- Email: [email protected]
To study the acceptance of postpartum intrauterine contraceptive device, CU T 380 A, in a tertiary care hospital in India
Journal of Reproductive Health and Medicine 2 (2016) 93–98
Contents lists available at ScienceDirect
Journal of Reproductive Health and Medicine journal homepage: www.elsevier.com/locate/jrhm
Original article
To study the acceptance of postpartum intrauterine contraceptive device, CU T 380 A, in a tertiary care hospital in India Shilpa Shreepad Bhat a,*, Hemant Damle b,e, Sameer Popat Darawade a,f, Ketaki Junnare c,g, Madhura Ashturkar d,h a
Assistant Professor, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India Professor and Unit Head, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India Associate Professor, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India d Public Health Expert, C-103, Nisarg Kiran, Rahatani, Pune, India b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2016 Received in revised form 18 May 2016 Accepted 21 May 2016 Available online 8 June 2016
Introduction: Family planning allows people to attain their desired number of children and determine the spacing of pregnancies. Contraception plays a major role in women’s health. Increased number of institutional deliveries allows us to offer family planning methods to couples. Postpartum intrauterine devices (PPIUCD) are the reversible long acting method. It does not interfere with breast feeding and can be provided before the woman leaves the hospital. This study of acceptance of postpartum intrauterine device was conducted in tertiary care hospital in India. Aim and objectives: To find out the (1) acceptance of PPIUCD CU T 380 A, (2) retention rate of PPIUCD and (3) spontaneous expulsion rate at end of 6 months of delivery. Material and methods: PPIUCD was inserted in 680 women either after vaginal delivery or during caesarian section. Data analysis was done at the end of 6 months. Results: (1) Insertion of PPIUCD amongst Para 2 was highest 375 (55.14%). (2) Retention rate was 86.33%. (3) Spontaneous expulsion was found in 55 (8.54%) women. (4) Bleeding was the main symptom perceived by 249 (88.71%) women followed by long thread 73 (26.02%) and pain in lower abdomen 45 (15.90%). (5) Total 361 (61.29%) women were satisfied and were continuing the method. Conclusion: Retention rate of PPIUCD was high. Spontaneous expulsion in intra-caesarian IUCD was less as fundal placement was assured at the time of insertion. Bleeding problems were the major complaint and the main reason for removal of PPIUCD. ß 2016 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd.
Keywords: CU T 380 A Postpartum IUCD Contraception
1. Introduction Every pregnancy should be a planned one. Family planning allows people to consider the number of children they desire and determine the period between each pregnancy. Family planning allows spacing of pregnancies and can delay pregnancies in young women with increased risk of health problems and can help to prevent death because of childbearing at an early age. It prevents unintended pregnancies, including
* Corresponding author at: Renuka Nagar, Lane 2, Warje, Pune, India. Tel.: +91 9422515275. E-mail address: [email protected] (S.S. Bhat). e Tel.: +91 8888800669. f Tel.: +91 9822266907. g Tel.: +91 9850029126. h Tel.: +91 9823558765. http://dx.doi.org/10.1016/j.jrhm.2016.05.002 2214-420X/ß 2016 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd.
those in older women who face increased risks related to pregnancy. Family planning enables women to limit the size of their families, if they wish to do so. Evidence suggests that women who have more than 4 children are at increased risk of maternal mortality. By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe abortion.1 Modern methods of contraception include female and male sterilization, oral hormonal pills, the intrauterine device (IUD), the male condom, injectables, the implant (including Norplant), vaginal barrier methods, the female condom, and emergency contraception.2 The unmet need for contraception remains too high. This situation is fueled by a growing population and a shortage of family planning services. In Africa, 23.2% of the women of reproductive age have an unmet need for modern contraception. In Asia, and Latin America and the Caribbean – regions with relatively high contraceptive prevalence – the levels of unmet need are 10.9% and 10.4%, respectively.3
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Family planning is important not only for population stabilization but also to improve maternal and newborn survival. Family planning can avert more than 30% of the maternal deaths and 10% of child mortality, if spacing between each pregnancy is more than 2 years.4 In 2015, worldwide, 64% of married or in-union women of reproductive age were using some form of contraception. However, contraceptive use was much lower in the least developed countries (40%) and was particularly low in Africa (33%). Worldwide, in 2015, 12% of married or in-union women are estimated to have had an unmet need for family planning; that is, they wanted to stop or delay childbearing but are not to do so using any method of contraception. According to WHO report 2015, use of contraception method in India is between 50 and 70%, with median of 59.8%, while unmet need of contraception is 13.1%. Among the various contraception methods used, IUD constitutes 2% of the total use.5 One of the modern methods of contraception is postpartum intrauterine contraceptive device (PPIUCD). PPIUCD is a reversible, long-acting method. It does not interfere with breast-feeding and can be provided before the patient leaves the hospital. In postpartum period, resumption of sexual activities, return of menses, and breast-feeding put women at considerable risk of pregnancy. If no family planning is done, she needs to perform repeated urine pregnancy tests and is always under stress of unplanned pregnancy. Women are highly motivated and receptive to accept Family planning methods during the postpartum period. Increasing number of institutional deliveries helps us to provide more number of couples with family planning services. Institutional deliveries in India in 2012–2013 were found to be 82.864%.6 Postpartum intrauterine contraceptive device (IUCD) has specific advantages over other methods, which include convenience, safety, no risk of uterine perforation because of thick wall of uterus, reduced perception of initial side effects (bleeding, cramping) due to presence of normal puerperal changes, no effect on breast-feeding, and stress-free postpartum period. Advantages for service providers include the following: certainty that the woman is not pregnant; saves time, as it is performed on the same delivery table for postplacental\intracesarean insertions; additional evaluations and separate clinical evaluation not required; need for minimal additional instruments, supplies, and equipment.7 Therefore, the present study is carried out to study the acceptance of postpartum intrauterine device among women who delivered at tertiary care hospital in India. 2. Material and methods The study was carried out during the period of June 2011 to May 2014 in Department of Obstetrics and Gynecology in Smt. Kashibai Navale Medical College, Narhe, Pune, Maharashtra, India. It is a prospective, observational study. 2.1. Inclusion criteria Inclusion criteria for study participants were all women of any age who opted for PPIUCD after vaginal birth and during lower segment cesarean section (LSCS). 2.2. Exclusion criteria The exclusion criteria were as follows: postpartum hemorrhage (PPH) and prolonged rupture of membranes (PROM). Institutional ethical committee approval was taken for this study.
During antenatal visits, all the registered women were counseled about the need for contraception in postpartum period, options available, and advantages and disadvantages of each option. The antenatal woman is expected to opt for one of the options for postpartum contraception. This counseling continues during labor and even after delivery. Sampling frame: The women who opted for PPIUCD and met World Health Organization (WHO) standard criteria were enrolled in the study. The written informed consent was obtained at the time of insertion of PPIUCD. All the concerned staff are well trained in the procedure. Time of insertion: Copper T 380 A (CU T 380 A) was inserted in women who were enrolled in the study after vaginal delivery or during caesarian section. Women were counseled about probable side effects and importance of follow-up and to visit the hospital in case of any complaints at the time of insertion of intrauterine contraceptive devices (IUCD) and also at time of discharge from hospital. Intrauterine contraceptive devices (IUCD) were inserted the following periods: Postplacental: Within 10 min of removal of placenta after vaginal delivery; Immediate postpartum: Within 48 h of vaginal delivery; Intracesarean: During LSCS. 2.3. Technique of insertion of PPIUCD After the active management of 3rd stage of labor was complete, bimanual examination was performed. Empty uterine cavity was ensured. All the required equipments were arranged in a tray. Written consent was obtained from the patients. Perineum was again properly inspected for lacerations. Cervix was visualized using speculum and retractor. Cervix and vagina were again cleaned up. IUCD pack was aseptically opened and copper-T was held in Kelly’s forceps and slowly inserted through the cervix to the fundus. Left hand was moved to suprapubic region to give pressure in upward and backward direction to straighten uterocervical angle. IUCD was left at the fundus and the instrument was slowly removed with prongs open. The strings were not to be cut. During intracesarean stage, after removing placenta and membranes, IUCD was placed at fundus with the help of the right hand. Follow-up after PPIUCD insertion was advised after one and half months and the next after 6 months. It was ensured that study participants would come for follow-up, but only few of them have turned out for the first follow-up. Following were some of the reasons that could lead to loss of follow-up: As it is tertiary care hospital, the women come from various places of Maharashtra for delivery, so difficult for follow up, change of focus from mother to baby after delivery, lack of awareness about self-health, women pay attention to new borne babies so even if they come for immunization of baby at one and half month, do not turn in Obstetrics and Gynecology OPD, migration of women from in law’s place to maternal side or vice versa after delivery and tendency of no complains no follow up. For the second follow-up, at the end of 6 months, prior telephonic confirmation was obtained and it was ensured that study participants would come for follow-up. At follow-up visit, per speculum examination was done to note down position of thread and signs of infection. Pelvic ultra sonography (USG) was performed if thread was not found on
S.S. Bhat et al. / Journal of Reproductive Health and Medicine 2 (2016) 93–98
per speculum examination. The patient was enquired regarding any symptoms of abnormality that related to PPIUCD. For the second follow-up, at the end of 6 months, prior telephonic confirmation was obtained and it was ensured that study participants would come for follow-up. At follow-up visit, per speculum examination was done to note down position of thread and signs of infection. Pelvic ultra sonography (USG) was performed if thread was not found on per speculum examination. The patient was enquired regarding any symptoms of abnormality that related to PPIUCD. The symptoms were treated accordingly. All the symptoms were noted down according to the following operational definitions:
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5. At the end of 6 months, the retention rate was 86.33%. 6. Spontaneous expulsion of IUCD was found in 55 (8.54%) participants. 7. 33 (5.12%) women opted for voluntary removal. 8. Bleeding was the main symptom perceived by 249 (88.71%) women. Long thread and pain in lower abdomen were perceived by 73 (26.02%) and 45 (15.90%) women, respectively. 9. 361 (61.29%) women were satisfied with IUCD and were continuing the method. Table 1 Demographic distribution among the study participants (N = 680). Demographic distribution
Bleeding problems: When there is spotting (blood stained per vaginal discharge apart from menstruation) and/or menorrhagia (heavy menstrual bleeding that affects day today work), it is called bleeding problems. Pain in lower abdomen: When there is on and off dull aching pain in lower abdomen, it is noted down as pain in lower abdomen. Long thread: IUCD thread out of vulva is called long thread.
Age in years 16–20 21–25 26–30 31–35 Education Illiterate Primary/literate Secondary Higher secondary Diploma Graduate Postgraduate
For the purpose of our study, following definitions were used to describe the acceptance at 6 months of PPIUCD: Acceptance: If woman retains the IUCD at the end of 6 months, she has accepted the method. Retention: When there is no spontaneous expulsion or voluntary removal of IUCD at the end of 6 months, it is called retention. Continued and satisfied: When woman has retained and is continuing IUCD at the end of 6 months and she does not have any complaint related to IUCD, it is called continued and satisfied. Continued but not satisfied: When woman has retained and is continuing IUCD at the end of 6 months but she does have complaints related to IUCD, it is called continued but not satisfied. Not satisfied and removed: When there is no spontaneous expulsion at the end of 6 months but woman removes IUCD due to complains related to IUCD, it is called not satisfied and removed. PPIUCD follow-up register was kept in Post Natal Care (PNC) Out Patient Department (OPD). The aforementioned findings were noted down in the register. As there was limited data for first follow-up, it was not considered for the purpose of analysis.
Data were analyzed at the end of 6 months of insertion. Data were verified and the validation was done with Microsoft Excel. Statistical analysis was done with Epi-Info 7 software. Frequency and proportion (percentages) and chi-square test were calculated. 3. Results 1. Among the study participants, 463 (68.08%) women had secondary education and above. 2. A total of 430 (63.23%) women had opted IUCD as long-term method of contraception. 3. Insertion of PPIUCD was highest among Para 2 women (55.14%). 4. PPIUCD insertion was highest during cesarean section (49.85%).
120 390 148 22
(17.64) (57.35) (21.76) (3.23)
23 194 144 122 12 181 4
(3.38) (28.53) (21.17) (17.94) (1.76) (26.61) (0.58)
This table shows the age-wise distribution among the study participants; maximum 57.35% (390) were in the age group of 21–25 years while 3.23% (22) were in the age group of 31–35 years. Total 463 (68.08%) women were educated secondary and above.
Table 2 Indication of IUCD among the study participants (N = 680). Indication
Frequency (%)
Spacing Long-term
2250 (36.76) 4430 (63.23)
This table shows that 63.23% women have opted IUCD for long-term method of contraception. Table 3 Relation of parity and time of insertion among the study participants (N = 680). Parity
Postpartum
Primipara Para 2 Para 3 and above Total
2.4. Data analysis
Frequency (%)
Intracesarean
Total (%)
84 98 29
Postplacental 57 61 12
109 216 14
250 (36.76) 375 (55.14) 55 (8.08)
211
130
339
680 (100)
This table shows parity-wise and type of PPIUCD distribution among the study group, which shows that the acceptance of intra-cesarean IUCD amongst Para 2 was found to be 216, which is statistically significant (p value = 0.000).
Table 4 Time of insertion of IUCD (CU T 380 A) among the study group (N = 680). Time of insertion of IUCD
Frequency (%)
Immediate postpartum Postplacental Intracesarean
211 (31.02) 130 (19.11) 339 (49.85)
Total
680 (100)
This table shows the time of insertion of IUCD among study participants; LSCS with Cu T insertion was done in 49.85% (339) women; immediate postpartum insertion was done in 31.02% (211) women and postplacental insertion was 19.11% (130) women.
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Table 5 Follow-up of IUCD at the end of 6 months after insertion among the study participants (n = 644). Time of insertion of IUCD
Frequency (%)
Follow up (%)
Retained (%)
Expelled (%)
Removed (%)
Immediate postpartum Postplacental Intracesarean
211 (31.02) 130 (19.11) 339 (49.85)
194 (91.94) 120 (92.30) 330 (97.34)
145 (74.74) 93 (77.5) 318 (96.36)
32 (16.49) 18 (15) 5 (1.51)
17 (8.76) 9 (7.5) 7 (2.12)
Total
680 (100)
644 (94.70)
556 (86.33)
55 (8.54)
33 (5.12)
This table shows the distribution of study subjects according to the outcome of PPIUCD and the type of insertion. The women in the study group were followed at the end of six months; follow-up rate was 94.7%. The proportion of retention of IUCD among the women who came for followup was 86.33%; retention rate was 96.96% among intra-cesarean IUCD (p < 0.05 significant) while 77.5% and 74.74% were of postplacental and immediate postpartum IUCD respectively. The overall retention rate was 86.33% among the women. Spontaneous expulsion of IUCD was found to be 8.54%; 16.495 in the women whom the IUCD was inserted in the immediate postpartum period. Voluntary removal for IUCD was observed 5.12% among the study group.
Table 6 Symptoms after insertion of PPIUCD among the participating women (n = 283). Symptoms
Frequency (%)
Bleeding problems Long thread Pain in lower abdomen
249 (88.71%) 73 (26.02%) 45 (15.90%)
Table 7 Acceptance of post-partum IUCD among the study group (n = 589). Continued and satisfied Continued but not satisfied Not satisfied and removed
361 (61.29%) 195 (33.10%) 33 (5.60%)
Percentage of women who were satisfied and continuing the method was 61.29% whereas 33.10% of women were not satisfied with IUCD but continuing the method.
Frequency is mutually exclusive as some women have multiple symptoms. 361 women (56.05%) were asymptomatic. Bleeding problems were the main symptom perceived by 249 (88.71%) women followed by long thread and pain in lower abdomen 26.02% and 15.90% respectively.
Table 8 Reasons for removal of PPIUCD insertion among study group (n = 33).
10. 195 (33.10%) women were not satisfied with IUCD but were continuing the method. 11. Bleeding (84.84%) was the main reason for removal of PPIUCD.
Frequency (%) 28 (84.84) 13 (39.39) 1 (3.03)
Frequency is mutually exclusive as some women have multiple reasons for removal. Bleeding problems (84.84%) were the most common symptom while pain in lower abdomen was 39.39% for the removal of IUCD.
4. Discussion There were 680 PPIUCD insertions during the specified period. The women were in the age group of 21–25 years; 390 (57.35%) women participated in the study. Out of 680 women, 644 (94.7%) women were followed up at the end of 6 months. The follow-up rate was 76.95% in the study conducted by Dr. Mishra8 on evaluation of safety, efficacy, and expulsion of postplacental and [(Fig._1)TD$IG]
Reasons for removal of PPIUCD Bleeding problems Pain in lower abdomen Long thread
intracesarean insertion of intrauterine contraceptive devices (PPIUCD) (Tables 1–8). Acceptance of PPIUCD insertion among Para 2 was 55.14% while in Primipara it was 36.74%. Study done by Kumar et al.9 showed that acceptance for PPIUCD insertion was 53% among Primipara
100% 90%
Time of inseron
80%
25.5 43.6
49.9
57.6
70%
21.8
60% 50% 40%
22.8
20% 10%
19.1
16.3
30%
52.7 33.6
31
26.1
0%
Primi para
Para 2
Para 3 and above
Total
Intra caeserean
43.6
57.6
25.5
49.9
Post Placental Post Partum
22.8 33.6
16.3 26.1
21.8 52.7
19.1 31
Parity Post Partum
Post Placental
Intra caeserean
Fig. 1. Relation of parity and time of insertion among the study participants (N = 680).
[(Fig._2)TD$IG]
S.S. Bhat et al. / Journal of Reproductive Health and Medicine 2 (2016) 93–98
31.02
The time of insertion of PPIUCD (Fig. 2) shows the following findings. Intracesarean period was in 49.85%, immediate postpartum was in 31.02%, and postplacental was in 19.11% among the study participants. The study performed by Jairaj and Dayyala10 has similar findings. In this study, the retention rate of PPIUCD was 86.3%; findings are coherent with the study done by Mishra.8 Retention rate for intracesarean IUCD insertion was 96.36%, which is comparable with the study by Singal et al.11 (Fig. 3). Fundal placement of IUCD is assured in intracesarean insertion; hence, retention rate is high (p < 0.05 significant). Among the followed up women (556), who retained IUCD at end of 6 months, 61.29% were continued and satisfied with the method and 33.10% women were continuing the method but were not satisfied with it. 92% of women were happy and satisfied in the study carried out by Kumar et al.9 (Fig. 4).
Immediate Postpartum
49.85
97
Post Placental Intra caeserean 19.11
Fig. 2. Time of insertion of IUCD (CU T 380 A) among the study group (N = 680).
while 33% in Para 2. The above findings are not in coherence; one of the reasons may be that long-acting and reversible, temporary method of contraception is accepted than the permanent method of contraception (Fig. 1).
[(Fig._3)TD$IG] Follow up of IUCD at the end of 6 months 100% 90%
2.12 1.51
8.76 16.49
7.5 15
74.74
77.5
91.94
92.3
97.34
Immediate post partum
Post Placental
Intra caeserean
Time of inseron
80% 70%
96.36
60% 50% 40% 30% 20% 10% 0%
Removed Expelled Retained Follow up
8.76
7.5
2.12
16.49
15
1.51
74.74
77.5
96.36
91.94
92.3
97.34
Follow up
Retained
Expelled
Removed
Fig. 3. Follow-up of IUCD at the end of 6 months after insertion among the study participants (n = 644).
[(Fig._4)TD$IG] Total Follow up 644(94.70%)
No spontaneous expulsion-
Spontaneous
589(91.45%)
expulsion55(8.54%)
Retained and Connued556(86.33% )
Sasfied361(61.29%)
Removed33(5.60%)
Notsasfied195(33.10%)
Fig. 4. Outcome of PPIUCD.
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Symptoms were noted down for acceptance of PPIUCD. The major symptom was bleeding problems in 88.71%, pain in lower abdomen in 15.9%, and problem because of long thread in 26.02%. The study carried out by Katheit and Agarwal,12 for acceptance of PPIUCD among the women who delivered vaginally after 6 weeks, showed follow-up rate as 83.37%, acceptance at 89.5%, bleeding problems at 10.5%, and pain in lower abdomen at 12.9%. Bleeding problems and pain in lower abdomen were less in proportion when compared to this study, as the follow-up was taken at the end of 6 weeks, while in this study, follow-up was taken at the end of 6 months. The expulsion rate was found to be 8.54% and the removal rate was 5.12%; similar findings were observed in the study done by Mishra8 where expulsion rate was 8.99% and removal was 9.91% among the study population. 5. Conclusion Retention rate of PPIUCD was high. Spontaneous expulsion in intracesarean IUCD was less as fundal placement was assured at the time of insertion. Bleeding was the major complaint and the main reason for removal of PPIUCD. Details of ethics approval Study was approved by ethical review board at SKNMC & GH, Narhe (Ref. SKNMC NO/Ethics/App/88/2011; dated 15.12.2011). Conflicts of interest The authors have none to declare.
Acknowledgments Our head, Dr. Pushpalata Naphade, provided guidance for the study. We are thankful to all the members of Department of OBGY at SKNMC & GH for their support and help in conducting the study. References 1. Family Planning/Contraception Fact Sheet. World Health Organization. Available from: http://who.int/mediacentre/factsheets/fs351/en/ [accessed 05.04.16]. 2. Current Contraceptive Use Among Married Women 15–49 Years Old, Modern Methods. Millennium Development Indicators. Available from: http://mdgs.un. org/unsd/mdg/ [accessed 12.04.16]. 3. World Contraceptive Patterns 2013. United Nations Department of Economic and Social Affairs. Available from: http://www.un.org/en/ [accessed 12.04.16]. 4. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368(November (9549)):1810–1827. 5. Trends in Contraceptive Use Worldwide, 2015. Department of Economic and Social Affairs Population Division, United Nations, New York; 2015. 6. Trends in Child Delivery at Health Facilities (Institutional Delivery) across India from 2008-09 to 2012-13. Available from: https://community.data.gov.in/ [accessed 09.04.16]. 7. Postpartum IUCD Reference Manual, New Delhi. Family Planning Division, Ministry of Health and Family Welfare, Government of India; 2010. 8. Mishra S. Evaluation of safety, efficacy, and expulsion of post-placental and intracesarean insertion of intrauterine contraceptive devices (PPIUCD). J Obstet Gynecol India. 2014;64(September–October (5)):337–343. 9. Kumar S, Sethi R, Balasubramaniam S, et al. Women’s experience with postpartum intrauterine contraceptive device use in India. Reprod Health. 2014;11:32. 10. Jairaj S, Dayyala S. A cross sectional study on acceptability and safety of IUCD among postpartum mothers at tertiary care hospital, Telangana. J Clin Diagn Res. 2016;10(January (1)):LC01–LC04. 11. Singal S, Bharti R, Dewan R, et al. Clinical outcome of postplacental copper T 380A insertion in women delivering by caesarean section. J Clin Diagn Res. 2014;8(September (9)):OC01–OC04. 12. Katheit G, Agarwal J. Evaluation of post-placental intrauterine device (PPIUCD) in terms of awareness, acceptance, and expulsion in a tertiary care centre. Int J Reprod Contracept Obstet Gynecol. 2013;2:539–543.
Contents lists available at ScienceDirect
Journal of Reproductive Health and Medicine journal homepage: www.elsevier.com/locate/jrhm
Original article
To study the acceptance of postpartum intrauterine contraceptive device, CU T 380 A, in a tertiary care hospital in India Shilpa Shreepad Bhat a,*, Hemant Damle b,e, Sameer Popat Darawade a,f, Ketaki Junnare c,g, Madhura Ashturkar d,h a
Assistant Professor, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India Professor and Unit Head, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India Associate Professor, Department of OBGY, Smt Kashibai Navale Medical College, Pune, India d Public Health Expert, C-103, Nisarg Kiran, Rahatani, Pune, India b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2016 Received in revised form 18 May 2016 Accepted 21 May 2016 Available online 8 June 2016
Introduction: Family planning allows people to attain their desired number of children and determine the spacing of pregnancies. Contraception plays a major role in women’s health. Increased number of institutional deliveries allows us to offer family planning methods to couples. Postpartum intrauterine devices (PPIUCD) are the reversible long acting method. It does not interfere with breast feeding and can be provided before the woman leaves the hospital. This study of acceptance of postpartum intrauterine device was conducted in tertiary care hospital in India. Aim and objectives: To find out the (1) acceptance of PPIUCD CU T 380 A, (2) retention rate of PPIUCD and (3) spontaneous expulsion rate at end of 6 months of delivery. Material and methods: PPIUCD was inserted in 680 women either after vaginal delivery or during caesarian section. Data analysis was done at the end of 6 months. Results: (1) Insertion of PPIUCD amongst Para 2 was highest 375 (55.14%). (2) Retention rate was 86.33%. (3) Spontaneous expulsion was found in 55 (8.54%) women. (4) Bleeding was the main symptom perceived by 249 (88.71%) women followed by long thread 73 (26.02%) and pain in lower abdomen 45 (15.90%). (5) Total 361 (61.29%) women were satisfied and were continuing the method. Conclusion: Retention rate of PPIUCD was high. Spontaneous expulsion in intra-caesarian IUCD was less as fundal placement was assured at the time of insertion. Bleeding problems were the major complaint and the main reason for removal of PPIUCD. ß 2016 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd.
Keywords: CU T 380 A Postpartum IUCD Contraception
1. Introduction Every pregnancy should be a planned one. Family planning allows people to consider the number of children they desire and determine the period between each pregnancy. Family planning allows spacing of pregnancies and can delay pregnancies in young women with increased risk of health problems and can help to prevent death because of childbearing at an early age. It prevents unintended pregnancies, including
* Corresponding author at: Renuka Nagar, Lane 2, Warje, Pune, India. Tel.: +91 9422515275. E-mail address: [email protected] (S.S. Bhat). e Tel.: +91 8888800669. f Tel.: +91 9822266907. g Tel.: +91 9850029126. h Tel.: +91 9823558765. http://dx.doi.org/10.1016/j.jrhm.2016.05.002 2214-420X/ß 2016 Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd.
those in older women who face increased risks related to pregnancy. Family planning enables women to limit the size of their families, if they wish to do so. Evidence suggests that women who have more than 4 children are at increased risk of maternal mortality. By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe abortion.1 Modern methods of contraception include female and male sterilization, oral hormonal pills, the intrauterine device (IUD), the male condom, injectables, the implant (including Norplant), vaginal barrier methods, the female condom, and emergency contraception.2 The unmet need for contraception remains too high. This situation is fueled by a growing population and a shortage of family planning services. In Africa, 23.2% of the women of reproductive age have an unmet need for modern contraception. In Asia, and Latin America and the Caribbean – regions with relatively high contraceptive prevalence – the levels of unmet need are 10.9% and 10.4%, respectively.3
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Family planning is important not only for population stabilization but also to improve maternal and newborn survival. Family planning can avert more than 30% of the maternal deaths and 10% of child mortality, if spacing between each pregnancy is more than 2 years.4 In 2015, worldwide, 64% of married or in-union women of reproductive age were using some form of contraception. However, contraceptive use was much lower in the least developed countries (40%) and was particularly low in Africa (33%). Worldwide, in 2015, 12% of married or in-union women are estimated to have had an unmet need for family planning; that is, they wanted to stop or delay childbearing but are not to do so using any method of contraception. According to WHO report 2015, use of contraception method in India is between 50 and 70%, with median of 59.8%, while unmet need of contraception is 13.1%. Among the various contraception methods used, IUD constitutes 2% of the total use.5 One of the modern methods of contraception is postpartum intrauterine contraceptive device (PPIUCD). PPIUCD is a reversible, long-acting method. It does not interfere with breast-feeding and can be provided before the patient leaves the hospital. In postpartum period, resumption of sexual activities, return of menses, and breast-feeding put women at considerable risk of pregnancy. If no family planning is done, she needs to perform repeated urine pregnancy tests and is always under stress of unplanned pregnancy. Women are highly motivated and receptive to accept Family planning methods during the postpartum period. Increasing number of institutional deliveries helps us to provide more number of couples with family planning services. Institutional deliveries in India in 2012–2013 were found to be 82.864%.6 Postpartum intrauterine contraceptive device (IUCD) has specific advantages over other methods, which include convenience, safety, no risk of uterine perforation because of thick wall of uterus, reduced perception of initial side effects (bleeding, cramping) due to presence of normal puerperal changes, no effect on breast-feeding, and stress-free postpartum period. Advantages for service providers include the following: certainty that the woman is not pregnant; saves time, as it is performed on the same delivery table for postplacental\intracesarean insertions; additional evaluations and separate clinical evaluation not required; need for minimal additional instruments, supplies, and equipment.7 Therefore, the present study is carried out to study the acceptance of postpartum intrauterine device among women who delivered at tertiary care hospital in India. 2. Material and methods The study was carried out during the period of June 2011 to May 2014 in Department of Obstetrics and Gynecology in Smt. Kashibai Navale Medical College, Narhe, Pune, Maharashtra, India. It is a prospective, observational study. 2.1. Inclusion criteria Inclusion criteria for study participants were all women of any age who opted for PPIUCD after vaginal birth and during lower segment cesarean section (LSCS). 2.2. Exclusion criteria The exclusion criteria were as follows: postpartum hemorrhage (PPH) and prolonged rupture of membranes (PROM). Institutional ethical committee approval was taken for this study.
During antenatal visits, all the registered women were counseled about the need for contraception in postpartum period, options available, and advantages and disadvantages of each option. The antenatal woman is expected to opt for one of the options for postpartum contraception. This counseling continues during labor and even after delivery. Sampling frame: The women who opted for PPIUCD and met World Health Organization (WHO) standard criteria were enrolled in the study. The written informed consent was obtained at the time of insertion of PPIUCD. All the concerned staff are well trained in the procedure. Time of insertion: Copper T 380 A (CU T 380 A) was inserted in women who were enrolled in the study after vaginal delivery or during caesarian section. Women were counseled about probable side effects and importance of follow-up and to visit the hospital in case of any complaints at the time of insertion of intrauterine contraceptive devices (IUCD) and also at time of discharge from hospital. Intrauterine contraceptive devices (IUCD) were inserted the following periods: Postplacental: Within 10 min of removal of placenta after vaginal delivery; Immediate postpartum: Within 48 h of vaginal delivery; Intracesarean: During LSCS. 2.3. Technique of insertion of PPIUCD After the active management of 3rd stage of labor was complete, bimanual examination was performed. Empty uterine cavity was ensured. All the required equipments were arranged in a tray. Written consent was obtained from the patients. Perineum was again properly inspected for lacerations. Cervix was visualized using speculum and retractor. Cervix and vagina were again cleaned up. IUCD pack was aseptically opened and copper-T was held in Kelly’s forceps and slowly inserted through the cervix to the fundus. Left hand was moved to suprapubic region to give pressure in upward and backward direction to straighten uterocervical angle. IUCD was left at the fundus and the instrument was slowly removed with prongs open. The strings were not to be cut. During intracesarean stage, after removing placenta and membranes, IUCD was placed at fundus with the help of the right hand. Follow-up after PPIUCD insertion was advised after one and half months and the next after 6 months. It was ensured that study participants would come for follow-up, but only few of them have turned out for the first follow-up. Following were some of the reasons that could lead to loss of follow-up: As it is tertiary care hospital, the women come from various places of Maharashtra for delivery, so difficult for follow up, change of focus from mother to baby after delivery, lack of awareness about self-health, women pay attention to new borne babies so even if they come for immunization of baby at one and half month, do not turn in Obstetrics and Gynecology OPD, migration of women from in law’s place to maternal side or vice versa after delivery and tendency of no complains no follow up. For the second follow-up, at the end of 6 months, prior telephonic confirmation was obtained and it was ensured that study participants would come for follow-up. At follow-up visit, per speculum examination was done to note down position of thread and signs of infection. Pelvic ultra sonography (USG) was performed if thread was not found on
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per speculum examination. The patient was enquired regarding any symptoms of abnormality that related to PPIUCD. For the second follow-up, at the end of 6 months, prior telephonic confirmation was obtained and it was ensured that study participants would come for follow-up. At follow-up visit, per speculum examination was done to note down position of thread and signs of infection. Pelvic ultra sonography (USG) was performed if thread was not found on per speculum examination. The patient was enquired regarding any symptoms of abnormality that related to PPIUCD. The symptoms were treated accordingly. All the symptoms were noted down according to the following operational definitions:
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5. At the end of 6 months, the retention rate was 86.33%. 6. Spontaneous expulsion of IUCD was found in 55 (8.54%) participants. 7. 33 (5.12%) women opted for voluntary removal. 8. Bleeding was the main symptom perceived by 249 (88.71%) women. Long thread and pain in lower abdomen were perceived by 73 (26.02%) and 45 (15.90%) women, respectively. 9. 361 (61.29%) women were satisfied with IUCD and were continuing the method. Table 1 Demographic distribution among the study participants (N = 680). Demographic distribution
Bleeding problems: When there is spotting (blood stained per vaginal discharge apart from menstruation) and/or menorrhagia (heavy menstrual bleeding that affects day today work), it is called bleeding problems. Pain in lower abdomen: When there is on and off dull aching pain in lower abdomen, it is noted down as pain in lower abdomen. Long thread: IUCD thread out of vulva is called long thread.
Age in years 16–20 21–25 26–30 31–35 Education Illiterate Primary/literate Secondary Higher secondary Diploma Graduate Postgraduate
For the purpose of our study, following definitions were used to describe the acceptance at 6 months of PPIUCD: Acceptance: If woman retains the IUCD at the end of 6 months, she has accepted the method. Retention: When there is no spontaneous expulsion or voluntary removal of IUCD at the end of 6 months, it is called retention. Continued and satisfied: When woman has retained and is continuing IUCD at the end of 6 months and she does not have any complaint related to IUCD, it is called continued and satisfied. Continued but not satisfied: When woman has retained and is continuing IUCD at the end of 6 months but she does have complaints related to IUCD, it is called continued but not satisfied. Not satisfied and removed: When there is no spontaneous expulsion at the end of 6 months but woman removes IUCD due to complains related to IUCD, it is called not satisfied and removed. PPIUCD follow-up register was kept in Post Natal Care (PNC) Out Patient Department (OPD). The aforementioned findings were noted down in the register. As there was limited data for first follow-up, it was not considered for the purpose of analysis.
Data were analyzed at the end of 6 months of insertion. Data were verified and the validation was done with Microsoft Excel. Statistical analysis was done with Epi-Info 7 software. Frequency and proportion (percentages) and chi-square test were calculated. 3. Results 1. Among the study participants, 463 (68.08%) women had secondary education and above. 2. A total of 430 (63.23%) women had opted IUCD as long-term method of contraception. 3. Insertion of PPIUCD was highest among Para 2 women (55.14%). 4. PPIUCD insertion was highest during cesarean section (49.85%).
120 390 148 22
(17.64) (57.35) (21.76) (3.23)
23 194 144 122 12 181 4
(3.38) (28.53) (21.17) (17.94) (1.76) (26.61) (0.58)
This table shows the age-wise distribution among the study participants; maximum 57.35% (390) were in the age group of 21–25 years while 3.23% (22) were in the age group of 31–35 years. Total 463 (68.08%) women were educated secondary and above.
Table 2 Indication of IUCD among the study participants (N = 680). Indication
Frequency (%)
Spacing Long-term
2250 (36.76) 4430 (63.23)
This table shows that 63.23% women have opted IUCD for long-term method of contraception. Table 3 Relation of parity and time of insertion among the study participants (N = 680). Parity
Postpartum
Primipara Para 2 Para 3 and above Total
2.4. Data analysis
Frequency (%)
Intracesarean
Total (%)
84 98 29
Postplacental 57 61 12
109 216 14
250 (36.76) 375 (55.14) 55 (8.08)
211
130
339
680 (100)
This table shows parity-wise and type of PPIUCD distribution among the study group, which shows that the acceptance of intra-cesarean IUCD amongst Para 2 was found to be 216, which is statistically significant (p value = 0.000).
Table 4 Time of insertion of IUCD (CU T 380 A) among the study group (N = 680). Time of insertion of IUCD
Frequency (%)
Immediate postpartum Postplacental Intracesarean
211 (31.02) 130 (19.11) 339 (49.85)
Total
680 (100)
This table shows the time of insertion of IUCD among study participants; LSCS with Cu T insertion was done in 49.85% (339) women; immediate postpartum insertion was done in 31.02% (211) women and postplacental insertion was 19.11% (130) women.
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Table 5 Follow-up of IUCD at the end of 6 months after insertion among the study participants (n = 644). Time of insertion of IUCD
Frequency (%)
Follow up (%)
Retained (%)
Expelled (%)
Removed (%)
Immediate postpartum Postplacental Intracesarean
211 (31.02) 130 (19.11) 339 (49.85)
194 (91.94) 120 (92.30) 330 (97.34)
145 (74.74) 93 (77.5) 318 (96.36)
32 (16.49) 18 (15) 5 (1.51)
17 (8.76) 9 (7.5) 7 (2.12)
Total
680 (100)
644 (94.70)
556 (86.33)
55 (8.54)
33 (5.12)
This table shows the distribution of study subjects according to the outcome of PPIUCD and the type of insertion. The women in the study group were followed at the end of six months; follow-up rate was 94.7%. The proportion of retention of IUCD among the women who came for followup was 86.33%; retention rate was 96.96% among intra-cesarean IUCD (p < 0.05 significant) while 77.5% and 74.74% were of postplacental and immediate postpartum IUCD respectively. The overall retention rate was 86.33% among the women. Spontaneous expulsion of IUCD was found to be 8.54%; 16.495 in the women whom the IUCD was inserted in the immediate postpartum period. Voluntary removal for IUCD was observed 5.12% among the study group.
Table 6 Symptoms after insertion of PPIUCD among the participating women (n = 283). Symptoms
Frequency (%)
Bleeding problems Long thread Pain in lower abdomen
249 (88.71%) 73 (26.02%) 45 (15.90%)
Table 7 Acceptance of post-partum IUCD among the study group (n = 589). Continued and satisfied Continued but not satisfied Not satisfied and removed
361 (61.29%) 195 (33.10%) 33 (5.60%)
Percentage of women who were satisfied and continuing the method was 61.29% whereas 33.10% of women were not satisfied with IUCD but continuing the method.
Frequency is mutually exclusive as some women have multiple symptoms. 361 women (56.05%) were asymptomatic. Bleeding problems were the main symptom perceived by 249 (88.71%) women followed by long thread and pain in lower abdomen 26.02% and 15.90% respectively.
Table 8 Reasons for removal of PPIUCD insertion among study group (n = 33).
10. 195 (33.10%) women were not satisfied with IUCD but were continuing the method. 11. Bleeding (84.84%) was the main reason for removal of PPIUCD.
Frequency (%) 28 (84.84) 13 (39.39) 1 (3.03)
Frequency is mutually exclusive as some women have multiple reasons for removal. Bleeding problems (84.84%) were the most common symptom while pain in lower abdomen was 39.39% for the removal of IUCD.
4. Discussion There were 680 PPIUCD insertions during the specified period. The women were in the age group of 21–25 years; 390 (57.35%) women participated in the study. Out of 680 women, 644 (94.7%) women were followed up at the end of 6 months. The follow-up rate was 76.95% in the study conducted by Dr. Mishra8 on evaluation of safety, efficacy, and expulsion of postplacental and [(Fig._1)TD$IG]
Reasons for removal of PPIUCD Bleeding problems Pain in lower abdomen Long thread
intracesarean insertion of intrauterine contraceptive devices (PPIUCD) (Tables 1–8). Acceptance of PPIUCD insertion among Para 2 was 55.14% while in Primipara it was 36.74%. Study done by Kumar et al.9 showed that acceptance for PPIUCD insertion was 53% among Primipara
100% 90%
Time of inseron
80%
25.5 43.6
49.9
57.6
70%
21.8
60% 50% 40%
22.8
20% 10%
19.1
16.3
30%
52.7 33.6
31
26.1
0%
Primi para
Para 2
Para 3 and above
Total
Intra caeserean
43.6
57.6
25.5
49.9
Post Placental Post Partum
22.8 33.6
16.3 26.1
21.8 52.7
19.1 31
Parity Post Partum
Post Placental
Intra caeserean
Fig. 1. Relation of parity and time of insertion among the study participants (N = 680).
[(Fig._2)TD$IG]
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31.02
The time of insertion of PPIUCD (Fig. 2) shows the following findings. Intracesarean period was in 49.85%, immediate postpartum was in 31.02%, and postplacental was in 19.11% among the study participants. The study performed by Jairaj and Dayyala10 has similar findings. In this study, the retention rate of PPIUCD was 86.3%; findings are coherent with the study done by Mishra.8 Retention rate for intracesarean IUCD insertion was 96.36%, which is comparable with the study by Singal et al.11 (Fig. 3). Fundal placement of IUCD is assured in intracesarean insertion; hence, retention rate is high (p < 0.05 significant). Among the followed up women (556), who retained IUCD at end of 6 months, 61.29% were continued and satisfied with the method and 33.10% women were continuing the method but were not satisfied with it. 92% of women were happy and satisfied in the study carried out by Kumar et al.9 (Fig. 4).
Immediate Postpartum
49.85
97
Post Placental Intra caeserean 19.11
Fig. 2. Time of insertion of IUCD (CU T 380 A) among the study group (N = 680).
while 33% in Para 2. The above findings are not in coherence; one of the reasons may be that long-acting and reversible, temporary method of contraception is accepted than the permanent method of contraception (Fig. 1).
[(Fig._3)TD$IG] Follow up of IUCD at the end of 6 months 100% 90%
2.12 1.51
8.76 16.49
7.5 15
74.74
77.5
91.94
92.3
97.34
Immediate post partum
Post Placental
Intra caeserean
Time of inseron
80% 70%
96.36
60% 50% 40% 30% 20% 10% 0%
Removed Expelled Retained Follow up
8.76
7.5
2.12
16.49
15
1.51
74.74
77.5
96.36
91.94
92.3
97.34
Follow up
Retained
Expelled
Removed
Fig. 3. Follow-up of IUCD at the end of 6 months after insertion among the study participants (n = 644).
[(Fig._4)TD$IG] Total Follow up 644(94.70%)
No spontaneous expulsion-
Spontaneous
589(91.45%)
expulsion55(8.54%)
Retained and Connued556(86.33% )
Sasfied361(61.29%)
Removed33(5.60%)
Notsasfied195(33.10%)
Fig. 4. Outcome of PPIUCD.
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Symptoms were noted down for acceptance of PPIUCD. The major symptom was bleeding problems in 88.71%, pain in lower abdomen in 15.9%, and problem because of long thread in 26.02%. The study carried out by Katheit and Agarwal,12 for acceptance of PPIUCD among the women who delivered vaginally after 6 weeks, showed follow-up rate as 83.37%, acceptance at 89.5%, bleeding problems at 10.5%, and pain in lower abdomen at 12.9%. Bleeding problems and pain in lower abdomen were less in proportion when compared to this study, as the follow-up was taken at the end of 6 weeks, while in this study, follow-up was taken at the end of 6 months. The expulsion rate was found to be 8.54% and the removal rate was 5.12%; similar findings were observed in the study done by Mishra8 where expulsion rate was 8.99% and removal was 9.91% among the study population. 5. Conclusion Retention rate of PPIUCD was high. Spontaneous expulsion in intracesarean IUCD was less as fundal placement was assured at the time of insertion. Bleeding was the major complaint and the main reason for removal of PPIUCD. Details of ethics approval Study was approved by ethical review board at SKNMC & GH, Narhe (Ref. SKNMC NO/Ethics/App/88/2011; dated 15.12.2011). Conflicts of interest The authors have none to declare.
Acknowledgments Our head, Dr. Pushpalata Naphade, provided guidance for the study. We are thankful to all the members of Department of OBGY at SKNMC & GH for their support and help in conducting the study. References 1. Family Planning/Contraception Fact Sheet. World Health Organization. Available from: http://who.int/mediacentre/factsheets/fs351/en/ [accessed 05.04.16]. 2. Current Contraceptive Use Among Married Women 15–49 Years Old, Modern Methods. Millennium Development Indicators. Available from: http://mdgs.un. org/unsd/mdg/ [accessed 12.04.16]. 3. World Contraceptive Patterns 2013. United Nations Department of Economic and Social Affairs. Available from: http://www.un.org/en/ [accessed 12.04.16]. 4. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368(November (9549)):1810–1827. 5. Trends in Contraceptive Use Worldwide, 2015. Department of Economic and Social Affairs Population Division, United Nations, New York; 2015. 6. Trends in Child Delivery at Health Facilities (Institutional Delivery) across India from 2008-09 to 2012-13. Available from: https://community.data.gov.in/ [accessed 09.04.16]. 7. Postpartum IUCD Reference Manual, New Delhi. Family Planning Division, Ministry of Health and Family Welfare, Government of India; 2010. 8. Mishra S. Evaluation of safety, efficacy, and expulsion of post-placental and intracesarean insertion of intrauterine contraceptive devices (PPIUCD). J Obstet Gynecol India. 2014;64(September–October (5)):337–343. 9. Kumar S, Sethi R, Balasubramaniam S, et al. Women’s experience with postpartum intrauterine contraceptive device use in India. Reprod Health. 2014;11:32. 10. Jairaj S, Dayyala S. A cross sectional study on acceptability and safety of IUCD among postpartum mothers at tertiary care hospital, Telangana. J Clin Diagn Res. 2016;10(January (1)):LC01–LC04. 11. Singal S, Bharti R, Dewan R, et al. Clinical outcome of postplacental copper T 380A insertion in women delivering by caesarean section. J Clin Diagn Res. 2014;8(September (9)):OC01–OC04. 12. Katheit G, Agarwal J. Evaluation of post-placental intrauterine device (PPIUCD) in terms of awareness, acceptance, and expulsion in a tertiary care centre. Int J Reprod Contracept Obstet Gynecol. 2013;2:539–543.