Women's experiences with immediate postpartum intrauterine device insertion: a mixed-methods study.

OBJECTIVE: To describe women's pain and experiences with immediate postpartum intrauterine device (IUD) insertion (IPPI) following vaginal delivery using a ring forceps insertion technique. STUDY DESIGN: This observational mixed-methods study included women who underwent successful IPPI using ring forceps, with and without epidural analgesia. To describe women's pain during the procedure, we recruited women during antenatal care and at the time of admission for delivery until we collected at least 30 sets of pain scores at two time points (preprocedure and immediately postprocedure) in both groups using two instruments: 100-mm visual analogue scale (VAS) and a 4-point Likert verbal rating scale (VRS) (0=none, 1=mild, 2=moderate, 3=severe). After placing the IUD, physicians rated ease of IUD insertion. A subset of participants in both groups underwent semistructured interviews prior to hospital discharge. Our goal was to explore women's (a) decisional influences and prior contraception experience, (b) experience during IPPI and (c) decisional regret. We conducted iterative analysis of interview content until thematic saturation was reached in both groups. Interviewees provided recall pain scores and rated satisfaction with IPPI. RESULTS: We collected 30 pain scores in the no-epidural group and 36 in the epidural group. At both time points, the VAS data exhibited very low pain scores in the epidural group and a uniform distribution in the no-epidural group; standard deviations were large. The majority of women in both groups reported "none-mild" pain on the VRS. Physicians reported minimal difficulty with IUD insertion in most cases. We conducted interviews with 12 women who had an epidural and 9 who did not. Both groups offered similar comments across all domains. Convenience was the primary motivation to undergo IPPI, and women recognized the barriers to obtaining effective contraception remote from delivery. The majority of interviewees, even those with high pain scores, characterized their procedural pain as less than expected, and IUD insertion pain was less than or similar to labor pain. Interviewees' recall pain scores were similar to those reported at the time of IUD insertion. An unanticipated theme that emerged was an ineffective informed consent process; women could not recall most procedural risks or how IPPI was accomplished. All interviewees endorsed IPPI, expressing a high degree of satisfaction; none regretted undergoing the procedure. CONCLUSION: The distributions of our VAS scores did not reveal useful summary statistics in either group. The VRS scores were a more informative representation of women's pain during IPPI; most women reported little pain. Convenience of obtaining highly effective contraception immediately postpartum was the key motivator for undergoing IPPI. All women voiced favorable experiences, even those who had high pain scores. IMPLICATIONS: Women in our study overwhelmingly described less pain than anticipated with IPPI and also reported a high degree of satisfaction. Our study offers valuable patient-centered guidance to inform antenatal contraceptive counseling with respect to IPPI and lays the groundwork for ongoing research towards optimizing women's experiences with the procedure.

Safety of the progesterone-releasing vaginal ring (PVR) among lactating women: A systematic review.

CONTEXT: Lactation causes a delay in ovulation in the postpartum period, and therefore a delay in the resumption of menses. However, return to fertility is variable in the postpartum period and is contingent upon numerous factors. The postpartum period is therefore a critical time to initiate effective contraception in order to support the numerous beneficial health outcomes of optimal pregnancy spacing. Breastfeeding women have an unmet need for highly effective birth control methods that do not interfere with lactation and that are safe for their infants. The progesterone-releasing vaginal ring (PVR) releases a natural progesterone that suppresses ovulation and is specifically designed for breastfeeding women in the first postpartum year. OBJECTIVE: To review the published peer-reviewed literature regarding the safety and effectiveness of the PVR used for contraception among lactating women, as well as the safety for their infants. Results of this review informed the decisions of the Guideline Development Group to include recommendations on contraceptive eligibility for the PVR within the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 5th Edition. METHODS: We searched the PubMed, Popline, and LILACS bibliographic databases for articles published in any language from database inception through October 1, 2014. We reviewed the literature for evidence regarding the safety of the PVR among breastfeeding women using the method, as well as for their infants. The US Preventive Services Task Force system was applied to assess the quality of the evidence. RESULTS: Seven articles met our criteria for inclusion in this review. All studies were of a prospective cohort design. All studies consistently showed that use of the PVR among breastfeeding women compares favorably to other methods of contraception with regard to effectiveness, does not compromise a woman's breastfeeding performance, and does not adversely affect infant growth during the first year postpartum. CONCLUSION: The PVR is a safe and highly effective method of contraception for use among breastfeeding women. It should be offered to women who plan to breastfeed in the context of postpartum contraceptive counseling.