**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

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

**Figure 1.**

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

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effective and safe contraceptive method rather than as indicated by the individual patient's circumstances and needs (unpublished data).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,


#### **Figure 2.**

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

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

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].
