Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007-2016, by term and preterm birth.

OBJECTIVES: To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery. STUDY DESIGN: We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC. RESULTS: Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%-32%). CONCLUSIONS: While postpartum LARC use increased among the privately insured 2007-2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike. IMPLICATIONS: Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

Postpartum permanent contraception: updates on policy and access.

PURPOSE OF REVIEW: To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels. RECENT FINDINGS: Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients. SUMMARY: Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.

Transcutaneous Electrical Nerve Stimulation for Pain Management of Aspiration Abortion up to 83 Days of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion. METHODS: We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required. RESULTS: Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003). CONCLUSION: We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local restrictions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03187002.

Management of bothersome bleeding associated with progestin-based long-acting reversible contraception: a review.

PURPOSE OF REVIEW: To describe common bleeding patterns and treatment strategies to minimize bothersome bleeding in users of progestin-based long-acting reversible contraception (LARC). RECENT FINDINGS: Most levonorgestrel intrauterine device users will establish a favorable bleeding pattern within a year; NSAIDs are the most effective bridge to help with bothersome bleeding during that time period. Early follicular phase insertion and fundal placement are associated with more favorable early bleeding profiles. Recent studies exploring tranexamic acid, mifepristone, and tamoxifen's adjunct role show modest or no benefit. The progestin implant is associated with more persistent unpredictable bleeding disproportionately affecting women with higher etonogestrel serum levels; recent studies indicate that oral contraceptives, ulipristal acetate, and tamoxifen may all provide temporary relief. SUMMARY: Women's healthcare providers can offer patients adjunct medical therapies to minimize bothersome bleeding associated with progestin LARC use, which may result in increased satisfaction and continuation rates of these effective forms of contraception.

Injectable contraception: emerging evidence on subcutaneous self-administration.

PURPOSE OF REVIEW: Injectable contraception is a widely available and popular family planning method globally. It has evolved to allow for subcutaneous self-injection (DMPA-SC, Depo medroxyprogesterone acetate-subcutaneous). In this review, we will focus on research evaluating DMPA-SC, with specific regard to continuation rates, safety, and satisfaction among users. RECENT FINDINGS: Emerging evidence from the United States, Malawi, Uganda, and Senegal has established safety and higher continuation rates among self-inject users, compared with provider-inject users. Continuation is 10-28% higher among DMPA-SC self-inject users. Self-inject users across studies were highly satisfied and reported DMPA-SC was easy to use. Studies indicate continuation is likely to be attributable to self-administration and user autonomy, rather than inherent properties of the DMPA-SC injection. SUMMARY: DMPA-SC should be made available in high-resource and low-resource settings. Future efforts should be focused on implementation and evaluating how to best add DMPA-SC to the method mix. Cost-benefit analyses will need to evaluate the up-front costs of DMPA-SC for clients, facilities, and health systems compared with the higher continuation rates and saved opportunity-costs over time. Task-shifting strategies and development of mobile phone technologies to assist users in adherence should be considered in future service scale-up.

Postabortion and Postpartum Intrauterine Device Provision for Adolescents and Young Adults.

Adolescents are at high risk for unintended pregnancy and rapid repeat pregnancy, both of which can be associated with negative health and social outcomes. Intrauterine device (IUD) use has been shown to decrease unintended pregnancy and rapid repeat pregnancy. Evidence supports IUD insertion postabortion and postpartum as safe and practical for nearly all women, including adolescent and young adult women. Providers of adolescent gynecology can play an important role in decreasing repeat and unintended pregnancy among adolescents by increasing access to IUDs, reducing barriers to care, and providing IUDs immediately postabortion and postpartum.

Comparing bleeding patterns for the levonorgestrel 52 mg, 19.5 mg, and 13.5 mg intrauterine systems.

OBJECTIVE: Compare bleeding patterns for levonorgestrel 52 mg, 19.5 mg, and 13.5 mg intrauterine system (IUS) products using the World Health Organization Belsey definitions. STUDY DESIGN: We extracted available data on bleeding patterns from published sources. Lower dose products had published data at 1 and 3 years; the 52 mg IUS had available data for 1, 2 and 3 years for amenorrhea and 1 and 2 years for other bleeding patterns. We interpolated 2-year data for the lower dose products based on 1- and 3-year data and compared bleeding pattern rates using Fisher exact testing. RESULTS: The studies evaluated bleeding patterns in 1700, 1566 and 1531 women using levonorgestrel 52 mg, 19.5 mg and 13.5 mg products, respectively. Amenorrhea rates were greater by 180 days after insertion for 52 mg IUS users (11%) as compared to 19.5 mg (5%, p<.0001) and 13.5 mg (3%, p<.0001). Infrequent bleeding rates were higher for 52 mg users by the end of year 1 (31%) compared to 19.5 mg (26%, p=.01) and 13.5 mg (20%, p<.0001). Irregular bleeding rates were higher with the lower dose products by 90 days after insertion with continued lower rates at the end of year 1 for 52 mg users (6%) compared 19.5 mg (17%, p<.0001) and 13.5 mg (23%, p<.0001). Frequent and prolonged bleeding patterns were similar over the first 2 years for all products, although the rates were statistically higher for levonorgestrel 13.5 mg IUS users compared to 19.5 mg and 52 mg IUS users (p≤.03 for all time points after 90-days post-insertion). CONCLUSIONS: Levonorgestrel 52 mg IUS users have more amenorrhea and infrequent bleeding and less irregular bleeding compared to women using lower dose levonorgestrel IUS products. IMPLICATIONS STATEMENT: All women considering levonorgestrel IUS placement should receive counseling on the differences in bleeding patterns related to the various available doses. Women who are interested in maximizing the likelihood of favorable bleeding should consider a levonorgestrel 52 mg IUS over the lower dose alternatives.

Postpartum intrauterine devices: clinical and programmatic review.

The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.

Simulation training for family planning procedures.

PURPOSE OF REVIEW: To review the current evidence for use of simulation in family planning procedural training. RECENT FINDINGS: A variety of simulation models exist for abortion, contraception, and sterilization procedures, ranging from low to high fidelity. Most models for abortion and contraception are low fidelity, inexpensive, and provide opportunities for acquisition and practice of procedural skills. Hysteroscopic and laparoscopic simulation models for sterilization procedures are generally higher fidelity, and their use has been shown to increase knowledge, skill performance, and procedural comfort. SUMMARY: Existing evaluation of family planning simulation education shows consistently positive results related to improved procedural knowledge and comfort. Although some studies have shown increased provision of family planning services following simulation-training interventions, further evaluation is needed to determine the impact on clinical outcomes.

Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study.

BACKGROUND: An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly. OBJECTIVE: We sought to compare expulsion rates by 12 weeks' postpartum for the levonorgestrel intrauterine system and copper intrauterine device. STUDY DESIGN: We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks' gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator's hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours' postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion. RESULTS: We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99-6.55; P = .05). At 24 hours' postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks' postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14). CONCLUSION: Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

Family planning and the Zika era.

PURPOSE OF REVIEW: To review the current evidence regarding the impact of the Zika virus epidemic on pregnancy and the implications for family planning and reproductive health services for women in affected countries. RECENT FINDINGS: In the past 2 years, over the course of the Zika epidemic, much has been learned about the virus. Specifically in regard to pregnancy, a causative relationship has been established between the Zika virus and adverse fetal outcomes, and sexual transmission of the virus has been documented. Broad recommendations by government agencies and public health officials regarding avoidance of pregnancy for women at risk of acquiring the Zika virus have theoretical and documented implications for abortion and contraception demand and access. SUMMARY: Additional research is needed to better understand the impact of Zika virus health recommendations and advisories on women's decision making around pregnancy, as well as their impact on demand, access and safety of family planning services.

Comfort With Skills and Knowledge After Immediate Postpartum Intrauterine Device Training.

OBJECTIVE: To estimate whether a standardized immediate postpartum intrauterine device (IUD) simulation results in sustained improvement in perceived comfort with procedural skills. METHODS: From November 2013 to April 2015, obstetric health care providers at two teaching hospitals participated in a 30-minute immediate postpartum IUD simulation workshop and program evaluation. We assessed knowledge of indications, insertion technique, safety, and comfort with knowledge and skills preintervention immediately after and 6 months posttraining. RESULTS: Training participants (N=84) included 39 residents and 45 attendings (25 certified nurse-midwives and 20 obstetrician-gynecologists). Fifty-seven participants (68%) completed the 6-month assessments. Many participants had placed immediate postpartum IUDs before the training (54% of residents compared with 64% of attendings, P=.32); 60% were comfortable with their knowledge and 52% with their insertion skills defined by self-assessment of 7 or greater on a 10-point scale. On the pretest, 77% answered 80% or greater of the knowledge-based questions correctly; this proportion rose to 95% and 97% on the immediate and 6-month assessments, respectively, and were similar between residents and attendings. Immediately posttraining, 94% of participants rated their comfort with knowledge at 7 or greater out of 10; this fell to 86% by 6 months. Likewise, 87% and 74% scored their comfort with skills at 7 or greater out of 10 immediately and at 6 months, respectively. By 6 months, 81% reported placing one or more immediate postpartum IUDs(92% of residents and 71% of attendings, P=.05). CONCLUSION: Residents and attendings demonstrate sustained improvement in knowledge and comfort with immediate postpartum IUDs 6 months after a standardized simulation workshop.

Immediate postpartum provision of long-acting reversible contraception.

PURPOSE OF REVIEW: The objective of this review is to describe current literature regarding the role and characteristics of long-acting reversible contraception (LARC) used immediately postpartum. RECENT FINDINGS: Copper and levonorgestrel intrauterine devices (IUDs) inserted immediately postpartum at the time of both vaginal and cesarean deliveries are associated with higher rates of continuation at 6-12 months when compared with IUDs placed at the postpartum visit (4-8 weeks after delivery), despite higher rates of expulsion. IUDs and contraceptive implants are cost-effective when used immediately postpartum, and they are associated with longer interpregnancy intervals. There is limited evidence regarding the effects of immediate postpartum LARC on breastfeeding. SUMMARY: Use of LARC methods in the immediate postpartum period is both effective and safe, and could reduce unmet need for contraception during this time. More research is needed to explore various immediate postpartum IUD insertion methods and the effects of immediate postpartum progestin-containing LARC on breastfeeding.

Adverse Birth Outcomes in Colorado: Assessing the Impact of a Statewide Initiative to Prevent Unintended Pregnancy.

OBJECTIVES: We assessed whether living in counties with Title X clinics and increased use of long-acting reversible contraception (LARC) in Colorado are associated with decreased risk of adverse birth outcomes. METHODS: We linked Title X clinic counties to the Colorado birth data set by using the mother's county of residence. We compared low birth weight (LBW) and preterm birth (PTB) in 2008 and 2012, in counties with and without Title X clinics. We compared the relationship between LARC use and the incidence of LBW or PTB in 2012 for women living in counties with Title X clinics. RESULTS: For women living in counties with Title X clinics, the odds of PTB were significantly lower in 2012 compared with 2008 (odds ratio = 0.85; 95% confidence interval = 0.81, 0.89; interaction P = .02). For women living in Title X clinic counties in 2012, a higher proportion of LARC use (> 12.4%) was significantly associated with decreased risk of PTB (P = .02) compared with a low proportion of LARC use (≤ 4.96%). CONCLUSIONS: Improved access to family planning services and increased use of LARC are associated with lower risk of PTB.

Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications.

OBJECTIVE: The objective of the study was to evaluate success and safety of intrauterine device (IUD) placement in a large cohort of adolescents. STUDY DESIGN: We examined the medical records of patients aged 13-24 years at the Children's Hospital Colorado Adolescent Family Planning Clinic with at least 1 attempt at IUD placement. We abstracted demographic, reproductive, and procedural variables. The primary outcome was successful placement at first IUD insertion visit. We compared nulliparous with parous adolescents and patients younger than 18 years with those 18 years of age and older. RESULTS: Between April 2009 and December 2011, 1177 adolescent women aged 13-24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement, 1012 (86%) of which were with an advanced practice clinician. The first attempt was successful for 1132 women (96.2%). The first-attempt success rate was 95.8% for nulliparous women and 96.7% for parous women (P = .45). The first-attempt success rate was 95.5% (n = 169) for women aged 13-17 years compared with 96.3% (n = 963) for women aged 18-24 years (P = .6). Only 1.8% (n = 21) of all first-attempt successful insertions required ancillary measures. Of the 45 patients with a failed first insertion attempt, 40% (n = 18) had a second attempt with a physician, of which 78% (n = 14) were successful. Within the first 6 months of IUD placement, no perforations were identified and 24 patients (3.0%) expelled the IUD. Insertion failures and IUD expulsions were not related to IUD type, age, or parity. CONCLUSION: Intrauterine devices can be inserted in nulliparous adolescents of any age with similar success to parous adolescents, by both physicians and advanced practice clinicians. Inability to provide ancillary measures such as paracervical block or cervical dilation should not limit access to this first-line contraceptive method.

Early hysteroscopic removal of intratubal microinserts with urologic stone retrieval forceps.

BACKGROUND: Nickel hypersensitivity reactions can be an indication for the removal of intratubal microinserts used for hysteroscopic sterilization. Although early removal can be attempted hysteroscopically, hysteroscopic grasping forceps may be inadequate to grasp deeply positioned inserts. CASE: Three days after hysteroscopic sterilization, the patient presented with a rash consistent with a nickel hypersensitivity reaction. Ten days after placement, we successfully performed hysteroscopic removal of an intratubal microinsert with tri-prong urologic stone retrieval forceps after standard hysteroscopic grasping forceps was unable to reach the deeply positioned device. Within 36 hours of bilateral microinsert removal, all symptoms resolved. CONCLUSION: In difficult cases, 1-mm tri-prong urologic stone retrieval forceps can be useful for early hysteroscopic removal of intratubal microinserts.

Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial.

OBJECTIVE: Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel. STUDY DESIGN: A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement. RESULTS: Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p<.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p<.001]. Satisfaction with tenaculum placement was similar for the two groups. CONCLUSION: Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.