Optimizing postpartum contraception in women with preterm births
Awarded 2013
Complex Family Planning Fellowship Research
Leah Torres, MD
University of Utah

Despite significant advancements in the management of preterm labor (PTL), preterm birth (PTB) remains one of the most poorly understood and costly outcomes in obstetrics. According to the Centers for Disease Control and Prevention (CDC), 12% of deliveries each year occur preterm (prior to 37 weeks) and PTB is the most frequent cause of infant mortality and long-term neurological morbidity, costing the US healthcare system $26 billion annually. 1 The etiologies of spontaneous PTL and PTB are not fully understood and the development of a cure or preventative therapy remains elusive. Great strides have been made in managing the neonatal ramifications of PTB, however the prediction and prevention of this substantial public health concern need attention.
The best predictor of PTB is a history of a previous PTB. Objective evidence supports unplanned pregnancy as another predictor of low birth weight and preterm delivery. Appropriate spacing and planning of pregnancy intervals is also important in avoiding PTB and other adverse neonatal outcomes. This creates the potential to investigate family planning as a mechanism to significantly decrease the preterm birth rate and improve neonatal outcomes. Though a Cochrane review in 2011 showed no difference in adherence and continuation of hormonal contraceptive methods with ancillary techniques of counseling, a recent study by Garbers et al shows promise for focused outpatient contraceptive counseling. Women with high-risk obstetrical issues are a critical target population for preventing or planning subsequent pregnancies through family planning services in order to optimize their health and the health of their children. 
We will examine the effectiveness of focused family planning counseling on the uptake and continuation of highly effective reversible contraceptive (HERC) methods (defined as the IUD, implant, and both male and female sterilization methods including vasectomy, tubal ligation and Essure) during the postpartum period up to 3 months in women who have recently experienced a preterm delivery. Baseline contraceptive knowledge will be collected prior to counseling and then compared to 3 month contraceptive knowledge in both groups to help distinguish the effect of counseling versus the effect of increased follow-up in the intervention group. We hypothesize there will be a difference in the two groups regarding contraceptive knowledge at 3 months compared to baseline. We also hypothesize that women with a recent PTB will be more likely to initiate and continue using a highly effective method of contraception when provided with focused family planning counseling. 
Of women who were at risk of pregnancy (meaning they were not using sterilization or abstinence), women who received focused counseling were significantly more likely to use HERC at 3 months postpartum compared to the control group (51% vs 30%). Women who were using HERC methods were similar in all regards to non-HERC users, except they were on average 2 years younger, had planned on HERC method prior to counseling, and received the focused counseling. Women using HERC methods also reported higher satisfaction with their method of choice. 
Giving a brief counseling session regarding the benefits of HERC during the postpartum hospital stay could increase the use of these HERC in the immediate months postpartum. Long-term continuation of methods remains to be seen, however by extension there is potential to reduce the number of unplanned pregnancies and preterm births. 
This study, although small, shows promising positive results in a high-risk population at risk for future preterm births. With little investment of time, the general use and knowledge of contraception could be improved. Some hospitals have a service known as a “lactation consult” and an experienced person will help new mothers initiate breastfeeding. This study supports the benefit of having a service available known as a “contraception consult.” While there is no one way to improve use of highly effective contraception in the postpartum period, it is critical to continue exploring different techniques for the health and well-being of newborns, new mothers, and new families. The results obtained here suggest that HERC use could be improved in a population at high risk for recurrent PTB. Wider application of this intervention has enormous potential to address the stagnant population level of PTB, increase cost savings and improve pregnancy planning and thereby public health on a larger level.