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OBJECTIVE: To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018. METHODS OF STUDY SELECTION: We searched databases for any published studies that examined post-partum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model. TABULATION, INTEGRATION, AND RESULTS: We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31–13.51; adjusted RR 6.17, 95% CI 3.19–11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85–6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50–2.43) compared with CuT380A. CONCLUSION: Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

OBJECTIVE: To examine contraceptive use among women with selected medical conditions. METHODS: We used a nationwide health care claims database to identify women aged 15-44 years continuously enrolled in private insurance during 2004-2011 with and without selected medical conditions. We assessed current permanent and reversible prescription contraceptive use during October 1 2010 to September 30 2011 with diagnosis procedure and pharmacy codes and calculated prevalence by age and condition. We used polytomous logistic regression to calculate odds of female sterilization or reversible prescription methods compared with neither. Among users of reversible methods we used logistic regression to calculate odds of using long-acting reversible contraceptives compared with shorter acting methods. RESULTS: A low proportion of women with medical conditions were using sterilization or reversible prescription methods (45% and 30% of women aged 15-34 and 35-44 years respectively) and this proportion was consistently lower among the older age group across all medical conditions. Across both age groups sterilization and long-acting reversible contraceptives were used less frequently than shorter acting methods (injectable pill patch or ring). The odds of sterilization were higher among women with any compared with no condition for women aged 15-34 years (odds ratio [OR] 4.9 95% confidence interval [CI] 4.5-5.3) and 35-44 years (OR 1.2 95% CI 1.1-1.2). Among women using reversible prescription methods the odds of using long-acting reversible contraceptives were increased among those with any compared with no condition for women aged 15-34 years (OR 2.2 95% CI 2.1-2.5) and 35-44 years (OR 1.1 95% CI 1.1-1.2). CONCLUSION: Despite the potential for serious maternal and fetal pregnancy-associated risks contraceptive use was not optimal among women with medical conditions. LEVEL OF EVIDENCE: III.

OBJECTIVE: To calculate incidence of postpartum venous thromboembolism by week after delivery and to examine potential risk factors for venous thromboembolism overall and at different times during the postpartum period. METHODS: A deidentified health care claims information database from employers, health plans, hospitals, and Medicaid programs across the United States was used to identify delivery hospitalizations among women aged 15–44 years during the years 2005–2011. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes were used to identify instances of venous thromboembolism and associated characteristics and conditions among women with recent delivery. Incidence proportions of venous thromboembolism by week postpartum through week 12 were calculated per 10,000 deliveries. Logistic regression was used to calculate odds ratios for selected risk factors among women with postpartum venous thromboembolism and among women with venous thromboembolism during the early or later postpartum periods. RESULTS: The incidence proportion of postpartum venous thromboembolism was highest during the first 3 weeks after delivery, dropping from nine per 10,000 during the first week to one per 10,000 at 4 weeks after delivery and decreasing steadily through the 12th week. Certain obstetric procedures and complications such as cesarean delivery, preeclampsia, hemorrhage, and postpartum infection conferred an increased risk for venous thromboembolism (odds ratios ranging from 1.3 to 6.4), which persisted over the 12-week period compared with women without these risk factors. CONCLUSION: Risk for postpartum venous thromboembolism is highest during the first 3 weeks after delivery. Women with obstetric complications are at highest risk for postpartum venous thromboembolism, and this risk remains elevated throughout the first 12 weeks after delivery.

OBJECTIVE: Health care providers should assess pregnancy in women seeking contraceptive services. Although urine pregnancy tests are available in most U.S. settings their accuracy varies based on timing relative to missed menses recent intercourse or recent pregnancy. We examined the performance of a checklist based on criteria recommended in family planning guidance documents to assist health care providers in assessing pregnancy in a sample of U.S. teenagers and young women. METHODS: Study participants were a convenience sample of sexually active black females aged 14-19 years seeking care in an urban family planning clinic. Each participant provided a urine sample for pregnancy testing and was then administered the checklist in two formats audio computer-assisted self-interview and in-person interview. We estimated measures of the checklist performance compared with urine pregnancy test as the reference standard including negative predictive value sensitivity specificity and positive predictive value. RESULTS: Of 350 participants 31 (8.9%) had a positive urine pregnancy test. The audio computer-assisted self-interview checklist indicated pregnancy was unlikely for 250 participants of whom 241 had a negative urine pregnancy test (negative predictive value=96.4%). The sensitivity of the audio computer-assisted self-interview checklist was 71% the specificity was 75.6% and the positive predictive value was 22%. The in-person checklist yielded similar results. CONCLUSION: The checklist may be a valuable tool to assist in assessing pregnancy in teenagers and young women. Appropriate use of the checklist by family planning providers in combination with discussion and clinically indicated use of urine pregnancy tests may reduce unnecessary barriers to contraception in this population.

To examine predictors of health care providers perceiving intrauterine devices (IUDs) as unsafe for nulliparous women and of infrequent provision of IUDs to nulliparous women.We analyzed questionnaire data obtained during December 2009 to March 2010 from 635 office-based providers (physicians) and 1,323 Title X clinic providers (physicians, physician assistants, certified nurse midwives, nurse practitioners, and nurses). Using multivariable logistic regression, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between patient, health care provider, and clinic and practice variables and provider misconceptions about the safety of IUDs for nulliparous women and with infrequent IUD provision.Approximately 30% of respondents had misconceptions about the safety of IUDs for nulliparous women. Factors associated with increased odds of misconceptions about the copper IUD and levonorgestrel-releasing IUD included: being an office-based family medicine physician (copper IUD adjusted OR 3.20, 95% CI 1.73-5.89; levonorgestrel-releasing IUD adjusted OR 2.03, 95% CI 1.10-3.76); not being trained in IUD insertion (copper IUD adjusted OR 4.72, 95% CI 2.32-9.61; levonorgestrel-releasing IUD adjusted OR 2.64, 95% CI 1.34-5.22); and nonavailability of IUDs on-site at their practice or clinic (copper IUD adjusted OR 2.18, 95% CI 1.20-3.95; levonorgestrel-releasing IUD adjusted OR 3.45, 95% CI 1.95-6.08). More than 60% of providers infrequently provided IUDs to nulliparous women. Nonavailability of IUDs on-site (copper IUD adjusted OR 1.78, 95% CI 1.01-3.14; levonorgestrel-releasing IUD adjusted OR 2.10, 95% CI 1.22-3.62) and provider misconceptions about safety (copper IUD adjusted OR 6.04, 95% CI 2.00-18.31; levonorgestrel-releasing IUD adjusted OR 6.91, 95% CI 3.01-15.85) were associated with infrequent IUD provision.Health care provider misconceptions about the safety of IUDs for nulliparous women are prevalent and are associated with infrequent provision. Improved health care provider education and IUD availability are needed to increase IUD use among nulliparous women.III.

Recommendations shaping policies, programs, and practices in global health should be based on the best available science, but how best to achieve this objective is less clear. We describe a new approach developed by the United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction within the World Health Organization Department of Reproductive Health and Research for addressing key challenges in global reproductive health. This approach leads to new recommendations for accelerating solutions to priority needs in the field and continued improvements in the science base-including the implementation science base-for meeting these needs. The key components of this new cycle for science-driven solutions include: 1) identifying priority needs of the field; 2) creating guidance that meets the needs of the field; 3) identifying research gaps and establishing and funding research priorities; 4) research synthesis and updating of the guidance in a timely fashion; and 5) supporting utilization in countries through systematic introduction of science-driven solutions. There is a synergistic effect when the contributions of the individual components of this cycle are linked. Strong institutional support is required for this collective effort, as is the creation of a team of researchers, practitioners, donors, and implementing agencies with shared responsibilities for its success. This new approach has already made important contributions toward addressing key challenges in family planning and maternal and perinatal health. We believe that it will help bridge the gap between knowledge and action for reproductive health and for global health more broadly.

To determine, from the literature, the risk of venous thromboembolism during the postpartum period.We searched PubMed and Cochrane Library databases for all articles (in all languages) published in peer-reviewed journals from database inception through May 2010 for evidence related to incidence of venous thromboembolism in postpartum women.We included studies reporting relative risk, incidence rate, or cumulative incidence of venous thromboembolism in postpartum women.We included 15 articles reporting findings from 13 studies. Two studies directly comparing venous thromboembolism during the first 6 weeks postpartum to nonpregnant, nonpostpartum women reported relative effect measures of 21.5 (rate ratio; 95% confidence interval [CI] unable to be calculated) and 84 (odds ratio; 95% CI 31.7-222.6), respectively. A third study reported relative effect measures for deep venous thrombosis (15.2, 95% CI 13.2-17.6; standardized incidence ratio) and pulmonary embolism (9.2, 95% CI 6.5-12.7) separately. Three studies reported incidence rates of venous thromboembolism during the postpartum period (range 25-99 per 10,000 woman-years). We compared these incidence rates to baseline rates among nonpregnant, nonpostpartum women reported in the literature to generate rate ratios; these rate ratios ranged from 2.5 to 21.5. Nine studies reported cumulative incidence proportions of postpartum venous thromboembolism, ranging from 0.14 to 3.24 per 1,000 deliveries at 6 weeks postpartum. Incidence of venous thromboembolism was highest immediately after delivery (standardized incidence ratio for deep venous thrombosis 115.1 [95% CI 96.4-137.0], and for pulmonary embolism 80.7 [95% CI 53.9-117.9]); between 4 and 6 weeks postpartum, risk declined but was still approximately five-times to seven-times that of nonpregnant, nonpostpartum women.During the first 6 weeks postpartum, women's risk of venous thromboembolism increased 21.5-fold to 84-fold from baseline in nonpregnant, nonpostpartum women in studies that included an internal reference group. Although incidence of venous thromboembolism declined quickly after delivery, when this risk returns to baseline is not clear from current data.

OBJECTIVE: To evaluate the evidence on the safety of contraceptive method use among women with systemic lupus erythematosus (SLE). DATA SOURCES: We searched the PubMed, MEDLINE, and LILACS databases for peer-reviewed articles published from database inception through January 2009, concerning the safety of contraceptive use among women with SLE. METHODS OF STUDY SELECTION: We included studies that examined health outcomes among women using a contraceptive method after the diagnosis of SLE. The quality of each individual piece of evidence was assessed using the U.S. Preventive Services Task Force grading system. TABULATION, INTEGRATION, AND RESULTS: Our search yielded 275 articles. A total of 14 articles that reported on 13 studies met our inclusion criteria. Available evidence, including two good-quality randomized controlled trials, indicates that use of combined oral contraceptives does not lead to increased flares of disease or worsening disease activity in women with inactive or stable active SLE. No increase in disease activity with use of progestogen-only contraceptives was noted in four studies. Limited evidence indicates a possible increased risk of thrombosis in women with positive antiphospholipid antibodies and history of oral contraceptive use. Limited evidence indicates that the use of the copper intrauterine device is not associated with worsening disease activity or infection in women with SLE. CONCLUSION: Available evidence indicates that many women with SLE can be considered good candidates for most contraceptive methods, including hormonal contraceptives. The benefits of contraception for many women with SLE likely outweigh the risks of unintended pregnancy in this population. Women with positive antiphospholipid antibodies are not good candidates for combined hormonal contraception given their elevated baseline risk of thrombosis.

OBJECTIVE: To review new evidence regarding ten controversial issues in the use of contraceptive methods among women with special conditions and to present World Health Organization recommendations derived in part from this evidence. DATA SOURCES: We searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to ten key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breast-feeding women, tubal sterilization among young women, hormonal contraception and intrauterine device use among women who are human immunodeficiency virus (HIV) positive, have AIDS, or are at high risk of HIV infection. Search terms included: “contraception,” “contraceptives, oral,” “progestational hormones,” “medroxyprogesterone-17 acetate,” “norethindrone,” “levonorgestrel,” “Norplant,” “contraceptives, postcoital,” “sterilization, tubal,” “intrauterine devices,” “hypertension,” “stroke,” “myocardial infarction,” “thrombosis,” “headache,” “migraine,” “adverse effects,” “bone mineral density,” “breast-feeding,” “lactation,” “age factors,” “regret,” and “HIV.” STUDY SELECTION: From 205 articles, we identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. TABULATION, INTEGRATION, AND RESULTS: Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to nonusers with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. CONCLUSION: Of ten contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly.