Four years of the FIGO postpartum intrauterine device initiative in Sri Lanka: Pilot initiative to national policy

To analyze the difficulties and challenges arising from introduction of postpartum intrauterine device (PPIUD) services into the Sri Lankan health system.


| BACKGROUND
Sri Lanka was the first country selected to implement the FIGO postpartum intrauterine device (PPIUD) initiative on account of its robust maternity care delivery system, relatively good health indicators in the region, and a committed national obstetrics and gynecology society experienced in implementing similar projects. Sri Lanka's success story in developing a health system at low cost that delivers both institutional and domiciliary services is well documented. 1 At present, Sri Lanka provides free health care, including family planning services, through a strong health delivery system with 9.3 physicians and 37 hospital beds per 10 000 population (2013). 2 In 2017, 79.4% of Sri Lankan women registered in government prenatal clinics before 8 weeks of pregnancy and attended 6.4 visits on average. 3 Prenatal care is provided through shared care, with domiciliary care given by Public Health Midwives (PHMs), whose contribution-particularly in rural areas-has been well documented. 4 All mothers (99.9%) deliver in a health facility, with 88% delivering in state hospitals with comprehensive emergency obstetric care under specialist obstetricians. 5 PHMs provide counseling on family planning covering all choices during home visits and at clinics. They also issue oral contraceptive tablets, condoms, and facilitate women who need other contraceptive services, such as insertion of interval IUDs, implants, and depo medroxyprogesterone acetate (DMPA) injections. Postpartum contraceptive methods, such as postpartum sterilization, are provided by national hospitals manned by specialist obstetricians. Provision of postpartum contraception services is not optimal and this is reflected in the significant percentage of unmet need for postpartum contraception noted in the maternal mortality surveillance statistics. 6 Strengthening postpartum contraceptive services in Sri Lanka's health system was therefore an important requirement.  Table 1 shows the percentage distribution of married women by family planning method. 10 Sixty-two percent of married women in Sri Lanka currently use contraception. There is 51.3% prevalence of modern methods in women aged 15-49 years, with 10.1% accepting an IUD out of the choices available. 10 The unmet need for family planning depicted in the Maternal Death Surveillance response analysis was 7.1% in 2013 and 6.22% in 2016.
PPIUD has been used in Sri Lanka as a contraceptive method since 1969, 11 but by the mid-1970s its use had waned, until it was reintroduced through the FIGO initiative as an effective and safe method of family planning. 12 The Sri Lanka College of Obstetricians and Gynaecologists (SLCOG) has been in existence for over 50 years. It plays an advisory role to the government and considers capacity building of healthcare providers as a key function.
The aim of the FIGO initiative in Sri Lanka was to introduce PPIUD services to women delivering vaginally or by cesarean in selected hospitals by capacitating care providers in counseling and delivery of services to eventually integrate PPIUD services into State health services.
The present paper analyzes the difficulties and challenges encountered and the methods adopted to overcome these challenges to successfully integrate PPIUD into the national family planning program.

| Implementation of PPIUD in 18 facilities
The project was implemented in two phases: phase I, involving six Following counselling, written informed consent was obtained from women in the peripheral prenatal clinics or in the hospital.
Medical Officers working in the labor room or operating theater inserted PPIUDs following vaginal or cesarean delivery in women who had provided consent. These women were then requested to attend the hospital after 4-6 weeks to ensure that the PPIUD was in place and no complications had arisen.
T A B L E 1 Current use of contraception in Sri Lanka-ever married women. The project employed Data Collection Officers (DCOs) to conduct face-to-face interviews and collect information from women admit-

| Nationalization
With a view to seeking nationalization, a review of the initiative was undertaken by SLCOG in 2016. A brief but focused opinion poll was conducted with the consultants implementing the PPIUD project in their hospitals since they had first-hand experience of the use of PPIUD. Seventy-four consultants were contacted via email and subsequently over the phone, and responses from 37 consultants were recorded. The results of the initiative review were used to help decide whether to move forward with seeking nationalization at country level.
The total number of staff trained in insertion and counseling is given in Table 3. The majority of women who did not accept PPIUD had decided on another contraceptive method (58%), as shown in Table 4. Reasons why PPIUD was not inserted are shown in Table 5. A total of 32 women (0.34%) out of 9346 reported having complications at the time of insertion (Table 6).
Follow-up information for women who received a PPIUD was obtained in 34% of insertion cases.    Other agencies e.g. FHB/MoH/Medical schools has a contraceptive method in place. This is an important factor in Sri Lanka, where termination of pregnancy is not a legal option. The low follow-up rate of 34% was a concern. It is difficult to motivate women to attend follow-up clinics, especially after delivery when they do not have any problems. Therefore, it can be assumed that women who did not attend did not have any complications.
Collaboration with the Ministry of Health and its directorates was crucial from the start for implementation and subsequent successful

| CONCLUSION
PPIUD is an important contraceptive method introduced into Sri Lankan health services, especially given that unmet need for postpartum contraception was recognized as an important cause of maternal deaths and the reality of clandestine abortion services. FIGO, the Family Health Bureau, and SLCOG jointly collaborated in introducing the pilot project to determine the acceptability of this method among Sri Lankan women. Analysis of the results showed that this was acceptable among women, especially given the low complication rate recorded with insertions. This, along with the advantages of reversibility and that it is nonhormonal, allowed PPIUD to be successfully integrated into the national family planning program in Sri Lanka.