Often, when people think of immediate postpartum LARC they think of postplacental IUDs. However, an implant also is an option, and that too is immediate postpartum LARC. Placing an implant is often a lot easier to do after the birth than placing an IUD. As clinicians work toward bringing an immediate postpartum LARC program to their hospital system, starting with implants is a smart thing to do because clinicians do not have to learn or teach new clinical skills. Because of that, immediate postpartum implants are a good troubleshooting mechanism for opening up the conversation about immediate postpartum LARC at your institution.
OBG MANAGEMENT: What advice do you have for administrators or physicians looking to implement an immediate postpartum LARC program into a hospital setting?
Dr. Hofler: Probably the best single resource is the American College of Obstetricians and Gynecologists’ Postpartum Contraception Access Initiative (PCAI). They have a dedicated website and offer a lot of support and resources that include site-specific training at the hospital or the institution; clinician training on implants and IUDs; and administrator training on some of the systems of care, the billing process, the stocking process, and pharmacy education. They also provide information on all the things that should be included beyond the clinical aspects. I strongly recommend looking at what they offer.
Also, because many hospitals say, "We love this idea. We would support immediate postpartum LARC, we just want to make sure we get paid," the ACOG LARC Program website includes state-specific guidance for how Medicaid pays for LARC devices. There is state-specific guidance about how the device payment can be separated from the global payment for delivery—specific things for each institution to do to get reimbursed.
Levonorgestrel vs copper IUD expulsion rates after immediate postpartum insertion
A 2017 prospective cohort study was the first to directly compare expulsion rates of the levonorgestrel (LNG) intrauterine device (IUD) and the copper IUD placed postplacentally (within 10 minutes of placental delivery). The study investigators found that, among 96 women at 12 weeks, 38% of the LNG-IUD users and 20% of the copper IUD users experienced IUD expulsion (odds ratio, 2.55; 95% confidence interval [CI], 0.99-6.55; P = .05 ). Women were aged 18 to 40 and had a singleton vaginal delivery at ≥ 35 weeks’ gestation. 1 The two study groups were similar except that more copper IUD users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). The study authors found the only independent predictor of device expulsion to be IUD type.
In a 2019 prospective cohort study, Hinz and colleagues compared the 6-month expulsion rate of IUDs inserted in the immediate postpartum period (within 10 to 15 minutes of placental delivery) after vaginal or cesarean delivery. 2 Women were aged 18 to 45 years and selected a LNG 52-mg IUD (75 women) or copper IUD (58 women) for postpartum contraception. They completed a survey from weeks 0 to 5 and on weeks 12 and 24 postpartum regarding IUD expulsion, IUD removal, vaginal bleeding, and breastfeeding. A total of 58 women had a vaginal delivery, and 56 had a cesarean delivery.
At 6 months, the expulsion rates were similar in the two groups: 26.7% of the LNG IUDs expelled, compared with 20.5% of the copper IUDs ( P = .38 ). The study groups were similar, point out the study investigators, except that the copper IUD users had a higher median parity (3 vs. 2; P = .03 ). In addition, the copper IUDs were inserted by more senior than junior residents (46.2% vs 22.7%, P = .02 ).
A 2018 systematic review pooled absolute rates of IUD expulsion and estimated adjusted relative risk (RR) for IUD type. A total of 48 studies (rated level I to II-3 of poor to good quality) were included in the analysis, and results indicated that the LNG-IUD was associated with a higher risk of expulsion at less than 4 weeks postpartum than the copper IUD (adjusted RR, 1.91; 95% CI, 1.50-2.43). 3
References
1. Goldthwaite LM, Sheeder J, Hyer J, et al. Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study. Am J Obstet Gynecol . 2017;217:674.e1-674.e8.
2. Hinz EK, Murthy A, Wang B, Ryan N, Ades V. A prospective cohort study comparing expulsion after postplacental insertion: the levonorgestrel versus the copper intrauterine device. Contraception . May 17, 2019. doi: 10.1016/j.contraception.2019.04.011.
3. Jatlaoui TC, Whiteman MK, Jeng G, et al. Intrauterine device expulsion after postpartum placement. Obstet Gynecol . 2018:895-905.