Worth the wait: Birth spacing and postpartum contraception

1. Worth theWait
Birth Spacing & Postpartum Contraception
Andrea Henkel, MD
Division of Family Planning
Stanford University
With contributions from: Kate Shaw, MD MS; Lisa Goldthwaite, MD MPH; Paul Blumenthal, MD MPH

2. Disclosures
I have no financial interests to disclose.
Notably, the dedicated post-placental IUD inserter described was developed at
Stanford University. I have no financial ties or incentives in discussing this product.

3. Understanding the Audience

4. Birth Spacing

5. Reproductive Justice
InternationalConference on Population and Development in 1994:
“Reproductive health…implies that people are able to have a satisfying and safe
sex life and that they have the capability to reproduce and the freedom to
decide if, when and how often to do so. … Reproductive rights rest on the
recognition of the basic right of all couples and individuals to decide freely and
responsibly on the number, spacing and timing of their children and to have
the information and means to do so, and the right to attain the highest
standard of sexual and reproductive health. It also includes their right to make
decisions concerning reproduction free of discrimination, coercion and violence.

6. Definitions
 Inter-pregnancy interval (IPI) is the spacing between a live birth and the
beginning of the following pregnancy.
 Inter-delivery interval (IDI) is the period between consecutive live births.
 Inter-outcome interval (IOI) is defined as the interval between one
pregnancy outcome and the next, regardless of pregnancy outcome.

7. WHO Recommendations
 After a live birth, the recommended minimum interval
before attempting the next pregnancy is at least 24
months in order to reduce the risk of adverse maternal,
perinatal and infant outcomes.
 After a miscarriage or induced abortion, the recommended
minimum interval to next pregnancy is at least 6 months
in order to reduce risks of adverse maternal and perinatal
outcomes.
Report of a WHO Technical Consultation on Birth Spacing, Geneva, Switzerland, June 2005.

8. Benefits of Birth Spacing
Birth intervals < 2 years are associated with:
 Lower birth weight
 Increased risk of preterm birth
 Malnutrition, infection, increased second year mortality for previous child
 Delayed and insufficient prenatal care
 Increased risk of rupture after cesarean
Report of a WHO Technical Consultation on Birth Spacing, Geneva, Switzerland, June 2005.

9. Benefits of Birth Spacing
Preterm birth:
 IPI < 6 months is associated with a
40% increase in risk for PTB
compared to IPI > 2 years1
 Short IPI increases the risk of PTB,
most dramatically for those with a
history of PTB2
1. Conde-agudelo A, Rosas-bermúdez A, Kafury-goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.
JAMA. 2006;295(15):1809-23.
2. Defranco EA, Stamilio DM, Boslaugh SE, Gross GA, Muglia LJ. A short interpregnancy interval is a risk factor for preterm birth
and its recurrence. Am J Obstet Gynecol. 2007;197(3):264.e1-6.

10. Benefits of Birth Spacing
Low birth weight:
 IPI < 6 months was associated with a
60% increase in risk of LBW (< 2500g)
when compared with IPI of 18-23
months1
 IPI < 6 months associated with a 15-
30% increase in risk of SGA (<10%ile)
compared with longer IPIs1,2
1. Conde-agudelo A, Rosas-bermúdez A, Kafury-goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.
JAMA. 2006;295(15):1809-23.
2. Zhu BP, Rolfs RT, Nangle BE, Horan JM. Effect of the interval between pregnancies on perinatal outcomes. N Engl J Med.
1999;340(8):589-94.

11. Benefits of Birth Spacing
MaternalAnemia:
 30% increase in maternal anemia after
IPI < 6 months compared to > 24 month
IPI1
 IPI < 24 months also been associated
with other potential causes of anemia,
such as third-trimester bleeding from
placental abruption or placenta previa
in the subsequent pregnancy2
1. Conde-agudelo A, Rosas-bermúdez A, Kafury-goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.
JAMA. 2006;295(15):1809-23.
2. Smits LJ, Essed GG. Short interpregnancy intervals and unfavourable pregnancy outcome: role of folate depletion. Lancet.
2001;358(9298):2074-7.

12. Benefits of Birth Spacing
Trial of LaborAfter Cesarean:
 TOLAC is associated with a 3x increase in risk of uterine rupture among
women with IDI <18 months
 The uterine rupture rate was 2.25% for IDI < 18 months compared with
1.05% with IDI > 19 months
Shipp TD, Zelop CM, Repke JT, Cohen A, Lieberman E. Interdelivery interval and risk of symptomatic uterine rupture. Obstet
Gynecol. 2001;97(2):175-7.

13. Options for Postpartum Contraception

14. Postpartum Considerations
 Most couples resume sexual activity within 1-2 months1
– 66% by first month
– 88% by second month
 Menstrual cycle return2
– 4-6 weeks postpartum if not exclusively breastfeeding
 Risk of thrombosis with estrogen products returns to baseline after 3 weeks
postpartum2
1. Speroff L, Mishell DR. The postpartum visit: it's time for a change in order to optimally initiate contraception. Contraception.
2008;78(2):90-8.
2. Baldwin MK, Edelman AB, Lim JY, Nichols MD, Bednarek PH, Jensen JT. Intrauterine device placement at 3 versus 6 weeks
postpartum: a randomized trial. Contraception. 2016;93(4):356-363.

15. Choosing a Method
World Health Organization Medical
EligibilityCriteria
 Categories 1 and 4 are clearly
defined recommendations.
 If clinical judgement is limited,
categories 1 and 2 both mean the
method can be used, and
categories 3 and 4 both mean the
method should not be used
WHO medical eligibility criteria update. Contraception Volume 94, Issue 3, September 2016, Pages 193–194

16. LactationalAmenorrhea Method
Mechanism: suppresses ovulation
To be effective:
 Exclusively breastfeeding
– q3-4hr (day), 6 hr (night)
– No supplementation
– Pumping schedule adheres to above
 No menses
 Within first 6 months postpartum
– 98% efficacy up to 6 months postpartum

18. Pills
 Progestin-only pills (POPs): <6 weeks postpartum (MEC Cat 2), > 6 weeks
postpartum (MEC Category 1)
 Combined-oral contraceptives (COCs):
– Breastfeeding
 < 6 weeks postpartum should not use COCs (MEC Category 4)
 > 6 weeks but < 6 months (MEC Category 3)
 > 6 months postpartum (MEC Category 2)
– Not breastfeeding
 21–42 days postpartum
 NoVTE risk factors (MEC Category 2)
 Risk factors forVTE (MEC Category 3)
 > 6 weeks postpartum (MEC Category 1)
WHO medical eligibility criteria update. Contraception Volume 94, Issue 3, September 2016, Pages 193–194

19. Longer-Acting Methods
 Depo Provera: >99% effective
– Not breast-feeding: injection should be given within 5 days postpartum (Category
2)
– Breastfeeding: no sooner than 6 weeks postpartum (MEC Category 3)
 Implant: >99% effective
– Insertion immediately postpartum (Category 2) or interval (Category 1)
 IUD: >99% effective
– Insertion immediately postpartum (Category 2) or interval (Category 1)

20. Contraceptive Implant
Mechanism: suppresses ovulation
Contraindications:
 Active Breast Cancer
Consider alternatives:
 Severe decompensated cirrhosis
 Malignant liver disease
 SLE - PositiveAntiphospholipidAntibodies

21. Contraceptive Implant
Breastfeeding
 Theoretical concern that initiating progestin-only
method prior to lactogenesis stage II can
negatively impact breastmilk production
 RCT: 69 women randomized early (1-3 days) vs
interval (4-8 weeks) implant insertion
 No difference in time to lactogenesis stage II or
lactation failure.
– Time to lactogenesis stage II: early 64.3+19.6 hours vs
standard: 65.2+18.5 hours
– Lactation failure: early 3% vs standard 0%, RR 0.03,
95%CI 0.02-0.08
– Use of formula supplementation was not significantly
different between the groups.
Gurtcheff SE, Turok DK, Stoddard G, Murphy PA, Gibson M, Jones KP. Lactogenesis after early postpartum use of the contraceptive implant: a
randomized controlled trial. Obstet Gynecol. 2011;117(5):1114-21.

22. Cu-IUD
Mechanism: interferes with sperm motility
Contraindications:
 Acute pelvic infection (not prior)
 Copper allergy
 Unexplained uterine bleeding
Consider alternative:
 Uterine abnormality
 Anemia

23. Post-placental IUD Placement
Insertion techniques:
 Post-placental insertion (“Delivery Room Insertion”)
– When the IUD is inserted within 10 minutes after the
expulsion of the placenta following a vaginal delivery
 Immediate postpartum insertion (“Morning After Delivery
Insertion”)
– When the IUD is inserted after the post-placental period
but within 48-72 hours of a vaginal delivery
 Trans-cesarean insertion
– When the insertion takes place following a cesarean
delivery, before the uterine incision is closed
 Interval insertion
– Insertion of the IUD at ≥ 4 weeks postpartum

24. Post-placental IUD Placement
Ringed forceps method:
 Grasp the anterior cervical lip with a ring forceps
 Grasp the IUD with the ring forceps – but DO NOT close the
ratchets on the forceps
 Exert gentle traction toward yourself with the cervix-holding
forceps
 Insert the forceps holding the IUD through the cervix and into the
lower uterine cavity
 Release the hand holding the cervix and place the hand on the
abdomen, palpating the fundus
 Move the IUD-holding forceps to the fundus
 Open the forceps and release the IUD
 Slowly remove the forceps from the uterine cavity, keeping it
slightly open
Voedisch, AJ, Blumenthal, P Postpartum Contraception Contemporary OB-GYN. 2012; 57 (1)

25. Post-placental IUD Placement
Manual insertion:
 Grasp the IUD between your 2nd and 3rd
fingers and insert your hand into the
uterus, to the fundus, using your other
hand to confirm fundal location
 Slowly open your fingers and remove
your hand from the uterus
Voedisch, AJ, Blumenthal, P Postpartum Contraception Contemporary OB-GYN. 2012; 57 (1)

26. Post-placental IUD Placement
Trans-cesarean insertion:
 After delivery of the infant and placenta, massage the
uterus
 Perform routine sweep
 Place the IUD at the fundus
 Place the IUD strings in the lower uterine segment near
the internal cervical os. DO NOT pass the strings
through the cervix as this may increase the risk of
infection, but ok to trim the strings to the length of the
cavity
 Close the hysterotomy in the standard fashion, taking care
not to incorporate the IUD strings into the uterine closure
Voedisch, AJ, Blumenthal, P Postpartum Contraception Contemporary OB-GYN. 2012; 57 (1)

27. Post-placental IUD Placement
Risk of Expulsion
 Cochrane review
– Risk of expulsion at 6 months: 17% for post-placental
placement vs 3% for interval insertion (OR 4.89, CI 1.47-
16.32)
– IUD use at 6 months 81% for post-placental placement vs
67% for interval group (OR 2.04, CI 1.01-4.09)
“The fact is, a woman simply cannot continue to use an
IUD that she never got”
Lopez LM, Bernholc A, Hubacher D, Stuart G, Van vliet HA. Immediate postpartum insertion of intrauterine device for
contraception. Cochrane Database Syst Rev. 2015;(6):CD003036.
Goldthwaite LM, Cahill EP, Voedisch AJ, Blumenthal PD. Postpartum intrauterine devices: clinical and programmatic review. Am J
Obstet Gynecol. 2018;219(3):235-241.
Blumenthal PD, Goldthwaite LM. Intrauterine Device Insertion During Cesarean Delivery: The Rising Tide of the Postdelivery
Intrauterine Device. Obstet Gynecol. 2015;126(1):1-2.

28. Post-placental IUD Placement
”10 Minute Rule”
 Historically, publications and training curricula have
emphasized the significance of “IUD insertion within 10
minutes of placental delivery”
 These guidelines are based largely on devices that are no
longer available and with insertion techniques that are no
longer utilized.
 Recent study of 500 women: PP-IUD placement <10 min vs
>10 min
 No difference of distance from fundus on immediate post-
insertion ultrasound
 No difference in subsequent expulsion
Lerma K. Delivery-to-insertion Interval in Immediate Postpartum IUD Provision: End of the “10-Minute Rule”. Presented at FIGO
World Conference 2018.

29. Interval Postpartum IUD Placement
Risk of perforation at interval insertion
may increase if breastfeeding
 EURAS IUD: prospective cohort of 61,448
women at 1230 study centers
 Breastfeeding at time of insertion was
associated with a six-fold increase (RR
6.1, 95% CI: 3.9–9.6)
Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the
European Active Surveillance Study on Intrauterine Devices. Contraception. 2015;91(4):274-9.

30. Conclusions

31. Conclusions
 IPI is a potentially modifiable risk factor for improved maternal and
neonatal outcomes.
 Women and their families should be counseled on the benefits of intervals
longer than 24 months between pregnancies.
 Women should be offered methods of contraception that will help them
achieve longer interpregnancy intervals.
 Women of lower socioeconomic status and younger women appear to be
at risk of the shortest interpregnancy intervals which highlights the
interpregnancy interval as a potential opportunity to address inequities in
adverse outcome.