Postpartum Contraception: A Systematic Review of the Literature

Context: Contraception is often discussed during postpartum care, and there is an extensive array of contraceptive options that may be considered. Contraceptive decisions should be guided by a critical review of the evidence in the context of women's own preferences.

Objective: To review the existing literature on postpartum contraception. Design: A systematic search of the MEDLINE, CINAHL, Psycinfo, and CochraneLibrary databases was performed up to September 1999 to find all English-language, human, randomized controlled trials of interventions pertaining to postpartum contraception conducted within North America, Europe, Australia, or New Zealand.

Main Outcome Measures: Four main areas were addressed in the literature. 1) efficacy/side effects of IUDs 2) interventions to reduce IUD expulsion rates 3) risks for perforation and infection with IUDs and 4) efficacy/side effects of a vaginal ring.

Results: Five randomized controlled trials (RCT's) met the inclusion criteria. Four addressed the use of IUDs, and one the use of a vaginal ring. No trials addressed other forms of birth control. Nine of 10 IUDs evaluated were shown to effectively prevent pregnancy, had low expulsion rates (0-11.8%), and low removal for pain and bleeding ( 2.5-11.9%). Although immediate insertion appeared to have a higher expulsion rate, none of the studies examined timing of insertion. The addition of catgut suture did not reduce IUD expulsion rates. There is no evidence for the efficacy or safety of a vaginal progesterone-containing ring.

Conclusion: The available literature supports the efficacy of most IUDs inserted in the postpartum period. The question of appropriate timing of insertion has not been addressed. Although all questions related to contraception in the postpartum period cannot be answered with an RCT, there is still a need for high quality trials to guide the practice of evidence-based postpartum care.