**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

### *Barriers and Challenges in the Acceptance and Continuation of Postpartum Intrauterine… DOI: http://dx.doi.org/10.5772/intechopen.112366*

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.

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

#### **Figure 3.**

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

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. Posttraining 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.
