Research: Immediate vs delayed IUD insertion after a cesarean delivery

Section of Family Planning and Contraceptive Research faculty Dr. Amy Whitaker and Section chief Dr. Melissa Gilliam co-authored an article e-published in December 2013 in the journal Contraception that discusses their randomized controlled trial (RCT) designed to compare levonorgestrel intrauterine device (LNG-IUD) use at one year after delivery between women who received the device at the time of cesarean delivery and those who underwent delayed insertion 4-8 weeks after delivery.

Long-acting reversible contraceptives are excellent methods for postpartum use because they allow adequate time between births and do not require repeat visits to a physician or pharmacy. Postplacental IUD insertion refers to the practice of inserting the IUD within 10 minutes of delivery of the placenta, which can occur through the uterine incision during cesarean delivery. Placement immediately after delivery may help to overcome some of the many barriers to insertion which occur during other time periods, and ensures that women receive the IUD even if they do not return for the postpartum visit.

Our trial showed that after twelve months, 60% of women who had the LNG-IUD inserted immediately after their cesarean delivery were still using the device, while 41% of the women who underwent delayed insertion were still using theirs. This difference, however, is not statistically significant. The women in the postplacental arm experienced significantly higher rates of expulsion (20% vs. 0%).

Future researchers can learn from the challenges of conducting a randomized controlled trial in this population. Due to slow enrollment and high losses to follow-up, the trial was stopped early. The fundamental challenge of conducting this type of research stems from the difficulties in studying an intervention that is most likely to benefit women who do not follow- up for a postpartum visit. However, those women may also be less likely to participate in an RCT. Thus, in our study and in similar trials, more women followed up for insertion in the delayed group than would be expected from the observational literature or clinical experience, making comparisons difficult.

Nonetheless, this trial does provide valuable insights for further study in this area. Immediate insertion of an IUD during a cesarean delivery may improve use of highly effective contraception during the postpartum period. Our results show higher expulsion rates after postplacental insertion compared to delayed insertion, but suggest similar IUD use at 12 months.

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