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 complications associated with Postpartum IntrauterineContraceptiveDevice is insignificant, still the awareness, acceptance and continuation are very low. Therefore, the Information Education Communication activity by the field workers must be enhanced to overcome this knowledge gap, in the long run this will improve the acceptance of Contraceptives especially the IUCDs in the general population.
Prior consent was received from all the study participants for insertion of IUCD. Preformed questionnaire having general socio demographic and obstetric details were used for the study. All the women were followed up at 6 week, 6 month and 12 months. Complications felt by the participants were recorded in each visit. Out of 150 females, 138 were followed up at the end of 1 year of insertion. Rests of the females were lost to follow up. Client satisfaction was measured at the end of one year. RESULTS
available for postpartum contraception viz. lactational amenorrhea (LAM method), Pills, IUCD, Condom, sterilization but the women in the postpartum period wants an efficacious, reliable, safe, easy to use and a reversible contraceptive method which provide long term protection. All these criteria’s are fulfilled by PPIUCD. In the immediate post delivery period, the women are highly motivated and need an effective method of contraception so that the child can be brought up with a relaxed mind without the worry of unintended pregnancy. On the other hand, if they are made to wait for 6 weeks for initiating an effective contraception, they may conceive accidently or may not come for contraception. This approach is more applicable to our country where delivery may be the only time when a healthy woman comes in contact with health care personnel. Compared with sterilization, however, use of an IUCD is simpler, less expensive and immediately reversible. With this background authors have under taken the present study to assess the acceptance and complications of usage of postpartum IUCDs.
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.
Results of present study revealed that acceptance is more in rural women (86 and 78 % in post placental and cesarean group) as compared to urban (14 and 22% respectively). PPIUCD were more accepted in less educated rural and low socioeconomic group (Table 1). This is probably because they are not aware of other methods of contraceptions, do not have transportation facility from remote areas, unavailability of peripheral health services and moreover no prefixed ideas regarding IUCD. Related social misbelieve in local community is more in urban and educated society. Proper information, motivation and guidance lead to high insertion in rural patients. Urban and higher educated women were more inclined towards the newer or modern method of contraception hence less interested in PPIUCD insertion. This is in contrast to majority of the studies where urban patient’s acceptance was more than rural patients. Katheit G et al also found that rural and urban patient’s ratio was almost equal among urban (52.4%) and rural (47.6%). 7
Advantages of immediate postpartum insertion of the IUCD include client motivation, safety, convenience, assurance of no pregnancy, does not interfere with lactation, facilitates adequate birth spacing, immediately reversible and does not require repeated health care visits for contraceptive refills. PPIUCD insertion gives these women an extra edge of leaving the hospital with contraception after institutional delivery.
PPIUCD has distinct advantages as contraceptive during postpartum period as it is one-time application, provider has assurance that patient is not pregnant at the time of application and it can serve as both spacing and limiting in some cases. Main advantage of post-placental IUCD is that no additional hospital visit is required for insertion of IUCD and no pain on insertion when used post-placental or intra-caesearean. Also, initial cramping due to IUCD is shadowed with pain due to uterine contraction in puerperium. Few side effects which worried the patients were missing thread which occurred mostly after LSCS (due to coiling of thread) which needed USG for localization of Cu T and further reassurance. Another problem was women who came for early removal of PPIUCD had to undergo hysteroscopic removal because thread was coiled inside and was not visible to be removed on OPD basis. What authors found in present study was there were lots of misconception regarding IUCD like perforation, migration pain and bleeding problem. Rate of removal was high due to myths and family pressure.
The next common reason for its acceptance was that women did not perceive PPIUCD insertion as a surgical procedure as no incision is required for its insertion. Among those women who declined the PPIUCD (71.67%) more than one third preferred LAM method for immediate contraception, 20.9% women wanted to discuss with their partners not accompanying them, 21.3% were satisfied with their non PPIUCD contraceptive method in the present study. In a study done in Egypt, among the 71.1% women who refused PPIUCD, planning another pregnancy in the near future (34.3%) was the most common reason followed by preference of interval IUCD (30.2%) and LAM method (9.3%). 9 Complications from previous use of IUCD
IUCD is most effective, safe, long acting and do not interfere with coitus and it can be inserted immediately or within 72 hours after delivery of placenta in a health care facility. It is convenient for those who are in outreach areas, where family planning facilities are not freely available and it may be utilized to overcome the unmet need of contraception, in a single hospital visit during institutional delivery.
The postpartum period is potentially an ideal time to begin contraception as women are more motivated to do so at this time, which also has the advantage of being convenient for both patients and health care providers . A descriptive study from Turkey reported expulsions in 235 women who had immediate post placental insertion of IUCD following either vaginal or caesarean delivery, combined expulsion rates were 5.1%, 7.0% and 12.3% at 1.5, 6 and 12 months respectively . One case control study at JPMC Karachi examined 100 women who had post placental IUCDinsertion. Follow up study was done at 1 week, 6 weeks and 6 months. Wound was infected in 10%, heavy lochia in 2%, at 6 months thread was visible in 92% and no perforation seen . Another retrospective study from India in 300 women with immediate IUCDinsertion reported lower abdominal pain (11.5%), menorrhagia (6.6%) dislodgment of IUCD (3.3%) and expulsion (6.6%) .
As a contraceptive used during post-partum period, the IUCD has a distinct advantages. It is a reversible method. In addition, IUCD does not require regular user compliance. It is free from systemic side effects and does not affect breast feeding as seen with hormonal methods. It is also not coital dependent and there is no pain on insertion when used post-placentally 2. No medical disease
Educational status was the other significant factor for utilization of IUCD. Those participants who could read and write were 4.64 times higher, those who were pri- mary school 8.08 times higher, those who were sec- ondary school 8.89 times higher and those who were attended college and above were 21.24 higher to use IUCD as compared to women who couldn’t read and write [AOR = 4.64, 95% CI 1.45–14.87, AOR = 8.08, 95% CI 2.19–29.76, AOR = 8.89, 95% CI 1.63–48.42 and AOR = 21.24, 95% CI = 5.05–89.39] respectively. This study is in line with studies done in Addis Ababa, and Tigre region, Shire Endasilase town [7, 9]. This might be due to the fact that those women who were educated might have knowledge about IUCD; they might know the negative impact of having many children in their family as well as in the country and they might have positive attitude for IUCD so that they might not accept negative misconceptions about IUCD. Therefore, these women might be used IUCD.
The intra uterine device is one of the most widely used methods of family planning with more than Seventy Million users world wide. The first generation are non-medicated devices includes lippes loop and coil devices used in 1960 and the second generation are medicated devices include copper used in late 60 and progesterone releasing devices. I.U.C.D. insanideal temporary contraceptive. It is effective, safe and has no systemic effects, even the para medical personnel can be trained for selecting counseling and insertion. The women using I.U.C.D. is more safer, more convenient, more effective in preventing pregnancy than condom, spermicide and any other barrier methods.
Knowledge of women regarding their sexual life, an awareness of the role of contraception in family life as well as access to safe and effective methods are essential to good health. 14 Improving the knowledge and practice of both women and men is necessary for achieving harmo- nious partnerships. 15 Knowledge, attitude and practice studies started in 1950 in Asian nations, followed by the United States in 1955. Cultural factors as well as age, parity, education status, family attitude, and acceptability of contraception are among the factors that affect the extent of contraception use. The proportion of couples using one or more contraceptive technique in developing countries ﬂ uctuate between 20% and 60%. 16 In Iraq, the National family planning strategy and the provision of contraception were started in 1993 but the policy has not been updated since. 17 To the best of our knowledge, there are very few studies on knowledge and practice of contra- ception in Iraq, so this study was aimed to evaluate the knowledge and practice of participants regarding birth
a risk factor for IUD expulsion [12, 13]. The probable mechanism behind the increased expulsion rate in pa- tients who delivered vaginally is cervical dilation as well as development of the thin lower segment. We assume this is particularly true for partial IUD expulsions. If this were the case, however, patients who had undergone caesarean delivery in active labour would have had a higher risk of IUD expulsion. On the contrary, our results suggest that the impact of vaginal delivery or cervical changes in active labour on IUD expulsion is less evident. Parity, however, increases the risk of IUD expulsion regardless of the mode of delivery. It should also be mentioned that in the current study all the IUDs were placed by experienced physicians, which controls for another potential confounder. Similar conclusions were reached in a study from Mexico, in which the authors found that parity was the only risk fac- tor for expulsion when the IUD was inserted immediately after delivery . On the other hand, a recent study which included only vaginal deliveries found that low parity was associated with a higher expulsion rate. The authors commented that uterine involution was more prominent in primiparous women .
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, .
“my experience so far is that my menstrual flow has reduced from 5 days to 4 days since using the IUD for six months now after I delivered my last baby. I decided to ask a doctor friend and he said nothing is wrong with me. I also realized, comparing this with the injectables that I used to be on, the severe heart beat and headache I used to have disappeared. Initially, I was a bit tensed, that maybe my husband will find out. So one day, I asked him about it whether he can feel anything. And he said no. So he asked is it like the other ones? I said no, your menstrual cycle is it normal? I said normal, regular 28days cycle. I said I’m ok. I don’t know; I’m not worried. I feel normal. I feel ok. So I’ve been encouraging some of my colleagues to do the IUD” (29year old married woman on Copper T 380 A for 2years)
Each subject was then assigned a study number and was randomized to a treatment within the Copper T380A or Levonorgestrel 52 mg arms by the investigational phar- macy on the day of enrollment. The patient chose which IUD they desired prior to enrollment and was not ran- domized to IUD type. The investigational pharmacist, who was otherwise not involved in the study, used computer generated block randomization. The pharmacy provided study packets that included an unlabeled syringe and oral medication so that physicians and patients were blinded to the assigned treatment group. The subject took the oral medication (naproxen 375 mg prepared in a capsule or similarly prepared placebo capsule) 1 h prior to the pro- cedure. After performing a bimanual exam, placing a speculum and cleansing the cervix with betadine, the study physician then instilled 5 ml of the intrauterine solu- tion (2% lidocaine or similarly prepared normal saline) through the endocervix using an 18-gauge angiocatheter advanced to the hub. The angiocatheter was left in place for 3 min before it was removed. Single tooth tenaculum was then placed and the uterus was measured with a metal sound. The intrauterinedevice was then inserted ac- cording to manufacturer’s instruction. To maintain consistency, three study physicians (KS, SD, SM) used the same technique to place the IUDs.