Abstract

BACKGROUND: Initiating a progestin-based contraceptive prior to the drop in progesterone required to start lactogenesis stage II (LII) could theoretically impact lactation. Previous studies have shown that initiating progestin-based contraception in the postnatal period prior to birth-hospitalization discharge has no detriment on breastfeeding initiation or continuation compared to interval initiation as an outpatient; however, there is currently no breastfeeding data on the impact of initiating the etonogestrel contraceptive implant (ETG-implant) in the early postnatal period immediately in the delivery room.OBJECTIVE: This study examined the effect of delivery room vs delayed birth-hospitalization contraceptive ETG-implant insertion on breastfeeding outcomes.STUDY DESIGN: This is a non-inferiority randomized controlled trial to determine if time to LII (initiation of copious milk secretion) differs by timing of ETG-implant insertion during the birth-hospitalization. We randomly assigned pregnant people to insertion at 0-2 hours (delivery room) versus 24-48 hours (delayed) post-delivery. Participants intended to breastfeed, desired a contraceptive implant for postpartum contraception, were fluent in English or Spanish, and without an allergy or contraindication to the ETG-implant. We collected demographic information and breastfeeding intentions at enrollment. Onset of LII was assessed daily using a validated tool. The non-inferiority margin for the mean difference in time to LII was defined as 12 hours in a per-protocol analysis. Additional electronic surveys collected data on breastfeeding and contraceptive continuation at 2 and 4 weeks, 3, 6, and 12 months.RESULTS: We enrolled and randomized 95 participants; 77 participants were included in the modified intention-to-treat analysis (n=38 in the delivery room group and n=39 in the delayed group) after excluding eighteen due to withdrawing consent, changing contraceptive or breastfeeding plans, or failing to provide primary outcome data. 69 participants are included in the as-treated analysis (n=35 delivery room, n=34 delayed); 8 participants who received the ETG-implant outside the protocol windows were excluded and 2 participants from the delivery room group received the ETG-implant at 24-48 hours and were analyzed with the delayed group. Participants were similar between groups in age, gestational age, prior breastfeeding experience. Delivery room insertion was non-inferior to delayed birth-hospitalization insertion in time to LII (delivery room: [mean+standard deviation] 65+25 hours; delayed: 73+61 hours, mean difference -9 hours, 95% confidence interval [CI] -27, 10). Onset of LII by postpartum day 3 was not significantly different between groups. Lactation failure occurred in 5.5% (n=2) participants in the delayed group. Ongoing breastfeeding rates did not differ between groups with decreasing rates of any/exclusive breastfeeding over the first postpartum year. Most people continued to use the implant at 12 months, which did not differ by group.CONCLUSION: Delivery room insertion of the contraceptive ETG-implant does not delay onset of lactogenesis when compared to initiation later in the birth-hospitalization and therefore should be offered routinely as part of person-centered postpartum contraceptive counseling regardless of breastfeeding intentions.

View details for DOI 10.1016/j.ajog.2022.08.012

View details for PubMedID 35964661