1. Institutionalisation of Immediate Post-Partum IUD (PPIUD) Services as a routine part of antenatal counselling and delivery room services “From misconceptions to delayed conceptions”
My name is Laura Banks; I’m from the FIGO. I manage the PPIUD project which is now into its 4th year of implementation.
I’m going to share a little on unmet need in family planning and the importance of birth spacing
before discussing why this initiative focuses particularly on the PPIUD
I’ll then explain in more detail what the initiative involves before sharing some of our challenges and achievements
Presentation for FPH Annual Conference 2017
Laura Banks – PPIUD Project Manager
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services

2. Institutionalization of Immediate Post-Partum IUD Services
Project Objective
The aim of the FIGO initiative is to address the postpartum contraceptive needs of women through institutionalisation of immediate postpartum IUD services as part of routine care:
Provision of counselling on immediate post-partum IUD
Provision of PPIUD services by training service providers to insert
Aiming for fundamental long lasting change in counselling and use of PPIUD
Funded for 5 years until June 2018
We are working through our Ob/Gyn Societies in 6 countries (SL, Tan, Ken, Bang, Nepal, India) in 48 facilities. Mostly teaching hospitals.
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services

3. 877 million women wanting to avoid pregnancy in 2014
Unmet need in family planning
In the developing world, 18% of women who want to avoid getting pregnant are not using contraception
877 million women wanting to avoid pregnancy in 2014
26%
81%
In 2014 there were a total of 877 million women who wished to avoid pregnancy
Of these 18% used no method of contraception and 8% used a traditional method
This is the equivalent of nearly 230 million women per year without an effective method of contraception
And points to the global need for better planned parenthood, including:
Better birth spacing
Fewer unwanted pregnancies
Many countries have achieved increasing rates of institutional deliveries; however, the proportion of postnatal women leaving the facilities without receiving a contraceptive method remains high
Source: Singh and Darroch, Adding it Up Guttmacher Institute

4. Institutionalization of Immediate Post-Partum IUD Services
Birth Spacing
Birth-to-pregnancy interval of <6 months associated with elevated rate of maternal mortality
Women who conceive within 6 months of delivering their last baby are 7.5 times more likely to terminate the pregnancy
Birth-to-pregnancy interval of 18 months related to increased infant, neonatal and perinatal mortality
The impact of avoiding the high risk interval would be a total of 1,836,000 under-five deaths avoided annually in less developed countries
Combined with increased time for the mother and father to care for the child, increased economic resources and possibility for mother to return to work if desired
We know that the WHO advocates for a birth to pregnancy interval of 2 yrs minimum and this can reduce maternal mortality by as much as ?? %
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services

5. Institutionalization of Immediate Post-Partum IUD Services
Why PPIUD
PPIUD constitutes a effective choice for women delivering in facilities
It is offered at a time when motivation is high
Circumvents need to return to a facility for a FP method
Safe, painless, effective inserted immediately after vaginal delivery or caesarean section
LARCs enable a woman to plan and space her pregnancies
It can last for up to 10 years with quick return to fertility after removal
Does not require repeat visits, top up nor is it subject to frequent stock out
The key difference with this initiate is about timing. IUDs have been provided to women for decades, but this initiative capitalises on the opportunity provided through increased facility based births and interaction with health providers to provide the IUD immediately after birth. It focuses on changing the mind-set of health providers with regards to when they provide contraception.
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Institutionalization of Immediate Post-Partum IUD Services

6. Awareness Raising and Sensitisation
Nursing and midwifery staff and students
Juniors and medical students
Senior staff in facilities
Government and Ministry personnel
In participating facilities and periphery clinics
Creating buy-in
Engaging providers
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Institutionalization of Immediate Post-Partum IUD Services

7. Importance of Training
Dedicated provider training and use of correct instruments for correct placement of IUD
Master trainers train facility staff who then cascade train locally
Use dedicated training days and existing CME activities
As I mentioned the key is about changing the timing of provision of the IUD - Historically IUD was not inserted pp due to the resulting high expulsion. However, with specific training on the correct insertion technique to ensure placement high up in the fundus IUD can be successfully and safely inserted up to 48hrs after birth.
The most ideal time is post placental – within 10 minutes
Here you can see a provider placing their hand on the abdomen to stabilise the uterus while inserting using long curved kelly’s forceps to allow the IUD to be places high up in the fundus and prevent inadvertently pull the IUD down while removing the
Beyond 48hrs the risk of perforation and Infection is increased and should not be attempted.
Correct IUD – Copper T 380
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services

8. Improving Access to and Quality of Counselling
Training and capacity building of all health facility ante-natal and delivery team personnel on all methods of contraception with emphasis on LARC and PPIUD
Effective counselling includes:
Giving women knowledge and choice/alternative methods
Helping women understand risks of another pregnancy after delivery
Informing about the effectiveness of PPIUD
Helping women make informed choices about whether to consent to PPIUD
So that she and her partner can make an informed choice
Development of counselling materials, videos for showing in the ante-natal clinics and training of health providers in how to counsel effectively
Myths and misconceptions
Barriers
Husbands/mothers in law
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Institutionalization of Immediate Post-Partum IUD Services

9. Institutionalization of Immediate Post-Partum IUD Services
Challenges
Creating demand
Busy, short-staffed maternity units
Supplies of insertion packs and PPIUD stock out
Overcoming prejudice
Follow-up
Ensuring long-term buy-in from professionals, facilities and societies to create sustainability
Diffusion
Busy – time for counselling
Prejudice – of both health providers and women and their families
Diffusion – ensuring equipment, provision of IUDs to facilities outside the initiative so that rotating providers and continue to provider PPIUD services.
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services

10. Institutionalization of Immediate Post-Partum IUD Services
Progress
Master training in all countries completed and facility training progressing
Interaction with ministries to promote sustainability
3,716 providers trained in counselling and inserting since start of initiative and 6,380 trained in counselling
31,476 women have had PPIUD inserted since start of initiative
Where good follow-up, low expulsion rates
632,563 deliveries. Insertions 4.98% of all deliveries
5710 Follow-Ups (July-Dec 2016). Expulsions 2.29% of all follow-ups.
Shows steady increase in the numbers being counselled and adopting PPIUD
Interaction with ministries to promote sustainability
Enthusiastic, committed staff in many facilities
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Institutionalization of Immediate Post-Partum IUD Services

11. Institutionalization of Immediate Post-Partum IUD Services
Thank you
Laura Banks
FIGO Project Manager
Thank you for your time and attention
We very much look forward to sharing further results with you during the next year
19/11/2018
Institutionalization of Immediate Post-Partum IUD Services