July 29, 2015 —Summary of "Intrauterine Device Placement During Cesarean Delivery and Continued Use 6 Months Postpartum," Erika Levi et al., Obstetrics & Gynecology, July 2015.
"Delaying the initiation of effective contraception until the postpartum visit puts some women at risk for rapid, repeat, and unintended pregnancy," according to Erika Levi, of the Division of Family Planning and Global Health at the Department of Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, and colleagues. They noted that, by six-weeks postpartum, more than half of women are sexually active, and more than half of women who do not breastfeed ovulate by that time.
The authors pointed out that "[w]omen who intend to use an intrauterine device (IUD) for postpartum contraception are often unable to return for a postpartum visit and never receive an IUD." According to the researchers, such women "are more likely to be socially and financially disadvantaged and face barriers such as lack of transportation, lack of stable housing, and difficulty communicating with their health care providers." Meanwhile, the researchers wrote that placing an IUD during the "immediate postpartum period has the potential to increase overall IUD use and decrease the rates of unintended pregnancy," although they noted that there is little research on IUD insertion immediately after cesarean delivery.
In this study, the researchers "compare[d] IUD use at 6 months postpartum among women who underwent intracesarean delivery IUD placement compared with women who planned for interval IUD placement 6 or more weeks after delivery."
According to the researchers, the study was conducted at the North Carolina Women's Hospital from March 2012 to June 2014 and involved women ages 18 to 45 who were having C-section and wanted an IUD. Women were assigned to one of two groups: One group had an IUD placed immediately after their C-section, while the other had the IUD placed at a visit that was at least six weeks after delivery.
Women were able to select either a copper IUD or a levonorgestrel IUD. The women had visits six weeks, three months and six months postpartum. The researchers "made at least five attempts to contact women" who missed follow-up study visits "by phone, e-mail, and certified letter before they were considered lost to follow-up."
"The primary outcome was IUD use at 6 months postpartum," while "[s]econdary outcomes included IUD expulsion, IUD discontinuation, IUD strings visible at 6 months postpartum, and women's satisfaction with the IUD," the researchers wrote. The researchers hypothesized that "25% more women in the intracesarean delivery group would be using an IUD at 6 months than in the [six-week] interval group."
According to the researchers, the study enrolled 112 women and the final analysis included data on 48 out of 56 of women (86%) in the intracesarean delivery group, and 50 out of 56 women (89%) in the interval group. Of the 56 women in the intracesarean group, 53 (95%) had the IUD implanted "at the time of cesarean delivery," while three were unable to receive the device at the time of delivery "because the surgical team did not remember or did not know to place the device." Of the three who did not receive the device at delivery, two had the device placed during the six-week visit. Among the women in the intracesarean delivery group, 73% selected a levonorgestrel IUD and 27% selected a copper IUD.
Meanwhile, out of the 56 women in the interval group, "34 (63%) had an IUD successfully placed," with 30 women (86%) selecting a levonorgestrel IUD and four (14%) selecting a copper device. Among women who did not receive an IUD, 14 (25%) did not return for any study visits; five (9%) opted against getting an IUD at their follow-up visit; and three (5%) "underwent an attempt at IUD placement," but the device was not "successfully placed."
At the six-month mark, 40 out of 48 (83%) in the intracesarean delivery group and 32 out of 50 (64%) in the interval group were using an IUD. Overall, 13% of women were "lost to follow-up," accounting for 14% of women in the intracesarean delivery group and 11% of women in the interval group.
The researchers noted that if they assumed that the proportion of women who retained their IUDs was the same among women lost to follow-up as it was among women who had follow-up data (83%) in the intracesarean group, then the overall "proportion of IUDs retained was 82% (46/56) for the intracesarean delivery group and 57% (32/56) in the interval group." Further, the researchers noted that if they "assumed the unlikely event that all eight women lost-to-follow-up in the intracesarean delivery group did not have an IUD in place at 6 months postpartum (40/56), the effect size between intervention groups remained similar to [the] original analysis estimate."
According to the researchers, there were four IUD expulsions in the intracesarean delivery group, all of which happened "within the first 3 weeks postpartum." Three of the four women had a new IUD implanted during the six-week visit, and the fourth opted for a contraceptive implant. By contrast, there was one expulsion in the interval group. That patient received a replacement, which was also expelled, and then "chose to use condoms as her contraceptive method." According to the authors, the expelled IUDs were all levonorgestrel intrauterine system devices.
Meanwhile, the researchers noted that seven (15%) women in the intracesarean group had the IUD taken out prior to the six-month visit. Reasons for having the device removed included postpartum hemorrhaging in one woman; endometriosis in another, who later had a new one inserted 12 weeks postpartum; and side effects, such as bleeding or pelvic pain, in five women. By contrast, two (4%) women in the interval insertion group had the device taken out; one experienced bleeding and another experienced pain. The latter had another IUD inserted at her three-month visit.
At the six-month visit, 55 women "returned ... and underwent a speculum examination to check for IUD strings," while the "remaining women provided follow-up information by phone." Among the 55 women who returned for an in-person visit, the researchers could see strings in 56% of women in the intracesarean group and 75% of women in the interval group. Overall, women with the levonorgestrel IUD had a higher likelihood of having visible strings than women with copper IUDs.
According to the researchers, the IUD satisfaction rate was 92% in the intracesarean group and 100% among women in the interval group. The authors learned of two pregnancies among study participants, both of which were among women in the interval group. One of the two women did not come to any visits after enrolling in the study, while another had a copper IUD inserted during the six-week visit that -- at the time of her pregnancy one year after the insertion -- was seen via imaging to be in her abdomen.
"Intrauterine device placement at the time of cesarean delivery resulted in a higher proportion of IUD use at 6 months postpartum," the researchers wrote. They noted that while women were offered IUDs at no cost and were compensated for each study visit, one-quarter "did not return for any visit after delivery." They cited earlier data indicating that "women who do not return for postpartum visits are more likely to be socially and economically disadvantaged," adding that their study "provide[s] another contraceptive option to women without the need for a postpartum visit."
Further, the researchers noted that the findings "add to the growing body of evidence that provision of long-acting reversible contraception (LARC) at the time of delivery leads to increased use of effective contraception." In addition, they noted that the providers who inserted IUDs were able to do so after just 10 minutes of training on the topic, which the researchers said "suggests that an 8% 6-month IUD expulsion risk among the women who received an IUD at the time of cesarean delivery is achievable for most practitioners without extensive training."
The authors recommended that women who have an IUD placed at the time of their C-section should receive counseling on the "possibility" that an IUD could be expelled and that strings might not be visible. They noted that it was "unclear" why "women in the interval group had an unexpectedly high proportion of nonvisible IUD strings at 6 months postpartum," adding that future research should also examine "the potential interventions and costs associated with IUD removal" when strings are not visible.
According to the researchers, "Reimbursement policies remain a significant barrier to the initiation of LARC methods during the immediate postpartum period." They wrote that as of December 2014 only 11 states have Medicaid policies that cover LARC devices implanted during delivery admission. The researchers cite support for such policies from the American College of Obstetricians and Gynecologists. "Because cesarean delivery represented 32.3% of all births in the United States in 2008, IUD placement at the time of cesarean delivery could be a safe, effective, and convenient method of postpartum contraception available to 1.4 million women a year," the researchers wrote.