Immediate postpartum insertion for intrauterine devices
Immediate postpartum insertion (within 10 minutes of delivery of the placenta) of copper-bearing intrauterine devices (IUDs) is generally safe and effective, although compared with interval insertion it carries a higher risk of expulsion. Immediate postpartum IUD insertions can be implemented in most developing-country settings and any available copper-bearing IUD can be used for this purpose.
RHL Commentary by Muthal-Rathore A
Although data are not available for all countries, over the period 2000–2007, the unmet need for contraception ranged from 13% in the WHO South-East Asia Region to over 24%, in the WHO African Region (1). The reasons for non-use of contraception are many, including lack of awareness, non-availability of accessible family planning services, and limitations on women’s mobility due mostly to cultural or geographical factors. For women with limited access to medical care, the time of delivery offers a unique opportunity to address their need for contraception if the delivery takes place in a health-care centre. The popularity of the intrauterine device (IUD) and its use in the immediate postpartum period in countries like China, Egypt, and Mexico reflects the practicality of this approach. This review (2) assesses the safety and efficacy of immediate postpartum insertion of the IUD. The a priori hypothesis was that this practice is safe, but is associated with a higher expulsion rate than interval insertion of the IUD.
2. METHODS OF THE REVIEW
The review was last updated in 2010. The randomized trials having at least one arm with immediate postpartum IUD insertion, defined as within ten minutes of passage of the placenta were included. The search strategy of the review authors was comprehensive. Trial quality was assessed rigorously and trial authors were contacted when necessary. Data were extracted by two authors independently and discrepancies resolved by discussion. Meta analysis could not be performed as studies were not judged to be similar enough. The principal outcome measures included pregnancy, spontaneous expulsions, and continuation of the method.
3. RESULTS OF THE REVIEW
A total of nine trials with 7660 subjects met the inclusion criteria. One recent trial (102 women) had compared immediate postpartum versus delayed insertion (6–8 weeks postpartum) of the levonorgestrel-releasing intrauterine system (IUS). Another eight trials had compared different IUDs, including those involving modifications to aid retention of the device in utero and/or different insertion techniques in women undergoing immediate postpartum IUD insertion.
The single trial that had directly compared immediate versus delayed insertion found that at 6 months the two groups were similar in terms of pregnancy prevention (there were no pregnancies) and use continuation [84% and 77%, respectively, with an odds ratio (OR) of 1.65; and the 95% confidence interval (CI) of 0.61–4.47]. At 6 months, expulsion was more likely to occur in the immediate insertion group than in the delayed insertion group (OR 6.77; 95% CI 1.43–32.14).
The other eight trials were 15-30 years old. They included 7558 women undergoing immediate postpartum IUD insertion. The comparisons made in these trials included different IUDs (5 trials) or modified IUDs designed to aid retention in utero (4 trials) and/or hand- versus instrument-insertion of IUDs (4 trials). The IUDs included copper-bearing devices (TCu 200, MLCu 250, Cu 7), progesterone devices (Progestasert/IPCS-52) and the Lippes loop. The copper-bearing devices proved superior to progesterone-releasing IUDs and the Lippes loop. The various copper-bearing devices were found to be similar in efficacy and safety. The modifications made to the IUDs (addition of chromic catgut or additional appendages) had little impact on clinical outcomes. The choice of insertion techniques (hand versus instrument insertion) was also apparently clinically unimportant.
The twelve-month pregnancy rates reported in these studies ranged from 0.0 to 12.1. The expulsion rates at 6–36 months ranged from 6.2 to 44.1 per 100 women and 6–36 month continuation rates varied between 57.3% and 93.3 per 100 women. Three trials studied removal due to pain and bleeding; at 6–12 months the removal rates ranged from1 to 5.5 per 100 women. The included trials did not assess rare outcomes such as displacement of the IUD, uterine perforation and infection.
4.1. APPLICABILITY OF THE RESULTS
The review suggests that the immediate postpartum insertion of IUD is generally safe and effective, although expulsion rates with immediate insertion appear to be higher than with interval insertion. Since the review includes multicentre trials conducted in different settings, including developing countries, the results of this review would be generally applicable to most low- and middle-income settings. However, many of the IUDs studied in these trials (such as the Lippes loop and Delta T) are no longer in use.
4.2. IMPLEMENTATION OF THE INTERVETNION
Insertion of the IUD immediately after delivery has the advantage of assurance that the woman is not pregnant. Moreover, immediately after delivery, the woman is also likely to have a high motivation for accepting contraception, and the health-care centre provides a convenient setting for inserting the IUD. This approach is more applicable to developing countries where delivery may be the only time when a healthy woman comes into contact with health-care providers and the chances of the woman returning for contraceptive advice are uncertain. Thus, the safety of postpartum IUD insertion in the included studies is reassuring and, in spite of the higher expulsion rates, it may cover some unmet need for contraception. None of the included trials studied outcomes such as displacement of the IUD, uterine perforation or infection, all of which are more relevant to developing-country settings where follow-up after IUD insertion is generally poor. Thus, counselling and early follow-up to detect expulsion or other complications should be an integral part of these services until more evidence becomes available.
The higher incidence of untreated reproductive tract infections in many developing countries (3, 4) may affect the immediate and long-term risk of pelvic infection. Use of prophylactic antibiotics (not evaluated in this review) can be considered with immediate insertion of the IUD, especially in women who experienced prolonged labour or rupture of membranes.
Immediate postpartum IUD insertions can be implemented in most developing-country settings and any available copper-bearing IUD can be used for postpartum insertion. There is a suggestion that clinician experience may influence expulsion rates; skilled clinicians have been associated with lower expulsion rates than unskilled clinicians (5). Thus, some additional training for postpartum IUD insertion will be desirable. The availability of IUD insertion kits in delivery areas would need to be ensured. Counselling at the time of insertion and early follow-up in the community are important until more experience is gathered.
4.3. IMPLICATIONS FOR RESEARCH
A larger randomized controlled trial of different timing of IUD insertions in developing-country settings will give a better picture of the benefits and risks of immediate postpartum insertion versus other timings. There is also a need to study the short- and long-term risk of pelvic infections (and any benefit from the use of prophylactic antibiotics) associated with the high incidence of untreated reproductive tract infections in developing countries and the higher risk of infection in the immediate postpartum period. Various outcomes associated with insertion of the IUD at the time of caesarean section can be another useful area of further research.
- Global Health Observatory. Unmet need for family planning. Geneva: World Health Organization; available at: www.who.int/entity/gho/mdg/maternal_health/situation_trends_family_planning/en.
- Grimes DA, Lopez LM, Schulz KF, Van Vliet HAAM, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2010;Issue 5. Art. No.: CD003036; DOI: 10.1002/14651858.CD003036.pub2.
- Marai W. Lower genital tract infections among pregnant women: a review. East Africa Medical Journal 2001;78(11):581-585.
- Kurewa NE, Mapingure MP, Munjoma MW, Chirenje MZ, Rusakaniko S, Stray-Pedersen B. The burden and risk factors of sexually transmitted infections and reproductive tract infections among pregnant women in Zimbabwe. BioMed Central Infectious Diseases 2010;10: 127; doi: 10.1186/1471-2334-10-127.
- Thiery M, Van Kets H, Van Der Pas H. Immediate postplacental IUD insertion: the expulsion problems. Contraception 1985;31;331-349.
This document should be cited as: Muthal-Rathore A. Immediate postpartum insertion for intrauterine devices: RHL commentary (last revised: 1 September 2010). The WHO Reproductive Health Library; Geneva: World Health Organization.