Long-acting reversible contraception (LARC) after pregnancy and childbirth

Abstract

Background and aims: Unmet need of contraception is a global challenge. The need of additional visits to initiate contraception is found to be a barrier for postpartum and postabortion contraceptive care. The IUDs and the implant are called long-acting reversible contraception (LARC). The LARC-method can be used for years without having to remember a contraceptive during sexual intercourse or, in case of hormonal contraception, every day, week or month. The overall aim of this thesis was to add knowledge to the field of long-acting reversible contraception after pregnancy in Sweden in our effort to improve the quality of contraceptive care after pregnancy and childbirth.

Methods and main results: Study 1 was a retrospective cohort study including 11,066 women. Data was extracted from medical records regarding attendance to the postpartum visit and choice of contraception, breastfeeding, and abortion during 12-24 months after delivery. The primary outcome was the proportion of induced abortions during follow-up, with the outcome measure of abortion being a surrogate for unintended pregnancy. Among attendees to the follow up 2.1 % had an abortion compared to 3.6 % among nonattendants. A decision to use LARC was associated with a lower risk of abortion (OR 0.74; 95% CI 0.60-0.91; p = .005), as was exclusive breastfeeding (p < .001). Smoking and having had an earlier abortion were associated with a higher risk of abortion during the follow-up. Study II and III were open-label, prospective, randomised, controlled, multicenter studies. In study II, 101 women were either allocated to early placement (52/101) of a hormonal IUD within 48 hours after vaginal delivery or to standard placement (49/101) at 6-8 weeks postpartum. Follow-up was one year after IUD placement. Inclusion was prematurely stopped after an interim analysis due to high expulsion rate in the early placement group, and instead of 600 women only 101 were included. In the early placement group 23/52 (44.2 %) of devices were expelled within a year and 10 women had the hormonal device replaced. In the standard placement group there were no expulsions. The IUD continuation rate for the early group was 37/52 (71.2%), compared to 41/49 (83.7%, p = .13) for the standard placement group at study closure. In study III, 240 women seeking medical abortion up to 63 days´ gestation were randomised to either IUD placement within 48 hours (120/240) after completed abortion or to IUD placement at 2-4 weeks (120/240) after abortion. Follow-up was one year after abortion. The primary outcome was IUD use at 6 months postabortion. In the early placement group (intervention), 91/111 (82%) women used IUD at 6 months compared to 87/112 (77.7%) in the later placement (control) group (p= .51) Pain scores at IUD placement (measured by the visual analogue scale) were lower in the intervention group (p= .002). Women in the intervention group preferred the allocated time significantly more often compared to the control group (p= .03). There was no difference regarding expulsion. In study II and III there were no differences regarding safety profile between groups. Study IV was a qualitative study where 20 women who had undergone elective caesarean section (CS) were interviewed within 6 weeks of CS, to enable deeper understanding of women´s preferences and needs regarding contraceptive services at the time of pregnancy. Ten of the interviewees had chosen IUD placement during the latest CS. Three themes were identified; Receptivity to contraceptive counseling during pregnancy; Communication and decision-making of postpartum contraception during pregnancy and Needs to navigate in the Maternal Health Care System to receive contraceptive services before and after caesarean section. Women were generally positive to contraceptive counseling from about 25 gestational weeks and expressed positive attitudes about the concept of antenatal counseling. Feeling involved and informed was important, but few women had been involved in antenatal counseling. Women who had chosen IUD placement during CS were usually satisfied with the decision. Some interviewees expressed a need to navigate in the contraceptive services by themselves. The communication and coordinating units that should integrate around the woman have not sufficiently adapted to new evidence, needs and conditions.

Conclusions: The choice of LARC postpartum is associated with lower risk for unintended pregnancy compared to the choice of other contraceptives or no choice at all. Attendance to the postpartum visit is a prerequisite to initiate LARC when provision of early/immediate LARC initiation postpartum is not part of the established contraceptive health care. Placement of a hormonal IUD within 48 hours after vaginal delivery seems safe, accepted by patients but associated with much higher expulsion rates compared to placement 6- 12 weeks postpartum. Early placement of an IUD within 48 hours after completed medical abortion does not lead to higher continuation rates at one year after abortion compared to standard placement 2-4 weeks after abortion when devices are provided free of charge. Early placement seems safe, preferred by patients, and associated with lower pain scores compared to standard IUD placement postabortion. Antenatal counseling for contraceptive method to use postpartum seems acceptable to women from around 25 gestational weeks. To have the opportunity to discuss contraception antenatally and enable placement during planned CS is generally considered valuable.