The impact of using nurses to perform postpartum intrauterine device insertions in Kalyani Hospital, India

In the postpartum period women are vulnerable to unintended pregnancy, which may lead to legal or illegal abortion and impact on maternal and neonatal morbidity and mortality. Although several postpartum family planning options are available, lack of access to and availability of family planning services and trained staff pose serious challenges. Peripheral centers may not have a doctor; however, they will have nursing staff that can be trained to offer family planning counselling and services. The present study demonstrates how task sharing with nurses to provide postpartum intrauterine device (PPIUD) services worked to give women a convenient and safe contraceptive method. PPIUD insertion provides women the additional advantage of leaving hospital with appropriate long‐term contraception after institutional delivery, and also decreases the costs borne by patients and the government. This approach also impacts maternal and newborn health by avoiding unwanted pregnancy.


| INTRODUCTION
During the postpartum period women are vulnerable to unintended pregnancy, which often leads to illegal abortion. In low-resource countries, delivery is probably the only time when a healthy woman comes into contact with a healthcare provider and the likelihood of her returning for contraceptive advice is low. 1 Despite the availability of a wide range of contraceptives, unmet need for family planning is estimated to be 12.8% in India. 2 The common reasons for unmet need include unsatisfactory services, lack of knowledge or information, and fear about adverse effects of the contraceptive method.
Moreover, doctors are not available in many of the peripheral health centers where nurses play a vital role in motivating women to choose a contraceptive method.
The World Health Organization's medical eligibility criteria state that the postpartum intrauterine device (PPIUD) is safe for postpartum lactating women and that its advantages outweigh any disadvantages. 3 Advantages of immediate postpartum insertion of an IUD include convenience, safety, client motivation, facilitation of proper birth spacing, noninterference with lactation, immediate reversibility, and no requirement for repeated healthcare visits for refills. PPIUD insertion gives women the additional advantage of leaving hospital with long-term contraception after institutional delivery, decreasing the costs borne by patients and the government.
Given the high unmet need for birth spacing and the rise in institutional deliveries, the Government of India has been working to reinvigorate and scale up the use of postpartum family planning, with a focused effort on expanding the capacity to provide PPIUD services. 4 In many rural centers, nurses routinely conduct vaginal deliveries. Task sharing with nurses and midwives can increase women's access to and the acceptability of quality PPIUD services. 4 To rapidly scale up PPIUD services in India, the government changed the policy in 2013 to allow trained nurses and midwives to insert PPIUDs. 5 The hypothesis is that if nurses are trained in family planning counselling and PPIUD insertion, then more women will accept long-term reversible contraception. To test this hypothesis we conducted a study at the College of Medicine and Jawaharlal Nehru Memorial Hospital, which has around 7500 deliveries per annum. At this institution, doctors attend to around 14 000 outpatients in gynecology and 9000 prenatal outpatients annually, in addition to performing operations and other hospital duties. Doctors have a considerable workload and, therefore, training nurses for PPIUD insertion should increase the capacity to deliver this service.
The International Federation of Gynecology and Obstetrics (FIGO) received funding from anonymous donors for an initiative to implement PPIUD services in low-resource countries. Kalyani Hospital in India was selected to participate owing to the high burden of maternal deaths in the region and poor availability of family planning options-PPIUD uptake was less than 1% when the project was initiated.

| RESULTS
During the study period, 171 team members including 47 nursing staff were trained, 19 235 women were counselled, and 19 170 women delivered during this period.  It is noteworthy that 63.4% of women returned for follow-up and, of these, 93.7% reported a willingness to continue with the PPIUD ( Table 4).
The total number of complications was low and given the small numbers, similar between the nurse and doctor insertion subgroups overall (Tables 5 and 6). There were 14 (0.3%) expulsions and 10 (0.2%) removals. Pain, irregular vaginal bleeding, and family pressure accounted for most (8/10) of the reasons given for removal of the IUD (Table 6).
Missing threads appeared to be more common after cesarean insertion compared with vaginal insertion (4.3% vs 2.7%). In 28 cases the thread was found to be coiled inside the vagina on speculum examination, and in 198 cases the IUD was found in situ on ultrasound scan.

| DISCUSSION
In The PPIUD is a highly effective, long-acting, reversible, costeffective, and easily accessible family planning method. It is safe for use by most postpartum women and has no adverse impact on breastfeeding. 8 Limited availability of skilled human resources-essential to ensure quality PPIUD services-poses a challenge for increasing access to PPIUD. Task sharing, which is a globally accepted solution for accelerating access to health services, was identified as a viable strategy to expand the provider base and make postpartum family planning services available to all women delivering at health facilities.
Task sharing refers to provision of additional training to existing cadres of providers to enable them to undertake new activities. 9 The World Health Organization has also recommended the option of insertion of IUDs by nurses and midwives. 9 Prior to the start of the program, PPIUD insertions at the center were less than 1%, which increased to 2.  T A B L E 4 Follow-up of women at 6 weeks after PPIUD insertion. T A B L E 6 Reasons given for removal of PPIUD.

Reason
No.

Misplaced IUD 2
Pain and vaginal bleeding irregularities 3 Influence of family 5 Total 10 Studies have found that provision of interval intrauterine contraceptive devices by nurse-midwives is effective and feasible in lowresource settings. 12 Task sharing, that is, allowing nurses and midwives to take on tasks previously limited to physicians, is a safe and effective way to address the shortage of health workers. 4 In our study, most importantly we found that task sharing with nurses allowed the method to be much more accessible to women, as demonstrated by the dramatic increase in insertion rates following nurse involvement.
Acceptance of having a PPIUD inserted increased because nurses Overall, the present study found that PPIUD insertion by nurses is safe and effective. There were no cases of perforation. After nurses began performing insertions, the acceptance rate improved drastically with no increase in complications. This is in keeping with findings by Yadav et al., 4 who also concluded that trained nurses and midwives who conduct deliveries in public health facilities can perform PPIUD insertions as safely as physicians.

| CONCLUSION
Immediate PPIUD insertion is a safe, effective, low-cost, long-acting, and reversible contraceptive method. Training nurses who conduct deliveries to insert IUDs during the postpartum period should be included in programs as they can help to increase women's access to PPIUD services without jeopardizing the quality of care. Following this study we recommend this strategy to be taken up by other units where nurses conduct vaginal deliveries.

AUTHOR CONTRIBUTIONS
BB, SKB, TS, and AB conceptualized the article, presented, cleaned and analyzed the data, drafted the article and made edits based on feedback. CNP and HD reviewed the article and made critical suggestions to improve it.

ACKNOWLEDGMENTS
We would like to thank the Government of India, Ministry of Health

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