Though some studies have suggested intrauterine devices (IUDs) have a tendency to be expelled when inserted immediately following vaginal childbirth, a new study shows that at least 85 percent of these devices placed after delivery are still in place six weeks later. According to the research team at the Perelman School of Medicine at the University of Pennsylvania, providing IUDs in the hospital immediately following delivery is an effective way to reduce unintended pregnancy and adverse maternal and infant outcomes associated with close pregnancy-spacing. Additionally, noting that IUDs are often covered by insurance (including plans under the Affordable Care Act) when inserted during a routine exam, the authors say the fact that they are not covered when inserted immediately following childbirth points to the need for revised private and public insurance policies. The results will be presented today at the American College of Obstetrics & Gynecology’s Annual Clinical and Scientific Meeting in Washington, DC.
Of the 6.1 million pregnancies that occur each year in the United States, 45 percent are unintended and about 7 percent occur within one year following delivery. These rapid repeat pregnancies are associated with complications for both mothers and babies, including increased rates of maternal death, third trimester bleeding, anemia, postpartum hemorrhage, premature birth, and higher neonatal intensive care unit admissions. And though research suggests most women want post-partum contraception, only about 40 percent will continue use of traditional methods such as the pill or patch for a full year following delivery.
“Inserting long-acting reversible contraception (LARC) methods — such as IUDs — immediately following delivery is an ideal opportunity to prevent unintended pregnancy, because we know that these patients are not pregnant, most want to avoid rapid repeat pregnancies, and they have immediate access to health care providers,” said lead author Alyssa Covelli Colwill, MD, a resident in the department of Obstetrics & Gynecology at the Hospital of the University of Pennsylvania, who will present the study’s findings. “However, these devices are not typically provided until a patient’s six-week follow-up appointment, and 40 percent of patients do not return for those visits, despite often having resumed intercourse.”
In the new study, researchers retrospectively examined data for 210 women who were provided with copper IUDs immediately following cesarean or vaginal delivery. Retention rates of the devices were tracked at six-week follow-up appointments. Though follow-up data was not available for 20 percent of participants — indicating those patients did not return for follow-up care — 95 percent of those who attended follow-up appointments had retained the IUD, including the 4 percent whose original IUDs had been expelled and replaced.
Secondary results showed that the method of delivery had a significant impact on retention rate. At the six-week follow-up, 100 percent of women who had delivered via caesarean section still had their devices in place, compared to 84 percent of women who delivered vaginally. The research team did not find any additional factors — including BMI, race, or insurance coverage — that appeared to be linked to greater likelihood of expulsion, though women who were less likely to attend the six-week follow-up appointment were more likely to be African American, single and have public insurance.
“Though IUDs inserted immediately after vaginal delivery have a slightly higher chance of falling out than IUDs inserted weeks later, these results are promising in that they show that when women have access to LARC devices, they are actively motivated to get them and the vast majority stay in place until at least the first postpartum follow-up appointment,” said senior author Courtney Schreiber, MD, MPH, an associate professor of Obstetrics and Gynecology at the Perelman School of Medicine at the University of Pennsylvania. “Women are requesting this method immediately postpartum, but because labor and delivery services are bundled, there is no additional reimbursement if an IUD is placed immediately following delivery. Some states have changed Medicaid policies to enable women to receive these highly effective contraceptives right after giving birth, but many other women are not yet being given the same option.”
Given the limitations of research based on retrospective data, the authors say future studies are necessary to evaluate the long-term continuation of the IUDs.