Expert Reviews
org
Postpartum intrauterine devices: clinical and
programmatic review
Lisa M. Goldthwaite, MD, MPH; Erica P. Cahill, MD; Amy J. Voedisch, MD, MS; Paul D. Blumenthal, MD, MPH
T he immediate postpartum period is
a critical moment for contraceptive
access and an opportunity to initiate
long-acting reversible contraception
(LARC). Women who are known to not
be pregnant and who have ready access to
their obstetrical providers are often highly
motivated to avoid another pregnancy
and are likely to have insurance coverage.
Yet, despite this fortuitous arrangement
of essential factors for contraceptive ac-
cess, as many as 62% of women globally
have an unmet need for contraception in
the postpartum period.1 A short interval
between births has been associated with
increased risk for maternal and infant
morbidity and death.2-5 For this reason
the American College of Obstetricians
and Gynecologists (ACOG) and the
World Health Organization (WHO)
recommend pregnancy spacing of at least
6e24 months between a delivery and
next conception; women who are not
using reliable contraception in the
extended postpartum period often
conceive much sooner.6,7 Even waiting to
address contraception until the first
postpartum visit can be problematic,
because ovulation can resume soon after
delivery, yet more than one-half of
women report unprotected intercourse
before the 6 week postpartum visit,8 and
nearly 40% of women do not ultimately
attend a postpartum visit.6
From the Department of Obstetrics and
Gynecology, Division of Family Planning
Services and Research, Stanford University
School of Medicine, Stanford, CA.
Received April 30, 2018; revised July 5, 2018;
accepted July 8, 2018.
P.D.B. has served as a consultant for Bayer
Pharmaceuticals. The remaining authors report
no conflicts of interest.
Corresponding author: Lisa M. Goldthwaite,
MD, MPH. lgoldthw@stanford.edu
0002-9378/$36.00
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.07.013
ajog.
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.
Key words: contraception, intrauterine device, postpartum
In the most recent Practice Bulletin on slowed in the 1980s after a multinational
LARC, ACOG supports immediate post- trial by the WHO was stopped because of
partum LARC insertion (ie, intrauterine IUD expulsions that exceeded the pre-
device [IUD] before hospital discharge) determined termination index of
as a best practice, recognizing its role in 20%.11,12 In addition, the 1970e1980s
preventing rapid repeat and unintended lawsuits related to the Dalkon Shield
pregnancy.9 However, rates of post- IUD and associated infections created a
partum IUD insertion remain low in the lasting clinical and cultural fear of IUDs
United States, with recently published for decades to come.13,14 More recently,
estimates of a national sample at fewer there has been a resurgence of interest
than 10 postpartum IUD insertions for and research into IUD use in general and
every 10,000 deliveries, as compared with in postpartum IUD use specifically.
683 tubal sterilizations for every 10,000 Expulsion remains a primary variable of
deliveries.10 This review will focus on the interest in studies of the postpartum
most recent clinical and programmatic IUD that is balanced by an evaluation of
updates on postpartum IUD practice. We IUD continuation, which may be the
will discuss postpartum IUD expulsion more clinically relevant outcome. When
and continuation, eligibility criteria and accounting for expulsions, requested
contraindications, safety in regards to removals, and reinsertions of IUDs in
breastfeeding, and barriers to access. Our the postpartum period, many studies
aim is to summarize evidence related to show high rates of continuation, despite
postpartum IUDs and encourage those expulsions. In a metaanalysis that was
involved in the healthcare system to included in the most recent Cochrane
remove barriers to this highly worthwhile review of immediate postpartum IUDs,
practice. IUD expulsion by 6 months was more
likely for women who were assigned
Expulsion and Continuation randomly to the immediate insertion
The use of the postpartum IUD began group in which IUDs were placed within
internationally in the 1960s; however, 10 minutes of placental delivery (17%),
the use of this contraceptive approach compared with those women assigned
SEPTEMBER 2018 American Journal of Obstetrics & Gynecology 235
Expert Reviews
randomly to receive the IUD at the
postpartum visit (3%; odds ratio, 4.89;
95% confidence interval, 1.47e16.32).15
However, IUD use at 6 months was also
more likely in the immediate insertion
group compared with the standard
insertion group (81% vs 67%; odds ratio,
2.04; 95% confidence interval
1.01e4.09).15 A shift from focusing
exclusively on expulsion rates to a
broader view of IUD continuation in
general has allowed for expansion of
postpartum IUD research and services in
recent years.
Postpartum IUD expulsion risk is
postulated to be affected by features
inherent in the insertion process. Many
elements of insertion have been investi-
gated with the aim of reducing expulsion
rates, including insertion technique,
insertion at the time of vaginal or ce-
sarean delivery, and insertion timing
relative to delivery. IUD insertion can
be accomplished with the use of a
number of techniques that include
forceps (standard ring forceps or the
Kelly placental forceps), the insertion
device from the manufacturer, or
the hand of the obstetrics provider.
Recently, a dedicated postpartum
IUD insertion instrument has been
developed and tested.16,17 An IUD can be
placed subsequent to both vaginal and
cesarean deliveries. In addition, IUD
insertion can occur at different times
relative to delivery: (1) “postplacental”
IUD insertion, with the patient still
in the delivery room (commonly
described as insertion within the first
10 minutes after placental delivery) or
(2) an “immediate postpartum” inser-
tion, generally meaning placement after
delivery room departure but within
48 hours of delivery.
The issue of expulsion itself is chal-
lenging because of inconsistent study
designs, definitions, and whether it is a
meaningful clinical or programmatic
outcome. Expulsion was identified his-
torically by patient report or on clinical
examination. Given ultrasound use in
more recent studies as well as more active
clinical follow-up evaluation, the cate-
gories of complete and partial expulsion
have been used to differentiate between
an IUD that has expelled completely vs
236 American Journal of Obstetrics & Gynecology SEPTEMBER 2018
one that is visible in the cervix. The
clinical utility of the identification of
partial expulsions remains unclear, as
does the appropriate management.
Insertion technique
Each of the various insertion techniques
has benefits and limitations, and they
have been studied primarily with the
goal of minimizing expulsion rates. The
manual insertion technique, where the
provider’s hand attempts to deliver the
IUD to the uterine fundus, is simple and
intuitive. It does not require additional
equipment, which makes it appealing in
low resource settings. However, because
a hand is larger than forceps, the patient
may experience more discomfort, par-
ticularly if she does not have effective
anesthesia. In addition, without
adequate personal protective equipment,
the provider may be at increased risk of
infectious exposures. Conversely, inser-
tion of an IUD with the use of forceps or
a dedicated inserter may be more
comfortable for a woman and may be
associated with less exposure risk to the
provider. Finally, the insertion of an IUD
at any time other than postplacental, the
contraction, and the immediate involu-
tion of the uterus may preclude the
ability for a provider to use his/her hand
to place the device. In regards to expul-
sion, Xu et al18 found that there was no
difference in expulsion rates between
devices placed by the manual method
and the forceps method. Additionally, in
a recent study that compared the use of
the dedicated insertion device with the
forceps insertion technique, there was no
comparative difference between com-
plete expulsion rates for these 2 insertion
methods.19
The use of ultrasound to guide the
postpartum IUD insertion has also been
explored. Although ensuring that an
IUD reaches the fundus may theoreti-
cally help with device retention, the
impact of ultrasound use in ensuring
fundal placement and on subsequent
outcomes has not been studied specif-
ically. In 1 trial that evaluated the posi-
tion of an IUD at 24-48 hours after
placement, the position of the device
within the uterus before hospital
discharge was not associated with
ajog.org
subsequent expulsion, because some
fundal-placed devices were expelled ul-
timately and some lower-lying devices
were retained.20 Thus, without studies
that will assess specifically the value of
ultrasound relative to expulsion or
continuation, its utility at time of inser-
tion cannot be determined.
Vaginal or cesarean delivery
Studies consistently have demonstrated
lower expulsion rates with IUDs placed
during a cesarean delivery compared
with vaginal delivery.21,22 There is no
clear reason for this difference, but it
may be related to true fundal IUD
position at insertion, to the fact that the
uterus is more contracted after cesarean
deliveries than within 10 minutes of a
vaginal delivery, or to the increased
likelihood of a less dilated cervix at the
time of delivery.
Timing of insertion
In an effort to determine whether
expulsion rates are related to insertion
timing, Chi et al12 investigated the inser-
tion of the Lippes Loop D and the Copper
T-220 IUDs (neither of which are in
current use) at 2 defined time points:
during and after the first 10 minutes after
placental delivery. They concluded “im-
mediate insertions (within 10 minutes
after placenta delivery) are possibly
associated with lower expulsion rates
than later insertions (eg, 2e72 hours after
placental delivery).” Based on this study’s
findings and with expulsion rates as the
only outcome of interest, subsequent
research and many guidelines have
incorporated the “postplacental” 10-
minute window approach.23
Physiologically, there is biologic
plausibility that the larger the uterus at
the moment of insertion and the more
open the cervix, the more likely an IUD
is to expel. This relationship can be seen
clearly when considering the range of
expulsion rates that have been seen in
studies when IUDs are placed at a time
point unrelated to pregnancy
(0e4%),24-27 after a first trimester
abortion (2e5%),28,29 after a second
trimester abortion (3e7%),29-31 after a
cesarean delivery when the uterus is also
more contracted and the cervix is often
ajog.org Expert Reviews

more closed (3e20%),24,25,32-34 or

FIGURE
immediately after a vaginal delivery
(variable, up to 30%; Figure).20,26,27,35
Continuum of intrauterine device expulsion
Therefore, there may be benefit to wait-
ing slightly >10 minutes after placental
delivery before inserting the IUD, which
allows time for the contraction of the
uterus and the closing of the cervix after
the third stage of labor and oxytocin
administration. In a study that
compared expulsion of IUDs after
postplacental insertion compared with
insertion within 48 hours of delivery, the
expulsion rates were 10.8% and 4.1%
respectively, which indicated this physi-
ologic effect.36
Finally, although there is conflicting
evidence regarding the ideal timing of
insertion related to expulsion alone, a
broader more patient-centered approach
should be taken in terms of offering
postpartum IUD services. Creating
guidelines and protocols based on a strict
10-minute insertion window can limit
access to IUDs for women who miss this
10-minute window. However, there is
Continuum of expulsion rates for intrauterine devices placed at various time points related to uterine
value to continuing an emphasis on
size and cervical dilation that included interval timing,24-27 after first-trimester abortion,28,29 after
“delivery room” insertion over a “morning
second-trimester abortion,29-31 after cesarean delivery,24,25,32-34 and after vaginal delivery.20,26,27,35
after delivery” insertion. Despite possibly
IUD, intrauterine device; PP, postpartum; Tri, trimester.
higher expulsion rates for postplacental
Goldthwaite. Postpartum IUD use and services. Am J Obstet Gynecol 2018.
insertion compared with insertions per-
formed later in the same hospital stay, but
after the patient has left the delivery room,
the programmatic benefits for post- Contraindications hemorrhage is related to the priority of
placental insertion over a next-day inser- There are few contraindications to the managing the hemorrhage over insertion
tion are significant and include impact insertion of IUDs whether they are in- of the IUD. There is no clear evidence of
on resources, clinical personnel, systems terval insertions or postpartum in- increased risk in placing an IUD for a
barriers (eg, bringing the patient back to sertions. The standard limitations that woman after a resolved episode of uterine
labor and delivery or finding a procedure apply to interval insertions according to atony or other resolved cause of excessive
room), patient comfort, and patient the Center for Disease Control and Pre- bleeding. With the recent ACOG shift
preferences. vention’s 2016 United States Medical toward defining postpartum hemorrhage
Eligibility Criteria for Contraceptive Use as >1000 mL of blood loss after any de-
IUD type (MEC) also apply to postpartum IUD livery (vaginal or cesarean), the use of a
Postpartum IUD expulsion rates vary by insertion.38 Contraindications include 1000-mL blood loss as a guideline is a
IUD type. Although most studies in this anatomic abnormalities that distort the reasonable cut point for the IUD
field have investigated the use of the cavity or interfere with insertion, cervical contraindication in the setting of
Copper IUD in the postpartum setting, or uterine cancer, breast cancer (levo- hemorrhage.40
more recent trials have included the le- norgestrel IUD only), after septic abor- Of note, the World Health Organiza-
vonorgestrel IUD. The levonorgestrel tion, active pelvic tuberculosis, current tion’s 2015 MEC has some differences
IUD consistently demonstrates higher purulent cervicitis, gonorrhea and chla- compared with the US MEC.41 Key dif-
expulsion rates compared with the mydia infections, and endometritis. ferences include not recommending
Copper IUD.20,24,37 Although there is no Contraindications unique to the post- initiation of the an IUD for (1) women
clear explanation for this difference in partum setting include chorioamnionitis, with clinically advanced HIV infections
expulsion rates, this could be a result of postpartum sepsis, and postpartum until the patient becomes well and (2)
properties inherent to the device itself or hemorrhage.38,39 The contraindication to women who are considered high indi-
the device’s long string length.19,20 insertion of an IUD in a woman with vidual risk for exposure to sexually

SEPTEMBER 2018 American Journal of Obstetrics & Gynecology 237

Expert Reviews
transmitted diseases. In general, the
WHO guidelines tend to be more
restrictive, which reflects the different
populations and variations in healthcare
resources worldwide as compared with
the United States.
Breastfeeding
There has been a longstanding contro-
versy regarding the impact of hormonal
contraception on breast milk production
and potential interference with a
mother’s breastfeeding goals. This
concern is based on the theoretic exog-
enous hormone impact on lactogenesis.
Lactogenesis is divided into 2 stages.
Stage 1 begins in midpregnancy and
continues until delivery. During this
stage, progesterone levels that are pro-
duced by the placenta and prolactin
levels rise. This stimulates the milk ducts
secretory function. Colostrum is formed
that may be expressed in the late stages of
pregnancy. Stage 2 begins 2e3 days after
delivery and is triggered by the rapid
decline in progesterone levels, which
results in milk production. Prolactin and
oxytocin then support continued pro-
duction in conjunction with other
stimuli, such as breast emptying and
infant suckling.42
Hormonal contraception that con-
tains progestins theoretically may inter-
fere with milk production by blocking
the natural postpartum progesterone
decline. In addition to the concern of
exogenous hormones on breast milk
production, there is also a concern about
the impact of exogenous hormones that
are expressed in breast milk on the in-
fant’s growth and development. Several
studies have been published that have
evaluated these potential concerns. A
systematic review in 2016 found no
negative impact of progestin-containing
contraceptives on breastfeeding or on
infant growth and development.43
Levonorgestrel IUDs work mostly
through a local progestin effect and have
low levels of circulating hormone. The
levels drop from a mean of 191e141 pg/
mL over the course of 4 years in the
52-mg levonorgestrel IUDs.44 These
levels are lower than those observed with
the etonogestrel hormonal implant,
which averages just above 200 pg/mL.45
238 American Journal of Obstetrics & Gynecology SEPTEMBER 2018
In addition, oral progestin levels
are 5e10 times higher, averaging
1500e2000 pg/mL.46 Given these
dramatically lower levels with the levo-
norgestrel IUD especially in comparison
to oral methods, the actual impact on
breastfeeding should be minimal.
Data that look at postpartum levo-
norgestrel IUDs and breastfeeding spe-
cifically are limited to 2 studies. The first
is a secondary analysis of a randomized
controlled trial of immediate vs delayed
insertion (6 weeks after delivery) of the
levonorgestrel IUD.47 There was no dif-
ference in reported breastfeeding be-
tween the 2 groups at 6e8 weeks and 3
months. However, there was a difference
in exclusive breastfeeding rates at 3 and 6
months, and more women continued to
breastfeed to 6 months in the delayed
insertion group.
A recent, larger noninferiority ran-
domized controlled trial looked at im-
mediate vs delayed initiation of the
levonorgestrel IUD (4e12 weeks after
delivery) and compared time to lacto-
genesis and breastfeeding at 8 weeks.48
The immediate group was noninferior
to the delayed group with onset to lac-
togenesis and any reported breastfeeding
at 8 weeks. Comparison of exclusive
breastfeeding at 8 weeks also was
noninferior in the immediate initiation
group.
Given these data, the US and WHO
MECs are supportive of the initiation of
both the hormonal and nonhormonal
IUDs in the immediate postpartum
period, regardless of breastfeeding
status.38,41
Barriers to Access
Although the rate of postpartum LARC
use in the United States has increased
from 1.86 (2008e2009) to 13.5 per
10,000 deliveries (2012e2013), it is still
uncommon, with the highest use in
women with medical comorbidities,
with no private insurance, and at aca-
demic centers.10,49 Interest in post-
partum LARC, in general, is much higher
than reported use, with some studies
reporting rates as high as 44%, which
suggests that barriers do exist.50 Barriers
to obtaining an IUD in the postpartum
period can be divided into 3 broad
ajog.org
categories: (1) financial, (2) hospital, and
system-based (3) provider knowledge.
Financial barriers
A common perception is that cost and
financial arrangements with hospitals and
insurance are significant issues that pre-
vent providers from offering postpartum
IUDs. However, it has been difficult to
evaluate the cost or cost-savings of a
postpartum IUD because different
studies have looked at this equation from
different perspectives. For example, a
postpartum IUD placed in the hospital
may be more cost-effective for a patient
because it is covered within the cost of her
delivery and paid for in part by insurance.
However, it may be less cost-effective to
the hospital, which may not be able to
charge separately for the IUD. Overall, a
postpartum IUD placement is beneficial
to society because the cost of subsequent
unintended short-interval pregnancy is
much greater than an IUD. Neither re-
searchers nor policymakers have deter-
mined definitively whose cost and whose
benefit should be the focus: the patient,
the physician, the hospital, or society. One
study evaluated the cost-effectiveness of
an IUD with the primary outcome of
number of pregnancies prevented and
secondary analysis for incremental sys-
tem cost-effectiveness ratio.51 The au-
thors found that, for every 1000 women
who received a postpartum IUD, the
result was a health system cost-savings of
$282,540 over a 2-year time horizon and a
gain of 10 quality-adjusted life years.
Additionally, they calculated that, per
1000 women, 88 unintended pregnancies
were prevented over a 2-year time period.
Another study evaluated the costs of a
postpartum IUD program for patients
with emergency Medicaid insurance
coverage for their pregnancies.52 The
authors compared the costs of a hospital-
funded postpartum IUD program with
the costs of the same program that was
funded by the state. They incorporated
costs of future unplanned pregnancies
and costs for IUD placement and com-
plications. They found that the hospital
lost 70 cents for every dollar spent on
postpartum IUD program. However, the
state would save $2.94 for every dollar
spent on a state-funded IUD program,
ajog.org
for a total net savings for the state of
$102,310 in the first year of funding a
state-sponsored program. This demon-
strates the importance of considering to
which entity we are interested in
exploring cost-effectiveness.
Finally, in our current healthcare de-
livery system, clinicians can charge
differently for those IUDs that are placed
in the office vs those placed in the hos-
pital. IUDs that are placed in the hospital
are often included in the global fee for
obstetric care and neither hospital nor
clinicians are provided additional pay-
ment for this service.53 Therefore, a
provider who places a postpartum IUD
potentially is paying for the cost of the
IUD and foregoing the revenue made
from the insertion procedure visit.
Additionally, should a patient decide that
she does not want a pharmacy-dispensed
IUD, it can often not be returned to the
pharmacy or used for another patient,
which leaves the provider to discard it at
a financial loss. Finally, some states limit
reimbursement only to initial IUD
placement, which provides a disincen-
tive for providers to place an IUD in the
postpartum period, when expulsion is
more likely.53 These flawed systems do
not incentivize best practices and pin the
financial success of an obstetric practice
or hospital against the needs of patients.
The Centers for Medicare and
Medicaid Services published a report in
April 2016 that detailed the strategies of
different states for addressing these bar-
riers and improving access. They divided
the strategies into categories that
included reimbursement for immediate
postpartum insertion of LARC, removal
of administrative barriers to LARC, and
improvement of supply management of
LARC.53 Several states have adopted
policies that combat these barriers; these
are reviewed in the April 2016 report by
state and include the specific billing
codes required for reimbursement. For
example, since 2014 in Alabama, post-
partum IUD placement at any time
during hospitalization after delivery is
billable to Medicaid, and the device itself
is covered in the hospital costs. This is a
logical approach because the hospital
can then stock IUDs for use by all prac-
titioners, which resolves the supply
barrier; the impact of the actual act of
postpartum IUD placement for hospital
costs is otherwise negligible.
Hospital and system barriers
The most significant systemic barrier to
access to postpartum IUDs is that they
are simply not available to women while
they are in the hospital. In this case, a
woman must return for a subsequent
visit for placement. In 1 study in the
southeastern United States where im-
mediate postpartum IUDs were not
offered, two-thirds of women who
desired a postpartum LARC method did
not receive it in the postpartum period.50
The authors found that many clinics
required multiple visits and/or addi-
tional testing before IUD placement.
Logistical barriers are often more
prohibitive than financial barriers. A
recent retrospective study evaluated
whether insurance type (Medicaid
compared with private insurance)
affected IUD placement for women at a
clinic where 2 visits were required for
LARC insertion: a screening visit and an
insertion visit.54 The authors found that
women with public insurance were more
likely to be postpartum (66% vs 24%),
less likely to return for LARC placement
(66% vs 79%), and more likely to
become pregnant within 1 year of their
request for LARC (18% vs 6%). The
women with public insurance did not
have any out-of-pocket expenses in this
clinic, which demonstrates that logistical
barriers can interfere even with cost-free
provision of IUDs.
Provider knowledge barriers
The barrier perhaps most easily changed
is provider knowledge regarding the
appropriate use of IUDs. One common
myth is that the increased expulsion rate
of postpartum placement compared with
interval IUD placement makes the prac-
tice “not worth it.” As discussed earlier,
studies consistently demonstrate that,
despite expulsion rates, women who
receive their desired postpartum IUD are
more likely to continue to use this device
than women who were planning to receive
one at a delayed interval.15 Additionally,
there are few actual contraindications to
postpartum IUD placement, as described
SEPTEMBER 2018 American Journal of Obstetrics & Gynecology
Expert Reviews
earlier, yet there remain many providers
with misconceptions of who is an appro-
priate IUD candidate. One study of 636
sites in California that received funding
from the Family Planning Medicaid
expansion evaluated providers’ knowl-
edge of IUDs and found a large range.55
The respondents were mostly physicians
(76%) in private practice (48%), and the
majority (83%) reported having IUD-
specific training. The authors found
many common misconceptions regarding
timing of use and appropriate patients
among this group. Specifically, only 53%
of providers knew that IUDs could be
inserted during the immediate post-
partum period, and only 43% of them
agreed that they could be used after de-
livery. Additionally, 11% believed that
placing an IUD was more likely to lead to
lawsuits. There were also misconceptions
about who should receive IUDs; >20% of
providers thought IUDs were inappro-
priate for nulliparous patients, teenagers,
women with a history of ectopic preg-
nancy, young adults (ages 20e29 years),
and women with a history of a sexually
transmitted infection in the past 2 years.
Comment
The provision of postpartum IUD ser-
vices is a powerful public health inter-
vention, with specific benefits to women,
families, and society. This simple practice
is safe and effective for women. Although
historically there has been concern for
“high” expulsion rates, there is a growing
appreciation of the opportunity to
continue an IUD over the risk of expul-
sion. Helping to meet women’s post-
partum contraceptive needs is a matter of
reproductive justice, with the overarching
goal of supporting women and families in
their decisions regarding when and how
to get pregnant, parent, and support their
families.49 As with all contraceptive ser-
vices, a patient-centered approach should
be taken to postpartum IUD use and
services, with a universal goal of
improving access while always avoiding
coercion and inequitable practices.
With the increased interest of post-
partum IUD services, there is a great
need for research into program dy-
namics and challenges in the imple-
mentation of postpartum IUD
239
Expert Reviews
programs. A recently published evalua-
tion of the launch of postpartum IUD
programs at 10 hospitals in Georgia
explored the steps and challenges of the
implementation of a postpartum IUD
program.56 The authors divide the pha-
ses of implementation into exploration,
installation, and sustainability. They
note that it is vital in each phase to
incorporate a team of clinicians, phar-
macists, members of the finance
department, and the medical records
group. With careful coordination to each
of these factors in program imple-
mentation, successful and sustainable
scale-up is possible. Overall, worldwide
experience coupled with considerable
data indicates that postpartum IUD
services are safe and clinically and pro-
grammatically effective and that overall
the benefits outweigh the limitations. -
REFERENCES
1. Rossier C, Bradley SE, Ross J, Winfrey W.
Reassessing unmet need for family planning in
the postpartum period. Stud Fam Plann
2015;46:355–67.
2. DeFranco EA, Ehrlich S, Muglia LJ. Influence
of interpregnancy interval on birth timing. BJOG
2014;121:1633–40.
3. Conde-Agudelo A, Rosas-Bermudez A,
Kafury-Goeta AC. Birth spacing and risk of
adverse perinatal outcomes: a meta-analysis.
JAMA 2006;295:1809–23.
4. Conde-Agudelo A, Rosas-Bermudez A,
Kafury-Goeta AC. Effects of birth
spacing on maternal health: a systematic
review. Am J Obstet Gynecol 2007;196:
297–308.
5. Shachar BZ, Lyell DJ. Interpregnancy interval
and obstetrical complications. Obstet Gynecol
Surv 2012;67:584–96.
6. ACOG Committee Opinion No. 736: opti-
mizing postpartum care. Obstet Gynecol
2018;131:e140–50.
7. Report of a WHO Technical Consultation on
Birth Spacing. Geneva, Switzerland: WHO. 2005.
Available at: http://apps.who.int/iris/bitstream/
handle/10665/69855/WHO_RHR_07.1_eng.pdf;
jsessionid¼1801E2D8531F2BA208161AC1F867
DE5B?sequence¼1. Accessed July 1, 2018.
8. McDonald EA, Brown SJ. Does method of
birth make a difference to when women resume
sex after childbirth? BJOG 2013;120:823–30.
9. Committee on Practice Bulletins-Gynecology
L-ARCWG. Practice Bulletin No. 186: long-
acting reversible contraception: implants and
intrauterine devices. Obstet Gynecol 2017;130:
e251–69.
10. Moniz MH, Chang T, Heisler M, et al. Inpa-
tient postpartum long-acting reversible contra-
ception and sterilization in the United States,
240 American Journal of Obstetrics & Gynecology SEPTEMBER 2018
2008-2013. Obstet Gynecol 2017;129:
1078–85.
11. Comparative multicentre trial of three IUDs
inserted immediately following delivery of the
placenta. Contraception 1980;22:9–18.
12. Chi IC, 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. Contra-
ception 1985;32:119–34.
13. Cox ML. The Dalkon Shield saga. J Fam
Plann Reprod Health Care 2003;29:8.
14. Darney PD. Time to pardon the IUD? N Engl
J Med 2001;345:608–10.
15. 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.
16. Blumenthal PD, Eber M, Vajpayee J. Dedi-
cated inserter facilitates immediate postpartum
IUD insertion. Glob Health Sci Pract 2013;1:
428–9.
17. Singh S, Das V, Agarwal A, et al. A dedicated
postpartum intrauterine device inserter: pilot
experience and proof of concept. Glob Health
Sci Pract 2016;4:132–40.
18. Xu JX, Rivera R, Dunson TR, et al.
A comparative study of two techniques used in
immediate postplacental insertion (IPPI) of the
Copper T-380A IUD in Shanghai, People’s Re-
public of China. Contraception 1996;54:33–8.
19. Blumenthal PD, Lerma K, Bhamrah R,
Singh S; Dedicated PIWG. Comparative safety
and efficacy of a dedicated postpartum IUD
inserter versus forceps for immediate post-
partum IUD insertion: a randomized trial.
Contraception 2018. https://doi.org/10.1016/j.
contraception.2018.04.019 [Epub ahead of
print].
20. Goldthwaite LM, Sheeder J, Hyer J,
Tocce K, Teal SB. Postplacental intrauterine
device expulsion by 12 weeks: a prospective
cohort study. Am J Obstet Gynecol 2017;217:
674.e1–8.
21. Zhou SW, Chi IC. Immediate postpartum
IUD insertions in a Chinese hospital: a two year
follow-up. Int J Gynaecol Obstet 1991;35:
157–64.
22. Letti Muller AL, Lopes Ramos JG, Martins-
Costa SH, et al. Transvaginal ultrasonographic
assessment of the expulsion rate of intrauterine
devices inserted in the immediate postpartum
period: a pilot study. Contraception 2005;72:
192–5.
23. Whitaker AK, Chen BA. Society of Family
Planning guidelines: postplacental insertion of
intrauterine devices. Contraception 2018;97:
2–13.
24. Levi EE, Stuart GS, Zerden ML, Garrett JM,
Bryant AG. Intrauterine device placement during
cesarean delivery and continued use 6 months
postpartum: a randomized controlled trial.
Obstet Gynecol 2015;126:5–11.
25. Whitaker AK, Endres LK, Mistretta SQ,
Gilliam ML. Postplacental insertion of the le-
vonorgestrel intrauterine device after
ajog.org
cesarean delivery vs delayed insertion: a
randomized controlled trial. Contraception
2014;89:534–9.
26. Dahlke JD, Terpstra ER, Ramseyer AM,
Busch JM, Rieg T, Magann EF. Postpartum
insertion of levonorgestrel–intrauterine system at
three time periods: a prospective randomized
pilot study. Contraception 2011;84:244–8.
27. Chen BA, Reeves MF, Hayes JL,
Hohmann HL, Perriera LK, Creinin MD. Post-
placental or delayed insertion of the levonor-
gestrel intrauterine device after vaginal delivery: a
randomized controlled trial. Obstet Gynecol
2010;116:1079–87.
28. Bednarek PH, Creinin MD, Reeves MF, et al.
Immediate versus delayed IUD insertion after
uterine aspiration. N Engl J Med 2011;364:
2208–17.
29. Fox MC, Oat-Judge J, Severson K, et al.
Immediate placement of intrauterine devices
after first and second trimester pregnancy
termination. Contraception 2011;83:34–40.
30. Cremer M, Bullard KA, Mosley RM, et al.
Immediate vs delayed post-abortal Copper
T 380A IUD insertion in cases over 12 weeks of
gestation. Contraception 2011;83:522–7.
31. Hohmann HL, Reeves MF, Chen BA,
Perriera LK, Hayes JL, Creinin MD. Immediate
versus delayed insertion of the levonorgestrel-
releasing intrauterine device following dilation
and evacuation: a randomized controlled trial.
Contraception 2012;85:240–5.
32. Lester F, Kakaire O, Byamugisha J,
et al. Intracesarean insertion of the Copper
T380A versus 6 weeks postcesarean: a
randomized clinical trial. Contraception
2015;91:198–203.
33. Sucak A, Ozcan S, Celen S, Caglar T,
Goksu G, Danisman N. Immediate postplacental
insertion of a Copper intrauterine device: a pilot
study to evaluate expulsion rate by mode of
delivery. BMC Pregnancy Childbirth 2015;15:
202.
34. Celen S, Sucak A, Yildiz Y, Danisman N.
Immediate postplacental insertion of an intra-
uterine contraceptive device during cesarean
section. Contraception 2011;84:240–3.
35. Jatlaoui TC, Marcus M, Jamieson DJ,
Goedken P, Cwiak C. Postplacental intrauterine
device insertion at a teaching hospital. Contra-
ception 2014;89:528–33.
36. Blumenthal PD, Chakraborty NM, Prager S,
Gupta P, Lerma K, Vwalika B. Programmatic
experience of post-partum IUD use in Zambia:
an observational study on continuation and
satisfaction. Eur J Contracept Reprod Health
Care 2016;21:356–60.
37. Eggebroten JL, Sanders JN, Turok DK.
Immediate postpartum intrauterine device and
implant program outcomes: a prospective
analysis. Am J Obstet Gynecol 2017;217:51.
e1–7.
38. Curtis KM, Tepper NK, Jatlaoui TC, et al. US
medical eligibility criteria for contraceptive use,
2016. MMWR Recomm Rep 2016;65:1–103.
39. American College of Obstetricians and
Gynecologists’ Committee on Obstetric Practice.
ajog.org
Committee Opinion No. 670: immediate post-
partum long-acting reversible contraception.
Obstet Gynecol 2016;128:e32–7.
40. Committee on Practice Bulletinse
Obstetrics. Practice Bulletin No. 183: Post-
partum hemorrhage. Obstet Gynecol 2017;130:
e168–86.
41. World Health Organization. Medical eligibility
criteria for contraceptive use, 5th ed. Geneva,
Switzerland: WHO Press; 2015.
42. Sriraman NK. The nuts and bolts of breast-
feeding: anatomy and physiology of lactation.
Curr Probl Pediatr Adolesc Health Care
2017;47:305–10.
43. Phillips SJ, Tepper NK, Kapp N, Nanda K,
Temmerman M, Curtis KM. Progestogen-only
contraceptive use among breastfeeding
women: a systematic review. Contraception
2016;94:226–52.
44. Seeber B, Ziehr SC, Gschliebetaer A, et al.
Quantitative levonorgestrel plasma level mea-
surements in patients with regular and pro-
longed use of the levonorgestrel-releasing
intrauterine system. Contraception 2012;86:
345–9.
45. Bennink HJ. The pharmacokinetics and
pharmacodynamics of Implanon, a single-rod
etonogestrel contraceptive implant. Eur J
Contracept Reprod Health Care 2000;5(suppl
2):12–20.
46. Orme ML, Back DJ, Breckenridge AM.
Clinical pharmacokinetics of oral contraceptive
steroids. Clin Pharmacokinet 1983;8:95–136.
47. Chen BA, Reeves MF, Creinin MD,
Schwarz EB. Postplacental or delayed levonor-
gestrel intrauterine device insertion and breast-
feeding duration. Contraception 2011;84:
499–504.
48. Turok DK, Leeman L, Sanders JN, et al.
Immediate postpartum levonorgestrel intrauter-
ine device insertion and breast-feeding out-
comes: a noninferiority randomized controlled
trial. Am J Obstet Gynecol 2017;217:665.e1–8.
49. Moniz MH, Spector-Bagdady K, Heisler M,
Harris LH. Inpatient postpartum long-acting
reversible contraception: care that promotes
reproductive justice. Obstet Gynecol 2017;130:
783–7.
50. Zerden ML, Tang JH, Stuart GS, Norton DR,
Verbiest SB, Brody S. Barriers to receiving long-
acting reversible contraception in the post-
partum period. Womens Health Issues 2015;25:
616–21.
51. Washington CI, Jamshidi R, Thung SF,
Nayeri UA, Caughey AB, Werner EF. Timing of
postpartum intrauterine device placement: a
SEPTEMBER 2018 American Journal of Obstetrics & Gynecology
Expert Reviews
cost-effectiveness analysis. Fertil Steril
2015;103:131–7.
52. Rodriguez MI, Caughey AB, Edelman A,
Darney PD, Foster DG. Cost-benefit analysis of
state- and hospital-funded postpartum intra-
uterine contraception at a university hospital for
recent immigrants to the United States.
Contraception 2010;81:304–8.
53. Wachino V. State Medicaid payment ap-
proaches to improve access to long-acting
reversible contraception. CMCS Informational
Bulletin: Department of Health and Human Ser-
vices Centers for Medicare and Medicaid
Services; 2016.
54. Higgins TM, Dougherty AK, Badger GJ,
Heil SH. Comparing long-acting reversible
contraception insertion rates in women with
Medicaid vs private insurance in a clinic with a
two-visit protocol. Contraception 2018;97:
76–8.
55. Biggs MA, Harper CC, Malvin J, Brindis CD.
Factors influencing the provision of long-acting
reversible contraception in California. Obstet
Gynecol 2014;123:593–602.
56. Hofler LG, Cordes S, Cwiak CA, Goedken P,
Jamieson DJ, Kottke M. Implementing immediate
postpartum long-acting reversible contraception
programs. Obstet Gynecol 2017;129:3–9.
241