Background: This study was conducted to evaluate the acceptance, safety, efficacy, complications and expulsion rate of post-partumintrauterinecontraceptivedevice (PPIUCD) insertion among post-partum pregnant women in a rural tertiary care center. Objective of this study was assessment of the efficacy and safety of post-partum IUCD insertion. Comparing the complications and client satisfaction in both groups (intra caesarean insertion versus vaginal route of insertion).
LMICs in South Asia such as Nepal are no exception to the challenge of low uptake and continuation of IUDs including the ones used in the immediate post-partum period . Post-partumintrauterinecontraceptivedevice (PPIUD) is an effective and affordable long-acting post-partum family planning (PPFP) method which can be used immediately after childbirth within 48 h of post-partum period. It is known to be safe and has broad eligibility criteria for post-partum mothers [6, 7]. PPFP such as PPIUD was first introduced in Nepal between 2008 and 2009 . Despite the decade-long effort, the country still lacks nationally representative data on the usage of PPIUD separately. Moreover, the overall usage of IUD remains as low as 1.4% in the country .
India contraceptive use is 54% but only 2% of married women of reproductive age use IUCD. Despite the fact that the govt. offers the IUCD service free of cost and IUCD is one of the most effective and safe contraception methods, it still remains largely underutilized. In order to improve the acceptance of IUCD, Indian government has introduced PPIUCD insertion in national programme, as the couples are being more counselled during antenatal visits and after delivery.
method of contraception in the community and media and FP projection is still low for PPPIUCD in our country. Women who were aware of PPIUCD had a significantly higher acceptance rate (p value 0.0001) in our study compared to those who were not aware of PPIUCD (58.3% versus 24.2%). Acceptance rate therefore, can be increased by increasing awareness of PPIUCD through counselling in the antenatal clinics, during early labor or in post-natal ward. There is a need for promoting awareness at community level and by health administrators by advertisements and awareness programmes.
Results: There were 2072 PPIUCD insertions in one year, out of which 1244 were post placental, 139 were in immediate postpartum and 689 were intra caesarean insertions. Fifty four (54) women discontinued PPIUCD during follow up .Main causes for removal were menstrual abnormalities (19), pain abdomen (13), wanting sterilisation procedure (12) and marital disharmony.
After counseling, 11.5% of post placental group and 11.23% of intra cesarean group accepted the PPIUCD insertion. Acceptance and actual insertion rates are not high because PPIUCD is still a new concept in the community. Majority of women who gave consent for PPIUCD belonged to the age group of 21-25 years (60% in post placental and 53% in cesarean group) followed by 26-30 years 23% and 32% respectively This was probably because majority of the women who came to our tertiary hospital for delivery also belong to the same group. Halder et al also found that acceptance of PPIUCD was best in the age group of 21-25 years (40 and 44 % in vaginal and intra cesarean group)) followed by 25-30 years (31 and 23%) (Table 1). 6
The results show self-reported expulsion rate of roughly 3.8% among clients, with more than three-quarters of women reporting no complaints with their PPIUCD. Only 5.4% of women suffered from symptoms suggestive of in- fection after the insertion. Symptoms that were considered suggestive of infection included lower abdominal pain, fever, foul smelling/abnormal vaginal discharge, painful intercourse, and bleeding after intercourse. Other self- reported side normal effects of PPIUCD insertion included cramps and abdominal pain which 8.9% of women reported experiencing, along with 5.5% reporting minor menstrual problems. There were no cases of uterine perforation. Table 1 Demographic characteristics of clients who accepted Post-PartumIntrauterineContraceptiveDevice (PPIUCD) and were interviewed at the time of discharge from the facilities
Postpartum women are especially vulnerable to unwanted pregnancy with increase rate of MTP or abortion after taking pill over the counter or septic abortion by untrained person especially in rural areas. Thus, there is increase in maternal morbidity and mortality. Women are highly motivated and receptive to accept family planning methods during post-partum period. Increase in Institutional deliveries all across the country created opportunities for providing quality family planning postpartum services.
Results: Eighty-four women (42%) had never used any method of contraception. Earlier Intrauterinedevice (IUD) use (including both interval and PPIUCD) was in only 18.9% of all contraceptive users. Only 2 women in the group had ever used PPIUCD. 79% of women were aware of IUDs. Those unaware were mainly nulliparous. Amongst those aware of an IUD, 88 (56%) were aware it could be inserted postpartum. Only 18% were aware it could be inserted intra-cesarean. All women who participated were offered the option for a PPIUCD. Fifty-nine (29.5%) of all women expressed their willingness but on follow up till delivery only 18 of these women got a PPIUCD inserted. Amongst those not willing for the PPIUCD insertion the commonest reason was general apprehension (39%) followed by partner refusal (33%) and fear of complications (31%). Six women (4.2%) gave history of complications following earlier use and were unwilling for its repeat use.
According to a study on impact of health education on unmet needs of con- traception in urban slums of Chandigarh India, lack of awareness of contracep- tion methods contributes to low uptake of PPIUCD. Awareness here means that the mothers did not hear or see any advertisement about FP in the last 6 months or did not participate in any educational session about FP during last 6 months hence contributing significantly to low contraception uptake . Lack of know- ledge was also evident in Nyanza western Kenya in a study by Pauline et al.  who found that lack of contraception awareness and low uptake is related to none visit to antenatal clinic where education on family planning is mostly done. Social demographic characteristic also contribute to low uptake. In a study on factors influencing contraceptive non-use among women of advanced reproduc- tive age in Nigeria by Bola et al.  found that socio-demographic characteristics exert more influence on non-use. There was a significant relationship between non use and current young age where three-quarters of the non-users were 21 - 30 years old related to the desire to get children early in marriage. None use was significantly influenced by woman’s occupation as a housewife  in Nyanza western Kenya in a study on overcoming barriers to family planning through integration. As well, other studies revealed that the contraceptive use was found higher among employed women (67%) than that of unemployed women . Reproductive characteristics of the mothers are some of the barriers to the up- take . In a study of postpartum intrauterinecontraceptivedevice acceptance between primiparous and multiparous women in a tertiary care centre, accep- tance of PPIUCD was significantly higher in multiparous women than primi- parous . Number of living children, and child preference were found to be significantly associated with current use of contraception . Cultural Norms, Myths, Concerns and Miss Conceptions are other barriers.
This study highlights the safety and efficacy of postpartum insertion of intra uterine device copper T 380A among the parturients by following them for 6 months. Totally 2630 primipara were delivered of which 1828 women were included in the study and IUCDS were inserted based on the medical eligibility criteria after getting written informed consent. Insertion of PPIUCD was done after excluding women who came with draining per vaginum for >18 hours, maternal fever, uterine anomalies, fibroid uterus, postpartum haemorrhage - atonic or traumatic and systemic examination was done as given in the proforma. Acceptance rate is 69.50%.
A frequent clinical problem is loss of the filament at the external cervical os as the lost tail. This may be due to retracted or torn off tail, misplacement within the cavity, and growing uterus due to pregnancy causing retraction of threads, intramural penetration as extra uterine location. Proposed risk factors of uterine perforation include the immediate post-partum period and breast feeding, regardless of the timing of insertion. Both Andersson and van Haudenhoven have discussed the role of uterine involution and increased uterine contractility as potential contributing factors to IUCD perforation occurring in the postpartum period. 2,3 Procedure for
Among the various method of family planning available for an women, insertion of post-partum IUCD appears appealing for several reasons: commencement of ovulation is unpredictable after delivery, women wish to avoid pregnancy, but still may not be using any form of contraception, delivery may be only time when a healthy women comes in contact with health care providers, ABSTRACT
Ensuring greater use of PPIUD among women looking for long-acting, reversible methods of contraception does not only involve scaling-up PPIUD access but also reducing rates of discontinuation among women who have been using the device. Recent data from 2016 Nepal Demographic and Health Survey indicate that about one in four (28.2%) of IUD users discontinue its use within 12 months . The literature on IUD discon- tinuation has identified several reasons for why women choose to discontinue, including desire to have another child, facing health-related complications, and changing preferences for contraceptive methods [9–13]. However, little is known about whether these reasons adequately capture the motivation of Nepali women who continue or discontinue PPIUD.
In this study, all the IUCD insertions were done within seven days of onset of menstruation after ruling out pregnancy. This time of insertion is associated with less discomfort and is generally easier to perform as the cervical canal is dilated. In addition, insertion related bleeding is masked during this time of insertion. IUCDs can also be inserted immediately post-partum but not more than 48 hours after delivery and post abortion [12, 27]. In our study, there were no post abortal or post-partum insertions. Levonorgestrel releasing intrauterine system (LNG-IUS) is yet to be made available in the family planning clinic of the hospital. IUCD has been cited by some workers as the best emergency contraception. Though the awareness of its use as an emergency contraception in our centre is very low, none of the clients used the IUCD for emergency contraception.
After the intervention, a statistically significant improvement was observed in favor of the study group at both the immediate post intervention and follow-up phases in all areas of tested knowledge about IUD (p= 0.001).This was consistent with a study done in Iran about the effect of motivational interviewing on using intrauterinedevice in women at high risk of pregnancy . They found that the mean score of knowledge was almost in the same level of deficiency before the intervention among the two studied groups (56.81 ± 18.11 vs. 54.93 ± 18.03). Post intervention, the mean score of knowledge increased in the study group in comparison with the control group (97.3 ± 3.9 vs. 56.7 ± 17.7 ; respectively) with a highly significant difference (p < 0.001). Furthermore, a study about the knowledge and attitudes of women of childbearing age and girls around puberty about Intrauterine devices, found an increase in the willingness of women to use IUDs by 53.0% . Women of childbearing age stated that the positive feature of IUDs that encouraged them to select IUD was their long- lasting effects (10 years). In the same line, a descriptive cross-sectional survey in Cape Town, South Africa about Information and Acceptability of the IntrauterineDevice in the Family Planning Services found that women were lacking information about IUD . Similarly,  documented the poor knowledge of LARC methods in their study in Cape Town. However, this study was done before the government embarked on the process of promoting the IUCD. In this respect, several factors influenced on the use and discontinuation of IUD in Ghana. Of these, comprehensive contraceptive counseling on the IUD was essential in promoting uptake and knowledge of the intrauterinedevice at the health facility level .
Globally, 14.3% of women of reproductive age use intrauterine contraception (IUCD). In some countries, the percentage of women using IUC is <2%, whereas in other countries, it is >40% . It was a widely accepted method for many women avoiding the systemic effects of hormonal contraception and the lower efficacy of the local methods or other physiological methods. However, IUCDs had their side effects, including the most common cause for discontinuation of using the method: menorrhagia. Excessive uterine bleeding up to iron deficiency anemia is among the most common causes of discontinuation of using the de- vices .
The intrauterinecontraceptivedevice (IUD) is one of the contraceptive methods that are under-utilized in many African countries, including Namibia. The aim of this study was to explore and describe knowledge, attitudes and practices regarding the IUD among family planning (FP) acceptors in Khomas Region, Namibia. A non-experimental, quantitative, exploratory, descriptive study was conducted at nine health facilities in Windhoek. A probability sampling technique was applied to select the sample which was calculated using the Epi Info version 7, Statcalc. A total of 582 FP acceptors were interviewed, using a structured questionnaire. Descriptive statistical analyses were done and results presented in percentages, proportions and displayed in tables, graphs. Overall, about half of FP acceptors were not aware of the IUD, while almost all knew the injectables and oral contraceptive pills. FP acceptors lacked adequate specific knowledge content of the IUD. This study did not only establish limited awareness of the IUD among FP acceptors but also inadequate knowledge on IUD characteristics, benefits, common-side effects, which woman can use an IUD and associated myths. Therefore, this study recommends to Ministry of Health and Social Services and its partners to sensitize and educate family planning users on the IUD in order to increase demand and utilization. (Afr J Reprod Health 2019; 23: 75-80).
Ectopy of cervix is found in 6% of IUD users .The thread of IUD tail being source of constant irritation and may be responsible for cervical erosion (Agarwal Krishna et al) Agarwal Krishna et al in the study of micro biological and cytopathological study in IUD users, 100 intra uterine device users were compared with 50 controls, found that cervical erosion is found in 20% among IUD users. Versus none in controls. Though cervical erosion in not considered something with severe implication but it may be responsible for white discharge in IUD users, .
The current study showed that the majority of the respondents had knowledge about contraception methods with a higher rate of knowledge toward intrauterine con- traceptive devices and oral pills followed by the injection method. These results are in accordance with previous studies in the region. 17,27,28 Knowledge about these two methods was obtained primarily from relatives and friends. Knowledge obtained from non-health professionals might be incorrect or incomplete. This may explain the high rate of women who were unfamiliar with how to deal with missing daily pills (79.4%). The result about the knowing what should be done if pills were missed was in contrast with a study conducted in Saudi Arabia, 29 in which 64.5% of their study participants knew how to deal with missed pills correctly.