL, Peipert JF, Armstrong MA, Raine-Bennett T, Getahun D, Fassett MJ, Postlethwaite DA, Shi JM, Asiimwe A, Pisa F, Schoendorf J, Saltus CW, Anthony MS. Intrauterine device-related uterine perforation incidence and risk (APEX-IUD): a large multisite cohort study. Lancet 2022; 399:2103-2112. [PMID: 35658995 DOI: 10.1016/s0140-6736(22)00015-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Reports of perforation risk related to intrauterine devices (IUDs) inserted immediately post partum and among non-post-partum individuals are scarce, and previous studies with only 12-month follow-ups underestimate the risk. Breastfeeding at IUD insertion and insertion within 36 weeks post partum have been associated with increased risk of uterine perforation. The aim of these analyses was to compare the incidence and risks of IUD-related uterine perforations by non-post-partum and post-partum intervals at IUD insertion, and among post-partum individuals, to assess the impact of breastfeeding on these outcomes. METHODS We did a multisite cohort study in the USA, using electronic health records (EHR). Study sites were three health-care systems and a site that used data from a health-care information exchange. The study population included individuals who were aged 50 years or younger and had an IUD insertion between Jan 1, 2001, and April 30, 2018. Individuals were excluded if they had not been in the health-care system for at least 12 months before IUD insertion. The primary outcome for this analysis was any IUD-related uterine perforation diagnosis for the first IUD insertion in this time period. Both complete and partial IUD-related perforations were identified. Chart abstraction was done to validate EHR-based algorithms or confirm perforations. The crude rate and cumulative incidence of uterine perforation were evaluated by non-post-partum and post-partum intervals at IUD insertion in the full cohort, and by breastfeeding status in a subcohort of post-partum individuals. Cox models estimated crude and adjusted hazard ratios (aHRs). FINDINGS Data from 326 658 individuals in the full cohort and 94 817 individuals in the post-partum subcohort were analysed. In the full cohort, we identified 1008 uterine perforations (51·2% complete), with the 5-year cumulative incidence being the lowest in the non-post-partum group (0·29%, 95% CI 0·26-0·34). The aHR for the post-partum interval relative to non-post partum ranged from 2·73 (95% CI 1·33-5·63; 0 to 3 days post partum) to 6·71 (4·80-9·38; 4 days to ≤6 weeks post partum). The post-partum subcohort of individuals with breastfeeding information had 673 uterine perforations (62% complete), with a 5-year cumulative incidence of 1·37% (95% CI 1·24-1·52) and an increased risk with breastfeeding (aHR 1·37, 95% CI 1·12-1·66). INTERPRETATION Although the risk for uterine perforation with IUD insertion 4 days to 6 weeks or less post partum is nearly seven times that of insertion non-post partum, perforation remains an incredibly rare event for all clinical time points. Despite a slight increased risk of perforation with breastfeeding at IUD insertion, the benefits of breastfeeding and effective contraception generally outweigh risks and should have little clinical impact. Therefore, IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to assure an IUD insertion can occur. Careful follow-up of individuals at higher risk of uterine perforation is warranted. FUNDING Bayer AG.
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Affiliation(s)
- Susan D Reed
- Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, USA.
| | - Xiaolei Zhou
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - Laura Ichikawa
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Jeffrey F Peipert
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN, USA
| | - Mary Anne Armstrong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science at the Kaiser Permanente, Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Darios Getahun
- Department of Health Systems Science at the Kaiser Permanente, Bernard J Tyson School of Medicine, Pasadena, CA, USA; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Michael J Fassett
- Department of Obstetrics & Gynecology, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Jiaxiao M Shi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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15
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Abdel-Ghany A, Khalifa E, El-Din MZ, Ibrahim E, Abdallah A, Abdel-Aziz M, Abdel-Rasheed M, Abdel-Azim A. Intrapartum versus postpartum insertion of intrauterine device in women delivering by cesarean section. BMC Pregnancy Childbirth 2022; 22:365. [PMID: 35484530 PMCID: PMC9047375 DOI: 10.1186/s12884-022-04681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intrauterine device (IUD), being a reversible and effective contraception method, is the most widely used worldwide. This study aims to demonstrate the efficacy of IUD insertion during elective lower segment cesarean section (LSCS) versus its insertion six weeks postpartum. METHODS A cohort study was conducted on 200 women planned for elective cesarean delivery and desired IUD as a contraceptive method. They were allocated into two groups; group I, in which IUD was inserted during LSCS, and group II, in which IUD was inserted six weeks or more after LSCS. Both groups were compared regarding failed insertion, post-insertion pain, and uterine perforation. They were followed for one year for the incidence of menorrhagia, vaginal infection, IUD displacement/expulsion, missed threads, or unintended pregnancy. RESULTS Women in the second group showed a significantly higher incidence of failed insertion and uterine perforation than women in the first group. On the contrary, women in the first group showed a significantly higher incidence of missed threads than women in the second group. Regarding other consequences, there were no significant differences between both groups concerning menorrhagia, vaginal infection, IUD displacement/expulsion, or unintended pregnancy. CONCLUSION IUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.
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Affiliation(s)
- Ahmed Abdel-Ghany
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Eissa Khalifa
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mohamed Zeen El-Din
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Emad Ibrahim
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Ameer Abdallah
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mahmoud Abdel-Aziz
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mazen Abdel-Rasheed
- Reproductive Health Research Department, National Research Centre, 33 El-Buhouth St, Dokki, Cairo, 12622, Egypt.
| | - Alaa Abdel-Azim
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
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16
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Kroelinger CD, Okoroh EM, Uesugi K, Romero L, Sappenfield OR, Howland JF, Cox S. Immediate Postpartum Long-Acting Reversible Contraception: Review of Insertion and Device Reimbursement Policies. Womens Health Issues 2021; 31:523-531. [PMID: 34602326 DOI: 10.1016/j.whi.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous assessment of statewide policies on long-acting reversible contraception (LARC) indicate that an increasing number of states are implementing policies specifically for provision immediately postpartum, supported by current clinical guidelines. Less is known about how state policies describe payment methodologies for the insertion procedure and device costs. METHODS We conducted a systematic, web-based review of publicly available statewide policy language on immediate postpartum LARC among all 50 states. We examined the payor/s identified in the policy and policy type, if the policy included language on the global obstetric fee, whether providers and/or facilities were authorized to bill for procedure or device costs, and if the billing mechanism was identified as inpatient and/or outpatient services. RESULTS Three-fourths of states (76%; n = 38) had statewide policies on immediate postpartum LARC. All policies identified Medicaid as the payor, although two also included non-Medicaid plans. Language allowing for reimbursement separate from the global obstetric fee for insertion procedures was present in 76% of states; 23 states permit it and 6 do not. Device cost reimbursement separate from the fee was identified in more state policies (92%); 31 states allow it and 4 do not. More policies included inpatient or outpatient billing mechanisms for device costs (82%; n = 31) than insertion procedures (50%; n = 19). CONCLUSIONS Medicaid reimbursement policies for immediate postpartum LARC services vary by state reimbursement process, type, and mechanism. Observed differences indicate payment methodologies more often include the cost of the device than provider reimbursement (31 states vs. 23 states). Fewer than one-half of states offer reimbursement for provider insertion fees, a significant systems barrier to contraceptive access for women who choose LARC immediately postpartum.
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Affiliation(s)
- Charlan D Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Ekwutosi M Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Keriann Uesugi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Olivia R Sappenfield
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Julia F Howland
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Powell J, Fuentes-Rivera E, Darney B. Comparison of immediate postpartum contraception among women with a high versus low risk pregnancy in Mexico: a retrospective cohort study. BMJ Open 2021; 11:e048048. [PMID: 34341048 PMCID: PMC8330582 DOI: 10.1136/bmjopen-2020-048048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We tested whether women who reported high-risk pregnancies or deliveries were more likely to receive immediate postpartum contraception prior to discharge compared with normal-risk women in Mexico. METHODS This is a retrospective study using the National Health and Nutrition Survey. We classified women as high-risk based on reported complications in pregnancy and delivery. We used multivariable logistic regression to test the association of high-risk status and receipt of postpartum contraception (any modern method and Tier one methods) prior to discharge. RESULTS Our sample included 5030 deliveries (population N=3 923 657). Overall, 19.1% of the sample were high risk. Over 60% of women in the high-risk and normal-risk group received immediate postpartum contraception, but a greater proportion of high-risk women received a method (67% vs 61% normal risk; p<0.001). However, in multivariable models, there were no significant differences in receipt of any modern method or tier 1 method by risk group. CONCLUSION Women with high-risk pregnancies were not more likely to receive postpartum contraception than the normal-risk group, once accounting for sociodemographic and clinical factors. Prenatal and postpartum contraception counselling should address the health effects of high-risk pregnancies and interpregnancy intervals to improve maternal health outcomes.
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Affiliation(s)
- Jacqueline Powell
- Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Evelyn Fuentes-Rivera
- Center for Health Systems Research, Instituto Nacional de Salud Publica (INSP), Mexico City, Mexico
| | - Blair Darney
- Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
- Center for Population Health Research, Instituto Nacional de Salud Publica (INSP), Mexico City, Mexico
- School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR, USA
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18
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Averbach SH, Ermias Y, Jeng G, Curtis KM, Whiteman MK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Tepper NK, Jatlaoui TC. Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 223:177-188. [PMID: 32142826 DOI: 10.1016/j.ajog.2020.02.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/13/2020] [Accepted: 02/24/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Sarah H Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California San Diego, San Diego, CA.
| | - Yokabed Ermias
- School of Medicine, University of California San Diego, San Diego, CA
| | - Gary Jeng
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maura K Whiteman
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Erin Berry-Bibee
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
| | - Polly A Marchbanks
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Naomi K Tepper
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tara C Jatlaoui
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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19
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Barbieri MM, Juliato CRT, Bahamondes L, Surita FG. ENG-releasing subdermal implants in postpartum teenagers - an open-label trial study protocol. Reprod Health 2020; 17:100. [PMID: 32576199 PMCID: PMC7310555 DOI: 10.1186/s12978-020-00952-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/17/2020] [Indexed: 11/21/2022] Open
Abstract
Background Higher than expected adolescent pregnancy high rates continue globally, with repeated unplanned pregnancy (UP) in this age group is a public health problem. In Brazil, 16% of pregnancies occur in adolescents under 18 years old, with high maternal morbidity and mortality rates in this age group. Effective and safe contraception is required to reduce UP rates. The objective of our study is to evaluate acceptance of etonogestrel (ENG)-releasing subdermal contraceptive implant after childbirth, before discharge, as well as clinical performance up to one year after placement. Comparison between teenagers who opt for ENG-implant versus other contraceptive methods after childbirth will be also evaluated, specifically regarding UP, continuation and discontinuation rates and reasons, body composition, pelvic ultrasound characteristics and user satisfaction. Methods A non-randomized open-label trial will be conducted with teenagers after childbirth and followed up to one year at the Women’s Hospital, University of Campinas (UNICAMP), Campinas, Brazil. The study group will consist of patients who accepted to use ENG-implant and placed before discharge. The comparison group will include adolescents who choose to use other contraceptive methods at the first postpartum visit (42 ± 3 days after childbirth). All women will follow-up at 40–60 days postpartum, as well as, at 6 and 12 months post-enrollment. Patient satisfaction, contraceptive effectiveness, reasons of discontinuation, continuation rate and body composition will be evaluated. Transvaginal ultrasound and electric bio impedance tests will be performed at all follow-up appointments. A 5% significance level was assumed, as well as, a sampling error (absolute) for 10% prevalence. The sample size was calculated at n = 100, obtaining an estimate of 50 to 70 adolescents who would accept the method offered, according to the prevalence and sample error assumed. Discussion Long-acting reversible contraceptive (LARC) methods include subdermal implants and intrauterine contraceptives, are considered first line contraception for teenagers. Immediate postpartum use is a safe option, which significantly reduces rates of repeated UP and all the undesirable consequences inherent to this process. Trial registration This study was approved by the Ethics and Research Commission of UNICAMP (CAAE: 92869018.5.0000.5404) and the Brazilian Registry of Clinical Trials (REBEC): http://www.ensaiosclinicos.gov.br/rg/RBR-4z7bc6, (number 2.901.752).
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Affiliation(s)
- M M Barbieri
- Department of Obstetrics and Gynecology, School of Medical Science, University of Campinas, Av. Alexander Fleming, Campinas, SP, 101, Brazil
| | - C R T Juliato
- Department of Obstetrics and Gynecology, School of Medical Science, University of Campinas, Av. Alexander Fleming, Campinas, SP, 101, Brazil
| | - L Bahamondes
- Department of Obstetrics and Gynecology, School of Medical Science, University of Campinas, Av. Alexander Fleming, Campinas, SP, 101, Brazil
| | - F G Surita
- Department of Obstetrics and Gynecology, School of Medical Science, University of Campinas, Av. Alexander Fleming, Campinas, SP, 101, Brazil.
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Haider S, Stoffel C, Rankin K, Uesugi K, Handler A, Caskey R. A Novel Approach to Postpartum Contraception Provision Combined with Infant Care: A Randomized, Controlled Trial. Womens Health Issues 2020; 30:83-92. [PMID: 31964564 PMCID: PMC8696743 DOI: 10.1016/j.whi.2019.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 11/05/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unintended pregnancy among women with short interpregnancy intervals remains common. Women's attendance at the 4- to 6-week postpartum visit, when contraception provision often occurs, is low, whereas their attendance at well-baby visits is high. We aimed to evaluate if offering co-located contraceptive services to mothers at well-baby visits increases use of long-acting reversible contraception (LARC) at 5 months postpartum compared with usual care in a randomized, controlled trial. METHODS Women with infants aged 4.5 months or younger who were not using a LARC method and had not undergone sterilization were eligible. Generalized linear models were used to estimate risk ratios. Likability and satisfaction of the contraception visit were assessed. RESULTS Between January 2015 and January 2017, 446 women were randomized. LARC use at 5 months was 19.1% and 20.9% for the intervention and control groups, respectively, and was not significantly different after controlling for weeks postpartum (risk ratio, 0.85; 95% confidence interval, 0.59-1.23). Uptake of the co-located visit was low (17.7%), but the concept was liked; insufficient time to stay for the visit was the biggest barrier to uptake. Women who accepted the visit were more likely to use a LARC method at 5 months compared with women in the control group (risk ratio, 1.97; 95% confidence interval, 1.26-3.07). CONCLUSIONS Women perceived co-located care favorably and LARC use was higher among those who completed a visit; however, uptake was low for reasons including inability to stay after the infant visit. Intervention effects were possibly diluted. Future research should test a version of this intervention designed to overcome barriers that participants reported.
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Affiliation(s)
- Sadia Haider
- The University of Illinois at Chicago, Chicago, Illinois.
| | | | - Kristin Rankin
- The University of Illinois at Chicago, Chicago, Illinois
| | - Keriann Uesugi
- The University of Illinois at Chicago, Chicago, Illinois
| | - Arden Handler
- The University of Illinois at Chicago, Chicago, Illinois
| | - Rachel Caskey
- The University of Illinois at Chicago, Chicago, Illinois
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Iftikhar PM, Shaheen N, Arora E. Efficacy and Satisfaction Rate in Postpartum Intrauterine Contraceptive Device Insertion: A Prospective Study. Cureus 2019; 11:e5646. [PMID: 31700748 PMCID: PMC6822878 DOI: 10.7759/cureus.5646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/13/2019] [Indexed: 11/05/2022] Open
Abstract
Background Postpartum intrauterine contraceptive device (PPIUCD) reduces the rate of abortions and it is a cost-effective, reversible, and convenient choice of contraception. The objective of our study was to evaluate the efficacy and satisfaction rate in women with postpartum intrauterine contraceptive device insertion. Methods This prospective study of immediate PPIUCD insertion was conducted at our institute from March 2016 to February 2019. Approval from the Institutional Review Board (IRB) was taken before starting the study. A total of 372 women were enrolled in the study after taking informed consent. All the women were counseled regarding different methods of contraception and birth control during antenatal checkups, early labor and immediately postpartum (within 48 hours). All the enrolled women in the study were followed for three years to determine the satisfaction and success rate of PPIUCD continuation. We also kept the record of women who discontinued PPIUCD. Results After the exclusion criteria, 372 women were recruited in the study. The mean gestation age at the time of delivery was 38.5 weeks with a standard deviation (SD) of 1.45. All the women were followed for short-term and long-term complications and satisfaction rates. Out of 372, 51.07% of women (n = 190) had a spontaneous vaginal delivery, and 48.9% of women (n = 182) had a cesarean section but there was no significant long-term satisfaction outcome difference in both the groups. The highest success rate of the postpartum long-acting intrauterine contraceptive device was noted in patients who were counseled thoroughly in the antenatal and intrapartum period 61.5% as compared to those patients who were counseled either antenatally 42.2 %, intrapartum 35.4%, or immediate postpartum 22.4% alone. Conclusion PPIUCD insertion is an opportunity not to be missed. It allows women to obtain safe, long-acting, highly effective contraception while already within the medical system. More research data are needed in the literature with regard to counseling timings for PPIUCD insertion during the antenatal and postnatal period as it can affect the decision of women to prevent unplanned pregnancy. PPIUCD has one of the highest patient satisfaction rates among all the contraceptives.
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Affiliation(s)
| | - Nighat Shaheen
- Obstetrics and Gynecology, Cantonment General Hospital, Rawalpindi, PAK
| | - Ena Arora
- Obstetrics and Gynecology, Icahn School of Medicine, Mount Sinai, New York, USA
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Postabortion and Postpartum Intrauterine Device Provision for Adolescents and Young Adults. J Pediatr Adolesc Gynecol 2019; 32:S30-S35. [PMID: 31585616 DOI: 10.1016/j.jpag.2019.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/24/2019] [Accepted: 05/29/2019] [Indexed: 11/23/2022]
Abstract
Adolescents are at high risk for unintended pregnancy and rapid repeat pregnancy, both of which can be associated with negative health and social outcomes. Intrauterine device (IUD) use has been shown to decrease unintended pregnancy and rapid repeat pregnancy. Evidence supports IUD insertion postabortion and postpartum as safe and practical for nearly all women, including adolescent and young adult women. Providers of adolescent gynecology can play an important role in decreasing repeat and unintended pregnancy among adolescents by increasing access to IUDs, reducing barriers to care, and providing IUDs immediately postabortion and postpartum.
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Tyson NA. Reproductive Health: Options, Strategies, and Empowerment of Women. Obstet Gynecol Clin North Am 2019; 46:409-430. [PMID: 31378285 DOI: 10.1016/j.ogc.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contraception is paramount to the overall health and longevity of women. Most women in the United States use birth control in their reproductive lifetimes. All options should be available and easily accessible to permit individualization and optimization of chosen methods. Current contraceptive methods available in the United States are reviewed. Emergency contraception, contraception in the postpartum period, and strategies to tailor methods to those affected by partner violence are also addressed. Tables and flow charts help providers and patients compare various contraceptive methods, optimize the start of a method, and identify resources for addressing safety in those with underlying medical conditions.
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Affiliation(s)
- Nichole A Tyson
- Department of Obstetrics and Gynecology, The Permanente Medical Group, 1600 Eureka Road, Medical Office Building C, 3rd Floor, Roseville, CA 95661, USA; UC Davis Medical Center, Sacramento, CA, USA.
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Shaaban OM, Abbas AM, Mahmoud HR, Yones EM, Mahmoud A, Zakherah MS. Levonorgestrel emergency contraceptive pills use during breastfeeding; effect on infants' health and development. J Matern Fetal Neonatal Med 2019; 32:2524-2528. [PMID: 29463142 DOI: 10.1080/14767058.2018.1439470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The current study aims to evaluate the effect of the use of single packet of levonorgestrel emergency contraceptive pills (LNG-ECPs) during breastfeeding on the health and development of the nursing infant. MATERIALS AND METHODS The current study was an ancillary observational cohort study carried out in a university hospital. We counseled all women delivered and planning birth-space and breastfeed for at least 1 year for participation during postpartum hospital stay. Eligible participants for inclusion in the randomized controlled trial (NCT01111929) were allocated to receive adequate Lactational Amenorrhea Method (LAM) counseling (LAM-only group) or the LAM counseling in addition to counseling about LNG-ECPs use (LAM + emergency contraception (EC) group). These pills were to be used once if unprotected intercourse did occur after expiry of any of the LAM prerequisites and before the couples started to use a reliable method of contraception. We included the first 100 women in the LAM + EC who did use the pills and the first 100 women in the control group who completed the follow-up visits for 6 months to draw the infants' outcome. The primary outcome was the difference of anthropometric measurements of the infants at 3 and 6 months postpartum. Secondary outcome was the difference in the Psycho-social, fine and gross motor, and language development using Denver development screening test. RESULTS There were no statistical significant differences between both the groups regarding the infants' weight, length, head circumference, chest circumference, and mid-arm circumference at each visit (p > .05). Additionally, there were no statistically significant differences regarding all items (psycho-social, fine and gross motor, and language) of Denver development screening test between the infants in LAM-only and LAM + EC groups (p = .081). CONCLUSIONS The use of single packet of LNG-ECPs during breastfeeding not objectively affects health and development of nursing infants or subjectively affects the quantity of breast milk.
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Affiliation(s)
- Omar M Shaaban
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
| | - Ahmed M Abbas
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
| | - Hanaa R Mahmoud
- b Department of Obstetric and Gynecological Nursing , Faculty of Nursing, Assiut University , Assiut , Egypt
| | - Entsar M Yones
- b Department of Obstetric and Gynecological Nursing , Faculty of Nursing, Assiut University , Assiut , Egypt
| | - Ahmed Mahmoud
- c Department of Pediatrics, Faculty of Medicine , Assiut University , Assiut , Egypt
| | - Mahmoud S Zakherah
- a Department of Obstetrics and Gynecology , Faculty of Medicine, Assiut University , Assiut , Egypt
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Williams HR, Goad L, Treloar M, Ryken K, Mejia R, Zimmerman MB, Stockdale C, Hardy-Fairbanks A. Confidence and readiness to discuss, plan and implement postpartum contraception during prenatal care versus after delivery. J OBSTET GYNAECOL 2019; 39:941-947. [PMID: 31192762 DOI: 10.1080/01443615.2019.1586853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
No studies exist to determine the optimal timing to counsel women regarding postpartum contraception which means opportunities for immediate postpartum contraception are often missed. Women between the gestational ages of 250/7 and 356/7 weeks, meeting inclusion criteria and attending an outpatient clinic were offered to participate in the study. Subjects completed surveys querying readiness, capability and confidence in discussing and committing to a postpartum contraceptive plan. Two hundred and forty-three patients were enrolled in the study. Sixty-three percent of patients responded they considered that the best time for contraception discussion was the second or third trimester. More women reported a contraception plan was important or very important postpartum than prenatally (78% vs. 56%; p<.0001). More women reported feeling ready or very ready to discuss (82% vs. 66%; p<.0001), and ready or very ready to choose (84% vs. 64%; p<.007), capable or highly capable of choosing (90% vs. 79%; p=.0009) postpartum than prenatally. Postpartum, more women felt confident or very confident (98% vs. 90%; p=.0006) in their ability to use effective contraception after delivery. Women reported higher levels of readiness and capability to choose and discuss contraception postpartum than prenatally. Most women felt ready and capable to choose a contraceptive option prior to postpartum discharge. IMPACT STATEMENT What is already known on this subject? Short interpregnancy interval is associated with increased maternal and neonatal morbidity and mortality. Effective postpartum contraception can be decided upon and administered, thereby increasing the interval between subsequent pregnancies. What do the results of this study add? The results of this study demonstrate that women report high levels of readiness and capability to choose and discuss contraception before postpartum discharge. What are the implications of these findings for clinical practice and/or further research? These findings imply that further research is needed to determine how to use motivational interviewing to encourage pregnant women to make a postpartum contraception decision prior to the postpartum period to facilitate uptake of their contraceptive choice.
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Affiliation(s)
- Heather R Williams
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City , IA , USA
| | - Lindsay Goad
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine , Iowa City , IA , USA
| | - Mackenzie Treloar
- Department of Public Health, Biostatistics Counseling Center, University of Iowa , Iowa City , IA , USA
| | - Katherine Ryken
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City , IA , USA
| | - Rachel Mejia
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City , IA , USA
| | - M Bridget Zimmerman
- Department of Public Health, Biostatistics Counseling Center, University of Iowa , Iowa City , IA , USA
| | - Colleen Stockdale
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City , IA , USA
| | - Abbey Hardy-Fairbanks
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics , Iowa City , IA , USA
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Maternal Sociodemographic Characteristics, Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012-2013. Matern Child Health J 2019; 22:589-598. [PMID: 29460217 DOI: 10.1007/s10995-018-2428-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n = 2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12-4.31), experiencing infant loss (OR 7.17, 95% CI 2.57-19.97), working during pregnancy (OR 0.44, 95% CI 0.31-0.63) and not receiving dental care (OR 2.03, 95% CI 1.43-2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54-17.4), not receiving dental care (aOR 1.54, 95% CI 1.06-2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41-0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.
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Abbott JL, Carty JR, Hemman E, Batig AL. Effect of Follow-Up Intervals on Breastfeeding Rates 5-6 Months Postpartum: A Randomized Controlled Trial. Breastfeed Med 2019; 14:22-32. [PMID: 30412416 DOI: 10.1089/bfm.2018.0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare the effect of early versus traditional postpartum follow-up intervals on breastfeeding continuation rates 6 months postpartum. METHODS This randomized controlled trial enrolled primiparous women planning to breastfeed to a postpartum appointment either 2-3 weeks or 6-8 weeks after delivery. The primary outcome was the breastfeeding rate in each group 5-6 months after delivery. The study was powered to detect a 50% difference between groups assuming a 34% rate of breastfeeding at 6 months. Participants were contacted by phone 5-6 months after delivery to assess outcomes. RESULTS From March 2014 to July 2016, 649 women were screened and 344 enrolled as follows: 172 to 2-3 week and 172 to 6-8 week follow-up. Demographic, delivery, and support characteristics were similar between groups; however, average infant birth weight and the distribution of gestational ages at the time of delivery were different between groups (p < 0.05). Participants in the 2-3 week group had a breastfeeding rate of 57.7% 6 months following delivery and participants in the 6-8 week group had a rate of 59.3%. Early follow-up was associated with a relative risk of 0.97 (95% CI 0.79-1.19, p = 0.80) and an adjusted relative risk of 1.45 (95% CI 0.71-2.95, p = 0.31), when adjusted for confounding variables, for breastfeeding continuation at 5-6 months. CONCLUSIONS Breastfeeding rates at 5-6 months postpartum were comparable between both groups; early follow-up was not associated with an increased rate of breastfeeding. At 6 months postpartum, the breastfeeding rate in both groups approximated the Surgeon General's Healthy People 2020 goal of 60.6%. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (Identifier NCT02221895).
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Affiliation(s)
- Jonathan L Abbott
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington
| | - Jenava R Carty
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington
| | - Eileen Hemman
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington
| | - Alison L Batig
- Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, Washington
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Coleman-Minahan K, Dillaway CH, Canfield C, Kuhn DM, Strandberg KS, Potter JE. Low-Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2018; 50:189-198. [PMID: 30506996 PMCID: PMC6314803 DOI: 10.1363/psrh.12083] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use. METHODS In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum. RESULTS Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum. CONCLUSION Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.
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Affiliation(s)
- Kate Coleman-Minahan
- Assistant Professor, College of Nursing, University of Colorado Anschutz Medical Campus, Aurora
| | - Chloe H Dillaway
- Graduate Student at Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Caitlin Canfield
- Evaluation Manager, Evaluation and Research, Louisiana Public Health Institute, New Orleans
| | - Daniela M Kuhn
- Research Associate, Population Research Center, University of Texas at Austin
| | | | - Joseph E Potter
- Professor, Population Research Center, University of Texas at Austin
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Eliason SK, Bockarie AS, Eliason C. Postpartum fertility behaviours and contraceptive use among women in rural Ghana. Contracept Reprod Med 2018; 3:13. [PMID: 30151239 PMCID: PMC6100709 DOI: 10.1186/s40834-018-0066-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/15/2018] [Indexed: 11/11/2022] Open
Abstract
Background Although most women would want to wait for more than two years before having another baby, their fertility behaviours during the first year following birth may decrease or increase the length of the birth interval. The objectives of this study were to: assess how protected postpartum women in the Mfantseman municipal were against pregnancy, based on their patterns of amenorrhoea and sexual abstinence; determine the timing of postpartum contraception in relation to amenorrhoea and sexual abstinence; and determine the predictors of postpartum contraceptive use. Methods This was a prospective study carried out in the Mfantseman Municipality of the Central region of Ghana. Out of 1914 women attending antenatal clinic in the municipal within the study period, 1350 agreed to be part of the study to ascertain their postpartum fertility and contraceptive behaviours a year following delivery. These women were traced to their communities using telephone and house numbers provided and only 1003 of the women were finally traced and interviewed. The women were asked about their breastfeeding behaviour, postpartum sexual abstinence, duration of amenorrhoea and postpartum contraceptive use. Results The mean age of the respondents was 29.9 ± 6.5 years; adolescents constituted the least proportion (3.3%) of the women. More than half (54.1%) of the women had Middle, Junior secondary school or Junior high school education. Most (43.3%) of the women were married by means of traditional rites and more than half (51.4%) of them were petty traders. The mean durations of breastfeeding, amenorrhoea and sexual abstinence were 6.6 ± 2.8 months, 7.8 ± 3.8 months and 4.4 ± 3.1 months respectively, whilst mean time of first contraceptive uptake was 3.5 ± 2.7 months postpartum. The time to first use of modern contraceptive method during the postpartum period indicates that about 50% of the women had started use of modern contraceptive methods by 2.7 months postpartum, and occured 0.6 and 3.6 months before sexual relations and resumption of menses respectively. Occupation (likelihood ratio p = 0.013), area of residence (likelihood ratio p = 0.004), mode of delivery (likelihood ratio p < 0.001), breastfeeding (p = 0.024), period since delivery (p < 0.001), preferred number of children (p < 0.001) and parity (p < 0.001) were found to be predictors of postpartum contraceptive use. Conclusion Postpartum women in the Mfantseman municipal who did not use contraceptives or delayed in the use of contraceptives after birth were least likely to be protected against pregnancy in the post partum period, whilst those who adopted postpartum family planning were likely to be better protected because they were likely to adopt it within the first three months after birth and before the onset of sexual relations and first menses. The predictors of postpartum contraceptive use were breastfeeding pattern, occupation, parity, preferred number of children, period since delivery, place of residence and mode of delivery.
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Affiliation(s)
- Sebastian Kofi Eliason
- 1Department of Community Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Ansumana Sandy Bockarie
- 1Department of Community Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Cecilia Eliason
- 2FWACN School of Nursing and Midwifery, University of Ghana, Accra, Ghana
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Gurney EP, Sonalkar S, McAllister A, Sammel MD, Schreiber CA. Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery. Am J Obstet Gynecol 2018; 219:183.e1-183.e9. [PMID: 29870737 DOI: 10.1016/j.ajog.2018.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited. OBJECTIVE We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion. STUDY DESIGN In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months. RESULTS We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7-13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1-22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2-21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2-14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8-11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21-3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20-23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90-43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0-86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9-31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5. CONCLUSION This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow-up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.
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Torres LN, Turok DK, Clark EAS, Sanders JN, Godfrey EM. Increasing IUD and Implant Use Among Those at Risk of a Subsequent Preterm Birth: A Randomized Controlled Trial of Postpartum Contraceptive Counseling. Womens Health Issues 2018; 28:393-400. [PMID: 30227936 DOI: 10.1016/j.whi.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/30/2018] [Accepted: 05/07/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the impact of contraceptive counseling on the uptake of long-acting reversible contraception (LARC), namely, intrauterine devices and the contraceptive implant, by 3 months postpartum among women with a recent preterm birth. DESIGN We enrolled patients in a single-blinded, one-to-one, randomized, controlled trial to assess the impact of enhanced family planning counseling immediately after a viable preterm birth in the inpatient setting. Participants received either structured counseling with an emphasis on LARC by a family planning specialist (intervention) or routine postpartum care (control). We followed participants to the primary outcome of LARC use 3 months postpartum. RESULTS We followed 121 participants for 3 months. Primary outcome data were available for 119 participants (61 intervention, 58 control). We found no demographic differences between the groups. Participants in the intervention group were significantly more likely to use LARC at 3 months postpartum compared with controls (51% vs. 31%; p < .05). For every six women who received the counseling intervention, one additional woman was using a LARC method at 3 months. CONCLUSIONS After a preterm birth, brief LARC-focused, structured counseling before hospital discharge significantly increased LARC method use at 3 months postpartum.
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Affiliation(s)
- Leah N Torres
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, Salt Lake City, Utah.
| | - David K Turok
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, Salt Lake City, Utah
| | - Erin A S Clark
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, Salt Lake City, Utah
| | - Jessica N Sanders
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, Salt Lake City, Utah
| | - Emily M Godfrey
- University of Washington School of Medicine, Departments of Family Medicine and Obstetrics & Gynecology, Seattle, Washington
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Kumaraswami T, Rankin KM, Lunde B, Cowett A, Caskey R, Harwood B. Acceptability of Postpartum Contraception Counseling at the Well Baby Visit. Matern Child Health J 2018; 22:1624-1631. [DOI: 10.1007/s10995-018-2558-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Brunner Huber LR, Smith K, Sha W, Zhao L, Vick T. Factors associated with pregnancy intention among women who have experienced a short birth interval: findings from the 2009 to 2011 Mississippi and 2009 Tennessee Pregnancy Risk Assessment Monitoring System. Ann Epidemiol 2018; 28:372-376. [PMID: 29653799 DOI: 10.1016/j.annepidem.2018.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 03/07/2018] [Accepted: 03/24/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE One-third of all pregnancies in the United States are conceived within 18 months of a prior live birth. Preventing unintended pregnancies may help to decrease the prevalence of pregnancies with these short interpregnancy intervals. However, data on factors associated with pregnancy intention among women who have had short birth intervals are sparse. Pregnancy Risk Assessment Monitoring System data were used to further evaluate these associations. METHODS Because only Mississippi and Tennessee Pregnancy Risk Assessment Monitoring System include a survey question about birth interval length, this analysis was limited to women from those states who recently had a short birth interval (n = 384). Pregnancy intention and demographic, lifestyle, and reproductive data were obtained from surveys and birth certificates. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Nearly 76% of women with short birth intervals reported their pregnancy as unintended. Women who were non-Hispanic black or consumed alcohol during pregnancy had statistically significant increased odds of reporting the pregnancy with a short birth interval as being unintended (OR = 3.98; 95% CI: 1.73-9.16 and OR = 10.56; 95% CI: 1.80-61.83, respectively). CONCLUSIONS Although all women should be counseled on postpartum contraceptive use, findings suggest that important subpopulations of women may benefit from more targeted counseling during prenatal care visits and the immediate postpartum hospital stay regarding the importance of using contraception to not only better space pregnancies but also prevent unintended pregnancies.
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Affiliation(s)
| | - Kenesha Smith
- UNC Charlotte, Department of Public Health Sciences, Charlotte, NC
| | - Wei Sha
- UNC Charlotte, Department of Bioinformatics and Genomics, Charlotte, NC
| | - Liang Zhao
- UNC Charlotte, Department of Bioinformatics and Genomics, Charlotte, NC
| | - Tara Vick
- Carolinas Medical Center, Department of Obstetrics and Gynecology, Charlotte, NC
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Bernard C, Wan L, Peipert JF, Madden T. Comparison of an additional early visit to routine postpartum care on initiation of long-acting reversible contraception: A randomized trial. Contraception 2018; 98:223-227. [PMID: 29778586 DOI: 10.1016/j.contraception.2018.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate whether an early 3-week postpartum visit in addition to the standard 6-week visit increases long-acting reversible contraception (LARC) initiation by 8 weeks postpartum compared to the routine 6-week visit alone. STUDY DESIGN We enrolled pregnant and immediate postpartum women into a prospective randomized, non-blinded trial comparing a single 6-week postpartum visit (routine care) to two visits at 3 and 6 weeks postpartum (intervention), with initiation of contraception at the 3-week visit, if desired. All participants received structured contraceptive counseling. Participants completed surveys in-person at baseline and at the time of each postpartum visit. A sample size of 200 total participants was needed to detect a 2-fold difference in LARC initiation (20% vs. 40%). RESULTS Between May 2016 and March 2017, 200 participants enrolled; outcome data are available for 188. The majority of LARC initiation occurred immediately postpartum (25% of the intervention arm and 27% of the routine care arm). By 8 weeks postpartum, 34% of participants in the intervention arm initiated LARC, compared to 41% in the routine care arm (p=.35). Overall contraceptive initiation by 8 weeks was 83% and 84% in the intervention and routine care arms, respectively (p=.79). There was no difference between the arms in the proportion of women who attended at least one postpartum visit (70% vs. 74%, p=.56). CONCLUSION The addition of a 3-week postpartum visit to routine care does not increase LARC initiation by 8 weeks postpartum. The majority of LARC users desired immediate rather than interval postpartum initiation. CLINICAL TRIAL REGISTRATION Clinicaltrials.govNCT02769676 IMPLICATIONS: The addition of a 3-week postpartum visit to routine care does not increase LARC or overall contraceptive initiation by 8 weeks postpartum when the option of immediate postpartum placement is available. The majority of LARC users desired immediate rather than interval postpartum initiation.
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Affiliation(s)
- Caitlin Bernard
- Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Leping Wan
- Division of Clinical Research, Department of Obstetrics & Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Jeffrey F Peipert
- Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tessa Madden
- Division of Family Planning, Department of Obstetrics & Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO
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Benfield N, Hawkins F, Ray L, McGowan A, Floyd K, Africa D, Barreto M, Levi E. Exposure to routine availability of immediate postpartum LARC: effect on attitudes and practices of labor and delivery and postpartum nurses. Contraception 2018; 97:411-414. [DOI: 10.1016/j.contraception.2018.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/05/2018] [Accepted: 01/09/2018] [Indexed: 11/27/2022]
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Mackenzie D, Pfitzer A, Maly C, Waka C, Singh G, Sanyal A. Postpartum family planning integration with maternal, newborn and child health services: a cross-sectional analysis of client flow patterns in India and Kenya. BMJ Open 2018; 8:e018580. [PMID: 29615443 PMCID: PMC5892750 DOI: 10.1136/bmjopen-2017-018580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Maternal, newborn and child health (MNCH) services represent opportunities to integrate postpartum family planning (PPFP). Objectives were to determine levels of MNCH-family planning (FP) integration and associations between integration, client characteristics and service delivery factors in facilities that received programmatic PPFP support. DESIGN AND SETTING Cross-sectional client flow assessment conducted during May-July 2014, over 5 days at 10 purposively selected public sector facilities in India (4 hospitals) and Kenya (2 hospitals and 4 health centres). PARTICIPANTS 2158 client visits tracked (1294 India; 864 Kenya). Women aged 18 or older accessing services while pregnant and/or with a child under 2 years. INTERVENTIONS PPFP/postpartum intrauterine device-Bihar, India (2012-2013); Jharkhand, India (2009-2014); Embu, Kenya (2006-2010). Maternal, infant and young child nutrition/FP integration-Bondo, Kenya (2011-2014). PRIMARY OUTCOME MEASURES Proportion of visits where clients received integrated MNCH-FP services, client characteristics as predictors of MNCH-FP integration and MNCH-FP integration as predictor of length of time spent at facility. RESULTS Levels of MNCH-FP integration varied widely across facilities (5.3% to 63.0%), as did proportion of clients receiving MNCH-FP integrated services by service area. Clients travelling 30-59 min were half as likely to receive integrated services versus those travelling under 30 min (OR 0.5, 95% CI 0.4 to 0.7, P<0.001). Clients receiving MNCH-FP services (vs MNCH services only) spent an average of 10.5 min longer at the facility (95% CI -0.1 to 21.9, not statistically significant). CONCLUSIONS Findings suggest importance of focused programmatic support for integration by MNCH service area. FP integration was highest in areas receiving specific support. Integration does not seem to impose an undue burden on clients in terms of time spent at the facility. Clients living furthest from facilities are least likely to receive integrated services.
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Affiliation(s)
- Devon Mackenzie
- Jhpiego/Maternal and Child Survival Program, Washington, DC, USA
| | - Anne Pfitzer
- Jhpiego/Maternal and Child Survival Program, Washington, DC, USA
| | | | | | | | - Abanti Sanyal
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Krans EE, Kim JY, James AE, Kelley DK, Jarlenski M. Postpartum contraceptive use and interpregnancy interval among women with opioid use disorder. Drug Alcohol Depend 2018; 185:207-213. [PMID: 29462768 PMCID: PMC5889719 DOI: 10.1016/j.drugalcdep.2017.12.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/28/2017] [Accepted: 12/02/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to describe postpartum contraceptive utilization patterns among women with OUD and evaluate the relationship between postpartum contraceptive method choice and interpregnancy interval. METHODS A retrospective cohort study was conducted with women in Pennsylvania Medicaid with a diagnosis of OUD between 2008 and 2013. Postpartum contraceptive use within 90 days after delivery was identified through claims data and categorized by effectiveness (highly-effective, effective, and no method observed). Kaplan-Meier time-to-event analyses and multivariable-adjusted marginal Cox regression models were used to evaluate the relationship between postpartum contraceptive method choice and interpregnancy interval. Multivariable logistic regression analyses were used to identify risk factors predictive of a short interpregnancy interval (≤18 months). RESULTS We identified 7805 women (9260 pregnancies) who had a diagnosis of OUD. Nearly three-quarters (74.5%) had no contraceptive method observed, 18.1% received an effective method, and only 7.4% received a highly-effective method (LARC or female sterilization) during the postpartum period. In Kaplan-Meier analyses, no significant differences were found in the time-to-next pregnancy interval when an effective contraceptive method vs. no contraceptive method was used. In multivariable analysis, predictors of a significantly longer interpregnancy interval were LARC use (HR 0.43, 95% CI 0.26-0.69), gestational hypertension (HR 0.80, 95% CI 0.65-0.97), and age (HR 0.95, 95% CI 0.94-0.96). Approximately 20% of women with OUD had a short interpregnancy interval. CONCLUSION Few women with OUD use highly-effective postpartum contraception, which is protective against short interpregnancy intervals.
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Affiliation(s)
- Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA; Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA, 15213, USA.
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto St., Pittsburgh PA,15261, USA
| | - Alton Everette James
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto St., Pittsburgh PA,15261, USA
| | - David K. Kelley
- Department of Human Services, Commonwealth of Pennsylvania, 625 Forster St., Harrisburg, PA, 17120, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto St., Pittsburgh PA,15261, USA
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Loree AM, Gariepy A, Ruger JP, Yonkers KA. Postpartum Contraceptive use and Rapid Repeat Pregnancy Among Women who use Substances. Subst Use Misuse 2018; 53:162-169. [PMID: 28937912 PMCID: PMC6025459 DOI: 10.1080/10826084.2017.1327976] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postpartum contraception is especially important for women who use alcohol and other substances, given the risk of possible rapid repeat pregnancy and prenatal substance exposure. However, little is known about postpartum contraceptive use among women with substance use histories. OBJECTIVE To characterize postpartum contraceptive initiation, 24-month continuation, and rapid repeat pregnancy among women who used substances during pregnancy. METHODS This is a secondary analysis of 161 pregnant women who enrolled in a randomized clinical trial to treat substance use in pregnancy and completed at least one follow-up assessment. Women were eligible if they were less than 28 weeks gestation and reported alcohol or illicit drug use within the past 30 days. Participants were recruited from two hospital-based OB/GYN clinics between 2006 and 2010, and completed assessments at delivery and 3-, 12-, and 24-months postpartum. RESULTS Past 30-day use of any substance (not including tobacco) was 52.4%, 58.3%, and 59.8% at 3-, 12-, and 24-month follow-up, respectively. Marijuana was the most commonly reported illicit substance (as high as 48.1%). Rates of any contraceptive use were 71.3%, 66.7% and 65.3% at 3-, 12-, and 24-month follow-up, respectively; DepoProvera and condoms were the most common methods. Rapid repeat pregnancy occurred in 28% of participants by 24-month follow-up. Conclusions/Importance: Postpartum contraceptive use among substance using women was at or near 70%, which is comparable to other samples of postpartum women. Innovative efforts are needed to promote effective contraceptive use among postpartum women in general and among those who use substances in particular.
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Affiliation(s)
- Amy M Loree
- a Psychology Service, VA Connecticut Healthcare System , West Haven , Connecticut , USA.,b Department of Psychiatry, Yale School of Medicine , New Haven , Connecticut , USA
| | - Aileen Gariepy
- c Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine , New Haven , Connecticut , USA
| | - Jennifer Prah Ruger
- d Department of Medical Ethics and Health Policy , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , Pennsylvania , USA
| | - Kimberly A Yonkers
- b Department of Psychiatry, Yale School of Medicine , New Haven , Connecticut , USA.,c Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine , New Haven , Connecticut , USA
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Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers. Matern Child Health J 2017; 20:132-143. [PMID: 27342600 PMCID: PMC5290059 DOI: 10.1007/s10995-016-2044-7] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.
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Averbach S, Kakaire O, Kayiga H, Lester F, Sokoloff A, Byamugisha J, Dehlendorf C, Steinauer J. Immediate versus delayed postpartum use of levonorgestrel contraceptive implants: a randomized controlled trial in Uganda. Am J Obstet Gynecol 2017; 217:568.e1-568.e7. [PMID: 28610898 DOI: 10.1016/j.ajog.2017.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/12/2017] [Accepted: 06/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Use of long-acting, highly effective contraception has the potential to improve women's ability to avoid short interpregnancy intervals, which are associated with an increased risk of maternal morbidity and mortality, and preterm delivery. In Uganda, contraceptive implants are not routinely available during the immediate postpartum period. OBJECTIVE The purpose of this study was to compare the proportion of women using levonorgestrel contraceptive implants at 6 months after delivery in women randomized to immediate or delayed insertion. STUDY DESIGN This was a randomized controlled trial among women in Kampala, Uganda. Women who desired contraceptive implants were randomly assigned to insertion of a 2-rod contraceptive implant system containing 75 mg of levonorgestrel immediately following delivery (within 5 days of delivery and before discharge from the hospital) or delayed insertion (6 weeks postpartum). The primary outcome was implant utilization at 6 months postpartum. RESULTS From June to October 2015, 205 women were randomized, 103 to the immediate group and 102 to the delayed group. Ninety-three percent completed the 6 month follow-up visit. At 6 months, implant use was higher in the immediate group compared with the delayed group (97% vs 68%; P < .001), as was the use of any highly effective contraceptive (98% vs 81%; P = .001). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again (P = .01). There were no serious adverse events in either group. CONCLUSION Offering women the option of initiating contraceptive implants in the immediate postpartum period has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals, and help women achieve their reproductive goals.
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Affiliation(s)
- Sarah Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Department of Reproductive Medicine, University of California, San Diego, San Diego, CA.
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Herbert Kayiga
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Felicia Lester
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Abby Sokoloff
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Christine Dehlendorf
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Jody Steinauer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Coleman-Minahan K, Aiken ARA, Potter JE. Prevalence and Predictors of Prenatal and Postpartum Contraceptive Counseling in Two Texas Cities. Womens Health Issues 2017; 27:707-714. [PMID: 28662935 PMCID: PMC5694359 DOI: 10.1016/j.whi.2017.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/07/2017] [Accepted: 05/15/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants. METHODS We used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using χ2 tests and logistic regression. RESULTS One-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice. CONCLUSIONS Prenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.
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Affiliation(s)
- Kate Coleman-Minahan
- College of Nursing, University of Colorado Denver, Aurora, Colorado; Population Research Center, University of Texas at Austin, Austin, Texas.
| | - Abigail R A Aiken
- Population Research Center, University of Texas at Austin, Austin, Texas; LBJ School of Public Affairs, University of Texas at Austin, Austin, Texas
| | - Joseph E Potter
- Population Research Center, University of Texas at Austin, Austin, Texas
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Women's experiences with immediate postpartum intrauterine device insertion: a mixed-methods study. Contraception 2017; 97:219-226. [PMID: 29080696 DOI: 10.1016/j.contraception.2017.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/12/2017] [Accepted: 10/17/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe women's pain and experiences with immediate postpartum intrauterine device (IUD) insertion (IPPI) following vaginal delivery using a ring forceps insertion technique. STUDY DESIGN This observational mixed-methods study included women who underwent successful IPPI using ring forceps, with and without epidural analgesia. To describe women's pain during the procedure, we recruited women during antenatal care and at the time of admission for delivery until we collected at least 30 sets of pain scores at two time points (preprocedure and immediately postprocedure) in both groups using two instruments: 100-mm visual analogue scale (VAS) and a 4-point Likert verbal rating scale (VRS) (0=none, 1=mild, 2=moderate, 3=severe). After placing the IUD, physicians rated ease of IUD insertion. A subset of participants in both groups underwent semistructured interviews prior to hospital discharge. Our goal was to explore women's (a) decisional influences and prior contraception experience, (b) experience during IPPI and (c) decisional regret. We conducted iterative analysis of interview content until thematic saturation was reached in both groups. Interviewees provided recall pain scores and rated satisfaction with IPPI. RESULTS We collected 30 pain scores in the no-epidural group and 36 in the epidural group. At both time points, the VAS data exhibited very low pain scores in the epidural group and a uniform distribution in the no-epidural group; standard deviations were large. The majority of women in both groups reported "none-mild" pain on the VRS. Physicians reported minimal difficulty with IUD insertion in most cases. We conducted interviews with 12 women who had an epidural and 9 who did not. Both groups offered similar comments across all domains. Convenience was the primary motivation to undergo IPPI, and women recognized the barriers to obtaining effective contraception remote from delivery. The majority of interviewees, even those with high pain scores, characterized their procedural pain as less than expected, and IUD insertion pain was less than or similar to labor pain. Interviewees' recall pain scores were similar to those reported at the time of IUD insertion. An unanticipated theme that emerged was an ineffective informed consent process; women could not recall most procedural risks or how IPPI was accomplished. All interviewees endorsed IPPI, expressing a high degree of satisfaction; none regretted undergoing the procedure. CONCLUSION The distributions of our VAS scores did not reveal useful summary statistics in either group. The VRS scores were a more informative representation of women's pain during IPPI; most women reported little pain. Convenience of obtaining highly effective contraception immediately postpartum was the key motivator for undergoing IPPI. All women voiced favorable experiences, even those who had high pain scores. IMPLICATIONS Women in our study overwhelmingly described less pain than anticipated with IPPI and also reported a high degree of satisfaction. Our study offers valuable patient-centered guidance to inform antenatal contraceptive counseling with respect to IPPI and lays the groundwork for ongoing research towards optimizing women's experiences with the procedure.
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Long-Acting Reversible Contraception Initiation With a 2- to 3-Week Compared With a 6-Week Postpartum Visit. Obstet Gynecol 2017; 130:788-794. [PMID: 28885429 DOI: 10.1097/aog.0000000000002246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether a department policy changing the scheduling of the postpartum visit from 6 weeks to 2-3 weeks after delivery is associated with higher long-acting reversible contraception initiation at the postpartum visit. METHODS We conducted a quasiexperimental before-after study to evaluate long-acting reversible contraception initiation, specifically an intrauterine device or contraceptive implant, at the postpartum visit between women scheduled for follow-up at 6 weeks (before policy change) and 2-3 weeks after delivery (after policy change). Secondary outcomes included postpartum visit completion, overall contraception initiation at the postpartum visit, overall contraceptive use at 6 months after delivery, and repeat pregnancies by 6 months postpartum. We obtained delivery and postpartum information using the electronic medical record and contacted participants 3 and 6 months after delivery to assess contraception use and repeat pregnancies. RESULTS We enrolled 586 participants between December 2014 and November 2015, of whom 512 women (256 in each cohort) continued to meet eligibility criteria after delivery. Long-acting reversible contraception initiation rates at the postpartum visit were lower in the 2- to 3-week (16.5%, 95% CI 12.2-21.8) compared with the 6-week group (31.1%, 95% CI 25.2-37.7, P<.01), primarily as a result of patient and health care provider preferences for delaying intrauterine device insertion to a later visit. More women completed a scheduled 2- to 3-week postpartum visit (90.2%, 95% CI 86.0-93.3) compared with a 6-week visit (81.6%, 95% CI 76.4-85.9, P<.01). Deferral of any contraception initiation was higher in the 2- to 3-week group (27.3%, 95% CI 21.9-33.4) compared with the 6-week group (15.8%, 95% CI 11.5-21.4, P<.01), but there were no differences in overall contraceptive use patterns at 6 months postpartum. No intrauterine device perforations or expulsions were observed in women who underwent insertion at 2-3 weeks postpartum. Five pregnancies were reported in each cohort by 6 months after delivery. CONCLUSION Scheduling a visit at 2-3 weeks after delivery was not associated with increased long-acting reversible contraception initiation at this visit despite higher postpartum visit attendance.
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Eggebroten JL, Sanders JN, Turok DK. Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis. Am J Obstet Gynecol 2017; 217:51.e1-51.e7. [PMID: 28342716 DOI: 10.1016/j.ajog.2017.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/07/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND In-hospital placement of intrauterine devices and contraceptive implants following vaginal and cesarean delivery is increasingly popular and responds to maternal motivation for highly effective postpartum contraception. Immediate postpartum intrauterine device insertion is associated with higher expulsion than interval placement, but emerging evidence suggests that the levonorgestrel intrauterine device may have a higher expulsion rate than the copper intrauterine device. OBJECTIVE This study evaluated in-hospital provision, expulsion, and 6-month continuation of immediate postpartum copper T380 intrauterine devices, levonorgestrel intrauterine devices, and contraceptive implants. STUDY DESIGN We offered enrollment in this prospective observational trial to women presenting to the University of Utah labor and delivery unit from October 2013 through February 2016 who requested an intrauterine device or implant for postpartum contraception during prenatal care or hospitalization at the time of delivery. Following informed consent, participants completed questionnaires prior to hospital discharge and at 3 and 6 months postpartum. Data on expulsions at 6 months were validated by chart abstraction. RESULTS During the study period, 639 patients requested a postpartum intrauterine device or implant and 350 patients enrolled in prospective follow-up prior to discharge from the hospital. Among enrollees, 325 (93%) received their preferred contraceptive device prior to hospital discharge: 88 (27%) copper intrauterine device users, 123 (38%) levonorgestrel intrauterine device users, and 114 (35%) implant users. Participants predominantly were Hispanic (90%), were multiparous (87%), reported a household income <$24,000 per year (87%), and underwent a vaginal delivery (77%). At 6 months postpartum, 289 of 325 device recipients (89%) completed follow-up. Among levonorgestrel intrauterine device users 17% reported expulsions relative to 4% of copper intrauterine device users. The adjusted hazard ratio for expulsion was 5.8 (confidence interval, 1.3-26.4). There was no statistically significant difference in expulsions by delivery type or continuation by device type. Among the 21 women who experienced intrauterine device expulsions, 14 (67%) requested a replacement long-acting reversible contraception device for contraception. The 6-month device continuation was ≥80% for all device types. CONCLUSION An immediate postpartum long-acting reversible contraception program effectively provides women who desire highly effective reversible contraceptive devices with their method of choice prior to hospital discharge. Immediate postplacental levonorgestrel intrauterine device users have higher expulsion rates than copper intrauterine device users, but >8 of 10 women initiating an intrauterine device or implant continue use at 6 months postpartum.
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Affiliation(s)
| | - Jessica N Sanders
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
| | - David K Turok
- University of Utah Department of Obstetrics and Gynecology, Salt Lake City, UT
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Abstract
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.
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Bryant AG, Bauer AE, Stuart GS, Levi EE, Zerden ML, Danvers A, Garrett JM. Etonogestrel-Releasing Contraceptive Implant for Postpartum Adolescents: A Randomized Controlled Trial. J Pediatr Adolesc Gynecol 2017; 30:389-394. [PMID: 27561981 DOI: 10.1016/j.jpag.2016.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/27/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women. DESIGN Non-blinded, randomized controlled trial. SETTING AND PARTICIPANTS Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina. INTERVENTIONS Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit. MAIN OUTCOME MEASURES Contraceptive implant use at 12 months postpartum. RESULTS Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02). CONCLUSION Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.
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Affiliation(s)
- Amy G Bryant
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Anna E Bauer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gretchen S Stuart
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erika E Levi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew L Zerden
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Antoinette Danvers
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joanne M Garrett
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Intrauterine Devices and Contraceptive Implants: Overview of Options and Updates on Method Use. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0200-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Sothornwit J, Werawatakul Y, Kaewrudee S, Lumbiganon P, Laopaiboon M, Cochrane Fertility Regulation Group. Immediate versus delayed postpartum insertion of contraceptive implant for contraception. Cochrane Database Syst Rev 2017; 4:CD011913. [PMID: 28432791 PMCID: PMC6478153 DOI: 10.1002/14651858.cd011913.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The spacing of pregnancies has a positive impact on maternal and newborn health. The progestin contraceptive implant, which is a long-acting, reversible method of contraception, has a well-established low failure rate that is compatible with tubal sterilization. The standard provision of contraceptive methods on the first postpartum visit may put some women at risk of unintended pregnancy, either due to loss to follow-up or having sexual intercourse prior to receiving contraception. Therefore, the immediate administration of contraception prior to discharge from the hospital that has high efficacy may improve contraceptive prevalence and prevent unintended pregnancy. OBJECTIVES To compare the initiation rate, effectiveness, and side effects of immediate versus delayed postpartum insertion of implant for contraception. SEARCH METHODS We searched for eligible studies up to 28 October 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE. We examined review articles and contacted investigators. We also 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 randomised controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant for contraception. DATA COLLECTION AND ANALYSIS Two review authors (JS, YW) 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 or SK). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables. MAIN RESULTS Three studies that included 410 participants met the inclusion criteria of the review. We did not identify any ongoing trials. Two included studies were at low risk of selection, attrition, and reporting biases, but were at high risk of performance and detection biases due to the inability to blind participants to the intervention. One included study was at high risk of attrition bias. The overall quality of the evidence for each comparison ranged from very low to moderate; the main limitations were risk of bias and imprecision.Initiation rate of contraceptive implants at the first postpartum check-up visit was significantly higher in the immediate insertion group than in the delayed insertion group (RR 1.41, 95% CI 1.28 to 1.55; three studies, 410 participants; moderate quality evidence).There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant used at six months after insertion (RR 1.02, 95% CI 0.93 to 1.11; two studies, 125 participants; low quality evidence) or at 12 months after insertion (RR 1.04; 95% CI 0.81 to 1.34; one study, 64 participants;very low quality evidence)Women who received an immediate postpartum contraceptive implant insertion had a higher mean number of days of abnormal vaginal bleeding within six weeks postpartum (MD 5.80 days, 95% CI 3.79 to 7.81; one study, 215 participants; low quality evidence) and a higher rate of other side effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; one study, 215 participants; low quality evidence) than those who received a delayed postpartum insertion. There appeared to be little or no difference between the groups in heavy, irregular vaginal bleeding or associated severe cramping within 12 months (RR 1.01, 95% CI 0.72 to 1.44, one study, 64 participants;very low quality evidence).It was unclear whether there was any difference between the groups in scores for participant satisfaction on a 0-10 scale (MD -0.40, 95% CI -1.26 to 0.46, low quality evidence), or in rates of unintended pregnancy (RR 1.82, 95% CI 0.38 to 8.71, 1 RCT, 64 women, very low quality evidence) at 12 months, or in rate of breastfeeding rate at six months (RR 2.01, 95% CI 0.72 ro 5.63, 1 RCT, 64 women, very low quality evidence) rate did not differ significantly between the groups. AUTHORS' CONCLUSIONS Evidence from this review indicates that the rate of initiation of contraceptive implant at the first postpartum check-up visit was higher with immediate postpartum insertion than with delayed insertion. There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant use at 6 months. It was unclear whether there was any difference between the groups in continuation of contraceptive use at 12 months or in the unintended pregnancy rate at 12 months.
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Affiliation(s)
- Jen Sothornwit
- Faculty of Medicine, Khon Kaen UniversityDepartment of Obstetrics and GynaecologyKhon KaenThailand
| | - Yuthapong Werawatakul
- Faculty of Medicine, Khon Kaen UniversityDepartment of Obstetrics and GynaecologyKhon KaenThailand
| | - Srinaree Kaewrudee
- Faculty of Medicine, Khon Kaen UniversityDepartment of Obstetrics and GynaecologyKhon KaenThailand
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Zerden ML, Stuart GS, Charm S, Bryant A, Garrett J, Morse J. Two-week postpartum intrauterine contraception insertion: a study of feasibility, patient acceptability and short-term outcomes. Contraception 2017; 95:65-70. [DOI: 10.1016/j.contraception.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
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Postpartum Visit Attendance Increases the Use of Modern Contraceptives. J Pregnancy 2016; 2016:2058127. [PMID: 28070422 PMCID: PMC5187481 DOI: 10.1155/2016/2058127] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/18/2016] [Accepted: 11/22/2016] [Indexed: 11/25/2022] Open
Abstract
Background. Delays in postpartum contraceptive use may increase risk for unintended or rapid repeat pregnancies. The postpartum care visit (PPCV) is a good opportunity for women to discuss family planning options with their health care providers. This study examined the association between PPCV attendance and modern contraceptive use using data from a managed care organization. Methods. Claims and demographic and administrative data came from a nonprofit managed care organization in Virginia (2008–2012). Information on the most recent delivery for mothers with singleton births was analyzed (N = 24,619). Routine PPCV (yes, no) and modern contraceptive use were both dichotomized. Descriptive analyses provided percentages, frequencies, and means. Multiple logistic regression was conducted and ORs and 95% CIs were calculated. Results. More than half of the women did not attend their PPCV (50.8%) and 86.9% had no modern contraceptive use. After controlling for the effects of confounders, women with PPCV were 50% more likely to use modern contraceptive methods than women with no PPCV (OR = 1.50, 95% CI = 1.31, 1.72). Conclusions. These findings highlight the importance of PPCV in improving modern contraceptive use and guide health care policy in the effort of reducing unintended pregnancy rates.
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