Shannon Carr, an ob/gyn in New Mexico, struggled with some questions: If intrauterine devices (IUDs) are such an effective form of contraception for new mothers, why are they still only used by a relatively small percentage of this demographic? Why hadn't anyone ever asked women who had elected to get one about their experience? After all, physicians could better counsel patients and patients to make more informed choices if they had first-person reviews of the procedure on hand. So Carr set out to do just that, interviewing 66 women who had elected to get an IUD after giving birth about their experience and how they rated the pain of getting the device inserted. Ultimately, 53.5 percent of women in the 'no epidural' group said they experienced none to mild pain; in the epidural group, 88.9 percent of women said the same. Carr found that women's satisfaction with the procedure was high in both groups and that actual procedural pain and duration were less than expected amongst both groups, too.
The predominant reason women in both groups elected to have the procedure was the same, too: convenience.
Given all this, it's hardly a surprise that in late July, the American College of Obstetricians and Gynecologists (ACOG) released a new Committee Opinion recommending that obstetricians counsel women on the option of immediate post-birth insertion of long-acting reversible contraception (LARC).
"The procedure is called immediate postplacental IUD placement—and it's exactly what it says it is," Carr says. "Whether you have a caesarean section or a vaginal delivery, the placenta comes out, and then the clinician is trained to place an IUD in the cervix if a conversation had previously been had with the patient about doing so….the woman is already in the position. It's not another effort to go to a clinic, put on a gown, get in the stirrups. Your cervix is there and pretty open and the instruments are there, the doctor is there. Literally, this can take less than a couple of minutes. The baby comes out, the placenta comes out, you make sure there's not a lot of bleeding—and then you just place the IUD. It's right there and you're right there. It's a pretty slick procedure."
Carr notes that postplacental IUD insertion "has been going on for quite some time…primarily in other countries—Egypt, Mexico, China. In the US, physicians started doing more of these placements in the '70s. And it makes so much sense from a contraception standpoint. For a patient, it's like, 'Wow—I get to walk out of the hospital with really great birth control.' And then you're not subjecting yourself to having to make an appointment for an additional procedure."
And yet the fact remains that despite their convenience and efficacy, LARCs are still a relatively uncommon contraception choice for most women. As Carr herself points out, "IUDs are a little bit of a pariah when it comes to contraception" and while "LARC methods" such as IUDs and implants are gaining traction amongst women, they're "still in the single digits in terms of uptake among other contraceptive options."
Unfortunately, she notes, a lot of the reason why IUDs—especially postpartum IUDs—remain the odd contraceptive out is that "some providers have a paternalistic idea about the IUD…either they're not comfortable with doing it procedurally or don't believe it's safe. A lot of providers aren't even offering it." Carr suspects there's some trickle-down stigma from the abortion culture wars.
"Anti-choice rhetoric and silly legislation just adds additional stigma associated with [IUDs] and people believe it," Carr says. "It's the whole contraception-abortion thing. And if you have a provider who is not on board and is a little bit paternalistic, they're not going to offer [postplacental IUD insertion] and there's no overcoming that."
It was IUDs, after all, that formed the crux of the case that the crafting megastore Hobby Lobby brought before the Supreme Court, arguing that the insurance provided to its employees through their company should not have to cover the device despite the Affordable Care Act mandate for contraception coverage since, in their belief, an IUD has the potential to induce an abortion by preventing the implantation of a fertilized embryo.
In reality, though, IUDs don't work like this—and definitely don't cause abortion. Rather, they emit hormones that prevent conception from ever happening in the first place.
"The reason why I believe a lot of patients aren't being offered immediate postpartum LARCs is a combination of factors due to a lack of knowledge and awareness that this is an available and recommended option for the appropriate patient," says Pratima Gupta, a fellow with Physicians for Reproductive Health.
When you mix providers not being comfortable with it and patients potentially not being comfortable with it, you wind up with a lot of reasons a really sound form of birth control is left out of the conversation between pregnant women and providers when they talk about family planning post-birth. And it's women, unfortunately, who have the most to lose when it comes to this conversation being halted before it can even begin.
Gupta says, "I think there is a great awareness about the safety and efficacy of LARCs, but not for the immediate postpartum period. Placing an immediate postpartum IUD is different than placing it in an office setting—some people just may not be trained. And there used to be some concerns around implants and hormonal IUDs about breastfeeding, but studies now show that they do not affect the quality or quantity of milk. And longer term studies of babies breastfed from a mother with a hormonal IUD are only more reassuring that the hormones from an implant and IUD do not affect breast milk."
"LARCs aren't the best option for everyone," notes Gupta. "The best birth control for a woman is the one she wants. But it's a provider's responsibility in the prenatal period to advise women about contraception, including information about postpartum LARCs. That's how you show respect for women and their families."
Gupta also emphasized that with their 99-plus percent efficacy rate, LARCs are "one of the most effective birth control methods we have" and that "the convenience of placing it in the immediate postpartum period is hard to beat." And a woman having an effective, convenient, reliable form of contraception in place that requires no additional work on her part makes for healthier moms and babies in the long run too.
Women have safer pregnancies and deliver healthier babies when there are longer intervals between subsequent pregnancies—and since, as she explains, a woman who is not breastfeeding can begin ovulating as early as three weeks after delivery and a woman exclusively breastfeeding might start ovulating as soon as three months postpartum, that could result in an accidental pregnancy pretty soon after giving birth.
"People have ideas of what their 'birth experience' should be, but that should include postpartum contraception," Gupta says.
Which is another reason why leaving the hospital with good birth control in your body and ready to go—just like an IUD inserted right after delivery—makes so much sense.
Providers have the power to change so much more than just destigmatizing this form of contraception and making it more accessible to their patients. For example, Carr notes that at the University of New Mexico, where she is based, providers are "highly supportive" of not just IUDs, postplacental IUD insertion, and full-spectrum reproductive healthcare for patients. They've gone as far as to have sent leaders to the statehouse to lobby for Medicaid to cover the procedure and done outreach to other communities throughout the state on both the benefits of the procedure for patients and the specifics of the procedure for providers who might be seeking additional information and training.
The remaining problem, Carr says, is that "we preach to the people who are on board [with postplacental IUDs and IUDs in general]—but what about those who aren't?" She answers her own question by insisting on the importance of research, namely the "robust medical research in and around these issues [of whether IUDs are] contraception or abortion. If the research has credence and these are well-done studies, they are very hard to refute. So getting more literature and research out there around these topics is the way to go."
Now, Carr says, her study provides a starting place for providers to further empower women in making their own healthcare decisions, which is especially crucial in our current political climate. She reflects, "Now we have some things we can tell women. 'Are you afraid of pain? Well, here is what we saw in this one small study in New Mexico about pain experience. Are you not having an epidural? Well, here's what the women in that study had to say about that.'"
Carr remains hopeful—not only for the future of postplacental IUD insertion and making its benefits more accessible to more women, but to the future of comprehensive reproductive healthcare too. She says she sees more and more medical students seeking residency programs where they are "guaranteed a robust program in reproductive health and social justice issues" and notes that with each subsequent generation of keyed-in women's healthcare providers, they will be the first line of defense in "legitimizing family planning and abortion as well as educating the next generation"—even in the face of zealots in the medical community who fail to see their misogynistic effect on women's health.