Fleming: Let’s be proactive, not political, about postpartum contraception

The grandstanding and speculation countering House Bill 1426 ignores the facts. While the bill mandates that a subdermal implant must be part of a conversation, doctors, midwives, and advanced practice nurses can offer and provide ALL forms of contraception in the immediate postpartum period (the time from delivery to discharge after birth). This includes pills, patches, and long-acting reversible contraceptives(LARCs) – intrauterine devices (IUDs) and implants. Remember, this bill applies ONLY to this critical period of time, especially important because about 30% of women do not return for any follow up after discharge.

Come with me to labor and delivery at a university hospital. A patient, who developed chorioamnionitis (an infection during labor), finally delivers after a long labor and wants a LARC. When she learns that 15% of IUDs placed now will fall out (after all, the cervix is gaping open), she opts for a subdermal implant. I'd be hesitant to place an IUD in an infected uterus anyway.

Now visit the postpartum unit, where I will offer all the above methods to new mothers. I especially try to engage those who haven't had care during pregnancy, as they are unlikely to seek care after discharge. When a patient decides on an implant, she rolls up her sleeve, I inject a local anesthetic into her upper arm, and place the device. It takes 5 minutes. Were she to decide on an IUD, I have to find a treatment room (beds in the postpartum unit don't “break down” — there aren't stirrups or leg supports). I have to find a nurse as an escort. I need to get the equipment — a speculum, tenaculum, uterine measuring device, ring forceps, and some cleaning solution. It's easier to perforate the uterus during the postpartum period, so I might need an ultrasound to make sure the IUD is in the right location. This can easily take up to two hours—really impractical on a busy unit.

I suspect that those who indignantly testified against this bill have never worked in a postpartum unit. When did the pulmonologist last counsel a woman in the grip of a drug addiction about contraception, or a 17-year-old mother about the health consequences of a second pregnancy next year? What's worse is the lack of support from those who know better. The opposition from representatives from the American College of Obstetricians and Gynecologists and the “neutral” stance from the Indiana State Medical Association baffles me. It's on your watch, for the past decades, that maternal and infant mortality has climbed, that more children are born addicted, that sexually transmitted diseases are affecting newborns in record numbers. Whatever you might be doing about those, it's obviously not working.

Half of the pregnancies in Indiana are unintended. More than half of all pregnancies will be covered by Medicaid next year. The health, workforce, and financial consequences are staggering. This bill just might help.