International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Agarwal N et al. Int J Reprod Contracept Obstet Gynecol. 2015 Aug;4(4):1137-1141

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20150442
Research Article

Antenatal counselling as a tool to increase acceptability of postpartum

intrauterine contraceptive device insertion in a
tertiary care hospital
Neelima Agarwal*, Manisha Gupta, Amita Sharma, Raksha Arora

Department of Obstetrics and Gynaecology, Santosh Medical College & Hospital, Santosh University, Ghaziabad,
Uttar Pradesh, India

Received: 07 June 2015

Accepted: 10 July 2015

*Correspondence:
Dr. Neelima Agarwal,
E-mail: agarwalneelima2@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Acceptance of postpartum intrauterine device (IUD) insertions in women in Uttar Pradesh is low. In
response to the concept that a good postpartum programme should begin prenatally, this study was designed to
determine whether the provision of expert contraceptive counselling during the antenatal period would have an impact
on its uptake as compared to women who were counselled in post partum period.
Methods: Expert contraceptive counselling was given to 264 and154 women during their antenatal visits and
postpartum hospitalization, respectively. Acceptors received IUCDs within 48 h of delivery in the case of vaginal
delivery or transcesarean insertion in case of abdominal delivery. The acceptance rate of PPIUCD and the percentage
of actual insertions were recorded. The causes of refusal were also recorded.
Results: Among the 264 couples counselled in antenatal period 116 (43.9%) had PPIUCD insertion. Among the 154
unbooked women who were counselled postpartum only PPIUCD was inserted in 36 (23.4%) women. PPIUCD
insertion was significantly high in women receiving expert counselling during antenatal period as compared to the
women who were counselled in postnatal period (p< 0.001). Family refusal, No knowledge of PPIUCD and
preference for another contraceptive methods were the most common reasons for refusing the use of PPIUCD.
Conclusion: Acceptability of PPIUCD insertion was high in women counselled in antenatal period. Hence, it is
suggested that counselling for PPIUCD should start in antenatal period.

Keywords: PPIUCD insertion, Acceptability, Antenatal counselling

INTRODUCTION be inserted in the 48 hours postpartum.2 It is effective for

5 years (Cu375) or 10 years (Cu380A).
An increase in contraceptive use during the postpartum
period should substantially reduce rates of maternal and According to 2005–2006 National Family Health Survey
infant mortality by preventing unplanned and unwanted III (NFHS III) data from Uttar Pradesh, India, two of
pregnancies, and spacing new pregnancies to at least two every three postpartum mothers were not using any
years after the previous birth.1 family planning method. Three out of every four
postpartum women expressed an unmet need for family
Postpartum intrauterine contraceptive device (PPIUCD) planning. Unmet need decreases but remains high
insertion is a component of postpartum family planning throughout the first year postpartum. Almost 60% women
and can serve for spacing. According to the World Health still desired to space or limit subsequent births by the end
Organization Medical Eligibility Criteria, an IUCD can of the year3. Studies have shown that, in general, women

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 Agarwal N et al. Int J Reprod Contracept Obstet Gynecol. 2015 Aug;4(4):1137-1141

who desire another child do not want to conceive for at Inclusion criteria
least 18 months after their last birth; this holds true in
India as well. However, this desire to delay pregnancy  Pregnant Women coming for antenatal check-up and
often does not translate into the use of contraceptives. eligible for PPIUCD insertion.
IUCDs are used by only two percent of current users of  Unbooked women delivered in our hospital and
contraception in India.3 The current national strategy in meeting all the eligibility criteria for post partum
India is for increasing IUCD uptake. The available target IUCD Insertion.
to cover with PPIUCD as a method of contraception has
expanded in the recent past; since there is a 10 fold Exclusion criteria: women having-
increase in women delivering in hospitals due to
maternity benefit scheme.4 a. Chorioamnionitis or Puerperal sepsis.
b. Prolonged rupture of membranes of >18hrs
Counselling about spacing methods can be time- c. Extensive genital trauma.
consuming and providers must work against the myths d. Unresolved PPH
and misconceptions about family planning use that are e. Any abnormality of uterus or a large fibroid
prevalent in the community. In a study even in the distorting its cavity
intervention area, the majority of women reported f. Pelvic Inflammatory Disease
condoms as the postpartum contraceptive method they g. Malignant or benign trophoblastic disease
h. HIV/AIDS
used4.There is a lack of decision-making power about
contraceptive use among young women.5 Improved
Four hundred pregnant women, in the reproductive age
interpersonal communications in the health facility at the
group 15-45 years, attending Santosh Medical college
time of ANC check-ups may be an ideal approach to
Hospital, Ghaziabad, Uttar Pradesh, during their antenatal
encouraging women for PPIUCD insertion. Women who visit were interviewed. Among them 264 couples were
receive antenatal care (ANC) services are more likely to found suitable and counselled for PPIUCD insertion
use postpartum family planning.3 along with their family members also.

ANC services allow multiple opportunities to address the One hundred fifty four unbooked women who delivered
woman’s concerns and answer her questions. As well, it in our hospital and considered suitable for insertion were
allows for a discussion with the husband or other family also counselled in the same manner postpartum for
members which is considered to be an important part of PPIUCD insertion.
the counselling process in India.
Their demographic characteristic and obstetric history were
In response to the concept that a good postpartum program noted. We also explored the reason for unwillingness for
should begin prenatally, this study was designed to PPIUCD insertion among the couples refusing for
determine whether the provision of expert contraceptive PPIUCD insertion. Acceptors received IUCDs (Cu 375)
counselling during the antenatal period would have an within 48 h of delivery in the case of vaginal delivery or
impact on acceptability of PPIUCD insertion. transcesarean insertion in case of abdominal delivery.

Our specific aims were to determine the demographic Data was analyzed in Excel 2007. Descriptive statistics,
characteristics of women who accepted PPIUCDs after chi-square tests were done and significance of tests was
contraceptive counselling during the antenatal period and decided at p-value <0.05.
women who were unbooked and received postnatal
counselling. The reasons for refusal in both the group RESULTS
were also noted. We also analysed the difference in
PPIUCD insertion, if any, between those two groups. Couples counselled during antenatal period

Out of the 264 couple counselled in antenatal period 186

METHODS
(70.5%) couples agreed for insertion of PPIUCD and the
rest declined (Table 1).
This prospective observational cohort study was conducted
in the Department of Obstetrics & Gynaecology, Santosh Among the women counselled 57.2% were of age group
Medical College Hospital, Santosh University, Ghaziabad, 20-25 yrs, 37.1% were of age group 26-30 yrs and rest
U.P. between January 2014 to June 2015 after getting were of of 31yers of age and above. Among the women
approval from the ethical committee. who agreed for PPIUCD insertion, 61.3% were from age
group 20-25 years (Table 1).
After informed consent, those women who met the
eligibility criteria for PPIUCD insertion were included in Among the women who agreed after counselling 73.2 %
the study. were educated and 59.1% of women belonged to upper-
middle and upper class (Table 1).

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 Agarwal N et al. Int J Reprod Contracept Obstet Gynecol. 2015 Aug;4(4):1137-1141

Out of the the 264 women who were counselled 196 the women who refused later was family refusal (53.6%)
women delivered in our hospital and among them (Figure 2).
PPIUCD was inserted in 116 (43.9%) women and it
included 163 women out of 186 women who agreed for Counselled postpartum
PPIUCD insertion at the time of counselling. The number
of women who agreed earlier and declined postpartum One hundred fifty four unbooked women who delivered
insertion of IUCD were 47 (28.8%) (Figure 1). in our hospital and found suitable for PPIUCD insertion
were counselled for PPIUCD insertion along with their
Table 1: Socio-demographic characteristics of women family members postpartum (Table 2).
counselled for PPIUCD in antenatal period.

Agreed Declined Family Refusal

Total PPIUCD
when when 4.8 4.8
Characteristics Counselled inserted
Counselled Counselled 10.4
Not enough knowledge of
n(%) n(%)
n(%) n(%) PPIUCD
Total no. of 116 13.6 53.6
264 186 (70.5) 78(29.5) Prefer to use another
women (43.9) method
12.8
25.5 ±
Age n ± SD 25.6± 3 25.4± 2.9 25.9±3.4 No reason
2.7
20-25 151 (57.2) 114 (61.3) 37(47.4) 69 (59.5)
Fear of pain and bleeding
26-30 98 (37.1) 62 (33.3) 36 (46.2) 42 (36.2)
31-35 11(4.2) 8 (4.3) 3(3.8) 4 (3.4)
≥ 36 4 (1.5) 2 (1.1) 2 (2.6) 1 (0.8)
Educational
Status
Figure 2: Reasons for non acceptance of PPIUCD in
No Formal women counselled in antenatal period (%).
94(35.6) 50(26.8) 44(56.4) 7 (6)
Education
Primary 77(29.2) 57(30.6) 20(74) 46 (39.7) Table 2: Socio-demographic characteristics of women
Secondary 69(26.1) 58(31.2) 11(25.6) 43(37.1) counselled for PPIUCD insertion postpartum.
Higher
24 (9.1) 21 (11.3) 3 (3.8) 20 (17.2)
Education
Declined
Religion Total PPIUCD
when
Hindu 214 (80.1) 157 (84.4) 57(73.1) 92 (79.3) Characteristics Counselled Inserted
Counselled
Muslim 50(19.9) 29(15.6) 21(26.9) 24 (20.7) n (%) n (%)
Parity
n (%)
0 60(22.7) 36(19.4) 24(30.8) Total no. of
154 118(76.6) 36 (23.4)
1 136 (51.6) 104 (55.9) 32(41.1) 13 (11.2) women
2 60(22.7) 39(21) 21(26.9) 67 (57.8) Age n ± SD 26.5± 3.7 26.6± 3.9 26 ± 3.2
≥3 8(3) 7(3.7) 1(1.2) 36(31) 20-25 83(53.9) 62(52.5) 21 (58.4)
Economic 26-30 60 (39) 48 (40.7) 12 (33.3)
Status 31-35 6(3.9) 4(3.4) 3(8.3)
Lower Class ≥ 36 5 (3.2) 5 (4.2) 0
and Lower 113 (42.8) 76(40.9) 37(47.4) 38 (32.8)
middle class
Educational
Middle, Upper Status
middle and 151 (57.2) 110 (59.1) 41(52.6) 78 (67.2) No Formal
68(44.2) 65(55.1) 3 (8.3)
Upper Class Education
Primary 49(31.8) 35(29.7) 14 (38.9)
Secondary 23(14.9) 8(6.8) 15(41.6)
300
264
Higher
14 (9.1) 10 (8.5) 4 (11.1)
250 Education
198
200
186 Religion
163

Total no. of women

Hindu 125(81.2) 97(82.2) 28 (77.8)
150
116 116
Muslim 29(18.8) 21(17.8) 8 (22.2)
78 82 Accepted
100
Parity
47 Declined
50 1 123(79.9) 101(85.6) 22 (61.1)
0
2 45(29.2) 22(18.6) 13(36.1)
Antenatal Counselling Delivered in Hospital Agreed for PPIUCD
(Agreed/Declined) (Insertion/Refusal) during ANC and
≥3 6(3.9) 5(4.2) 1(2.8)
delivered in Hospital Economic
(Agreed/Refusal)
Status
Lower Class
Figure 1: Acceptance of PPIUCD in women and Lower 65(42.2) 54(45.8) 11(30.6)
counselled during antenatal visits. middle class
Middle, Upper
The commonest reason for non-acceptance of PPIUCD middle and 89(57.8) 64(54.2) 25(69.4)
insertion by couples during antenatal counselling and Upper Class

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 Agarwal N et al. Int J Reprod Contracept Obstet Gynecol. 2015 Aug;4(4):1137-1141

Among the 154 women who were counselled postpartum she along with her family members had time to think and
only PPIUCD was inserted in 36 (23.4%) women. The discuss about it among themselves after receiving expert
most common reason for refusal was family refusal medical advice. A majority of the accepters rely on their
(62.7%) (Figure 3). physician and counselling of the couples during antenatal
period helps.

Family Refusal A prospective cohort study in India found a significant

increase (61.8% versus 30.6%) in contraceptive use at 9
6.8 2.5 3.4
Not enough knowledge months postpartum by women in the intervention group
ofPPIUCD
12.7
compared with the control group. The intervention
No reason included an educational campaign carried out by
11.9 62.7 community workers using leaflets, posters, wall paintings
Fear of pain and and booklets. The campaign addressed pregnant women,
Bleeding
their husbands, mothers-in-law and community opinion
Prefer to use another leaders.4
method

Religious belief A non-equivalent control group study found increased

use of postpartum contraception following ANC
Figure 3: Reasons for refusal of PPIUCD in women counselling that included husbands. However, this article
counselled postpartum (%). included little description of the intervention.6 A study
from Delhi, which explored the reasons behind the low
acceptance of PPIUCD in users, found that the most
The demographic characteristic of both the groups were
similar. About 46% of women of both the group common reason affecting the readiness for PPIUCD
insertion was lack of involvement of husband in
combined, who accepted PPIUCD insertion, made their
counselling during antenatal period, regarding the need
own decision to use a PPIUCD and 24.3% more decided
for birth spacing & benefits of PPIUCD as an effective
after consulting their family members (Table 3).
means of contraception right from the time of delivery.7

Table 3: Decision Making in PPIUCD Insertion n=116 Acceptance of PPIUCD was very poor among the
+36 (152). illiterate women in both the antenatally counselled and
postnatally counselled group and it was 6% and 8.3%
Self, alone n (%) 70(46.1) respectively. A large study from Uttar Pradesh looking at
Self after consulting with Family n (%) 37 (24.3) family planning among the urban poor showed that less
Husband n(%) 31(20.4) educated women (1-11 years) living in both slum and
Mother in law n(%) 14 (9.2) non-slum areas are more likely to be sterilized, less likely
to use other modern contraceptives, and more likely to
have an unmet demand for family planning than more
PPIUCD insertion in women who received contraceptive
educated women (+12years of education).8
counselling in antenatal period was 43.9% as compared to
to women who were counselled in postpartum period Our study result were also similar to a study done in
which was 23.4% only and is highly significant (p< 0.001). Odisha by Mishra et al.9 where acceptance of PPIUCD was
higher among women with Primary and Secondary
DISCUSSION education (28.56 % and 13.88), than those with no formal
or higher education (7.75 and 8.21%). Our study confirms
In our study among the 264 couples counselled in the importance of education in deciding future pregnancy.
antenatal period 116 (43.9%) had PPIUCD insertion.
Among the 154 unbooked women who were counselled PPIUCD insertion was most common among women
postpartum only PPIUCD was inserted in 36 (23.4%) who were either nullipara or primipara during antenatal
women. PPIUCD insertion was significantly high in counselling (69%) and among the primipara in the post
women receiving expert counselling during antenatal natally counselled group (62.8%). This finding is
period as compared to the women who were counselled contrary to that of the study by Grimes et al.10 where they
in postnatal period (p< 0.001). found higher acceptance in multiparous clients (65.1%).

The postpartum phase is regarded as a time of The commonest reason for declining PPIUCD insertion
vulnerability for mother and infant, and any perception was family refusal (53.6%) followed by preference for
that use of PPIUCD insertion might hinder their chance other methods (13.6%) in women counselled in antenatal
for future conception acts as a powerful disincentive for period. In unbooked patient the commonest reason for not
early postpartum use. accepting PPIUCD insertion was also family refusal
(62.7%) but was higher as compared to other group. This
A plausible explanation of the relatively high acceptance again highlights the importance of couple counselling in
of PPIUCD in the antenatally counselled women was that antenatal period.

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 Agarwal N et al. Int J Reprod Contracept Obstet Gynecol. 2015 Aug;4(4):1137-1141

A study by Kumar et al. which covered a large sample of 2. World Health Organization: Medical Eligibility
women from eight states of India found that while more than Criteria for Contraceptive Use. 4th edition. Geneva:
half of the women based their decision to use a PPIUCD World Health Organization; 2010.
based on discussing with multiple individuals, more 3. International Institute for Population Sciences (IIPS),
than 70% of the women choosing to use a PPIUCD as a The Third National Family Health Survey (NFHS-3),
contraceptive method received PPFP counselling by a India: 2005–06 (Mumbai: International Institute for
dedicated counsellor at the facilities, and many stated they Population Sciences, 2007).
made the own decision to use a PPIUCD before delivery, 4. Sebastian MP et al. Increasing postpartum
either during antenatal care or before delivery.11 In our study contraception in rural India: evaluation of a
about 46% of women who accepted PPIUCD insertion, community-based behaviour change communication
made their own decision to use a PPIUCD and 24.3% more intervention. International Perspectives on Sexual
decided after consulting their family members. and Reproductive Health. 2012;38(2):68–77.
5. Stephenson R and Tsui AO. Contextual influences
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Rajasthan and Odisha till January 2014. Total India. New Delhi, India, Population Council,
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The high acceptability in our study may be due to high 7. Priya et al. Exploring reasons behind Low
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Postpartum Women. Stud Fam Plann. A, Arora R. Antenatal counselling as a tool to
2009;40(3):235-45. increase acceptability of postpartum intrauterine
contraceptive device insertion in a tertiary care
hospital. Int J Reprod Contracept Obstet Gynecol
2015;4:1137-41.

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