Obesity is a major public health problem in the United States, and the number of bariatric procedures has exponentially increased in the last decade concordant with this epidemic. Bariatric surgery affords several important long-term benefits, but for women of reproductive age there may be complications that are of particular importance to pregnancies conceived in the immediate postoperative period including nutritional and metabolic deficiencies with subsequent maternal and fetal morbidity. Consequently, both the American Congress of Obstetricians and Gynecologists and the American Society of Metabolic and Bariatric Surgery recommend abstaining from pregnancy for 12 to 24 months after bariatric surgery and the use of effective and reliable contraception in this time period. Obese women may be less likely than women with a normal body mass index to use contraception, and not all bariatric centers have protocols in place to standardize preoperative pregnancy and contraceptive counseling. Previous studies have focused on quantitative assessments of contraceptive use among women undergoing bariatric surgery as well as counseling and referral patterns of bariatric providers regarding this issues however no studies have assessed patients’ conceptualizations of contraception and pregnancy intention among patients or have evaluated potential interventions to improve and standardize preoperative counseling.
This study evaluated contraceptive use, perioperative counseling experiences and pregnancy intention in the context of bariatric surgery. This was a nationally-distributed survey study using Facebook for recruitment. We enrolled women ages 18 to 45 years who had undergone bariatric surgery within the last 24 months or who were actively engaged in a bariatric program currently. Those women who had a hysterectomy or tubal ligation preoperatively or were sexually active exclusively with women were excluded from this study as we wanted to identify those women who would potentially be at-risk for pregnancy and to whom issues of contraception and pregnancy would hold more relevance. Once women were found to be eligible to take the study, they then answered survey questions that collected demographic, obstetrics and surgical information as well as pregnancy intention, contraceptive use and experiences with perioperative contraceptive and pregnancy interval recommendations. The primary aim of this study was to determine the prevalence of women’s receipt of perioperative contraception and pregnancy interval information. We additionally wanted to determine the prevalence of postoperative contraceptive use within the first 12 months, perioperative counseling preferences as well as pregnancy intention, desire and orientation.
We enrolled 430 women total who submitted complete surveys; 363 of these women were postoperative. About 74% reported having a perioperative discussion about either contraception or recommended pregnancy interval as it pertained to their bariatric surgery. Most women heard this information at their surgery orientation or immediately before surgery. Over half of the women felt that is was “very important” to have these discussions perioperatively. Bariatric surgeons were the most commonly cited source of the information. Less than 10% of women were referred to another provider from their bariatric surgeon, such as a gynecologist or primary care provider for continued discussion. Approximately two-thirds of women who were postoperative were using some form of contraception in the first 12 months after surgery – the most common method types were oral contraceptives (27%) and intrauterine devices (26%). Approximately 26% pursued bariatric surgery for improved fertility. The majority reported no desire to get pregnant before (51%) or within 24 months after surgery (59%). However, among women with no desire for pregnancy, many reported they would feel “very happy” if they became pregnant before (31%) or 24 months after surgery (29%).
Our results suggest that women’s needs may be unmet for perioperative pregnancy interval and contraceptive counseling. We hope that data garnered from this investigation of patients about perioperative contraceptive use, pregnancy interval counseling and pregnancy intention will lay the groundwork to guide development of patient education tools and improved counseling experiences for women. This counseling should be tailored to women’s needs and consider their reproductive desires, as some women may be pursuing bariatric surgery for improvement in fertility and subsequent pregnancy. In order to deliver patient-centered counseling future research is needed to understand women’s desires and orientations surrounding pregnancy in the context of bariatric surgery, as well as their preferences for counseling.