Postpartum contraception: Increasing patient access while maximizing resident education Julie Johnston MD Lawrence Family Medicine Residency Julia McDonald DO, MPH Maine Dartmouth Family Medicine Residency

Disclosures Dr. Johnston Merck Nexplanon faculty trainer Spouse with stock holdings Johnson and Johnson Dr. McDonald-Nothing to disclose

Objectives Upon completion of this session, participants should be able to: Identify safe and effective immediate postpartum contraceptive methods. Name one barrier in your health setting that inhibits immediate postpartum contraceptive provision. Develop a strategy for improving access to postpartum contraception through resident involvement.

Why the rush for postpartum contraception? The U.S. has the highest rate of unintended pregnancy of any developed country ~ 50% Nationwide 10-40% miss the postpartum (PP) visit <50% women who desire an IUD PP receive it Infant spacing is important for maternal and child health Unintended rate is 10% in the first year PP Non-breastfeeding women return to ovulation in 45 days Most women resume sexual intercourse prior to their PP visit

Contraception and US Medical Eligibility Criteria (MEC) <1 month Postpartum Breastfeeding Not Breastfeeding Progestin only pills 2 1 Depo Levonorgestrel IUD* Paragard IUD* Etonogestrel *<10 minutes after delivery of the placenta

U.S. Selected Practice Recommendations for Contraceptive Use, 2013 Guidelines reflect the U.S. Medical Eligibility Criteria for immediate placement of IUDs and Implants postpartum

Women’s interest in IPP IUDs Women may be more motivated in the immediate post-partum period to start contraception. Women who agree to IPP placement are more than 10x more likely to have the IUD inserted than those women who decided to wait until the post-partum visit Mohamed S., Kamel, M., Shaban O., Salem, H. Acceptability for the use of postpartum intrauterine contraceptive devices: Assuit experience.Med Princ. Pract 2003;12:170-5.

Etonogestrel and Breastfeeding 40 exclusive breastfeeding moms Randomized to ETG 24-48hr after delivery or Depo at 6 weeks Outcome: ETG had larger maternal weight loss ETG had increased infant weight gain Brito, M., Ferriani, R., et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80:519-526.

Postplacental IUDs Placed within 30 minutes of a vaginal placental delivery or during a c-section Post-placental IUD placement does not increase the risk of endometritis Welkovic, S., et al. Post-placental IUD placement does not increase the risk of excessive bleeding Welkovic, S., et al. IPP expulsions are higher but total pregnancies at 1 yr were not (3.1% overall IPP and INT) K. Eroglu et al. 6-19% after vaginal birth, 12.1% is often quoted 1.2-9.6% after c-section IUDs can be replaced if expelled

What we did in Lawrence, MA 2013: Initiated in-hospital post-partum ETG implant placement. HOW: If ETG implant desired, ordered in EMR (device billed through GLFHC 403b pharmacy), delivered to LGH pharmacy for verification, then brought to floor for (unbilled) placement. Multiple benefits: — In women with ante partum stated intention to use, receipt of device (w/i 6wks PP) INCREASED from 26.5% to 93.5% — Increased procedural numbers for residents — Communication between residents and staff (RN, lactation)

Resident Procedures: ETG 3/12-3/14 Insertions: 31 Removals: 15 3/14-3/15 Insertions: 189 Removals: 54

LARC Funding Programs RHEDI Get LARC Now Ryan (OB/GYN programs)

Medicaid Coverage Alabama Montana Colorado (+/-) New Mexico Georgia New York Iowa Oklahoma Louisiana South Carolina Maryland http://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Coding-and-Reimbursement-for-LARC/Reimbursement-Resources-for-Postpartum-LARC-Initiation/Medicaid-Reimbursement-for-Postpartum-LARC-By-State

Contacts Alicia Luchowski at the ACOG LARC Program:ALuchowski@acog.org

References Celen, S., Moroy, P., Sucak, A., Aktulay, A., Danisman, N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception 2004; 69 279-82. Chi, I., Wilkens, L., Rogers, S. Expulsions in Immediate Postpartum Insertions of Lippes Loop D and Copper T IUDs and their Counterpart Delta Devices-An epidemiological Analysis Contraception 1985 Aug;32(2):119-134. Grimes, D.A., Schulz, KF., Van Vliet, HHAAM, Stanwood, NL., Lopez, LM. Immediate post-partum insertion of intrauterine devices (Review). Cochrane Collaboration 2008 (3). J. L. Hayes et al. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007 Oct;76(4):292-6. Welkovic, S., et al. Post-partum bleeding and infection after post-placental IUD insertion. Contraception 2001; 63:155-9. K Eroglu et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early post partum period with interval period: I year follow-up. Contraception 2006; 74(5):376-81. Mohamed S., Kamel, M., Shaban O., Salem, H. Acceptability for the use of postpartum intrauterine contraceptive devices: Assuit experience.Med Princ. Pract 2003;12:170-5. Muller, A., et al. Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study. Contraception 2005; 72:192-195. Gurtcheff, S, MS; Turok, D., et. al. Lactogenesis After Early Postpartum Use of the Contraceptive Implant: A Randomized Controlled Trial. Obstetrics and Gynecology 2011;117:1114-1121. Kapp N, Curtis K, Nanda K. Progestogen-only contraceptive use among breastfeeding women: a systematic review. Contraception 2010;82:17–37. Chen, B., Reeves, M. Postplacental or delayed levonorgestrel intrauterine device insertion and breastfeeding duration. Contraception. 2011; 84(5):499-504. Stevermer, J., Jones, K., Egan, M. Offer this contraceptive to breastfeeding new moms. J Fam Pract. 2011; 60(12):744-746. Brito, M., Ferriani, R., et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study. Contraception. 2009;80:519-526.

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