The effect of a 3-week postpartum visit vs. usual postpartum care on contraceptive method choice and initiation: A randomized trial
Contraception
Awarded 2016
Complex Family Planning Fellowship Research
Caitlin Bernard, MD
Washington University School of Medicine
$99,765

Postpartum contraception to promote birth spacing and prevent unwanted pregnancies is important but under-utilized. A key time for contraceptive initiation is at the postpartum visit, but this is traditionally scheduled for 6 weeks postpartum, after many women return to fertility and lose pregnancy-related health insurance. This creates barriers to accessing long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and implants. One strategy is to change the model of postpartum care to include an additional visit at 2-3 weeks postpartum. This may increase access to contraception prior to return to fertility and may improve visit attendance.
The purpose of this study was to investigate whether an early 3-week postpartum visit in addition to the standard 6-week visit increases LARC initiation by 8 weeks postpartum compared to the routine 6-week visit alone.
We enrolled pregnant and immediate postpartum women into a prospective study in which women were randomly assigned to receive a single 6-week postpartum visit (routine care arm) or two visits at 3 and 6 weeks postpartum (intervention arm), with initiation of contraception at the 3-week visit, if desired. All participants received structured contraceptive counseling. Participants completed surveys in-person at baseline and at the time of each postpartum visit. We calculated that we would need to include 200 total participants to detect a 2-fold difference in LARC initiation (20% vs. 40%).
Between May 2016 and March 2017, 200 participants were enrolled; outcome data are available for 188. The majority of LARC initiation occurred immediately postpartum (25% of the intervention arm and 27% of the routine care arm). By 8 weeks postpartum, there was no difference between the two groups, with 34% of participants in the intervention arm compared to 41% in the routine care arm initiating LARC. Overall contraceptive initiation by 8 weeks was also similar, with 83% and 84% in the intervention and routine care arms, respectively, receiving a method of contraception. There was also no difference between the arms in the proportion of women who attended at least one postpartum visit (70% vs. 74%).
The addition of a 3-week postpartum visit to routine care does not increase LARC or overall contraceptive initiation by 8 weeks post-partum when the option of immediate postpartum placement is available. The majority of LARC users desired immediate rather than early or interval postpartum initiation. Further study needs to be done in setting where immediate postpartum LARC is not available to determine whether early postpartum visits might be effective at improving LARC access.  

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