Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Medically complex women are at increased risk for unintended pregnancy compared to a healthy cohort, and for these women, an unintended pregnancy in the setting of poor disease control could increase risk of adverse pregnancy outcomes, disease progression, fetal compromise, or long-term childhood health issues. The postpartum period is an especially vulnerable time, as 70% of pregnancies that occur within 1 year of delivery are unplanned. Interpregnancy intervals shorter than 6 months are associated with increased risks of preterm birth, low birth weight, and small for gestational age infants.
Despite the need for pregnancy planning, medically complex women face many barriers to contraceptive use. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers.
LARC methods include hormonal and nonhormonal intrauterine devices (IUDs) as well as subdermal contraceptive implants. In the United States, the levonorgestrel intrauterine system (IUS) is available in several commercial preparations (Liletta, Mirena, Kyleena, and Skyla), and the nonhormonal copper IUD is commercially available as Paragard. The etonogestrel implant is commercially known as Nexplanon.
1 | What is the role of contraception in the care of high-risk women?
The interconception period is a time that allows for optimization of maternal health. Contraception facilitates adequate birth spacing to achieve this goal. This is particularly important for women with comorbid conditions or who have had a complication during pregnancy. The most effective way to prevent an unintended pregnancy is through consistent and correct use of contraception.
2 | What is the role of LARC in reproductive planning in medically complex women?
The American College of Obstetricians and Gynecologists (ACOG) recommends that LARC methods be offered to all appropriate candidates. LARC methods have low failure rates, similar to those of sterilization, making them appealing to women for whom future pregnancy is not recommended or when sterilization is not an option. For medically complex women, LARC methods provide the benefit of allowing a pregnancy to occur in a well-planned and highly supervised medical setting for women in whom an unplanned pregnancy would pose a high medical risk. The long-acting nature of LARC allows women to optimize chronic health conditions prior to conception, but LARC methods remain easily reversible when pregnancy is desired. LARC methods do not contain estrogen, making them safe options for women with a history of medical conditions, such as thromboembolic disease, for whom estrogen is contraindicated.
3 | What is immediate postpartum LARC?
Immediate postpartum placement is defined as insertion of an IUD after placental delivery following a vaginal or cesarean delivery and insertion of an implant at any time during the delivery hospitalization.