JMSCR Vol||10||Issue||01||Page 197-202||January 2022

http://jmscr.igmpublication.org/home/
ISSN (e)-2347-176x ISSN (p) 2455-0450
DOI: https://dx.doi.org/10.18535/jmscr/v10i1.31

A Prospective Study of Acceptability, Safety and Efficacy of Postpartum

Insertion of Intrauterine Copper Device (CU-T380a) in Tertiary Care
Teaching Hospital in South India
Authors
Shanthi Ponusamy , Minthami Sharon*2, Akanksha Singh3
1
1
Associate Professor, Department of Obstetrics and Gynaecology, Shree Balaji medical college and hospital,
Chennai, Tamil Nadu, India
2
Associate Professor, Department of Obstetrics and Gynaecology, Shree Balaji medical college and hospital,
Chennai, Tamil Nadu, India
3
Resident Department of Obstetrics and Gynaecology, Shree Balaji medical college and hospital, Chennai,
Tamil Nadu, India
*Corresponding Author
Minthami Sharon
Abstract
Introduction: Many national postpartum family planning (PPFP) programmes are progressively
including postpartum intrauterine contraceptive devices (PPIUCD). Effectiveness of Intrauterine
contraceptive device (IUCD) is an inexpensive method of family planning which is reversible, once
inserted gives 5–10 years of protection against pregnancy.
Aim: We aimed to compare numerous IUCD-related clinical parameters to assess acceptability, safety,
and efficacy in immediate postpartum vaginal insertion, intra-caesarean insertion.
Materials and Methods: It was a prospective analysis of data collected regarding maternal age,
socioeconomic status, education, occupation, and parity of 354 eligible postpartum mothers in a tertiary
care teaching hospital and Medical College in Tamil Nadu from January 2017 to January 2020. These
women's data included acceptability, safety, and efficacy, as well as the spontaneous expulsion rate of
IUCD, reasons for removal, and IUCD up to a 12-month follow-up period.
Results: The majority of the women were between the ages of 24 and 35, literate, primiparous, employed,
and from a middle/lower socioeconomic status. Leukorrhea and abdominal discomfort were the most
common side effects at 6 weeks,6 months, and a year, followed by vaginal bleeding. The majority of Cu- T
was withdrawn in this trial due to p/v haemorrhage and stomach pain. After that, there is a per-vaginum
discharge. At the end of the 12-month follow-up, the continuation rate was 94.61 percent.
Conclusion: The benefits of contraceptive protection outweigh the potential inconvenience of needing to
return for care for women who receive PPIUCD, and the rates of expulsion were low enough.
Keywords: Intrauterine contraceptive device, Postpartum, Acceptance, Counselling, Complications.

Introduction (NFHSH-4), India's total unmet contraceptive

Long-acting contraceptives are promoted and need is 12.9 percent, and its unmet spacing need is
made available to all eligible women seeking 5.7 percent.[2] Hence good contraceptive coverage
long-term spacing.[1] According to a survey in the reproductive age group population not only
conducted by the National Family Health Service bring the population under control but also pave a
Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 197
JMSCR Vol||10||Issue||01||Page 197-202||January 2022
path to better health care in India by bringing Materials and Methods
down the burden on health care infrastructure. This is a prospective observational study
The intrauterine contraceptive device (IUCD) is a conducted at a tertiary care teaching medical
highly effective (99%) and low-cost family college and hospital in Tamil Nadu. The women
planning tool that is reversible, needs no effort on presenting to antenatal OPD were counselled
the user's part once installed, and provides 5–10 about family planning and encouraged to opt for
years of pregnancy protection.[3] IUCD is used by cu-T insertion immediately after delivery. The
roughly one out of every five women of reproduc- women presenting to labour room were counselled
tive age around the world, but only about three out and invited to participate in the study. All
of every hundred women in India utilise it.[4] postpartum patients who are willing to use IUCD
Although the government of India provides the for contraception in post-partum period were
Copper T 380A (CuT380A) device free of charge included in this study from January 2017 to
and it is effective for ten years, it is still generally October 2020.
unused. There are several myths and In this study copper T 380A was used. Insertion
misconceptions, and the benefits are downplayed, was done by trained obstetricians who followed
while the risks and side effects are overstated.[5] all recommended clinical and infection prevention
The effectiveness of various copper IUD devices measures for successful insertion as per the
has been studied by a number of researchers. The national family welfare guidelines. Before hospital
published cumulative pregnancy rate for the discharge all the patients were examined for
Copper T-380A's remaining contraceptive life vaginal bleeding and discharge. At 6 weeks, 6
lifetime has always been exceptionally low, at 2.2 months and one year interval follow up visit were
per100 women.[6] scheduled. During the follow up visit, all patients
IUCD has some unpleasant side effects, but they were undergone pelvic examination to check for
are not hazardous, and they usually go away any signs of bleeding, infection, displacement and
within a few months in most women. The abdominal USG to check the IUCD position.
provider's knowledge and up-to-date information, Expulsions were confirmed clinically and
correct case selection, and pre- and post-insertion radiologically.
counselling of patients and family members about The study was analysed the data using SSPS 11.6
probable adverse effects and the benign nature of software, all the categorical data is presented with
the procedure can all help to reduce the frequency and percentage.
discontinuation rate and boost acceptability.[7] Inclusion Criteria
 Women fulfilling WHO medical eligibility
Aim criteria.
In a single setting in the Indian scenario, studies  Women who gave informed written
comparing IUCD insertion immediately after consent and had either vaginal delivery or
vaginal and caesarean delivery, in the delayed caesarean section.
postpartum period, and after 6 weeks are scarce. Patients were subdivided into three categories
As a result, we conducted our research in an based on timing of insertion and mode of delivery.
Indian tertiary care centre that serves a vast Post placental insertion was done within 10
population. At a tertiary-care centre in south India, minutes of delivery in labour ward. Immediate
we aimed to compare numerous IUCD-related postpartum insertion was done within 48 hours of
clinical parameters to assess acceptability, safety, delivery in post-natal ward. Intra caesarean
and efficacy in immediate postpartum vaginal insertion that takes place during a caesarean
insertion, intra-caesarean insertion. delivery, after removal of the placenta and before
closure of the uterine incision

Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 198

JMSCR Vol||10||Issue||01||Page 197-202||January 2022
Exclusion Criteria More number of patients opting PPIUCD during
Patients who had the following conditions were post LSCS and post placental PPIUCD suggest a
excluded from the study, greater number of counselling during antenatal
 Pregnant patients who were below 28 period and during early labour. Post placental is
weeks gestation more common in our study (50.0%) compare to
 Genital tuberculosis intra caesarean insertion (27.96%) and postpartum
 PPH (postpartum haemorrhage) PPIUCD consist of (22.08%). [Table 3].
 Uterine fibroids & anomalies Follow up rate was about 70.05%% in 6week
 PROM >12 hours (i.e.248 patients out of 354 patient). After 6
 History of ectopic pregnancy in the past. months, it was increased to 80.79 % and was
Sample Size reduced up to 74.57% at 12 months. [Table 4]
In this study 850 patients were counselled for In present study, follow up at 6 weeks, months
postpartum IUCD insertion, out of which 354 and 1 year, leukorrhea and abdominal pain was
patients accepted and were followed up for one- the common side effect followed by bleeding p/v
year post IUCD insertion. (Table 5). No perforation found in present study.
None of the studies as per literature search have
Results reported uterine perforation after PPIUCD
In this study 675 patients were counselled for insertion. Missing string was no problem up to six
postpartum IUCD insertion, out of which 354 month follow up, but it was found in cases at one
[52.88%] of patient accepted the procedure year of follow up.
[Table1]. Out of 354 cases who accepted for The continuation rate i.e. number of women
PPIUCD, majority of patient belong to 26-30 continuing the IUCD inserted in the postpartum
years of age group [51.97%]. Majority of women was 94.61% at the end of 12th month of follow up.
opting for PPIUCD are of middle and low socio- [Table -6]
economic class [64.4%]. This may be due to the In the study it was found that 20 patients removed
fact that these women are taking services more at cu-T, maximum number of Cu- T removed due to
authors setup. In present study, out of 354 patient bleeding p/v and abdominal pain. (each no 4)
greater number of primipara patients are accepting followed by discharge pervaginum (i.e. 2). [Table-
PPIUCD [55.93%] and who were employed 7]
[66.94%]. [Table 2]

Table 1 Characteristics of subjects counselled for IUCD use

Characteristic Antenatal counselling [n %] Postpartum counselling [ n % ] TOTAL
Acceptors 276 [40.98%] 78 [11.70%] 354[52.88%]
Refusers 217 [32.14%] 104 [15.40%] 321[47.55%]
Total counselled 493 182 675

Table 2 Demographic and clinical profile of studied women

S. No. Variables PPIUCD acceptors Acceptance rate
1 Maternal age
<20 22 6.21%
21-25 118 33.33%
26-30 184 51.97%
>31 32 9.03%
2 Maternal education status
No formal education 36 10.16%
Primary 116 32.76%
Secondary 167 47.17%
Higher education 35 9.88%

Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 199

JMSCR Vol||10||Issue||01||Page 197-202||January 2022
3 Maternal socioeconomic status
Upper 126 35.59%
Middle/lower 228 64. 40%
4 Mother occupation
Employed 237 66.94%
Unemployed 117 33.05%
5 Parity
Primipara 198 55.93%
Multipara 156 44.06%

Table 3 Time of insertion of IUCD among patients

TIME OF INSERTION NO OF CASE [%]
Caesarean 99 [27.96%]
Post placental 177[50.00%]
Within 48 hours of delivery 78[22.03%]

Table 4 Distribution based on follow-up of patients after IUCD insertion

TIME INTERVEL NUMBER [%]
After 6 Weeks YES 248[70.05%]
NO 106 [29.94%]
After 6 Months YES 286 [80.79%]
NO 68 [19.20%]
After 1 Year YES 264 [74.57%]
NO 90 [25.64%]

Table 5 Complications of PPIUCD at the time of follow-up visit in one year

COMPLICATIONS No of case
Abdominal pain 14 [3.9%]
Leukorrhea 24 [6.77%]
Bleeding per vaginum 11 [3.10%]
Missing thread 3 [0.84%]
Bleeding and abdominal pain 16 [4.51%]
Expulsion 6 [1.69%]
Perforation 0 [0%]

Table 6 Association between time of insertion and continuation of IUCD

TIME OF INSERTION Continued use of IUCD after 12 months
YES NO
Caesarean 92[25.98%] 7 [1.9%]
Post placental 172[48.58%] 6 [1.6%]
Within 48 hours of 71 [20.05%] 7 [1.9%]
delivery

Table 7 Causes of removal of IUCD over a period of 12 months

Cause of Removal No of case =20
Bleeding P/V 4 [20%]
Discharge P/V 2 [ 10%]
PID/Pain 4[20%]
For Conception 0 [0%}
Othersocial factor 10 [50%]

Discussion about family planning services in order to avoid

The IUCD is a reversible and long-lasting unplanned pregnancy. Women who have been
technique of birth control. The postpartum time counselled for PPIUCD had a 10 times higher risk
allows a healthcare provider to counsel a lady of employing IUCD than those whose insertion

Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 200

JMSCR Vol||10||Issue||01||Page 197-202||January 2022
was postponed until the uterus had completely insertion within the first 48 hours, indicating that
involved.[8] acceptability is higher when insertion is done
Following vaginal and caesarean delivery, the within 10 minutes after placenta delivery. This is
immediate post placental implantation is an similar to Goswami et al's study, which found that
optimal moment to achieve long-term acceptance.[13]
contraception with minimal discomfort to the In this study, 354 patients were observed for six
woman, and it is becoming more popular due to weeks, six months, and one year. At 6 months, 68
its safety and decreased expulsion rates.[9,10] patients had not been followed up on. The
A total of 675 patients were counselled for majority of follow-up is due to improved methods
postpartum IUCD insertion in this study, with 52 and more post-LSCS insertion, as a result of
percent of them agreeing to the procedure. The concerns about post-operative problems. Only 12
majority of them refused owing to a lack of women suffered issues such as leucorrhoea,
knowledge about contraception and a fear of bleeding, pain abdomen, and expulsion when the
complications. Acceptance was based on the fact authors assessed the safety of the PPIUCD. This is
that it was a reversible contraception method. In comparable to the study by Mishra S. Gupta. In a
the current study, women of reproductive age 26- study conducted by A et al in a western Uttar
30 years opted for PPIUCD at a rate of 51.97 Pradesh hospital, 8% of patients reported per
percent, with middle and low socioeconomic class vaginal haemorrhage.[14]
women selecting for PPIUCD at a rate of 64.4 Expulsion of IUCD is a significant aspect that
percent. This could be attributable to a higher affects the device's efficacy. In the current
proportion of lower socioeconomic class patients analysis, 6 (1.6 percent) patients experienced
visiting our hospital. IUCD expulsion with a maximum of 6 to 12
The majority of the women in the sample group months, whereas Celen S et al.[10] had a 17.6
(57.05 percent) had completed at least secondary percent expulsion rate at the end of 12 months.
school. Women with higher and secondary In the current study, 20 patients had their IUCD
education were more accepting of PPIUCD (9.88 removed for a variety of causes, including
percent and47.17 percent). This was comparable bleeding (20%), abdominal pain (20%), others
to a research by Safwat et al [11] and Thomas D[12] (10%), and the remaining (50%) had their IUCD
in Egypt. removed owing to misperceptions such as
Patients were primipara 55.93 percent of the time discomfort and fear of displacement into the
and multipara 44.06 percent of the time. abdomen. Mishra S[15] and Sharma A et al[16]
Primiparas had a higher level of acceptance, found that the cumulative elimination rate was 7%
which aided in optimum birth spacing. Similar and 13.5 percent, respectively, in their studies.
findings were obtained in a study by Maluchuru S Psychosocial issues were the most common
et al, Gautam R et al, and Vidyarama R et al, who reason for removal, followed by menstruation
showed that primipara acceptability was greater at issues and persistent pelvic pain.
15.42 percent, 71.91 percent, and 15.47 percent,
respectively. This is similar to what Grimes et al Conclusion
discovered in their investigation.[2] The current study found that PPIUCD has a high
The acceptability rates for vaginally delivered level of acceptance, which is comparable to other
patients and LSCS patients were 72.03 percent global studies. Despite high acceptance, many
and 27.96 percent, respectively, in this study. women had little knowledge of the PPIUCD. The
Patients delivering vaginally showed higher PPIUCD was unfamiliar to the majority of the
approval with post placental insertion (45.9%), women, and acceptance was higher among
compared to just (3.5%) in the group getting educated women and primigravida. The benefits

Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 201

JMSCR Vol||10||Issue||01||Page 197-202||January 2022
of contraceptive protection outweigh the potential 10 Celen S, Moroy P, Sucak A, Aktulay A,
inconvenience of needing to return for care for Danisman N. Clinical outcomes of early
women who receive PPIUCD. post placental insertion of intrauterine
contraceptive devices. Contraception.
Reference 2004; 69: 279-82.
1. WHO Unmet Need for Family Planning. 11 Safwat A, Mohamed Momen A, Kamel
Available from: Omar M, et al. Acceptability for the use of
http;//www.who.int/reproductivehealth/top postpartum intrauterine contraceptive
ics/family planning/unmet need fp/en. devices: assiut experience. Med Prince
2. LA Lopez. LM Grimes. D. A et all – Proact. 2003; 12: 170–175
immediate post-partum insertion of 12 Thomas D, Maluccio J. Fertility,
intrauterine devices. Cochrane database contraceptive choice, and public policy in
System. Rev 2010:5: CD 003036’. Zimbabwe. World Bank Econ Rev. 1996;
3. Azmat SK, Shaikh BT, Hameed W, 10(1): 189–222.
Bigrami M, Mustafa G, Ali M, et al. Rates 13 Goswami G, Yadav K, Patel A. A
of IUCD discontinuation and its associated prospective study to evaluate safety,
factors among the clients of a social efficacy and expulsion rate of post
franchising network in Pakistan. BMC placental insertion of intra uterine device. J
Women’s Health 2012; 12:8. Evol Med Dent Sci. 2015;4(56):9770.
4. IUD Guidelines for Family Planning 14 Gupta A, Verma A, Chauhan J. Evaluation
Service Programs. Available from: of PPIUCD versus interval IUCD (380A)
http://www.jhpiego.org/files/IUD_ insertion in teaching hospital of western
Manual_0.pdf. Uttar Pradesh. Int J Reprod Contracept
5. Grimes DA, Lopez LM, Schulz KF, Van Obstetric Gynecol. 2013;2(2):294-8
Vliet HA, Stanwood NL. Immediate post- 15 Mishra S. Evaluation of safety, efficacy
partum insertion of intrauterine devices. and expulsion of post placental and Intra
Cochrane Database Syst Rev. caesarean insertion of intrauterine
2010;5:CD003036. contraceptive devices. J Obstetric Gynecol
6. Long-term reversible contraception. India. 2014; 64(5): 337–43.
Twelve years of experience with the 16 Arti Sharma, Vineeta Gupta, Neeta Bansal,
TCu380A and TCu220C. Contraception. Utkarsh Sharma ,Archna Tandon.A study
1997; 56:341–352 of immediate postpartum intra uterine
7. Megha Sharma, Shubham Joshi, Obey device insertion in a tertiary level hospital
Nagar, and Akash Sharma J Obstetric International Journal of Research in
Gynaecology India. 2014 Jun; 64(3): 208– Medical Sciences Sharma A et al. Int J Res
211. Med Sci.2015 Jan; 3(1): 183-187.
8. Thonneau P F, Almont T. Contraceptive
efficacy of intrauterine devices. Am J
Obstetric Gynecol. 2008; 198(3): 248–53.
9 Xu J X, Reusché C, Burdan A. Immediate
post placental insertion of the intrauterine
device: a review of Chinese and the
world’s experiences. Adv Contracept.
1994; 10(1): 71–82.

Shanthi Ponusamy et al JMSCR Volume 10 Issue 01 January 2022 Page 202