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A Decision Analysis Model of 1-Year Effectiveness of Intended Postplacental Compared With Intended Delayed Postpartum Intrauterine Device Insertion

Sonalkar, Sarita, MD, MPH; Hunter, Tegan, SB; Gurney, Elizabeth P., MD, MPH; McAllister, Arden, MPH; Schreiber, Courtney A., MD, MPH

doi: 10.1097/AOG.0000000000002926
Contraception: Original Research: PDF Only

OBJECTIVE: To compare, using decision analysis methodology, the 1-year probability of pregnancy after intended postplacental intrauterine device (IUD) insertion with intended delayed insertion at an outpatient postpartum visit (delayed postpartum placement).

METHODS: We developed an evidence-based decision model with the primary outcome of 1-year probability of pregnancy. We compared 1-year probability of pregnancy after intended postplacental or intended delayed postpartum IUD placement. We obtained estimates from the literature for the proportions of the following: mode of delivery, successful IUD placement, IUD type, postpartum visit attendance, IUD expulsion, IUD discontinuation, and contraceptive use, choice, and efficacy after IUD discontinuation. We performed sensitivity analyses and a Monte Carlo simulation to account for variations in proportion estimates.

RESULTS: One-year probabilities of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a postplacental IUD after vaginal birth and 1,250,000 women intending to receive a postplacental IUD after cesarean birth were 17.3% and 11.2%, respectively; the 1-year probability of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a delayed postpartum IUD was 24.6%. For delayed postpartum IUD placement to have effectiveness equal to postplacental placement, 91.4% of women delivering vaginally and 99.7% of women delivering by cesarean would need to attend postpartum care. Once placed, the effectiveness of postplacental IUDs was lower than that of delayed postpartum IUDs: 1-year probabilities of pregnancy after IUD placement at a vaginal birth, cesarean birth, and an outpatient postpartum visit were 15.4%, 6.6%, and 3.9%, respectively.

CONCLUSION: After accounting for factors that affect successful IUD placement and retention, this decision model indicates that intended postplacental IUD insertion results in a lower 1-year probability of pregnancy as compared with intended delayed postpartum IUD insertion.

Decision analysis methodology indicates that intended postplacental intrauterine device insertion has higher effectiveness at 1 year than intended delayed postpartum intrauterine device insertion.

Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; the University of Miami Miller School of Medicine, Miami, Florida; and Einstein Medical Center, Philadelphia, Pennsylvania.

Corresponding author: Sarita Sonalkar, MD, MPH, University of Pennsylvania, Perelman School of Medicine, 1000 Courtyard, 3400 Spruce Street, Philadelphia, PA 19104; email: sarita.sonalkar@uphs.upenn.edu.

This study was funded in part by Women's Reproductive Health Research award (Sonalkar): K12-HD001265-18 and a Society of Family Planning Research Fund Midcareer Mentor Award (Schreiber).

Financial Disclosure Dr. Schreiber receives research funding from Medicines360, ContraMed, Bayer Pharmaceuticals, and the National Institutes of Health and has served as a consultant for Bayer Pharmaceuticals. The other authors did not report any potential conflicts of interest.

Presented at the American College of Obstetricians and Gynecologists' Annual Clinical and Scientific Meeting, April 27–30, 2018, Austin, Texas.

Peer review history is available at http://links.lww.com/AOG/B160.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received June 08, 2018

Accepted August 16, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.