**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 [32–35].
