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Am J Obstet Gynecol. 2019 Feb 7. pii: S0002-9378(19)30352-7. doi: 10.1016/j.ajog.2019.02.011. [Epub ahead of print]

Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high-risk for medical complications.

Abstract

Reproductive planning is important for all women but essential for those with complex health conditions or at high-risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that directly impact maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum LARC, is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine (MFM) subspecialists, about the benefits of postpartum contraception and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be encouraged for women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the MEC guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum IUD insertion should be counseled that while expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion as the long term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (Best Practice); in women who desire and are eligible for LARC, we recommend that immediate postpartum placement be recommended after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encourages to breastfeed as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that the contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (Best Practice).

KEYWORDS:

Long-acting reversible contraception (LARC); high-risk pregnancy; medically complex woman; postpartum contraception

PMID:
30738885
DOI:
10.1016/j.ajog.2019.02.011

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