An umbrella review of nine systematic reviews, yielding 92 comparisons, examined immediate versus delayed insertion of long-acting reversible contraception after delivery and after abortion.
Immediate insertion produced higher initiation, higher six-month utilisation and fewer six-month pregnancies — a risk ratio of 0.16 with an interval from 0.04 to 0.71, rated moderate certainty. The postabortion findings were similar.
The cost is expulsion. Immediate intrauterine device insertion raised expulsion risk with a risk ratio of 5.09 (interval 2.04 to 12.73) in the vaginal delivery subgroup — high-certainty evidence, the strongest rating in the review — and 2.02 after first-trimester medical abortion, at moderate certainty.
This is a genuine trade rather than a close call, and which side wins depends on whether the woman will return. Where postpartum follow-up is reliable, delayed insertion avoids a fivefold expulsion risk. Where it is not — and a large share of postpartum contraception is never started because the visit does not happen — a device that may be expelled still outperforms one that is never inserted. The review's own framing, that immediate insertion was more effective at preventing unintended pregnancy, reflects that.
- Fewer six-month pregnancies with immediate insertion, moderate certainty
- Fivefold expulsion risk after vaginal delivery, high certainty — the firmest finding
- The decision turns on the likelihood of a follow-up visit actually happening
- Counselling must include the expulsion risk and how to check for it
- Abortion method affects the trade; the evidence there is low certainty
The statistics, in plain English
Note that the expulsion finding carries high-certainty evidence while the pregnancy-prevention finding carries moderate. The pregnancy risk ratio of 0.16 also has a very wide interval, 0.04 to 0.71, reflecting few events. So the harm is better established than the benefit — which does not mean the harm outweighs it, only that the two estimates are not equally firm.
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