Postpartum Intrauterine Device Services Research Articles

Perspectives of obstetricians and midwives on the provision of immediate postpartum intrauterine devices: a qualitative service evaluation

BackgroundImmediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited....

The effect of antenatal counseling and intrauterine device insertion services on postpartum contraceptive use in Nepal: Results from a stepped-wedge randomized controlled trial

ObjectiveThere is high unmet need for family planning in the postpartum period in Nepal. The current study assessed the effects of a contraceptive counseling and postpartum intrauterine device (PPIUD) insertion intervention on use of contraception in the postpartum period. Study designWe utilized a cluster, stepped-wedge design to randomly assign two hospital clusters (compromised of six hospitals) to begin the intervention at time one or time two. From 2015 to 2017, women completed surveys after delivery but before discharge (n = 75,893), and then at one year and two years postpartum. We estimated the intent-to-treat effect of the intervention using weighted, linear probability models and the adherence-adjusted effect (antenatal counseling) using an instrumental variable approach. Outcomes included modern contraceptive use and method mix measured at one and two years postpartum in a sample of 19,298 women (year I follow-up sample) and a sample of 19,248 women (year II follow-up sample). We used inverse probability weights to adjust for incomplete follow-up and bootstrap methods to give correct causal inference with the small number of six clusters. ResultsThe intervention increased use of modern contraceptives by 3.8 percentage points [95% CI: −0.1, 9.5] at one-year postpartum, but only 0.3 percentage points [95% CI: −3.7, 4.1] at two years. The intervention significantly increased the use of PPIUDs at one year and two years postpartum, but there was less use of sterilization. Only 42% of women were counseled during the intervention period. The adherence-adjusted effects (antenatal counseling) were four times larger than the intent-to-treat effects. ConclusionsProviding counseling during the antenatal period and PPIUD services in hospitals increased use of PPIUDs in the one- and two-year postpartum period and shifted the contraceptive method mix. ImplicationsIn order for antenatal counseling to increase postpartum contraceptive use, counseling may need to be provided in a wider range of prenatal care settings and at multiple time points. Healthcare providers should be trained on contraceptive counseling and PPIUD insertion, with the goal of expanding the available method mix and meeting postpartum women’s contraceptive needs.

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.

Implementation of postpartum intrauterine device (PPIUD) services across 10 districts in Malawi.

Malawi has a high maternal mortality and unmet need for family planning, which could be reduced by improving access to postpartum intrauterine device (PPIUD) insertion. Our objective is to describe the implementation of PPIUD services by 4 local organizations at 14 government health services across 10 districts in Malawi. This program was a collaborative effort between the Malawi Ministry of Health's Reproductive Health Directorate and 4 supporting organizations. Training, educational, and monitoring and evaluation materials for PPIUD insertion were developed between December 2013 and April 2014. Each organization was then responsible for PPIUD community sensitization, provider training, and tracking of PPIUD insertions (via PPIUD register books) at their targeted health facilities. Community sensitization activities included Open Day campaigns, which were organized by local leaders to sensitize their communities, and Population Weekends, which were organized by religious leaders to target their congregations. Community sensitization activities, provider trainings, and mentoring occurred from January 2014 to June 2015, and monitoring and evaluation continued until December 2016 at some sites. One national Radio Discussion Panel with religious leaders was broadcast, 20 Open Day campaigns and 2 Population Weekends were held, 429 providers were trained during 27 trainings, and 249 PPIUD insertions occurred. PPIUD can be safely offered in Malawi. However, the biggest challenge with program implementation was with encouraging providers to take the extra time and effort to insert an IUD within 48 hours of delivery. In addition, frequent rotation of trained labour ward staff to other clinical areas hindered the program's sustainability since new trainings had to be held whenever staff members were rotated. Further research should be done to determine the best strategies to motivate busy providers to insert PPIUD, and PPIUD should be integrated into both medical and nursing curriculums to reduce the number of postgraduate trainings required to sustain PPIUD services.

Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship.

To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD). In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in-depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories. The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on-the-job training (OJT) was more effective than group-based training (GBT). Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long-term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers.

Evaluation of a multi-level intervention to improve post-partum intrauterine device services in Rwanda

Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used post-partum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention targeting supply, demand, and sustainability to increase uptake of the post-partum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of promotions and service delivery. Formative work informed development of a PPIUD promotional flipchart delivered in-clinic (during antenatal care, labor and delivery, or infant vaccination visits) or in the community. Two-day PPIUD didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two health centers were selected. In the 6-months prior to our intervention, only one nurse and one midwife from each hospital were providing PPIUD services, and just 46 PPIUDs had been placed at the selected health facilities. From August 2017-July 2018, we trained 83 promotional agents and 39 providers to provide PPIUD services. N=9,073 women received PPIUD promotions who later delivered at a selected health facility, and of those n=2,633 had PPIUDs inserted (29% uptake). Most PPIUDs (60%) were inserted within 10 minutes of delivery of the placenta, with an additional 13% intra-cesarean, 17% between 10 minutes and 48 hours after delivery, and 8% between 4 and 6 weeks after delivery. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.

Institutionalizing postpartum intrauterine device (IUD) services in Sri Lanka, Tanzania, and Nepal: study protocol for a cluster-randomized stepped-wedge trial.

BackgroundDuring the year following the birth of a child, 40% of women are estimated to have an unmet need for contraception. The copper IUD provides safe, effective, convenient, and long-term contraceptive protection that does not interfere with breastfeeding during the postpartum period. Postpartum IUD (PPIUD) insertion should be performed by a trained provider in the early postpartum period to reduce expulsion rates and complications, but these services are not widely available. The International Federation of Obstetricians and Gynecologists (FIGO) will implement an intervention that aims to institutionalize PPIUD training as a regular part of the OB/GYN training program and to integrate it as part of the standard practice at the time of delivery in intervention hospitals.MethodsThis trial uses a cluster-randomized stepped wedge design to assess the causal effect of the FIGO intervention on the uptake and continued use of PPIUD and of the effect on subsequent pregnancy and birth. This trial also seeks to measure institutionalization of PPIUD services in study hospitals and diffusion of these services to other providers and health facilities. This study will also include a nested mixed-methods performance evaluation to describe intervention implementation.DiscussionThis study will provide critical evidence on the causal effects of hospital-based PPIUD provision on contraceptive choices and reproductive health outcomes, as well as on the feasibility, acceptability and longer run institutional impacts in three low- and middle-income countries.Trial registrationTrial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1160-0) contains supplementary material, which is available to authorized users.

Increasing Use of Postpartum Family Planning and the Postpartum IUD: Early Experiences in West and Central Africa.

A global resurgence of interest in the intrauterine device (IUD) as an effective long-acting reversible contraceptive and in improving access to a wide range of contraceptive methods, as well as an emphasis on encouraging women to give birth in health care facilities, has led programs to introduce postpartum IUD (PPIUD) services into postpartum family planning (PPFP) programs. We describe strategic, organizational, and technical elements that contributed to early successes of a regional initiative in West and Central Africa to train antenatal, maternity, and postnatal care providers in PPFP counseling for the full range of available methods and in PPIUD service delivery. In November 2013, the initiative provided competency-based training in Guinea for providers from the main public teaching hospital in 5 selected countries (Benin, Chad, Côte d'Ivoire, Niger, and Senegal) with no prior PPFP counseling or PPIUD capacity. The training was followed by a transfer-of-learning visit and monitoring to support the trained providers. One additional country, Togo, replicated the initiative's model in 2014. Although nascent, this initiative has introduced high-quality PPFP and PPIUD services to the region, where less than 1% of married women of reproductive age use the IUD. In total, 21 providers were trained in PPFP counseling, 18 of whom were also trained in PPIUD insertion. From 2014 to 2015, more than 15,000 women were counseled about PPFP, and 2,269 women chose and received the PPIUD in Benin, Côte d'Ivoire, Niger, Senegal, and Togo. (Introduction of PPIUD services in Chad has been delayed.) South-South collaboration has been central to the initiative's accomplishments: Guinea's clinical centers of excellence and qualified trainers provided a culturally resonant example of a PPFP/PPIUD program, and trainings are creating a network of regional trainers to facilitate expansion. Two of the selected countries (Benin and Niger) have expanded their PPFP/PPUID training programs to additional sites. Inspired after learning about the initiative at a regional meeting, Togo has outperformed the original countries involved in the initiative by training more providers than the other countries. Challenges to scale-up include a lack of formal channels for reporting PPFP and PPIUD service delivery outcomes, inconsistent coordination of services across the reproductive health continuum of care, and slow uptake in some countries. Continued success will rely on careful recordkeeping, regular monitoring and feedback, and strategic data use to advocate scale-up.

Attitude of Reproductive Healthcare Providers to the Post-Partum Intrauterine Device (PPIUD) in Jos, Nigeria

Context: The knowledge, attitude and practice of the post partum IUD among staff in the obstetrics and gynaecological unit of the Jos University Teaching Hospital has been in doubt all along. Clients were not forth coming for this method of contraception despite the fact that it was readily available in the facility. Objective: To assess the knowledge, attitude and practice of the post partum IUD among the clinical staff of the obstetric and gynaecological unit of the Jos University Teaching Hospital, Jos Plateau State. Method: A semi-structured self-administered questionnaire was developed and administered to a sample of randomly selected health providers working in the Obstetrics and Gynaecology department of the Jos University Teaching Hospital. Of the 200 questionnaires that were distributed, 166 were completed and returned giving a response rate of 83%. All the returned questionnaires were analyzed. Results: The highest number of responders was within the 31-40 year age-group, and 59.6% were females. About 95% had heard about intrauterine devices, 30% had had a formal training in family planning, but none of them had had training in offering PPIUD services. Up to 60% thought that the IUD could be inserted at any time within 6 weeks of delivery. Most (67.5%) of the responders were not willing to recommend the use of PPIUD to anyone for contraception. The commonest reason for not recommending the method was that the complications were more that those inserted as interval procedures, followed by high fall out rate of the IUD. The practice of the method among the respondents was absent, as none of them had actually performed the procedure. Conclusion: There is need for proper education of the health workers themselves about the PPIUD and its benefits to our women especially at the various points of contact with both the obstetric and gynaecological services. This, we believe, would positively influence the attitude and subsequent practice of the method by the majority of the respondents who were clinicians. Key Words: Knowledge, Attitude, Practice, Postpartum Intrauterine Device (PPIUD) [Trop J Obstet Gynaecol, 2004 21:91-94]