Women’s experiences of accessing postpartum intrauterine contraception in a public maternity setting: a qualitative service evaluation

Pain experiences during intrauterine device procedures: a thematic analysis of tweets

INTRODUCTION

In June 2021, high-profile testimonials in the media about pain during intrauterine device (IUD) procedures in the UK prompted significant discussion across platforms including Twitter (subsequently renamed X). We examined a sample of Twitter postings (tweets) to gain insight into public perspectives and experiences.

METHODS

We harvested tweets posted or retweeted on 21-22 June 2021 which contained the search terms coil, intrauterine system, IUD or intrauterine. We analysed the dataset thematically and selected illustrative tweets with the authors' consent for publication.

RESULTS

Following deduplication and screening, we included 1431 tweets in our analysis. We identified testimonials with descriptions of varied pain experiences. Twitter users reported that clinicians had not warned them that pain could be severe or explained the options for pain relief. Some raised concerns about pain being minimised or dismissed and linked this to the management of women's pain in medicine more broadly. Twitter users described connecting to an online community with shared experiences as validating and used this as a springboard for collective action.

CONCLUSIONS

While we acknowledge the limitations of our sample, this study highlights important perspectives and accounts relating to pain during IUD procedures. Our findings attest to the need for strategies to improve the patient experience for those opting for IUD as a clinical priority. Further research should explore IUD users' experiences, expectations and wishes around pain management.

Scoping review protocol: exploration of the barriers and facilitators to the uptake of early postnatal contraception

INTRODUCTION

It is well documented that many women do not desire a short interpregnancy interval. Medical societies, government agencies and leaders in the field recommend that contraception should be part of maternity care. Short spaced and unplanned pregnancies increase the chances of mortality and morbidity in the mother and child. The WHO recommends a 24-month interpregnancy interval; however, short pregnancy intervals remain common. The goal of this scoping review will be to explore barriers and facilitators to the uptake of early postnatal contraception. A review of globally published literature relating to the implementation of a postnatal contraception service provision globally will be carried out which will highlight evidence gaps, strengths and weaknesses of studies associated with uptake and known barriers and facilitators to the uptake of early postnatal contraception.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The search strategy aims to locate both published and unpublished studies. An initial limited search of PubMed and CINAHL was undertaken to identify articles on the provision of postnatal contraception. The search strategy will be adapted for each included database CINAHL, SCOPUS, MEDLINE, PROSPERO and COCHRANE from 1 January 1993 to 1 January 2023 and reviewed by two reviewers. The data will be analysed and presented in tables, diagrams and text.

ETHICS AND DISSEMINATION

Ethical approval is not required. This review is a retrospective review of widely and publicly available evidence. The review findings will be disseminated via publication in peer-reviewed journals, as part of a PhD thesis and conference presentation.

SCOPING REVIEW QUESTION

What are the barriers and facilitators to early postnatal contraception provision and uptake?

Understanding women's views of and preferences for accessing postpartum contraception: a qualitative evidence synthesis

BACKGROUND

Nearly half of women experience unintended pregnancies. These are associated with increased risk of poor maternal physical and psychosocial health outcomes. Many pregnancies in the first year postpartum are unintended, further increasing risks of poor outcomes and complications. We undertook a qualitative evidence synthesis to evaluate qualitative research on women's views and preferences for accessing postpartum contraception, and identify evidence gaps and opportunities for postpartum contraception provision.

METHODS

Five databases were searched to identify relevant qualitative studies. Included studies focused on views of, and preferences for, accessing postpartum contraception for women of reproductive age in high-income countries.

RESULTS

Of 1854 studies identified, 28 full texts were assessed and 19 studies included. These were critically appraised using Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) and analysed using thematic synthesis. Included studies indicated the majority of women desire postpartum contraception, but face a range of financial, health system and personal barriers. Women felt unclear about the ideal interpregnancy interval (IPI) and the rationale for this. Women preferred contraceptive counselling at varying times both antenatally and postnatally, and commonly preferred to receive contraception in the immediate postpartum period before hospital discharge. Women commonly saw their obstetrician or general practitioner for contraceptive counselling, but welcomed midwifery involvement.

CONCLUSIONS

Most women were interested in postpartum contraception and pregnancy spacing, but felt unclear about the optimal IPI, highlighting the need for further education and support around this issue. Contraceptive counselling was viewed as valuable antenatally and postnatally, and by varying maternal health providers, as was the provision of immediate postpartum contraception.

Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review

BACKGROUND

Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden.

METHODS

This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included.

RESULTS

133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare.

CONCLUSIONS

PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.

Improving Access to and Quality of Postpartum Contraception Provision

Sexual activity and fertility can resume shortly after childbirth, but there are barriers to contraceptive access in the postpartum period. Unintended pregnancy and short interpregnancy intervals (of less than one year) can increase the risk of obstetric and neonatal complications. The antenatal period presents an opportunity to discuss contraceptive options, many of which can be safely initiated immediately after childbirth. Successful delivery of a postpartum contraception program requires an adequate number of maternity staff trained to provide the full range of methods.

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

BACKGROUND

Immediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited. The objective of this qualitative evaluation was to explore the views and experiences of obstetricians and midwives providing PPIUD within a UK maternity setting, in order to identify areas for improvement and inform service provision in other areas.

METHODS

Qualitative health services research within two public maternity hospitals in Lothian (Edinburgh and surrounding region), UK. Interviews with 30 maternity staff (obstetricians n=8; midwives n=22) involved in PPIUD provision. Data were analysed thematically.

RESULTS

Maternity staff were positive about the benefits of PPIUD for women. Midwives reported initial concerns about PPIUD safety, and the impact on workload; these views shifted following training, and as PPIUD was embedded into practice. Having a large pool of PPIUD-trained staff was identified as an important factor in successful service implementation. Having PPIUD 'champions' was important to address staff concerns, encourage training uptake, and advocate for the service to ensure continued resourcing.

CONCLUSIONS

PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. We emphasise the importance of widespread engagement around PPIUD among all healthcare professionals involved in the care of women, to ensure staff are informed and supported. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.