National Partnership for Women & Families

Monthly Women's Health Research Review

Increased Use of LARCs Could Help Women Avoid Closely Spaced Pregnancies

Summary of "Contraception After Delivery and Short Interpregnancy Intervals Among Women in the United States," White et al., Obstetrics and Gynecology, June 2015.

"Given the risks associated with closely spaced pregnancies, there has been considerable emphasis on the importance of counseling expectant [women] or recent mothers about their contraceptive options and providing them with their chosen method on a timely basis, yet more than half of the unintended pregnancies experienced by parous women in the [U.S.] occur within 2 years after delivery, and 35% of women have interpregnancy intervals less than 18 months, often referred to as short interpregnancy intervals," according to Kari White, of the University of Alabama-Birmingham's Department of Health Care Organization and Policy, and colleagues.

According to White and colleagues, use of long-acting reversible contraceptives, such as implants and intrauterine devices, could help to reduce the rates of short pregnancy intervals and unintended pregnancies. However, they wrote that recent research has shown low rates of IUD insertion occurring at the hospital following delivery, despite other research showing women's desire to use IUDs shortly after delivery.

In this study, the researchers "assess[ed] women's contraceptive use in the 18 months after delivery and the association between type of method used and the risk of having a short interpregnancy interval." They "also examined the percentage of pregnancies occurring 18 months after delivery or less that were unintended."

Methods

White and colleagues used data from the 2006-2010 National Survey of Family Growth to assess "a cohort of women who delivered a liveborn singleton neonate within 3 years of the survey date." In that cohort, the researchers "also identified women having short pregnancy intervals, defined as conceptions resulting in live births that occurred 18 months or less after the index pregnancy."

Meanwhile, White and colleagues also tracked "[w]omen's contraceptive method use in the 18 months after delivery," as well as "women's pregnancy intentions for births that occurred 18 months or less after the index birth."

Results

White and colleagues found that of the 3,005 deliveries in their initial group of women, 621 (21%) used some type of contraceptive immediately postpartum, with most women using female sterilization or a less-effective method, such as male and female condoms, withdrawal and rhythm method. At three months following delivery, 72% of women used contraceptive methods, including:

~ Hormonal contraceptives (28%);

~ Less-effective methods (25%);

~ Female sterilization (11%);

~ LARC (6%); and

~ Their partners' vasectomies (2%).

According to the researchers, the "distribution of contraceptive method use was similar in subsequent months." At 18 months postpartum:

~ 24% of women "us[ed] less effective or no methods";

~ 15% used female sterilization; and

~ 9% used LARC.

Meanwhile, 434 of the women had live deliveries that were conceived within 18 months of the index pregnancy. According to the researchers, women ages 15 to 24 (20.2%) and 25 to 29 (15.3%) were more likely to experience a short interval pregnancy than those ages 30 to 34 (8.2%). Further, short interval pregnancies were more common among women who:

~ Already had one child, at 20%, compared with those who had two (12%);

~ Had less than a high school education (19.2%), compared with those who had at least a high school education;

~ Had Medicaid coverage (16.4%), compared with those who had private coverage (12.6%); and

~ Were cohabitating or married at the time of birth.

White and colleagues also found an association between the type of contraceptives used at the beginning of each interval and short interval pregnancies. Specifically, women using LARC or permanent contraceptive methods were less likely to experience short interval pregnancies than women who used no method, less-effective methods or hormonal methods. Specifically, the researchers found that "women using LARC or permanent methods had a 0.5% chance of getting pregnant by 12 months, whereas women using hormonal methods had a 9% chance and women using less-effective methods or no method had a 15% and 18% chance, respectively." Overall, "[w]omen's chances of getting pregnant using these methods were almost twice as high by 18 months," the researchers wrote.

According to the researchers, of the 434 pregnancies that occurred within 18 months, "Overall, pregnancies that occurred 2 months or less postpartum and 3-5 months and 6-11 months after delivery were more likely to be reported as unintended compared with those occurring between 12 and 18 months after delivery."

Discussion

According to White and colleagues, the findings that roughly half of U.S. women "rely on less-effective or no method of contraception in the 18 months after delivery" support the results of another study showing that "more than half of publicly insured women did not have a contraceptive claim within 90 days postpartum." Further, the researchers wrote that their study "demonstrates that unintended pregnancies are common in the 18 months after delivery, and at least 70% of these occur within the first year after the index birth." In addition, the study "shows that less-effective contraceptive use was the leading predictor of having a short interpregnancy interval after controlling for women's sociodemographic characteristics."

Overall, White and colleagues noted that the study's "results raise the question as to why U.S. women do not make greater use of the most highly effective contraceptive methods in the months after delivery." The researchers list several possible reasons, such as women having "little interest in using more effective methods because of side effects or other perceived problems they associate with [LARC] use"; being "opposed to using LARC because they do not like the idea of having a foreign object in their body or being unable to discontinue these methods without visiting a health care provider"; or avoiding contraceptive use "because they plan to stay abstinent or underestimate their risk of pregnancy."

However, White and colleagues cited research that postpartum women have high demand for LARC methods, but that many are "unable to access their preferred method and instead relied on less-effective forms of contraception." The researchers suggest that "the low use of highly effective methods after delivery [might be] that women face insurance-related barriers." For example, "[w]omen may be unable to access LARC in the hospital because the cost of the device and insertion are not included in the global fee for delivery and because few states have revised their Medicaid policies to permit separate billing." Meanwhile, others "may lose contraceptive coverage soon after delivery as a result of changes in employment or if they are not automatically enrolled in their state's Medicaid family planning waiver."

The researchers added, "The importance of barriers to access has been demonstrated by the rapid uptake of LARC in several states where measures have been taken to make these methods more widely available."

White and colleagues noted that the study "indicates that many U.S. women rely on less-effective contraceptive methods -- or use no method -- in the 18 months after delivery, which results in short interpregnancy intervals and unintended pregnancies." They wrote that "[t]o reduce adverse maternal and neonatal health outcomes associated with closely spaced births, programs and policies that remove barriers to initiating effective contraception are needed so that women can realize their contraceptive preferences and achieve their childbearing goals."