Immediate postplacental intrauterine device placement: retrospective cohort study of expulsion and associated risk factors

Abstract

Background: Postpartum contraception is typically provided during postpartum visits. When desired and accessible, the immediate postpartum period provides an additional opportunity to increase the use of more effective contraceptive methods to potentially reduce subsequent unintended pregnancies and improve pregnancy outcomes. In New York State, recent policy changes expanded Medicaid coverage to include immediate postplacental intrauterine device insertion.

Objective: This study aimed to investigate clinically documented intrauterine device expulsion within 12 months of placement in patients who depend on state-funded health insurance.

Study design: This retrospective cohort study included Medicaid patients with an immediate postplacental intrauterine device placed after third-trimester delivery, who delivered between March 2, 2017 and September 2, 2019. Current Procedural Terminology code billing data were used to identify 238 patients who underwent intrauterine device placement during their delivery admission. Electronic medical record data were analyzed using chi-squared tests, t tests, and multivariable logistic regression.

Results: There were 17.6% (42/238) documented intrauterine device expulsions within the first year after placement. Among patients with vaginal deliveries, 22.1% (29/131) of intrauterine devices placed had a documented expulsion, whereas the expulsion rate was 12.2% (13/107) among patients who had cesarean deliveries (P=.04). After controlling for body mass index, parity, intrauterine device type, and gestational age, patients who delivered vaginally were more likely to experience intrauterine device expulsion within 1 year compared with those who had cesarean delivery (adjusted odds ratio, 2.71; 95% confidence interval, 1.27-5.80). Patients with a documented intrauterine device expulsion within 1 year were more likely to have a subsequent pregnancy before October 2020 (35.7% [15/42] vs 15.3% [30/196] in the no-expulsion group; P=.002).

Conclusion: The overall percentage of documented intrauterine device expulsion within 1 year following immediate postplacental placement was 17.6%, with a greater percentage of expulsion in patients who underwent vaginal delivery. Patients with a documented intrauterine device expulsion within 1 year of placement were significantly more likely to experience a subsequent pregnancy.

Keywords: contraception; intrauterine device expulsion; intrauterine devices; long-acting reversible contraception; postpartum period.

Figure

Identified patients with an immediate postplacental IUD placed at 2 affiliated hospitals in Rochester, NY from 2017 to 2019^{a a}Between March 2, 2017 and September 2, 2019. IUD, intrauterine device.