Design: Umbrella review of 9 systematic reviews, AMSTAR-2 and GRADE
Population: Postpartum and postabortion women having LARC
Primary outcome: Pregnancy, LARC use and IUD expulsion, immediate vs delayed insertion
Effect: Postpartum 6-month pregnancy RR 0.16 (0.04-0.71); expulsion after vaginal birth RR 5.09 (2.04-12.73)

An umbrella review pooled nine systematic reviews comparing immediate with delayed long-acting reversible contraception (LARC) after delivery or abortion, grading certainty with GRADE.

After delivery, immediate insertion led to higher LARC initiation and use at six months and fewer pregnancies by six months (RR 0.16, 95% CI 0.04-0.71; moderate certainty). The trade-off was intrauterine device expulsion, which was about five times more likely after vaginal birth (RR 5.09, 2.04-12.73; high certainty). After first-trimester medical abortion, expulsion roughly doubled (RR 2.02, 1.37-2.98).

Many women do not return for a delayed insertion, which is why the immediate approach prevents more pregnancies despite more expulsions.

The practical answer is to offer immediate insertion, explain the expulsion risk, and arrange a check.

Offer LARC before discharge after delivery or abortion rather than deferring to the six-week visit.
Tell women having an IUD after vaginal birth that expulsion is more likely and how to check threads.
Book a string check or ultrasound follow-up and give interim contraception advice.
An implant avoids the expulsion problem entirely and is worth offering alongside the IUD.

Why it matters

Waiting for a postnatal appointment loses women who never come back; the higher expulsion rate is a counselling point, not a reason to delay.

The statistics, in plain English

A relative risk of 0.16 for pregnancy means about an 84% reduction, but the wide confidence interval (0.04 to 0.71) shows the size is uncertain even if the direction is clear. The expulsion estimate is high certainty, so it can be quoted with confidence.