The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial

Abstract

Background Depot medroxyprogesterone acetate (DMPA) is the most commonly used hormonal contraceptive method in South Africa. It is frequently administered in the immediate postnatal period, yet it is unclear whether it affects the risk of postnatal depression (PND). Aim To determine whether DMPA increases the risk of PND compared with the coppercontaining intrauterine device (IUD) when administered after delivery. Design and setting A single-blind randomised controlled trial conducted at two teaching hospitals in East London, South Africa. Methods Eligible, consenting women (N=242) requiring postnatal contraception were randomised to receive DMPA or an IUD within 48 hours of childbirth and interviewed at 1 and 3 months postpartum. Depression was measured using the Beck Depression Inventory (BDI-II) and the Edinburgh Postnatal Depression Scale (EPDS). Resumption of sexual intercourse, menstrual symptoms and breastfeeding rates were also assessed. Results One-month EPDS depression scores were statistically significantly higher in the DMPA arm compared with IUD arm ( p=0.04). Three-month BDI-II scores were significantly higher in the DMPA arm than in the IUD arm ( p=0.002) and, according to the BDI-II but not the EPDS, more women in the DMPA arm had major depression at this time-point (8 vs 2; p=0.05). There were no statistically significant differences in other outcome measures except that fewer women had resumed sexual activity by 1 month postpartum in the DMPA arm (13% vs 26%; p=0.02). Conclusions The possibility that immediate postnatal DMPA use is associated with depression cannot be excluded. These findings justify further research with longer follow-up. Clinical trial number PACTR201209000 419241.

Psychological, behavioural and physiological effects of three long-acting reversible contraception (LARC) methods: protocol for an ancillary study of the ECHO randomised trial

“… 2 3 These studies conducted by our South African research unit include a randomised double-blind, placebo controlled trial (RCT) of injectable norethisterone (NET-EN) versus placebo 2 and a single-blind randomised trial of DMPA versus the IUD. 3 Dysmenorrhea and heavy periods were reported more frequently among women in the IUD arm of the latter study; however, this effect did not reach statistical significance. Another randomised trial conducted in our unit among women who had recently undergone termination of pregnancy found that more women in the injectable progestogen group had reduced libido and were more likely to use condoms than women in the IUD arm.…”

“…While immune suppression and hypo-oestrogenic effects are thought to contribute to an increased risk of HIV acquisition among women using DMPA, it has been countered that this injectable method could also have protective effects for HIV acquisition due to associated amenorrhoea. 5 Reduced libido with injectable progestogens shown in two previous RCTs 3 4 might also mitigate the potential to increase HIV acquisition risk. Thus, the summary effect of psychological, behavioural and physiological mechanisms associated with effects of DMPA (and other LARCs) on HIV acquisition cannot be predicted without further research on non-contraceptive effects.…”

“…Another randomised trial conducted in our unit among women who had recently undergone termination of pregnancy found that more women in the injectable progestogen group had reduced libido and were more likely to use condoms than women in the IUD arm. 4 Reduced menstrual flow and amenorrhoea were effects seen more commonly in the injectable progestogen arms of the progestogen versus IUD studies, 3 4 whereas substantially more ‘troublesome bleeding’ occurred in the progestogen arm of the NET-EN versus placebo study in postnatal women. 2 …”

Postnatal contraception discontinuation: different methods, same problem

“…Following publication of our trial on the effects of postnatal depot medroxyprogesterone acetate (DMPA) compared with the copper intrauterine device (IUD) on postnatal depression in this journal in July 2016,1 we have sought to evaluate contraceptive discontinuation in our study sample. Postnatal contraception is promoted as part of the WHO strategy to reduce the unmet need for family planning in low- and middle-income countries (LMICs) and to reduce preventable maternal and child mortality 2.…”

Commentary on ‘The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised clinical trial’

“…In their J Fam Plann Reprod Health Care paper, Singata-Madliki et al 3. provide evidence that immediate administration of DMPA to postpartum mothers may put them at greater risk of depressive symptoms than using other long-acting forms of birth control.…”