Postpartum Intrauterine Device Insertion Research Articles

Improving the Post-Placental Intrauterine Device Protocol to Reduce Patient Visits [2H

INTRODUCTION: Immediate post-partum intrauterine device (IUD) insertion is a safe and effective means of long-acting birth control. This project analyzes demographics, string visualization, and follow up of women who opted for post-partum IUD insertion and considers the need for follow up including ultrasound (TVS). METHODS: From March 2016 to March 2017, the Post-Placental IUD Insertion Protocol was used for immediate post-partum Mirena® and ParaGard® IUD insertion at University Hospital, San Antonio, Texas. Retrospective chart analysis was used to assess patient demographics, follow up rates, and expulsion rates. RESULTS: A total of 128 women received post-partum IUDs, 70 post-cesarean and 58 post-vaginal delivery. Patient age ranged from 16-43 (average = 26.76) and parity ranged from 1-10 (average = 3.1). Over 80% of the population was Hispanic. Per protocol, patients were scheduled for a string check follow up 7-14 days post insertion. Of the 89 patients who followed up, 27 were in the first three weeks of post-insertion. Over 88% (15/17) of the post-cesarean and 25% (2/8) of post-vaginal insertions did not have visible strings at the visit and 50% (44-89) eventually needed a TVS to confirm placement, 75% of which were post-cesarean. The expulsion rate was 9% (8/89) and 9 IUDs required removal per patient request or IUD not being at the uterine fundus. CONCLUSION: The Post-Placental IUD Insertion Protocol can be improved in efficiency and cost-effectiveness by reducing the number of post-partum visits to only one at six weeks as well as scheduling a pre-clinic TVS, especially for post-cesarean patients.

Postpartum IUD insertion: Is there any difference between vaginal and cesarean births?

Postpartum IUD insertion: Is there any difference between vaginal and cesarean births?

Women’s experiences with immediate postpartum intrauterine device insertion: a mixed-methods study

ObjectiveTo describe women's pain and experiences with immediate postpartum intrauterine device (IUD) insertion (IPPI) following vaginal delivery using a ring forceps insertion technique. Study designThis observational mixed-methods study included women who underwent successful IPPI using ring forceps, with and without epidural analgesia. To describe women's pain during the procedure, we recruited women during antenatal care and at the time of admission for delivery until we collected at least 30 sets of pain scores at two time points (preprocedure and immediately postprocedure) in both groups using two instruments: 100-mm visual analogue scale (VAS) and a 4-point Likert verbal rating scale (VRS) (0=none, 1=mild, 2=moderate, 3=severe). After placing the IUD, physicians rated ease of IUD insertion. A subset of participants in both groups underwent semistructured interviews prior to hospital discharge. Our goal was to explore women's (a) decisional influences and prior contraception experience, (b) experience during IPPI and (c) decisional regret. We conducted iterative analysis of interview content until thematic saturation was reached in both groups. Interviewees provided recall pain scores and rated satisfaction with IPPI. ResultsWe collected 30 pain scores in the no-epidural group and 36 in the epidural group. At both time points, the VAS data exhibited very low pain scores in the epidural group and a uniform distribution in the no-epidural group; standard deviations were large. The majority of women in both groups reported “none–mild” pain on the VRS. Physicians reported minimal difficulty with IUD insertion in most cases. We conducted interviews with 12 women who had an epidural and 9 who did not. Both groups offered similar comments across all domains. Convenience was the primary motivation to undergo IPPI, and women recognized the barriers to obtaining effective contraception remote from delivery. The majority of interviewees, even those with high pain scores, characterized their procedural pain as less than expected, and IUD insertion pain was less than or similar to labor pain. Interviewees' recall pain scores were similar to those reported at the time of IUD insertion. An unanticipated theme that emerged was an ineffective informed consent process; women could not recall most procedural risks or how IPPI was accomplished. All interviewees endorsed IPPI, expressing a high degree of satisfaction; none regretted undergoing the procedure. ConclusionThe distributions of our VAS scores did not reveal useful summary statistics in either group. The VRS scores were a more informative representation of women's pain during IPPI; most women reported little pain. Convenience of obtaining highly effective contraception immediately postpartum was the key motivator for undergoing IPPI. All women voiced favorable experiences, even those who had high pain scores. ImplicationsWomen in our study overwhelmingly described less pain than anticipated with IPPI and also reported a high degree of satisfaction. Our study offers valuable patient-centered guidance to inform antenatal contraceptive counseling with respect to IPPI and lays the groundwork for ongoing research towards optimizing women's experiences with the procedure.

Immediate postpartum levonorgestrel intrauterine device insertion and breast-feeding outcomes: a noninferiority randomized controlled trial

Immediate postpartum levonorgestrel intrauterine device insertion is increasing in frequency in the United States, but few studies have investigated the effect of early placement on breast-feeding outcomes. This study examined the effect of immediate vs delayed postpartum levonorgestrel intrauterine device insertion on breast-feeding outcomes. We conducted this noninferiority randomized controlled trial at the University of Utah and the University of New Mexico Health Sciences Centers from February 2014 through March 2016. Eligible women were pregnant and planned to breast-feed, spoke English or Spanish, were aged 18-40 years, and desired a levonorgestrel intrauterine device. Enrolled women were randomized 1:1 to immediate postpartum insertion or delayed insertion at 4-12 weeks' postpartum. Prespecified exclusion criteria included delivery <37.0 weeks' gestational age, chorioamnionitis, postpartum hemorrhage, contraindications to levonorgestrel intrauterine device insertion, and medical complications of pregnancy that could affect breast-feeding. We conducted per-protocol analysis as the primary approach, as it is considered the standard for noninferiority studies; we also report the alternative intent-to-treat analysis. We powered the study for the primary outcome, breast-feeding continuation at 8 weeks, to detect a 15% noninferiority margin between groups, requiring 132 participants in each arm. The secondary study outcome, time to lactogenesis, used a validated measure, and was analyzed by survival analysis and log rank test. We followed up participants for ongoing data collection for 6 months. Only the data analysis team was blinded to the intervention. We met the enrollment target with 319 participants, but lost 34 prior to randomization and excluded an additional 26 for medical complications prior to delivery. The final analytic sample included 132 in the immediate group and 127 in the delayed group. Report of any breast-feeding at 8 weeks in the immediate group (79%; 95% confidence interval, 70-86%) was noninferior to that of the delayed group (84%; 95% confidence interval, 76-91%). The 5% difference in breast-feeding continuation at 8 weeks between the groups fell within the noninferiority margin (95% confidence interval, -5.6 to 15%). Time to lactogenesis (mean ± SD) in the immediate group, 65.3 ± 25.7 hours, was noninferior to that of the delayed group, 63.6 ± 21.6 hours. The mean difference between groups was 1.7 hours (95% confidence interval, -4.8 to 8.2 hours), noninferior by log-rank test. A total of 24 intrauterine device expulsions occurred in the immediate group compared to 2 in the delayed group (19% vs 2%, P < .001), consistent with the known higher expulsion rate with immediate vs delayed postpartum intrauterine device insertion. No intrauterine device perforations occurred in either group. Our results of noninferior breast-feeding outcomes between women with immediate and delayed postpartum levonorgestrel intrauterine device insertion suggest that immediate postpartum intrauterine device insertion is an acceptable option for women planning to breast-feed and use the levonorgestrel intrauterine device. Expulsion rates are higher with immediate postpartum levonorgestrel intrauterine device insertion compared to delayed insertion, but this disadvantage may be outweighed by the advantages of immediate initiation of contraception. Providers should offer immediate postpartum intrauterine device insertion to breast-feeding women planning to use the levonorgestrel intrauterine device.

Immediate Postpartum Intrauterine Device Insertion, Implant Insertion and Sterilization, U.S., 2008-2013 [33B

INTRODUCTION: Our objective was to measure trends in immediate postpartum intrauterine device (IUD) insertion, contraceptive implant insertion, and tubal sterilization. METHODS: Among all delivery hospitalizations in the 2008-2013 National Inpatient Sample, we identified those with codes for tubal sterilization, IUD insertion, or contraceptive implant insertion. We used multivariate and multinomial logistic regression to examine associations between these outcomes and maternal and hospital characteristics over time. RESULTS: While the rate of sterilization remained similar over time, the rate of IUD/implant insertion increased over the study period (1.86 per 10,000 deliveries in 2008-09; 13.5 per 10,000 deliveries in 2012-13). Compared with receiving neither IUD/implant nor sterilization and adjusting for year and sociodemographic factors, IUD/implant insertion was more likely among women with medical comorbidity (adjusted odds ratio [aOR]=1.92; 95% confidence interval 1.72-2.13), with non-private insurance (aOR=5.23; 3.82-7.15), and delivering at teaching hospitals (aOR=19.8; 9.41-41.5). Sterilization was more likely among women with medical comorbidity (aOR=1.17; 1.14-1.20) and non-private insurance (aOR=2.20; 2.10-2.30), and less likely among women receiving care at urban versus rural facilities (aOR=0.59, 0.55-0.63). Comparing only women receiving IUD/implant insertion or sterilization, IUD/implant insertion was more likely among women with non-private insurance (aOR=1.9; 1.38-2.63), delivering at urban (aOR=2.18; 1.01-4.70) or teaching (aOR=17.6; 8.50-36.5) hospitals, and delivering later in the study period (aOR=4.51 in 2010-11; aOR=8.26 in 2012-13, compared to 2008-09). CONCLUSION: During delivery hospitalizations in the US from 2008-2013, the IUD/implant insertion rate increased by an order of magnitude. Immediate postpartum IUD/implant insertion is associated with medical comorbidities, non-private insurance status, and urban/teaching hospital status.

Immediate postpartum intrauterine device and implant program outcomes: a prospective analysis

In-hospital placement of intrauterine devices and contraceptive implants following vaginal and cesarean delivery is increasingly popular and responds to maternal motivation for highly effective postpartum contraception. Immediate postpartum intrauterine device insertion is associated with higher expulsion than interval placement, but emerging evidence suggests that the levonorgestrel intrauterine device may have a higher expulsion rate than the copper intrauterine device. This study evaluated in-hospital provision, expulsion, and 6-month continuation of immediate postpartum copper T380 intrauterine devices, levonorgestrel intrauterine devices, and contraceptive implants. We offered enrollment in this prospective observational trial to women presenting to the University of Utah labor and delivery unit from October 2013 through February 2016 who requested an intrauterine device or implant for postpartum contraception during prenatal care or hospitalization at the time of delivery. Following informed consent, participants completed questionnaires prior to hospital discharge and at 3 and 6 months postpartum. Data on expulsions at 6 months were validated by chart abstraction. During the study period, 639 patients requested a postpartum intrauterine device or implant and 350 patients enrolled in prospective follow-up prior to discharge from the hospital. Among enrollees, 325 (93%) received their preferred contraceptive device prior to hospital discharge: 88 (27%) copper intrauterine device users, 123 (38%) levonorgestrel intrauterine device users, and 114 (35%) implant users. Participants predominantly were Hispanic (90%), were multiparous (87%), reported a household income <$24,000 per year (87%), and underwent a vaginal delivery (77%). At 6 months postpartum, 289 of 325 device recipients (89%) completed follow-up. Among levonorgestrel intrauterine device users 17% reported expulsions relative to 4% of copper intrauterine device users. The adjusted hazard ratio for expulsion was 5.8 (confidence interval, 1.3-26.4). There was no statistically significant difference in expulsions by delivery type or continuation by device type. Among the 21 women who experienced intrauterine device expulsions, 14 (67%) requested a replacement long-acting reversible contraception device for contraception. The 6-month device continuation was ≥80% for all device types. An immediate postpartum long-acting reversible contraception program effectively provides women who desire highly effective reversible contraceptive devices with their method of choice prior to hospital discharge. Immediate postplacental levonorgestrel intrauterine device users have higher expulsion rates than copper intrauterine device users, but >8 of 10 women initiating an intrauterine device or implant continue use at 6 months postpartum.

Location and content of counselling and acceptance of postpartum IUD in Sri Lanka

BackgroundThe immediate postpartum IUD (PPIUD) is a long-acting, reversible method of contraception that can be used safely and effectively following a birth. To appropriately facilitate the immediate postpartum insertion of IUDs, women must be informed of the method’s availability and must be counselled on its benefits and risks prior to entering the delivery room. We examine the relationship between the location and quality of antenatal counselling and women’s acceptance of immediate postpartum IUD (PPIUD) in four hospitals in Sri Lanka.MethodsData were collected between January 2015 and May 2015. Modified Poisson regressions with robust standard errors are used to assess the relationships between place of counselling, indicators of counselling quality, and PPIUD uptake following delivery.ResultsWe find that women who were counselled in hospital antenatal clinics and admission wards were much more likely to have a PPIUD inserted than women who were counselled in field clinics or during home visits. Hospital-based counselling had higher quality indicators for providing information on PPIUD, and women were more likely to receive PPIUD information leaflets in hospital locations than in lower-tiered clinics or during home visits. Women who were counselled at hospital locations also reported a higher level of satisfaction with the counselling that they received. Receipt of hospital-based counselling was also linked to higher PPIUD uptake, in spite of the fact that women were more likely to be given information about the risks and alternatives to PPIUD in hospitals. The information about the risks of and alternatives to PPIUD, whether provided in hospital or in non-hospital settings, tended to lower the likelihood of acceptance to have a PPIUD insertion. Counselling in hospital admission wards was focused on women who had not been counselled at field clinics.ConclusionsThe study findings call for efforts that improve the training of midwives who provide PPIUD counselling at field clinics and during the home visits. We also recommend that routine PPIUD counselling be conducted in hospitals, even if women have already been counselled elsewhere.

Intra-cesarean insertion and fixation of frameless intrauterine devices

Various contraceptive methods are available to postpartum women including hormonal and nonhormonal barriers, as well as injectable forms. Of all the available birth control methods, intrauterine devices (IUD) are felt by many to be the near-ideal form of contraception, and are recommended by advocacy groups, physicians, and gynecological organizations worldwide. Immediate postpartum IUD insertion deserves greater attention because it can provide immediate contraception, prevents repeat unintended pregnancies, and may serve to reduce the incidence or need for secondary cesarean delivery; however, insertion of conventional T-shape IUDs immediately post placenta delivery is limited by their high expulsion and displacement rates. Anchoring of frameless-design IUDs that lack conventional cross-arms to the uterine fundal surfaces has been medically and commercially available throughout Europe for many years. The placement technique is simple, has minimal patient discomfort, and high long-term patient acceptance due to its high degree of uterine compatibility as a consequence of its small size and segmented design. Frameless-design IUD implantation appears to represent a major advance, suitable for general use, due to its lack of timing restraints and its simplicity of attachment, which only requires limited training.

Utilization of Immediate Post-Partum Intra Uterine Contraceptive Device and Associated Factors: A Facility based Cross Sectional Study among Mothers Delivered at Public Health Facilities of Sidama Zone, South Ethiopia

Background: Insertion of an Intra Uterine device (IUD) immediately after delivery have a proven record of very high effectiveness, protection against unintended pregnancy, cost effectiveness, suitability and high user satisfaction. Despite these benefits, information on Post-Partum Intra Uterine device (PPIUD) acceptance and utilization was limited in Ethiopia. Therefore, this study was aimed to assess postpartum intra uterine contraceptive device utilization and its associated factors among mothers delivered in selected facilities found in South Ethiopia. Methods: A facility based cross-sectional study was conducted in two health facilities providing PPIUD insertion service (Yirgalem hospital and Bursa health center). Data were collected using structured questionnaire among 310 selected women. Frequency tables and graphs were used to describe the study variables. Bivariate and multivariate logistic regression analysis methods were used to identify factors associated with postpartum intrauterine device use. Variables with P-value of <0.05 with 95% CI were used to declare statistical significance. Results: Postpartum intra uterine contraceptive device use within 48 h of delivery was 21.6% while 38% of the respondents were interested in using PPIUD. Only 22.8% of participant mothers were counselled during ANC, labor and postpartum period. Mother who do not have a plan to have another child [AOR=2.36, 95% CI, (1.25, 4.47)], undecided plan to have another child [AOR=0.17, 95% CI, (0.05, 0.58)], mothers who did not heard [AOR=0.41, 95% CI: 0.41 (0.20, 0.83)] and not counselled about PPIUD [AOR=0.17, 95% CI: 0.17 (0.06, 0.52)] were associated with PPIUD utilization. Conclusion: Despite more than one-third of participants were accepted PPIUD, the actual utilization was low. Most mothers were not counselled during the important contact points through the whole cascade of pregnancy. Program managers need to develop strategies to raise pregnant mother awareness on PPIUCD through media sources. This study also highlights, the need to improve and integrate standard PPIUD counselling scheme during FANC, labor and postpartum period.

Healthcare Provider Attitudes of Safety of Intrauterine Devices in the Postpartum Period.

Immediate postpartum intrauterine devices (IUDs) have been underutilized in the United States despite their known safety. Understanding how providers' attitudes contribute to underutilization is important in improving access. Our objective was to examine healthcare providers' perceptions of the safety of immediate postpartum IUDs before publication of United States contraceptive guidelines. We analyzed survey data collected from December 2009 to March 2010 from 635 office-based physicians and 1368 Title X clinic providers (overall response rate of 64.8%). Providers were asked how safe they thought copper and levonorgestrel (LNG) IUDs were in postpartum women (very safe, safe, unsafe, very unsafe, and unsure). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for characteristics associated with considering immediate and delayed postpartum IUDs to be safe. Less than 40% of respondents considered immediate or delayed IUD insertion to be safe. Providers with <1 day of family planning training had decreased odds of considering immediate postpartum IUD insertion to be safe compared with unsafe/unsure (aOR 0.18, 95% CI 0.04-0.84 for copper IUD and aOR 0.17, 95% CI 0.04-0.81 for LNG-IUD). Providers without training in postpartum or interval copper IUD insertion had decreased odds of considering immediate postpartum copper IUD insertion (aOR 0.40, 95% CI 0.16-0.79) and delayed postpartum insertion for both IUD types to be safe (aOR 0.34, 95% CI 0.18-0.66 for copper IUD and aOR 0.41, 95% CI 0.21-0.77 for LNG-IUD). Before United States contraceptive guidelines, a majority of providers perceived immediate postpartum IUDs to be unsafe.

Acceptance, perception, experience and satisfaction of the couple with postpartum intrauterine contraceptive devices (PPIUCD) insertion

Family planning can avert nearly one-third of maternal deaths and 10% of child mortality when couples space their pregnancies more than two years apart.In India 65% women in 1st year of postpartum period have unmet need for FP, but only 26% are using any contraceptive. Delivery may be the only time when they come into contact with health care providers; thereafter the chances of returning for contraceptive advice are uncertain. Insertion of intrauterine contraceptive device (IUCD) at 10 minutes after delivery is appealing. The Copper T 380A intra-uterine contraceptive device (IUCD) is a highly effective, non-hormonal method, long acting reversible and coitus independent contraceptive device that can be safely used by all women regardless of breastfeeding status during this interval. Thus increasing awareness and creating demand for postpartum intra-uterinecontraceptive devices (PPIUCD) is essential. Apart from the fact that its usage has to be increased, follow-up of the cases after insertion is an important factor since complications related to IUCD are extensive and vary with individuals. Thus routine followups and early measure is the base of PPIUCD insertion. Satisfaction related to IUCD insertion varies considerably. The studies also include the input of the husband’s opinion regarding the satisfaction related to IUCD as many problems related to interference in the sexual activity were recorded. We will conduct a study for acceptance, perception, experience and satisfaction of the couple with postpartum intrauterine contraceptive devices (PPIUCD) insertion at our institute.Objectives:1. Acceptability of postpartum intrauterine devices as a contraceptive method among women of reproductive age. 2. To record the experienceduring the procedure and first six weeks after insertion of IUCD. 3. To learn about satisfaction with PPIUCD among the couple. 4. Desire to continue the service in future. Methods: Study design- This will be an open prospective and longitudinal study toassess the acceptance, perception, experience and satisfaction of the 100 couples in the reproductive age group (19-49 years) who are willing for; with postpartum insertion of the Cu T 380 A within 10 minutes of placental expulsion. Couples will be recruited in this study after obtaining written informed consent. Institutional ethical committee clearance will be taken. Exclusion criteria will be severe anemia Hb 38°C during or after labor, and the patients with Postpartum Hemorrhage. Method of insertion: The Copper T model Cu T 380 A will be inserted with all asepticprecautions within 10 minutes of placental expulsion with a sponge holder and fundal placement will be ensured. String will be cut to the level of the cervix. The string will be visible at the cervix after the insertion. Participants will be interviewed prior and after insertion of PPIUCD and then six weeks later. Data collection: Data will be collected from participants using a structured questionnaire that includes basic demographic information, questions related to acceptance and perception of pain on insertion of PPIUCD. After six weeks, PPIUCD clients will again be interviewed using a structured follow-up questionnaire that will collect information about the clients overall satisfaction, problems or any complications, and retention /expulsion of the PPIUCD. In the cases where the client fails to return to the health facility for her follow-up visit, she will be contacted by telephone for the follow-up interview. Data analysis: Continuous variables will be reported using mean (standard deviation) and categorical variables will be reported using percentages. For two group comparisons, wherever applicable a student t-test will be used to compare means of continuous variables, and chi-square tests shall be used to compare categorical variables.Results:1.Acceptance of PPIUCD was 88% after counseling than 46% before counseling. 2. 79.54% did not have any pain during insertion. 3. 17.06% had mild discomfort while insertion and only 03.40% had painful insertion. 4. After 6 weeks 83% women followed-up. Rest 17% could not be contact even through telephones. 5. Major complications encountered were abdominal pain and expulsion 13.6% each than other complications. However 54.5% women had no complications. 6. 75.3% women were willing to continue the PPIUCD, rest demanded removal either due to complications or family opposes being the major reason. 7. Overall satisfaction rate was 78% in women and 73.9% in husbands Conclusions: The study thus concludes that acceptance rate was significantly improved after proper counseling and the complication rate of the PPIUCD were less as compared to the overall benefits.

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.

Use of the World Health Organization's Medical Eligibility Criteria for Contraceptive Use Guidance in sub-Saharan African Countries: A Cross-Sectional Study.

Given recent updates to the postpartum contraception recommendations in the fifth edition of the Medical Eligibility Criteria for Contraceptive Use (MEC), published by the World Health Organization (WHO), the purpose of this qualitative study was to assess the extent to which national family planning policies in sub-Saharan African countries are in agreement with the WHO MEC, particularly with regard to postpartum contraceptive use. WHO headquarters sent questionnaires to country-level focal points to complete with their Ministry of Health counterparts. Between February and May 2016, 23 of 32 (72%) surveys were completed. All respondents reported that their countries had used the MEC document in the past, with most reporting that they had used the guidance as a reference (n = 20, 87%), for training purposes (n = 19, 83%), to change clinical practices (n = 17, 74%), and to develop national policies (n = 16, 70%). While many respondents (16, 70%) indicated their countries already include immediate postpartum intrauterine device insertion among breastfeeding women in their family planning policies, few reported currently allowing use of progestogen-only pills (n = 8, 35%) or implants (n = 8, 35%) during the immediate postpartum period (i.e., less than 48 hours after delivery) for breastfeeding women. A higher percentage of respondents indicated their countries allowed breastfeeding women the option of progestogen-only pills (n = 16, 70%) and implants (n = 13, 57%) between 48 hours and 6 weeks postpartum. Findings from this baseline assessment suggest that many countries may benefit from training and policy formulation support to adapt both new WHO MEC updates as well as existing recommendations from previous MEC revisions into national family planning guidelines.

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.

Programmatic experience of post-partum IUD use in Zambia: an observational study on continuation and satisfaction

Objectives: The aim of the study was to assess continuation rates and satisfaction among post-partum intrauterine device (PPIUD) accepters.Methods: This prospective observational study comprised 591 Zambian women who underwent PPIUD insertion at sites of the Society for Family Health, Lusaka, Zambia. The women were contacted 6–12 months after PPIUD insertion and asked to return to the clinic for interview and examination. If the IUD strings were not visible, an ultrasound was performed. Participants were asked about their satisfaction with the PPIUD. Main outcome measures were short-term PPIUD continuation and reported complications according to time of insertion.Results: Of 591 women enrolled, 305 women attended the follow-up appointment for interview and examination, giving a power of 80% to estimate an expulsion rate of 10 ± 5%. The IUD was inserted within 10 min of placental delivery (post-placental insertion) in 24.3% of participants (n = 74) and within 48 h (immediate post-partum insertion) in 71.1% of participants (n = 217). The total expulsion rate was 5.6%. Expulsion rates for post-placental and immediate post-partum insertions were 10.8% and 4.1%, respectively. No significant difference in expulsion rates was found (p = 0.10). Of those with an expulsion, 76.5% (n = 13) recognised that it had occurred. There were no reported complications, and 94.1% of women reported being satisfied or very satisfied with their PPIUD (n = 287).Conclusions: Overall, expulsion rates were lower than previously reported, particularly for immediate post-partum insertions. Attention to high fundal placement at insertion is a likely explanation for the low expulsion rates. Contrary to conventional wisdom, these low expulsion rates indicate that previous notions regarding insertion timing may not be accurate. Satisfaction levels were also favourable. PPIUD can be safe, acceptable and feasible in an African setting.

Success Providing Postpartum Intrauterine Devices in Private-Sector Health Care Facilities in Nigeria: Factors Associated With Uptake.

Use of modern contraceptive methods in Nigeria remained at 10% between 2008 and 2013 despite substantive investments in family planning services. Many women in their first postpartum year, in particular, have an unmet need for family planning. We evaluated use of postpartum intrauterine device (IUD) insertion and determined factors associated with its uptake in Nigeria. Data were collected between May 2014 and February 2015 from 11 private health care facilities in 6 southern Nigerian states. Women attending antenatal care in participating facilities were counseled on all available contraceptive methods including the postpartum IUD. Data were abstracted from participating facility records and evaluated using a cross-sectional analysis. Categorical variables were calculated as proportions while continuous variables were calculated as medians with the associated interquartile range (IQR). Multivariate logistic regression analysis was used to identify factors associated with uptake of the postpartum IUD while controlling for potential confounding factors, including age, educational attainment, marital status, parity, number of living children, and previous use of contraception. During the study period, 728 women delivered in the 11 facilities. The median age was 28 years, and most women were educated (73% had completed at least the secondary level). The majority (96%) of the women reported they were married, and the median number of living children was 3 (IQR, 2-4). Uptake of the postpartum IUD was 41% (n = 300), with 8% (n = 25) of the acceptors experiencing expulsion of the IUD within 6 weeks post-insertion. After controlling for potential confounding factors, several characteristics were associated with greater likelihood of choosing the postpartum IUD, including lower education, having a higher number of living children, and being single. Women who had used contraceptives previously were less likely to choose the postpartum IUD than women who had not previously used contraception (adjusted odds ratio, 0.68; 95% confidence interval, 0.55 to 0.84). A high percentage (41%) of women delivering in private health care facilities in southern Nigeria accepted immediate postpartum IUD insertion. Scale-up of postpartum IUD services is a promising approach to increasing uptake of long-acting reversible contraceptives among women in Nigeria.

Initial assessment of a dedicated device for immediate postpartum IUD insertion

Initial assessment of a dedicated device for immediate postpartum IUD insertion

Limited Uptake of Planned Intrauterine Devices During the Postpartum Period.

The primary objective of this study was to determine the percentage of women with a documented plan for postpartum intrauterine device (IUD) insertion who had a device inserted within 8 weeks of delivery. The secondary objective was to determine factors associated with successful initiation of postpartum IUDs as planned. We conducted a retrospective chart review of women who had at least one prenatal visit and delivered a viable pregnancy at our academic medical center. Methods of planned and established postpartum contraceptive methods were recorded, as well as demographic information and documented reasons for failure to initiate planned intrauterine contraception. A total of 110 women planned postpartum IUD placement. Of these women, 84 (76%) presented for at least one postpartum appointment. Only 22.6% (95% confidence interval 13.7-31.5) of those presenting for postpartum follow-up underwent IUD placement within 8 weeks of delivery. Women planning postpartum IUD insertion were just as likely as women with no planned postpartum contraceptive method to fail to establish contraception within 8 weeks (P = 0.55). Failure to establish planned postpartum intrauterine contraception occurs frequently, even in a setting with a high rate of postpartum follow-up.

Immediate postpartum insertion of intrauterine device for contraception.

Women who want to start intrauterine contraception (IUC) during the postpartum period might benefit from IUC insertion immediately after delivery. Postplacental insertion greatly reduces the risk of subsequent pregnancy and eliminates the need for a return visit to start contraception. Without the option of immediate insertion, many women may never return for services or may adopt less effective contraception. Our aim was to examine the outcomes of IUC insertion immediately after placenta delivery (within 10 minutes), especially when compared with insertion at other postpartum times. We focused on successful IUC placement (insertion), subsequent expulsion, and method use. We searched for trials until 1 April 2015. Sources included PubMed (MEDLINE), the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, Web of Science, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. For the original review, the authors contacted investigators to identify other trials. We sought randomized controlled trials (RCTs) with at least one treatment arm that involved immediate IUC placement (i.e., within 10 minutes of placenta delivery). Comparison arms could have included early postpartum insertion (from 10 minutes postplacental to hospital discharge) or standard insertion (during a postpartum visit). Trials could also have compared different IUC methods or insertion techniques. Delivery may have been vaginal or cesarean. Primary outcomes were placement (insertion), subsequent expulsion, and method use at study assessment. For dichotomous outcomes, we used the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Earlier studies primarily reported results as life-table rates. We aggregated trials in a meta-analysis if they had similar interventions and outcome measures. A sensitivity analysis included studies with moderate or high quality evidence and sufficient outcome data. We included 15 trials. Seven studies reported from 2010 to 2014 were added to eight from the original 2001 review. Newer trials compared immediate postplacental insertion versus early (10 minutes to 48 hours) or standard insertion (during the postpartum visit). Of four with full reports, three were small trials. The other three studies had conference abstracts. The eight early trials examined immediate insertion of different devices or insertion techniques. Most studies were published in the 1980s, some with limited reporting.Our sensitivity analysis included trials with sufficient outcome data and moderate or high quality evidence. Four newer trials comparing insertion times met the inclusion criteria. Two studies used the levonorgestrel-releasing intrauterine system (LNG-IUS) after vaginal delivery. The other two trials placed IUC after cesarean section; one used the CuT 380A intrauterine device (IUD) and the other used the LNG-IUS.A pilot trial compared immediate insertion versus early or standard insertion. In groups comparing immediate versus early insertion (N = 30), all women had the LNG-IUS inserted. By six months, the groups had the same expulsion rate and did not differ significantly in IUC use.For immediate versus standard insertion, we conducted meta-analyses of four trials. Insertion rates did not differ significantly between study arms. However, the trial from Uganda showed insertion was more likely for the immediate group, although the estimate was imprecise. In the meta-analysis, expulsion by six months was more likely for the immediate group, but the confidence interval was wide (OR 4.89, 95% CI 1.47 to 16.32; participants = 210; studies = 4). IUC use at six months was more likely with immediate insertion than with standard insertion (OR 2.04, 95% CI 1.01 to 4.09; participants = 243; studies = 4). Study arms did not differ in use at 3 or 12 months in individual small trials. Recent trials compared different insertion times after vaginal or cesarean delivery. Evidence was limited because studies with full reports generally had small sample sizes. Overall, the quality of evidence was moderate; abstracts and older studies had limited reporting. Ongoing trials will add to the evidence, although some are small. Trials of adequate power are needed to estimate expulsion rates and side effects.The benefit of effective contraception immediately after delivery may outweigh the disadvantage of increased risk for expulsion. Frequent prenatal visits during the third trimester provide the opportunity to discuss effective contraceptive methods and desired timing for initiation. Clinical follow-up can help detect early expulsion, as can educating women about expulsion signs and symptoms.

Awareness about postpartum insertion of intrauterine device among antenatal cases

BackgroundIn spite of many available contraceptives numerous unwanted and unplanned pregnancies occur. Though the couples desire contraception but are not able to accept it due to their ignorance and misconceptions. Intrauterine Contraceptive Device (IUCD); an effective contraceptive is usually inserted six weeks after delivery. It can be inserted within 48 h of delivery called postpartum insertion for which government has started the program in many states. The study was undertaken to find out the choices about contraception after delivery and awareness about postpartum insertion. MethodsThe present observational study was conducted in one of the zonal service hospitals. 500 antenatal cases were included in the study. Their choice of contraception after delivery and awareness was determined through a questionnaire. Reasons for refusal of postpartum insertion were recorded. A small sample of staff also was included in the study. Results500 cases were included in the study, a large number had decided about contraception; mainly breast feeding supplemented by barrier contraceptive. 94 of 500 were willing for insertion of contraceptive device but not immediately after delivery due to apprehension in general and fear of side effects. Staff's awareness about postpartum insertion was poor. ConclusionKnowledge and acceptance of postpartum insertion is very low among antenatal women; probably because the concept is new in the community. There is a strong need to increase the knowledge and awareness about this by health education and counseling.