Globally, 225 million women need contraception. Birth spacing reduces perinatal and maternal morbidity and mortality. PPIUD is cost‐effective and reversible with minimal expulsions and complications

Arulkumaran, S

Makins, A

St George's Online Research Archive

Int J Gynecol Obstet 2018; 143 (Suppl. 1): 1–3	 wileyonlinelibrary.com/journal/ijgo	 	 | 	1DOI: 10.1002/ijgo.12597E D I T O R I A LInstitutionalization of postpartum intrauterine devicesAnita Makins1,2,* | Sabaratnam Arulkumaran1,31International	Federation	of	Gynecology	and	Obstetrics,	London,	UK2Oxford	University	Hospitals	NHS	Foundation	Trust,	Oxford,	UK3St	George’s,	University	of	London,	London,	UKK E Y W O R D S : 	 Birth	spacing;	FIGO	initiative;	Illegal	abortions;	Long-acting	reversible	contraceptives;	Maternal	mortality;	Postpartum	intrauterine	device;	PPIUD;	Task	sharingIt	 is	 estimated	 that	 220	million	women	need	modern	 contraception	but	are	unable	to	access	it	for	a	variety	of	reasons.1	Poverty,	gender	inequality,	 lack	 access	 to	 health	 services,	 poor	 quality	 services,	 as	well	 as	 stock	 outs	 of	 commodities	 are	 some	of	 the	 reasons	 for	 the	high	unmet	need.	Many	women	in	low-	and	middle-	income	countries	(LMICs)	 are	young	when	 they	have	 their	 families.	 Permanent	meth-ods	that	may	be	available,	such	as	tubal	ligation,	are	not	ideal	owing	to	 their	 irreversibility	 and	women’s	 options	may	be	 limited	 to	 user-	dependent	methods	with	high	failure	rates,	such	as	condoms,	the	oral	contraceptive	pill,	and	depot	injections.2	Reliable	family	planning	may	be	hard	to	achieve,	meaning	that	the	likelihood	of	caring	adequately	for	their	live	children	and	contributing	to	the	upkeep	of	the	family	eco-nomically	is	difficult,	thus	perpetuating	the	cycle	of	poverty.WHO	recommends	24	months	before	attempting	the	next	preg-nancy	 to	 reduce	 the	 risk	 of	 adverse	maternal,	 perinatal,	 and	 infant	outcomes.3	 From	 a	 pediatric	 perspective,	 short	 birth	 intervals	 are	associated	with	 an	 increased	 risk	 of	 neonatal	mortality,	 infant	mor-tality,	deaths	in	children	under	5	years,	and	child	malnutrition.3,4	From	an	obstetric	point	of	view,	short	birth	intervals	have	been	associated	with	increased	risk	of	preterm	birth,	birth	of	small	for	gestational	age	babies,	and	spontaneous	abortion.5	Moreover,	optimal	use	of	 family	planning	could	avert	32%	of	maternal	deaths	 through	prevention	of	unsafe	 births	 as	well	 as	 legal	 and	 illegal	 abortions.6	Tackling	mater-nal	mortality	 the	 traditional	way	by	 improving	access	 to	and	quality	of	obstetric	 care	 is	 a	 complex	 intervention,	whereas	addressing	 low	contraceptive	prevalence	rates	presents	a	relatively	simpler	and	more	cost-	effective	option,	often	with	more	rapid	results.Although	long-	acting	reversible	contraceptives	(LARCs)	have	been	on	the	market	for	many	years	(with	a	few	newer	products	in	the	recent	past),	their	increased	reliability	has	not	been	capitalized	on.	Subdermal	hormonal	 implants	 and	hormonal	 intrauterine	 systems	are	 relatively	unaffordable	for	low-	and	some	middle-	income	country	governments	in	 the	 absence	 of	 subsidies	 and	 price	 adjustments.	The	 copper	 coil	intrauterine	device	(IUD)	on	the	other	hand	has	been	widely	available	as	an	interval	contraceptive	method	for	years	and	has	the	advantage	of	being	cost-	effective	and	nonhormonal.7	Although	copper	IUDs	are	available,	their	uptake	is	not	high.	In	LMICs,	women	are	often	unable	to	attend	family	planning	clinics	as	they	are	busy	and	inaccessible;	or,	if	they	do	attend,	they	may	find	them	nonfunctional	or	that	providers	are	unwilling	or	unskilled	in	IUD	insertion.	Providing	depot	injections,	contraceptive	pills,	and	condoms	is	a	much	quicker	solution	for	health-care	providers	overworked	in	busy	clinics.The	increasing	number	of	institutional	births	at	a	global	level	pro-vides	an	opportunity	 to	 introduce	postpartum	copper	 IUDs	that	are	reliable	and	can	be	kept	for	up	to	10	years,	should	the	woman	choose.	Insertion	in	the	postpartum	period,	especially	if	performed	following	delivery	of	the	placenta	at	vaginal	or	cesarean	birth,	is	a	relatively	easy	procedure	that	can	be	done	immediately	after	birth,	therefore	avoid-ing	any	extra	intervention.	This	one-	stop	approach	allows	the	woman	to	return	home	knowing	she	has	a	reliable	contraceptive	in	situ	that	will	not	influence	her	ability	to	breastfeed	or	require	her	to	return	for	frequent	follow-	up.Implementing	 contraception	 in	 maternity	 services	 moves	 away	from	the	traditional	model	of	women’s	care	where	family	planning	is	discussed	after	6	weeks	in	designated	clinics;	hence,	implementation	has	to	be	strategically	thought	out.The	International	Federation	of	Gynecology	and	Obstetrics	(FIGO)	recognized	the	potential	public	health	impact	that	the	postpartum	IUD	(PPIUD)	could	have,	particularly	in	LMICs,	and	to	this	end	embarked	on	an	initiative	that	began	in	2013.8	The	project	approached	countries	This	is	an	open	access	article	under	the	terms	of	the	Creative	Commons	Attribution	License,	which	permits	use,	distribution	and	reproduction	in	any	medium,	provided	the	original	work	is	properly	cited.©	2018	The	Authors.	International Journal of Gynecology & Obstetrics	published	by	John	Wiley	&	Sons	Ltd	on	behalf	of	International	Federation	of	Gynecology	and	Obstetrics2  |     Editorialthat	were	interested	in	PPIUD	not	only	because	they	could	afford	the	services,	but	also	because	of	the	advantages	that	this	method	confers	on	maternal	and	perinatal	health	in	addition	to	offering	reliable	con-traception	 to	women.	However,	 there	was	 skepticism	 about	PPIUD	among	some	health	personal	as	the	literature	quotes	variable	expul-sion	and	complication	rates	and	previous	attempts	had	failed	to	pop-ularize	the	method.9After	an	initial	successful	pilot	phase	in	six	hospitals	in	Sri	Lanka,	FIGO	had	confidence	in	the	model	and	believed	in	the	potential	pub-lic	health	impact;	the	initiative	was	therefore	expanded	to	a	total	of	48	hospitals	across	six	countries:	Sri	Lanka,	India,	Nepal,	Bangladesh,	Kenya,	 and	 Tanzania.	 This	 Supplement	 presents	 the	 planning	 and	implementation	of	both	phases	of	the	FIGO	PPIUD	initiative,	outlin-ing	the	steps	taken	and	the	overall	results	on	counselling,	insertion,	and	follow-	up	at	6	weeks.	Lessons	from	the	initiative	as	a	whole	and	from	individual	countries	on	various	aspects	are	described.In	total,	36	766	women	had	PPIUD	inserted	across	the	six	coun-tries	 and	 follow-	up	 of	 just	 over	 50%	 demonstrated	 that	 expulsion	rates	were	lower	than	previously	reported	at	2.6%.10	Rates	of	severe	infection	 (pelvic	 inflammatory	 disease)	 were	 as	 low	 as	 0.01%	 and	there	 was	 not	 one	 single	 case	 of	 perforation.	 The	 methodology	taught	and	used	was	high	insertion	at	the	uterine	fundus	using	the	Kelly	forceps.	On-	the-	job	training	was	developed	in	Nepal	and	was	found	to	be	highly	successful,	with	the	benefit	of	not	taking	health	personnel	 away	 from	 the	work	place	 for	organized	 training.11	Task	sharing	 of	 insertion	 of	 IUDs	 by	 midwives	 and	 nurses	 in	 India,12 Nepal,10	Kenya,10	and	Tanzania13	proved	to	be	extremely	successful,	with	escalation	of	acceptance	rates	and	very	 little	variance	 in	com-plication	 rates.	Training	of	 lay	people	 as	 counsellors	 in	Bangladesh	had	 some	 advantages	 albeit	 not	 the	 anticipated	 impact	 on	 PPIUD	acceptance,14	which	 reflected	 the	multifaceted	 factors	 that	 are	 at	play	 in	 some	cultures	where	 the	woman	 is	not	 the	decision	maker	when	it	comes	to	her	own	sexual	and	reproductive	health.	Analysis	of	counselling	 factors	across	 four	countries	exemplified	the	unique	role	that	each	context	plays	in	women’s	acceptance	of	contraception	and	PPIUD	in	particular.15	As	a	result	of	this	initiative,	the	Sri	Lankan	Government	has	made	postpartum	contraception	a	mainstay	of	 its	policy,	including	both	PPIUD	and	hormonal	implants	into	the	menu	of	options	that	women	can	choose	from.16	The	article	from	Edinburgh17 demonstrates	 that	 PPIUD	 is	 not	 only	 for	 LMICs	 by	 describing	 the	experience	of	successful	implementation	within	the	National	Health	Service	of	the	United	Kingdom.The	positive	experience	of	the	FIGO	PPIUD	project	is	distilled	in	this	Supplement.	We	urge	governments	to	take	on	board	the	lessons	learnt	and	described	here,	and	to	appreciate	 the	enormous	benefits	that	 offering	 PPIUD	 could	 bring	 to	 women	 around	 the	 world.	 The	Supplement	is	a	tool	book	on	how	to	introduce	PPIUD	into	different	health	systems	and	expand	contraceptive	choices.	The	work	at	FIGO	and	with	 the	 six	participating	national	 societies	will	 continue	 in	 the	years	 ahead;	 the	 respective	governments	 have	welcomed	 continua-tion	of	the	initiative	with	a	view	to	sustainability	and	further	embed-ding	 the	 practice	 of	 offering	 postpartum	 contraception	 as	 part	 of	routine	postpartum	care.AUTHOR CONTRIBUTIONSAM	and	SA	contributed	equally	to	writing	the	editorial	and	directed	the	initiative	in	the	six	countries.ACKNOWLEDGMENTSOn	behalf	of	FIGO,	we	thank	the	national	societies	who	participated	in	the	PPIUD	initiative,	the	governments	of	the	six	countries,	the	FIGO	Contraception	Working	Group	who	acted	as	the	scientific	and	techni-cal	advisory	group,	and	most	importantly	the	generous	grant	provided	by	our	anonymous	donors.CONFLICTS OF INTERESTThe	authors	have	no	conflicts	to	declare.REFERENCES	 1.	 Guttmacher	 Institute.	Adding	 it	 up:	 Investing	 in	 contraception	 and	maternal	newborn	health,	2017.	2017.	https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-2017.	Accessed	June	19,	2018.	 2.	 Mansour	D,	 Inki	P,	Gemzell-Danielsson	K.	Efficacy	of	 contraceptive	methods:	A	 review	of	 the	 literature.	Eur J Contracept Reprod Health Care. 2010;15:4–16.	 3.	 World	Health	Organization.	Report of a WHO Technical Consultation on Birth Spacing.	Geneva:	WHO;	2007.	 4.	 Rutstein	SO.	Effects	of	preceding	birth	 intervals	on	neonatal,	 infant	and	 under-	five	years	mortality	 and	 nutritional	 status	 in	 developing	countries:	Evidence	from	the	demographic	and	health	surveys.	 Int J Gynecol Obstet. 2005;89(Suppl.1):S7–S24.	 5.	 Shulman	JJ,	Merritt	CG.	Postpartum	contraception:	Subsequent	preg-nancy,	delivery,	and	abortion	rates.	Fertil Steril. 1976;27:97–103.	 6.	 Arulkumaran	S,	Hediger	V,	Manzoor	A,	May	J.	Saving	Mothers’	Lives:	Transforming	 Strategy	 into	 Action.	 Report	 of	 the	 Maternal	 Health	Working	 Group	 2012.	 https://www.imperial.ac.uk/media/imperi-al-college/institute-of-global-health-innovation/public/Mothers-lives.pdf.	Accessed	June	19,	2018.	 7.	 Trussel	J.	Update	on	and	correction	to	the	cost-	effectiveness	of	con-traceptives	in	the	United	States.	Contraception. 2012;85:611.	 8.	 de	Caestecker	L,	Banks	L,	Bell	E,	Sethi	M,	Arulkumaran	S.	Planning	and	implementation	of	a	FIGO	postpartum	intrauterine	device	initia-tive	in	six	countries.	Int J Gynecol Obstet. 2018;143(Suppl.1):4–12.	 9.	 Goldthwaite	L,	Sheeder	J,	Hyer	J,	Tocce	K,	Teal	S.	Postplacental	intra-uterine	device	expulsion	by	12	weeks:	A	prospective	cohort	study.	Am J Obstet Gynecol. 2017;217:674.e1–674.e8.	10.	 Makins	 A,	 Taghinejadi	 N,	 Sethi	 M,	 Machiyama	 K,	 Munganyizi	P,	 Odongo	 E,	 et	 al.	 FIGO	 postpartum	 intrauterine	 device	 initia-tive:	 Complication	 rates	 across	 six	 countries.	 Int J Gynecol Obstet. 2018;143(Suppl.1):20–27.	11.	 Thapa	K,	Dhital	R,	Karki	YB,	Rajbhandari	S,	Amatya	S,	Pande	S,	et	al.	Institutionalizing	postpartum	 family	planning	and	postpartum	 intra-uterine	device	services	in	Nepal:	Role	of	training	and	mentorship.	Int J Gynecol Obstet. 2018;143(Suppl.1):43–48.	12.	 Bhadra	B,	Burman	SK,	Purandare	CN,	Divakar	H,	Sequeira	T,	Bhardwaj	A.	 The	 impact	 of	 using	 nurses	 to	 perform	 postpartum	 intrauterine	device	insertions	in	Kalyani	Hospital,	India.	Int J Gynecol Obstet. 2018; 143(Suppl.1):33–37.	13.	 Muganyizi	PS,	Kimario	G,	Ponsian	P,	Howard	K,	Sethi	M,	Makins	A.	Clinical	outcomes	of	postpartum	intrauterine	devices	 in	serted	     |  3Editorialby	midwives	 in	Tanzania.	 Int J Gynecol Obstet. 2018;143(Suppl.1): 38–42.	14.	 Fatima	P,	Antora	AH,	Dewan	F,	Nash	S,	Sethi	M.	Impact	of	contracep-tive	counselling	training	among	counsellors	participating	in	the	FIGO	postpartum	intrauterine	device	initiative	in	Bangladesh.	Int J Gynecol Obstet. 2018;143(Suppl.1):49–55.	15.	 Makins	A,	Taghinejadi	N,	Sethi	M,	et	al.	Factors	influencing	the	like-lihood	of	acceptance	of	postpartum	intrauterine	devices	across	four	countries:	India,	Nepal,	Sri	Lanka,	and	Tanzania.	Int J Gynecol Obstet. 2018;143(Suppl.1):13–19.	16.	 Weerasekera	DS,	Senanayeke	L,	Ratnasiri	PU,	et	al.	Four	years	of	the	FIGO	postpartum	intrauterine	device	initiative	in	Sri	Lanka:	Pilot	initia-tive	to	national	policy.	Int J Gynecol Obstet. 2018;143(Suppl.1):28–32.	17.	 Cooper	M,	Cameron	S.	Successful	 implementation	of	immediate	post-partum	intrauterine	contraception	services	in	Edinburgh	and	framework	for	wider	dissemination.	Int J Gynecol Obstet. 2018;143(Suppl.1):56–61.

Institutionalization of postpartum intrauterine devices.

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Institutionalization of postpartum intrauterine devices

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Institutionalization of postpartum intrauterine devices.

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