Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

The safety and efficacy of immediate post placental IUD insertion versus the post puerperal IUD insertion in women undergoing cesarean delivery.. [DOI: 10.21203/rs.3.rs-2412988/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective asses the safety and efficacy of immediate IUD insertion following delivery of the placenta in women undergoing cesarean delivery. Study: Randomized clinical trial that included 66 women, were divided equally in two arms, where each arm included 33 patients. The first group had IUD inserted 10 min after delivery of the placenta (post placental group) and the second group had their IUD inserted at 6weeks following delivery (interval group). Results The complication rate related to post placental IUD insertion was comparable to that of interval insertion. The expulsion and displacement rates were the same in both post placental and interval groups at 6 weeks and 3 months follow up. Conclusion Post placental IUD insertion is a safe and attractive option for postpartum contraception that should be offered to all women undergoing elective cesarean section after proper counseling.

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

BACKGROUND

Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement.

OBJECTIVE

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.

STUDY DESIGN

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.

RESULTS

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.

CONCLUSION

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.

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

BACKGROUND

The 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.

METHODS

A 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.

RESULTS

Women 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.

CONCLUSION

IUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.

Continuation of Copper T in Immediate Postplacental, Immediate Postabortal and Interval Period of Insertion

AIM

Copper containing IUCDs are one of most effective mode of contraception for birth spacing. We conducted this prospective observational study to suggest a possible better period of insertion of IUCDs with cost-saving benefits.

METHODS

All married women in the reproductive age group desirous of Copper-T 375 IUD insertion in either immediate postplacental (PP), immediate postabortal (PA) or interval (INT) period were recruited. The women were asked to return for scheduled follow-up visits at 6 weeks, 6 months and 12 months. They were advised to visit family planning clinic any time if they experienced pelvic pain, discharge per vaginum, unusual bleeding or missed periods. At each visit, women were interviewed for any side effects they have experienced and were asked to elaborate. Pelvic pain was assessed from visual analogue scale. Continuation rate was measured at the end of one year.

RESULTS

Women in INT group (90.14%) had the highest continuation rate followed by PP (83.18%) and PA (80%) groups. Women in PP (AOR = 3.37, 95% CI 1.17-9.72) and PA (AOR = 4.53, 95% CI 1.33-14.04) groups had higher odds of discontinuation compared to INT group after adjusting for age, parity, working and education status. There was a significant difference between the groups when cumulative expulsion was considered (p = 0.045), but none when cumulative removal (p = 0.107) was taken into account.

CONCLUSION

The continuation rate remained high in women who had insertion in the interval period compared to immediate postplacental and postabortal periods.

Study on the use practices and knowledges of French practitioners about the use of intra-uterine devices in early post-partum contraception in France

OBJECTIVES

Intra-Uterine Device (IUD) insertion is possible in early postpartum. Although this contraception method is recognized and used in lots of country, it seems infrequent and poorly known in France. Our study aims to assess the barriers to the application of this method in France.

METHODS

A questionnaire was sent to obstetricians-gynaecologist professionals and midwives in France, through the affiliation to CNGOF (French National College of Obstetricians and Gynecologists) and to CNSF (French National College of Midwives). Questions were focused on the practices and knowledge about the insertion of IUD in early postpartum.

RESULTS

four hundred eight practitioners responded. Amongst them, 63% knew about the possibility to use IUDs after a vaginal delivery and 31% knew it could be inserted during cesarean section. Ten percent of them used this method. Most of these practitioners (80% of them) would like to discuss the insertion of an IUD in early postpartum with their patients and 71% would like to perform the insertion themselves after training. Besides, this study shows that contraception is rarely addressed by physicians during the follow-up of pregnancies. Less than 15% of respondents report discussing the topic systematically with the patient during the pregnancy follow during pregnancy follow.

CONCLUSION

insertion of IUDs in early postpartum is uncommon in France. The main limitation seems to be a lack of knowledge, but practitioners seem to be interested in this practice. Training courses could be created in order to rase up the adoption of this practice.

Understanding factors associated with continuation of intrauterine device use in Gujarat and Rajasthan, India: a cross-sectional household study

The Government of India has promoted the expansion of access to and uptake of intrauterine devices (IUDs), during both the interval (IIUD) and postpartum (PPIUD) periods, as part of its Family Planning 2020 initiative. This study, conducted by EngenderHealth as part of the Expanding Access to IUD Services in India project, examines IIUD and PPIUD continuation rates over time and investigates factors associated with IUD continuation. We recruited respondents (N = 5024) through a repeated cross-sectional household study between February and December 2019. We identified respondents using IUD client data from public health facility registers in 20 districts of Gujarat and Rajasthan. We compared continuation rates for IIUD and PPIUD adopters and used regression analyses to measure the association between continuation and demographic, quality of care, and counselling variables. IIUD continuation rates decreased from 85.6% to 78.3% and PPIUD rates decreased from 78.5% to 70.7% between month 3 and month 12. Clients experiencing side effects or other problems were 15 times more likely to discontinue IUD use than clients who did not. Clients who received IUD counselling prior to insertion were more likely to continue than those who did not. IUD continuation increased significantly in cases where both partners jointly selected the method compared to situations where women decided alone. Several sociodemographic factors were associated with continuation. Our study demonstrates the value and benefits of programmes offering IUD services emphasising quality counselling and client-centred care to increase access, uptake, and continuation.

Risk factors for postpartum intrauterine device expulsion among women delivering at a tertiary Hospital in Uganda: a prospective cohort study

Background

Postpartum intrauterine device (PPIUD) use refers to intrauterine device (IUD) insertion after delivery but within 48 h of birth. In Uganda, the general use of modern methods of contraception is low with < 1% of the women adopting the IUD as a method of contraception. An important limiting factor to increased uptake of immediate postpartum IUD insertion may be its expulsion rates which vary widely. There is minimal documentation PPIUD expulsion rates and factors associated with PPIUD expulsion during puerperium in Uganda.

Objective

We aimed to determine the proportion of TCu380A (copper) intrauterine devices expelled by 6 weeks postpartum, and identify risk factors for expulsion among women delivering at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.

Methods

We conducted a prospective cohort study from September 1, 2014 to January 31, 2015 at MRRH. We administered a structured questionnaire to all participants, to capture data on their baseline demographic, clinical and obstetric characteristics. We followed up women who accepted the PPIUD insertions at 6 weeks post insertion for any IUD expulsion. We fit multivariable log binomial regression models to identify risk factors for IUD expulsion.

Results

We enrolled 167 women who had PPIUDs inserted. Of the144 women who returned at 6 weeks for follow up, 13 (9%; 95%CI:4.9–15%) of them had the IUDs expelled. In the multivariable model, the significant risk factors for PPIUD expulsion were: IUD insertion more than 10 min post-delivery (aRR 8.1, 95%CI 1.26–51.98, p = 0.027) and bloody lochia flow of ≥15 days (aRR 8.5, 95%CI 1.47–48.47, p = 0.017).

Conclusion

The cumulative expulsion rate of postpartum IUDs among women delivering at MRRH was low and comparable to expulsion rates in interval insertions. Longer duration from delivery to IUD insertions and longer duration of bloody lochia flow were key risk factors for postpartum IUD expulsion. More emphasis should be put on prenatal counseling for postpartum family planning to allow for postplacental IUD insertions, which are associated with lower expulsion rates.

A 47-Year-Old Woman with Gastric Transmigration of an Intrauterine Contraceptive Device Managed by Laparoscopic Wedge Gastric Resection

Patient: Female, 47-year-old

Final Diagnosis: Perforated intrauterine contraceptive device

Symptoms: Asymptomatic

Medication:—

Clinical Procedure: —

Specialty: Surgery

Impact of immediate postpartum insertion of TCu380A on the quantity and duration of lochia discharges in Tanzania

BACKGROUND

The insertion of Intrauterine Contraceptive Device (PPIUD) for the purpose of contraception immediately after delivery is becoming popular in countries where the use of IUD for contraception has been extremely low. Since 2015, Tanzania implemented the initiative by the International Federation of Gynecology and Obstetrics (FIGO) to institutionalize PPIUD. As a result of capacity building and information delivery under the initiative, there have been increased uptake of the method. Working in this context, the focus of the study was to generate evidence on the effect of TCu380A IUD on amount and duration of lochia and equip service providers with evidence-based knowledge which can help them in counselling their PPIUD clients.

OBJECTIVE

Establish impact of postpartum TCu380A on amount and duration of lochia.

METHODS

A prospective cohort study of delivered women in two teaching hospitals in Tanzania with immediate insertion of TCu380A or without use of postpartum contraception in 2018. TCu380A models; Optima (Injeflex Co. Brazil) and Pregna (Pregna International, Chakan, India) were used. Follow-up was done by weekly calls and examination at 6th week. Lochia was estimated by Likert Scale 0-4 relative to the amount of lochia on the delivery day. An estimated 250 women sample (125 each group) would give 80% power to detect a desired 20% difference in the proportion of women with prolonged lochia discharges among the Exposed and Unexposed groups. Data analysis was by SPSS.

RESULTS

Two hundred sixty women were analysed, 127 Exposed and 133 Unexposed. Medical complaints were reported by 41 (28.9%) Exposed and 37 Unexposed (27.8%), p = 0.655. Lack of dryness by end of 6th week was to 31 (23.3%) Exposed and 9 (7.1%) Unexposed, p < 0.001. Exposed had higher weekly mean lochia scores throughout with the difference most marked in 5th week (3.556 Versus 2.039, p < 0.001) and 6th week (1.44 Versus 0.449, p<0.001).

CONCLUSION

PPIUD is associated with increased amount of lochia and slows progression to dryness within 6 weeks of delivery. The implications of PPIUD clients' needs to be informed about the possibility of delayed dryness of lochia at time of counseling are discussed.

A one-year cohort study of complications, continuation, and failure rates of postpartum TCu380A in Tanzania

Background

Less than 1% of married women in Tanzania use an Intrauterine Contraceptive Device (IUD) for contraception. An initiative by the International Federation of Gynecology and Obstetrics (FIGO) has been in progress since 2015 resulting in escalated method uptake in implementing hospitals. This study investigates failure rate, complications, and risk factors for one-year continuation of TCu380A IUD when used for immediate postpartum contraception under the initiative in Tanzania.

Methodology

A prospective cohort study of women who had TCu380A insertion within 48 h of delivery in 6 hospitals in Tanzania between 1st December 2017 and 18th April 2018 was conducted. Face to face post insertion interviews were made with 1114 clients before discharge and later through phone calls up to the beginning of 13th month postpartum. Postpartum Intrauterine Device (PPIUD) continuation status, complications, duration of time they stayed with the IUD and the currently used method if PPIUD was discontinued were enquired. The outcome variable was PPIUD continuation at one year of IUD insertion. Data were analyzed using Statistical Product and Service Solutions software (SPSS) for Windows version 20 (IBM SPSS Statistics, Chicago, IL, USA).

Results

In total 511(45.8%)clients had consented and availed to complete the one-year follow-up. Out of these, 440 still had IUD, giving a one-year continuation rate of 86.1%. Most (63%) IUD discontinuations occurred in the period between 7th week and 6 months of insertion. One-year method expulsion rate was 2.1%. There was one reported pregnancy that gives a method failure rate of about 2 per 1000. The independent risk factors in favor of method continuation at one year were absence of medical or social problem, being a youth (16–24 years), and delivery by Cesarean section.

Conclusions

The continuation rate when CuT380A is used for immediate postpartum contraception is high, with low complication and failure rates. Some medical and social factors are important for method continuation, hence the need to consider in training, counselling and advocacy.

Post-placental intrauterine device insertion vs puerperal insertion in women undergoing caesarean delivery in Egypt: a 1 year randomised controlled trial

OBJECTIVE

The aim of the study was to compare 6 month expulsion rates of the copper-bearing intrauterine device (IUD) inserted after delivery of the placenta or at the 6 week postpartum visit in women undergoing caesarean section.

METHODS

A parallel-group randomised trial was conducted in an Egyptian university hospital between February 2016 and December 2018. Participants were randomised to either post-placental IUD insertion or IUD insertion at the 6 week postpartum visit. Participants were followed for 12 months. Primary outcomes were IUD expulsion and the proportion of women using an IUD at 6 months. A secondary outcome was the cumulative pregnancy rate at 12 months.

RESULTS

Five hundred participants were enrolled in each group. At 6 months the total expulsions were 58/416 (13.9%) in the post-placental group and 4/214 (1.9%) in the puerperal group; IUD use at 6 months was 416/478 (87.0%) in the post-placental group and 214/232 (92.2%) in the puerperal group. Data collected by phone at 12 months showed a higher cumulative pregnancy rate in the puerperal group (84/500, 16.8%) vs the post-placental group (22/500, 4.4%). IUD continuation at 12 months was higher in the post-placental group.

CONCLUSION

Participants in the post-placental group had a higher expulsion rate at 6 months, but more IUDs were placed in this group and fewer pregnancies had occurred at 12 months compared with the puerperal group.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02679820.

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

OBJECTIVES

To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.

STUDY ELIGIBILITY CRITERIA

We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.

STUDY APPRAISAL AND SYNTHESIS METHODS

We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.

RESULTS

We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65).

CONCLUSION

Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.

Importance of the delivery-to-insertion interval in immediate postpartum intrauterine device insertion: A secondary analysis

OBJECTIVE

To evaluate the delivery-to-insertion interval for copper postpartum intrauterine devices (PPIUDs).

METHODS

Secondary analysis of two related studies at five academic sites in India from March 2015 to July 2016. IUDs were inserted within 48 hours of vaginal delivery. Women (n=560) were grouped by whether they underwent postplacental (≤10 minutes) or immediate (>10 minutes) insertion. Outcomes were complete expulsion at the 6-8-week follow-up (primary), and IUD-to-fundus distance, as assessed by postinsertion ultrasound (secondary).

RESULTS

Overall, 93 (16.6%) women received a postplacental PPIUD and 467 (83.4%) received an immediate PPIUD. Complete expulsion at follow-up was 3.2% (n=3) in the postplacental and 7.5% (n=35) in the immediate postpartum group (P=0.176; difference in proportions, 4.3%; 95% confidence interval, -2.0 to 8.1). Distance from the fundus did not differ between the two groups (P=0.107); high fundal placement (≤10 mm from the internal endometrial verge) was achieved for most women.

CONCLUSION

The present data challenge previous guidance on the timing of PPIUD insertion. The 10-minute insertion window is a barrier to uptake and should be reassessed for inclusion in service delivery guidelines. A flexible interval would accommodate the multiple post-delivery tasks of providers and increase access to PPIUD.

Post-placental Intrauterine Device Insertion Versus Delayed Intrauterine Device Insertion: An Observational Study

Abstract

Immediate post-placental IUD insertion is defined as IUD insertion within 10 min of the expulsion of the placenta. Although the expulsion rate in post-placental insertion is higher than interval insertion, the benefits of highly effective contraception immediately after delivery may outweigh the risks of expulsion.

Aims

To compare post-placental IUD (PPIUD) insertion with interval IUD insertion (IIUD) in terms of safety, effect on menstrual cycle, efficacy and satisfaction.

Materials and Methods

After meeting all eligibility criteria, the patients were asked to choose between post-placental IUD insertion and interval/delayed IUD insertion. In PPIUD group, insertion was done within 10 min of expulsion of placenta by hand technique. Individuals in IIUD group were asked to return after 6 weeks for IUD insertion by withdrawal technique. Both the groups were followed at 6 weeks, 6 months, 12 months by history, physical examination, per speculum examination and ultrasonography.

Observations

238 patients were allocated to PPIUD group and 273 to IIUD group. In the PPIUD group, there was no bleeding/spotting demonstrable as it was masked by the lochia. Mild pain at insertion was seen in only 11 patients in the PPIUD group. Slight bleeding/spotting was seen in 7.8% patients in the IIUD group, while mild to moderate pain was seen in 39.9% patients. At 6 weeks, 6 months and 1 year follow up with regard to patients complaining of pelvic pain/dysmenorrhea, the difference between the two groups was not statistically significant. Our study found that irregular bleeding or spotting was more in interval insertion than in the post-placental group. The difference in the two groups was statistically significant at 6 weeks and 6 months, but was not significant at 1 year. There was no case of perforation in either group. Our study found a statistically significant difference in expulsion after post-placental compared to delayed insertion. The difference between the two groups was statistically significant (p = 0.006) for cumulative expulsion. However, for interval expulsion rate, the difference was not statistically significant (p = 0.6). In our study, continuation rates appear to be higher in the PPIUD group, but the difference is not statistically significant.

Conclusion

PPIUD is a safe, easy and effective alternative to interval IUD insertion and qualifies to be popularized as a first-line contraceptive agent in eligible patients owing to its immediate and sustained contraceptive benefit, patient comfort, convenience and lower incidence of side effects.

Immediate Postpartum Long-Acting Reversible Contraception Programs in Texas Hospitals Following Changes to Medicaid Reimbursement Policy

OBJECTIVES

Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption.

METHODS

Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services.

RESULTS

Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs.

CONCLUSIONS FOR PRACTICE

We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.

Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

METHODS OF STUDY SELECTION

We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

TABULATION, INTEGRATION, AND RESULTS

We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A.

CONCLUSION

Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

One-year continuation of postpartum intrauterine contraceptive device: findings from a retrospective cohort study in India

Objective

To evaluate outcomes of a national postpartum (within 48 h of delivery) copper intrauterine device placement (PPCuIUD) program in six “high-focus states” with high unmet family planning need in India.

Study design

We identified high-volume district hospitals that provided PPCuIUD in six (Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Chhattisgarh) Indian states (two per state). Each selected hospital maintained a list of PPCuIUD acceptors with contact phone numbers. We randomly selected 100 women at each site for inclusion in a telephone survey of IUD outcomes at 1 year. Questions regarded IUD expulsion, discontinuation because of symptoms (e.g., pain, bleeding, discharge), discontinuation for other reasons and use of alternative contraception if discontinuation reported.

Results

We could contact 844 of the 1200 randomly selected women, of whom 673 (79.7%) had postplacental insertion (within 10 min of delivery), while 171 (20.3%) had an early postpartum insertion (between 10 min to 48 h after delivery). Of those contacted, 530 women (62.8%) reported continuing with the method beyond 1 year, 63 (7.5%) reported having an expulsion, 163 (19.3%) reported having removals for associated side effects (bleeding, pain and discharge), and 88 (10.4%) reported having removals for other reasons. After removal or expulsion, almost half of the women (46.5%) did not switch to any other modern contraceptive method.

Conclusion

PPCuIUD continuation rate at 1 year was 62.8%. Most removals within 1 year were due to associated side effects. Almost half of the women discontinuing PPCuIUD did not switch to an alternative modern contraceptive method.

Implications

The 1-year continuation rate of PPCuIUD achieved through a large-scale national program in India is satisfactory. The program though needs to address the low uptake of other modern contraceptive methods after discontinuation.

A Decision Analysis Model of 1-Year Effectiveness of Intended Postplacental Compared With Intended Delayed Postpartum Intrauterine Device Insertion

OBJECTIVE

To compare, using decision analysis methodology, the 1-year probability of pregnancy after intended postplacental intrauterine device (IUD) insertion with intended delayed insertion at an outpatient postpartum visit (delayed postpartum placement).

METHODS

We developed an evidence-based decision model with the primary outcome of 1-year probability of pregnancy. We compared 1-year probability of pregnancy after intended postplacental or intended delayed postpartum IUD placement. We obtained estimates from the literature for the proportions of the following: mode of delivery, successful IUD placement, IUD type, postpartum visit attendance, IUD expulsion, IUD discontinuation, and contraceptive use, choice, and efficacy after IUD discontinuation. We performed sensitivity analyses and a Monte Carlo simulation to account for variations in proportion estimates.

RESULTS

One-year probabilities of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a postplacental IUD after vaginal birth and 1,250,000 women intending to receive a postplacental IUD after cesarean birth were 17.3% and 11.2%, respectively; the 1-year probability of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a delayed postpartum IUD was 24.6%. For delayed postpartum IUD placement to have effectiveness equal to postplacental placement, 91.4% of women delivering vaginally and 99.7% of women delivering by cesarean would need to attend postpartum care. Once placed, the effectiveness of postplacental IUDs was lower than that of delayed postpartum IUDs: 1-year probabilities of pregnancy after IUD placement at a vaginal birth, cesarean birth, and an outpatient postpartum visit were 15.4%, 6.6%, and 3.9%, respectively.

CONCLUSION

After accounting for factors that affect successful IUD placement and retention, this decision model indicates that intended postplacental IUD insertion results in a lower 1-year probability of pregnancy as compared with intended delayed postpartum IUD insertion.

Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery

BACKGROUND

Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited.

OBJECTIVE

We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion.

STUDY DESIGN

In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months.

RESULTS

We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7-13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1-22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2-21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2-14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8-11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21-3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20-23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90-43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0-86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9-31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5.

CONCLUSION

This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow-up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.

Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study

BACKGROUND

An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly.

OBJECTIVE

We sought to compare expulsion rates by 12 weeks' postpartum for the levonorgestrel intrauterine system and copper intrauterine device.

STUDY DESIGN

We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks' gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator's hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours' postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion.

RESULTS

We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99-6.55; P = .05). At 24 hours' postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks' postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14).

CONCLUSION

Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

Long-Acting Reversible Contraception Initiation With a 2- to 3-Week Compared With a 6-Week Postpartum Visit

OBJECTIVE

To evaluate whether a department policy changing the scheduling of the postpartum visit from 6 weeks to 2-3 weeks after delivery is associated with higher long-acting reversible contraception initiation at the postpartum visit.

METHODS

We conducted a quasiexperimental before-after study to evaluate long-acting reversible contraception initiation, specifically an intrauterine device or contraceptive implant, at the postpartum visit between women scheduled for follow-up at 6 weeks (before policy change) and 2-3 weeks after delivery (after policy change). Secondary outcomes included postpartum visit completion, overall contraception initiation at the postpartum visit, overall contraceptive use at 6 months after delivery, and repeat pregnancies by 6 months postpartum. We obtained delivery and postpartum information using the electronic medical record and contacted participants 3 and 6 months after delivery to assess contraception use and repeat pregnancies.

RESULTS

We enrolled 586 participants between December 2014 and November 2015, of whom 512 women (256 in each cohort) continued to meet eligibility criteria after delivery. Long-acting reversible contraception initiation rates at the postpartum visit were lower in the 2- to 3-week (16.5%, 95% CI 12.2-21.8) compared with the 6-week group (31.1%, 95% CI 25.2-37.7, P<.01), primarily as a result of patient and health care provider preferences for delaying intrauterine device insertion to a later visit. More women completed a scheduled 2- to 3-week postpartum visit (90.2%, 95% CI 86.0-93.3) compared with a 6-week visit (81.6%, 95% CI 76.4-85.9, P<.01). Deferral of any contraception initiation was higher in the 2- to 3-week group (27.3%, 95% CI 21.9-33.4) compared with the 6-week group (15.8%, 95% CI 11.5-21.4, P<.01), but there were no differences in overall contraceptive use patterns at 6 months postpartum. No intrauterine device perforations or expulsions were observed in women who underwent insertion at 2-3 weeks postpartum. Five pregnancies were reported in each cohort by 6 months after delivery.

CONCLUSION

Scheduling a visit at 2-3 weeks after delivery was not associated with increased long-acting reversible contraception initiation at this visit despite higher postpartum visit attendance.

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

BACKGROUND

During 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.

METHODS

This 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.

DISCUSSION

This 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 REGISTRATION

Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Feasibility, acceptability, and uptake of postpartum intrauterine contraceptive devices in southern Nigeria

OBJECTIVE

To evaluate the effect of postpartum intrauterine contraceptive device (PPIUD) implantation on existing low contraceptive uptake and utilization in Nigeria.

METHODS

A prospective analytical cohort study was conducted at eight medical facilities in southern Nigeria between June 1, 2014 and May 31, 2015. Patients undergoing delivery during the study period were considered for eligibility and the exclusion criteria included any contraindications to PPIUD implantation. Following counselling, participants underwent PPIUD insertion within either 10minutes (post-placental) or 48hours (immediate) of delivery, or at cesarean delivery. All participants were scheduled to attend 14-day and 6-week follow-up. The primary outcome measure was the PPIUD-uptake rate and secondary outcome measures included patient satisfaction and complication rates.

RESULTS

There were 1061 deliveries recorded during the study period; 746 patients were offered PPIUDs, with 374 (50.1%) accepting and undergoing insertion. Immediate post-partum insertion was performed for 199 (53.2%) participants, with 169 (45.2%) and 6 (1.6%) undergoing post-placental and intra-cesarean insertion, respectively.

CONCLUSION

PPIUD was safe and acceptable to Nigerian women. Increasing the education of patients and training of healthcare providers is recommended to scale-up PPIUD use in Nigeria.

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

41% of women delivering in the social franchise private facilities chose the postpartum IUD. Factors associated with acceptance included lower education, higher parity, and being single. Scale-up of postpartum IUD services in both public and private facilities has the potential to significantly increase use of long-acting reversible contraception in Nigeria.

Background:

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.

Methods:

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.

Results:

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).

Conclusion:

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.

A facility birth can be the time to start family planning: postpartum intrauterine device experiences from six countries

Initiation of family planning at the time of birth is opportune, since few women in low-resource settings who give birth in a facility return for further care. Postpartum family planning (PPFP) and postpartum intrauterine device (PPIUD) services were integrated into maternal care in six low- and middle-income countries, applying an insertion technique developed in Paraguay. Facilities with high delivery volume were selected to integrate PPFP/PPIUD services into routine care. Effective PPFP/PPIUD integration requires training and mentoring those providers assisting women at the time of birth. Ongoing monitoring generated data for advocacy. The percentages of PPIUD acceptors ranged from 2.3% of women counseled in Pakistan to 5.8% in the Philippines. Rates of complications among women returning for follow-up were low. Expulsion rates were 3.7% in Pakistan, 3.6% in Ethiopia, and 1.7% in Guinea and the Philippines. Infection rates did not exceed 1.3%, and three countries recorded no cases. Offering PPFP/PPIUD at birth improves access to contraception.

Intrauterine devices and risk of uterine perforation: current perspectives

Uterine perforation is an uncommon complication of intrauterine device insertion, with an incidence of one in 1,000 insertions. Perforation may be complete, with the device totally in the abdominal cavity, or partial, with the device to varying degrees within the uterine wall. Some studies show a positive association between lactation and perforation, but a causal relationship has not been established. Very rarely, a device may perforate into bowel or the urinary tract. Perforated intrauterine devices can generally be removed successfully at laparoscopy.

Comparison of outcomes at 6 weeks following postpartum intrauterine contraceptive device insertions by doctors and nurses in India: a case-control study

Objective

As part of a strategy to revitalize postpartum family planning services, Government of India revised its policy in 2013 to permit trained nurses and midwives to insert postpartum intrauterine contraceptive devices (PPIUCDs). This study compares two key outcomes of PPIUCD insertions — expulsion and infection — for physicians and nurses/midwives to generate evidence for task sharing.

Study design

We analyzed secondary data from the PPIUCD program in seven states using a case–control study design. We included facilities where both doctors and nurses/midwives performed PPIUCD insertions and where five or more cases of expulsion and/or infection were reported during the study period (January–December 2013). For each case of expulsion and infection, we identified a time-matched control who received a PPIUCD at the same facility and had no complaints. We performed a multiple logistic regression analysis focusing on provider cadre while controlling for potential confounding factors.

Results

In 137 facilities, 792 expulsion and 382 infection cases were matched with 1041 controls. Provider type was not significantly associated with either expulsion [odds ratio (OR) 1.84; 95% confidence interval (CI): 0.82–4.12] or infection (OR 0.73; 95% CI: 0.39–1.37). Compared with centralized training, odds of expulsion were higher for onsite (OR 2.32, 95% CI: 1.86–2.89) and on-the-job training (OR 1.23, 95% CI: 1.11–1.36), but odds of infection were lower for onsite (OR 0.45, 95% CI: 0.27–0.75) and on-the-job training (OR 0.31, 95% CI: 0.25–0.37).

Conclusion

Trained nurses and midwives who conduct deliveries at public health facilities can perform PPIUCD insertions as safely as physicians.

Implications

Institutional deliveries are increasing in India, but most normal vaginal deliveries at public health facilities are attended by nurses and midwives due to a shortage of physicians. Task sharing with nurses and midwives can increase women's access to and the acceptability of quality PPIUCD services.

Adolescent Pregnancy Guidelines

OBJECTIVE

To describe the needs and evidence-based practice specific to care of the pregnant adolescent in Canada, including special populations.

OUTCOMES

Healthy pregnancies for adolescent women in Canada, with culturally sensitive and age-appropriate care to ensure the best possible outcomes for these young women and their infants and young families, and to reduce repeat pregnancy rates.

EVIDENCE

Published literature was retrieved through searches of PubMed and The Cochrane Library on May 23, 2012 using appropriate controlled vocabulary (e.g., Pregnancy in Adolescence) and key words (e.g., pregnancy, teen, youth). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to English or French language materials published in or after 1990. Searches were updated on a regular basis and incorporated in the guideline to July 6, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, national and international medical specialty societies, and clinical practice guideline collections.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS/HARMS/COSTS: These guidelines are designed to help practitioners caring for adolescent women during pregnancy in Canada and allow them to take the best care of these young women in a manner appropriate for their age, cultural backgrounds, and risk profiles.

RECOMMENDATIONS

1. Health care providers should adapt their prenatal care for adolescents and offer multidisciplinary care that is easily accessible to the adolescent early in the pregnancy, recognizing that adolescents often present to care later than their adult counterparts. A model that provides an opportunity to address all of these needs at one site may be the preferred model of care for pregnant adolescents. (II-1A) 2. Health care providers should be sensitive to the unique developmental needs of adolescents through all stages of pregnancy and during intrapartum and postpartum care. (III-B) 3. Adolescents have high-risk pregnancies and should be managed accordingly within programs that have the capacity to manage their care. The unique physical risks of adolescent pregnancy should be recognized and the care provided must address these. (II-1A) 4. Fathers and partners should be included as much as possible in pregnancy care and prenatal/infant care education. (III-B) 5. A first-trimester ultrasound is recommended not only for the usual reasons for properly dating the pregnancy, but also for assessing the increased risks of preterm birth. (I-A) 6. Counselling about all available pregnancy outcome options (abortion, adoption, and parenting) should be provided to any adolescent with a confirmed intrauterine gestation. (III-A) 7. Testing for sexually transmitted infections (STI) (II-2A) and bacterial vaginosis (III-B) should be performed routinely upon presentation for pregnancy care and again in the third trimester; STI testing should also be performed postpartum and when needed symptomatically. a. Because pregnant adolescents are inherently at increased risk for preterm labour, preterm birth, and preterm pre-labour rupture of membranes, screening and management of bacterial vaginosis is recommended. (III-B) b. After treatment for a positive test, a test of cure is needed 3 to 4 weeks after completion of treatment. Refer partner for screening and treatment. Take the opportunity to discuss condom use. (III-A) 8. Routine and repeated screening for alcohol use, substance abuse, and violence in pregnancy is recommended because of their increased rates in this population. (II-2A) 9. Routine and repeated screening for and treatment of mood disorders in pregnancy is recommended because of their increased rates in this population. The Edinburgh Postnatal Depression Scale administered in each trimester and postpartum, and more frequently if deemed necessary, is one option for such screening. (II-2A) 10. Pregnant adolescents should have a nutritional assessment, vitamins and food supplementation if needed, and access to a strategy to reduce anemia and low birth weight and to optimize weight gain in pregnancy. (II-2A) 11. Conflicting evidence supports and refutes differences in gestational hypertension in the adolescent population; therefore, the care usual for adult populations is supported for pregnant adolescents at this time. (II-2A) 12. Practitioners should consult gestational diabetes mellitus (GDM) guidelines. In theory, testing all patients is appropriate, although rates of GDM are generally lower in adolescent populations. Practitioners should be aware, however, that certain ethnic groups including Aboriginal populations are at high risk of GDM. (II-2A) 13. An ultrasound anatomical assessment at 16 to 20 weeks is recommended because of increased rates of congenital anomalies in this population. (II-2A) 14. As in other populations at risk of intrauterine growth restriction (IUGR) and low birth weight, an ultrasound to assess fetal well-being and estimated fetal weight at 32 to 34 weeks gestational age is suggested to screen for IUGR. (III-A) 15. Visits in the second or third trimester should be more frequent to address the increased risk of preterm labour and preterm birth and to assess fetal well-being. All caregivers should be aware of the signs and symptoms of preterm labour and should educate their patients to recognize them. (III-A) 16. It should be recognized that adolescents have improved vaginal delivery rates and a concomitantly lower Caesarean section rate than their adult counterparts. (II-2A) As with antenatal care, peripartum care in hospital should be multidisciplinary, involving social care, support for breastfeeding and lactation, and the involvement of children's aid services when warranted. (III-B) 17. Postpartum care should include a focus on contraceptive methods, especially long-acting reversible contraception methods, as a means to decrease the high rates of repeat pregnancy in this population; discussion of contraception should begin before delivery. (III-A) 18. Breastfeeding should be recommended and sufficient support given to this population at high risk for discontinuation. (II-2A) 19. Postpartum care programs should be available to support adolescent parents and their children, to improve the mothers' knowledge of parenting, to increase breastfeeding rates, to screen for and manage postpartum depression, to increase birth intervals, and to decrease repeated unintended pregnancy rates. (III-B) 20. Adolescent women in rural, remote, northern, and Aboriginal communities should be supported to give birth as close to home as possible. (II-2A) 21. Adolescent pregnant women who need to be evacuated from a remote community should be able to have a family member or other person accompany them to provide support and encouragement. (II-2A) 22. Culturally safe prenatal care including emotional, educational, and clinical support to assist adolescent parents in leading healthier lives should be available, especially in northern and Aboriginal communities. (II-3A) 23. Cultural beliefs around miscarriage and pregnancy issues, and special considerations in the handling of fetal remains, placental tissue, and the umbilical cord, must be respected. (III).

Urgent need to change clinical practices about postpartum contraception

In the United States, maternal mortality and unintended pregnancy rates are increasing. There are growing disparities in maternal health between indigent, minority women and Caucasian women of higher socioeconomic status. Family planning has long been viewed as a solution to these problems. As reliance on permanent contraception has diminished, timely access to highly effective contraceptive methods, namely long acting reversible contraceptives, which includes the contraceptive hormonal implant and intrauterine device - has become even more important. For women in the United States and abroad, the time of delivery is the one reliable opportunity for women to receive medical care. Consistently, research has shown that providing contraception in the immediate postpartum period is safe, effective, feasible and cost effective. However, misperceptions, lack of supplies, and reimbursement issues combine to defeat attempts to provide the most effective methods of contraception during that hospitalization. We believe that it is time to tackle the problem of unintended and rapid repeat pregnancy using an evidence-based, patient-centered paradigm and to eradicate systemic barriers blocking access to contraceptive methods during hospital stay. This editorial will outline some of the more compelling evidence supporting this move and will provide insights from successful programs.

Postpartum contraception

As birth spacing has demonstrated health benefits for a woman and her children, contraception after childbirth is recognized as an important health issue. The potential risk of pregnancy soon after delivery underscores the importance of initiating postpartum contraception in a timely manner. The contraceptive method initiated in the postpartum period depends upon a number of factors including medical history, anatomic and hormonal factors, patient preference, and whether or not the woman is breastfeeding. When electing a contraceptive method, informed choice is paramount. The availability of long-acting reversible contraceptive methods immediately postpartum provides a strategy to achieve reductions in unintended pregnancy.

Use of ultrasound in predicting success of intrauterine contraceptive device insertion immediately after delivery

OBJECTIVES

To assess by ultrasound examination the success of insertion of an intrauterine contraceptive device (IUD) immediately after delivery and to determine the optimal distance between the lower end of the IUD and the internal os in predicting successful retention of an IUD.

METHODS

This was a prospective study carried out between December 2012 and April 2013. Two ultrasound examinations, transabdominal and transvaginal, were performed prior to hospital discharge following delivery and again at 6 weeks following delivery in women who received a postpartum IUD. Distance from the internal os to the lower end of the IUD was measured at each examination and compared in unsuccessful and successful cases of postvaginal delivery (PVD) and post-Cesarean section (PCS) IUD insertion. Logistic regression and receiver-operating characteristics (ROC) curve analysis were used to determine the difference in success between the two modes of delivery and to determine the optimal cut-off of the internal os-to-IUD distance for successful retention, respectively.

RESULTS

Ninety-one women were included in the study, comprising 60 PVD and 31 PCS IUD insertions. Thirteen PVD (22.4%) and eight PCS (25.8%) IUDs were either expelled spontaneously or removed at the 6-week scan because of improper placement. Mean distance from the internal os to the lower end of the IUD on ultrasound examination immediately after insertion was significantly greater in successful cases than in those in which IUDs were subsequently expelled/displaced (mean difference after PVD insertion, 20.1 mm (P = 0.006); mean difference after PCS insertion, 10.3 mm (P = 0.05)). Logistic regression analysis demonstrated that mode of delivery was not independently associated with successful retention of the IUD (P = 0.72; OR, 0.831 (95% CI, 0.301-2.189)). The distance from the lower end of the IUD to the internal os measured at ultrasound examination prior to hospital discharge provided reasonable predictive accuracy for determining retention of the IUD, with an area under the ROC curve of 0.74 (95% CI, 0.60-0.88) and an optimal cut-off of ≥ 30 mm (sensitivity, 64.71% (95% CI, 52.17-75.92%) and specificity, 80.95% (95% CI, 58.09-94.55%)).

CONCLUSIONS

IUD insertion immediately postpartum is feasible but carries a substantial risk of unsuccessful IUD retention. Ultrasound examination after insertion of an IUD could be considered for predicting the success of IUD retention.

Immediate postpartum insertion of intrauterine device for contraception

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Expulsion of Nova-T380, Multiload 375, and Copper-T380A contraceptive devices inserted during cesarean delivery

OBJECTIVE

To compare the expulsion rate of Nova-T380, Multiload 375, and Copper-T380A intrauterine contraceptive devices (IUCDs) inserted during cesarean delivery.

METHODS

A comparative randomized study was conducted between January 1, 2013, and June 30, 2014, in three maternity centers in Egypt and Saudi Arabia. All women scheduled for an elective cesarean and accepting intraoperative insertion of an IUCD were randomly allocated to receive the Nova-T380 (group 1), Multiload 375 (group 2), or Cu-T380A (group 3) using a computer-generated table. Researchers and participants were not masked to the type of IUCD. Follow-up was for 1 year. The primary outcome was IUCD expulsion (complete or partial [i.e. displacement]).

RESULTS

Each group contained 40 participants. At 1 year, expulsion had been reported for 5 (13%) women in group 1, 2 (5%) in group 2, and 6 (15%) in group 3 (P>0.05 for all). The frequency of displacement was significantly lower in group 2 (5 [13%] participants) than in group 1 (15 [38%]; P=0.001) and group 3 (14 [35%]; P=0.008).

CONCLUSION

Despite a comparable risk of expulsion following IUCD insertion during cesarean delivery, the Multiload 375 device showed the lowest risk of displacement.

Woman's contraceptive needs and preferences in the postpartum period: an Italian study

AIMS AND OBJECTIVES

To describe what puerperal women know about postpartum contraception and to identify their related needs and expectations.

BACKGROUND

Puerperal women face the problem of beginning or resuming contraception, the choice of the right method of contraception and the right time to start it. This choice becomes particularly important in case they breastfeed since the contraceptive method should not interfere with breastfeeding. Different factors, such as the level of knowledge women have about various contraceptive methods, their individual preferences or their desire to have a baby, can strongly influence this choice.

DESIGN

A cross-sectional study had been carried out within the period of six months, from November 2011-February 2012.

METHODS

Three hundred puerperal women were interviewed before their discharge from a Maternity Home. The women were asked for their personal characteristics, their maternity history, the information they had received, their knowledge and expectations about postpartum contraception and their intention to use contraception.

RESULTS

During pregnancy and postpartum, 45.5% of the women reported that they had received adequate information about contraception. Of these ones, 64.3% reported their intention to use contraception either to avoid pregnancy or to space out future births, even if they did not always have appropriate knowledge about fertility and the use of contraceptive methods during postpartum. During this study, we also discovered that women's intention to use contraception was proportional to their level of education.

CONCLUSION

Women need more and appropriate information about postpartum contraception, to make a conscious choice in relation to their needs and without putting their health at risk.

RELEVANCE TO CLINICAL PRACTICE

To promote awareness of the choices related to postpartum contraception, it is important to understand the personal characteristics that influence or hinder this choice. Midwives can play a very important role in informing women and in developing educational interventions to support a safe contraceptive choice.

Intrauterine device insertion in the postpartum period: a systematic review

OBJECTIVES

Given new research on postpartum placement of levonorgestrel and copper intrauterine devices (IUDs), our objective was to update a prior systematic review of the safety and expulsion rates of postpartum IUDs.

METHODS

We searched MEDLINE, CENTRAL, LILACS, POPLINE, Web of Science, and ClinicalTrials.gov databases for articles between the database inception until July 2013. We included studies that compared IUD insertion time intervals and routes during the postpartum period. We used standard abstract forms and the United States Preventive Services Task Force grading system to summarise and assess the quality of the evidence.

RESULTS

We included 18 articles. New evidence suggests that a levonorgestrel releasing-intrauterine system (LNG-IUS) insertion within 48 hours of delivery is safe. Postplacental insertion and insertion between 10 minutes and 48 hours after delivery result in higher expulsion rates than insertion 4 to 6 weeks postpartum, or non-postpartum insertion. Insertion at the time of caesarean section is associated with lower expulsion rates than postplacental insertion at the time of vaginal delivery.

CONCLUSIONS

This review supports the evidence that insertion of an intrauterine contraceptive within the first 48 hours of vaginal or caesarean delivery is safe. Expulsion rates should be further studied in larger randomised controlled trials.

Clinical Outcome of Postplacental Copper T 380A Insertion in Women Delivering by Caesarean Section

INTRODUCTION

Short interconception period after caesarean section and its associated risk of increased morbidity, mortality and surgical interventions could be avoided by postplacental IUCD insertion during the procedure. Despite the safety reports on intracaesarean IUCD insertion, obstetricians are still hesitant to extend the benefit of this long acting reversible contraception to women undergoing operative delivery.

OBJECTIVE

To study the clinical outcome (safety, efficacy, expulsion and continuation rates) of postplacental Copper T 380A insertion in primiparous women undergoing caesarean section.

MATERIALS AND METHODS

This study was a prospective observational study, carried out in the Department of Obstetrics and Gynaecology, Safdarjung hospital, which is a tertiary care hospital of Northern India. Primiparous women who delivered by caesarean section over a period of six months (July 2012 to December 2012), willing for postplacental intracaesarean IUCD insertion, and willing to comply with the study protocol, were recruited for the study. All these subjects fulfilled the WHO Standard Medical Criteria for PPIUCD insertion; follow up visits were scheduled at 1, 3, 6 and 12 months.

RESULTS

A total of 300 primiparous women underwent postpartum intracaesarean insertion of Copper T 380A. The mean age of women included in the study was 23.12 ± 2.42 years. Most common postinsertion complication observed in the immediate postoperative period was febrile morbidity (2%). Majority of women (94.33%) had hospital stay of less than 4 days. The common adverse events observed during follow-up of 12 months were menstrual complaints, excessive vaginal discharge and persistent pelvic pain. At the end of one year, there were 16 expulsions, 21 removals, and 2 pregnancies with gross cumulative expulsion, removal, failure and continuation rates of 5.33%, 7%, 0.67% and 91%, respectively.

CONCLUSION

Postplacental intracaesarean Copper T 380A insertion in primiparous women is a safe and effective method of reversible contraception, with low expulsion and high continuation rates.

Association of the Position of the Copper T 380A as Determined by the Ultrasonography Following its Insertion in the Immediate Postpartum Period with the Subsequent Complications: An Observational Study

PURPOSE

Incorrectly placed copper T 380A leads to increased contraception failure. This study aimed to find an association between the ultrasonographic position of the copper T 380A in the immediate postpartum period and the adverse effects observed during the period of 6 months after its insertion.

METHODS

This descriptive study was carried out in the Department of Obstetrics & Gynaecology of a tertiary-care-center of India from September 2011 to February 2013. The women eligible for immediate postpartum copper T 380A insertion with previous regular menstrual cycles for at least 6 months before the current pregnancy, and those who were willing for follow-up visits and had easy accessibility to the hospital, were recruited. A clinical evaluation and ultrasonographic assessment of Intra-Uterine-Contraceptive-Device (IUCD) after insertion was carried out after enrolment. The complications (expulsions, vaginal discharge, menstrual irregularity, and lower abdominal pain) were subsequently assessed during a 6-month follow-up period. The primary objective was the ultrasonographic assessment of the placement of IUCD immediately after insertion. The incidence of complications and their association with the presence of malposition was also studied.

RESULTS

Hundred patients were evaluated during the study period. Forty-four (44 %) women were found to have malpositioned IUCDs on ultrasonographic evaluation done following insertion. The complications among the IUCD users included menstrual irregularity (27.17 %), pain in lower abdomen (20.65 %), vaginal discharge (7.6 %), and expulsions (9.7 %). The IUCD expulsions, menstrual irregularities, and pain were significantly more in patients with malpositions (p < 0.05).

CONCLUSIONS

Malpositioning of IUCD is common immediately following insertion and is significantly associated with more complications during the follow-up.