Planning and implementation of a FIGO postpartum intrauterine device initiative in six countries

To describe the process of planning and implementing a program of counselling and delivery of postpartum intrauterine devices (PPIUD) in 48 hospitals across six countries in Africa and Asia.


| INTRODUCTION
It has been estimated that 214 million women of reproductive age in low-income regions want to avoid pregnancy but are not using a modern contraceptive method. 1 Despite many countries achieving increasing rates of institutional deliveries, the proportion of postnatal women leaving facilities without having received a contraceptive method or having had a discussion about a reliable contraceptive plan remains high. 2 Moreover, in some countries women delivering in health facilities rarely return after delivery for contraceptive services; thus; the immediate postpartum period presents an ideal opportunity to serve these women with a much-needed service. 3 The postpartum period is also an especially vulnerable time for women to have unintended pregnancies and conception at this time presents increased challenges to the mother and fetus. 4 A reliable contraceptive method enables a woman to space her pregnancies and plan her family, which allows more time to look after the family. A pregnancy-free interval also provides time for a woman to be more economically productive, increasing the income of the family and, in turn, the community. In addition, birth spacing helps to improve the health of the mother and her baby, 5 and it is well documented that effective contraception can improve maternal health and, as a consequence, reduce maternal mortality. 6,7 Long-acting, reversible, low-cost contraceptive methods, such as the intrauterine device (IUD), can be very effective in facilitating birth spacing, particularly in low-and middle-income countries where women do not visit health facilities regularly. A major advantage of an IUD is that it can be inserted immediately after the placenta is delivered after normal or operative vaginal or abdominal delivery, or within 48 hours of delivery, providing immediate postpartum protection from unintended pregnancies. Postpartum IUD insertion (PPIUD) is advantageous because it does not interfere with breastfeeding and is associated with less discomfort, lower risk of perforation of the uterus (attributed to ease of insertion via an open cervix and the thick postpartum myometrium), and fewer adverse effects compared with interval IUD insertion. 8 The International Federation of Gynecology and Obstetrics (FIGO) is committed to addressing the high maternal mortality rates in lowresource countries and supporting women to make informed decisions about the contraceptive methods available.
To this end, various national societies and, through them, their governments were approached to participate in a FIGO initiative to provide long-acting reliable contraceptives to ease the challenges of unmet need for contraception and to reduce maternal mortality by contraception. However, there was some skepticism over the use of PPIUD from some sides because expulsion rates were reported to be low in some studies, but high in others. Scrutiny of these studies revealed that low expulsion rates were associated with use of long (33 cm) curved Kelly forceps, which place the IUD at the fundus, whereas those with high expulsion rates showed different methods of insertion. FIGO wanted to establish that low expulsion rates could be achieved with proper training and long curved Kelly forceps. A research proposal was sent to anonymous donors, who granted funding for Phase 1 in six hospitals in Sri Lanka. After sufficient experience in Phase 1 with low expulsion rates, Phase 2 began in six hospitals in each of six countries and an additional 12 hospitals in Sri Lanka.
Funding was obtained for Phase 2 from the anonymous donors.
The aim of the FIGO PPIUD initiative was to address the gap in the continuum of maternal health care and to provide for the postpartum contraceptive needs of women by increasing the capacity of healthcare professionals to offer PPIUDs by training community midwives, health workers, doctors, and delivery unit staff, as appropriate, in counselling and insertion of PPIUD. It links well to the United Nations' Sustainable Development Goals (SDGs), particularly goals 3.1 and 3.7, and their aim to reduce maternal mortality and increase access to sexual and reproductive healthcare services. 9 Influencing factors for the choice of participating facilities within the countries included: facilities where PPIUD services were not already being provided; large teaching hospitals were preferred on the understanding that they would be able to impact medical and nursing curricula; ability to conduct the necessary providers' trainings; access to the biggest pool of interns/trainee providers; widest reaching impact in terms of juniors rotating out and taking the practice with them; and reaching the largest number of women with deliveries of approximately 5000 per year (Table 1). An expanded table providing more data on the facilities for the selection process is given as Supporting Information Table S1. FIGO operates its projects via national professional societies or colleges. This model was adopted for the PPIUD initiative as a tried and tested method of implementation that facilitated ownership T A B L E 1 Baseline data collection for facility selection.  The initiative was planned to be integrated with maternity services in the participating facilities, which differed from the traditional service model of separate family planning services in these countries. 12,13 The initiative aimed to provide prenatal counselling on all aspects of contraception with a focus on postpartum family planning. Within the menu of methods of contraception, there was a special emphasis on the advantages of PPIUD as a safe, effective, and reversible long-acting method. 14 The program aimed to provide PPIUD after vaginal or cesarean deliveries in women who consented. Specific consent forms were designed in the local language for this purpose and a purple sticker was placed on the case notes to identify consenting women so that provision of PPIUD was not missed once they had delivered in the hospital. Women who had not been counselled prenatally could be counselled in early labor or postnatal to ensure insertion within 48 hours, prior to discharge.
The plan was to encourage existing staff to counsel women in order to facilitate sustainability. However, this option was not considered

| Training
The

| Challenges
There were number of challenges to implementation, some that could be overcome, whereas others had to be actively managed. It In planning which facilities were included in the initiative, it proved impossible to define a geographic catchment for the hospitals. Women travelled from all over the country to teaching hospitals in the major cities. Many women did not attend the teaching hospital for their prenatal care, either having very little care or accessing it at local clinics. Other women attended the teaching hospital for prenatal care but delivered elsewhere. It was not uncommon for a woman to move to her mother's home toward the end of her pregnancy and therefore deliver in a different hospital from that in which she received her prenatal care. This resulted in problems with counselling women about postpartum family planning prenatally as women would be counselled but deliver somewhere with no offer of PPIUD. This had the potential to reduce the credibility of the counselling, where a service was advised but not offered, and also meant that no data could be collected on these women delivering elsewhere. For others their first encounter with the teaching hospital and counselling on PPIUD was in early labor, giving them limited time to ask questions, consult with family members, and make a decision. Furthermore, as most of the participating facilities were teaching hospitals, many women were referred because they were high risk or had complications. These women had the potential to accrue major benefit from effective contraception, but the need for rapid lifesaving interventions was rightly prioritized over the insertion of an IUD.

| Follow-up
In normal practice in many areas most women do not attend for follow-up visits at the teaching hospital and in the majority of countries only a small proportion of women attend for any postnatal follow-up at all. 18 This emphasizes the need to deliver effective postpartum contraception at one of the few times that a woman is in contact with services. However, lack of postnatal follow-up also reduces the opportunity to find out if the IUD is still in place and whether the woman is happy with it. As the initiative progressed it was possible to collect information on women attending peripheral clinics for follow-up, but it is inevitable that many women who had a PPIUD inserted were not followed up or were missed. As

| Data collection
High levels of data collection were obtained, with an average of We also instituted an audit of structure and process at regular intervals using fixed proformas to ensure that the institutions met all the requirements to carry out high-quality counselling and insertion services. These proformas are shown in Tables 2 and 3.

| DISCUSSION
A great deal of learning has been achieved from this PPIUD initiative that would be useful for similar programs The major strength of implementation in teaching hospitals with well-trained staff and the best facilities in a country has to be balanced with the need to link with the community to raise awareness and confidence in the method among recipients, and to deliver PPIUD services in peripheral units where many women receive their prenatal care. Can they refer for an ultrasound in the event of unknown location of the IUCD?
Is there a fee incurred for an ultrasound scan? If so, how much?
Can they refer for an X-ray in the event of unknown location of the IUCD?
Is there a fee incurred for an X-ray. If so, how much?
T A B L E 3 Profoma used for audit of process. those facilities where the clinical leads believed it was a positive intervention and so embraced it from the start.

Audit of process
It has to be acknowledged that in resource-strapped systems with high-volume activity and staff shortages, any additional workload is challenging. Any new initiative has to be designed in a way that makes it easy for busy staff to implement, including simple, supportive documentation, easy access to appropriate equipment, and genuine belief in and support for the intervention. Experience from this initiative suggested that in smaller facilities with cohesive teams, changing practice and making PPIUD part of normal business was more straightforward than in the larger teaching hospitals. This emphasizes the importance of working with individual teams using the bottom-up as well as the top-down approach.

| CONCLUSION
Planning and implementing an initiative that required a change in clinical practice in six countries would always be challenging, but this initiative showed that working through national societies has major benefits in ensuring links to local systems and clinical support. Effective implementation requires strong country leadership and belief and commitment from clinicians for the change in practice.
Audit of structure, process, and outcome at regular intervals based on good quality data is a prerequisite for successful implementation.
These provide feedback to clinicians to identify problems, and enable provision of additional training or support to individual providers, counsellors, or facilities as early as possible; they also help us to learn from and celebrate success and make the case for popularizing this useful public health intervention.

AUTHOR CONTRIBUTIONS
LdC and LB wrote the manuscript with help from EB, MS, and SA.
SA planned the initiative and directed implementation with the FIGO PPIUD team. All authors reviewed the manuscript before submission. LB and MS worked on the project while they were employed by FIGO.

ACKNOWLEDGMENTS
We wish to acknowledge the past and present members of the PPIUD team at FIGO headquarters and each country team that has worked hard to make this initiative possible. We would like to thank Societies of India), as well as AVNI Health Foundation for their commitment and hard work in implementing this initiative. We would like to thank the governments of the six countries for their support and involvement in the initiative. Finally, we would also like to thank our anonymous donors for their generous grant and continued support.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.