Trends in postpartum contraceptive methods shift in US
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Between 2016 and 2018, the rate of immediately postpartum long-term contraceptive placement increased while the rate of tubal ligations decreased, according to a retrospective, nationally representative cohort study.
However, “the rates of inpatient permanent contraception still outnumber rates of [long-acting reversible contraception (LARC)] insertion,” Nancy Z. Fang, MD, MS, an assistant professor in the department of OB/GYN and family planning at the University of Colorado Medicine, told Healio.
Fang and colleagues used data from the National Inpatient Sample to evaluate the rates of LARC placement — which included receiving an IUD or contraceptive implant — and tubal ligation among patients with a delivery-related discharge between 2016 and 2018.
LARC insertion
Among 11,083,180 delivery hospitalizations, 55,775 women received a LARC device during the study period. The rate increased from 2.4 insertions per 1,000 deliveries in 2016 to 7.5 per 1,000 deliveries in 2018. Specifically, IUD insertions increased from 2.2 to 5 per 1,000 deliveries between 2016 and 2018, while implant insertions increased from 0.3 to 2.5 per 1,000 deliveries.
Women were more likely to receive LARC vs. tubal ligation if they were aged younger than 25 years (adjusted OR = 7.38; 95% CI, 6.9-7.9).
Tubal ligation
Overall, 698,299 women underwent tubal ligation between 2016 and 2018, with the rate of tubal ligation decreasing from 64.2 to 62.1 per 1,000 deliveries during that time. Tubal ligation was more likely in women who had a cesarean delivery compared with those who delivered vaginally (aOR = 8.83; 95% CI, 8.73-8.97).
Although rates of inpatient tubal ligation remained higher than those of LARC placement during the study period, inpatient tubal ligation was “half as common” in 2018 as it was in 2006, according to Fang.
Of note, women with public insurance were more likely to either receive LARC (aOR = 4.83; 95% CI, 4.59-5.06) or undergo tubal ligation (aOR = 2.1; 95% CI, 2-2.1) compared with women who had private insurance. Among women with public insurance, LARC placement was more likely than tubal ligation (aOR = 1.98; 95% CI, 1.88-2.09).
Moving forward, Fang emphasized the importance of addressing the “reproductive justice issue” of access to permanent and reversible contraception.
“I would like to see national trends for outpatient permanent contraception and continued work in identifying barriers in access to permanent contraception and LARC,” she said. “There is also a critical need to identify and prevent coercion related to these methods.”
Perspective
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After delivery, we recommend that patients avoid pregnancy for at least 12 to 18 months, as short-interval pregnancies can lead to increased rates of poor outcomes, such as preterm birth. Some patients know that they have completed their families already and may seek permanent contraception at the time of delivery, while others may be considering more children in the future.
This study by Fang and Westhoff uses the National Inpatient Sample to look at changes in rates of these two contraceptive services at the time of delivery from 2016 to 2018. They show that rates of LARC insertion at time of delivery are increasing and tubal ligation rates are slowly decreasing. Comparison to earlier studies shows that this is part of a larger trend. The patients receiving these services are different in some very important ways: younger patients are more likely to receive a LARC than tubal ligation, and patients with public insurance are more likely to receive either of these contraceptive modalities. Further studies are needed to tease apart the reasons for these discrepancies, which include access to care following the perinatal period, clinician bias in providing contraception care and insurance reimbursement policies. Patients having a cesarean delivery were more likely than those having vaginal delivery to receive either method, indicating that there is still an unmet need for these services.
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