Postplacental Intrauterine Device Insertion: A Mixed Methods Assessment of Women's Experience

Postplacental IUD insertion following vaginal or cesarean delivery is as effective in preventing pregnancy as interval insertion, and it is utilized more often in other countries such as China, Mexico and Egypt compared with the US (Celen, Moroy et al. 2004; Eroglu, Akkuzu et al. 2006; Kapp and Curtis 2009; Grimes, Lopez et al. 2010). In addition, current evidence supports the safety and superior cost effectiveness of IUD use (Trussell, Lalla et al. 2009; ACOG 2011). Postplacental IUD insertion is practiced routinely in US hospitals with active family planning faculty (including University of New Mexico Hospital), and has become standard of care for postpartum contraception options counseling in these institutions. Despite ample evidence supporting the safety and effectiveness of postplacental IUD insertion, the practice is uncommon among US providers and many women remain unaware of this option. Reasons for underutilization in the US may include lack of reimbursement, sufficient provider knowledge and training, and patient awareness.

Postplacental IUD insertion is also an attractive method for provision of postpartum contraception for several reasons: women are motivated to initiate contraception, they are not pregnant, and access to medical care is readily available.

Pain is a subjectively complex and universal experience which encompasses more experiential aspects than objective measurements of physical pain can capture. We know that interval IUD placement is painful, and that anxiety and fear of pain can be a barrier to IUD uptake, particularly among adolescent women (Allen, Bartz et al. 2009). Pain and low satisfaction with the IUD insertion procedure may limit patients' endorsement of the method to other women. There is insufficient research examining the patient's subjective experience with postplacental IUD placement. In addition, there is limited data about the physical pain level associated with postplacental IUD insertion.

Several studies have examined the efficacy of interventions to reduce pain for interval IUD insertion for nulliparous and multiparous women (Hubacher, Reyes et al. 2006; Edelman, Schaefer et al. 2011; Maguire, Davis et al. 2012; Swenson, Turok et al. 2012). Procedural aspects and clinical circumstances of postplacental IUD insertion differ substantially from those associated with interval insertion, preventing extrapolation of findings from studies of interval IUD insertion to postplacental insertion.

Specific aims:

1. Obtain an understanding of women's experiences with ring forceps postplacental IUD insertion through semi-structured interviews conducted prior to discharge from the hospital.
2. Establish objective assessments of physical pain associated with ring forceps postplacental IUD insertion using the 100mm Visual Analog Scale (VAS) and a categorical Verbal Rating Scale (VRS).

Participants will be recruited within the third trimester of pregnancy, when standard counseling typically occurs to address postpartum contraception options with patients; this usually occurs at 30 weeks gestation or later. The pain score assessment and interview data collection for each participant will take place while the patient is admitted for vaginal delivery at the University of New Mexico Hospital (UNMH).

The primary and secondary endpoints will occur at the conclusion of study enrollment when the last postpartum interview has been completed (when we have reached thematic saturation), and when we have at least 30 pain score assessments for the epidural and no epidural groups. The study is not designed to detect a difference in VAS scores between those women who have an epidural and those who do not (a power analysis was not performed), but rather this secondary objective is intended to establish the mean VAS score for each group. Because women will not know for certain if they will elect a labor epidural at the time of antenatal recruitment and because some women may not get undergo postplacental IUD placement for obstetric reasons (e.g., chorioamnionitis, postpartum bleeding, etc), it may be necessary to recruit more women than needed to achieve 30 women for each group. Up to 175 women will be recruited in the study.

When a participant presents to UNMH L\&D to deliver her baby, we will confirm her ongoing desire to participate in the study, and will review the expectations for participation. We will confirm that the subject continues to meet the inclusion and exclusion criteria. Following vaginal birth, all eligible participants will undergo postplacental IUD insertion using the standardized ring forceps technique under ultrasound guidance, within 10-30 minutes of vaginal delivery, per standard of care for this procedure.

We will obtain a VAS and VRS score after the placenta delivers and prior to inserting the IUD, and a second set of scores within 5 minutes of insertion. We will assess provider ease of procedure using a four-point Likert scale. Prior to discharge from the hospital, we will confirm that subjects remain willing to participate in the postpartum interview portion of the study. If they elect to continue participation, they will undergo a semi-structured interview designed to explore their perceptions of the postpartum IUD insertion experience. Participants will have an appointment with their primary obstetric providers within two weeks of delivery for an IUD string check, per standard of care. We will not collect data from the postpartum IUD string check visit.

Data will be managed with the following methods: 1) Only the research team will have access to the data; 2) The data will be stored separately from consents; 3) Data sheets will be coded with the participant's assigned study code.

Data will be stored using the following methods: 1) The UNM Redcap database reposing study data will not contain unique patient identifiers; 2) The database for both quantitative and qualitative data will be stored on a secure, password protected server; 3) The identifiers will be linked to the patient's code number on a spreadsheet in a secure, designated password protected computer in the UNMH Ob-Gyn Department.

Data will be destroyed using the following methods: 1) Audio recordings of the interviews will be erased once they have been transcribed; 2) The link between study code and unique participant identifiers will be destroyed when the study is closed through the UNM Human Research Protections Office; 3) Study records will be kept for a minimum of three years; 4) HIPAA authorizations will be retained for a minimum of six years.

This study poses not more than minimal risk to subjects. There is a small risk that protected health information will be identified with study data. Study participation may be considered inconvenient by subjects.

The subjects will be permitted to withdraw from the study at any time without any effect on their access or options for care. The investigators have the right to end a subject's participation in this study if they determine that she no longer meets inclusion or exclusion criteria or if they, for whatever reason, believe that it is not in her best interests to continue participation. The investigators may also withdraw a subject if they determine that the subject is not following study protocol.

No further data collection will occur on a participant who withdraws from this study. The Institutional Review Board (IRB) will be notified of such withdrawals per IRB protocol.