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

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

doi:10.1002/14651858.CD011913.pub3

Cochrane Database of Systematic Reviews

Inserción posparto inmediata versus diferida de implantes anticonceptivos y DIU para la anticoncepción

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DOI:

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

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

27 octubre 2022see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Regulación de la fertilidad

Copyright:

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Jen Sothornwit

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

[email protected]
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
Porjai Pattanittum

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

OB/GYN and Reproductive Sciences, University of California, San Diego, La Jolla, USA

Contributions of authors

Jen Sothornwit initiated the review topic.

Jen Sothornwit and Srinaree Kaewrudee screened and selected the studies.

Jen Sothornwit and Sarah Averbach made risk of bias judgements.

Jen Sothornwit and Srinaree Kaewrudee extracted data.

Porjai Pattanittum entered data into RevMan 5.

Pisake Lumbiganon or Sarah Averbach checked all study characteristics for accuracy against the trial reports.

Porjai Pattanittum and Jen Sothornwit performed the meta‐analysis.

Jen Sothornwit, Sarah Averbach, Porjai Pattanittum, Srinaree Kaewrudee, 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
Long‐term Institutional Development HUBs (LID‐HUBs), the Human Reproduction Programme (HRP) Alliance for Research Capacity Strenghtening, Department of Reproductive Health and Research, World Health Organization, Switzerland
National Institutes of Health, USA

Dr. Averbach is supported by the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) physician scientist award (K12HD001259).

Declarations of interest

Jen Sothornwit: none known

Srinaree Kaewrudee: none known

Pisake Lumbiganon: none known

Porjai Pattanittum: none known

Sarah Averbach: none known

Acknowledgements

We thank the Cochrane Fertility Regulation Review Group for their contributions to the editorial process and clinical advice, Robin Paynter for designing the search strategies and running the search, and the referees for their useful suggestions and comments during the prepublication editorial process.

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 rephrased as 'Rate of contraceptive implant initiation at the first postpartum visit (four to eight weeks postpartum)'. 'Continuation rate' has been rephrased as 'utilization rate'.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Female; Humans; Pregnancy;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

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: 1.4 Other adverse effects

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Figure 6

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

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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: Utilization rate

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Analysis 1.3

Comparison 1: Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 3: Adverse effect: mean days of duration of vaginal bleeding

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Analysis 1.4

Comparison 1: Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 4: Other adverse effects

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Analysis 1.5

Comparison 1: Immediate versus delayed postpartum insertion of contraceptive implants, Outcome 5: Participant 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 6 months postpartum

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Analysis 2.1

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 1: Rate of initiation of IUDs

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Analysis 2.2

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 2: Utilization rate

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Analysis 2.3

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 3: Expulsion

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Analysis 2.4

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 4: Participant satisfaction

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Analysis 2.5

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 5: Unintended pregnancy rate

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Analysis 2.6

Comparison 2: Immediate versus delayed postpartum insertion of IUDs, Outcome 6: Breastfeeding (LNG‐IUS)

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Summary of findings 1. Immediate compared to delayed postpartum insertion of contraceptive implants for contraception

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Immediate compared to delayed postpartum insertion of contraceptive implants for contraception
Participant or population: postpartum people who desire a contraceptive implant for contraception Settings: tertiary hospitals Intervention: immediate postpartum insertion Comparison: delayed insertion
Outcomes	Risk with delayed postpartum insertion of contraceptive implants	Risk with immediate postpartum insertion of contraceptive implants	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Rate of initiation of contraceptive implants	Study population		RR 1.48 (1.11 to 1.98)	715 (5 studies)	⊕⊕⊕⊝ Moderate¹
Rate of initiation of contraceptive implants	633 per 1000	936 per 1000 (702 to 1000)	RR 1.48 (1.11 to 1.98)	715 (5 studies)	⊕⊕⊕⊝ Moderate¹
Utilization rate at 6 months postpartum	Study population		RR 1.16 (0.90 to 1.50)	330 (3 studies)	⊕⊝⊝⊝ Very low^1,2,3
Utilization rate at 6 months postpartum	712 per 1000	826 per 1000 (641 to 1000)	RR 1.16 (0.90 to 1.50)	330 (3 studies)	⊕⊝⊝⊝ Very low^1,2,3
Utilization rate at 12 months postpartum	Study population		RR 0.98 (0.93 to 1.04)	164 (2 studies)	⊕⊝⊝⊝ Very low^2,3,4
Utilization rate at 12 months postpartum	922 per 1000	904 per 1000 (858 to 959)	RR 0.98 (0.93 to 1.04)	164 (2 studies)	⊕⊝⊝⊝ Very low^2,3,4
Adverse effect: mean days of prolonged vaginal bleeding within 6 weeks postpartum	Mean 17.8 days	MD 2.98 higher (2.71 less to 8.66 more)	MD 2.98 (2.71 to 8.66)	420 (2 studies)	⊕⊕⊝⊝ Low^1,2
Adverse effects other than prolonged vaginal bleeding	Study population		RR 2.06 (1.38 to 3.06)	215 (1 study)	⊕⊕⊝⊝ Low^3,5
Adverse effects other than prolonged vaginal bleeding	229 per 1000	472 per 1000 (317 to 702)	RR 2.06 (1.38 to 3.06)	215 (1 study)	⊕⊕⊝⊝ Low^3,5
Unintended pregnancy rate at 12 months postpartum	Study population		RR 1.82 (0.38 to 8.71)	64 (1 study)	⊕⊝⊝⊝ Very low^2,3,4
Unintended pregnancy rate at 12 months postpartum	74 per 1000	135 per 1000 (28 to 645)	RR 1.82 (0.38 to 8.71)	64 (1 study)	⊕⊝⊝⊝ Very low^2,3,4
Any breastfeeding at six months postpartum	Study population		RR 0.97 (0.92 to 1.01)	225 (2 studies)	⊕⊕⊝⊝ Low^2,3
Any breastfeeding at six months postpartum	775 per 1000	751 per 1000 (713 to 782)	RR 0.97 (0.92 to 1.01)	225 (2 studies)	⊕⊕⊝⊝ Low^2,3
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded by one level owing to inconsistency across studies (I² > 50%). ²Downgraded by one level owing to serious imprecision (e.g. 95% CI includes both appreciable appreciable benefit and harm, or because of low number of participants (total number of participants < 400)) ³Downgraded by one level owing to serious imprecision (low number of events (total number of events < 300)). ⁴Downgraded by one level owing to serious risk of attrition bias. ⁵Downgraded by one level owing to serious risk of assessment bias.

Summary of findings 1. Immediate compared to delayed postpartum insertion of contraceptive implants for contraception

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Summary of findings 2. Immediate compared to delayed postpartum insertion of IUDs for contraception

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Immediate compared to delayed postpartum insertion of IUDs for contraception
Patient or population: postpartum people who desire IUDs for contraception Setting: tertiary hospitals Intervention: immediate postpartum insertion Comparison: delayed postpartum insertion of IUDs
Outcomes	Risk with delayed postpartum insertion of IUD	Risk with immediate insertion of IUD	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Rate of initiation of IUDs	Study population		RR 1.27 (1.07 to 1.51)	1894 (10 studies)	⊕⊕⊕⊝ Moderate¹
Rate of initiation of IUDs	614 per 1000	780 per 1000 (657 to 927)	RR 1.27 (1.07 to 1.51)	1894 (10 studies)	⊕⊕⊕⊝ Moderate¹
Expulsion by 6 months	Study population		RR 4.55 (2.52 to 8.19)	1206 (8 studies)	⊕⊕⊝⊝ Low^2,3
Expulsion by 6 months	21 per 1000	94 per 1000 (52 to 170)	RR 4.55 (2.52 to 8.19)	1206 (8 studies)	⊕⊕⊝⊝ Low^2,3
Utilization rate at 6 months postpartum	Study population		RR 1.02 (0.64 to 1.62)	971 (6 studies)	⊕⊝⊝⊝ Very low^1,3,4
Utilization rate at 6 months postpartum	822 per 1000	838 per 1000 (534 to 1000)	RR 1.02 (0.64 to 1.62)	971 (6 studies)	⊕⊝⊝⊝ Very low^1,3,4
Utilization rate at 12 months postpartum	Study population		RR 0.86 (0.50 to 1.49)	796 (3 studies)	⊕⊝⊝⊝ Very low^1,3,4
Utilization rate at 12 months postpartum	781 per 1000	672 per 1000 (391 to 1000)	RR 0.86 (0.50 to 1.49)	796 (3 studies)	⊕⊝⊝⊝ Very low^1,3,4
Unintended pregnancy at 12 months postpartum	Study population		RR 0.26 (0.17 to 0.41)	1000 (1 study)	⊕⊕⊝⊝ Low^2,3
Unintended pregnancy at 12 months postpartum	168 per 1000	44 per 1000 (29 to 69)	RR 0.26 (0.17 to 0.41)	1000 (1 study)	⊕⊕⊝⊝ Low^2,3
Any breastfeeding at 6 months (hormonal IUD)	Study population		RR 0.90 (0.63 to 1.30)	435 (5 studies)	⊕⊝⊝⊝ Very low^1,2,3
Any breastfeeding at 6 months (hormonal IUD)	468 per 1000	421 per 1000 (295 to 608)	RR 0.90 (0.63 to 1.30)	435 (5 studies)	⊕⊝⊝⊝ Very low^1,2,3
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded by one level owing to inconsistency across studies (I² > 50%). ²Downgraded by one level owing to serious imprecision (low number of events (total number of events < 300)). ³Downgraded by one level owing to serious risk of attrition bias. ⁴Downgraded by one level owing to serious imprecision (e.g. 95% CI includes both appreciable appreciable benefit and harm, or because of low number of participants (total number of participants < 400)). ⁵Downgraded by one level owing to serious risk of assessment bias.

Summary of findings 2. Immediate compared to delayed postpartum insertion of IUDs 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
1.1 Rate of initiation of contraceptive implants Show forest plot	5	715	Risk Ratio (IV, Random, 95% CI)	1.48 [1.11, 1.98]

1.1.1 High‐income countries	3	410	Risk Ratio (IV, Random, 95% CI)	1.41 [1.28, 1.55]
1.1.2 Middle‐ to low‐income countries	2	305	Risk Ratio (IV, Random, 95% CI)	1.57 [0.61, 4.05]
1.2 Utilization rate Show forest plot	4		Risk Ratio (IV, Random, 95% CI)	Subtotals only

1.2.1 At 6 months postpartum	3	330	Risk Ratio (IV, Random, 95% CI)	1.16 [0.90, 1.50]
1.2.2 At 12 months postpartum	2	164	Risk Ratio (IV, Random, 95% CI)	0.98 [0.93, 1.04]
1.3 Adverse effect: mean days of duration of vaginal bleeding Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.3.1 Mean days of prolonged vaginal bleeding within 6 weeks postpartum	2	420	Mean Difference (IV, Random, 95% CI)	2.98 [‐2.71, 8.66]
1.4 Other adverse effects Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.4.1 Prolonged bleeding at 3 months postpartum	2	225	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.10, 1.47]
1.4.2 Prolonged bleeding at 6 months postpartum	2	252	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.29, 4.94]
1.4.3 Other vaginal bleeding or associated severe cramping within 12 months	1	64	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.72, 1.44]
1.4.4 Adverse effects other than prolonged vaginal bleeding	1	215	Risk Ratio (M‐H, Fixed, 95% CI)	2.06 [1.38, 3.06]
1.5 Participant satisfaction Show forest plot	2		Risk Ratio (IV, Fixed, 95% CI)	Subtotals only

1.5.1 At 6 months postpartum	1	152	Risk Ratio (IV, Fixed, 95% CI)	0.97 [0.90, 1.04]
1.5.2 At 12 months postpartum	1	64	Risk Ratio (IV, Fixed, 95% CI)	1.01 [0.77, 1.31]
1.6 Unintended pregnancy rate Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.6.1 At 6 months postpartum	1	205	Risk Ratio (M‐H, Fixed, 95% CI)	0.20 [0.01, 4.08]
1.6.2 At 12 months postpartum	1	64	Risk Ratio (M‐H, Fixed, 95% CI)	1.82 [0.38, 8.71]
1.7 Breastfeeding at 6 months postpartum Show forest plot	3		Risk Ratio (IV, Fixed, 95% CI)	Subtotals only

1.7.1 Exclusive breastfeeding	2	261	Risk Ratio (IV, Fixed, 95% CI)	0.89 [0.66, 1.21]
1.7.2 Any breastfeeding	2	225	Risk Ratio (IV, Fixed, 95% CI)	0.97 [0.92, 1.01]

Comparison 1. Immediate versus delayed postpartum insertion of contraceptive implants

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Comparison 2. Immediate versus delayed postpartum insertion of IUDs

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Rate of initiation of IUDs Show forest plot	11	1894	Risk Ratio (IV, Random, 95% CI)	1.27 [1.07, 1.51]

2.1.1 Copper IUDs	5	1329	Risk Ratio (IV, Random, 95% CI)	1.38 [0.96, 1.97]
2.1.2 Levonorgestrel IUDs	5	453	Risk Ratio (IV, Random, 95% CI)	1.11 [1.05, 1.18]
2.1.3 Any types of IUDs	1	112	Risk Ratio (IV, Random, 95% CI)	1.56 [1.25, 1.94]
2.2 Utilization rate Show forest plot	7		Risk Ratio (IV, Random, 95% CI)	Subtotals only

2.2.1 At 6 months postpartum	6	971	Risk Ratio (IV, Random, 95% CI)	1.02 [0.65, 1.62]
2.2.2 At 12 months postpartum	3	796	Risk Ratio (IV, Random, 95% CI)	0.86 [0.50, 1.47]
2.3 Expulsion Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.3.1 Expulsion by 6 months postpartum	8	1206	Risk Ratio (M‐H, Fixed, 95% CI)	4.55 [2.52, 8.19]
2.4 Participant satisfaction Show forest plot	2		Risk Ratio (IV, Fixed, 95% CI)	Subtotals only

2.4.1 At 6 months postpartum	1	69	Risk Ratio (IV, Fixed, 95% CI)	0.93 [0.83, 1.03]
2.4.2 At 12 months postpartum	1	598	Risk Ratio (IV, Fixed, 95% CI)	1.05 [0.98, 1.12]
2.5 Unintended pregnancy rate Show forest plot	4		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.5.1 at 6 months postpartum	3	268	Risk Ratio (M‐H, Fixed, 95% CI)	Not estimable
2.5.2 at 12 months postpartum	1	1000	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.17, 0.41]
2.6 Breastfeeding (LNG‐IUS) Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.6.1 Exclusive breastfeeding at 6 months	2	297	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.08, 3.19]
2.6.2 Any breastfeeding at 6 months	5	435	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.63, 1.30]

Comparison 2. Immediate versus delayed postpartum insertion of IUDs

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Inserción posparto inmediata versus diferida de implantes anticonceptivos y DIU para la anticoncepción

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