Postpartum LARCs help avert repeat pregnancy

Postpartum LARCs help avert repeat pregnancy

By Anita Brakman, MS
Director of Education, Research & Training
Physicians for Reproductive Health
New York City

Melanie Gold, DO, FAAP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
Staff Physician
University of Pittsburgh Student Health Service

The Colorado Department of Health Care Policy and Financing recently issued a bulletin notifying healthcare providers that hospitals can be reimbursed for the devices and placement of long-acting reversible contraceptive (LARC) methods inserted immediately postpartum while women are in the hospital following deliveries. Previously, this cost could not be billed separately from a global labor and delivery expense, and hospitals wishing to insert LARC methods postpartum would have to cover the upfront costs of methods such as intrauterine contraception (IUC) and implants with no option for reimbursement. Implementation of this new policy began on Oct. 1, 2013, and is sure to benefit hospitals and patients throughout the state, especially adolescent mothers wishing to delay repeat pregnancy.

Adolescent mothers are at especially high risk of rapid repeat pregnancy, with 20% giving birth again within two years of delivery.¹ These additional births make it extremely difficult for young mothers to achieve their educational goals and economic self-sufficiency, even when compared to peers who experienced only one birth before age 20.²

A recent analysis of data from the Pregnancy Risk Assessment and Monitoring System found a lack of consistent use of highly effective contraception puts young mothers at particular risk for repeat pregnancy. An examination of data across seven states demonstrated that at four months postpartum, 20% of respondents ages 15-19 were not using any contraception, while 14% relied solely on condoms or withdrawal. Use of LARCs was reported by only 12% of respondents, with the preponderance (11%) using IUC and only 1% using implants.³

Why LARC methods?

Why are LARC methods better for adolescent mothers compared to other contraceptives? In addition to high levels of efficacy, discontinuation rates are lower among adolescent mothers using LARCs than other hormonal methods including depot medroxyprogesterone.⁴ The US Medical Eligibility Criteria for Contraceptive Use gives IUC and implants a category 1 for postpartum adolescent women, which affirms these as safe choices. For breastfeeding mothers, the US MEC give hormonal LARCs a category 2, indicating that the benefit of the method outweighs potential risk.⁵

The American College of Obstetricians and Gynecologists’ 2012 Committee Opinion on adolescents and LARCs also recommends implants and IUC as first-line options for postpartum adolescents. The opinion emphasizes that the slightly higher risk for expulsion of an IUC does not outweigh the benefit of exceptional prevention of unintended pregnancy for youth who might not be able to access these methods in a timely way.⁶

Unfortunately many barriers block adolescent mothers, even those who planned to use a LARC postpartum, from successful initiation of LARC in a timely way. A study by Tocce et al found that even when adolescents intended to obtain an implant within two weeks of delivery, only two-thirds had received the implant by 14 weeks postpartum.⁷ Even when women are able to attend a six-week postpartum visit and discuss contraceptive options, by that time they are likely to have already resumed sexual activity.

Eliminate protection gap

Inserting a LARC immediately postpartum helps women initiate a highly effective method and eliminates gaps in protection, just as Quick Start does for routine contraceptive initiation. Tocce and her co-authors have published several recent studies indicating that inserting LARCs, especially implants, on the labor and delivery floor can make a huge impact on decreasing rapid repeat pregnancy among adolescents.

One study of adolescent mothers in Colorado assessed pregnancy rates among those receiving an immediate postpartum implant compared to a control group. Data indicates 10% of the control group were pregnant six months postpartum, and 19% were pregnant within a year. No women who received implants were pregnant within six months. Within a year, there were four pregnancies among the group. Three of these pregnancies occurred in women who had the implant removed, and the other was a patient using another medication that might have reduced the implant’s efficacy.⁸ This data was crucial to convincing the state to make the administrative changes necessary to allow hospitals to bill for LARC devices separately from the global labor and delivery charges.

Time for a change

Policy changes such as those implemented in Colorado need to occur at the state level. South Carolina and New Mexico also have improved access to immediate postpartum LARC devices. While state departments of health, hospitals, and LARC advocates work together to improve immediate postpartum access for adolescents and all women, women in states without these policies might find relief from improvements in contraceptive coverage through the federal Affordable Care Act (ACA).

Under the ACA, insurers are required to cover all Food and Drug Administration-approved contraceptives without any patient cost-sharing.⁹ For women who are motivated and have timely access to a healthcare provider, this new policy might allow them to obtain a LARC at a six-week postpartum check-up or any other time they wish to initiate.

REFERENCES

1. Schelar E, Franzetta K, Manlove J. Repeat teen childbearing: differences across states and by race and ethnicity. Washington, DC: Child Trends; 2007. Accessed at http://bit.ly/1aJn3Tl.
2. Klerman LV. Another Chance: Preventing Additional Births to Teen Mothers. Washington, DC: The National Campaign to Prevent Teen Pregnancy; 2004.
3. Wilson EK, Fowler C, Koo HP. Postpartum contraceptive use among adolescent mothers in seven states. J Adol Health 2013; 52:278-283.
4. Lewis LN, Doherty DA, Hickey M, et al. Implanon as a contraceptive choice for teenage mothers: A comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 81:421-426.
5. Centers for Disease Control and Prevention (CDC). U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep 2010; 59(RR-4):1-86.
6. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee opinion No. 539. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 120:983-988.
7. Tocce K, Sheeder J, Python J, et al. Long acting reversible contraception in postpartum adolescents: early initiation of etonogestrel implant is superior to IUDs in the outpatient setting. J Pediatr Adolesc Gynecol 2012; 25:59-63.
8. Tocce K, Sheeder J, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? AJOG 2012; 481:e1-e7.
9. National Women’s Law Center. Preventive services, including contraceptive coverage under the health care law. Accessed at http://bit.ly/RIJltf.