|Year : 2020 | Volume
| Issue : 2 | Page : 94-98
Intraoperative insertion of intrauterine contraceptive device at cesarean section: A survey on the experiences of trainee and practicing obstetricians
Tokunbo Omolola Adeoye1, Afolabi Korede Koledade2, Oladapo S Shittu2
1 Department of Obstetrics and Gynecology, Dr. Gwamna Awan General Hospital, Kaduna, Nigeria
2 Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
|Date of Submission||22-Sep-2018|
|Date of Decision||11-Nov-2018|
|Date of Acceptance||17-Feb-2019|
|Date of Web Publication||10-Jul-2020|
Dr. Tokunbo Omolola Adeoye
Department of Obstetrics and Gynaecology, Dr. Gwamna Awan General Hospital, Kakuri, Kaduna
Background: Intrauterine contraceptive device (IUCD) placement during cesarean section has been shown to be a safe and effective method of contraception with very low complication and disuse following insertion. Its practice can be of immense benefit, especially in developing countries like Nigeria where high unmet needs for contraception and increasing cesarean section rates are prevalent. Objective: The objective of this study is to evaluate the practice of obstetricians and trainees on counseling and insertion of IUCD during cesarean section. Materials and Methods: A questionnaire-based cross-sectional study was conducted among obstetricians and trainees at the 49th Annual Scientific Conference of the Society of Gynecology and Obstetrics of Nigeria held in November 2015. The data were analyzed using the SPSS version 20. Results: Of 150 respondents, 134 returned completed questionnaires, giving a response rate of 89.3%, 130 of these were adjudged to be correctly filled and were analyzed. Majority of the respondents, 97 (74.6%), were consultants. The mean age of the respondents was 42.01 years ± 7.00. About 95% (125) of the respondents admitted performing cesarean sections, but only 13 (10%) had ever inserted IUCD during cesarean operations. Counseling for the procedure was also low, as only 35 (26.9%) of the respondents had ever counseled the clients toward IUCD placement at cesarean section. Conclusion: For counseling and practice of insertion of IUCD at cesarean section is very low among Nigerian obstetricians, revealing a major barrier to clients' access to this effective and safe method of contraception. Advocacy, education, and training of this category of health-care providers are necessary for improved contraceptive access to cesarean section clients.
Keywords: Cesarean section, intraoperative, intrauterine contraceptive device, obstetricians
|How to cite this article:|
Adeoye TO, Koledade AK, Shittu OS. Intraoperative insertion of intrauterine contraceptive device at cesarean section: A survey on the experiences of trainee and practicing obstetricians. Sahel Med J 2020;23:94-8
|How to cite this URL:|
Adeoye TO, Koledade AK, Shittu OS. Intraoperative insertion of intrauterine contraceptive device at cesarean section: A survey on the experiences of trainee and practicing obstetricians. Sahel Med J [serial online] 2020 [cited 2020 Aug 10];23:94-8. Available from: http://www.smjonline.org/text.asp?2020/23/2/94/289361
| Introduction|| |
Intrauterine contraceptive device (IUCD) is an effective long-acting contraceptive method, that is, of particular advantage in developing countries where a high unmet need for contraception is prevalent. Insertion of IUCD immediately after delivery of the placenta at cesarean section is a well-known safe, effective, inexpensive, and accessible means of postpartum contraception that does not interfere with lactation and has minimal side effects.,,,,, It takes advantage of the indicated surgery, does not significantly increase the duration of the delivery procedure and obviates the need for additional cost for another procedural insertion.
Against the background of the immense public health benefits of this contraceptive technique, little is known of practitioners' experience with it, especially in a developing country like Nigeria that has had negligible change in total fertility rate over the past decade, remaining high at 5.5 and also a low use of modern contraceptive methods of 10%, with increasing rates of cesarean delivery. Consequently, it is necessary to assess the knowledge, perception, and practices of obstetricians who play a key role in providing cesarean delivery and contraceptive services. A study done by Els et al. revealed that the evaluation of knowledge, attitudes, and training of the postpartum IUCD (PPIUCD) insertion, including transcesarean IUCD insertion among obstetric specialists and other family planning providers improved uptake among the women from 15 to 67 which is >400% within 6 months of the study intervention.
There is a dearth in the literature in Nigeria; hence, the study was therefore, carried out to evaluate the knowledge, perception, and practice of obstetricians and trainees in obstetric practice on counseling and insertion of IUCD during cesarean section.
| Materials and Methods|| |
This was cross sectional and descriptive in design.
The study population comprised consultants and resident doctors in the field of Obstetrics and Gynecology who were actively practicing in hospitals spread across Nigeria.
Those who were not practicing Obstetrics and Gynecology were excluded from the study.
The study conducted among obstetricians and obstetric trainees at the 49th annual scientific conference of the Society of Gynecology and Obstetrics of Nigeria which held in Abuja in November 2015. A total of 150 pretested self administered questionnaires were served among consenting participants at the conference venue after seeking ethical approval.
The data were analyzed using SPSS version 20.0 statistical software for Windows (IBM, Armonk, N.Y., USA) using descriptive statistics. Categorical variables are presented as percentages while continuous variables are presented as means and standard deviation.
Ethical clearance (ABUTHZ/HREC/W29/2019) was obtained from Health and Research Committee of Ahmadu Bello University Teaching hospital, Zaria on 19th June 2015.
| Results|| |
Only 134 of a study sample of 150 participants returned their completed questionnaires, giving a response rate of 89.3%, of which 130 (86.6%) were adjudged correctly filled and the same were analyzed. Most of the respondents, 97 (74.6%), were consultants. The overall mean age of all respondents was 42.01 years ± 7.00. [Table 1] shows the sociodemographic characteristics of the respondents. [Figure 1] illustrates the responses of participants on the safety of IUCD during cesarean section.
|Figure 1: Counseling on intraoperative intrauterine contraceptive device insertion|
Click here to view
The counseling for the procedure was low, as only 35 (26.9%) of the respondents had ever counseled the clients for IUCD placement at cesarean section as seen in [Figure 2]. [Table 2] outlines the reasons for excluding counseling on IUCD insertion at cesarean section.
|Figure 2: Safety of intrauterine contraceptive device at cesarean section|
Click here to view
|Table 2: Reasons for excluding counseling on intraoperative intrauterine contraceptive device insertion at cesarean section|
Click here to view
Up to 125 (95.2%) of the respondents had performed cesarean sections of which only 13 (10%) had ever inserted IUCD during cesarean section, and only 12 (9.2%) providers had inserted within the last year of the study.
| Discussion|| |
Most of the respondents were at the peak of their profession with the majority of 97 (74.6%) being consultants followed 25 (19.2%) being senior residents. This assumes good wealth of the experience in practice. Furthermore, of note is that most of the respondents 97 (74.6%) practice in the tertiary health-care centers where medical students and or residents are being trained [Table 1].
The level of counseling for transcesarean IUCD insertion in this study was 26.9% even though 70.8% of the respondents agreed that the procedure was safe with 10% ever performing the procedure. Although a common practice of withholding contraception counseling until the postnatal period might have contributed to this observation, it most probably suggests that most of the respondents counsel patients on other contraceptive options that they find preferable despite their knowledge that the procedure may be beneficial to their patients which negates the comprehensiveness and objectivity of counseling that requires the provider to be free from bias. The implication of this, therefore, is that the knowledge of these practitioners on the efficacy and safety of IUCD insertion at cesarean section has not been transmitted into their services to clients who potentially need it. It, therefore, limits the access of the method to this cohort of women who are denied awareness of its benefits.
Service providers have the opportunity of offering counseling to the patients during antenatal care, and therefore, practitioners have to be aware of their role in counseling patients on insertion of an intrauterine device at cesarean section. This also presents an avenue for the clients to obtain information about various contraceptive methods for them to make informed choices. Proper counseling on postplacental IUCD insertion, especially at cesarean section will likely enhance uptake if it is offered to them. This is much so particularly useful in developing countries with a high unmet need for family planning where the maximum benefits of this method can be exploited. A study done in five West African countries Benin, Côte d'Ivoire, Niger, Senegal, and Togo that improved counseling of women enhanced the uptake of PPIUCD from 1% to about 10% within a year with majority 32.9% being intra-cesarean insertions further emphasizing the role of counseling by skilled health professionals.
The success of postplacental insertion of IUCD is dependent on good counseling-based patient selection and skillful IUCD placement in the uterine cavity. The procedure involves inserting the intrauterine device at the uterine fundus through the uterine insertion, after delivering the fetus and placenta. The placement can be performed either with the Kelly's forceps or manually by grasping the IUCD between the apposed 2nd and 3rd fingers and introducing the hand through the uterine incision. The hand should be slowly withdrawn to ensure the IUCD is in place and the strings are left in the lower uterine segment near the internal os taking care not to pass it through the cervix to prevent displacement of the IUCD and ascending infection. The uterine incision is then closed cautiously ensuring the strings are not taken along with the suture. This procedure should be done only after ruling out contraindications which include chorioamnionitis, prolonged rupture of membranes >18 h, and primary postpartum hemorrhage.
Lack of the requisite skill may be another reasonable explanation for not counseling patients for the procedure as 29% did not have the necessary skill needed to perform the procedure. This may constitute a major provider barrier to addressing the considerable problem of unmet need for family planning in Nigeria, which currently stands at 16%. A study in Nigeria demonstrated that training providers in PPIUCD counseling and insertion techniques resulted in a high acceptance of the procedure as 41% of women who delivered during the study period chose to use the PPIUCD. This further reiterates the missed opportunities of accepting this method as a result of lack of expertise and this can be averted through structured and simulated training on the procedure during the residency program to help improve the practice.
The number of respondents who had ever performed postplacental IUCD insertion at cesarean section was very low (10%) despite the possibility and potential of this technique helping in the reduction of the unacceptably high unmet need for family planning in Nigeria. This is against the background of other factors contributing to these unmet needs such as nonexistence or poor attendance of postnatal clinics which is supposed to be the link to the family planning and reproductive health clinics in most health-care centers. These ultimately lead to potential contraceptive users being lost to follow-up. Failure to use contraception in the postpartum period is fifty-seven times more likely to cause short inter-pregnancy interval which accounts for high morbidity in subsequent pregnancies, particularly for those delivered via cesarean section that might have benefited from a vaginal birth after cesarean (VBAC) section in subsequent deliveries. Hence, counseling of patients on the postplacental insertion of IUCD insertion at primary cesarean section could be of immense value in ensuring that short inter-pregnancy interval is prevented, and hence that the patient can be optimized before next pregnancy and very importantly to give opportunity for the patient to benefit from VBAC if she meets the necessary criteria.
Despite the fact that 102 (70.8%) of the respondents were of the opinion that the procedure was safe [Figure 1]. A total of 47 (49.5%) of the respondents feared complications or did not disclose why they exclude this option during patients counseling [Table 2]. This shows that there is still need for hands-on training and continuous medical education on the safety and efficacy of this option which is essentially based on the appropriate patient selection and techniques for placing the IUCD after placenta delivery at cesarean section.
This study, however, did not evaluate the clinical outcomes of transcesarean IUCD insertion which highlights the need for multi-centered studies to investigate this and also evaluate the potential uptake of transcesarean IUCD among eligible women after adequate counseling.
| Conclusion|| |
Counseling and practice of insertion of IUCD at cesarean section are very low among Nigerian obstetricians. Continuous education and training of trainee and practicing gynecologists on transcesarean IUCD insertion are necessary to maximize potential benefits arising from its increased use among eligible clients. It is also imperative to construct advocacy and training meetings to target consultant obstetricians and gynecologists to change this tide.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
United States Agency for International Development. Postpartum Intrauterine Contraceptive Device (PPIUD) Services. A Reference Manual to Providers. Maryland: Jhpiego Corporation; 2010. p. 1-101.
Goldstuck ND, Steyn PS. Insertion of intrauterine devices after cesarean section: A systematic review update. Int J Womens Health 2017;9:205-12.
Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: A systematic review. Contraception 2009;80:327-36.
Shukla M, Qureshi S, Chandrawati. Post-placental intrauterine device insertion – A five year experience at a tertiary care centre in North India. Indian J Med Res 2012;136:432-5.
] [Full text]
Sharma A, Gupta V, Bansal N, Sharma U, Tandon A. A prospective study of immediate postpartum intra uterine device insertion in a tertiary level hospital. Int J Res Med Sci 2017;3:183-7.
Singal S, Bharti R, Dewan R, Divya, Dabral A, Batra A, et al.
Clinical outcome of postplacental copper T 380A insertion in women delivering by caesarean section. J Clin Diagn Res 2014;8:OC01-4.
Hooda R, Mann S, Nanda S, Gupta A, More H, Bhutani J, et al.
Immediate postpartum intrauterine contraceptive device insertions in caesarean and vaginal deliveries: A comparative study of follow-up outcomes. Int J Reprod Med 2016;2016:7695847.
National Population Commision. Nigerian Demographic and Health Survey Reports. National Population Commision; 2013.
Els C, van der Merwe H, Steyn P. The Effect of Skills Training on Attitudes, Knowledge and Clinical Uptake of Post – Placental Intra-Uterine Device Use; 2015. p. 5278.
Pleah T, Hyjazi Y, Austin S, Diallo A, Dao B, Waxman R, et al.
Increasing use of postpartum family planning and the postpartum IUD: Early experiences in West and central Africa. Glob Health Sci Pract 2016;4 Suppl 2:S140-52.
Eluwa GI, Atamewalen R, Odogwu K, Ahonsi B. Success providing postpartum intrauterine devices in private-sector health care facilities in Nigeria: Factors associated with uptake. Glob Health Sci Pract 2016;4:276-83.
Somefun OD, Ibisomi L. Determinants of postnatal care non-utilization among women in Nigeria. BMC Res Notes 2016;9:21.
Bassey G, Nyengidiki T, Dambo N. Determinants of interpregnancy interval among parturient in Port Harcourt, Nigeria. Sahel Med J 2016;19:180-4. [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2]