Immediate versus delayed postpartum insertion of contraceptive implant for contraception

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

doi:10.1002/14651858.CD011913.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Figure 4

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

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Figure 5

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

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Figure 6

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

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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Analysis 1.6

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

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Analysis 1.7

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

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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 low^2,4
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)	⊕⊕⊝⊝ low^1,3
	23 per 100	47 per 100 (32 to 70)	RR 2.06 (1.38 to 3.06)	215 (1 study)	⊕⊕⊝⊝ low^1,3
	67 per 100	68 per 100 (48 to 96)	RR 1.01 (0.72 to 1.44)	64 (1 study)	⊕⊕⊝⊝ very low^2,4
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)	⊕⊕⊝⊝ low^1,4
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 low^2,4
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 low^2,4
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.

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

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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]

Comparison 1. Immediate versus delayed postpartum insertion of contraceptive implants

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