Banashree Nath completed her senior residency from the Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi, during which she undertook the study. She is an efficient and brilliant academician as well as astute clinician. She is an avid mentor to her juniors and is presently working as Assistant Professor in All India Institute of Medical Sciences, Raebareli.
Aim Copper containing IUCDs are one of most effective mode of contraception for birth spacing. We conducted this prospective observational study to suggest a possible better period of insertion of IUCDs with cost-saving benefits.
Methods All married women in the reproductive age group desirous of Copper-T 375 IUD insertion in either immediate postplacental (PP), immediate postabortal (PA) or interval (INT) period were recruited. The women were asked to return for scheduled follow-up visits at 6 weeks, 6 months and 12 months. They were advised to visit family planning clinic any time if they experienced pelvic pain, discharge per vaginum, unusual bleeding or missed periods. At each visit, women were interviewed for any side effects they have experienced and were asked to elaborate. Pelvic pain was assessed from visual analogue scale. Continuation rate was measured at the end of one year.
Results Women in INT group (90.14%) had the highest continuation rate followed by PP (83.18%) and PA (80%) groups. Women in PP (AOR = 3.37, 95% CI 1.17–9.72) and PA (AOR = 4.53, 95% CI 1.33–14.04) groups had higher odds of discontinuation compared to INT group after adjusting for age, parity, working and education status. There was a significant difference between the groups when cumulative expulsion was considered (p = 0.045), but none when cumulative removal (p = 0.107) was taken into account.
Conclusion The continuation rate remained high in women who had insertion in the interval period compared to immediate postplacental and postabortal periods.
Keywords : Intrauterine device · Postplacental · Postabortal · Interval · Continuation rate
The intrauterine device (IUD) has received global acceptance as one of the best methods of contraception for reasons well attributed to its least adverse systemic effects, prolonged and effective contraceptive action, non-interference with sexual intercourse and cost-effectiveness [1]. India being one of the most populous nations, population control remains the foremost goal for planners of the health policies. Copper T is one such tool to achieve this goal. With the introduction of Lippes Loop in 1965 to Copper-T 375 IUD in 2012 by the National Family Welfare Program of the Government of India [2], Copper T remained the most effective, reversible and long acting mode of contraception. Presently, Copper T is being inserted at either of postplacental (PP), postabortal (PA) and interval (INT) periods depending on feasibility and eligibility.
According to National Family Health Survey, 2015–2016, the contraceptive prevalence rate of currently married women in the age 15–49 in India was 54 percent. Among them, female sterilization remained the most popular modern contraceptive method. IUD/PPIUD (intrauterine device/ postpartum intrauterine device) was used by only 1.5% of women. Contraceptive discontinuation rate for IUDs/PPIUDs was 26% [3]. Even in our institution, a significant number of women opted to discontinue copper T after insertion at different intervals with respect to menstruation, delivery and abortion. There were, however, no comparison studies to find differences between them. This has motivated us to conduct an analysis of the expulsion, removal and continuation of copper T in patients who had insertion in immediate postplacental, immediate postabortal and interval periods. We conducted this study to explore the best time of insertion to achieve lower complication and discontinuation rates. This will guide us to suggest a possible better period of insertion with cost-saving benefits in terms of lesser clinical visits.
The study group consisted of 534 women who were approached for consent for the following insertions: 346 PP, 102 PA and 86 INT. However, 495 patients were actually recruited to the study: 337 in PP group, 86 in PA group and 72 in INT group. 25 patients refused to participate in the study and 14 patients were not eligible. 409 (83.64%) women were still using the primary contraceptive device, 6 (1.22%) patients were lost to follow up while 80 (16.35%) women discontinued the use due to various reasons at 12 months. The number of women who attended follow-up visits were recorded for the three groups (Fig. 1). In our observational analysis, the women in all groups had a high user acceptability reflected in the continuation rate. With an average continuation rate of 83.64%, women in INT group (90.14%) had the highest rate followed by PP (83.18) and PA (80%) groups. The significance test applied to the three groups regarding the descriptive and obstetrics characteristics of the women showed no statistically significant difference except for age (p < 0.05) and parity (p < 0.05). Higher proportion of women in PP group were young with a significant difference between PP and INT group (p = 0.011). Higher number of women in the PP group (49.85%) were primiparous while the majority of women in PA (67.44%) and INT group (38.9%) were parity 2. There was no difference in mode of delivery between the groups (Table 1). When demographic characteristics were stratified into dichotomous variables (Table 2), women < 21yrs of age (p = 0.051, OR = 1.73, 95% CI 1.01–2.96) and those having education up till primary (p = 0.006, OR = 1.94, 95% CI 1.19–3.15) were more likely to discontinue although the continuation rates (p = 0.216) and mean duration (months) of continuation (10.68 ± 3.12, P = 0.249) between the groups did not reach statistical significance. Regression analysis revealed women in PP (AOR = 3.37, 95% CI 1.17–9.72) and PA (AOR = 4.53, 95% CI 1.33–14.04) groups had slightly higher odds of discontinuation compared to INT group after adjusting for potential confounders viz age, parity, working and education status. Women opting for removal were found in all the three groups (PP-10.81%, PA-18.82%, INT- 9.85%) in different proportions but did not reach statistical significance. Out of a total 59 cases opting for removal, 25 (42.37%) cases had excessive vaginal bleeding, 18 (30.50%) cases had lower abdominal pain, 12 (20.33%) cases had vaginal discharge and 4 (6.78%) cases had subjective issues (Table 3). The reasons for removal among the groups had almost no difference except for abdominal pain (p = 0.001) (Table 4). The difference was significant between the groups when cumulative expulsion was considered (p = 0.045) but none when cumulative removal (p = 0.107) was taken into account. Only 1 case at the end of one year had pregnancy with copper T in situ in the PP group.
Copper T continuation rates in the three groups were evaluated by survival analysis curve that revealed no significant difference in the first year follow period (Fig. 2) though the hazard of discontinuation at 12 months was higher in PP and PA group. Consequent to data stratification to dichotomous variables, higher discontinuation rates were observed with certain patient characteristics that included young age (< 21yrs), multiparity and lack of adequate education.
Conflict of interest All authors declare they have no conflict of interest.
Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Human or Animal Rights This article does not contain any studies with animals performed by any of the authors.
Informed Consent Informed consent was obtained from all individual participants included in the study.
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