Immediate versus interval postpartum use of the levonorgestrel contraceptive implant: A randomized controlled trial
Awarded 2015
Complex Family Planning Fellowship Research
Sarah Averbach, MD
University of California, San Francisco

In low resource settings like Uganda, when contraception is not offered immediately after delivery, many women don’t access contraception at all. Uganda has the third highest unmet need for contraception in the world.
Contraceptive implants are safe in the postpartum period and highly effective but are not widely used in low resource settings like Uganda. Globally, postpartum implant placement has traditionally occurred at a postpartum visit 6 weeks after delivery.  This timing of the postpartum visit at 6 weeks is based on historical precedent and does not have a clinical rationale. 
Implants are offered immediately postpartum in many US hospitals, prior to leaving the hospital. This practice has been shown to decrease short interpregnancy intervals (time between pregnancies). Waiting 6 weeks to initiate contraception puts women at risk for unintended pregnancy and short interpregnancy intervals. Short interpregnancy intervals of less than 18-24 months are associated with an increased risk of maternal morbidity and mortality, preterm delivery and low birth weight infants. The purpose of this study was to evaluate the effect of initiating contraceptive implants immediate after delivery compared to placement at 6 weeks postpartum on implant use at 6 months postpartum among women in Uganda.
This study was conducted among women in Kampala, Uganda. Women who desired a contraceptive implant were randomly assigned to implant insertion immediately following delivery (within 5 days of delivery and before discharge from hospital) or delayed insertion (6 weeks postpartum). The primary outcome evaluated was implant use at 6 months postpartum. 
From June to October 2015, 205 women were enrolled, 103 to the immediate group and 102 to the delayed group. At 6 months, implant use was higher in the immediate group compared to the delayed group (97% versus 68%). Women in the immediate group were more satisfied with the timing of implant placement. If given the choice, 81% of women in the immediate group and 63% of women in the delayed group would choose the same timing of placement again.
Offering women the option of initiating contraceptive implants in the immediate postpartum period in low resource settings like Uganda has the potential to increase contraceptive utilization, decrease unwanted pregnancies, prevent short interpregnancy intervals and help women achieve their reproductive goals.