Women have two main choices for intrauterine contraception (IUC): one that releases the hormone levonorgestrel, and one without hormones that contains copper. Beginning IUC use right after childbirth and before hospital discharge can be good for many reasons. The woman knows she is not pregnant, and the time and place are convenient for starting a method that works well. We looked at whether IUC would be more likely to come out on its own if put in right after birth of a baby. For women who wanted IUC but did not have it placed right away, we studied whether they returned later for insertion.
Until 1 April 2015, we ran computer searches for randomized trials of IUC inserted within 10 minutes of placenta (afterbirth) delivery. We wrote to researchers to find more studies. Trials could compare different times for insertion as well as types of IUC and ways to insert the device.
We found 15 trials. Seven recent studies compared IUC insertion right after childbirth versus early insertion (before hospital discharge) or later insertion (weeks after discharge). Four had full reports, although three were small studies. Insertion was as likely to occur when placed right after childbirth as when planned for later placement, except in a study from Uganda. For the four trials overall, the IUC came out more often on its own when placed right after childbirth than when inserted weeks later. Use at six months was more likely with insertion right after childbirth than weeks later. In single studies, the groups did not differ in use at 3 months or 12 months.
Eight older studies looked at types of IUC put in right after childbirth. Changing IUC design did not seem to affect whether IUC stayed in or whether it was used later on. Inserting IUC by hand or with a holding instrument did not seem to make a difference.
We found newer trials with full reports that compared placement times. The studies were of good quality. Ongoing trials will provide additional data, although some sample sizes are small. Larger studies would provide better information on whether the IUC came out on its own and on whether side effects occurred.
Recent trials compared different insertion times after vaginal or cesarean delivery. Evidence was limited because studies with full reports generally had small sample sizes. Overall, the quality of evidence was moderate; abstracts and older studies had limited reporting. Ongoing trials will add to the evidence, although some are small. Trials of adequate power are needed to estimate expulsion rates and side effects.
The benefit of effective contraception immediately after delivery may outweigh the disadvantage of increased risk for expulsion. Frequent prenatal visits during the third trimester provide the opportunity to discuss effective contraceptive methods and desired timing for initiation. Clinical follow-up can help detect early expulsion, as can educating women about expulsion signs and symptoms.
Women who want to start intrauterine contraception (IUC) during the postpartum period might benefit from IUC insertion immediately after delivery. Postplacental insertion greatly reduces the risk of subsequent pregnancy and eliminates the need for a return visit to start contraception. Without the option of immediate insertion, many women may never return for services or may adopt less effective contraception.
Our aim was to examine the outcomes of IUC insertion immediately after placenta delivery (within 10 minutes), especially when compared with insertion at other postpartum times. We focused on successful IUC placement (insertion), subsequent expulsion, and method use.
We searched for trials until 1 April 2015. Sources included PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, Web of Science, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. For the original review, the authors contacted investigators to identify other trials.
We sought randomized controlled trials (RCTs) with at least one treatment arm that involved immediate IUC placement (i.e., within 10 minutes of placenta delivery). Comparison arms could have included early postpartum insertion (from 10 minutes postplacental to hospital discharge) or standard insertion (during a postpartum visit). Trials could also have compared different IUC methods or insertion techniques. Delivery may have been vaginal or cesarean. Primary outcomes were placement (insertion), subsequent expulsion, and method use at study assessment.
For dichotomous outcomes, we used the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Earlier studies primarily reported results as life-table rates. We aggregated trials in a meta-analysis if they had similar interventions and outcome measures. A sensitivity analysis included studies with moderate or high quality evidence and sufficient outcome data.
We included 15 trials. Seven studies reported from 2010 to 2014 were added to eight from the original 2001 review. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). Of four with full reports, three were small trials. The other three studies had conference abstracts. The eight early trials examined immediate insertion of different devices or insertion techniques. Most studies were published in the 1980s, some with limited reporting.
Our sensitivity analysis included trials with sufficient outcome data and moderate or high quality evidence. Four newer trials comparing insertion times met the inclusion criteria. Two studies used the levonorgestrel-releasing intrauterine system (LNG-IUS) after vaginal delivery. The other two trials placed IUC after cesarean section; one used the CuT 380A intrauterine device (IUD) and the other used the LNG-IUS.
A pilot trial compared immediate insertion versus early or standard insertion. In groups comparing immediate versus early insertion (N = 30), all women had the LNG-IUS inserted. By six months, the groups had the same expulsion rate and did not differ significantly in IUC use.
For immediate versus standard insertion, we conducted meta-analyses of four trials. Insertion rates did not differ significantly between study arms. However, the trial from Uganda showed insertion was more likely for the immediate group, although the estimate was imprecise. In the meta-analysis, expulsion by six months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; participants = 210; studies = 4). IUC use at six months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; participants = 243; studies = 4). Study arms did not differ in use at 3 or 12 months in individual small trials.