|Ahead of print publication
Study of the client experience and continuation rate of postpartum intrauterine copper-T device in semi-urban population in India
Swati Agrawal, R Induja, Kanika Chopra, Anuradha Singh, Shilpa Sood, Manju Puri
Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi, India
|Date of Submission||04-Nov-2021|
|Date of Decision||20-Jan-2022|
|Date of Acceptance||20-Feb-2022|
|Date of Web Publication||12-Apr-2022|
Gyankhand 1, Indirapuram - 201 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Postpartum intrauterine copper device (PPIUCD) is a reliable and efficient method of contraception for women. In spite of its ease of administration, its acceptance is very low owing to a number of factors. The current study was undertaken to analyze the continuation rates and problems among women accepting PPIUCD as contraceptive method. Methods: The present study was undertaken in the family planning department of a teaching hospital in New Delhi. It was an ambispective, observational study in which 880 beneficiaries of PPIUCD were telephonically contacted and interviewed. A pro forma containing demographic profile, obstetric history of the women, date and timing of insertion of PPIUCD, source of information about PPIUCD, side effects encountered, willingness to continue, and reasons of discontinuation, if applicable, was filled and the data, collected thus, were analyzed. Results: Most of the women enrolled in the study had a mean age of 26.5 (±4.1) years; the average parity was two. The timing of insertion of PPIUCD was postplacental in majority of women (91.7%). Most of the women received information about PPIUCD from health-care workers (90.1%). It was found that 86.7% of women were using PPIUCD at the time of interview and 73.3% were satisfied with it and willing to continue further. The predominant side effect observed was pain abdomen (15%), followed by menstrual irregularity. Conclusion: The present study revealed a high continuation rate of PPIUCD. Health-care professionals were the foremost source of information for PPIUCD. It is a highly effective method which needs to be popularized among the masses by the active participation of media and other agencies as it has the potential to bridge the gaps in existing family planning services.
Keywords: Client experience, continuation rate, counseling, expulsion, intra-cesarean insertion, menstrual irregularity, postpartum intrauterine device
|How to cite this URL:|
Agrawal S, Induja R, Chopra K, Singh A, Sood S, Puri M. Study of the client experience and continuation rate of postpartum intrauterine copper-T device in semi-urban population in India. Int J Adv Med Health Res [Epub ahead of print] [cited 2022 May 22]. Available from: https://www.ijamhrjournal.org/preprintarticle.asp?id=343073
| Introduction|| |
India is the second-most populous country in the world with a high unmet need for contraception. According to NFHS-4 (2015–16), the unmet need for contraception in India is at 12.9%. This indicates the need to improve communication and provider skills for better reach. IUCD is a good spacing method which has not been given its due credit due to various misconceptions associated with it. The role of husband and family members is also one of the main reasons behind poor acceptance of postpartum intrauterine copper device (PPIUCD). PPIUCD was introduced in the National Family Planning Program in India in 2009–2010. The main advantage of PPIUCD is that the woman is already at a health facility and is more receptive in the postpartum period. The associated side effects of slight bleeding and cramping go unnoticed in the postpartum period.
However, even after a decade of its launch and impetus given by the government in the form of monetary incentives, the acceptance of IUCD has not improved as per expectations. The rate of discontinuation is also high owing to side effects such as pain, menstrual disturbances, and missing string issues. This problem was also identified at our facility. A quality improvement initiative was launched in 2019. The baseline PPIUCD insertion rate was 4.5% which increased to 19.2% at 3 months and further increased to 30%–35% after 1.5 years of QI initiative. This study envisaged to analyze the continuation rate and problems faced among acceptors of PPIUCD at our institution.
| Methods|| |
Source population was around 3000 postpartum women. Inclusion criteria in our study included all women in whom at least 6 weeks had elapsed after insertion of PPIUCD. They were included after taking verbal consents. The phone numbers of all the women included in the study were taken from the PPIUCD register maintained in the hospital which included the day of insertion of PPIUCD and type of IUCD inserted. Exclusion criteria were women who could not be contacted telephonically or who were unable to understand spoken Hindi or English language or who expressed their unwillingness to participate in the study.
Ethical clearance was obtained for the study from the Institutional Ethics Committee. Authors developed a pro forma including demographic profile and obstetric history of the women, date and timing of insertion of PPIUCD (i.e., postplacental, immediate postpartum within 48 h, or intra-cesarean), source of information about PPIUCD (i.e., either from media, health care workers [HCWs], husband, friends, or relatives), side effects encountered (menstrual irregularities, infection, abdominal pain, missing thread, expulsion, or any other), willingness to continue, and reasons of discontinuation if applicable. Women recruited in the study were interviewed telephonically by the interns posted in the family planning department of the institution in the language preferred by the women. The data, thus collected from 880 women, based on the pro forma filled during the telephonic interview, were analyzed.
| Results|| |
The demographic profile of the acceptors of PPIUCD is shown in [Table 1]. The acceptors of the method had a mean age of 26.53 ± 4.06 years with an average parity of two. The timing of insertion of PPIUCD was postplacental after vaginal delivery in the majority of women (91.7%), intra-cesarean in 6.7%, and postpartum (within 48 h) in 1.5%. The information about the method was given by HCWs in 90.1%, media in 2.3%, and friends and family in 7.2% [Figure 1]. A greater number of the women (73.3%) were pleased with PPIUCD. Most of the women (56.7%) had no complaints with PPIUCD use, while abdominal pain and menstrual irregularities were the most common side effects observed in 132 (15%) and 117 women (13.3%), respectively [Figure 2]. Seven hundred and sixty-three women (86.7%) in the study group were willing to continue the method at the time of interview. Among the women who discontinued, the majority of them did so within the 1st month (64.1%). The discontinuation of PPIUCD was not associated with parity. The main reason for discontinuation was expulsion, seen in 51 women (5.7%). Among the women who got the PPIUCD removed (n = 66, 7.5%), abdominal pain and menstrual irregularities were the main reasons.
|Figure 2: Problems associated with the use of postpartum intrauterine copper-t device (%)|
Click here to view
| Discussion|| |
Postpartum period is considered the best time to accept contraceptive methods and thus decrease this unmet need in the population. As noted in a study from Ethiopia, among the total number of unintended pregnancies, 20.2% were among the breastfeeding women. In India, a stratified analysis found that 65% of women have unmet need for contraception, especially in their first postpartum year. PPIUCD is a long-acting reversible contraceptive method with a failure rate of 0.8%. However, the potential of this method has not been tapped optimally. Thus, this study was planned with the aim of an in-depth analysis into the problems associated with PPIUCD among the acceptors of this method which will help in devising strategies to improve continuation rates and decrease the unmet need of contraception.
The average age in our study population was 26.53 ± 4.06 years with almost equivalent numbers in the age group of 20–25 years (43%) and 26–30 years (42%). In a study done by Rana et al., a maximum number of acceptors of the method were in the age group of 26–30 years (38.4%), followed by 30.8% in the age group of 21–25 years. In our study, illiteracy was seen in 23.7% as compared to an Ethiopian study, where it was found to be 32%.
The major source of information about PPIUCD was HCWs in our study, with relatives and friends being a distant second. This shows that there is a need to increase the involvement of media to enhance awareness about the benefits of this contraceptive method among the general public. Furthermore, joint counseling along with male partners can play a role in increasing the acceptance and continuation rate of any method of contraception including PPIUCD.
The timing of insertion of PPIUCD was postplacental in majority of women (91.7%). Postplacental insertion was much higher in our study as compared to 51% in the study by Bansal et al. and 83.6% in the study by Rana et al., This may be attributed to the fact that counseling for PPIUCD is started during the antenatal visits in our facility.
Most of the women interviewed in our study were satisfied with the use of PPIUCD (73.3%), and the continuation rate in our study was found to be 86.7%. Continuation rates in previous studies ranged from 17.1% to 82.4%; this difference can be explained as a function of different study settings and populations.,, This may also be attributed to variations in the educational status of participants, beliefs, misconceptions, and side effects encountered.
Majority of the women (56.7%) in our study reported no problem with the contraceptive method. Abdominal pain was the main complaint in 15% of women, followed by menstrual disturbance in 13.3%. Spontaneous expulsion, infection, and missing threads were seen in 6%, 3.5%, and 2.9%, respectively. Another study showed similar rates of observed side effects. Previously, irregular vaginal bleeding was observed in 11.6% of users. Other studies have shown varying rates of irregular vaginal bleeding ranging from 4.3% to 27.2%; the side effect was more common in cases with the use of CuT 200., The type of CuT used may influence observed side effects, especially menstrual problems. In our study, CuT 380A was inserted in 56.5% of cases and CuT 375 in 43.5% of cases. The incidence of irregular vaginal bleeding was, however, found to be similar in both groups. Reported rates of spontaneous expulsion vary among different studies from 5.23% to 12.12%;, in our study, it was 6%. Rate of spontaneous expulsion is determined by factors such as method of insertion, training of the person inserting it, and timing of insertion. Expulsions were higher with vaginal delivery than following cesarean section; corresponding rates in a prior study were 9.1% and 2.1%, respectively. In the present study too, the expulsion rates in postvaginal insertion were 5.5%, whereas they were 1.3% with intra-cesarean insertions.
As reported in various studies, the rate of IUCD removal due to bleeding/pain is around 6%–8%.,, In a study conducted in 2017, heavy menstrual bleeding was found in 17.8% of PPIUCD acceptors and pelvic pain in 16.1%. The expulsion rate was 5.1%, and IUCD removal was done in 12.7% of women. In the present study also, pain and irregular vaginal bleeding were the major causes of discontinuation of PPIUCD by the women. In another study done in 2019, among 295 acceptors of PPIUCD, 79.3% of users did not have any complaints. The complaints of heavy menstrual bleeding, lower abdominal pain, and both symptoms were found in 11.8%, 1%, and 7.4% of women, respectively. Spontaneous expulsion rate was noted in one patient (0.3%) at 6 weeks, and IUCD removal was done in four patients (1.3%) only.
In our study, 381 women (43.3%) faced some or the other problem with PPIUCD insertion; however, only 7.5% of women got their PPIUCD removed. Among these 381 women, majority (64.5%) had not come for physical follow-up. Follow-up rates in other studies at 6 months have been reported at 48.2%, 69%, and 82.6%.,, Variations in follow-up rates can be explained due to factors such as lack of adequate counseling at the time of insertion explaining the importance of follow-up, issues with accessibility of care in faraway referral institutions, and relative ease of follow-up in nearby centers.
The sample size of previous studies was limited by attrition following PPIUCD insertion. Moreover, women returning for follow-up often suffer from one or other problems; hence, these studies may not be reflective of the true acceptance rate of PPIUCD in the general population. In our study, a telephonic follow-up was done for all acceptors of PPIUCD which is likely to better reflect the continuation rate of the method.
| Conclusion|| |
PPIUCD is a highly effective long-acting reversible contraception method with very few adverse effects and has the potential to bridge the gap of the unmet need of contraception, especially in developing countries. However, awareness about this method is sub-optimal due to insufficient media coverage. There is a need to disseminate knowledge and awareness about PPIUCD and expected gains from this method. Proper counseling of the women regarding the possible side effects, their treatment, and importance of follow-up is a must to enhance its acceptance and continuation rates. Proper training in the method of insertion of postpartum IUCD for the HCWs can also play a vital role in decreasing the rates of spontaneous expulsions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
National Family Health Survey, NFHS-4, 2015-16. India Fact sheet, Government of India. Available on net as http://www.rchiips.org/nfhs
PPIUCD Reference Manual. Family Planning Division, Ministry of Health and Family Welfare, GOI; 2010.
Agrawal S, Puri M, Singh A, Sehrawat S, Sood S, Choudhary K, et al.
Increasing postpartum IUCD coverage through a QI initiative: A step towards reducing the unmet need of postpartum contraception. BMJ Open Qual 2021;10:e001346.
Fite RO, Mohammedamin A, Abebe TW. Unintended pregnancy and associated factors among pregnant women in Arsi Negele Woreda, West Arsi Zone, Ethiopia. BMC Res Notes 2018;11:671.
Speroff L, Darney P. Intrauterine contraception. In: A Clinical Guide for Contraception. 5th
ed. Philadelphia, PA, USA: Lippincott Williams and Wilkins; 2010. p. 239-80.
Rana M, Atri SK, Chib V, Kumari N. Postpartum intrauterine contraceptive device, a method of contraception: A study from rural North India. Int J Clin Obstet Gynaecol 2019;3:169-73.
Jemal Mohammed S, Gebretsadik Kelbore W, Endashaw Yesera G, Shegaze Shimbre M, Assfa Mossa K, Nuriye Metebo K, et al.
Determinants of postpartum IUCD utilization among mothers who gave birth in gamo zone public health facilities, Southern Ethiopia: A case-control study. Open Access J Contracept 2020;11:125-33.
Bansal M, Lagoo J, Pujari K. Study of efficacy and complications of PPIUCD insertion at Government Medical College, Bastar. Int J Reprod Contracept Obstet Gynecol 2016;5:4128-31.
Kanhere A, Pateriya P, Jain M. Accessibility and feasibility of immediate post-partum IUCD insertion in a tertiary care center in Central Delhi. Int J Reprod Contracept Obstet Gynecol 2015;4:1.
Goswami G, Yadav K, Patel A.
A prospective study to evaluate safety, efficacy and expulsion rate of post-placental insertion of IUD. J Evol Med Dent Sci 2015;4:9770-4.
Shukla M, Qureshi S, Chandrawati. Post-placental intrauterine device insertion – A five year experience at a tertiary care centre in north India. Indian J Med Res 2012;136:432-5.
] [Full text]
Gupta A, Verma A, Chauhan J. Evaluation of PPIUCD versus interval IUCD (380A) insertion in a tertiary hospital of western UP. Int J Reprod Contracept Obstet Gynecol 2013;2:204-8.
Kittur S, Kabadi YM. Enhancing contraceptive usage by post-placental IUCD insertion with evaluation of safety, efficacy and expulsion. Int J Reprod Contracept Obstet Gynecol 2012;1:26-32.
Hooda R, Mann S, Nanda S, Gupta A, More H, Bhutani J. Immediate postpartum intrauterine contraceptive device insertions in caesarean and vaginal deliveries: A comparative study of follow-up outcomes. Int J Reprod Med 2016;2016:7695847.
Ranjana, Verma A, Chawla I. A follow up study of postpartum intrauterine device insertion in a tertiary health care centre. Int J Reprod Contracept Obstet Gynecol 2017;6:2800-5.
Garg N, Sarkar B, Singla S, Meena RK. Demographics and follow up of post-partum intra-uterine copper device in tertiary hospital in Delhi, India. Int J Reprod Contracept Obstet Gynecol 2019;8:2232-5.
Charles M. Clinical outcomes of two early PPIUCD insertion programs in Africa. Contraception 1996;53:17-2.
Nilesh SA. Evaluation of safety, efficacy and expulsion of PPIUCD. Indian J Res 2015;4:537-9.
[Figure 1], [Figure 2]