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The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion.
Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined.
Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9–12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8–23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1–4.3; P = .03).
IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.
In the same study, social interventions such as frequent clinic visits, contact with supportive healthcare providers, and return to school did not reduce the risk of another pregnancy within 2 years. In another study, continuation rates for the levonorgestrel implant were significantly higher than those of depot medroxyprogesterone acetate (DMPA) and oral contraceptive pills (OCPs) in adolescents.
This implant was withdrawn voluntarily from the market in 2002 for nonmedical reasons; currently, the etonogestrel implant (Implanon; Merck, Darmstadt, Germany) is the only subdermal contraception available in the United States. This implant offers contraceptive effectiveness with an excellent safety profile for up to 3 years.
Theoretically, the immediate postpartum period is an ideal time for etonogestrel implant insertion in adolescents; however, data on continuation and repeat pregnancy rates in the immediate postpartum adolescent population are scant. Investigators in Australia reported that, when the etonogestrel implant was inserted at 6 weeks after delivery, the teenagers who used the implant were significantly less likely than those who used OCPs, DMPA, barrier methods, or nothing to become pregnant within 24 months after delivery.
The aim of this study was to compare contraceptive continuation and repeat pregnancy rates in adolescents who received postpartum subdermal contraception before hospital discharge with postpartum adolescents who initiated other contraceptive methods after delivery. We hypothesized that immediate postpartum implant (IPI) initiators would have significantly higher rates of consistent contraception use and significantly lower rates of repeat pregnancy at 6 and 12 months compared with initiators of any other contraceptive method, including long-acting methods that were initiated >4 weeks after delivery.
Materials and Methods
In this prospective observational study, all adolescents (defined by the Centers for Disease Control and Prevention as age 13-24 years
) who were attending the Colorado Adolescent Maternity Program (CAMP) and who delivered at the University of Colorado Hospital over the 18-month period of June 1, 2008, to November 30, 2009, were eligible for inclusion in the study cohort. All of the patients expressed the desire to prevent pregnancy for at least 1 year after delivery. Exclusion criteria included contraindications to etonogestrel use, relinquishing the child for adoption, stillbirth, being delivered at a different hospital, and having no postpartum visits at the CAMP.
CAMP is a comprehensive, multidisciplinary, adolescent-oriented program that provides prenatal, delivery, postnatal, and infant care that emphasizes consistent contraceptive use and goal-oriented future planning regarding school completion, job training, and parenting. The importance of consistent contraceptive use is emphasized at prenatal and postpartum visits. Contraceptive counseling begins at the first prenatal visit and is discussed at most subsequent visits by the midwife and the case manager. Counseling occurs in both individual and group settings and is supported by written materials. During the period of this study, providers emphasized that the subdermal implant could be received immediately after delivery.
Each patient is encouraged to have a firm contraceptive plan by 32 weeks gestation; however, group assignment was determined by whether the patient had an implant placed before hospital discharge. After delivery, patients continue care in the CAMP clinic where mothers and children receive follow-up care together. Adolescent mothers thus are seen more frequently than in traditional care models and have many opportunities to initiate contraception. Participants in CAMP provide informed consent for noninvasive procedures that include medical record review, surveys, and phone contact under an institutional review board–approved protocol that allows minors to consent for themselves.
During the period of this study, young women who were enrolled in CAMP who elected to have an immediate subdermal implant and who received this implant before hospital discharge were included in the IPI group. A few participants elected immediate placement but were unable to receive it because of a lack of provider availability; all of those participants had placement within 4 weeks after delivery and were included in the IPI group. Those who initiated any other contraceptive method according to standard clinical protocols were included in the control group. The control group consisted of participants who chose no contraception, condoms, implant insertion at >4 weeks after delivery, levonorgestrel-intrauterine system or copper-T 380A (IUD) insertion any time >6 weeks after delivery (the standard timing for postpartum insertion in our clinical setting during the study period), DMPA, progestin-only pills that were initiated at any time after delivery, and combined hormonal contraception (pills, patch, ring) that was started at any time after 4 weeks after delivery. DMPA was not available before discharge during the study period. All participants remained in the IPI group or the control group based on the contraceptive method that they selected before discharge home.
The manufacturer currently recommends insertion of the etonogestrel implant in lactating women after the fourth postpartum week.
Participants' electronic medical records were reviewed to determine contraceptive use, discontinuation of contraceptive methods, reasons for the discontinuation, and pregnancy at various time points of interest. Participants with incomplete data were contacted by telephone. Up to 3 attempts were made. Participants who were reached by phone were administered a standard questionnaire that assesses birth control method continuation and pregnancy occurrence. Data from the electronic medical record and phone interviews were combined to create the most complete measurement of contraceptive use.
The primary outcome was repeat pregnancy by 12 months after delivery. This was documented in the medical record or by participant report during the phone questionnaire. We hypothesized the 1-year repeat pregnancy rate in our population would decrease from 15% in the control group to 5% in the IPI group. To demonstrate this difference with an alpha of .05 and a power of 0.8, 160 women were required in each group.
Consistent contraception was the secondary outcome. For this study, we defined consistent contraception as maintaining ≥1 highly effective contraceptive method(s) for 80% of the year of observation. Highly effective contraceptive methods included all hormonal methods or the copper T380 IUD. The year of observation for this endpoint was defined as beginning at 6 weeks after delivery and ending at 13.5 months after delivery. This time period was chosen because some contraceptive methods were not available to patients at <6 weeks after delivery. We chose 80% as a conservative endpoint because many young women in this population have periods of abstinence during which they discontinue contraception yet are not at risk of pregnancy.
Summary statistics were used to describe the population as well as the outcomes. The Student t test was used to compare means; the χ2 test was used to compare proportions, and the Fisher's exact test was used for small cell sizes. Univariable analysis and multivariable logistic regression were performed to determine significant variables that influenced repeat pregnancy. Variables that were significant (P < .05) in the univariable analyses were included in the logistic regression. SPSS statistical software (version 19.0.0; SPSS Inc, Chicago, IL) was used for all the analyses. The study was approved by the Colorado Multiple Institutional Review Board.
Over the 18-month study period, 420 young women received prenatal care and delivered in the CAMP program. Twenty-four patients were excluded from the cohort because of stillbirth (n = 4), relinquishing the infant for adoption (n = 2), or delivery at a different hospital that precluded immediate implant placement (n = 18). Thus, 396 CAMP patients were delivered and eligible for the study cohort. No one declined study participation. The subject demographics are described in Table 1. Most were mid-to-late adolescents (mean age, 18.6 years; range, 13–23 years) and unmarried. The population was ethnically diverse. Two hundred forty-three subjects (61.4%) had obtained a graduate equivalency degree or were in at the appropriate grade level in school. Seventy-seven percent of the young women were primiparous.
TABLE 1Demographic characteristics of participants by group
A total of 171 adolescent girls (43.2%) received immediate postpartum etonogestrel implants. One hundred fifty-eight of them (92.4%) underwent insertion on the Labor and Delivery unit before discharge home after delivery; the remaining 13 the young women intended to have immediate insertion but, because of no trained provider available on Labor and Delivery, received it in the CAMP clinic within 4 weeks of delivery.
The 225 subjects (56.8%) who delivered within the study period but did not choose IPI insertion were classified as control subjects (Figure). There were no significant differences in baseline characteristics between the 2 study groups aside from parity (Table 1); the IPI group members were more likely to be primiparous (82.5% vs 72%; P = .01). Lost to follow-up rates were similar between groups at both 6 months (IPI group, 5.8%; control group, 5.3%; P = .8) and 12 months (IPI group, 10.5%; control group, 9.3%; P = .7). Women who were lost to follow-up evaluation did not differ from the rest of the cohort on any demographic or reproductive factors.
In the IPI group, 96.9% of the subjects (156/161) continued implant use at 6 months after delivery, and 86.3% of the subjects (132/153) continued use at 12 months after delivery. Of the 21 IPI participants who discontinued implant use at <12 months, 12 participants noted irregular bleeding as a reason for discontinuation, and 7 participants reported this as the sole reason for discontinuation. Nine participants cited >1 reason for discontinuation (Table 2). Consistent contraception use (defined as maintaining ≥1 contraceptive methods for 80% of the observation period) was 99.4% in the IPI group at 6 months after delivery vs 54.9% among control subjects (P < .001). At 12 months, consistent contraception was 94.3% in the IPI group and 52.3% in the control group (P < .001).
TABLE 2Reasons for discontinuation of implant in immediate postpartum implantation group
Participants could change contraceptive methods throughout the course of the study. In the control group and among IPI participants who discontinued the implant, a variety of contraceptive strategies were followed. Method distribution at 8 weeks, 6 months, and 12 months after delivery are presented in Table 3. Notably, 42.7% of the control participants (91/213) were using long-acting methods (either implants or IUDs) at 6 months after delivery, and 48.6% of them (89/183) were using these methods at 12 months after delivery.
TABLE 3Contraceptive methods of nonpregnant participants at 8 weeks, 6 months, and 12 months after delivery
RRP was significantly higher in the control group at both 6 and 12 months. There were no pregnancies in the IPI group at 6 months, compared with 21 in the control group (0 vs 9.9%; P ≤ .001). By 12 months after delivery, 4 members of the IPI group were pregnant compared with 38 members of the control group (2.6% vs 18.6%; P ≤ .001; Figure). Of the 4 pregnancies in the IPI group, 1 was an implant failure in a participant who started carbamazepine, which is an enzyme-inducing antiseizure medication. The other 3 pregnancies occurred after the implant was removed; 2 of these participants reported condom use, and 1 participant reported no contraception use at the time of conception. Of the 38 control group pregnancies, by 8 weeks after delivery, 21 participants had not yet initiated birth control; 5 participants had initiated DMPA; 4 participants used condoms; 3 participants used OCPs; 3 participants used the ring; 1 participant used withdrawal, and 1 participant used the levonorgestrel-intrauterine system. Outcomes of repeat pregnancies in both groups are reported in Table 4. Most of these pregnancies were maintained and delivered.
Compared with the IPI group, control adolescents had a relative risk of repeat pregnancy of 5.0 (95% confidence interval [CI], 1.9–12.7) at 12 months after delivery. In univariable analyses, there were no associations between repeat pregnancy at 6 or 12 months and participant age, race, education, relationship status, body mass index, gestational age at delivery, or birthweight of the index newborn infant. In multivariable analysis that included primiparity and receipt of IPI, repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8–23.0) and having >1 child already (odds ratio, 2.1; 95% CI, 1.1–4.3).
Approaches that consistently and effectively prevent RRP in adolescents have eluded clinicians, social scientists, and policy makers. One decade ago Stevens-Simon et al
showed that the only intervention that reduced RRP in adolescent mothers who were enrolled in a comprehensive, multidisciplinary, adolescent-oriented maternity program was the use of long-acting contraceptives and that the use of the levonorgestrel implant had 4 times stronger effect than DMPA. Most other interventions to prevent teen RRP have been unsuccessful.
In this study, we found that, when immediate postpartum etonogestrel implants are offered, adolescents accept them and continue using them. Implant retention was at least as high in this high-risk population as in the general reproductive age population (82% continuation at 12 months).
found overall 12-month continuation to be 18.5 per 100 woman-years, with a maximum of 32.7 per 100 woman-years for the best-continued method (OCP). There were no implant users in that cohort. In our study of IUD continuation by adolescent mothers, we found 55% continuation at 12 months after placement.
Although the patients were very similar demographically, these IUD recipients differed from the implant recipients in that they were not immediately after delivery; IUD placement occurred at a mean of 8 months after delivery. Removal for pregnancy desire was likely higher in these patients who had already achieved greater birth spacing. Although not tested in our study, it is possible that the implant is a better choice for parous adolescents because 30% of the IUD discontinuations were attributed to symptoms that would not be expected with the implant, such as expulsion, pelvic pain, and infection. Consistent use of the implant is reflected in the significantly lower rates of RRP at 6 and 12 months when compared with similar postpartum adolescents who chose any other contraceptive strategy.
Although not choosing IPI was the strongest predictor of RRP, we could not easily distinguish who chooses IPI and why. There is little consensus as to which risk factors are the most important predictors of RRP; previously identified risk factors have included race, young maternal age, school failure, and relationship status.
These factors were not associated with choice of IPI in our study. This finding is consistent with previous work that has shown sociodemographic characteristics to affect the timing of subsequent conceptions, but not intervention participation.
The only measured significant difference between our groups was already having delivered a child before the index pregnancy. Multiparity has been identified previously as an independent risk factor for a repeat pregnancy.
We also found that having ≥2 children was an independent risk factor for RRP, even when we controlled for choice of IPI.
In those teens who did not accept IPI, 42.7% had a form of long-acting reversible contraception (LARC) or permanent sterilization in place by 6 months after delivery. In a clinical setting that is committed to encouraging and facilitating LARC use, patient nonacceptance of IPI or other postpartum LARC options in the early postpartum period may serve as a surrogate marker for the unmeasured factors that predispose to RRP. However, accepting LARC by 6 months after delivery is not an adequate goal in this patient population. Of the 38 pregnancies among the control subjects, 21 pregnancies occurred at <6 months, and 5 pregnancies were delivered within the 12-month study period.
Although it is traditional, waiting to administer contraception at the 6-week postpartum visit is suboptimal.
Outpatient initiation of etonogestrel implants during the early postpartum period is also less effective than IPI. We previously demonstrated that, when striving for implant insertion within the first 2 weeks after delivery (during 1 of 3 combined mother-baby visits), only 37% of adolescents who intend postpartum implant use receive the device within 2 weeks; by 14 weeks only 68% had received the implant.
In that study, we found social stressors, medical issues, and waning patient motivation often caused deferment of outpatient implant insertion. Offering implant insertion in the relatively protected space of the Labor and Delivery or Postpartum unit allows for a high capture rate.
This study used a prospective nonrandomized design. Unmeasured factors that guide patient preferences were accounted for and generalizability to clinical practice was enhanced because young women were allowed to choose from any available contraceptive method. The continually updated database allowed us to follow the cohort over time. Thus, we were able to effectively describe method continuation, reasons for implant discontinuation, repeat pregnancy rates, and pregnancy outcomes. All participants in this study had simplified healthcare access through the CAMP, with many more opportunities for contraceptive intervention than typical postpartum patients. Therefore, our control population may represent close to a “best-case scenario” for avoidance of RRP.
Our study has several limitations. Follow-up evaluation was limited to a 1-year period, and we do not know whether the increased rate of consistent contraception and decreased rate of RRP will persist beyond this study period. Because all our participants were parous, the results should not be generalized to implant continuation or avoidance of a first pregnancy in nulliparous adolescents, who may have different motivations to avoid pregnancy or tolerate side-effects. Provider bias is a possibility. The contraceptive counselors throughout the pregnancies were limited to the same 4 providers: 2 midwives, a social worker, and a case manager, all of whom are very supportive of LARC for all interested patients. However, the residents and faculty on Labor and Delivery may have influenced the group assignment through their counseling. Immediate postpartum insertion of IUDs was not available to our participants, and no conclusion can be drawn from this study regarding the superiority of 1 immediate LARC method vs another. Finally, the breastfeeding rate in this population is so low at baseline that we did not attempt to measure any effects of contraceptive choice on this outcome.
Despite these limitations, our results indicate that the contraceptive strategy most likely to prevent RRP in adolescents may be IPI of the etonogestrel contraceptive implant. This strategy allows a high capture rate of those young women who are interested in implant insertion, an excellent continuation rate, and a significantly reduced rate of RRP in a cohort of young women who are at high risk. Institutions and payers that currently do not support implant insertion before discharge should reconsider their policies to facilitate avoidance of RRP in adolescent mothers.
We thank our research assistant, Ms Cricket Mchugh, for her tireless data collection and the Obstetrics and Gynecology residents and faculty at University of Colorado Hospital for their commitment to this protocol.
Systematic review of sexual risk among pregnant and mothering teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat pregnancy.