Abstract / Description of output
INTRODUCTION: Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter-pregnancy intervals, however provision across Europe is limited. Our aim was to the determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model.
MATERIAL AND METHODS: Phased introduction of PPIUC across two Lothian maternity hospitals. All women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or copper intrauterine device within 48 hours of vaginal birth. Follow-up was conducted in-person at six weeks' postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion-related variables.
RESULTS: Uptake of PPIUC was 4.6% of all vaginal births. 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose levonorgestrel intrauterine system (73%). At six weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n=113) and most had symptoms (n=79). Of the additional 121 devices removed, 118 were due to partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared to doctors. The reinsertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%.
CONCLUSIONS: Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Reinsertion and therefore longer-term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely-spaced pregnancies.