Postpartum Intrauterine Contraceptive Device (PPIUD) © Jhpiego Corporation, 2010. All rights reserved. Photos by Jhpiego staff unless otherwise noted. The “narrations notes” included in this presentation (below each slide) are intended as an aid to the trainer and, sometimes, to supplement information on the slide. Text that duplicates/paraphrases the text on the slides appears as regular font. Additional information and instructions for the trainer are underlined, bolded and/or in brackets[].

Presentation Objectives By the end of this presentation, learners will be able to: Discuss basic attributes of the IUD, including new information Describe the key method characteristics of the IUD when provided postpartum Discuss the advantages and limitations of the PPIUD [SLIDE 2]Presentation Objectives • Discuss basic attributes of the IUD, including new information • List the clinical criteria for provision of the IUD in the immediate/early postpartum setting • Describe the key method characteristics of the IUD when provided postpartum • Discuss the advantages and limitations of the PPIUD • Discuss the key elements of PPIUD service provision

Why Women Using the IUD Like It Offers highly effective, long-term protection against pregnancy, with immediate return to fertility upon removal Is inexpensive over time (no costs after initial cost) Is convenient—does not require daily action on the part of the user, or repeated clinic visits for supplies [SLIDE 7]Why Women Using the IUD Like It COMMENT: Formative research shows that what IUD users like most about the method are that it: • Offers highly effective, long-term protection against pregnancy, with immediate return to fertility upon removal • Is inexpensive over time (no costs after initial cost) • Is convenient—does not require daily action on the part of the user, or repeated clinic visits for supplies [Sources: Forrest JD. 1996. US Women’s perceptions of and attitudes about the IUD. Obstet Gynecol Surv 51:S30–S34.; Association of Reproductive Health Professionals (ARHP). 2004. New developments in intrauterine contraception. In: Clinical Proceedings of the ARHP, Washington, DC, September. ARHP:Washington, DC.; Rivera et al. 2006. Essential knowledge about the IUD (electronic version). In: The Maximizing Access and Quality Initiative—IUD Toolkit. (http://www.maqweb.org/iudtoolkit/knowledge_base/index.shtml)]

IUDs—The Basics Mechanism of action Effectiveness and length of use Advantages and limitations Client assessment Side effects and precautions Myths and misconceptions [SLIDE 8]IUDs—The Basics COMMENT: Despite the popularity of the IUD in some parts of the world, it is still regarded as a widely underutilized. As a tool for addressing unmet need among postpartum women, many believe this underutilization of the IUD represents a MAJOR MISSED OPPORTUNITY. To help us all move past some of the barriers to IUD and PPIUD use, we are going to review the basics about this method, including: • Mechanism of action • Effectiveness and length of use • Advantages and limitations • Client assessment • Side effects and precautions • Myths and misconceptions

Copper-Bearing IUDs Copper T 380A Regular Safe-Load Note: For programs and providers offering the PPIUD, the Copper T 380A is recommended at this time. [SLIDE 10]Copper-Bearing IUDs COMMENTS: Before moving on, let’s look at the IUD: • The IUD is a small, flexible frame generally made of plastic in the shape of a “T,” which is inserted into the uterine cavity by a trained service provider. • Almost all types of IUDs have one or two monofilament (single-strand) strings that extend, through the cervix, from the uterus into the vagina. Types of IUDs— • Common types of IUDs available worldwide are: • Copper-bearing: such as the Copper T 380A (Regular or with Safe Load) and the Multiload; AND • Hormone-releasing: such as Mirena® and the levonorgestrel-releasing intrauterine system®   NOTE: For programs and providers who wish to offer the IUD in the postpartum period, the use of the Copper T 380A is recommended at this time. With additional evidence and experience, this recommendation may be revised.

POP QUIZ! Duration of Efficacy Fill in the Blank: The Copper T 380A is effective for ____ years of continuous use. [SLIDE 13]POP QUIZ! Duration of Efficacy [ASK:] • Fill in the Blank: The Copper T 380A is effective for ____ years of continuous use. [ALLOW learners a chance to answer before moving on to the next slide.]

POP QUIZ! Duration of Efficacy Answer: The Copper T 380A is effective for 12 years of continuous use. [SLIDE 14]POP QUIZ! Duration of Efficacy • The Copper T 380A is effective for 12 years of continuous use. [Note: Although 10 years was the old guidance, the latest scientific evidence shows that the Copper T 380A is effective for at least 12 years. Source: United Nations Development Programme et al. 1997. Long-term reversible contraception: Twelve years of experience with the TCu380A and TCu220C. Contraception 56(6):341–352.]

IUDs: Advantages High client satisfaction Minimal client action/responsibility: No resupply needed Single, routine follow-up visit Inexpensive Few complications Few side effects and no hormonal side effects Overall reduced risk of ectopic pregnancy [SLIDE 18]IUDs: Advantages • High client satisfaction (Note:Data compiled from a US-based study and an international World Health Organization (WHO) study suggest that about 92% of women still are using the Copper T 380A at one year after insertion. Women who use the IUCD are more satisfied with their choice of contraception than are those using other reversible methods [99% versus 91% for pill users], according to research conducted in the United States. Source: Forrest JD. 1996. U.S women’s perceptions of and attitudes about the IUD. Obstetrical and Gynecological Survey 51[12 Suppl]:S30-S34.) • Minimal client action/responsibility • No resupply needed • Single, routine follow-up visit • Inexpensive [Note: PPIUD is especially convenient and cost-effective because it is done in the facility before the woman is discharged.] • Few complications • Few side effects and no hormonal side effects • Overall reduced risk of ectopic pregnancy (compared to non-contraceptive users)

IUDs: Limitations Heavier, more painful menses and changes in menstrual patterns may occur—mostly in first 3 months Procedure by trained provider required for insertion and removal Spontaneous expulsion occurs in small number of cases [SLIDE 19]IUDs: Limitations • Women with IUDs may have heavier, more painful menses and changes in menstrual patterns (e.g., spotting/bleeding between periods)—mostly in first 3 months [Note: These side effects may be perceived as less or better tolerated among postpartum women—more on this later.] • Procedure by trained provider required for insertion and removal (Woman has to go to facility for IUD removal when she wants to discontinue; can’t just discontinue on her own) • Spontaneous expulsion in small number of cases [Note: The risk is higher with PPIUDs, but proper technique can dramatically reduce this risk—as we’ll discuss more later.]

STI-Related Health Risks Rates of pelvic infection or clinical PID are very low among IUD users—lower than previously thought and much lower than providers may realize: 1.6 cases PID per 1,000 women per year or 998.4 per 1,000/year did not get PID [SLIDE 21]STI-Related Health Risks • Rates of clinical PID are very low among IUD users—lower than previously thought and much lower than providers may realize. • 1.6 cases PID per 1,000 women per year or 998.4 per 1,000/year did not get PID (Farley et al. 1992) [Sources: Farley et al. 1992. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet Mar 28;339(8796):785-788; Grimes DA. 2000. Intrauterine device and upper-genital-tract infection. Lancet Sep 16;356(9234):1013-1019.]

STI-Related Health Risks (cont.) In IUD users, PID is caused by (recognized or unrecognized) sexually transmitted infections (STIs) with the organisms chlamydia trachomatis or gonococcus, not by the IUD itself. New Recommendation: If a woman develops a pelvic infection with the IUD in place, do not remove the IUD. Treat with the IUD in place. [SLIDE 22]STI-Related Health Risks (cont.) • In IUD users, PID is caused by (recognized or unrecognized) sexually transmitted infections (STIs) with the organisms chlamydia trachomatis or gonococcus NOT by the IUD itself (Grimes 2000). • NEW RECOMMENDATION: If a woman develops a pelvic infection with the IUD in place, DO NOT REMOVE the IUD. Treat with the IUD in place. [Note: Women with a history of pelvic infection or PID can use the IUD.] [ASK: What is the number 1 organism that causes infection in IUD users? ALLOW learners to answer before moving on to next slide.] [Sources: Farley et al. 1992. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet Mar 28;339(8796):785-788; Grimes DA. 2000. Intrauterine device and upper-genital-tract infection. Lancet Sep 16;356(9234):1013-1019.]

Timing of PPIUD Insertion Immediate postpartum (within 10 minutes of delivery of placenta)—postplacental or intracesarean Early postpartum (<48 hours after delivery) NOTE: IUDs should not be inserted between 48 hours and 4 weeks. [SLIDE 35]Timing of PPIUD Insertion COMMENT: PPIUD insertion refers only to those IUDs placed during the immediate or early postpartum period (within 10 minutes or up to 48 hours after birth). The three types of PPIUD insertion are: • Postplacental: Immediately following the delivery of the placenta (active management of the third stage of labor [AMTSL]) in a vaginal birth, the IUD is inserted with an instrument or manually. • Intracesarean: Immediately following the removal of the placenta during a cesarean section, the IUD is inserted manually before closure of the uterine incision. • Early postpartum: Not immediately following the delivery/removal of the placenta but within two days/48 hours of the birth (preferably within 24 hours, e.g., on the morning of postpartum Day 1), the IUD is inserted with an instrument during a separate procedure. [Note: At 4 weeks and beyond, IUD insertion is no longer considered PPIUD insertion; it is regular or interval IUD insertion because the uterus and cervix have mostly returned to their pre-pregnancy state.] NOTE: IUDs should not be inserted between 48 hours and 4 weeks because of a higher risk of complications during this time.

Anatomy of Postpartum Uterus [SLIDE 36]Anatomy of Postpartum Uterus • The woman’s body is undergoing major changes during the first 48 hours postpartum. • The state of the uterus and cervix are favorable to quick, easy placement of the IUD. • However, there is also a sharp angle between the vagina and uterus. This angle must be carefully negotiated during insertion.

PPIUD and Active Management of Third Stage Labor (AMTSL) No clinical trials, but expert review panel finds: No increase in IUD expulsions or perforations associated with AMTSL Postpartum uterine contractions more likely to hold IUD in than push it out Immediate postpartum (postplacental) insertion has lower risk of expulsion and perforation than early postpartum insertion [SLIDE 45]PPIUD and Active Management of Third Stage Labor (AMTSL) There have been no clinical trials, but expert review panel finds: • No increase in IUD expulsions or perforations associated with AMTSL [NOTE: The use of oxytocic agents and fundal massage does not increase the risk of IUD expulsion or perforation—even when IUD is inserted 2 to 40 hours after expulsion of the placenta.] • Postpartum uterine contractions more likely to hold IUD in than push out • Immediate postpartum (postplacental) insertion has lower risk of expulsion and perforation than early postpartum insertion

Risks Associated with the PPIUD Are the risks for the following higher or lower with the PPIUD than with the interval IUD? Uterine perforation Infection Expulsion [SLIDE 47]Risks Associated with the PPIUD [COMMENT: Risks are uncommon or rare with both the PPIUD and IUD. But let’s get more specific. [ASK: Which of the following risks do you think are higher with the PPIUD than with the interval IUD? Lower? The same?] [ALLOW learners a chance to respond before moving on to the next slides…]

Risk of Expulsion after Postpartum Insertion Expulsion rates vary widely—from 3% to 37% Expulsion rates for PPIUD range between 10% and 15% (higher than for interval) Related to technique (and instruments) used Good technique can reduce expulsion to 4–5% Immediate postpartum (postplacental, intracesarean) expulsion rates are lower than early postpartum (<48 hours) expulsion rates [SLIDE 50]Risk of Expulsion and Timing of Insertion Postpartum • Expulsion rates vary widely—from 3% to 37% • In general, expulsion rates for PPIUD range between 10% and 15% (higher than for interval) • Related to technique (and instruments) used • Good technique can reduce expulsion to 4–5% • AGAIN, immediate postpartum (postplacental, intracesarean) expulsion rates are lower than early postpartum (<48 hours) expulsion rates

Proper Technique and Instruments for Postpartum IUD Insertion Perform immediate postpartum (postplacental, intracesarean) insertion if possible: If early postpartum insertion is planned, perform by 24 hours if possible [SLIDE 51]Proper Technique and Instruments for Postpartum IUD Insertion Expulsion rates are related to provider technique and instruments used. To reduce risk of expulsion: 1. Perform immediate postpartum (postplacental, intracesarean) insertion if possible; If early postpartum insertion is planned, perform by 24 hours if possible

Proper Technique and Instruments for Postpartum IUD Insertion (cont.) Use appropriate instrument, properly: Long placental forceps (33 cm) or hand (with elbow-length glove) for immediate postpartum insertion Keep forceps closed until fundus is reached [SLIDE 52]Proper Technique and Instruments for Postpartum IUD Insertion To reduce risk of expulsion (cont.): 2. Use appropriate instrument, properly • Long placental forceps (33 cm) (e.g., KELLY) or hand (with elbow-length glove) for immediate postpartum insertion • Keep forceps closed until fundus is reached

Proper Technique and Instruments for Postpartum IUD Insertion (cont.) Elevate uterus: With base of hand on abdomen, push lower segment of uterus up—toward woman’s head This straightens the sharp vagino-uterine angle that is present after delivery [SLIDE 53]Proper Technique and Instruments for Postpartum IUD Insertion To reduce risk of expulsion (cont.): 3. Elevate uterus • With base of hand on abdomen, push lower segment of uterus up—toward woman’s head • This straightens the sharp vagino-uterine angle that is present after delivery

Proper Technique and Instruments for Postpartum IUD Insertion (cont.) Place IUD carefully at fundus: Release IUD at fundus (when resistance is felt) Sweep forceps to the side, keeping them slightly open to avoid catching strings during withdrawal Ensure that IUD or strings are not visible at cervix or in vagina after insertion [SLIDE 54]Proper Technique and Instruments for Postpartum IUD Insertion To reduce risk of expulsion (cont.): 4. Place IUD carefully at fundus • Release IUD at fundus (when resistance is felt) • Sweep forceps to the side, keeping them slightly open to avoid catching the strings during withdrawal • Ensure that IUD or strings are not visible at cervix or in vagina after insertion

Management of Strings During Insertion Do not cut strings while placing IUD postpartum, postplacental or intracesarean During cesarean section, do NOT pass the strings through cervix; leave in lower uterine segment Strings will typically descend during involution and curl in posterior vaginal fornix (75–80% of strings descend by 12 weeks postpartum) [SLIDE 55]Management of Strings during Insertion Another difference between PPIUD and IUD insertion technique is how the strings are managed: • Do not cut strings while placing IUD postpartum, postplacental or intracesarean • During cesarean section, do NOT pass the strings through cervix; leave in lower uterine segment • Strings will typically descend during involution and curl in posterior vaginal fornix (75–80% of strings descend by 12 weeks postpartum)

Management of Strings During Insertion (cont.) Sometimes strings do not descend (remaining in the uterus), but this is not usually a problem Strings CAN be cut at follow-up visit Strings SHOULD be cut if the woman complains or they protrude from the vagina [SLIDE 56]Management of Strings during Insertion (cont.) • Sometimes strings do not descend (remaining in the uterus), but this is not usually a problem • Strings CAN be cut at follow-up visit • Strings SHOULD be cut if the woman complains or they protrude from the vagina [BEFORE moving on to next slide, ASK learners: Let’s review again some of the advantages and limitations of the PPIUD. What are some advantages? (ALLOW them to answer.) What are some advantages? (ALLOW them to answer.)]

PPIUDs: Summary Cost-effective and convenient way to provide a safe, highly effective and reversible long-acting method—before woman leaves facility! Powerful tool in global refocusing on health benefits of FP/PPFP to mothers, children, families Exclusions/precautions of method are few, especially for postpartum woman [SLIDE 59]PPIUDs: Summary • Cost-effective and convenient way to provide a safe, highly effective and reversible long-acting method—BEFORE WOMAN LEAVES FACILITY! • Powerful tool in the global refocusing on health benefits of FP/PPFP to mothers, children, families • Exclusions/precautions of the method are few, especially those specifically relevant to the postpartum woman

PPIUDs: Summary (cont.) Insertion times include immediate postpartum (postplacental, intracesarean) and early (<48 hours) postpartum—immediate postpartum insertion has a higher retention rate The main disadvantage of PPIUD versus interval IUD—higher expulsion rates—is related to provider skill… and this is why we are here We must work together to correct myths and misinformation about the IUD/PPIUD [SLIDE 60]PPIUDs: Summary (cont.) • Insertion times include immediate postpartum (postplacental, intracesarean) and early (<48 hours) postpartum—immediate postpartum insertion has a higher retention rate • The main disadvantage of the method—higher expulsion rates—is related, not to the IUD, but to provider skill. And this is why we are here. • We must work to correct myths and misinformation about the IUD/PPIUD!

Objectives At the end of this presentation: Learners should be able to define extended postpartum period Define unmet need in the extended postpartum period Understand the WHO recommendation on birth spacing Enumerate FP options during extended postpartum period Understand the importance of integrating FP into maternal care

Postpartum Period Traditional postpartum period: 0–6 months post delivery Extended postpartum period: 0–23 months post delivery

FHS 2011 Unmet Need 19.3 unmet need 8.8 spacing 10.5 limiting

Prospective Unmet Need Across Postpartum Periods Facilitator Notes: This graphs illustrates prospective unmet need for spacing and limiting births through two years postpartum. Total unmet need decreases as the number of months post-delivery increases. Among women 0–5 months postpartum, overall unmet need is 72%. Overall unmet need decreases to 51% among women 6–11months postpartum, and then decreases further to 40% among women 12–23 months postpartum. With regard to women’s fertility desires among the total unmet need, the levels of unmet need for limiting decrease throughout the two-year postpartum period, from 42% (0–5 months) to 31% (6–11 months) to 25% (12–23 months). Similarly, the unmet need for spacing decreases over this same period, going from 29% (0–5 months) to 20% (6–11 months) to 15% (12–23 months).

2006 WHO Recommendation for Birth Spacing Birth-to-pregnancy (BTP) interval: two years Birth-to-birth (BTB) interval: three years Miscarriage-to-pregnancy interval: 6 months Defer pregnancy until 18 years of age Birth spacing prevents 30% of maternal mortality and 10% of child mortality

FP Options: 0–6 Months Post Delivery LAM POP IUD Implant Progesterone-only injectable COC Condoms NFP

FP Options: Mechanisms of Action Mechanism of Action LAM Inhibition of ovulation POP Thickens cervical mucus IUD Alters sperm and egg motility PO injectable IMPLANT Thickens cervical mucus and inhibition of ovulation COC inhibition of ovulation and thickens cervical mucus

FP Options: 0–6 Months Post Delivery Postpartum Situations FP options When to start Fully Breastfeeding LAM Progestin-only Pills (POP) Progestin-only Injectables Intrauterine Contraceptive Device (IUD) Implant Combined Oral Contraceptive (COC) Condom Natural Family Planning Within an hour post delivery 6 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery (manufacturer’s recommendation: 3 weeks) 6 months post delivery When sexually active Not applicable

FP Options: 0–6 Months Post Delivery Postpartum Situations FP options When to start Partially Breastfeeding POP Progestin-only Injectables IUD Implant COC Condom NFP 3 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery When sexually active With onset of period

FP Options: 0–6 Months Post Delivery Postpartum Situations FP options When to start Non Breastfeeding POP Progestin-only injectables IUD Implants COC Condom NFP Prior to discharge 3 weeks post delivery Within 10 minutes of placental expulsion Within 48 hours post delivery When sexually active With onset of period

Extended Postpartum Period Rationale: Based on the WHO recommendation on birth spacing Women are most vulnerable for unintended pregnancy during the extended postpartum period

FP Options During 7–23 Months Post Delivery LARCS IUD Implant Short Acting contraceptives Progesterone-only injectable COC Condoms NFP Permanent Non scalpel vasectomy and bilateral tubal ligation

FP Options Extended Postpartum Period When to Start? Hormonal contraceptives: 1st five days of the menstrual cycle or QUICK START IUD: 1st five days of the menstrual cycle or QUICK START Vasectomy: anytime BTL: follicular phase of the menstrual cycle or anytime that the client is reasonably sure not to be pregnant

What is Quick Start? Starting the contraceptive on the first clinic visit Assessment using the WHO pregnancy checklist to rule out pregnancy Follow up after three weeks for re-assessment of undetected pregnancy in the first visit

[SLIDE 11][GRAPHIC COMPARING EFFECTIVENESS OF DIFFERENT FP METHODS] [ASK QUESTION(S) of learners:] • How did we do? According to this graphic, which methods are: Most effective at preventing pregnancy? Most convenient and easiest to use? • Do you notice any patterns? [ALLOW learners time to answer, briefly discussing their observations, before moving on to next slide.]

Method Effectiveness and Continuation Failure Rates (unintended pregnancy) Continuation at 1 year Typical Use Perfect Use No method 85% Withdrawal 27% 4% 43% “Standard Days Method” 25% 5% 51% Male condom 15% 2% 53% COCs/Progestin-only methods 8% 0.3% 68% DMPA (injections) 3% 56% Copper T 380A (IUD) 0.8% 0.6% 78% Implants 0.05% 84% Female sterilization 0.5% 100% Male sterilization 0.15% 0.10% [SLIDE 12]Method Effectiveness and Continuation This table provides additional information on contraceptive effectiveness of different methods. Note that “perfect use” refers to what can be expected under ideal circumstances (e.g., the woman consistently comes for her injections on time); “typical use” refers to what may happen in real life (e.g., a woman may forget to take a pill or two). The table also provides information on method continuation, which is a good indication of method effectiveness and user satisfaction. [BRIEFLY REVIEW CHART AS APPPROPRIATE.] [ASK QUESTION(S) of learners: Does anything surprise you? Do you notice any patterns?] [ALLOW learners time to answer, briefly discussing their observations, before moving on to next slide.] [COCs = Combined oral contraceptive (pills containing estrogen and progestin)]

The Need to Integrate FP Into Maternal Care A successful integration of FP services in the maternal and child care entails: Integrate FP counseling in the antenatal care, early labor and immediate postpartum Come up with a standardized protocol for postpartum FP service delivery Make sure that there different methods available for the mothers in the birthing facility

Summary Extended postpartum period is 0–23 months post delivery when the woman is at risk unintended pregnancy and unmet need for FP is high Birth spacing prevents pregnancy complications and child morbidity and mortality There are several FP options for postpartum women depending on their reproductive intentions

Summary Key to successful integration of postpartum family planning in MCH is to offer the service including counseling while the mother is still under the care of the provider

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