Efficacy and Satisfaction Rate in Postpartum Intrauterine Contraceptive Device Insertion: A Prospective Study

Effect of the timing of insertion of postpartum intrauterine contraceptive device (PPIUCD) copper T380A on expulsion rates

Background & objectives

Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications.

Methods

This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly's placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates.

Results

The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion.

Interpretation & conclusions

In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group.

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.

Correlates of post-partum intra-uterine copper-T devices (PPIUCD) acceptance and retention: an observational study from North India

BACKGROUND

Postpartum intrauterine contraceptives device (PPIUCD) offers an effective means of providing contraceptive services to women in countries with high rates of unmet needs for family planning services. However, scientific literature estimating the long-term retention rates is scarce. We estimate the factors affecting acceptance and retention of PPIUCD and explore the risk factors against PPIUCD Discontinuation at six months".

MATERIAL AND METHOD

This prospective observational study was conducted between 2018 and 20 at a tertiary care institute in North India. PPIUCD was inserted following a detailed counseling session and consent. The women were followed up for six months. Bivariate analysis was done to depict the association between socio-demographic characteristics and acceptance. Logistic regression, cox regression, and Kaplan Meier analysis were applied to explore factors affecting acceptance and retention of PPIUCD.

RESULTS

Of the 300 women counseled for PPIUCD, 60% accepted them. The majority of these women were between 25 and 30 years (40.6%), primigravida (61.7%), educated (86.1%), and from urban areas (61.7%). Retention rates at six months were about 65.6%, while 13.9% and 5.6% were either removed or expelled. Women declined PPIUCD due to refusal by spouses, partial knowledge, inclination towards other methods, non-willingness, religious beliefs, and fear of pain and heavy bleeding. Adjusted logistic regression depicted that higher education, housewife status, lower-middle and richest SES, Hinduism, and counseling in early pregnancy promoted acceptance of PPIUCD. The most common reasons for removal were AUB, infection, and family pressure (23.1%). Adjusted hazard ratio depicted religion other than Hinduism, counseling in late stages of pregnancy, and normal vaginal delivery were significant predictors for early removal or expulsion. While education, higher socio-economic status favoured retention.

CONCLUSION

PPIUCD is a safe, highly effective, low-cost, long-acting, and feasible method of contraception. Skill enhancement of healthcare personnel for insertion techniques, adequate antenatal counseling, and advocacy of PPIUCD can help increase the acceptance of PPIUCD.

Increasing postpartum IUCD coverage through a QI initiative: a step towards reducing the unmet need of postpartum contraception

Background

Unintended pregnancies have a negative impact on the health and economy of a nation, which can be prevented by effective family planning (FP) services. Postpartum intrauterine device (PPIUCD) is a safe and effective FP method which allows women to obtain long-acting contraception before discharge from the point of delivery. We observed poor coverage of deliveries with PPIUCD at our facility. This was the trigger to initiate a quality improvement (QI) initiative to increase the PPIUCD coverage from current rate of 4.5%–10% in 3-month period.

Method

A fishbone analysis of the problem was done and the following causes were identified: lack of focused counselling for FP, lack of sensitisation and training of resident doctors and inconsistent supply of intrauterine contraceptive devices (IUCDs). A QI team was constituted with representatives from faculty members, residents, interns, nursing officers and FP counsellors. The point of care quality improvement methodology was used.

Interventions

Daily counselling of antenatal women was started by the counsellors and interns in antenatal wards. A WhatsApp group of residents was made initially to sensitise them; and later for parking of problems and trouble shooting. The residents were provided hands-on training at skills lab. Uninterrupted supply of IUCDs was ensured by provision of buffer stock of IUCDs with respective store keepers.

Result

The PPIUCD insertion rates improved from 4.5% to 19.2% at 3 months and have been sustained to a current 30%–35% after 1 ½ years of initiation of the project tiding through the turbulence during the COVID-19 pandemic using QI techniques.

Conclusion

Sensitisation and training of residents as well as creation of awareness among antenatal women through targeted counselling helped improve PPIUCD coverage at the facility. QI initiatives have the potential to facilitate effective implementation of the FP programmes by strategic utilisation of the resources.