CuT380A postpartum intrauterine contraceptive device (PPIUD) is the insertion of CuT380A into the fundus of the uterine cavity within the first 48 hr of childbirth. It is a safe, cheap, long-acting, reversible, and non-hormonal contraceptive method that is highly effective for prevention of unwanted pregnancies and the abortion-related complications [1-5]. PPIUD can promote the health of mothers and children by preventing financial, psychological, obstetric, and other health complications associated with short-interval pregnancies [2].

It increases mother’s opportunities of starting effective contraceptive methods before being discharged after facility childbirths because the time of commencement of postpartum ovulation is unpredictable and may occur as early as 25 days in non-breast feeding mothers. It can be commenced on most mothers who are not at risk of sexual transmitted infections irrespective of their breastfeeding, hypertension and obesity status, and it can be continued up to 12 years as a longacting contraceptive method to limit childbirths. It is an alternative option to sterilization. PPIUD is cheap because the mothers do not incur extra costs and inconveniences of coming back to the facility for contraceptive methods [6]. The time of facility childbirth is a great opportunity for PPIUD service providers to counsel and provide the method to large numbers of women that need contraception to space or limit childbirths especially in settings where there are cultural or geographical limitations of women’s mobility and access to healthcare. Such unique opportunities were missed in Southeast, Nigeria where high facility childbirth rate of 78.1% have been documented [7]. Out of 133,375 family planning clients seen in University of Nigeria Teaching Hospital, Enugu between 1999 and 2007, 6,947 were on IUD, but none of the clients received PPIUD [8].

Poor perception of the complications of unwanted pregnancies and unsafe abortions by families, lack of awareness, poor access to services, socio-cultural issues, provider bias, limited availability of contraceptive methods, and poor educational status of women, medico-legal restrictions, and fear of complications were known barriers to the uptakes of postpartum family planning [9-12]. None involvement of the husbands during PPIUD counseling was identified as the most common barrier to PPIUD uptake in India [12].

Many women in the first postpartum year who do not want to become pregnant have regular sexual intercourse without effective contraception (i.e. unmet need for effective family planning method) [9,13]. Darroch and Singh [14] reported very high unmet needs in sub- Saharan Africa (60%), south Asia (34%) and western Asia (50%). This unmet need reduced in India when there was increase in facility births [15,16]. Okafor et al. also documented tremendous increase in facility births when maternal and child healthcare services were free in this study population [17]. Making facility births free in Nigeria, involving husbands during counseling and expanding PPIUD services will have great impact on increasing contraceptive prevalence and in reducing maternal morbidity and mortality. PPIUD expulsion, missing strings, infection and its other complications are minimal when the IUD is inserted aseptically by a skilled provider with proper techniques and by placing the device in the uterine fundus [18]. The higher incidence of untreated reproductive tract infections in many developing countries is a serious concern in the provision of PPIUD [19,20]. The use of prophylactic antibiotics was suggested by Muthal-Rathore [21] in prolonged labour and prolonged rupture of membranes.

In 2013, Society for Family Health in Nigeria organized three sessions of PPIUD trainings in Enugu State University Teaching Hospital, Enugu with a total of 59 family planning providers from health facilities from Northern and Southern Nigeria as participants. As the provision of PPIUD is being rapidly scaled up in Nigeria, it is pertinent that its complications should be monitored. Data on mother’s demographic profiles, complications, and satisfactions with PPIUD have not been documented in this study population in Nigeria. The aim of this study is therefore to fill this gap in knowledge by assessing the experiences of mothers who had PPIUD for one year in this study.

The study subjects were the mothers who accepted PPIUD during caesarean deliveries or within 48 hr of vaginal deliveries in Semino Hospital and Maternity, and Redeemer Maternity both in Abakpa Nike, Enugu; and Enugu State University Teaching hospital, Enugu from August 1, 2013 to July 31, 2014. The health facilities were selected by convenience (where I have access to mothers’ data). The mothers were counseled during antenatal care, intrapartum and postpartum periods, and oral consents were obtained before the PPIUD were inserted. Participants were followed up in the family planning clinics at 6 week postpartum, 3 months, 6 months and one year. At 6 week visit, vaginal examination was done to visualize the string at the cervix and to trim it. They were interviewed at one year with a questionnaire (Appendix A). Mothers who did not come after one year of PPIUD usage were tracked with mobile telephone calls. Data collected from clients during the interview included demographic information, complications and mother’s satisfactions. Three trained nurse counselors administered the questionnaires in the three selected health facilities. Data was entered in excel 2007 software, analyzed and presented using percentages and graphs. Three mothers out 84 participants were lost to follow at six months and were not included in the study.

Mothers who are medical eligible and accepted PPIUD after counseling and within the first 48 hr of facility childbirths in the selected facilities were included. The mothers were followed up to one year in the family planning clinics and interviewed.

Mothers who opted out after counseling were excluded. Mothers who were bleeding, had evidence of pelvic infection or have multiple sexual partners and were at risks of sexual transmitted infections were also excluded. Mothers who failed to be tracked or evaluated after one year were not included.

Caesarean PPIUD insertion into the uterine fundus is simple and can be done during caesarean delivery with a sponge holding forceps or manually after removal of blood clots, placenta, and membranes also ensuring that there was no significant uterine bleeding (Figure 1). The uterine incision is then closed as in normal caesarean delivery.

Figure 1: Caesarean PPIUD insertion with a sponge holding forceps.

a. Ensure the mother is counseled and not pale. Palpate, and massage the uterus to assess the size and ensure the uterus is contracted.

b. Clean the external genital area with antiseptic solution and place sterile drapes over the mother’s abdomen and underneath her buttocks. Insert the Graves vaginal speculum to visualize the cervix. Ensure there is no active bleeding. Evacuate blood clots if present. Liberally apply an antiseptic solution to the cervix and the vagina and allow time for it to act.

c. Gently grasp the anterior lip of the cervix with ring forceps. Grasp the CuT380A IUD by its vertical arm with Kelly’s forceps and in the same direction of the strings as shown in Figure 2 to facilitate the placement of the IUD in the fundus and decrease the risk of pulling it out when removing the forceps.

Figure 2: Kelly’s forceps holding CuT380A IUD for insertion.

d. Exert gentle traction on the cervix-holding forceps and insert the Kelly’s forceps holding the IUD through the cervix and to the lower uterine cavity. Avoid touching the walls of the vagina with the IUD during this procedure.

e. Release the hand holding the cervix-holding forceps and move it to the top of the uterine fundus to stabilize the uterus, confirm that the uterus is contracted and then apply firm downward pressure on the fundus.

f. Move the Kelly’s forceps with the IUD downwards and then in an upward motion toward the fundus with the wrist joint acting as pivot. Apply slight pressure to advance the IUD and achieve fundal placement Figure 3. Avoid placing the IUD through any defect in cases of previous caesarean delivery by maintaining the Kelly’s forceps pressure against the posterior uterine wall.

Figure 3: Confirmation of fundal placement of CuT380A IUD.

g. Feel the tip of the Kelly’s forceps with the abdominal hand to confirm the IUD has reached the fundus before opening the forceps to release the IUD. Slowly withdraw the forceps from the uterine cavity, keeping it slightly open and in upward letter C.

h. Examine the cervix to ensure that the strings are not visible at the cervix as an indication that the IUD has been placed at the uterine fundus. Sometimes, when the uterus is well contracted or small, the strings can be seen through the cervix even when the IUD is placed in the fundus. Remove the cervix-holding forceps from the anterior lip of the cervix and clean the woman and appreciate her for her cooperation.

Enugu State University Teaching Hospital ethical committee approved the study before its commencement. The author funded the research and had no conflict of interest to declare.

Table 1 showed 81 PPIUD were inserted in the three selected facilities. Fifteen were caesarean PPIUD while 66 were vaginal insertions. Majority of the clients were of ages 31-40 years 43 (53%), married 76 (93.8%), Para 2-4 68(84%), Christians 79 (97.5%), and had secondary education 46(56.8%). PPIUD was accepted because it was convenient after childbirth 81 (100%), and to limit childbirth 52(64.2%). The mother and her husband jointly decided to accept the method in 70 (86.4%). Other characteristics of the mothers were as shown in tables 1 and 2 and (Figures 4-6) showed that few clients experienced few complications like missing IUD strings 8 (9.9%) and spontaneous expulsions 2 (2.5%). Contraceptive failure, infection, excessive menstrual bleeding, IUD strings causing discomfort to sexual partners and uterine perforations were not experienced in this cohort as shown in Figure 4.

Table 1: Characteristics of the Mothers.

Table 2: Client’s experiences with CuT380A PPIUD.

Figure 4: Complications associated with PPIUD.

Over 74 (91.4%) of the mothers were satisfied with PPIUD and sources of their satisfactions were as shown in figure 5. The method was convenient after childbirth 81(100%), few complication 78(96.30%), effective and safe during breast feeding 78 (96.30%), frequent sex 63(77.8%), and family happiness 64(79.0%) were sources of satisfactions in this study. Other sources of satisfaction include husbands preference of PPIUD to condom 72(88.9%), 62 mothers (76.5%) wanted to continue to use PPIUD while 25 mothers (30.9%) recommended the method to friends. Seven 7/81 mothers acted as PPIUD peer counselors during their recommendations. Eight (9.9%) of the clients removed their PPIUD to achieve pregnancy while 1/81 switched from PPIUD to implanon as shown in Figure 6.

Figure 5: Assessment of the sources of client’s satisfactions.

Figure 6: Reasons for discontinuation of PPIUD.

CuT380A PPIUD is a safe, effective, long-acting, reversible, and non-hormonal postpartum family planning method that are being introduced to mothers in Enugu, Nigeria since July 2013.

The characteristics of the mothers in this cohort showed that most of them were married (93.8%), para 2-4 (84%), had secondary education (56.8%), and most of them had no previous family planning experience. They were first-time PPIUD users, and the decisions to accept the method were reached jointly by the mothers and their husbands in 86.4% of cases for either child spacing (35.8%) or limiting childbirth (64.2%) intentions. These findings were in agreement with others studies [22-24]. The acceptance of PPIUD was also higher among educated women in India [22,23]. Grimes et al. [25] found high PPIUD acceptance rate of 65.1% in multiparous mothers as in this study. Maluchuru et al. [23] contrarily reported high acceptance rate of 31.4% among primigravida against 1.2% documented in this study.

The commonest side effect in this study was missing IUD strings in 9.9% of the mothers at 6 week postpartum, and all the missing strings occurred in caesarean PPIUD. This figure is lower than 16% and 24.76% missing strings reported by other authors [23,24]. Abdominal ultrasounds were used to confirmed that the IUDs were in situ in the uterine fundus. The women were reassured. I used manual vacuum aspirator to bring the strings down to the cervix in four clients who removed their IUD after one year use to achieve pregnancy. Alligator forceps could also be used to probe the cervical canal and uterine cavity to remove the IUD when the strings were not visible at the cervix.

The PPIUD expulsion rate in this study was 2.5%. This is higher than 1.6% in Paraguay [26], but lower than 5.6% reported in India and Zambia. [24,27] and 10.7% at six months in North India [28]. All the expulsions in this study occurred in vaginal PPIUD. There was no expulsion in caesarean PPIUD in Enugu study. This is in contrary to 18% caesarean PPIUD expulsion rate reported in Turkey [29] other complications like PPIUD failure, infections, uterine perforation, IUD strings causing discomfort to sexual partners, and excessive menstrual bleeding were not experienced by the mothers at one year of PPIUD use in this study. PPIUD inserted by skilled providers with aseptic and correct techniques are associated with few complications as was reported in this study.

The desire to conceive (9.9%) and method switch to implanon (1.20%) were the reasons for the removal of IUD in this study. The rate of discontinuation of PPIUD in Enugu was higher than 7.6% reported in India [24], 3.4% in Paraguay [26], and 3% in Zambia [27]. Proper counseling of the clients, their husbands and other important members of their families on what to expect as normal side effects and complications of PPIUD will decrease the rate of discontinuation of the method and increase rate of satisfaction with PPIUD.

Over 90% of the mothers in Enugu were happy and satisfied with their choice of PPIUD. This finding is in agreement with the high satisfaction rates reported by other authors [22-24]. The major sources of satisfactions in this cohort were convenient time of insertions after childbirth (100%), its effectiveness and safety during breast feeding (96.30%), frequent sexual intercourse (77.80%), and family cohesion, understanding and happiness (79.00%). Some clients (8.60%) disclosed to mothers that they are on PPIUD (i.e. as peer counselors) when recommending the method to friends.

This study was limited to three centers in Enugu, and only 81 mothers on PPIUD at one year were studied. The results cannot be generalized to entire study population.

The present study has shown that acceptors of PPIUD in Enugu were highly satisfied with the method at one year of use. Most of them were first-time users, educated and multiparous mothers. PPIUD has been shown to be safe, effective and with few side effects. The expulsion rate of 2.5% is low. The major sources of satisfactions in this study were convenient time of insertions after childbirth, few complications, and its safety during breast feeding. Some mothers acted as peer counselors when recommending the method. Increasing awareness of PPIUD among mothers and clinicians in the forms of counseling and training may remove some of the barriers to PPIUD.