Postpartum contraceptive choice after high-risk pregnancy: a retrospective cohort analysis

To evaluate the effect of high-risk pregnancy status on antepartum contraceptive planning and postpartum use.

We performed a retrospective cohort study of women delivering at a university hospital during 2009-2010 who received prenatal care in the faculty or resident clinics. We defined high-risk status by Society for Maternal-Fetal Medicine guidelines. We abstracted contraceptive planning and postpartum administration from medical records and categorized these into World Health Organization tiers of contraceptive effectiveness. We identified subsequent pregnancies through March 2013. Chi-squared tests and binary logistic regression were used to assess correlations between risk status and contraceptive choice, actual postpartum use, and subsequent pregnancy.

This study included 2048 low-risk and 1015 high-risk parturients. The index pregnancy was more likely to be unintended among low-risk than high-risk women (48.4% vs. 42.9%, p=.02). Low-risk and high-risk women showed interest in Tier 1 contraceptives while antepartum (54.4% low-risk vs. 58.0% high-risk, p=.2), with lower interest at discharge (42.3% vs. 50.7%, p<.001) and at the postpartum visit (33.8% vs. 40.1%, p=.002). Just 776 women (25.3%) actually received a Tier 1 method. 656 women (21.4%) had a subsequent pregnancy lasting more than 20weeks. Unintended pregnancy rates did not differ between low (36.6%) and high-risk (32.4%) women (p=.38).

High-risk women had similar rates of planning for Tier 1 contraceptives but similar rates of subsequent unplanned pregnancy. Intention to use highly effective contraception did not translate into actual use. Further work is needed to identify barriers to uptake.

Identification of barriers to uptake of highly effective contraceptive methods after high-risk pregnancy represents an important area for future research. Providers should continue to address postpartum contraception throughout pregnancy and be prepared to address barriers to such methods in the postpartum period.