Immediate vs. Delayed Postpartum Long-Acting Reversible Contraception

By Ahizechukwu C. Eke, MD, PhD, MPH

Synopsis: Administering long-acting reversible contraceptives before hospital discharge reduced pregnancy risk and increased usage at six months, making it an effective option for postpartum contraception.

---

Source: Provinciatto H, Meirelles Dias YJ, Abonizio Magdalena SL, et al. Immediate vs delayed postpartum insertion of long-acting reversible contraception methods: Meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2024; Sep 18. doi: 10.1016/j.ajog.2024.09.019. [Online ahead of print].

In the United States, unintended pregnancies remain a significant public health issue, with nearly 45% of all pregnancies being unintended.¹ Postpartum patients are particularly vulnerable to unintended pregnancies because of the rapid return of fertility and potential challenges in accessing postpartum care.² Immediate postpartum long-acting reversible contraceptives (LARC), which includes progestin- and copper-containing intrauterine devices (IUDs) and contraceptive implants, have increasingly been recognized as an effective strategy for preventing both unintended pregnancies and short interpregnancy intervals.^3,4

Despite the proven efficacy of LARC, immediate postpartum use remains relatively low in the United States. A 2020 study reported that only about 16% of women who delivered in hospitals across the United States between 2017 and 2019 received LARC before hospital discharge.⁵

In contrast, delayed LARC use (initiation at the standard postpartum visit, typically six weeks after delivery) is more common but often is hindered by barriers such as missed follow-up appointments and insurance coverage lapses. The American College of Obstetricians and Gynecologists (ACOG) endorses immediate postpartum LARC as a best practice to improve contraceptive access and prevent unintended pregnancies, yet logistical and financial barriers continue to limit its widespread adoption.⁶

Research on immediate vs. delayed postpartum LARC has shown consistently that immediate initiation is associated with higher continuation rates and fewer unintended pregnancies compared to delayed initiation.⁷ Studies have demonstrated that women who receive LARC immediately postpartum are significantly less likely to experience an unintended pregnancy within six to 12 months after delivery compared to those with delayed LARC uptake.⁸

However, there still are notable research gaps. Much of the existing research has focused on short-term outcomes, with fewer studies exploring the long-term effects of immediate vs. delayed postpartum LARC on maternal health, contraceptive continuation, and adverse events.

Additionally, research has not sufficiently addressed disparities in access to immediate vs. delayed LARC uptake among different racial, ethnic, and socioeconomic groups. These gaps highlight the need for more comprehensive research to better understand the efficacy and safety of immediate vs. delayed uptake of LARC.

Provinciatto and colleagues conducted this study to evaluate the immediate vs. delayed provision of LARCs in postpartum women, focusing on short-interval pregnancies, utilization rates, and adverse events.⁹

This study is a systematic review and meta-analysis of randomized clinical trials comparing immediate vs. delayed uptake of LARC in postpartum individuals. The immediate group included patients who received a contraceptive implant or IUD before hospital discharge, while the delayed insertion group consisted of those who received it between four and 12 weeks postpartum.

Studies were included if they were randomized controlled trials (RCTs) focused on postpartum individuals and compared immediate to delayed LARC insertion. Studies were excluded if they involved overlapping populations (from the same institution during the same period) or did not report relevant outcome measures, such as LARC methods, six-month utilization, pregnancy rates, breastfeeding (any or exclusive), serious adverse events, or IUD expulsion.⁹ Trials reporting data on at least one of these outcomes were included.

The outcomes were categorized into two groups: efficacy and safety. Efficacy outcomes included LARC insertion rates, six-month utilization, and both confirmed and suspected pregnancies. Safety outcomes encompassed any breastfeeding, exclusive breastfeeding, and serious adverse events.

Additionally, the analysis included expulsion rates of IUDs between the immediate and delayed groups. “Any breastfeeding” was defined as mothers breastfeeding their infants, regardless of whether other liquids or solids were introduced. Serious adverse events included uterine perforation and pelvic inflammatory disease. A six-month follow-up period was implemented for all outcomes to minimize heterogeneity across the studies.

To compare early vs. late postpartum insertion of LARC, the authors calculated relative risk (RR) for dichotomous outcomes using the inverse variance method. Heterogeneity was assessed using Cochran’s Q test and I² statistics, with I² values categorized as: < 40% indicating low heterogeneity, 40% to 75% indicating moderate heterogeneity, and > 75% indicating high heterogeneity. The analysis employed the restricted maximum likelihood estimator and a random effects model to address potential differences between studies.

Predefined outcomes were further analyzed through subgroup analysis based on each type of LARC method, specifically contraceptive implants and IUDs. The meta-analysis was performed using the meta package in RStudio version 4.2.2. Results were presented as 95% confidence intervals (CIs), with P values < 0.05 considered statistically significant.

A total of 2,507 individuals enrolled in 24 RCTs, with 1,293 (51.6%) subjects meeting the inclusion criteria for the immediate insertion group and 1,214 (48.4%) subjects in the delayed group. Compared to the delayed insertion group, postpartum patients in the immediate group demonstrated a 22% increase in LARC insertion rates (relative risk [RR], 1.22; 95% CI, 1.09-1.36; P < 0.01; I² = 88%), an 84% significantly lower risk of becoming pregnant (RR, 0.16; 95% CI, 0.04-0.71; P = 0.02; I² = 0%), and a 23% higher rate of LARC use at the six-month postpartum follow-up visit (RR, 1.23; 95% CI, 1.09-1.37; P < 0.01; I² = 63%).

There were no statistically significant differences in any breastfeeding (RR, 1.01; 95% CI, 0.89-1.15; P = 0.82; I² = 39%), exclusive breastfeeding (RR ,0.88; 95% CI, 0.66-1.17; P = 0.38; I² = 27%), or serious adverse events (RR, 0.55; 95% CI, 0.17-1.79; P = 0.32; I² = 0%) between the two groups. Patients in the immediate group experienced higher rates of IUD expulsion compared to the delayed group (RR, 3.08; 95% CI, 1.35-7.01).

Commentary

The results indicate that postpartum patients who received immediate LARC insertion had a higher uptake compared to those who had delayed insertion. Additionally, they faced a substantially reduced risk of becoming pregnant and demonstrated increased utilization of LARC at six-month follow-up. However, there were no significant differences observed in rates of any breastfeeding, exclusive breastfeeding, or serious adverse events between the two groups.

Notably, women in the immediate insertion group did experience higher rates of IUD expulsion compared to their counterparts in the delayed insertion group. Overall, these findings suggest that while immediate LARC insertion offers advantages in contraceptive effectiveness and usage, it is associated with an increased risk of IUD expulsion.

The results of this study align with previous research indicating the benefits of immediate insertion of LARCs for postpartum women.^3,4,9 Several studies have shown that immediate LARC insertion leads to higher rates of contraceptive uptake and reduced pregnancy rates in the postpartum period. For instance, a 2022 Cochrane systematic review and meta-analysis by Sothornwit et al highlighted that individuals who received LARC immediately after delivery had significantly improved initiation and continuation rates compared to delayed insertion.⁷

This early initiation of LARC not only enhances contraceptive effectiveness but also addresses the urgent need for family planning during the postpartum period when women are at a heightened risk of unintended pregnancies. Furthermore, the increased use of LARC at six months post-insertion suggests that immediate access can lead to confidence in LARC as a method of effective contraception, which is essential for effective family planning and reproductive health.

However, the findings emphasize the higher rates of IUD expulsion with immediate insertion. Previous studies have reported similar findings, indicating that although immediate insertion can improve contraceptive uptake, it also may increase the risk of complications, such as expulsion, particularly within the first few months postpartum, with as high as 27% at six months postpartum (with immediate postpartum IUD insertion) compared to 1% to 4% with delayed insertion (at four to six weeks after delivery).^10,11 There also is a risk of missing IUD strings and IUD malposition with immediate insertion compared to delayed insertion. These potential risks highlight the importance of providing thorough counseling and follow-up care for patients who opt for immediate LARC insertion.

Ultimately, while immediate LARC insertion has clear advantages, healthcare providers should weigh these benefits against the potential risks, such as IUD expulsion, and ensure that women receive appropriate support and information to make informed choices regarding their contraceptive options.

In conclusion, the study underscores the significant advantages of immediate insertion of LARC for postpartum patients, notably in enhancing contraceptive uptake and reducing the risk of unintended pregnancies. Given these positive outcomes, it is recommended that clinicians prioritize immediate LARC insertion in postpartum care settings, ensuring that individuals are informed about the benefits and risks associated with this approach, as recommended by ACOG.⁶ Additionally, it is essential to implement comprehensive counseling and follow-up support to address potential issues, such as IUD expulsion.

Ahizechukwu C. Eke, MD, PhD, MPH, is Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore.

References

1. Guttmacher Institute. Unintended pregnancy in the United States. Published January 2019. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states#
2. Benjamin Guzzo K, Eickmeyer K, Hayford SR. Does postpartum contraceptive use vary by birth intendedness? Perspect Sex Reprod Health. 2018;50(3):129-138.
3. Harrison MS, Goldenberg RL. Immediate postpartum use of long-acting reversible contraceptives in low- and middle-income countries. Matern Health Neonatol Perinatol. 2017;3:24.
4. Kroelinger CD, Okoroh EM, Uesugi K, et al. Immediate postpartum long-acting reversible contraception: Review of insertion and device reimbursement policies. Womens Health Issues. 2021;31(6):523-531.
5. Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2017-2019. NCHS Data Brief. 2020;(388):1-8.
6. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2017;130(5):e251-e269.
7. Sothornwit J, Kaewrudee S, Lumbiganon P, et al. Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception. Cochrane Database Syst Rev. 2022;10(10):CD011913.
8. Goldthwaite LM, Shaw KA. Immediate postpartum provision of long-acting reversible contraception. Curr Opin Obstet Gynecol. 2015;27(6):460-464.
9. Provinciatto H, Meirelles Dias YJ, Abonizio Magdalena SL, et al. Immediate vs delayed postpartum insertion of long-acting reversible contraception methods: Meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2024; Sep 18. doi:10.1016/j.ajog.2024.09.019. [Online ahead of print].
10. Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: A randomized controlled trial. Obstet Gynecol. 2010;116(5):1079-1087.
11. Chen MJ, Hou MY, Hsia JK, et al. Long-acting reversible contraception initiation with a 2- to 3-week compared with a 6-week postpartum visit. Obstet Gynecol. 2017;130(4):788-794.