POSTPARTUM IUCD Reviving An Old Ally

1. POSTPARTUM IUCDReviving An Old Ally Jeffrey M. Smith, MD, MPH Regional Technical Director, Asia Jhpiego soon-to-be Senior Maternal Health Advisor MCHIP

2. 2 Pillars of Safe Motherhood

3. 3 Unmet Need among Postpartum Women Unmet need refers to a woman�s non-use of family planning methods although she is not planning on having a child in the near future. According to the Indian DHS �Unmet need for spacing includes pregnant women whose pregnancy was mistimed; amenorrhoeic women who are not using family planning and whose last birth was mistimed, or whose last births was unwanted but now say they want more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; amenorrhoeic women who are not using family planning, whose last child was unwanted and who do not want any more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who became pregnant while using a method (these women are in need of a better method of contraception). The pie chart on the left illustrates unmet need as defined by DHS. This definition is based on the question �At the time of you became pregnant did you want to become pregnant then, did you want to want to wait until later, or did you want not more children at all?� This analysis redefines unmet need. The pie chart on the right reflects prospective unmet need. This definition is based on the question �Would you like your next child within the next 2 years or would you like no more children?�. The category ��No sex� in the DHS definition of unmet need refers to unmarried women or women who are not living with their spouse who have had sex in the past but not recently had sex.�� In the prospective definition of unmet need these women are allocated to unmet need categories based on their fertility preferences looking into the future. According to the traditional definition of unmet need 31% of postpartum women have an unmet need while according to the prospective definition of unmet need 65% of postpartum women have an unmet need. Women with unmet need by definition want to delay their next birth or limit future births, however, they are not using a method of contraception. Postpartum women are susceptible to pregnancy and many of them want to delay or limit pregnancies however they are not accessing family planning services. This is an unfortunate missed opportunity. 10 missing observations Unmet need refers to a woman�s non-use of family planning methods although she is not planning on having a child in the near future. According to the Indian DHS �Unmet need for spacing includes pregnant women whose pregnancy was mistimed; amenorrhoeic women who are not using family planning and whose last birth was mistimed, or whose last births was unwanted but now say they want more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and say they want to wait 2 or more years for their next birth. Also included in unmet need for spacing are fecund women who are not using any method of family planning and say they are unsure whether they want another child or who want another child but are unsure when to have the birth. Unmet need for limiting refers to pregnant women whose pregnancy was unwanted; amenorrhoeic women who are not using family planning, whose last child was unwanted and who do not want any more children; and fecund women who are neither pregnant nor amenorrhoeic, who are not using any method of family planning, and who want no more children. Excluded from the unmet need category are pregnant and amenorrhoeic women who became pregnant while using a method (these women are in need of a better method of contraception). The pie chart on the left illustrates unmet need as defined by DHS. This definition is based on the question �At the time of you became pregnant did you want to become pregnant then, did you want to want to wait until later, or did you want not more children at all?� This analysis redefines unmet need. The pie chart on the right reflects prospective unmet need. This definition is based on the question �Would you like your next child within the next 2 years or would you like no more children?�. The category ��No sex� in the DHS definition of unmet need refers to unmarried women or women who are not living with their spouse who have had sex in the past but not recently had sex.�� In the prospective definition of unmet need these women are allocated to unmet need categories based on their fertility preferences looking into the future. According to the traditional definition of unmet need 31% of postpartum women have an unmet need while according to the prospective definition of unmet need 65% of postpartum women have an unmet need. Women with unmet need by definition want to delay their next birth or limit future births, however, they are not using a method of contraception. Postpartum women are susceptible to pregnancy and many of them want to delay or limit pregnancies however they are not accessing family planning services. This is an unfortunate missed opportunity. 10 missing observations

4. 4 Birth-to-birth Intervals, past 5 years Large percentage of births in last five years in India have too short intervals Source: National Family Health Survey, 2005-06. Chapter 4: Fertility. Table 4.7 Birth intervals, page 89. N =39,215 Note: 7-17 months- woman getting pregnant before 9 months postpartum 18-23 months- woman getting pregnant between 9 and 14 months postpartum 24-35 months women getting pregnant between 14 and 26 months postpartum Postpartum women�s susceptibility to pregnancy in the first twelve months after giving birth can lead to births that are spaced too close together. Research shows that birth spacing intervals less than 24 months are detrimental to the to the mother and child�s health. This slide shows birth intervals for non-first births in the 5 years preceding the survey. The pie chart shows that 11% of births took place within 18 months after the preceding birth and that 16% of infants were born between 18 and 23 months after their sibling. Approximately a third (27%) of births occurred within or less than a two year period. Large percentage of births in last five years in India have too short intervals Source: National Family Health Survey, 2005-06. Chapter 4: Fertility. Table 4.7 Birth intervals, page 89. N =39,215 Note: 7-17 months- woman getting pregnant before 9 months postpartum 18-23 months- woman getting pregnant between 9 and 14 months postpartum 24-35 months women getting pregnant between 14 and 26 months postpartum Postpartum women�s susceptibility to pregnancy in the first twelve months after giving birth can lead to births that are spaced too close together. Research shows that birth spacing intervals less than 24 months are detrimental to the to the mother and child�s health. This slide shows birth intervals for non-first births in the 5 years preceding the survey. The pie chart shows that 11% of births took place within 18 months after the preceding birth and that 16% of infants were born between 18 and 23 months after their sibling. Approximately a third (27%) of births occurred within or less than a two year period.

5. Risk of Unplanned Pregnancy This graph shows factors influencing return to fertility � return of menses, exclusive breastfeeding, and sexual activity. 40% of postpartum women have returned to sexual activity during the first three months of postpartum. During these first three months women may be protected from another pregnancy by breastfeeding exclusively and the absence of menses. However, in the 4-6 month postpartum period the percent of women who are sexually active increases to 78% yet there is a dramatic decrease in the percent of women breastfeeding exclusively and an increase in the percent of women whose menses has returned. Women return to sexual activity and are less protected from another pregnancy during the latter months of the postpartum period.  According to NFHS-3 , the median number of months for postpartum amenorrhea is 7 months, for abstinence it is 2.3 months, and for postpartum insusceptibility is 8.1 months (Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility, page 174). N � for sexually active 11639 N � for return to menses 11644 N � for exclusively breastfeeding 2953 This graph shows factors influencing return to fertility � return of menses, exclusive breastfeeding, and sexual activity. 40% of postpartum women have returned to sexual activity during the first three months of postpartum. During these first three months women may be protected from another pregnancy by breastfeeding exclusively and the absence of menses. However, in the 4-6 month postpartum period the percent of women who are sexually active increases to 78% yet there is a dramatic decrease in the percent of women breastfeeding exclusively and an increase in the percent of women whose menses has returned. Women return to sexual activity and are less protected from another pregnancy during the latter months of the postpartum period. According to NFHS-3 , the median number of months for postpartum amenorrhea is 7 months, for abstinence it is 2.3 months, and for postpartum insusceptibility is 8.1 months (Table 6.8 Postpartum amenorrhoea, abstinence, and insusceptibility, page 174). N � for sexually active 11639 N � for return to menses 11644 N � for exclusively breastfeeding 2953

6. Postpartum Intrauterine Contraceptive Device 6 Resurgence of Interest in the IUCD Focus on Postpartum Family Planning and HTSP Global changes in thinking about IUCD Recent research has lead to important changes in WHO Medical Eligibility Criteria (MEC) Previously: 39 MEC Category 4 conditions; now: 10 IUCD as Long Acting Reversible Contraception Alternative to sterilization Postpartum IUCD is the only long acting, reversible method, that does not interfere with breastfeeding that can be provided before the woman leaves the birthing facility

7. Worldwide Use of IUCDs

8. Worldwide Use of IUCDs Postpartum Intrauterine Contraceptive Device 8

9. Postpartum Intrauterine Contraceptive Device 9 The Context for Postpartum IUCD Spacing of at least 3 years between births Large unmet need for postpartum FP Long acting reversible method Emphasis on Skilled Attendance at Birth

10. Comparative Effectiveness and Continuation IUCDs used longer than most other reversible contraceptives: About as high as implants; higher than oral contraceptives, condoms or diaphragms A WHO study found 44% continuing to use the CuT-380A after 7 years. IUCDs used longer than most other reversible contraceptives: About as high as implants; higher than oral contraceptives, condoms or diaphragms A WHO study found 44% continuing to use the CuT-380A after 7 years.

11. Our own misconceptions Dr. David Grimes: Senior Scientist at Family Health International �All the data about IUCDs from before 1985 should be thrown out. It is essentially useless.� Poorly designed studies Lumping all IUCDs together Inappropriate attribution of risks 11

12. 12 The IUCD in the Postpartum Period

13. 13 Timing of Postpartum IUCD Insertion IUCDs can be inserted postpartum Right after birth = Postplacental (10 minutes after placenta) Manual or instrumental insertion Soon after birth = Immediate postpartum (within < 48 hours) During cesarean section = Intracesarean Following cesarean section = Postcesarean Four or more weeks postpartum IUCDs are likely best not inserted between 48 hrs and 4 weeks

14. 14 Review of Safety of Postpartum IUCDCochrane database review, 2003 Main results Immediate post-partum insertion of IUCDs appeared safe and effective. Advantages: high motivation, assurance that the woman is not pregnant, and convenience. No real differences between manual and instrumental insertion. Few contraindications to method Expulsion rates appear to be higher than with interval insertion. The popularity of immediate post-partum IUCD insertion in countries as diverse as China, Mexico, and Egypt support the feasibility of this approach. Early follow-up important in identifying spontaneous IUCD expulsions

15. 15 PPIUCD: Program Effectiveness Postpartum insertion in Turkey Results: 74% vaginal deliveries, 26% cesarean deliveries Follow-up visit: 94% at 6 w, 89% at 6 m, 78% at 12 m Continuation rates: 87.6% at 6 mo., 76.3% at 12 mo 1-year cumulative expulsion rate: 12.3%

16. 16 PPIUCD: Convenience for Women PPIUCD Experience in Egypt 1,024 women counseled for Immediate Postpartum Insertion of IUCD Were asked; �Do you want it inserted now, or come back later for insertion?� Want it now: 71.2 % had it inserted Come back later: 7.2% had it inserted Conclusion: Making things easy and convenient for women makes a big difference in ultimate acceptance

17. 17 PPIUCD: Cost Effective Operations research in Peru 90% of experimental group accepted FP prior to discharge; 25% of women with PPIUCD. At six months postpartum, 82% were using FP with 40% using an IUCD. Cost for in-patient IUCD $9 compared to $24 for interval IUCD

18. 18 PPIUCD Side Effects/Complications Perforation: Entire world literature reports 1 perforation Uterine wall very thick, and PP uterus responsive to oxytocin Infection: Large series (more than 1000 patients) show infection rates of less than 1% No need for prophylactic antibiotics Increased cramping and bleeding: Masked by normal postpartum symptoms

19. 19 PPIUCD Insertion & Active Management Third Stage Labor No clinical trials, but expert review panel: No increase in IUD expulsions or perforations associated with AMTSL The use of oxytocic agents and fundal massage does not increase the risk of IUD expulsion or perforation, even in the cases when IUD is inserted two to forty hours after expulsion of the placenta. Postplacental insertion has lower risk of expulsion and perforation than postpartum insertion

20. Expulsion Rates Are Related to Provider To reduce expulsion: Use long instrument Kelly placental forceps is 33 cm Ring forceps is 20 cm Elevate uterus Push uterus up using the base of the hand on the body of the uterus Smooth out vagino-uterine angle Place IUCD carefully at fundus Release IUCD at fundus Sweep instrument to the side Take care that IUCD does NOT come out during withdrawal Perform postplacental insertion

21. 21 Weighing Convenience and Expulsion for Public Health Impact

22. 22 Program Experience in Providing Postpartum IUCDs

23. Postpartum IUCD

26. 26 Programs initiated under ACCESS-FP INDIA Service Delivery Sites in 16 States Doctor led program National Expansion

27. Holly Blanchard June 4, 2010 PPIUCD as part of PPFP in Kenya

28. PNC-FP/Pilot Sites in Embu 28

29. Background In Kenya 44% deliver with skilled attendant* ACCESS-FP Program October 2006 to March 2010 Reinvigorated PNC/FP services in collaboration with Frontiers 23 Program sites for PNC-FP/PPIUCD-4 Pilot sites 3-day training for PNC timing, number of visits, content PNC-FP/PPIUCD packages finalized Conducted PPIUCD follow-up study 29 It has been estimated that if 90 percent of babies and mothers received routine postnatal care (PNC) 10 to 27 percent of newborn deaths could be averted (Warren, Daly, Tour� and Mongi 2006)It has been estimated that if 90 percent of babies and mothers received routine postnatal care (PNC) 10 to 27 percent of newborn deaths could be averted (Warren, Daly, Tour� and Mongi 2006)

30. PPIUCD Follow-up Study: Objectives To learn about Service providers� perspectives, practice and experience with PPIUCD services Women�s experience with PPIUCD insertion with regard to: Decision making about method choice Insertion procedure experience Compliance with follow-up visits Continuation of method Any problems and satisfaction with the method

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33. Service Statistics: October �07 � March �10 =720

34. How PNC has been Scaled-Up Scale-up of PPIUCD services to 4 provinces Eastern Coast Rift Central Aphias and other projects (Pathfinder) 34

35. 35 FP � Maternal Health Integration PPFP and PPIUCD services are an excellent example of FP � MNH Integration Counseling starts during ANC Services are provided to women during their delivery care Follow up and support are provided during postpartum PPFP implementation requires FP and MNH expertise Integration is Respectful of women and their needs and ways of accessing care Logical in terms of program implementation

36. PPIUCD Materials Available Service Delivery: National Service Delivery Guidelines Program Planning and Site Visit template Operational standards (SBM-R) Job Aids Clinical follow up and data collection templates Training: Learning Resource Package (Reference Manual, Course NB Trainers, Course NB Participants, PowerPoints) Clinical Insertion Video Anatomic model Counseling and Communications Patient education materials �Waiting room video� 36

37. 37 Postpartum IUCDsSummary High unmet need, especially for PPFP Integrated service delivery platform Ease of provision Safe, long term method � alternative to sterilization

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