As a contraceptive used during the postpartum period, the IUD has a distinct advantage: It does not affect breastfeeding, as do many systemic contraceptive methods. The postpartum period may also be a convenient time during a woman's life to have an IUD inserted, since it may be one of the few times she is in contact with medical services.
In addition, IUDs do not require regular user compliance. Coital-dependent methods may be used inconsistently during the postpartum period by couples who think conception is less likely during this period. Also, if a woman says she wants no more children but has not had time to consider sterilization carefully, an IUD offers a reversible alternative.
Timing of insertion, counseling, provider training and programmatic support are critical factors for IUD use during the postpartum period.
The timing of insertion is important primarily because it influences the risk of expulsion. Expulsion can leave a woman unprotected from pregnancy without her realizing it. Ideally, postpartum insertion should take place within 10 minutes of placental delivery (immediate postplacental) or at about six weeks after birth, when a woman returns for a routine postpartum care visit.
Postpartum insertion can be done before hospital discharge (up to 48 hours after delivery), but it should not be done between 48 hours and about six weeks postpartum because of an increased risk of expulsion and perforation. Special training is required for immediate postplacental insertions and for insertion within the first 48 hours. Copper T IUDs may be safely inserted as early as four weeks postpartum, but for other IUDs, one should wait until six weeks postpartum. This is because the so-called "push insertion technique," used for some types of noncopper IUDs, might result in higher perforation rates.1
Immediate postplacental insertion should only be done if there is adequate prenatal counseling. Ideally, choices of methods should be discussed during routine prenatal visits, allowing women to choose the most appropriate method at that point. In some cases, a woman in the early stages of labor could receive enough information after arriving at the clinic to decide to have a postplacental insertion. Likewise, a woman could decide after delivery to have an IUD inserted before leaving the hospital. A woman should never receive an IUD immediately after delivery without having received adequate counseling and giving her informed consent. Counseling should be done once the emotional and physical stresses of labor have ended.
Good postpartum IUD programs in hospitals need national and regional support. Clinicians need specialized insertion training, and prenatal clinics must give priority to contraceptive counseling. A variety of methods should be available to potential users. Also, the obstetric unit of the health-care center must work in close coordination with the family planning or maternal and child health unit. Only a few countries, including Mexico and Colombia, have committed major resources and programmatic attention to postpartum IUD programs.
Safe and effective
Studies have shown that postpartum IUD insertions, including those done immediately after placental delivery or cesarean section, are generally safe and effective. Compared with interval insertions, postpartum insertions do not increase the risk of infection, bleeding, uterine perforation or endometritis, nor do they affect the return of the uterus to its normal size.2 ("Interval insertions" are those that are done after the postpartum period of six weeks following delivery.)
Research shows that with the Copper T 380A IUD, breastfeeding women have less pain at insertion, and have lower removal rates due to bleeding or pain than nonbreastfeeding women.3
An IUD can also be safely inserted immediately after a spontaneous or induced abortion except when the uterus is infected or at risk of infection, there is serious injury to the genital tract, or there is hemorrhage or severe anemia. If the abortion occurs after 16 weeks of pregnancy, IUD insertion should only be done by someone specially trained in correct fundal placement. Otherwise, the insertion should be delayed for six weeks after abortion because the uterine cavity is too enlarged for using routine insertion techniques.
The main problem with postpartum insertions is that they generally result in higher expulsion rates than interval insertions. Risk of expulsion is lower for insertions done within 10 minutes of delivery than for those done between 10 minutes and hospital discharge.4 One multisite study found that after six months, the cumulative expulsion rate was 9 percent for immediate postplacental insertion, or nine of every 100 women, compared with 37 percent for insertions done between 24 and 48 hours after delivery, or about one out of three women.5 The risk of expulsion can be reduced substantially with appropriate training in postpartum insertion techniques.
For interval insertions, the rate of expulsion after 12 months is about 6 percent, or six out of 100 women.6 Expulsion rates for insertions following cesarean deliveries are about the same as for interval insertions, according to studies conducted in Mexico, Belgium and China. Expulsion rates can vary extensively, depending on the timing of insertion, the technique used, skill of the person doing the insertion, and the type of IUD used. These factors are especially important in postpartum insertions. A study of immediate postplacental insertions reported three-year cumulative expulsion rates of 28 percent for the Lippes Loop compared to 11 percent for Copper T's.7
High fundal placement by hand or with forceps during the postpartum period reduces the risk of expulsion. The provider should feel the IUD against the fundus both internally and through the abdominal wall. An inexperienced person might tend to place the IUD too low in the uterus.8
A recent FHI study in Africa showed the importance of training and experience. The study evaluated postpartum IUD programs at the Provincial General Hospital of Nyeri, Kenya and the Maternité Hamdallaye of Bamako, Mali. All women who received an IUD during a seven-month period were interviewed. In Kenya, 224 IUD acceptors were interviewed at six weeks, three months and six months after insertion along with 185 nonacceptors. In Mali, a similar approach involved 110 acceptors and 273 nonacceptors.9
The six-month cumulative expulsion rates in Kenya were 1 percent for immediate insertions and 5 percent for insertions done before hospital discharge, rates comparable to or even lower than interval insertions. These low rates might be attributable to the extensive training and experience of the Kenyan providers.
In Mali, the six-month expulsion rates of 15 percent (immediate postplacental) and 27 percent (before leaving the hospital) were skewed by the high rates for one of the three providers, who had far less training and experience than the other two. All of the providers were midwives. Removals for medical reasons and pelvic infections were rare in both countries, and no uterine perforations were reported.
Counseling critical
In the Kenya and Mali programs, women who had received counseling in the prenatal period or during the first stage of labor at the hospital were eligible for an immediate insertion. Women who were counseled about IUD insertion after delivery could choose to have an IUD inserted before hospital discharge, generally within 72 hours of delivery. "Prenatal counseling is important because it allows for immediate postplacental placement, which is associated with lower expulsion rates," says Dr. Charles Morrison of FHI, study coordinator.
Few studies have examined counseling issues and other service delivery questions regarding postpartum IUD use. Often, providers discuss the method choice only with the woman. But later, a husband or other family member such as a mother-in-law may object to the choice. Ideally, a couple would receive thorough prenatal counseling together about contraceptive choices, including IUDs. Such a counseling approach would better prepare the family for the method and encourage longer continuation rates. In the Africa postpartum study, for example, husbands' desire for IUD removals was a significant reason for removal, emphasizing the importance of involving the husband in prenatal counseling.
Because most expulsions occur in the early months, it is particularly important to give clear instructions about recognizing expulsion through the string length. The Copper T device has a string 12 cm long that can easily move into the enlarged postpartum uterus and therefore can no longer be felt by the woman.
"A number of relevant questions with regard to missing strings need to be answered," says Dr. I-cheng Chi of FHI, an IUD specialist. "Do the missing threads indicate expulsions or retraction of the strings into the uterus? Should the IUDs be removed when the strings are missing, and is this removal difficult? Should follow-up visits for immediate postpartum insertion be scheduled earlier than for interval insertions so as to discover the missing threads in time?"
Characteristics of successful postpartum contraceptive programs were identified at a 1990 worldwide meeting sponsored by FHI, the Mexican Ministry of Health and the Instituto Mexicano del Seguro Social (IMSS). Among the important characteristics are good training in counseling, quality of care, and clinical issues for personnel at all levels.
-- William R. Finger
Footnotes
Curtis KM, Bright PL, eds. Recommendations for Updating Selected Practices in Contraceptive Use: Results of a Technical Meeting, Volume I. (Chapel Hill: Technical Guidance Working Group, U.S. Agency for International Development, 1994) 74.
Chi I-c. Postpartum IUD insertion: Timing, route, lactation and uterine perforation. Proceedings from the Fourth International Conference on IUDs. Ed. Bardin CW, Mishell DR. (Newton, MA: Butterworth-Heinemann, 1994) 219-27.
Farr G, Rivera R. Interactions between intrauterine contraceptive device use and breastfeeding status at time of intrauterine contraceptive device insertion: Analysis of TCu-380A acceptors in developing countries. Am J Obstet Gynecol 1992;167(1): 144-51.
Chi I-c, Farr G. Review article: Postpartum IUD contraception -- a review of an international experience. Adv Contracept 1989;5(3):127-46.
Chi I-c, Wilkens LR, Rogers S. Expulsions in immediate postpartum insertions of Lippes Loop D and Copper T IUDs and their counterpart Delta devices -- an epidemiological analysis. Contraception 1985;32(2):119-34.
Sivin I, Greenslade F, Schmidt F, et al. The Copper T 380 Intrauterine Device: A Summary of Scientific Data. (New York: The Population Council, 1992) 15.
Thiery M, Van Kets H, Van Der Pas H. Immediate postplacental IUD insertion: The expulsion problem. Contraception 1985;31(4):331-49.
