Long-Acting Reversible Contraception: Expanding Access Immediately After Childbirth and in Young Women
While the rate of unplanned pregnancies in the United States declined over the past decade, the rate still remains high with 45% of all pregnancies being unintended.1 Of great concern, while the number of teenagers giving birth or having a repeat birth before age 20 has declined, still, in the US, more than 38,000 teens (16%) had a repeat birth in 2015.20 Unplanned pregnancies and teen pregnancies are associated with increased risks of maternal and child morbidity and mortality as well as socioeconomic costs to families and societies.1,2 This high rate of unintended pregnancies is pervasive through all socioeconomic and racial/ethnicity groups.1
A variety of effective contraceptive options are available; however, delays in implementation as well as incorrect or inconsistent use may lead to failure. In fact, half of all unintended pregnancies are among women who report use of contraception at the time of conception.1,3
Increased access to long-acting reversible contraception (LARC)—the contraceptive implant and intrauterine devices (IUDs)—is a critical strategy for decreasing the rate of unplanned pregnancies among all women of reproductive age.1 LARCs are highly effective (<1% failure rate), safe, and eliminate compliance issues as their efficacy is not user-dependent.4 Despite these benefits, LARCs are underutilized in the United States due to a variety of barriers.4-6
Guidelines on LARC
The American College of Obstetricians and Gynecologists (ACOG) endorses the contraceptive implant and intrauterine devices as safe and effective for nulliparous women and adolescents as well as in women who are immediately postpartum or postabortion (Table 1).7 In addition, the American Academy of Pediatrics endorses use of LARC as a first-line contraceptive choice in adolescents.8
Nearly all women are eligible for LARC, as there are few contraindications to the contraceptive implant or IUDs. The U.S. Medical Eligibility Criteria (U.S. MEC) for Contraceptive Use provides recommendations from the Centers for Disease Control and Prevention (CDC) on selection of contraceptive methods for patients with certain characteristics or medical conditions (eg, human immunodeficiency virus, migraine headaches, multiple sclerosis, postpartum).9 The criteria, which are endorsed by ACOG, also can be used to assist with patient education.
Efficacy of LARCs
LARCs, along with male or female sterilization, are the most effective forms of contraception with failure rates of <1 for both intrauterine devices and the contraceptive implant.4 Failure rates with typical use are considerably higher for diaphragms (17%), male condoms (13%), and combined or progestin-only oral contraceptives (7%).10
Recent Updates on Currently Available LARCs
While the etonogestrel implant is FDA-approved for use up to 3 years, ACOG endorsed routine use of this implant for 4 years in November 2017.7,11 Data from a recent clinical trial involving 291 women showed a failure rate of 0% in year 4 and year 5 following implantation.12 In addition, this study showed minimal decline in etonogestrel level at year 3 or 4 regardless of BMI level.12
Insertion may occur at any time during the menstrual cycle as long as pregnancy is reasonable excluded, according to ACOG.7 In terms of placement, recommended insertion location was changed to 8-10 cm above the medial epicondyle of the humerus over the triceps to avoid the biceps sulcus (groove) between the biceps and triceps muscles, an area that is rich in large blood vessels and nerves.11 Insertion may occur at any time during the menstrual cycle as long as pregnancy is reasonable excluded, according to ACOG.7
In October 2018, the FDA extended the duration of use for the LNG-releasing IUD Liletta to up to 5 years, and an ongoing phase 3 study is examining the efficacy through 8 years.13,14
In addition, new data on the LNG-releasing IUD Mirena suggest that it is effective past its 5-year approved duration of use, for off-label use of up to 6 or 7 years.12 The failure rates at years 6 and 7 were 0.25 and 0.43 per 100 woman years, respectively.
In terms of timing, placement of IUDs with menses has little impact on continuation rates, safety, and efficacy; expulsion risk (immediate or long-term); pregnancy risk; or pain/bleeding at the time of placement.15 As with the contraceptive implant, ACOG recommends IUD insertion at any point during the menstrual cycle as long as pregnancy is reasonably excluded.7
Safety of LARCs
Complications from IUDs—including uterine perforation, ectopic pregnancy, and pelvic inflammatory disease (PID)—are uncommon in all users, including adolescents and nulliparous women.7 In fact, data from a retrospective cohort study of 57,728 IUD insertions found that the overall risk of PID was 0.54% within 90 days of insertion.16 The risk for PID was similar between women who were or were not screened for sexually transmitted infections (STIs) prior to insertion and among women who were screened on the same-day as insertion versus prescreened.
In U.S. trials with etonogestrel implants, 11% of women discontinued the implant use due to bleeding complaints.17 It is recommended to consider short courses of NSAIDs or tranexamic acid during days of bleeding for patients presenting with bleeding complaints.7,18 In addition, patient counseling is critical to long-term continuation of the contraceptive implant.
After IUD placement, NSAID may help reduce cramping and bleeding, and possibly insertion pain.7,19,20
In terms of STIs, women who have not undergoing routine screening or who are at increased risk based on patient history should undergo screening at the time of a single-visit for IUD insertion, according to ACOG.7 Insertion should not be delayed while waiting for test results.7 In addition, women with an IUD who test positive for an STI or who do develop PID should be treated with the IUD in place.7,21 If the patient does not show clinical improvement in PID within 48–72 hours of treatment initiating, the CDC recommends considering removal of the IUD.21 Routine STD screening at the time of IDU insertion is not needed for asymptomatic women at low risk for infection.7
Breastfeeding at the time of IUD insertion increases the risk for perforation by approximately six-fold, according to a study following more than 60,000 women from insertion to 1 year.22 Overall 81 perforations were identified, and the proportion of perforations per 1,000 insertions was 1.4 for levonorgestrel (LNG)-releasing IUDs and 1.1 for copper IUDs.22
Immediate Postpartum LARC Placement
ACOG cites the immediate postpartum period as “particularly favorable” for LARC insertion, as women are often highly motivated to use contraception, the cervix is open for IUD placement, the contraceptive implant and IUDs typically do not interfere with breastfeeding, and the hospital setting is convenient for the patient and the health care provider.7 As many as one-third of women fail to return for postpartum care, often due to childcare, transportation and other barriers.23-25 In addition, women are at risk of an unintended pregnancy in the immediate postpartum period because ovulation resumes shortly after delivery (between 1 to 2 months) in 25% of nonlactating women, and because 40% to 57% of women report having unprotected intercourse before their 6-week postpartum visit.7,26-28
ACOG recommends insertion of the contraceptive implant before hospital discharge, regardless of breastfeeding status.7 Immediate postpartum IUD insertion (ie, within 10 minutes after placental delivery in vaginal and cesarean births) also can be performed. While there is a theoretical risk of a reduced duration of breastfeeding with hormonal IUDs, most available evidence has not demonstrated a negative effect on breastfeeding outcomes.7 In addition, while starting IUDs immediately postpartum is associated with a slightly increased risk for expulsion, cost-benefit analysis data suggest that immediate in-hospital placement is superior to delayed placement given the reduction of unintended pregnancy, according to ACOG.7 Six weeks after delivery, 84% of IUDs remain in place, and 100% remain in place after a caesarean section.29
In addition, in-hospital placement circumvents common reimbursement issues and upfront costs to women, as the procedure can be billed in the context of the global fee for delivery. Healthcare providers should advocate for contraceptive coverage from health insurance plans. In addition, women who are paying out-of-pocket for birth control can contact the National Women’s Law Center’s hotline at 1-866-PILL4US, by email CoverHer@nwlc.org, or visit CoverHer.org for assistance accessing contraceptive coverage.
Thus, ACOG recommends counseling all women in the prenatal settings about the option of immediate postpartum LARC as well as the advantages and disadvantages of this approach to allow for informed decision-making at time of delivery.7
Best Practices in Contraceptive Counseling
Counseling should be based on a comprehensive patient centered process with the patient as the informed consumer. Young women in particular often express the following concerns regarding LARC: effectiveness, future fertility, duration of devices, and perceived invasiveness.30 The CHOICE study demonstrated that given appropriate counseling, the majority of adolescents and women at high risk for pregnancy would choose LARC as their method of contraception.31
The counseling lessons in Table 2 may be used to guide conversations regarding contraception, particularly among teens and young women.32
LARCs are effective first-line contraceptives for women of all ages, are safe and effective when implanted in the immediate postpartum period and are associated with reduction in unplanned pregnancy risk and repeat birth among teens. New insights regarding available options have demonstrated long-term safety and efficacy up to 7 years for some options, as well as efficacy among a wide range of patient’s presentations and BMI. Pre-partum counseling regarding patients’ birth control plans as well as immediate postpartum insertion is recommended for best outcomes.
- Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;9(374):843-852.
- Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev. 2010;32:152-174.
- Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
- Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;21(366):1998-2007.
- Wu JP, Moniz MH, Ursu AN. Long-acting reversible contraception-highly efficacious, safe, and underutilized. JAMA. 2018;320(4):397-398.
- Moniz MH, Chang T, Heisler M, et al. Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008-2013. Obstet Gynecol. 2017;129(6):1078-1085.
- 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.
- Adolescence Co. Contraception for adolescents. Pediatrics 2014;134(4):1244-1256.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016;65(3):1-103.
- Hatcher RA, Nelson AL, Trussell J, et al. Contraceptive Technology, 21st edition. New York, NY: Ardent Media 2018.
- Etonogestrel implant [package insert]. Whitehouse Station, NJ: Merck & Co., Inc.; 2017.
- McNicholas C, Swor E, Wan L, Peipert JF. Prolonged use of the etonogestrel implant and levonorgestrel intrauterine device: 2 years beyond Food and Drug Administration-approved duration. Am J Obstet Gynecol. 2017;216(6):586 e581-586 e586.
- Levonorgestrel-releasing intrauterine system [package insert]. Irvine, CA: Allergan USA, Inc.; 2018.
- Teal SB, Turok DK, Jensen JT, Chen BA, Kimble TD, Creinin MD. Five-year efficacy and safety of the Liletta levonorgestrel intrauterine system. Obstet Gynecol. 2018;131(5 suppl):66S−67S.
- Whiteman MK, Tyler CP, Folger SG, Gaffield ME, Curtis KM. When can a woman have an intrauterine device inserted? A systematic review. Contraception. 2013 87(5):666-673.
- Sufrin CB, Postlethwaite D, Armstrong MA, Merchant M, Wendt JM, Steinauer JE. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol. 2012;120(6):1314-1321.
- Mansour D, Korver T, Marintcheva-Petrova M, Fraser IS. The effects of Implanon on menstrual bleeding patterns. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1:13-28.
- Friedlander E, Kaneshiro B. Therapeutic Options for Unscheduled Bleeding Associated with Long-Acting Reversible Contraception. Obstet Gynecol Clin North Am. 2015;42(4):593-603.
- Godfrey EM, Folger SG, Jeng G, Jamieson DJ, Curtis KM. Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception. 2013;87(5):549-566.
- Mansour D, Bahamondes L, Critchley H, Darney P, Fraser IS. The management of unacceptable bleeding patterns in etonogestrel-releasing contraceptive implant users. Contraception. 2011;83(3):202-210.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
- Barnett C, Moehner S, Do Minh T, Heinemann K. Perforation risk and intra-uterine devices: results of the EURAS-IUD 5-year extension study. Eur J Contracept Reprod Health Care. 2017;22(6):424-428.
- Wilcox A, Levi EE, Garrett JM. Predictors of non-attendance to the postpartum follow-up visit. Matern Child Health J. 2016;20(Suppl 1):22-27.
- Henderson V, Stumbras K, Caskey R, Haider S, Rankin K, Handler A. Understanding factors associated with postpartum visit attendance and contraception choices: listening to low-income postpartum women and health care providers. Matern Child Health J. 2016;20(Suppl 1):132-143.
- Weir S, Posner HE, Zhang J, Willis G, Baxter JD, Clark RE. Predictors of prenatal and postpartum care adequacy in a medicaid managed care population. Womens Health Issues. 2011;21(4):277-285.
- Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657-662.
- Brito MB, Ferriani RA, Quintana SM, Yazlle ME, Silva de Sa MF, Vieira CS. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80(6):519-526.
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(4):263-267.
- Colwill AC, Schreiber CA, Sammel MD, Sonalkar S. Six-week retention after postplacental copper intrauterine device placement. Contraception. 2018;97(3):215-218.
- Coates C, Gordon CM, Simpson T. A qualitative study exploring contraceptive practices and barriers to long-acting reversible contraceptive use in a sample of adolescents living in the southern United States. J Pediatr Adolesc Gynecol. 2018.
- Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120(6):1291-1297.
- The Center for Community Solutions. Whoops Proof in NEO: Contraceptive Awareness Campaign Implementation and Findings. April 2017. Available at: https://www.communitysolutions.com/research/whoops-proof-in-neo-contraceptive-awareness-campaign-implementation-and-findings.