Implementing Immediate Postpartum Long-Acting Reversible Contraception Programs

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We read with great interest the recent article by Hofler et al1 regarding implementing immediate postpartum long-acting reversible contraception (LARC). We agree that immediate postpartum LARC programs can positively affect public health and that overcoming educational barriers can take a significant amount of effort.
Although lactation consultants were mentioned superficially in the evaluation of immediate postpartum LARC implementation, we believe there was an underestimation of the profession's objection to immediate postpartum LARC. Consequently, the authors overlook a critical barrier to program success.
The Academy of Breastfeeding Medicine lists a theoretical adverse effect on milk supply for the etonogestrel implant and a statement warning that levonorgestrel intrauterine devices placed immediately postpartum may be associated with shorter duration of breastfeeding in its protocol on Contraception During Breastfeeding.2 In a review of lactation consultants' knowledge of contraception,3 93% felt that the etonogestrel implant's risk to breastfeeding was “an unacceptable health risk.” Even the American College of Obstetricians and Gynecologists' Committee Opinion on this subject4 recommends counseling women on the theoretical risk of reduced breastfeeding duration despite literature demonstrating noninferiority of a progesterone-containing method.
Lactation consultants are an invaluable part of postpartum care and are trusted caregivers. When they recommend against LARC, patients listen—and decline contraception. Because the researchers talked to only two lactation consultants and reported no specific results from this group, we worry that their recommendations for implementation may be incomplete.
In our experience, these concerns may be addressed with early and frequent involvement of lactation consultants in implementation planning and an agreement on a unified message incorporating both breastfeeding and contraception.

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