ACOG recommends immediate postpartum long-acting reversible contraception (LARC) to reduce unintended and short-interval pregnancy.
Washington, D.C. – Obstetrician-gynecologists should counsel pregnant women about immediate postpartum LARC as a convenient and effective option for postpartum contraception. In a new Committee Opinion, ‘Immediate Postpartum Long-Acting Reversible Contraception’ the American College of Obstetricians and Gynecologists (ACOG) recommends obstetric care providers counsel women on the option of immediate postpartum LARC during prenatal appointments. The opinion details how immediate postpartum LARC may benefit women, particularly those at highest risk for unplanned or short interval pregnancy, while also underscoring the need for these conversations to be comprehensive, covering risks of intrauterine device (IUD) expulsion, the option of the contraceptive implant, contraindications, and alternative methods of contraception to allow women to make informed decisions.
Recognizing that LARC, which includes the contraceptive implant and IUDs, are safe and highly effective birth control options for most females, including adolescents, ACOG has long supported efforts to promote education around, access to, and uptake of LARC. However, this is ACOG’s first clinical opinion specifically dedicated to immediate postpartum LARC, which refers to placement of LARC in the period between delivery and hospital discharge. This process streamlines women’s access to contraception, limiting barriers to access in the weeks and months following delivery, and reducing the risk of unintended and/or short interval pregnancy.
In the United States, nearly 50% of pregnancies are unplanned, and those women at highest risk are of low socioeconomic status, younger (18-24), and minority women. Immediate postpartum LARC offers a convenient and effective option for all women to prevent an unplanned or short interval pregnancy before they have even left the hospital. Additionally, placing LARC in the immediate postpartum period reduces the barriers to access many women face in the weeks and months following delivery. While many women may plan to resume or implement a contraceptive method at their postpartum follow up visit, up to 40% of women do not attend a follow up appointment, and as a result never obtain an IUD, contraceptive implant (or alternate method of contraception). Even women who attend a postpartum follow up visit may face barriers receiving a LARC at that appointment, including the need for an additional visit for placement and potential loss of insurance coverage postpartum.
“We encourage maternity providers to begin discussions about postpartum contraception prior to delivery to ensure women have the time and information they need to select the best method for them, which may be immediate postpartum LARC for many women,” said Ann Borders, MD, Msc, MPH, who co-authored the opinion. She continued, “The period following delivery is a busy, exhausting and often stressful time and immediate postpartum insertion of LARC may eliminate some of the stressors during that time, like scheduling multiple appointments for LARC insertion. Although expulsion rates for immediate postpartum placement of IUDs are higher, many women find that the advantages of insertion before leaving the hospital outweigh the disadvantages. Additionally, the contraceptive implant does not have contraindications or risks specific to insertion in the immediate postpartum period. As obstetricians, we should be prepared to counsel all of our pregnant patients about the option of immediate postpartum LARC. We should also support our institutions in developing the infrastructure and processes needed to operationalize this practice.”
Widespread provision of immediate postpartum LARC has been limited. However, since 2012 there has been a slow increase in states offering Medicaid payment policy changes that support immediate postpartum LARC, ACOG supports expansion of institutional and payment policy changes that make immediate postpartum LARC more accessible and affordable.
On the topic of cost and access, Dr. Borders urged increased accessibility, “Women should make decisions about the best method of contraception for them in discussion with their maternity care provider. Their choices should not be limited by inability to access certain options, including immediate postpartum LARC.”
The opinion also notes that systems should be in place to ensure that women who desire LARC can receive it during the comprehensive postpartum visit if immediate postpartum placement is not undertaken.
The Committee Opinion is endorsed by the American College of Nurse-Midwives and the Society for Maternal-Fetal Medicine and is supported the Association of Women's Health, Obstetric and Neonatal Nurses, and the American Academy of Family Physicians.
‘Immediate Postpartum Long-Acting Reversible Contraception’ is published in the August 2016 issue of Obstetrics and Gynecology.
For more information and resources visit www.acog.org/LARCImmediatePostpartum.
Other recommendations issued in the August Obstetrics & Gynecology:
Committee Opinion #668, Menstrual Manipulation for Adolescents With Physical and Developmental Disabilities
For an adolescent with physical disabilities, intellectual disabilities, or both, and for her caregivers, menstruation can present significant challenges. If, after an evaluation, the adolescent, her family, and the obstetrician–gynecologist have decided that menstrual intervention is warranted, advantages and disadvantages of hormonal methods should be reviewed and individualized to each patient’s specific needs. Complete amenorrhea may be difficult to achieve, and realistic expectations should be addressed with the patient and her caregivers. The goal in menstrual manipulation should be optimal suppression, which means a reduction in the amount and total days of menstrual flow. Menstrual suppression before menarche and endometrial ablation are not recommended as treatments. Optimal gynecologic health care for adolescents with disabilities is comprehensive; maintains confidentiality; is an act of dignity and respect toward the patient; maximizes the patient’s autonomy; avoids harm; and assesses and addresses the patient’s knowledge of puberty, menstruation, sexuality, safety, and consent.
Committee Opinion #669, Planned Home Birth
In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended. Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.
Technology Assessment #12, Sonohysterography
The primary goal of sonohysterography is to visualize the endometrial cavity in more detail than is possible with routine transvaginal ultrasonography. Sonohysterography also can be used to assess tubal patency. The indications for sonohysterography include, but are not limited to, evaluation of the following: abnormal uterine bleeding; uterine cavity, especially with regard to uterine leiomyomata, polyps, and synechiae; abnormalities detected on transvaginal ultrasonography, including focal or diffuse endometrial or intracavitary abnormalities; congenital abnormalities of the uterus; infertility; recurrent pregnancy loss; and suboptimal visualization of the endometrium on transvaginal ultrasonography. Sonohysterography should not be performed in a woman who is pregnant or who could be pregnant. Credentialing obstetrician–gynecologists to perform or supervise diagnostic sonohysterography should be based on education, training, experience, and demonstrated competence in performing and interpreting transvaginal ultrasonography and sonohysterography. The obstetrician–gynecologist should be skilled in the transcervical placement of catheters. The sonohysterography procedure, including benefits and risks, should be explained fully to the patient before the procedure is performed.