By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: In this retrospective cohort study of 1,015 women at one institution, there was no association between type of contraceptive prescribed immediately postpartum and attendance at the postpartum visit.
SOURCE: Chiruvella M, Schaffir J, Benedict JA, et al. Is provision of contraception at discharge following delivery associated with postpartum visit attendance? Contraception 2021;103:103-106.
The postpartum period, often called the fourth trimester, is an opportunity to provide patients with important healthcare interventions after delivery. Therefore, it is critical to examine any factors that may either promote or decrease patient engagement with postpartum care.
This was a retrospective cohort study conducted at the Ohio State University Wexner Medical Center in 2013. Women were included if they had two or more regular prenatal visits, a pregnancy lasting 24 weeks or more, and at least one visit to any department in the health system after delivery. The provision of contraception upon hospital discharge after delivery was categorized into four groups: sterilization, depot medroxyprogesterone acetate (DMPA) injection or etonogestrel implant insertion as an inpatient, prescriptions for hormonal contraception, and no contraception. At the time, postplacental intrauterine device (IUD) insertion was not an option at this institution. The primary outcome was any postpartum visit attendance within 90 days of delivery.
Of the 1,015 women identified, 128 (12.6%) were prescribed hormonal contraception, 296 (29.6%) were given DMPA or an implant, 134 (13.2%) underwent sterilization, and 457 (45%) did not receive any contraception. Patients in the sterilization group were more likely to be older, to be of higher parity, and to have delivered by cesarean compared to the other groups. A total of 333 (33%) patients attended a postpartum visit. After controlling for age, race/ethnicity, parity, insurance status, smoking status during pregnancy, and history of substance abuse, there was no difference in postpartum visit attendance by type of contraception prescribed at discharge.
COMMENTARY
The American College of Obstetricians and Gynecologists (ACOG) released guidelines recently outlining ways to improve postpartum care for patients.1 They recommend that the timing of the comprehensive postpartum visit should be individualized and patient-centered, but that, ideally, the patient should be seen within the first three weeks postpartum and then at least one more time prior to 12 weeks postpartum. The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including contraceptive options. The postpartum care plan also should include a discussion of the infant feeding plan, management of pregnancy complications and postpartum problems, and treatment plans for ongoing chronic health conditions.
Many factors affect postpartum visit attendance. Barriers may include cost, transportation, childcare responsibilities, and a lack of perceived benefit to the visit.2 Depending on the population, as much as 40% of women fail to attend the postpartum visit.1 Increasing engagement with postpartum care is important, and strategies have included discussing the importance of postpartum care during prenatal visits, scheduling the visit during prenatal care so that the appointment already is on the patient’s calendar, and using postpartum nurses and other reminders to encourage postpartum follow-up.
During the postpartum hospital stay, most patients are counseled regarding contraception, and methods are provided, if desired. Some women are offered a short-term bridge method until their postpartum visit, such as the progestin-only pill, with the idea that they may be incentivized to return for more effective contraceptive methods, e.g., the intrauterine device (IUD) or implant. The authors of this study did not find that the provision of any type of contraceptive, or even the provision of no contraceptive method, influenced postpartum visit attendance rates. The study is limited to a single institution in the Midwest and the findings may not be generalizable, especially given the very low rate of postpartum visit adherence (33%).
Postpartum contraception is important for reproductive life planning and birth spacing. ACOG recommends that women avoid interpregnancy intervals shorter than six months and, ideally, 18 months should be the minimum.1 Rapid repeat pregnancies often are unintended or mistimed, and studies have shown that the postpartum contraceptive method chosen influences the rate of this outcome. Investigators at one large hospital in Pennsylvania reported that rapid repeat pregnancy occurred in 27% of their population and the risk was 2.5 times higher among women who did not use IUDs and implants in the postpartum period.3
Another study of women in the U.S. military demonstrated a short interdelivery interval rate of 17%, with rates varying according to postpartum contraceptive method used: 1% with sterilization; 6% with IUD/implant; 12% with DMPA; 21% with pill, patch, or ring; and 23% with no prescription for contraception.4 Therefore, using shared decision-making with patients and incorporating their future pregnancy intentions in selecting a postpartum contraceptive method is important.
REFERENCES
- The American College of Obstetricians and Gynecologists. Optimizing Postpartum Care. Published May 2018. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
- Henderson V, Stumbras K, Caskey R, et al. Understanding factors associated with postpartum visit attendance and contraception choices: Listening to low-income postpartum women and health care providers. Matern Child Health J 2016;20:132-143.
- Sackeim MG, Gurney EP, Koelper N, et al. Effect of contraceptive choice on rapid repeat pregnancy. Contraception 2019;99:184-186.
- Brunson MR, Klein DA, Olsen CH, et al. Postpartum contraception: Initiation and effectiveness in a large universal healthcare system. Am J Obstet Gynecol 2017;217:55.e1-55.e9.
