The Effect of a Postpartum IUD (PPIUD) Intervention on Counseling and Choice: Evidence from a Cluster-Randomized Stepped-Wedge Trial in Sri Lanka

The World Health Organization (WHO) recommends women wait at least 24 months after a live birth before attempting the next pregnancy in order to reduce the risk of adverse maternal and child health outcomes. However, fertility may return as soon as four weeks after delivery, and because most women are unaware of this timeline, they may not initiate contraception in a timely fashion and may be at greater risk of unintended pregnancy. 

The provision of effective postpartum contraception, particularly long-acting reversible methods such as the copper intrauterine device (IUD), has been shown to reduce the risk of pregnancy and is associated with higher continuation of use than other methods six months following a delivery. The immediate postpartum IUD (PPIUD) is a long-acting, reversible method of contraception that can be used safely and effectively within 48 hours of delivery and offers a convenient contraceptive option to women who cannot return for follow-up visits because of distance, travel costs, time constraints or other barriers to access. 

In a new journal article published in Trials, Mahesh Karra and colleagues evaluate the effect of a 2014 intervention by the International Federation of Gynaecology and Obstetrics (FIGO) and the Sri Lankan College of Obstetrics and Gynaecologists (SLCOG) to institutionalize PPIUD services as a routine part of antenatal counseling and delivery room services in Sri Lanka. The intervention included training of healthcare providers to counsel women in postpartum family planning during antenatal care visits and in hospitals; training of doctors in the insertion of the PPIUD, ensuring the provision of required supplies for PPIUD insertion in delivery rooms; and follow up of women who chose PPIUD.

Main findings:

• The intervention increased rates of postpartum counseling, from an average counseling rate of 12 percent in all hospitals prior to the intervention to an average rate of 51 percent in all hospitals after the rollout of the intervention.
• In contrast, the impact of the intervention on choice of PPIUD was less robust and mixed, with 4.1 percent of women choosing PPIUD prior to the intervention compared to 9.8 percent of women choosing PPIUD after the rollout of the intervention.

The study demonstrates incorporating PPIUD services into postpartum care is feasible and potentially effective. Taking the evidence on both counseling and choice of PPIUD together, the authors find the intervention had a generally positive impact on receipt of PPIUD counseling and, to a lesser degree, on choice of the PPIUD. Nevertheless, it is clear the intervention’s effectiveness can be improved to meet the demand for postpartum family planning among women.