Barriers and Challenges in the Acceptance and Continuation of Postpartum Intrauterine Contraceptive Device

Abstract

Postpartum family planning (PPFP) interventions have immense potential to address the unmet contraceptive need in women from the time their baby is delivered till a variable period in their reproductive span. Postpartum intrauterine contraceptive device (PPIUCD) is one among the birth-spacing and birth-limiting contraceptive options. They have most attributes of an ideal contraceptive providing prolonged contraception akin to permanent contraceptives with scope of reversibility should the reproductive intentions of the couple change in future. This appeals to the societies and religious communities, who oppose permanent contraception. However, the acceptance and long-term continuation of the IUCD remains limited to and fails to total fertility rates (TFR) in populations who need it most. Global studies indicate this is often due to service providers’ adverse negative perception of PPIUCD, poor counseling skills, lack of technical skills in its insertion, and logistical limitations in various health facilities where deliveries occur, as well as the women’s and their family’s perspective about it rather than any intrinsic adverse characteristic of the device. The chapter is discourse about PPIUCD from multiple dimensions to define the barriers and challenges to its use in current practice. Interventions suggested may be incorporated into the national PPFP policy and program implementation as it is rolled out as a sustainable population control measure with far-reaching implications.

1. Introduction

The postpartum period in the lives of women in the reproductive age group is characterized by certain features, which are related to her future reproductive performance. She is vulnerable to the risk of an unintended pregnancy (!! surprise/? shock pregnancy), especially in the first year postpartum. This is because she has the common misconception that as long as she breastfeeds her infant, she cannot get pregnant. She is unaware that factors such as the duration and frequency of breastfeeding and any supplementary top-up feeds she may be giving to her child affect the time when ovulation may be resumed postpartum. Such factors account for the unpredictability of the resumption of ovulation and menstruation [1]. Coupled with this is the fact that most couples resume coital relations within a month of delivery [2]. The combined impact of these factors is that the woman is exposed to the risk of a subsequent pregnancy before the optimal delivery-conception interval, thus shortening the inter-delivery interval as well. Such closely -spaced pregnancies are contrary to the recommendations of the World Health Organization (WHO) regarding birth spacing [3]. Data from India show a huge unmet need of contraception as high as 65% in the first postpartum year (USAID India, 2009). Similarly, National Family Health Survey (NFHS), 2005–2006 also showed similar findings in relation to postpartum contraceptive usage as a result of which 65% births occur within 36 months of the previous birth. Similar situation is present in countries such as Pakistan [4, 5].

2. Health, economic, and other societal impact of unmet need for contraception

Postpartum family planning (PPFP) contraceptive options are an effective strategy to reduce this unmet need for contraception [3]. This has the potential to have short-term and long-term impacts on the total fertility rate (TFR) of populations, as well as their maternal, neonatal, and infant morbidity and mortality statistics [6].

PPFP reduces not only the family size but also the number of women seeking induced abortion. However, due to gaping lacunae in PPFP service delivery in LMIC women often suffer from morbidity and mortality related to complications of induced abortion. Women who conceive very soon after childbirth often become aware of their current pregnancy in the late first trimester, or even in the second trimester when she notices a lump in her lower abdomen. She may even have perceived fetal movements. If she has lactational amenorrhea missed periods will not indicate to her that she may be pregnant. If she does not want to continue such late-diagnosed pregnancy the termination itself becomes a protracted and unsafe procedure. Very often such women in their desperation turn to unqualified untrained persons to terminate their pregnancy often in suboptimal settings and beyond the safe limits of pregnancy termination.

If such women who are often multiparous die during the termination they leave behind young children whose care and upbringing are affected having disastrous consequences for their families and the society at large.

3. Status of copper IUCDS as a contraceptive option

The copper-containing intrauterine contraceptive device (Cu T IUCD) in its various designs has been available globally both in the government sector and in private health facilities for several decades. In government facilities, the IUCD is provided free of cost. In private facilities, social marketing strategies often make it available at very subsidized rate so that it becomes affordable for the user. However, the timing of its insertion was restricted to the interval period (i.e. between pregnancies and interval insertion) or immediately following pregnancy termination (post MTP insertion). Apart from registered medical practitioners and specialist obstetricians and gynecologists, nurses and auxiliary nurse midwives trained in insertion procedures were delegated the task of interval IUCD insertions as part of task shifting /sharing approach in the health service delivery system. However, this timing and strategy of contraceptive provision failed to cater to the unmet contraceptive needs of the vulnerable postpartum women. An unintended pregnancy for such women poses risks for their own health as well as that of their children [7, 8, 9].

Technical experts on reproductive health and contraception reached the consensus that health care providers (HCP) had the opportunity for IUCD insertion in the immediate postpartum period when the parturient/puerpera was still within a healthcare facility. The delivery site could function both as an institutional delivery setup and contraceptive provision center. Since the commencement of this millennium, this strategy has been rolled out in several low- and middle-income countries (LMIC)—first as pilot projects in a few targeted centers with high delivery rates and then introduced into health facilities at various tiers of health care delivery system [10].

The FIGO initiative is the largest intervention study to date which examined the feasibility and efficacy of PPIUCD as a contraceptive option provided in the basket of choices offered in government hospitals in six LMICs in Asia—India, Nepal, Bangladesh, Sri Lanka, Tanzania, and Kenya [11, 12, 13, 14, 15]. The study highlighted certain important observations related not only to the satisfactory rating of the PPIUCD as an effective contraceptive option for women having institutional delivery but also how task-sharing by specialist obstetricians, general duty medical officers trained in vaginal delivery, and staff nurses, and midwives could dramatically increase the number of women who could avail the benefits of the IUCD and leave the health care facility with a highly effective and safe contraceptive option in place in order to protect them from unintended pregnancies. Community health workers like dedicated family planning counselors and ASHAs (accredited social health activists) in India who are oriented and trained in contraceptive counseling can effectively contribute to demand generation in the community for PPIUCD acceptance and continuation.

4. Status of PPIUCD as a viable popular contraceptive option.

PPIUCD has an established reputation as an efficient, safe, reversible, long-acting nonhormonal contraceptive. It is also cost-effective and readily available, with a short learning curve for service providers to learn its insertion technique [16, 17, 18, 19]

Despite the promising results elicited by the FIGO endeavor and government enthusiasm and support in the participating six countries, PPIUCD remains an under-utilized contraceptive option and falls short of expectations in lowering fertility rates in those populations, where it is most needed. A recent systemic review on the utilization of PPIUCD globally comes to the conclusion that despite its safety and efficacy it remains an underused contraceptive option [20]. It concludes with the observation that future research is warranted and vital to explore the reasons behind these discouraging trends and the low acceptance and provision of PPIUCDs currently. The analysis needs to be in various dimensions including the innate characteristics of the device and the logistics of its availability and utilization by the service providers. Without an in-depth analysis, it would not be prudent for governments to withdraw it as a freely available, free-of-cost/subsidized option in the contraceptive basket provided by government and private health care setups.

5. Factors affecting contraceptive usage

Various studies have shown that the acceptance and continuation of any contraceptive method is directly related to the efficacy of method counseling, availability and cost of the method, and quality of the involved service delivery system. Given the rigorous quality assurance standards to which Cu-T devices were subjected before being launched as a globally highly-rated contraceptive method, it is imperative to critically examine the service delivery systems in place in various countries. These logistics may be the actual determining/influencing factors affecting the uptake and continuation of PPIUCD in LMIC [21].

6. Women’s expectations from a contraceptive method

After having experienced a pregnancy and birthing experience—either vaginal or abdominal—most women would personally prefer to defer any subsequent pregnancy. Whether she can avail of any contraceptive method or not is another issue, which contributes to the proportion of women who have an unmet need for contraception in the postpartum and subsequent period when she resumes coital relations. During this phase of her life, the expectations of women from any contraception, which she would like to use include the following:

1. Protect her against any unwanted and/or mistimed pregnancy

2. Maintain her normal menstrual cycle and flow pattern

3. Not have any effect on her lactation

4. Cause no/minimal side effects

5. Not have any serious adverse effects for her general health

6. Not adversely affect any co-morbidities she may be having concomitantly or their management (Table 1).

Success rate	At par with oral contraceptives, injectables, sterilization
Ectopic pregnancy	<1 per 1000 years of use
Reversal of fertility	Immediately on removal of device
Effect on lactation	None
Need for follow-up visits	Initially after a month at regular postnatal visit, then annually till effective period of contraception lasts when woman can have repeat insertion if desired
Post-insertion abdominal/ pelvic pain or discomfort	Co-exists with after-pains of delivery and woman not unduly concerned
Heavy/irregular vaginal bleeds	Lactation delays menstruation; if periods later bothersome most women respond to conservative management like tranexamic acid and hematinics
Acceptability in communities who eschew permanent contraception	High
Shelf life	Long (5–10 years)
Learning curve for service providers	Short
Cost- effectiveness	High
Instruments needed for insertion	Cheap, minimum number, readily available, reusable, easily sterilized
Anesthesia at vaginal insertions	None
Removal	Usually easy, in OPD, without anesthesia

Table 1.

Positive attributes of PPIUCD as a contraceptive.

7. Attributes of an ideal contraceptive

Historically, and even up to current times, the search for an ideal contraceptive method/device continues and remains incomplete and unsuccessful—a single method, which would be acceptable to all women who need and desire contraception globally in developed and developing countries across the board. Given the expectations of the users (male and female clients), service providers, government, and private agencies involved in the logistics and financial aspects of contraception provision, as well as other stakeholders; any contraceptive method should have the following attributes to qualify for the epithet of an ideal contraceptive method:

1. Success rate approaching 100%

2. Minimal chances of ectopic pregnancy in the event of contraceptive failure

3. Minimal or no change from normal menstrual cycle or flow pattern

4. Not have any bothersome side effects disrupting her usual life pattern

5. Not have life-threatening or serious morbid risks for any other systems

6. Not have any adverse impact on any concurrent morbidities she may be suffering from or affect its management

7. Convenient to use for the client

8. Not affect her fertility in the future with easy quick return to fertility on stoppage of use

9. Minimal difference between the success rate for perfect use and typical use

10. Be available either free or at subsidized rates by social marketing

11. Be readily available at government setups and retail over-the-counter outlets

12. Should not place an economic burden on the health services of the government at the expense of other services to be provided by the government also as part of its national health policy

13. Counseling and usage skills are easy to learn by the service providers and support staff involved in contraceptive counseling

14. Long shelf life to reduce wastage of contraceptive resources

15. Should not interfere with normal sexual drive and couple sexual relation [22]

Given these varied aspects of contraceptive usage and provision coupled with the fact that the contraceptive needs and choices of males and females are not constant throughout their reproductive phase of life the search for the single “ideal contraceptive” for all women remains elusive akin to a mirage. It is more reasonable, practical, and feasible to tailor and customize the chosen contraceptive to the dynamics of the user’s needs, health, and financial status. The PPIUCD to a large extent provides these benefits [23].

8. Who medical eligibility criteria and PPIUCD

The WHO medical eligibility criteria guideline is a useful clinical tool for contraceptive service providers and counselors. It is available as easy to use “wheel,” which should be provided in the contraceptive basket of choices discussed with the clients, whenever they make their contraceptive decisions and choices (Figure 1a and b).

Figure 1.

(a) WHO medical eligibility wheel for contraceptives (front) (b) WHO medical eligibility wheel for contraceptives (back).

Against this backdrop, the PPIUCD measures high as a suitable contraceptive for a large section of women for a long period of their life. The following attributes of the PPIUCD have the potential to make it a popular choice for women starting from the immediate postpartum/post abortal/post MTP period to a variable period in months or years depending on the circumstances of the user (Table 1).

9. Barriers to acceptance of PIUCD

Despite so many positive attributes of an ideal contraceptive, the PPIUCD has not lived up to the expectations of family planning proponents and those who frame health policies and programs. PPIUCD has not gained the expected widespread acceptance and popularity to have a forceful impact on the fertility indices of most countries, which are hard-pressed to rein in their booming population growth. The reasons contributing to this “below expected” performance need to be examined both by the service providers at the individual and institutional level, as well as the policy makers and funding agencies, which have invested in PPFP and PPIUCD programs in various countries. In most LMICs, use of IUCDs remains extremely low often below 1% [24, 25].

It is a sobering and undeniable fact that the attitude and enthusiasm of any intervention or procedure are directly related to its frequency and appropriateness of use. The author has direct experience of how lack of enthusiasm and unstructured protocol for counseling and provision of PPIUCD in a tertiary care center for institutional deliveries caused the PPIUCD program to nosedive to no insertions after vaginal deliveries and skewed insertions at cesarean sections depending on the enthusiasm and motivation of the surgeon performing the cesarean section toward PPIUCD as an effective and safe contraceptive method rather than as indicated by the individual patient’s circumstances and needs (unpublished data).

Several studies have examined the perceptions of service providers and allied health workers, as well as users’ perceptions about PPIUCD as a contraceptive option. A study by Singh et al. in Bihar, an economically less developed state of Eastern India with high total fertility rate, concluded that the major barriers for acceptance of PPIUCD by the section of the population who were eligible to use it were lack of awareness about PPIUCD, preference for another method vis-a-vis PPIUCD based on personal experience or on shared experience of friends and family users who influenced their choice, husband or family members’ disapproval, social or religious taboos, rumors, fears, myths and misconceptions(cancers, migration of PPIUCD to other body organs), past or current health problems or fear of side effects due to a foreign body lodged within their womb. These factors also contributed to the significant removal and discontinuation rates, which were as high as 25.9% in the above-mentioned observational study and damped the success rate of PPIUCD as a game-changer in PPFP initiatives of the government overall [26].

The PPFP index is predicted by descriptive norms, perceptions of the larger community’s approval or disapproval of a particular method, normative expectations, rejection of PPFP myths and misconceptions, perceived behavioral control by the user, self-efficacy, and autonomy in making reproductive choices. Normative expectations regarding PPFP intentions vary across ethnic groups and societies. Governments need to acknowledge these sociological determinants and variations while working on the policy and program evolution strategy by integrating norm-based and empowerment strategies [27].

The integrated behavior model (IBM), which is derived from theory of personal belief (TPB) and theory of reasoned action (TRA), provides a valid framework for developing PPFP programs including PPIUCD protocols (Figure 2) [27]. It delineates the socioeconomic influences and demographic variables that operate through an individual and their family to shape/define their behavioral intentions collectively. A study from Nigeria reinforced such premises in relation to the PPIUCD. Generally, injunctive norms have a negative impact and descriptive norms have a positive impact in reproductive choices. Peer norms and social norms similarly affect a person’s choices in such matters. In the patriarchal society, prevalent in many LMIC reproductive decisions are not solely made by the woman. It is usually a shared family decision in which often the will and voice of the woman is the feeblest [28].

Figure 2.

Integrated behavioral model of postpartum family planning use. https://doi.org/10.1371/journal.pone.0254085.g001 [11].

10. Administrative and community interventions to increase PPIUCD acceptance

To translate PPFP attitudes into specific messages that can be tested and refined before being scaled up into the target population, it would be useful for programs to deliberate on which myths and misconceptions are most associated with PPFP intentions in a given society and to develop culture appropriate IEC materials to persuade the target population to modify or reverse their current behavior in that respect. This can be done by popular role models and brand ambassadors with similar cultural experiences and values who would be instrumental in dispelling negative perceptions. Involvement of spouse and dominant family members in the decision-making dialog with health service providers and counselors will also contribute to reaching out to the eligible women to try PPIUCD as their long-term contraceptive option. Group counseling and peer discussions also increase confidence among users and would be users [29]. Joint decision-making by couples has also been shown to increase rates of acceptance of PPIUCD [29].

Community engagement and community-level reflection of prevailing societal practices and perceptions in order to root in PPFP into their regular reproductive lifestyle, and value system is also bound to give dividends. Facilitating young women’s education and employment opportunities also empowers them to make such personalized choices, which first and foremost directly affect their health and well-being [29].

11. Barriers to PPIUCD usage at service provider level

Service providers who insert PPIUCD in the labor room, postnatal ward, or at cesarean section have varied experiences with the insertion procedure. Hence, perception regarding the efficacy and safety of PPIUCD as an option in the contraceptive basket is varied among different levels of service providers. Those who were not trained by participation in a formal training program using simulators followed by in-house training in real patients often inserted the device manually following placental delivery. Also, they were not conversant with the universal infection prevention practices and the aseptic and antiseptic precautions mandated before and during insertion of the IUCD. This may account for complications associated with PPIUCD use, which often necessitated its removal. This defeats the very purpose and benefits of PPIUCD as a long-acting reversible contraceptive (LARC). Inadequate training also leads to improper non-fundal placement of the IUCD, which is responsible for the high percentage of complete or partial expulsion intrauterine translocation causing uterine cramps or a length of IUCD thread reaching low into the vagina causing anxiety and discomfort to the woman and her spouse. Such service providers include staff nurses and auxiliary nurse midwives (ANMs) who admit lack of confidence in the procedure and therefore avoid the insertion within the stipulated time limits for postpartum insertion and postpone it for a later period. Such women who are eligible for contraception may or may not return for contraceptive provision later. This contributes to a substantial percentage of the unmet need for contraception in willing women who are vulnerable to unwanted too early subsequent pregnancies. This is a missed opportunity for providing them a reliable contraception, and they have not come back into the health care system for family planning counseling and services. Several studies have defined the health care-seeking behavior of in lower income populations as “crisis-oriented,” that is they return to health facilities only if they need curative services and not for preventive services such as using a contraceptive method [30].

Similarly, at cesarean section, there is lack of uniform technique in putting in an IUCD. Some surgeons do it manually, and others use the applicator provided in the pack. What is important to be noted, especially if the device has been placed by junior surgeons who usually man the labor suites, whether the placement is at the uterine fundus in the coronal section of the cavity. Also, the direction in which the tip of the thread is pointing is also important if the tip curls up toward the fundus instead toward the external os the incidence of “missing thread” at subsequent follow-up visit becomes correspondingly high. This is a cause of worry both to the user and the service provider since in the event of irregular or heavy vaginal bleeding or infection–associated complications or if for any reason the woman insists on removal of the device the procedure becomes cumbersome. Often, a simple probing of the cervical canal with an artery forceps in the outpatient clinic is not successful in accessing the thread and frequently necessitates taking the woman to the operation theater to retrieve the device under general anesthesia often with special device retrievers. Such an intervention in a scarred uterus is itself fraught with dangers combined with the risks of G.A. This mars the confidence of the service providers who tend to eschew further intra-cesarean PPIUCD in subsequent patients. However, as for vaginal insertions, what is important is proper evidence-based training in the insertion technique rather than decrying the indication and timing of the insertion itself [31].

Apart from the faulty technique of insertion, another very important factor negatively affecting the acceptance of PPIUCD by women is the inappropriate counseling provided to them about the method in terms of timing, content, and manner of counseling. The various aspects related to PPIUCD should be discussed at antenatal visits. This is the time when women and their families are most likely to understand its various aspects and implications, voice their doubts, and concerns and make a truly informed choice. However, due to the enormous workload on the obstetricians, midwifery, and nursing staff, as well as a dearth of dedicated FP counselors who have the requisite skills and sole specific responsibility to familiarize women about their various contraceptive options many antenatal clients do not have the benefits of such structured contraceptive counseling. This causes a sharp reduction in the number of puerperal women accepting PPIUCD in the immediate postpartum period when they are still in the delivery facility. In hospitals where regular antenatal checkups are combined with repeated FP counseling the uptake of PPIUCD has been shown to be substantially higher with better long-term continuation rates also [32, 33, 34, 35].

12. Interventions to remove service provision barriers to PPIUCD services

In order to simplify the procedure of the vaginal insertion, dedicated PPIUCD inserters have been devised which simplifies and ensures the fundal placement with minimal risk of uterine perforation [36, 37]. The complicated cumbersome steps of uterine axis straightening by abdominal man oeuvres followed by rotation of the IUCD into the coronal plane at the fundus are circumvented in this straightforward method. This enhances the confidence of the service providers who use it in the labor room (Figure 3). The total cost of the inserter including the device is less than 1US dollar, making it a very cost-effective device comparing very favorably with other methods [38]. However, it is available at some centers only, and hence insertion continues to be predominantly with the help of Kelly’s placental.

Figure 3.

Comparison between copper T 380A IUCD with standard inserter and with a dedicated PPIUCD inserter.

Considering the long-term economic benefits of an efficient national population policy with its resultant population stabilization effects on the overall nation’s economy, IUCDs are being provided free of cost at government health facilities of many LMICs such as India. Also, at several private delivery facilities, they are available at subsidized rates through social marketing schemes and strategies, thus making it affordable and accessible to a greater reach of population in such countries.

At cesarean section also it is important to emphasize to the junior surgeons and trainees who do the bulk of abdominal deliveries at the tertiary level care centers the need to ensure that the device has to be advanced through the uterine incision up to the fundus, ensuring that the device is left flat in the cavity in the coronal plane of the uterus and that its tail tip is directed toward the os. Also, once the IUCD is in situ at the fundus, there should be no further exploration or mopping of the uterine cavity, which would be likely to dislodge it from its proper high position. This will ensure proper placement and retention of the device as also ease of removal if it is required in any circumstances. Some surgeons have introduced techniques for intra-cesarean PPIUCD insertion to eliminate chances of expulsion of the device at any later date. One such technique is to anchor the device to the fundus with a catgut knot with the help of a straight needle passing through the fundus [37, 39].

One of the major reasons why service providers—general duty doctors and staff nurses working in labor wards, specialist obstetricians, midwives, and auxiliary nurse midwives— desist from inserting PPIUCD is lack of training and subsequent hand-holding in the early days of their post-training period. To address this issue nongovernmental agencies, such as JHpiego, United States Agency for International Development(USAID), and maternal and child health integrated program(MCHIP), have extended their support to several LMICs and pitched in with them to train obstetric personnel in correct standardized PPIUCD counseling method, insertion technique, infection prevention practices (IPP), follow-up protocol, and management of post-insertion problems and complications. They have developed learning resource packages (LRP), job aids, behavior change communication (BCC), materials and toolkits in order to streamline counseling messages and insertion techniques across centers providing PPIUCD services. Training are imparted at regional and nodal centers initially to some medical and nursing staff of a delivery site. Their competency is determined on the basis of checklists of the various competencies; they have achieved in order to effectively and safely provide PPIUCD services at their workplace. Post-training these trained personnel start PPIUCD services at their workplace. A cascade effect of such formal training ensues as the few personnel who attend such formal training at nodal and regional training centers go back to their parent institutions and are in a position to do in-house training and supervision in PPIUCD counseling and insertion of their work colleagues there. Such initiatives have been shown to increase rates of PPIUCD acceptance and continuation rates with very low rates of reported expulsion (2.5%), infection (0.9%), and removals (4.2%). The efforts of such agencies, which extend technical training support, are laudable since they continue to support them at their workplace. They maintain their communication lines with them so that in the event of any difficulty they feel supported. This is a very important confidence-building measure for the staff especially those working in remote isolated places [33].

Maintenance of quality performance standards is done by regular audits of the PPIUCD documentation and records. During training service providers are also trained in record-keeping related to PPIUCD service. This helps in assessment of service delivery quality in terms of client follow-up data relating to expulsions, infection, request for removals, and overall patient satisfaction with respect to the device, service provision center, and the service provider. Client follow-up is done either at the time of their follow-up visits at the health care facility or telephonically if they do not report back. Monitoring of PPIUCD programs through audits helps gap analysis of the services being currently provided at a center, and how services could be improved both in terms of quality and number of insertions.

Demand generation can be enhanced by hiring and training dedicated counselors who are provided with job aids and IEC materials, which have been customized to culturally and linguistically appropriate standards. A cafeteria approach during family planning counseling sessions will allow women to make a truly informed contraceptive choice. PPIUCD has the potential to satisfy the requirements of many primipara and multipara women following delivery.

Supply management in government facilities needs to be bolstered to prevent stock-outs. This will ensure that supply meets demand, otherwise, it may lead to unmet need for contraception for women who are keen to prevent pregnancies. In women seeking contraceptive provision in private facilities vouchers, social marketing campaigns, and mobile service delivery systems can ensure availability and affordability for them.

An increase in number of service providers trained in PPIUCD counseling and insertion skills can be done by regular training-of-trainers sessions. Updated guidelines and incorporation of PPIUCD in regular medical curricula will also improve the service delivery system by increasing the number of service providers.

13. Conclusion

Despite WHO evidence-based recommendations of birth–spacing of at least three years, PPFP remains a neglected area in obstetrics, especially in developing countries with burgeoning population. However, during the last two decades, there has a resurgence of interest globally in the use of the IUCD during the immediate postpartum period within forty-eight hours of delivery when the woman is still within the delivery site. FIGO’s initiative in popularizing it in six LMICs as a viable PPFP option in the contraceptive basket has been strengthened by nongovernmental organizations, such as JHpiego, USAID, PSI, and MCHIP. They are collectively extending technical and training support to various governments in southeast Asia and sub-Saharan Africa who have recognized the immense potential in promoting their respective national population control policies and programs.

As for any program launched on a widespread scale, PPIUCD FP program also requires robust field data pertaining to the users, as well as service providers, administrative, and budgetary cells in order to evaluate, whether it is performing satisfactorily as regards its expected primary and secondary related outcomes. Accumulated data from systematic reviews on the topic indicate that the main barriers and challenges in increasing acceptance and continuation of PPIUCD are low awareness, and hence demand for its use by prospective clients. This is coupled with low motivation, poor counseling and technical skills, and confidence of service providers in its insertion. Other issues of concern relate to supply chain, which has to be addressed by policy makers and health and FP budget planners.

From whatever data that have accumulated from diverse LMIC populations PPIUCD despite its “below expected” success in lowering TFR remains a promising PPFP option for eligible women provided it is backed up by proper IEC strategies coupled with training in quality counseling and insertion skills and practice by the service providers. Individual prejudices based on limited personal experience and opinion need to be aggressively curtailed in order to prevent reduction in rates of user acceptance of a very useful contraceptive method. Future research in the individual country specific contexts should be directed at obviating such obstacles for the wider use of this effective PPFP method, which has the benefit of being an extremely effective LARC, which compares favorably with permanent birth limiting methods.