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Cochrane Database of Systematic Reviews

Inserción posparto inmediata versus diferida del implante anticonceptivo para la anticoncepción

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Information

DOI:
https://doi.org/10.1002/14651858.CD011913.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 22 April 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Fertility Regulation Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Jen Sothornwit

    Correspondence to: Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

    [email protected]

  • Yuthapong Werawatakul

    Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

  • Srinaree Kaewrudee

    Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

  • Pisake Lumbiganon

    Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

  • Malinee Laopaiboon

    Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand

Contributions of authors

Jen Sothornwit initiated the review topic. Jen Sothornwit, Yuthapong Werawatakul, Srinaree Kaewrudee, Malinee Laopaiboon and Pisake Lumbiganon drafted the review. All authors reviewed and approved the final version of the review.

Sources of support

Internal sources

  • Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand.

  • Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Thailand.

External sources

  • Thailand Research Fund (Distinguished Professor Awards), Thailand.

  • Cochrane Thailand, Thailand.

Declarations of interest

Jen Sothornwit: none known

Yuthapong Werawatakul: none known

Srinaree Kaewrudee: none known

Pisake Lumbiganon: none known

Malinee Laopaiboon: none known

Acknowledgements

We thank Anja Helmerhorst, Frans M Helmerhorst, and Helen Nagels for their contributions to the editorial process and clinical advice, Carol Manion for designing the search strategies and running the search, and the referees for their useful suggestions and comments during the prepublication editorial process. We also thank Chumnan Kietpeerakool for his input in the revision of the review.

Version history

Published

Title

Stage

Authors

Version

2022 Oct 27

Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception

Review

Jen Sothornwit, Srinaree Kaewrudee, Pisake Lumbiganon, Porjai Pattanittum, Sarah H Averbach

https://doi.org/10.1002/14651858.CD011913.pub3

2017 Apr 22

Immediate versus delayed postpartum insertion of contraceptive implant for contraception

Review

Jen Sothornwit, Yuthapong Werawatakul, Srinaree Kaewrudee, Pisake Lumbiganon, Malinee Laopaiboon

https://doi.org/10.1002/14651858.CD011913.pub2

2015 Oct 25

Immediate versus delayed postpartum insertion of contraceptive implant for contraception

Protocol

Jen Sothornwit, Yuthapong Werawatakul, Srinaree Kaewrudee, Pisake Lumbiganon, Malinee Laopaiboon

https://doi.org/10.1002/14651858.CD011913

Differences between protocol and review

Primary review outcome

In our protocol the primary outcome was 'Postpartum contraceptive prevalence at the first postpartum check‐up visit'. This has been re‐worded as 'Rate of contraceptive implant initiation at the first postpartum check‐up visit'.

Unit of analysis issues

We intended to include studies where individual postpartum women were randomised and cluster‐randomized studies where, for example, the hospital was the unit of randomisation. However, we did not find any related cluster‐randomised study. In future updates of this review, for studies that use a cluster‐randomised design but did not have any information related to the design effect, we will estimate the design effect based on a fairly large assumed intra‐cluster correlation of 0.10. We will base this assumption by analogy on studies about implementation research (Ukoumunne 1999; Campbell 2000).

Assessment of reporting biases

As only three RCTs met the inclusion criteria, we were unable to construct funnel plots to determine the possibility of publication bias as previously stated in the protocol (Sothornwit 2015). In future updates of this review, we will construct funnel plots that correspond to the findings of the meta‐analysis of the primary outcome that this review needs to address if we identify a sufficient number of included studies (i.e. more than 10). We will also perform sensitivity analyses to investigate the effect on the pooled results of the funnel plots (Sterne 2011).

Subgroup analysis and investigation of heterogeneity

We did not perform subgroup analyses, as we stated in the Cochrane protocol, due to the limited number of included studies. All included studies were conducted in the USA. In future versions of this review, we will perform subgroup analysis to investigate heterogeneity, if feasible, and we will employ the following methods for subgroup analysis.

  • We will consider whether an overall summary is meaningful, and if it is, use a random‐effects analysis to produce it.

  • We plan to perform subgroup analyses according to age of participants (teenagers versus non‐teenagers) and population differences (high‐income versus low‐ and middle‐income countries).

  • We will assess subgroup differences by interaction tests available within RevMan 5 (RevMan 2014). We will report the results of subgroup analyses quoting the Chi² statistic and P value, the interaction test, and I² statistic value.

Sensitivity analysis

Only three published RCTs were available for this review. which were at low risk of selection bias. Furthermore, we did not find any unpublished studies. Thus we were unable to perform sensitivity analyses as we stated in the Cochrane protocol (Sothornwit 2015). In future versions of the review we will perform sensitivity analyses, if feasible, in order to determine the impact of the following factors on effect size.

  • Repeating the analysis by excluding unpublished studies (if any).

  • Repeating the analysis by excluding trials rated as at 'high’ or ’unclear’ risk of bias for allocation concealment.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.
Figures and Tables -
Figure 2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.
Figures and Tables -
Figure 3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.1 Rate of initiation of contraceptive implants.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.1 Rate of initiation of contraceptive implants.

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.2 Continuation rate.
Figures and Tables -
Figure 5

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.2 Continuation rate.

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.4 Other side effects.
Figures and Tables -
Figure 6

Forest plot of comparison: 1 Immediate versus delayed postpartum insertion of contraceptive implants, outcome: 1.4 Other side effects.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 1 Rate of initiation of contraceptive implants.
Figures and Tables -
Analysis 1.1

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 1 Rate of initiation of contraceptive implants.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 2 Continuation rate.
Figures and Tables -
Analysis 1.2

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 2 Continuation rate.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 3 Side effect: mean days of abnormal vaginal bleeding.
Figures and Tables -
Analysis 1.3

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 3 Side effect: mean days of abnormal vaginal bleeding.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 4 Other side effects.
Figures and Tables -
Analysis 1.4

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 4 Other side effects.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 5 Participant's satisfaction.
Figures and Tables -
Analysis 1.5

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 5 Participant's satisfaction.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 6 Unintended pregnancy rate.
Figures and Tables -
Analysis 1.6

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 6 Unintended pregnancy rate.

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 7 Breastfeeding at six months postpartum.
Figures and Tables -
Analysis 1.7

Comparison 1 Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 7 Breastfeeding at six months postpartum.

Summary of findings for the main comparison. Immediate postpartum insertion compared with delayed insertion of contraceptive implant for contraception

Immediate postpartum insertion compared with delayed insertion of contraceptive implant for contraception

Participant or population: postpartum women who desire a contraceptive implant for contraception

Settings: hospitals in United States

Intervention: immediate postpartum insertion

Comparison: delayed insertion

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Delayed insertion

Immediate insertion

Rate of initiation of contraceptive implants

69 per 100

97 per 100
(88 to 100)

RR 1.41
(1.28 to 1.55)

410
(3 studies)

⊕⊕⊕⊝
moderate1

Continuation rate at 6 months

Continuation rate at 12 months

90 per 100

92 per 100
(84 to 100)

RR 1.02
(0.93 to 1.11)

125
(2 studies)

⊕⊕⊝⊝
low2

78 per 100

81 per 100

(63 to 100)

RR 1.04

(0.81 to 1.34)

64

(1 study)

⊕⊕⊝⊝
very low2,4

Side effects: Abnormal vaginal bleeding within 6 weeks post partum

Side effects: Other side effects within 6 weeks

Side effects: Heavy, irregular vaginal bleeding or associated severe cramping within 12 months

Mean 22.4

Mean 5.80 higher
(95% CI 3.79 higher to 7.81 higher)

MD 5.80
(3.79 to 7.81)

215
(1 study)

⊕⊕⊝⊝
low1,3

23 per 100

47 per 100
(32 to 70)

RR 2.06
(1.38 to 3.06)

215
(1 study)

⊕⊕⊝⊝
low1,3

67 per 100

68 per 100

(48 to 96)

RR 1.01 (0.72 to 1.44)

64
(1 study)

⊕⊕⊝⊝
very low2,4

Participants' satisfaction at 12 months

Mean 8.7

Mean 0.40 lower
(95% CI 1.26 lower to 0.46 higher)

MD ‐0.40
(‐1.26 to 0.46)

64

(1 study)

⊕⊕⊝⊝
low1,4

Unintended pregnancy rate at 12 months

7 per 100

13 per 100

(3 to 61)

RR 1.82
(0.38 to 8.71)

64

(1 study)

⊕⊕⊝⊝
very low2,4

Breastfeeding at six months postpartum

15 per 100

30 per 100

(11 to 84)

RR 2.01
(0.72 to 5.63)

64

(1 study)

⊕⊕⊝⊝
very low2,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Abbreviations: CI: confidence interval; RR: risk ratio; MD: mean difference.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Downgraded one level owing to serious imprecision (small number of participants)
2Downgraded two levels owing to very serious imprecision (small number of participants, and the CI includes appreciable benefit and harm).
3Downgraded one level owing to serious risk of assessment bias.
4Downgraded one level owing to serious risk of attrition bias.

Figures and Tables -
Summary of findings for the main comparison. Immediate postpartum insertion compared with delayed insertion of contraceptive implant for contraception
Comparison 1. Immediate versus delayed postpartum insertion of contraceptive implants

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Rate of initiation of contraceptive implants Show forest plot

3

410

Risk Ratio (IV, Fixed, 95% CI)

1.41 [1.28, 1.55]

2 Continuation rate Show forest plot

2

Risk Ratio (IV, Fixed, 95% CI)

Subtotals only

2.1 At 6 months postpartum

2

125

Risk Ratio (IV, Fixed, 95% CI)

1.02 [0.93, 1.11]

2.2 At 12 months postpartum

1

64

Risk Ratio (IV, Fixed, 95% CI)

1.04 [0.81, 1.34]

3 Side effect: mean days of abnormal vaginal bleeding Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Mean days of abnormal vaginal bleeding within 6 weeks postpartum

1

215

Mean Difference (IV, Fixed, 95% CI)

5.80 [3.79, 7.81]

4 Other side effects Show forest plot

2

Risk Ratio (IV, Fixed, 95% CI)

Subtotals only

4.1 Heavy, irregular bleeding or associated severe cramping within 12 months

1

64

Risk Ratio (IV, Fixed, 95% CI)

1.01 [0.72, 1.44]

4.2 Adverse effects other than abnormal vaginal bleeding

1

215

Risk Ratio (IV, Fixed, 95% CI)

2.06 [1.38, 3.06]

5 Participant's satisfaction Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5.1 At 12 months post partum

1

64

Mean Difference (IV, Fixed, 95% CI)

‐0.40 [‐1.26, 0.46]

6 Unintended pregnancy rate Show forest plot

1

Risk Ratio (IV, Fixed, 95% CI)

Subtotals only

6.1 At 12 months after delivery

1

64

Risk Ratio (IV, Fixed, 95% CI)

1.82 [0.38, 8.71]

7 Breastfeeding at six months postpartum Show forest plot

1

64

Risk Ratio (IV, Fixed, 95% CI)

2.01 [0.72, 5.63]

Figures and Tables -
Comparison 1. Immediate versus delayed postpartum insertion of contraceptive implants