Increasing access to immediate postpartum intrauterine contraception in the UK

Abstract

BACKGROUND: Early resumption of fertility after childbirth can lead to unintended pregnancy (UIP), with short interpregnancy intervals linked to poorer obstetric and neonatal outcomes. Barriers exist for women accessing contraception during the postpartum period, particularly long-acting reversible methods such as intrauterine contraception which are the most effective at preventing UIP. Immediate postpartum intrauterine contraception (PPIUC) insertion is known to be safe and effective but is not widely available in the UK. In the few maternity centres offering this, it is generally restricted to women having a caesarean birth. Improving access to PPIUC after vaginal birth could reduce UIP in the postpartum period and expand contraceptive choice and convenience for women after childbirth.

AIMS AND OBJECTIVES: The aim of this research was to investigate the routine provision of PPIUC after vaginal birth in the UK. Firstly, to determine the feasibility and clinical outcomes of the technique in this setting, and secondly to increase knowledge of service implementation in order to increase access.

METHODS: A variety of methods were used to achieve the research objectives. Using a health services research model, vaginal PPIUC was newly introduced and evaluated across Lothian maternity services. This initially involved the design and delivery of a training package for midwives and obstetricians. After service introduction, all pregnant received information about PPIUC during antenatal contraceptive discussion. Eligible women received their choice of PPIUC method (52mg LNG-IUS or CU-IUD) within 48 hours of vaginal birth. After insertion, women were invited to attend a follow-up visit at six weeks (questionnaire, clinical examination and pelvic ultrasound) and further telephone surveys were conducted at three, six and 12 months. Clinical outcomes of interest included the uptake, complications (infection, perforation), expulsion and patient satisfaction at six weeks’ postpartum. Method continuation up to 12 months was also determined. Key aspects of service provision, namely training and aftercare, were further evaluated by means of two structured surveys conducted with multi-professional staff groups. Knowledge gained through local service introduction was consolidated using an implementation science framework to aid wider dissemination.

RESULTS: During the 18-month study period, the overall uptake of vaginal PPIUC was 4.6%. Of the 465 eligible women who requested PPIUC, 447 (96.1%) had a successful insertion. There were no cases of uterine perforation and the overall infection rate was 0.8%. 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 reinsertion rate after expulsion or removal was 87.6% and overall method continuation was 79.6% at 12 months. Median satisfaction scores were 10/10 and 98% of women said they would recommend the service. All staff who received training rated the complexity as ‘easy’ or ‘about right.

CONCLUSIONS: It was feasible to train midwives and obstetricians to provide PPIUC after vaginal birth and to introduce this service within a UK maternity care model. PPIUC was associated with a good uptake, low risk of complications and high patient satisfaction. Although there was a moderately high expulsion rate, method continuation at 12 months remained high. Access to follow-up and the opportunity for reinsertion after expulsion were important service delivery considerations. Staff were positive about offering vaginal PPIUC, but several challenges were identified in relation to training and service introduction. Structured training and a clear implementation framework may aid the wider availability in UK maternity settings.