Uptake Of Postpartum Intrauterine Device Research Articles

A mixed-methods study of factors influencing postpartum intrauterine device uptake after family planning counseling among women in Kigali, Rwanda.

Rwanda has high unmet need for family planning (FP), especially in the postpartum period when women are advised to space pregnancies at least two years for improved maternal-child health. Despite interest in the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low. This study aimed to determine factors associated with postpartum IUD (PPIUD) uptake after postpartum family planning (PPFP) counseling as well as provider perceptions of facilitators and barriers to clients' PPIUD uptake. Postpartum women who received PPFP counseling and were less than 6 weeks postpartum were recruited for a case-control study in Kigali, Rwanda in 2018. We recruited n = 74 women who had accepted and n = 91 women who had declined the PPIUD. Multivariate logistic regression analyses evaluated associations between women's socio-demographics, FP knowledge and decision-making, and the outcome of PPIUD uptake. Six focus groups (FGs) were conducted with FP providers (n = 24) and community health workers (n = 17) trained to deliver PPFP counseling to assess perceptions of PPFP counseling and facilitators and barriers to PPIUD uptake. FG discussions were recorded, translated, and analyzed for themes. Factors associated (P<0.1) with PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Exclusive male partner control over FP decisions (relative to women's control or joint decision-making) was associated with non-use. Overall, limited knowledge about some aspects of the PPIUD persisted among clients even after counseling. Provider FGs highlighted client concerns, inconsistent FP messaging, and lack of male partner involvement as factors influencing non-use. Knowledge of the IUD and its benefits was associated with PPIUD uptake. There is need to refine PPFP counseling messages to address remaining knowledge gaps and concerns. Additionally, male partner involvement in FP counseling and decisions with their partners could be a key strategy to increase both PPIUD and FP uptake in Rwanda.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal

Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Integrating postpartum contraceptive counseling and IUD insertion services into maternity care in Nepal: results from stepped-wedge randomized controlled trial

BackgroundIn Nepal, 54% of women have an unmet need for family planning within the 2 years following a birth. Provision of a long-acting and reversible contraceptive method at the time of birth in health facilities could improve access to postpartum family planning for women who want to space or limit their births. This paper examines the impact of an intervention that introduced postpartum contraceptive counseling in antenatal care and immediate postpartum intra-uterine device (PPIUD) insertion services following institutional delivery, with the intent to eventually integrate PPIUD counseling and insertion services as part of routine maternity care in Nepal.MethodsThis study took place in six large tertiary hospitals. All women who gave birth in these hospitals in the 18-month period between September 2015 and March 2017 were asked to participate. A total of 75,587 women (99.6% consent rate) gave consent to be interviewed while in postnatal ward after delivery and before discharge from hospital. We use a stepped-wedge cluster randomized design with randomization of the intervention timing at the hospital level. The baseline data collection began prior to the intervention in all hospitals and the intervention was introduced into the hospitals in two steps, with first group of three hospitals implementing the intervention 3 months after the baseline had begun, and second group of three hospitals implementing the intervention 9 months after the baseline had begun. We estimate the overall effect using a linear regression with a wild bootstrap to estimate valid standard errors given the cluster randomized design. We also estimate the effect of being counseled on PPIUD uptake.ResultsOur Intent-to-Treat analysis shows that being exposed to the intervention increased PPIUD counseling among women by 25 percentage points (pp) [95% CI: 14–40 pp], and PPIUD uptake by four percentage points [95% CI: 3–6 pp]. Our adherence-adjusted estimate shows that, on average, being counseled due to the intervention increased PPIUD uptake by about 17 percentage points [95% CI: 14–40 pp].ConclusionsThe intervention increased PPIUD counseling rates and PPIUD uptake among women in the six study hospitals. If counseling had covered all women in the sample, PPIUD uptake would have been higher. Our results suggest that providing high quality counseling and insertion services generates higher demand for PPIUD services and could reduce unmet need.Trial registrationTrial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222.

Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study

BackgroundThe use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal.MethodsThis qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework.ResultsThe themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women’s intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband’s preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions.ConclusionAs suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

An Exploratory Analysis of Factors Associated With Interest in Postpartum Intrauterine Device Uptake Among Pregnant Women and Couples in Kigali, Rwanda.

Background:The desire to space or prevent future pregnancies is high among postpartum women in Rwanda. However, the use of long-acting reversible contraception (LARC), especially the highly effective and cost-effective copper intrauterine device (IUD), is very low, whereas the rates of unintended pregnancy are high. This study aims to identify factors associated with pregnant women’s and couple’s interest in receiving a postpartum intrauterine device (PPIUD) within 6 weeks after delivery.Methods:A total of 150 pregnant women or couples attending antenatal care (ANC) in Kigali, Rwanda participated in this cross-sectional study. After participating in a postpartum LARC counseling session, surveys assessed participants’ demographics, pregnancy experiences and desires, and PPIUD knowledge, attitudes, practices, and interest. Multivariable logistic regression was used to model factors associated PPIUD interest within 6 weeks postpartum.Results:Although only 3% of women had ever used an IUD previously, 124 (83%) women were interested in receiving a PPIUD after counseling. Self-reporting physical side effects (adjusted odds ratio [aOR], 0.21; 95% confidence interval [CI], 0.06-0.75) and infection (aOR, 0.19; 95% CI, 0.04-0.85) as disadvantages to the IUD were significantly associated with no interest in receiving a PPIUD. Interest did not differ by male involvement.Conclusion:Recommendations to increase PPIUD uptake include educating pregnant women and couples about the method during ANC and addressing client myths and misconceptions about the IUD. This strategy allows pregnant women and couples to make informed decisions about their future contraception use, reduce unmet need for family planning, and reduce unintended pregnancy.

Helping Postpartum Women in Mali Achieve Their Fertility Intentions: Perspectives From Introduction of the Dedicated Postpartum IUD Inserter.

Mali has one of the highest maternal mortality ratios in the world coupled with one of the lowest modern contraceptive use rates. Nearly a quarter of the country's 750,000 annual births occur within 24 months of a previous birth, increasing the risks for mothers and babies. Nearly 70% of postpartum women have an unmet need for family planning. In 2016, Population Services International Mali (PSI-Mali) introduced a dedicated postpartum intrauterine device (PPIUD) inserter to replace the technique of using forceps for PPIUD insertion, with the aim of helping to address this substantial family planning gap. A mixed-methods approach was used to assess program results and the experiences of PSI-trained providers using the dedicated PPIUD inserter in 5 health facilities in Bamako. We conducted 10 key informant interviews with providers and 4 key informant interviews with operational and clinical staff involved in training and supporting providers. Further data were collected from district health surveys and facility registers. Secondary data encompassed documentation from 2011 through 2017, with the service delivery figures of PPIUD using the dedicated inserter focused on the pilot period of March 2016 through December 2017. Primary data were collected in Mali in July 2017. Between March 2016 and December 2017, PSI-Mali trained 134 providers on the dedicated PPIUD inserter and provided more than 3,500 voluntary PPIUDs. Of the 1,840 voluntary PPIUDs provided in 2017 alone, 67% were provided by facilities trained to use the dedicated PPIUD inserter. Providers stated a preference for the inserter (compared with the use of forceps) due to its ease, speed, and perceived lower associated risks of infection. Service data from the 5 facilities visited showed an overall average PPIUD uptake of 7.3% of deliveries in 2017. Although private facilities had considerably fewer deliveries than public facilities (600-900 compared with 20-30, respectively), a much higher proportion of women delivering in the private facilities chose a PPIUD. The acceptance of the dedicated PPIUD inserter by providers may help reduce some of the supply-side barriers that inhibit women's access to postpartum family planning methods. With continued support to providers, coupled with ongoing efforts to address differences in service trends between sectors and demand-side barriers to the PPIUD and family planning more broadly, the dedicated PPIUD inserter could play an important role in responding to the high unmet need among postpartum women in Mali.

Successful implementation of immediate postpartum intrauterine contraception services in Edinburgh and framework for wider dissemination.

Provision of immediate postpartum intrauterine device (PPIUD) insertion within maternity settings can overcome many of the barriers faced by women in accessing this method after childbirth. Uptake of PPIUD can help reduce the risk of a subsequent unintended pregnancy and improve spacing between births. PPIUD insertion is not yet routinely available in the UK and evidence to support the practical implementation of the service in this setting is lacking. Shared learning and experience of providers may assist in the wider availability of PPIUD. A routine PPIUD service has been successfully established within a public maternity setting in Edinburgh (UK) and this article utilizes an implementation framework to discuss the approach.