Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications

Abstract

The Society of Family Planning (SFP) endorses this document. The American College of Obstetricians and Gynecologists (ACOG) supports the value of this clinical document as an educational tool; February 2019. Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).

Comparison of immediate postpartum contraception among women with a high versus low risk pregnancy in Mexico: a retrospective cohort study

“…23 We found that nearly one in five deliveries (19.1%) in Mexico were to women with high-risk pregnancies or deliveries. Our definition of high risk is supported by the Society of Maternal Fetal Medicine 6 and previous research which has used a binary classification as the basis for their analysis. 21 Our proportion of high-risk pregnancies or deliveries is comparable to a US cohort studied in 2011 where 24% of women had a prepregnancy chronic disease, classifying them as high risk.…”

“…[8][9][10] Specific counselling about the health effects of high-risk pregnancies, medical comorbidities and IPI should be standard to improve maternal health outcomes. 6…”

“…Women with chronic medical conditions are at a higher risk of unintended pregnancies and a pregnancy in the setting of poor chronic disease control can lead to adverse pregnancy outcomes and disease progression. 6 For example, women with gestational diabetes experiencing short interval pregnancies have an increased risk of developing type 2 diabetes mellitus in the future. 7 It is important that women with pre-existing conditions and other complications of pregnancy or delivery have access to immediate postpartum contraception to reduce poor outcomes associated with a short interval pregnancy.…”

Addressing postpartum contraception practices utilizing a multidisciplinary Pregnancy Heart Team approach

“… 2 , 3 , 14 The study's primary outcome focused on Tier 1 plan and uptake of contraception on the basis of the American College of Obstetricians and Gynecologists (ACOG) and SMFM guidance to offer Tier 1 contraception to the most high-risk pregnancies given the low failure rate. 2 , 22 However, it is important to note that Tier 2 and 3 methods are safe and reliable methods, with typical-use 1-year failure rate ranging from 6% to 28% depending on the method. 20 This study included cardiovascular conditions with contraindications to estrogen-containing contraception and a heterogeneous group of providers with different levels of training in complex contraception counseling; therefore, we did not include Tier 2 methods uptake within the primary outcome.…”

Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder

“…1,2 Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population, [3][4][5] with current estimates indicating the unintended pregnancy rate in women with opioid use disorder is over 75% [5][6][7][8][9] (Table 1). Maternal substance use disorder, which includes drug or alcohol use, is associated with an increased risk for pregnancy-related morbidity 10 and neonatal abstinence syndrome (NAS), a condition that occurs when an infant experiences physical withdrawal symptoms due to exposure to maternal medication or drug use, most commonly opioids, before birth. The incidence of NAS in the United States increased over 5-fold between 2004 and 2014, from 1.5 to 8.0 per 1000 births.…”