Immediate post-partum initiation of intrauterine contraception and implants: a review of the safety and guidelines for use

Women are particularly susceptible to unintended pregnancies in the first year after birth, with 10-44% of pregnancies being unintended. In many settings, post-partum birth control is initiated at the six-week post-partum visit but most women are sexually active by this time, and ovulation can occur as early as day 28. There are many potential advantages of initiating intrauterine contraception (IUC) and implants use in the immediate post-partum period, including their high efficacy and reversibility which rivals sterilisation as well as ease of access to providers trained in their insertion. This review aims to describe the benefits and risks of use of IUC and implants in the immediate post-partum period. It discusses the maternal and infant health safety issues of early initiation of the progestogen containing methods and provides a critical review of existing international guidelines. Overall low rates of adverse effects such as pain, bleeding, infection and perforation, are documented to occur in all studies regardless of the timing or route of IUC insertion. Expulsion rates are significantly higher immediately after vaginal delivery compared to interval insertions, but are no higher after insertion at caesarean section. Post-partum implants appear to have the same side effects as interval insertions, and to date, no adverse impact on breast milk or infant growth has been demonstrated. Most international evidence-based guidelines support the initiation of IUC and progestogen containing contraceptive methods in the immediate post-partum period as they regard the advantages of provision at this time to outweigh the risks.