When we use the term 'people' in this summary, we mean individuals with a current ability to become pregnant.
Key messages
- Insertion of contraceptive implants or intrauterine devices (IUDs) within days of childbirth (immediate insertion, while in hospital), rather than waiting 4 to 6 weeks for insertion (delayed insertion), increases the number of people in whom they are inserted.
- Timing of insertion makes little or no difference to the number of people who use these methods of contraception 6 or 12 months after childbirth.
- Expulsion of IUDs seems to occur more frequently in people who have immediate insertion.
- Further research is needed about the rates of unintended pregnancy with both immediate insertion and delayed insertion of implants and IUDs.
What are contraceptive implants or intrauterine devices?
Contraceptive implant and intrauterine devices (IUDs) are highly effective methods of birth control that are reversible and safe for use shortly after childbirth. Implants are inserted into the upper arm, and IUDs into the womb (uterus) by doctors or nurses. People who use these methods of contraception use either an implant or an IUD.
Appropriate spacing of pregnancies is good for the health of both pregnant people and newborn babies. Normally, contraception is provided at the first comprehensive health visit after childbirth (usually around six weeks after giving birth). However, some people have sex before this visit, or do not attend it, which increases the risk of unplanned pregnancy. Insertion of a contraceptive implant or IUD within days of childbirth, before discharge from hospital, is convenient for patients and medical staff. The person having the implant or IUD is known not to be pregnant, and this practice may increase the number of people who are able to use these contraception methods.
What did we want to find out?
We wanted to find out if inserting contraceptive implants or IUDs within days of childbirth was better than waiting 6 to 8 weeks for:
- the number of people who agreed to insertion (insertion rate);
- the number of people who continued to use these contraception methods (utilization rate);
- preventing pregnancy; and
- whether insertion of contraceptive implants or IUDs within days of childbirth was associated with any unwanted effects.
What did we do?
We searched for studies that investigated insertion of contraceptive implants or IUDs in people within days of childbirth ('immediate insertion') compared to insertion 6 to 8 weeks after childbirth ('delayed' insertion).
We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 16 studies that involved a total of 2609 people (715 people in contraceptive implant studies, and 1894 people in IUD studies). All studies were conducted in hospitals. Most took place in the USA, but others took place in Uganda, Eygpt, Brazil and Sri Lanka. The studies included people who had just given birth, most of whom were 18 years old or older, though 1 study included younger people. The studies investigated different types of contraceptive implants and IUDs.
Main results
Contraceptive implants
People were 48% more likely to have contraceptive implants inserted when they could be inserted within days of childbirth compared to delayed insertion.
The timing of insertion made little or no difference to the number of people using contraceptive implants 6 or 12 months after childbirth.
Vaginal bleeding seemed to last longer in people who had implants inserted a few days after childbirth compared to delayed insertion (3 days more bleeding), but there was no difference between groups for bleeding 6 months after childbirth.
We are uncertain if there was a difference in rates of unintended pregnancy between the groups at 6 and 12 months after childbirth.
IUDs
People were 27% more likely to have IUDs inserted when they could be inserted within days of childbirth compared to delayed insertion.
It was unclear whether the timing of insertion made any difference to the number of people using IUDs 6 or 12 months after childbirth.
Six months after childbirth, expulsion of IUDs from the womb seemed to occur more frequently in people who had had an IUD inserted within days of childbirth.
We are uncertain if there was a difference in rates of unintended pregnancy between the groups at 6 and 12 months after childbirth.
What are the limitations of the evidence?
Our confidence in the evidence for the different results ranges from moderate to uncertain. This is because people in the studies were aware of when their implants or IUDs were inserted, which may have affected reporting of some outcomes, and because of the dropout rate from the studies. Also, not all of the studies provided data about everything in which we were interested, which meant some results are based on a lower number of people.
How up to date is this evidence?
The evidence is up to date to December 2020.
Evidence from this updated review indicates that immediate postpartum insertion improves the initiation rate of both contraceptive implants and IUDs by the first postpartum visit compared to delayed insertion. However, it is not clear whether that there are differences in utilization rates at six and 12 months postpartum. We are uncertain whether there is any difference in the unintended pregnancy rate at 12 months. Provision of progestin-releasing implants and IUDs immediately postpartum may have little or no negative impact on breastfeeding. However, the expulsion rate of IUDs and prolonged vaginal bleeding associated with immediate implants appears to be higher.
Long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants, are highly effective, reversible methods of contraception. Providing LARC methods during the postpartum period is important to support contraceptive choice, and to prevent unintended pregnancy and short interpregnancy intervals. Delaying offering contraception to postpartum people until the first comprehensive postpartum visit, traditionally at around six weeks postpartum, may put some postpartum people at risk of unintended pregnancy, either due to loss to follow-up or because of initiation of sexual intercourse prior to receiving contraception. Therefore, immediate provision of highly effective contraception, prior to discharge from hospital, has the potential to improve contraceptive use and prevent unintended pregnancies and short interpregnancy intervals.
To compare the initiation rate, utilization rates (at six months and 12 months after delivery), effectiveness, and adverse effects of immediate versus delayed postpartum insertion of implants and IUDs for contraception.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE for eligible studies up to December 2020. We examined review articles and contacted investigators. We checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.
We sought randomized controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant and IUDs for contraception.
Two review authors (JS, SK) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL, SA or PP). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel or inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables.
In this updated review, 16 studies met the inclusion criteria; five were studies of contraceptive implants (715 participants) and 11 were studies of IUDs (1894 participants). We identified 12 ongoing studies. We applied GRADE judgements to our results; the overall certainty of the evidence for each outcome ranged from moderate to very low, with the main limitations being risk of bias, inconsistency, and imprecision.
Contraceptive implants
Immediate insertion probably improves the initiation rate for contraceptive implants compared with delayed insertion (RR 1.48, 95% CI 1.11 to 1.98; 5 studies, 715 participants; I2 = 95%; moderate-certainty evidence).
We are uncertain if there was a difference between the two groups for the utilization rate of contraceptive implants at six months after delivery (RR 1.16, 95% CI 0.90 to 1.50; 3 studies, 330 participants; I2 = 89%; very low-certainty evidence) or at 12 months after insertion (RR 0.98, 95% CI 0.93 to 1.04; 2 studies, 164 participants; I2 = 0%; very low-certainty evidence).
People who received an immediate postpartum contraceptive implant insertion may have had a higher mean number of days of prolonged vaginal bleeding within six weeks postpartum (mean difference (MD) 2.98 days, 95% CI -2.71 to 8.66; 2 studies, 420 participants; I2 = 91%; low-certainty evidence) and a higher rate of other adverse effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; 1 study, 215 participants; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups for prolonged bleeding at six months after delivery (RR 1.19, 95% CI 0.29 to 4.94; 2 studies, 252 participants; I2 = 0%; very low-certainty evidence).
There may be little or no difference between the two groups for rates of unintended pregnancy at six months (RR 0.20, 95% CI 0.01 to 4.08; one study, 205 participants; low-certainty evidence). We are uncertain whether there was a difference in rates of unintended pregnancy at 12 months postpartum (RR 1.82, 95% CI 0.38 to 8.71; 1 study, 64 participants; very low-certainty evidence). There may be little or no difference between the two groups for any breastfeeding rates at six months (RR 0.97, 95% CI 0.92 to 1.01; 2 studies, 225 participants; I2 = 48%; low-certainty evidence).
IUDs
Immediate insertion of IUDs probably improves the initiation rate compared with delayed insertion, regardless of type of IUD (RR 1.27, 95% CI 1.07 to 1.51; 10 studies, 1894 participants; I2 = 98%; moderate-certainty evidence). However, people who received an immediate postpartum IUD insertion may have had a higher expulsion rate at six months after delivery (RR 4.55, 95% CI 2.52 to 8.19; 8 studies, 1206 participants; I2 = 31%; low-certainty evidence) than those who received a delayed postpartum insertion.
We are uncertain if there was a difference between the two groups in the utilization of IUDs at six months after insertion (RR 1.02, 95% CI 0.65 to 1.62; 6 studies, 971 participants; I2 = 96%; very low-certainty evidence) or at 12 months after insertion (RR 0.86, 95% CI 0.5 to 1.47; 3 studies, 796 participants; I2 = 92%; very low-certainty evidence).
Immediate IUDs insertion may reduce unintended pregnancy at 12 months (RR 0.26, 95% CI 0.17 to 0.41; 1 study, 1000 participants; low-certainty evidence). We are uncertain whether there was difference in any breastfeeding rates at six months in people receiving progestin-releasing IUDs (RR 0.90, 95% CI 0.63 to 1.30; 5 studies, 435 participants; I2 = 54%; very low-certainty evidence).