番茄社区

Women who had an intrauterine device (IUD) placed immediately following a cesarean delivery had higher rates of IUD use postpartum than women who waited until their 6-week follow-up appointment, according to the results of a small randomized trial.

Among 112 women, 83% of women with intracesarean IUD placement were still using an IUD at 6 months postpartum compared with 64% of women who had an IUD placed at their 6-week postpartum appointment (relative risk 1.3, 95% CI 1.02-1.66), reported , of Albert Einstein College of Medicine in New York City, and colleagues,

Also, 95% of women underwent successful IUD placement when it was offered at the time of cesarean delivery, while 63% of the "interval" (control) group underwent successful IUD placement at their follow-up appointment, they wrote in .

Among the group randomized for IUD placement at their later follow-up appointment, nearly 40% of women did not have an IUD placed. This group comprised five women (9%) who declined an IUD, three women (5%) who had unsuccessful IUD placement, and 14 women (25%) who never attended the appointment.

While 13% of women were lost to follow-up overall, the authors estimated that assuming the same proportion of IUDs were retained in both groups, the effect size between groups would be slightly larger between intervention and control (RR 1.44, 95% CI 1.11-1.86). But they added that if they assumed all women lost to follow-up in the intervention group did not have an IUD placed, the effect size remained similar to the original estimate (RR 1.25, CI 0.94-1.66).

Levi told 番茄社区 that she wanted to see if IUD use would increase postpartum if it was placed during delivery -- when most women have access to health insurance -- as opposed to the 6-week follow-up appointment, which is often difficult for women to attend due to the intensity of the postpartum period.

"We hoped that providing IUDs at the time of cesarean delivery would lead to increased IUD use postpartum and that is in fact what we found," she said.

Levi added that prior research had shown IUDs placed at the time of vaginal delivery have a higher expulsion rate, but there was scant research on expulsion rates following cesarean deliveries. Researchers noted that of the IUDs placed at the time of intracesarean delivery, there were four expulsions occurring within the first 3 weeks postpartum, and three of those women had an IUD placed at the 6-week appointment.

The parallel, nonblinded randomized trial of women, ages 18 to 45, undergoing cesarean delivery took place from March 2012 to June 2014 at North Carolina Women's Hospital. Participants were excluded if they had a positive test for gonorrhea or chlamydia during pregnancy, had known or suspected cervical, uterine, or breast neoplasia, an allergy to IUDs, or a post-delivery complication.

Of the 172 women screened, 56 apiece were randomized to either the intervention or control group, with 86% (n=48) and 89% (n=50) of the intervention and control groups. The primary outcome was IUD use at 6 months postpartum.

Characteristics of both groups were similar, with 73% of the intervention group and 86% of the control group preferring the levonorgestrel intrauterine system over the copper IUD. Mean time for placement of the IUD in the intervention group was 1.6 minutes from placental delivery (95% CI 1.2-1.9). The study authors noted they became aware of two pregnancies after the 6-month follow-up appointment, both from the control group: one who never attended her postpartum checkup and one whose IUD was found in her abdomen a year after insertion.

Study limitations included the "significant" racial, ethnic, and socioeconomic characteristics of the patient population, which may limit the generalizability of the results. Missing data from the women lost to follow-up is another weakness, the authors noted.

The authors also pointed out that "reimbursement policies remain a significant barrier to the initiation of [long-acting reversible contraception or LARC] methods during the immediate postpartum period."

and are on the rise in the U.S. and , pointed out , of Stanford University in Stanford, Calif., and , of the University of Colorado School of Medicine in Aurora, in an accompanying editorial.

Blumenthal and Goldthwaite highlighted the numerous benefits of post-cesarean IUD placement, including that the "provider and patient are in the same place at the same time [with] access to the uterine cavity ... facilitated by the hysterotomy." They also called the insertion process "highly expeditious," and that it added "no appreciable cost or duration to the primary delivery procedure."

They added that Medicaid policies in 11 states now cover some postpartum IUDs.

The authors pointed out that American College of Obstetricians and Gynecologists (ACOG) is a proponent of all types of insurance covering postpartum IUDs.

"[ACOG] supports the practice of and expert consensus supports aligning practice and reimbursement incentives to promote immediate postpartum initiation of LARC methods," they concluded.

Levi said she would like to see research that follows up with women who use LARC in "real life outside of research circumstances" over a longer period of time.

"What happens to these women many years out -- do these devices prevent rapid repeat and unintended pregnancy?" she said. "What is the continuation rate for these devices when they are placed in the immediate postpartum period? I would like to see a large cohort study looking at some of those questions."

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