Inpatient Postpartum Long-Acting Reversible Contraception

Abstract

Inpatient insertion of long-acting reversible contraceptives (LARC) (intrauterine devices and implants) is increasingly offered to women immediately after childbirth. Enthusiasm for this approach stems from robust safety, effectiveness, and cost-effectiveness data, and responsiveness to women’s needs and preferences. While clinical evidence for immediate postpartum LARC is well-established, the ethical implications of enhancing access to this care have not been fully considered. Contraceptive policies and practices often embody a tension between fostering liberal availability and potentially coercive promotion of some methods. Historical contraceptive policies and contemporary disparities in LARC use point to the need to consider if health policies and health care practices support all women’s reproductive wishes. Immediate postpartum LARC services need to be designed and implemented with the goal of ensuring autonomy and equity in postpartum contraceptive care. To this end, these services should include strategic plans to promote universal availability, prevent coercion, and enable device removal.

Society of Family Planning clinical recommendations: contraception after surgical abortion

“…Some women report feeling pressure from providers to choose a birth control method at the time of abortion [16,30]. Clinicians should respect patient autonomy, including the choice to not adopt a contraceptive or to choose a less-effective method, and take care to avoid contraceptive coercion [31][32][33].…”

Immediate Postpartum Contraception: Intrauterine Device Insertion

“…Shared decision making can be a partnership in which the midwife has the ability to limit potential coercion and close gaps in comprehension or recall . Furthermore, Moniz et al suggest that immediate postpartum options should be presented even in the face of reimbursement or other challenges, including religious proscriptions, as a means to promote reproductive justice.…”

“…However, this option is underused because of barriers at the clinician, institution, and system levels . Barriers include knowledge gaps, challenges to implementing immediate postpartum IUD programs institutionally, reimbursement apart from the global fee, and racial and ethnic bias . Moniz et al found that, among midwives surveyed, clinician‐level barriers exist, including knowledge gaps around IUD expulsion rates, eligibility, and technique.…”

Applying a critical race lens to relationship‐centered care in pregnancy and childbirth: An antidote to structural racism

“…Enthusiasm for this approach stems from robust safety, efficacy, and cost‐effectiveness data, and responsiveness to patient needs and preferences. Although clinical evidence for immediate postpartum LARC is well established, the ethical implications of both the timing of when to offer contraceptive counseling and the enhanced access to this care have not been fully considered . For Black birthing people, this type of clinical practice could be considered a form of reproductive coercion.…”

“…Although clinical evidence for immediate postpartum LARC is well established, the ethical implications of both the timing of when to offer contraceptive counseling and the enhanced access to this care have not been fully considered. 38 For Black birthing people, this type of clinical practice could be considered a form of reproductive coercion. A clinician who has not considered or is not prepared to articulate and discuss eugenics and the history of experimentation and reproductive exploitation that Black communities have experienced until as recently as the 1980s is unprepared to adequately care for Black birthing people.…”