Postpartum LARC use lacking in women on medical therapy for opioid use disorder

March 13, 2019

Physicians and pregnant patients with OUD may have a communication disconnect when it comes to postpartum contraception counseling.

Many women being treated for opioid use disorder (OUD) express interest in using long-acting reversible contraception (LARC) before they become pregnant. But results of a new study show that few follow through on that intention after giving birth, suggesting that clinicians need to do more counseling with these patients about birth control options.

A retrospective cohort study in the journal Contraception found that among 791 pregnant women receiving treatment for OUD, 34.8% (n = 275) intended to use postpartum LARC, but only 29.9% of the entire cohort (n = 237) attended a postpartum visit within 8 weeks of delivery, which places this high-risk group at risk for a subsequent unintended pregnancy.

Of the women interested in LARCs (n = 275), only 45.1% (n= 124) attended their postpartum visit, and a mere 18.2% (n = 50) of them actually received that form of contraception.

Prenatal contraceptive counseling was positively linked to LARC intent (OR 6.67; 95% CI: 3.21 – 13.89), whereas older patients (OR 0.95; 95% CI: 0.91 – 0.98) and private practice providers (OR 0.48; 95% CI: 0.32 – 0.72) had a negative effect.

On the other hand, parity was not predictive of LARC intent, although first-time mothers were less likely to receive postpartum LARC (OR 0.49; 95% CI: 0.26 – 0.97).

“Many women with opioid use disorder do not use highly effective postpartum contraception such as LARC,” the authors wrote, noting that immediate postpartum LARC services could reduce LARC access barriers by addressing poor attendance at the postpartum visit.

All study participants delivered an infant at the urban, academic institution Magee-Womens Hospital of the University of Pittsburgh between 2009 and 2012, and without immediate postpartum LARC services.

Mean age of the LARC intent group (n = 275) was 26.9 years compared to 27.5 years for the no-LARC-intent group (n = 516).

Most patients were white, single and unemployed, had high school educations and were Medicaid insured and multiparous.

In addition to all patients receiving medication-assisted treatment for opioids during their pregnancy, 80% used methadone and 20% used buprenorphine.

On average, women attended eight prenatal visits.

LARC intent was defined as a documented plan for postpartum LARC during pregnancy; receipt of the contraceptives was a documented LARC placement by 8 weeks postpartum.

Contraceptive methods were divided into five categories:  LARC, female sterilization, short-acting methods, barrier methods and no documented methods.

Roughly 80% of women had documentation of prenatal contraceptive counseling by their provider; however, at hospital discharge, one-third of patients did not have a documented contraceptive plan. Among women with a plan, one-third planned to use a short-acting method.

“Because our institution did not provide immediate postpartum LARC services, the contraceptive plan was also evaluated at the time of delivery,” the authors wrote.

At delivery, 57.8% (n = 159) of women who intended to use a postpartum LARC did not have a contraceptive plan documented. And about 20% of women lacked documentation of such a plan at their postpartum visit.

Women were more likely to receive a LARC method postpartum if they were married (22.0% vs. 10.3%) or had a plan for postpartum LARC without any interim contraception (66.0% vs. 20.9%).

Conversely, women were less likely to receive postpartum LARC if they had Medicaid insurance (94.1% vs. 86.0%), were primiparous (51.3% vs. 34.0%) or had hepatitis C virus (50.8% vs. 32.0%). 

“The documentation of contraceptive plans in the medical record is critical for provider communication, especially in health systems where multiple providers care for patients across the perinatal period,” the authors wrote.

Prenatal contraceptive plans should also be discussed in the immediate postpartum period and clinicians should try to match patients’ preferences with available services. This study provides a powerful argument for provision of immediate postpartum LARC.