Postpartum Intrauterine Device Insertion Research Articles

Expanding access to postpartum contraception.

Women are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field. Current models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness. Antenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

The association of insertion methods on immediate postpartum intrauterine device expulsion rates: A retrospective cohort study

ObjectiveTo evaluate the method of immediate postpartum IUD (ppIUD) insertion (manual versus ring forceps) and expulsion rate within 6-week postpartum. Study designWe performed a retrospective cohort study of patients who had a singleton vaginal delivery and an immediate ppIUD inserted at Rush University from January 2014 to September 2023. The primary outcome was rate of expulsion within 6-week postpartum. We compared the rate of expulsion by method of insertion, either using a manual technique versus using ring forceps. We performed univariable analysis for the association between baseline maternal characteristics and the primary outcome and we performed multivariable logistic regression to determine the independent association of the method of insertion and the primary outcome. ResultsTwo hundred nineteen patients met eligibility with 117 immediate ppIUDs inserted manually and 102 inserted with ring forceps. Baseline maternal demographics were similar across study groups. After adjusting for factors selected a priori (estimated blood loss, body mass index, gestational age at delivery, nulliparity, type of IUD), use of ring forceps was more likely to result in expulsion compared to manual insertion (30.4% vs 16.2% respectively; adjusted OR 2.49, 95% confidence interval 1.28–4.90). ConclusionIn this retrospective analysis, insertion of immediate ppIUD with ring forceps was independently associated with an increased rate of expulsion within 6 weeks postpartum when compared to manual insertion. ImplicationsIn this setting, ring forceps was associated with high rates of immediate postpartum IUD expulsion compared to manual technique. Studies disagree, suggesting need for additional work.

Women's experiences with the post-placental intrauterine device: a qualitative study.

To explore women's experiences with postpartum intrauterine device (PPIUD) insertion and the decision-making process in the postpartum period. A qualitative design was employed with face-to-face interviews using a semi-structured script of open questions. The sample was intentionally selected using the concept of theoretical information saturation. Interviews were conducted (1) in the immediate postpartum period, and (2) in the postpartum appointment. 25 women (N = 25) over 18 years old who had a birth followed by PPIUD insertion were interviewed between October 2021 and June 2022. Three categories were constructed: (1) Choice process, (2) Relationship with the health team at the time of birth and the postpartum period, and (3) To know or not to know about contraception, that is the question. Professionals' communication management, popular knowledge, advantages of the PPIUD and the moment PPIUD is offered play a fundamental role in the construction of knowledge about the IUD. Choice process did not end in the insertion.

Postpartum intrauterine device (PPIUD) insertion: A single centre follow-up telephone survey assessing clinical outcomes and client perception

Introduction: Closely spaced pregnancies result in adverse maternal perinatal and infant outcomes. Postpartum Family Planning (PPFP) enables women to achieve healthy intervals between births, potentially averting maternal deaths and reducing child mortality. The PPIUD enables women to leave the birth facility with a safe, effective, long-acting, reversible method already in place.The aim of the study was to study clinical outcomes and client perceptions on follow-up after insertion of PPIUD from 2014 to 2019 at the Teaching Hospital, Mahamodara (THM), Galle, Sri Lanka.Results: A total of 46,815 deliveries were reported in the facility during the study period, and 470 (3.4%) PPIUD insertions were carried out. Only 67/470 (14.3%) women who had PPIUD responded to the survey. The median (IQR) duration of PPIUD in situ was 63 (39 - 76) months, and it was positively correlated with the satisfaction score (Spearman’s rho 0.29, p=0.02). Out of all, 58 (86.6%) women recommended PPIUD to a friend as a PPFP method. Median (IQR) satisfaction score for the PPIUD was 9.5 (5.5 - 9.5), and most women (65.7%) were satisfied with PPIUD. However, 19.4% of women responded as ‘Neutral’ to the questionnaire. There were no uterine perforations or ectopic pregnancies.Conclusions: The study shows that PPIUD is a good option as an effective contraceptive method before leaving the birth facility.

Knowledge, Attitude, and Practice of Brazilian Physicians about Immediate Postpartum and Postabortion Intrauterine Device Insertion.

To assess the knowledge, attitude, and practice of Brazilian physicians about immediate postpartum and postabortion intrauterine device insertion. Cross-sectional online survey involving physicians on duty in public Brazilian hospitals. Participants answered an anonymous questionnaire with close-ended questions to assess their knowledge, attitude, and experience on the immediate postpartum and postabortion insertion of copper intrauterine devices. One hundred twenty-seven physicians working in 23 hospitals in the 5 geographic regions of Brazil completed the questionnaire. Most were female (68.5%) and worked in teaching hospitals (95.3%). The mean (standard deviation) knowledge score (0-10 scale) was 5.3 (1.3); only 27.6% of the participants had overall scores ≥ 7.0. Most physicians (73.2%) would insert a postpartum intrauterine device in themselves/family members. About 42% of respondents stated that they had not received any training on postpartum or postabortion intrauterine device insertion. In the past 12 months, 19.7%, 22.8%, and 53.5% of respondents stated they had not inserted any intrauterine device during a cesarean section, immediately after a vaginal delivery, or after an abortion, respectively. Most study participants have a positive attitude toward the insertion of intrauterine devices in the immediate postpartum period, but they have limited knowledge about the use of this contraceptive method. A large percentage of respondents did not have previous training on postpartum and postabortion intrauterine device insertion and had not performed any such insertions in the last 12 months. Strategies are needed to improve the knowledge, training, and experience of Brazilian physicians on immediate postpartum and postabortion intrauterine device insertion.

Postpartum IUD insertion: Best practices

Postpartum IUD insertion: Best practices

What Is the Most Cost-Effective Timing for Postpartum IUD Insertion? [ID: 1379571

INTRODUCTION: Postpartum intrauterine device (IUD) insertion is an effective contraception choice for reducing rates of unplanned and short-interval pregnancies. However, timing of placement is controversial, and risk of perforation and expulsion vary with timing. We aim to analyze the cost-effectiveness of postpartum IUD insertion intervals when considering risk of perforation or expulsion. METHODS: A decision-analytic model compared four intervals of postpartum IUD insertion: between 0 and 3 days, 4 days and 6 weeks, 6 and 14 weeks, or 14 and 52 weeks postpartum. A theoretical cohort of 600,000 was calculated using the estimate that 15.3% of postpartum people receive a long-acting reversible contraceptive. Probabilities, costs, and utilities were procured from the literature. Primary outcomes included IUD-related uterine perforation, expulsion, unplanned short-interval pregnancy, termination, stillbirth, ectopic pregnancy, and preterm delivery. The cost-effectiveness threshold was $100,000/quality-adjusted life-year (QALY). RESULTS: IUD insertion between 6 and 14 weeks postpartum was the cost-effective strategy despite having 1,978 and 1,982 additional perforations in intervals between 0–3 days and 14–52 weeks, respectively. All other outcomes were reduced. When compared to the intervals of 0–3 days, 4 days–6 weeks, and 14–52 weeks postpartum, this strategy resulted in 3,054, 282, and 3,816 more QALYs and decreased costs by $91 million, $22 million, and $316 million, respectively. CONCLUSION: Intrauterine device insertion between 6 and 14 weeks postpartum is the cost-effective strategy despite increased risk of perforation. Appropriately counseling patients on the risks and benefits associated with timing of IUD insertion is an important component of postpartum care.

Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion

ABSTRACT Intrauterine device (IUD) expulsion is more common among women with heavy menstrual bleeding, parity, higher body mass index (BMI), younger age, dysmenorrhea, or immediate postabortion or postpartum insertion. The APEX-IUD study was an observational cohort study of 326,658 individuals examining the association with breastfeeding, IUD type, and timing of postpartum IUD insertion with IUD expulsion and uterine perforation. This data set provides an opportunity to examine specific demographic, reproductive, and medical risk factors associated with IUD expulsion. This analysis of APEX-IUD data aimed to determine the associations of 6 risk factors (age, race/ethnicity, parity, BMI, heavy menstrual bleeding, and dysmenorrhea) and IUD expulsion, as well as the extent to which these associations differed for LNG-IUD compared with copper IUD users. Individuals aged 50 years or younger at the time of IUD insertion without a delivery 52 weeks or less before insertion were included. Individuals were followed from IUD insertion until IUD expulsion, uterine perforation, removal, reinsertion, expiration, pregnancy, hysterectomy, death, disenrollment from the health care system, or end of study period (June 2018). Crude incidence rates for each risk factor category were calculated using the number of expulsions during the time at risk divided by the total person-years at risk and were reported as the number of expulsions per 1000 person-years at risk. Hazards ratios (HRs) and 95% confidence intervals from Cox regression models were used to evaluate associations of the risk factors with IUD expulsion. These models were adjusted for potential confounding effects and were separately used to assess the association of covariates with IUD expulsion varied by IUD type. The total study cohort included 228,834 individuals (LNG-IUD: 184,733 [80.7%]; copper IUD: 41,123 [18.0%]; unknown type: 2978 [1/3%]). The average length of follow-up was 2.0 years, and there were 6762 expulsions with a crude incidence rate of 14.9 per 1000 person-years (95% confidence interval, 14.6–15.3). Adjusted hazards ratios (aHRs) showed the younger age groups having a higher risk of IUD expulsion and a trend toward lower aHRs with increasing age. Individuals with parity of 4 or more had the highest risk of IUD expulsion, and a parity of 2 was associated with the lowest risk on adjusted analysis. Adjusted analysis revealed a greater risk of IUD expulsion among individuals with higher BMI or heavy menstrual bleeding diagnosis compared with the comparator group. Multiple racial and ethnic groups including non-Hispanic Black, Hispanic Black, Hispanic White, Asian, or Pacific Islander were associated with a greater risk of IUD expulsion compared with non-Hispanic Whites when adjusting for covariates. When comparing aHRs by copper IUD or LNG-IUD; younger age was more strongly associated with expulsion among copper IUD users than LNG-IUD users, the risk for expulsion associated with obesity was significantly attenuated for copper IUD users compared with LNG-IUD users, and the risk of expulsion for those with heavy menstrual bleeding was partially attenuated by copper IUDs. Adjusted analysis revealed no association between dysmenorrhea and IUD expulsion. The results of this study show that, among the 6 risk factors investigated here, the risk of IUD expulsion was highest among individuals with a diagnosis of heavy menstrual bleeding, particularly in recent and past periods.

Integrating postpartum IUD counselling and insertion into routine maternity care in Nepal: Assessing trends over time.

To meet the postpartum family planning (PPFP) needs of women in Nepal, an intervention was launched to integrate PPFP counselling and postpartum IUD (PPIUD) insertion into maternity care. Women delivering in study hospitals over a period of 18 months were interviewed at the time of delivery and at 15 months following the end of the study enrollment period to assess if the impact of the intervention observed at the end of the study was maintained. Data were collected prior to the intervention, at the middle month of the intervention roll out, at the end of the enrollment period and 15 months after the end of the enrollment period. We compared PPFP counselling and insertion rates before, during, at the end of and after the intervention study period, using cross-tabulation and chi-square tests. Overall, PPFP counselling rates increased from 11% at the baseline month to 45% at the end of the enrollment in February 2017 and remained the same 15 months later in July 2018. PPIUD uptake, however, rose from a negligible 0.1% at the baseline to 4.3% in February 2017, but declined to 3.4% in July 2018. PPIUD uptake among women who were counselled showed a similar trend, increasing from 1.9% at the baseline to 9.6% in February 2017 and declining to 6.0% in July 2018. The intervention had an appreciable continued impact on PPIUD counselling rates and although PPIUD uptake rose during the intervention, this trend was not observed in the 15 months post-study follow up. The impact of the intervention was greater and persistent in hospitals that had a longer period of exposure to intervention. The results suggest that counselling was well integrated with the maternity care, though uptake of PPIUD dropped after intervention activities such as active monitoring, technical supervision, provision of IUDs and training were withdrawn. Trial registration: This study has been registered with Clinical Trial.gov. The registration number is NCT02718222. Details about the study design have been published by Canning et al, 2016.

Effectiveness, safety, and acceptability of postplacental insertion of GyneFix postpartum intrauterine device among women undergoing cesarean section: A multicenter prospective cohort study in China

ObjectivesTo assess the effectiveness, safety, and acceptability of postplacental insertion of GyneFix postpartum intrauterine device (PPIUD) in women undergoing cesarean section (C-section). Study designWe conducted a prospective cohort study at 14 hospitals in four eastern coastal provinces of China between September 2017 and November 2020. A total of 470 women who underwent C-section and consented to the postplacental insertion of GyneFix PPIUD were enrolled, and 400 completed the 12-month follow-up. Participants were interviewed in the wards after delivery and followed up at 42 days, and months 3, 6, and 12 after delivery. We used Pearl Index (PI) to measure the rate of contraceptive failure, life-table method to measure the rate of PPIUD discontinuation, including IUD expulsion, and Cox regression model to explore the risk factors associated with discontinuation of the device. ResultsNine pregnancies were detected during the first year after GyneFix PPIUD insertion: seven were due to device expulsion and two occurred with PPIUD in situ. The PIs for overall 1-year pregnancy rate and pregnancies with IUD in situ were 2.3 (95% CI: 1.1–4.4) and 0.5 (95% CI: 0.1–1.9), respectively. The 6- and 12-month cumulative expulsion rates for PPIUD expulsion were 6.3% and 7.6%, respectively. The overall 1-year continuation rate was 86.6% (95% CI: 83.3–89.8). We did not identify any patient with insertion failure, uterine perforation, pelvic infection, or excess bleeding due to GyneFix PPIUD insertion. Women's age, education, occupation, previous history of C-section, parity, and breastfeeding were not associated with removal of GyneFix PPIUD in the first year of use. ConclusionsPostplacental insertion of GyneFix PPIUD is effective, safe, and acceptable for women undergoing C-section. Expulsion is the most common reason for GyneFix PPIUD discontinuation and pregnancy. The expulsion rate for GyneFix PPIUD is lower than that for framed IUDs, but more evidence is needed for a firm verdict.

Provision of postpartum long-acting reversible contraception: A quality improvement intervention with pre- and postintervention evaluation.

Background. Unintended pregnancies remain an important health challenge in South Africa (SA) and worldwide. Improving access to contraception and long-acting reversible contraception in particular, may reduce the number of unintended pregnancies.Objective. To determine the impact of a training and supportive mentoring programme on postpartum uptake of long-acting reversible contraceptive (LARC) methods.Methods. A quality-of-care improvement intervention with pre- and post-intervention evaluation of LARC uptake was conductedat a midwife-led, on-site obstetric unit in the Eastern Cape, SA. Midwives were trained in contraceptive counselling and postpartum etonorgestrel implant insertion. The researcher provided counselling and postpartum intrauterine device (IUD) insertion services.Results. In the 10 weeks prior to the intervention, neither the IUD nor the implant were provided in the unit. In the 10 weeks after the intervention, uptake of the IUD was n=27/289 (9.3%) and the implant n=21/289 (7.3%). Use of no contraception or condoms increased from n=22/273 (8.1%) to n=41/289 (14.2%) (p<0.02). The increase was accounted for by a change in staff in the last 4 weeks of the intervention period (n=33/105 (31.4%) v. n=8/184 (4.4%) during the first 6 weeks; p<0.00).Conclusion. Competing responsibilities of maternity staff may limit the contraceptive options offered to postpartum women. Aprogramme of training and supportive supervision resulted in a substantial increase in levels of LARC uptake. Strategies are needed to institutionalise comprehensive postpartum contraceptive provision nationally.

Safety profile of immediate post-partum intrauterine device insertion during caesarean delivery – a clinical trial with three years of follow up

Background: Many countries recommend the use of long-acting reversible contraceptive intrauterine device immediately after cesarean delivery. The cesarean delivery rate in Iraqi public hospitals is 32.2% and may reach 85.8% in private hospitals. Immediate post-partum intrauterine device insertion at cesarean is rarely done in Iraq. Objectives: To assess the safety and practicality of immediate post-partum intrauterine device insertion during cesarean delivery for family planning and pregnancy spacing in Iraqi women. Subjects and Methods: A single arm clinical trial included 150 eligible women who attended Al-‎Elwiyah Maternity Teaching Hospital or Al Hayat Rahibat Hospital for term delivery. A copper intrauterine device was placed in the uterine cavity immediately after delivery of the placenta during cesarean delivery. The intrauterine device was fixed in place at the fundus using an absorbable suture. Patients were followed up at six weeks, then annually for three years. Results: Expulsion of the intrauterine device was not reported by any of the participants. The most-reported complaints in the first twelve months of intrauterine device placement were abdominal pain, abnormal vaginal discharge, and ‎heavy menstrual blood loss, however, none were statically significant (P= 0.256). After the first year, there was a significant reduction in the ‎frequency of complaints (P= 0.002). Only 7.33% (95% CI: 6.92–7.75%) of the patient requested intrauterine device removal within the three years. The main reason was to plan a new pregnancy followed by recurrent infection associated with uncontrolled diabetes ‎mellitus. Diabetes was ‎a significant predictor for immediate post-partum intrauterine device removal, P= 0.049. Conclusion: The intrauterine device placement during cesarean delivery with suture fixation is a safe procedure with a zero-expulsion rate and is an effective reversible long-term contraceptive method.

Intrapartum versus postpartum insertion of intrauterine device in women delivering by cesarean section

BackgroundThe intrauterine device (IUD), being a reversible and effective contraception method, is the most widely used worldwide. This study aims to demonstrate the efficacy of IUD insertion during elective lower segment cesarean section (LSCS) versus its insertion six weeks postpartum.MethodsA cohort study was conducted on 200 women planned for elective cesarean delivery and desired IUD as a contraceptive method. They were allocated into two groups; group I, in which IUD was inserted during LSCS, and group II, in which IUD was inserted six weeks or more after LSCS. Both groups were compared regarding failed insertion, post-insertion pain, and uterine perforation. They were followed for one year for the incidence of menorrhagia, vaginal infection, IUD displacement/expulsion, missed threads, or unintended pregnancy.ResultsWomen in the second group showed a significantly higher incidence of failed insertion and uterine perforation than women in the first group. On the contrary, women in the first group showed a significantly higher incidence of missed threads than women in the second group. Regarding other consequences, there were no significant differences between both groups concerning menorrhagia, vaginal infection, IUD displacement/expulsion, or unintended pregnancy.ConclusionIUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.

Patient acceptability, continuation and complication rates with immediate postpartum levonorgestrel intrauterine device insertion at caesarean section andvaginal birth.

Immediate postpartum long-acting reversible contraception (LARC) has been shown to reduce unintended pregnancy but uptake of this type of contraception in Australia is low compared to European counterparts. To assess self-reported continuation rates, complications and satisfaction in patients having immediate postpartum hormonal intrauterine device (IUD) inserted at caesarean section (CS) or after vaginal birth (VB). Retrospective cohort study of all patients with immediate postpartum hormonal IUD insertion over three years at a tertiary maternity service. Primary outcomes were patient satisfaction, continuation and expulsion rates. Secondary outcomes were reason for discontinuation, patient-reported complications, attendance for postpartum check with a general practitioner (GP) and rate of unplanned pregnancy. Simple descriptive statistics were used to analyse the data. One hundred and ninety-three women had a hormonal IUD inserted and 143 consented to involvement (CS n= 79; VB n= 64). Six and 12months continuation rates for CS were 60.8% and 54.4%, and VB were 46.9% and 39.1%. The most common reasons for removal were: pain (34.5%), heavy or irregular bleeding (25.9%) and partial expulsion (24.1%). Expulsion was more likely after VB (34.1%) than CS (10.1%), (odds ratio 2.72; 95% CI 1.07-6.90; P= 0.036). There were 60.8% of women post-CS and 56.3% of women post-VB who were satisfied with their decision to have immediate postpartum insertion and most women attended routine postpartum follow-up with their GP (89.5%). Immediate postpartum hormonal IUD insertion in this cohort is associated with higher rates of expulsion and lower satisfaction rates compared to those documented in the literature for delayed postpartum insertion cohorts.

Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion

Intrauterine device (IUD) expulsion increases the risk of unintended pregnancy; how timing of postpartum IUD insertion and breastfeeding are associated with risk of expulsion is relevant to the benefit-risk profile. To evaluate the association of postpartum timing of IUD insertion and breastfeeding status with incidence and risk of IUD expulsion. The Association of Perforation and Expulsion of Intrauterine Devices (APEX-IUD) cohort study included women aged 50 years or younger with an IUD insertion between 2001 and 2018. The breastfeeding analysis focused on a subcohort of women at 52 or fewer weeks post partum with known breastfeeding status. The study was conducted using data from electronic health records (EHRs) at 4 research sites with access to EHR: 3 Kaiser Permanente sites (Northern California, Southern California, Washington) and the Regenstrief Institute (Indiana). Data analysis was conducted from June to November 2019. Timing of IUD insertion post partum was categorized into discrete time periods: 0 to 3 days, 4 days to 6 or fewer weeks, more than 6 weeks to 14 or fewer weeks, more than 14 weeks to 52 or fewer weeks, and non-post partum (>52 weeks or no evidence of delivery). Breastfeeding status at the time of insertion was determined from clinical records, diagnostic codes, or questionnaires from well-baby visits. Incidence rates and adjusted hazard ratios (aHRs) were estimated using propensity scores to adjust for confounding. The full cohort included 326 658 women (mean [SD] age, 32.0 [8.3] years; 38 911 [11.9%] Asian or Pacific Islander; 696 [0.2%] Hispanic Black; 56 180 [17.2%] Hispanic other; 42 501 [13.0%] Hispanic White; 28 323 [8.7%] non-Hispanic Black; 137 102 [42.0%] non-Hispanic White), and the subcohort included 94 817 women. Most IUDs were levonorgestrel-releasing (259 234 [79.4%]). There were 8943 expulsions. The 5-year cumulative incidence of IUD expulsion was highest for insertions 0 to 3 days post partum (10.73%; 95% CI, 9.12%-12.61%) and lowest for insertions more than 6 weeks to 14 or fewer weeks post partum (3.18%; 95% CI, 2.95%-3.42%). Adjusted HRs using women with non-post partum IUD insertion as the referent were 5.34 (95% CI, 4.47-6.39) for those with postpartum insertion at 0 to 3 days; 1.22 (95% CI, 1.05-1.41) for those with postpartum insertion at 4 days to 6 or fewer weeks; 1.06 (95% CI, 0.95-1.18) for those with postpartum insertion at more than 6 to 14 or fewer weeks; and 1.43 (95% CI, 1.29-1.60) for those with postpartum insertion at more than 14 to 52 or fewer weeks. In the subcohort, 5-year cumulative incidence was 3.49% (95% CI, 3.25%-3.73%) for breastfeeding women and 4.57% (95% CI, 4.22%-4.95%) for nonbreastfeeding women; the adjusted HR for breastfeeding vs not breastfeeding was 0.71 (95% CI, 0.64-0.78). In this study of real-world data, IUD expulsion was rare but more common with immediate postpartum insertion. Breastfeeding was associated with lower expulsion risk.

Status of Postpartum Intra Uterine Contraceptive Device in a Tertiary Care Hospital in Dhaka

Background: Timing of insertion, counseling, provider training and institutional support are critical factors for intrauterine contraceptive devices (IUCD) use during the postpartum period.
 Objective: The objective of the study was to determine the rate of acceptation, discontinuation, expulsion, infection and displacement of PPIUCD after vaginal delivery and cesarean section along with other complications among the study population.
 Methodology: This was a prospective observational study done in Shaheed Suhrawardy Medical College and Hospital from July 2015 to June 2016 among the pregnant women who delivered healthy baby by normal vaginal delivery and cesarean section. Data was collected by a structured questionnaire. Women who gave informed consent and who gave birth of healthy baby without complications were included. Women who had premature ruptured membrane with chorioamnionitis, pelvic inflammatory disease intrauterine fetal death or who did not give consent were excluded.
 Result: In this study, only 8.4% gave consent for this method, 77.1% had regular follow up after this method. Only 5.05% had removal and 1.8% had spontaneous expulsion. 10.5% had lower abdominal pain and 4.13% had per vaginal bleeding after this method.
 Conclusion: This study showed that post-partum intrauterine contraceptive devices insertion rate is low even in a tertiary center, which means, there is a lot of space for counseling the target population in our country. On the contrary, follow up rate was quite high which means that people are being concerned about this health care service. Similarly, the removal rate was also satisfying with minimum expulsion rate.
 Journal of National Institute of Neurosciences Bangladesh, July 2021, Vol. 7, No. 2, pp. 165-168

The Effectiveness of Postpartum IUD Compared to Interval IUD in ‘Aisyiyah Hospital Klaten

BACKGROUND: Postpartum IUD (PPIUD) insertion is performed 10 min after the placenta is born until 48 h postpartum, interval method is installed after 4 weeks postpartum. The use of this contraception will provide a distance between pregnancies not to be too close. AIM: To assess the effectiveness of PPIUD and the interval on complaints and complications in acceptors. METHODOLOGY: This study used a cross-sectional design. The subjects were women who gave birth vaginally and cesarean section at the ‘Aisyiyah Hospital Klaten with PPIUD and interval acceptors installed. Complaint data obtained through history taking, complications obtained from ultrasound, inspeculo examination, and vaginal swab. Data were analyzed by univariate, bivariate, and multivariate analysis. RESULTS: One hundred and twenty-nine subjects consisted of 82 (63.6%) PPIUD and 47 (36.4%) interval. On ultrasound examination, 126 (97.7%) subjects had no abnormalities, two (1.6%) had abnormalities, and one (0.8%) found ovarian cysts. On inspeculo examination, 89 (69.0%) subjects found no erotion, and 40 (31.0%) did not find abnormalities. Vaginal swab examination showed that 119 (92.2%) subjects had pathogenic bacteria, ten (7.8%) were normal. The fungus was positive in 75 (58.1%) subjects, and no fungus was in 54 (41.9%), while in NGO, positive was 18 (14.0%) subjects, and negative was 111 (86.0%). There was a significant relationship that the type of IUD insertion had husband’s complaints (p = 0.021), the erosion incidence (p = 0.011), the presence/absence of threads (p = 0.01), and the presence of fungus (0.00). PPIUD is more effective than interval IUD. CONCLUSION: PPIUD is more effective in terms of the lack of complaints from the husband, the incidence of erosion, the presence or absence of threads, and found of fungus on the vaginal swab than interval IUD.

Making the financial case for immediate postpartum intrauterine device: a budget impact analysis

Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement. The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing. Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost. Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement. For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

Prevalence of Complications after Interval Postpartum Intrauterine Device Insertion

Background and Aim: Postpartum intrauterine device (PPIUD) is a reversible, long-term and effective technique of contraception. The intrauterine device (IUD) is inserted within 48 hours of delivery. The immediate insertion of an intrauterine device causes certain complications. The present study aimed to assess the prevalence of complications after Interval Postpartum Intrauterine Device Insertion. Materials and Methods: This cross-sectional study was carried out on 147 women who underwent postpartum IUD (PPIUD) insertions during from January 2021 to June 2021 at Gynecology department, Mufti Mehmood Memorial Teaching Hospital (MMMTH), Dera Ismail Khan and Muhammad Teaching Hospital Peshawar. All the women who delivered and showed willingness for PPIUCD insertion were enrolled and continuously follow-up for 4 to 6 weeks after delivery. Demographic, obstetric, and clinical parameters were recorded on pre-designed medical proforma. PPIUCD insertion after 6 weeks of delivery were followed-up for the evaluation of complications. Uterine infection, medical removal of IUD, IUD expulsion, perforation, and method discontinuation were the outcome variables. SPSS version 20 was used for data analysis. Results: Of the total deliveries, 147 women inserted the postpartum intrauterine contraceptive device (PPIUCD). Of the total, about 122 (83%) women returned for follow-up after 6 weeks. All the women underwent transvaginal insertion of intrauterine contraceptive devices. The PPIUCD insertion related complications with prevalence were uterine infection 26 (21.3%), overall method suspension 17 (13.9%), perforation 20 (16.4%), interceptive uterine device expulsions 25 (20.5%), and intrauterine device removal 32 (26.2%). The severe uterine infection was in 2 (1.7%) cases who were hospitalized. Conclusion: The postpartum intrauterine device cumulative expulsion rate was higher among women compared to the expulsion rate of insertions. The longer duration of bloody lochia flow and delivery intrauterine device insertions were the key risk factors for expulsion of PPIUCD. Women can safely utilize intrauterine contraceptive devices with low complications beyond four week. Keywords: Postpartum intrauterine device; Complications; Intrauterine device expulsion

Efficacy and Safety of Immediate Postpartum Intrauterine Contraceptive Devices in C-Section and Vaginal Deliveries

Aim: To determine the safety and efficacy of immediate postpartum intrauterine contraceptive devices insertion after vaginal and caesarean and vaginal deliveries. Study Design: Retrospective study Place & Duration: Conducted at Gyne & Obs Department, Shahida Islam Teaching Hospital Lodhran, during from 1-06-2020 to 30-06-2021. Methods: In this study 120 patients were included in this study. Patients’ ages were ranging from 20 to 45 years. Patients’ detailed medical history including age, residence and socioeconomic status were examined after taking written consent. All the patients divided into two groups, 60 caesarean, 60 vaginal. IPPIUCDs were inserted in all the patients. Outcomes were examined at follow-up and compared between both groups. Data was analyzed by SPSS 24.0. P-value <0.05 was considered as significant. Results: 48 (40%) patients had ages between 20 to 30 years, 56 (46.7%) patients had ages 31 to 40 years and 16 (13.3%) patients had ages above 40 years. Complications rate was low. Perforation and pregnancy rate was 0%. Menstrual disturbance reported in 20 (16.7%) which was significantly higher in vaginal group. Expulsion rate was 9 (7.5%) and significant higher in vaginal group p<0.05. Removal was done in 14 (11.7%) cases and rate of removal of IUCD was high in vaginal group. Continuation rate at follow-up was 106 (88.3%). Conclusion: It is concluded that the insertion of immediate postpartum intrauterine contraceptive devices was effective and safe method with low complications rate.