The Centers for Disease Control and Prevention reports that 50 percent of pregnancies are unintended. Those affected most are adolescents and young women, women who are of racial or ethnic minorities, and women with lower levels of education and income
Sheila Chhutani, M.D., OB/GYN and physician on the medical staff at Texas Health Dallas, said this statistic proves true locally and that many of her patients are somewhat ambivalent about becoming pregnant.
“Many of these women aren’t trying to become pregnant, but they aren’t using anything for birth control either,” she said. “Some of them think they can’t get pregnant for one reason or another, or they just didn’t mind whether they became pregnant or not. Once a woman is receiving prenatal care, however, we discuss plans for contraception after the baby is born.
“Whether we talk about permanent options like tying her tubes often depends on what number pregnancy it is and the mother’s age. A woman on her first or even second pregnancy may not want anything permanent done, but we discuss her choices during pregnancy and then after delivery as well.”
According to a study published in Obstetrics & Gynecology, non-lactating women may start ovulating again as soon as six weeks postpartum. And because this may occur before a woman’s period even returns, she is at risk for becoming pregnant again before she knows it’s possible. This is why coming up with a plan for postpartum birth control before giving birth is so important.
Chhutani explained that part of the problem is that women hold misconceptions about when it’s possible to get pregnant again after having a baby.
“The No. 1 thing women need to know is that if they aren’t breastfeeding, they can get pregnant six weeks after giving birth because ovulation starts again around that time,” she said. “That’s usually how much time off employers give you, so it’s important to come back into the office and talk about what kind of birth control you want to use.
“Another of the biggest misconceptions is that breastfeeding women can’t get pregnant, which just isn’t true. Women can’t rely on lactating amenorrhea because it all depends on how often you breastfeed, which fluctuates as the baby gets older and you go back to work.”
Options range from short-term contraceptives like barrier methods or hormonal birth control to permanent postpartum sterilization (tubal ligation). Another choice that is gaining in popularity is long-acting reversible contraception (LARC), which includes intrauterine devices (IUD) and birth control implants, which are as effective as sterilization but can be removed. The use of LARC has risen from 2.4 percent of women using contraception in 2002 to 11.6 percent in 2013.
Often the best choice for a woman will be determined based on whether she is breastfeeding or not.
“If you are breastfeeding, you can’t use the pill, ring or patch because the estrogen in them reduces your milk supply,” Chhutani explained. “In that case, IUDs, barrier methods or the progestin-only pill are your best options. I frequently push for IUDs whether it’s a woman’s first, second or third child, just because having a new baby brings on a whole new set of responsibilities. Sometimes taking a pill every day gets left by the wayside in the busyness of things, so IUDs are a great option because they are effective and can help space out pregnancies.”
According to the American College of Obstetricians and Gynecologists, LARC methods are 20 times more effective than birth control pills, the patch or the ring over the long term. Additionally, IUDs can be inserted immediately after childbirth, a miscarriage or an abortion, as well as while breastfeeding.
Texas is one of several states attempting to curb the number of unintended pregnancies for patients on Medicaid by paying hospitals to insert an IUD in the delivery room immediately postpartum. ACOG reports that postpartum insertion is often favorable because the hospital setting is convenient to both the patient and physician, and new moms are often highly motivated to use contraception.
While Chhutani said she and her colleagues haven’t started offering IUDs for patients on Medicaid immediately after delivery, the idea is on their radar.
“Right now we haven’t started this practice, but it’s definitely something we’ve talked about,” she said. “An IUD needs to be placed within 10 minutes after the placenta is delivered, but research shows that there is a 10 to 15 percent higher expulsion rate versus waiting six to eight weeks postpartum. As a result, we have to determine whether the benefits outweigh that risk.
“If we have a patient who showed up regularly to her prenatal appointments, she is more likely to come back and have the IUD placed several weeks after delivery. If a patient doesn’t have a steady history, perhaps we’d be more likely to put in an IUD immediately after delivery. Even with the higher potential failure rate, if we could prevent nine out of 10 pregnancies in that population, it’s worth it.”
Chhutani said that whatever a woman’s postpartum situation, it’s important to make a decision about birth control and stick with it until the situation changes.
“Long-term reversible contraception gives you options because you’re not closing that door and locking it forever like with a tubal,” she said. “I like to keep our options open, especially with younger patients who may have a larger window to have another baby, which also means more time for regret if they make a permanent decision.
“Both IUDs and tubals are 99 percent effective, but with the IUD, you can change your mind and then do something more permanent later. Sometimes women find themselves in a new relationship or in a different place in life. Those life changes happen and they realize they want to become pregnant again.”