Training private providers on counseling women about postpartum contraceptive options—including the IUD—and on how to insert the IUD postpartum may lead to high uptake of the method. According to a study in Nigeria among 728 women who received contraceptive counseling and delivered at one of 11 private facilities with a provider trained to insert an IUD postpartum,1 41% chose to have an IUD inserted immediately following or within 48 hours of delivery; of those, 8% experienced expulsion of the device within six weeks. In multivariate analyses, having no more than a primary education (rather than a postsecondary education), being single (rather than married) and having two or more living children were positively associated with selecting a postpartum IUD; reporting previous use of a contraceptive method was negatively associated with the outcome.
In April 2014, 11 private health care facilities that provided obstetric services but not postpartum family planning services in South East and South South Nigeria were selected from among a nongovernmental organization’s network in the country; at each, one provider received training on postpartum IUD insertion, including practicum sessions and monthly supportive posttraining supervision. For their study, researchers used the sample of all women who gave birth at one of the 11 sites between May 2014 and February 2015. Women received counseling on all available contraceptive methods, including the IUD, and those without medical contraindications for its use were offered the IUD as a postpartum method; women who experienced prolonged labor, fever, ruptured membranes for longer than 12 hours, genital infection or postpartum hemorrhage were excluded. Those who consented received a copper IUD inserted by the provider either manually while in the delivery room or with forceps within 48 hours of delivery; the cost to women for the procedure was about US$5. Women who accepted an IUD returned for a six-week follow-up appointment to check for method expulsion and infection. The researchers collected women’s demographic and reproductive health information from their client intake forms, and used multivariate logistic regression analysis to examine characteristics associated with IUD uptake.
During the study period, 728 women delivered at one of the study sites. On average, women were 28 years old and had three living children; 72% had at least a secondary education, 96% were married and 36% reported previous contraceptive use. Forty-one percent of women accepted a postpartum IUD; 26% of the devices were inserted manually and 74% with forceps. At the six-week follow-up, 8% of women had experienced expulsion of the IUD; 72% of expulsions involved devices inserted with forceps.
In adjusted multivariate analyses, several characteristics were independently associated with women’s acceptance of a postpartum IUD. Women with no more than a primary-level education had twice the odds of those with a postsecondary education of selecting a postpartum IUD (odds ratio, 2.0), and single women had nearly seven times the odds of married women of the outcome (6.8). In addition, women who had two or more living children had greater odds than those with one living child or none of accepting a postpartum IUD (4.5–17.8). Finally, women who reported previous contraceptive use were less likely to choose a postpartum IUD than those who did not (0.7).
Limitations noted by the study’s authors include lack of data on patients’ socioeconomic status, unwanted pregnancies and abortions; previous types of contraceptives used by women; and IUD expulsions after the six-week follow-up. Also, because the study was conducted solely at private health care facilities, financial barriers and other factors that may specifically affect uptake by women using public health services were not evaluated. Nevertheless, according to the authors, the study’s findings suggest that training private providers on postpartum IUD counseling and insertion contributed to high IUD uptake in their sample. They conclude that “postpartum IUD service delivery has the potential to address unmet need and increase contraceptive use among women in Nigeria and should be considered for scale-up in both public and private facilities.”—C. Olah