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Abstract
Background Immediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited. The objective of this qualitative evaluation was to explore the views and experiences of obstetricians and midwives providing PPIUD within a UK maternity setting, in order to identify areas for improvement and inform service provision in other areas.
Methods Qualitative health services research within two public maternity hospitals in Lothian (Edinburgh and surrounding region), UK. Interviews with 30 maternity staff (obstetricians n=8; midwives n=22) involved in PPIUD provision. Data were analysed thematically.
Results Maternity staff were positive about the benefits of PPIUD for women. Midwives reported initial concerns about PPIUD safety, and the impact on workload; these views shifted following training, and as PPIUD was embedded into practice. Having a large pool of PPIUD-trained staff was identified as an important factor in successful service implementation. Having PPIUD ‘champions’ was important to address staff concerns, encourage training uptake, and advocate for the service to ensure continued resourcing.
Conclusions PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. We emphasise the importance of widespread engagement around PPIUD among all healthcare professionals involved in the care of women, to ensure staff are informed and supported. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.
- health services research
- qualitative research
- long-acting reversible contraception
- intrauterine devices
- medicated
- copper
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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- health services research
- qualitative research
- long-acting reversible contraception
- intrauterine devices
- medicated
- copper
Key messages
Postpartum intrauterine device (PPIUD) provision can help address unmet need for effective contraception in the postpartum period. PPIUD-trained obstetricians and midwives recognised the benefits for women, and in enhancing holistic maternity care.
Concerns around PPIUD were identified among maternity staff during the implementation process, but shifted over time as benefits to women, staff and services were realised.
PPIUD ‘champions’ play an important role in engaging maternity staff in PPIUD training and service delivery, and in advocating for continued resourcing of the service.
Introduction
Short inter-pregnancy intervals (<12 months) are linked to poor outcomes for mother and child.1 Research evidence suggests that conception within 1 year of childbirth is common, with one UK study finding that around 1 in 13 women giving birth or presenting for abortion had conceived within the last 12 months.2 The importance of providing women with immediate postpartum contraception, including long-acting reversible contraception (LARC), is supported by evidence that demonstrates it can reduce the incidence of short inter-pregnancy intervals and unintended pregnancy.3 4 The COVID-19 pandemic has underscored the benefits of provision of immediate postpartum contraception; disruptions in access to contraception in the community, and reductions in face-to-face appointments, demonstrate the importance of encounters with maternity staff who can provide effective postpartum contraception.5
In the UK, contraception and maternity care are provided free-of-charge by the National Health Service (NHS); however, challenges with integrating services persist, particularly for contraceptive methods such as intrauterine devices (IUDs) that require insertion by trained healthcare providers. Women choosing an IUD typically have the device inserted no sooner than 4 weeks after giving birth, and the requirement to attend a clinic for insertion creates a potential barrier to access.6 The option of IUD insertion within 48 hours of childbirth – immediate postpartum intrauterine device (PPIUD) insertion – offers women an alternative, and has consistently been shown to be a safe7–9 and convenient option.10
In July 2015, PPIUD at caesarean delivery was introduced across NHS Lothian maternity services (Edinburgh and surrounding region), UK. In this region, there were 8350 births in the year 2018/2019.11 Antenatally, all women receive contraceptive counselling from a community midwife, including the option to receive a copper IUD or levonorgestrel intrauterine system (IUS) immediately after vaginal or planned caesarean birth. Vaginal PPIUD insertion, performed by both midwives and obstetricians, was introduced in 2017.12 The feasibility and acceptability to women of providing PPIUD, and the process of service implementation, are reported elsewhere.10 12–14
This article reports on a qualitative evaluation exploring the perspectives of maternity staff involved in providing PPIUD, with the aim of informing PPIUD provision in maternity services in the UK and other countries.
Methods
The qualitative evaluation explored two key research questions: What are the views of maternity staff towards PPIUD, and their role in its implementation? What areas for service improvement do staff identify in relation to PPIUD service provision?
Between August 2017 and October 2018 we recruited 30 maternity staff (midwives and obstetricians) from the two public maternity hospitals in NHS Lothian. A phased approach to recruitment was used to capture staff views at different points during PPIUD implementation. We purposively sampled to provide representation across occupational groups and grades. Maternity staff involved in PPIUD were provided with information on the study, and invited to participate in an interview using an ‘opt-in’ approach.
Sixteen individual interviews were conducted. Staff were offered the option of a group interview where this was more convenient; 14 staff participated in three group interviews. Interviews were conducted by one of the authors (NB), a female qualitative researcher (not clinically trained). A topic guide was used, which covered: the role of staff in, and experience of, PPIUD provision; perceived barriers and facilitators to PPIUD implementation within maternity services; and areas for service improvement (online supplemental table S1). Interviews were conducted in the participant’s workplace (n=26) or by telephone (n=4), lasted on average 50 min, and were digitally recorded and transcribed.
Supplemental material
The qualitative data were analysed thematically15 16 by two of the authors (NB and JH), both medical sociologists with extensive experience of conducting research on sexual and reproductive health. Transcripts were read repeatedly, following which a coding scheme was developed that encapsulated the original research questions and issues identified through engagement with the data. NVivo Qualitative Data Analysis Software17 was used to facilitate data coding and retrieval. Data were then cross-compared to identify recurrent themes. These two authors met frequently to discuss findings and compare analytic interpretations. They also reflected on how their ‘non-clinical status’ influenced interviews and analysis; checking language and understandings during interviews, and discussing interpretations with the wider study team (all healthcare providers).
The study received favourable ethical opinion from the Usher Research Ethics Group at the University of Edinburgh (12 July 2017). Consent for study participation was obtained prior to interview.
Patient and public involvement
A steering group, including patient and public involvement (PPI) representatives, provided guidance on both the study and PPIUD service development. A summary of the research findings was offered to all participants.
Results
The final sample comprised 30 maternity staff (22 midwives and 8 obstetricians) outlined in table 1. We present three thematic areas from our analysis: (1) views on the benefits of PPIUD; (2) staff experiences of implementing and providing PPIUD; and (3) views on areas for service improvement.
Sample of maternity staff by occupational group
Views on the benefits of PPIUD
Benefits of PPIUD for women
A primary motivation for staff in supporting PPIUD provision were the benefits to women in enabling them to leave hospital with the knowledge that they had effective ‘contraceptive cover’. IUDs were understood to be highly effective, reliable and ‘non-user dependent’. Furthermore, staff noted that many women were anxious about ‘normal’ (interval) IUD insertion, and were less focused on contraception in the postnatal period. PPIUD at the time of birth was perceived as helping to overcome concerns around pain at interval insertion, and reduce the need for additional appointments. As such, PPIUD was understood to remove barriers to uptake of effective contraception.
Benefits of PPIUD for health service provision
Staff noted several benefits of PPIUD related to health service provision. PPIUD was understood to create opportunities for service improvements by reducing the ‘burden’ of missed postnatal appointments. PPIUD was also described as having public health benefits; use of effective contraception was understood to play a critical role in addressing pregnancy spacing and reducing abortion rates. Lastly, staff noted that regardless of whether women opted for PPIUD, providing the option encouraged conversations around topics such as pregnancy spacing, resuming sex and return of fertility, and thus raised awareness of the benefits of postnatal contraception (table 2).
Verbatim quotes – views on the benefits of postpartum intrauterine device (PPIUD) insertion
Staff views and experiences of providing PPIUD
Expanding staff skills and supporting holistic maternity care
The ability to insert PPIUD was understood by staff, especially midwives, as expanding their skill set and contributing to their ongoing professional development. Midwives also highlighted PPIUD as enhancing their satisfaction in providing a holistic service, and caring for women through their maternity journey: labour, birth and provision of postpartum contraception. Nevertheless, some midwives argued that PPIUD training may not be appropriate for all (ie, those nearing retirement, or newly qualified).
Role and workload extension
Understanding of professional roles and expectations around workload shaped staff views on PPIUD provision. In the early stages of implementation, midwives articulated unease around the issue of ‘role extension’; specifically, taking on responsibility for a procedure typically undertaken by obstetricians. This was often linked to concerns around increased workload, and that PPIUD would add to midwives’ already busy workload, which could undermine the care provided to women. These concerns were mitigated for some, as they began to practise PPIUD insertion. However, midwives noted that these views continued to circulate and, for some, acted as a barrier to engaging in PPIUD training and delivery.
Concerns about potential drawbacks of PPIUD
Concerns around potential drawbacks (and risks) of PPIUD circulating among staff were identified during the pre-implementation phase and early stages of service introduction.10 These included: women’s experience of pain during vaginal PPIUD; potential complications of IUD insertion; and the impact of immediate insertion at vaginal birth on mother–baby bonding and breastfeeding initiation. Extant research on PPIUD was presented during staff training sessions, and staff reported this as going some way towards addressing such concerns. Furthermore, the clinical research team supported ‘feedback loops’ to share experiences of PPIUD practice as implementation progressed. As PPIUD became established, staff reported observing benefits to women and midwives noted that widespread concerns around PPIUD insertion pain, and impact on breastfeeding, did not materialise. Indeed, midwives reported no negative impact on the women’s birth experience, and noted that women tended to experience less pain than a ‘normal’ insertion. Furthermore, staff described the advantages of PPIUD insertion taking place soon after birth as this reduced logistical challenges, such as finding a suitable space and equipment for insertion. Taken together, this led to a shift towards increasingly positive views on the benefits of PPIUD over the course of the evaluation.
Some staff expressed concerns about expulsion rates (following vaginal PPIUD) as a potential disadvantage of immediate IUD insertion, and a barrier to uptake of PPIUD in the long term. Obstetricians noted that the benefits of PPIUD were contingent on expulsions/partial expulsions being identified at follow-up review, and a new device inserted (or alternative contraception provided). They reflected on potential challenges for women in accessing follow-up review at their general practitioner (GP) practice in the postpartum period. Similarly, midwives reported emphasising the importance of attending for follow-up during discussions with women (at the time of insertion) as a way of addressing concerns around expulsion (table 3).
Verbatim quotes – staff views and experiences of postpartum intrauterine device (PPIUD) provision
Staff views on areas for PPIUD service improvement
Leading the ‘culture shift’
The extent to which staff ‘bought into’ the rationale for PPIUD in the context of maternity care was reported by participants as being critical to their engagement in service delivery. Staff emphasised the importance of leadership by senior obstetricians and midwives in championing PPIUD, and leading a ‘culture shift’ in which PPIUD was prioritised within maternity care.
Reaching a ‘critical mass’ of PPIUD-trained staff
Having a pool of PPIUD-trained staff large enough (relative to the size of the maternity unit) to facilitate full service cover for all women wanting PPIUD was identified by midwives and obstetricians as an important factor in successful service implementation. Staff articulated their belief that once a ‘critical mass’ of trained staff were available, challenges to service delivery, such as delays to insertion after vaginal birth, would be reduced, if not eliminated.
PPIUD information provision and support
Staff, particularly midwives, reported encountering some women who had not discussed, or been offered, PPIUD during the antenatal period; they emphasised the importance of raising awareness of PPIUD antenatally. Staff noted that women often share experiences of pregnancy and birth and so addressing misconceptions about IUDs and insertion could help address barriers to uptake.
Staff, particularly obstetricians providing PPIUD at caesarean section, emphasised the need for consistent post-insertion information provision and support (ie, what to expect after insertion, contraceptive cover, and attending for follow-up review). Without this, staff noted the risk that IUD expulsion would not be identified and women could experience unintended pregnancy. To mitigate this risk, many noted that a comprehensive approach to raising awareness of PPIUD was required, among all healthcare professionals involved in women’s care antenatally, around birth and postnatally.
Resourcing and sustaining PPIUD services
The cost of PPIUD was perceived as a potential barrier to the sustainability of service provision. Although the long-term benefits of PPIUD were recognised, staff across occupational groups expressed the view that the sustainability of PPIUD provision at vaginal birth was contingent on increased resources to support training, funding for IUD devices, and patient follow-up. Some senior midwives and obstetricians with responsibility for managing maternity budgets highlighted the cost of PPIUD as an issue that could be a drawback for service provision (table 4).
Verbatim quotes – staff views on areas for postpartum intrauterine device (PPIUD) service improvement
Discussion
A growing body of evidence suggests women desire access to, value and benefit from immediate postpartum contraception2 7 12 13 18–21; this emphasises the role maternity services can (and should) play in providing contraception prior to discharge.22 23 There is limited evidence relating to healthcare professionals’ views, specifically in relation to PPIUD, which requires direct support from maternity professionals to be successful.
Midwives and obstetricians identified PPIUD as a positive development, linking it to ‘holistic’ care for women around the time of childbirth, and reducing barriers to contraceptive access and subsequent intended pregnancy. However, concerns were also articulated by staff, particularly midwives, about: role expansion and increased workload; safety of PPIUD; and impact of immediate insertion on mother–baby bonding. Some of these concerns have been identified in other research.7 24 25 Our findings suggest that many concerns dissipate following training in, and practise of, PPIUD. This underscores the importance of evidence-based training, and the challenges for implementing PPIUD when this is lacking.25 26 Despite the impact of effective training, some concerns persisted among midwives, highlighting challenges associated with shifting the culture around provision of immediate postpartum contraception, and emphasising the need for continuing education.
In this study the average time between giving birth and insertion was 6.6 hours, with almost one-third (28.2%) of insertions taking place within 1 hour of giving birth and 77.0% within 6 hours.12 As the study progressed, and PPIUD started to become embedded into practice, staff increasingly emphasised the benefits of PPIUD, ideally in the birthing room. Staff recognised that logistical issues (eg, other clinical demands, space and equipment for insertion, and the availability of a trained inserter) impacted on the birth-to-insertion interval time, but highlighted the advantages of shorter intervals for services and women (contributing to a positive PPIUD experience).
Clinician ‘champions’ have been identified as central to shifting cultures around PPIUD.27–30 These are frequently individuals, operating at a local or national level, who demonstrate leadership by extolling the benefits of PPIUD and advancing learning and practice developments. Our findings provide further support for this critical role in shifting mindsets, and supporting new services to become established. This shift can encourage more staff to become involved in service delivery, which is important because having a large pool of PPIUD-trained staff was identified as a factor in successful service implementation.
While PPIUD has been demonstrated to be cost effective,31 there may be concerns around the upfront costs of resourcing PPIUD services (eg, staff training, cost of IUD devices, and patient follow-up in primary care settings). Champions can play a leading role in advocating for the service.
Strengths and limitations
This robust qualitative study, the first of its kind in the UK and Europe, contributes evidence on healthcare professionals’ views on PPIUD. A strength of the study is that it incorporates the views of obstetricians and midwives at different grades, and at different time points, thereby illuminating changes to staff views on PPIUD as the service was being established. Our findings, from a large UK maternity service, may not be generalisable to other health systems and contexts of PPIUD provision, particularly where there are differences in PPIUD funding and follow-up. Furthermore, the introduction and evaluation of vaginal PPIUD service provision happened concurrently; the findings may not reflect staff views and experiences when a PPIUD service is fully embedded.
Conclusions
PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. Changing the hearts and minds of staff towards PPIUD is possible as staff become familiar with the benefits to women and maternity care, and through evidenced-based training. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study received favourable ethical opinion from the Usher Research Ethics Group at the University of Edinburgh (12 July 2017).
Acknowledgments
The authors wish to thank the midwives and obstetricians who kindly agreed to take part in the study. The authors also wish to acknowledge the significant contributions of Anne Johnstone, Karen McCabe and Lindsay McCracken (research nurse/midwives) to the overall service implementation and evaluation, and to the postpartum intrauterine device (PPIUD) project steering group members for their feedback and guidance.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @NBW80, @CoopMhc, @JeniHarden
Contributors STC, JH, AG, FMcG, SC: original idea and overall study design. NB, JH: qualitative study design, data collection and analysis. MC, STC: led/directly involved in clinical service implementation. NB, JH: initial manuscript preparation. MC, SC, STC, AG: manuscript editing. All authors reviewed the final draft.
Funding The study was funded through a joint Chief Scientist Office and Wellbeing of Women research grant (RG1903). The review process included external (lay and expert) peer review of the scientific content and overall study design. The study funders were not involved in research conduct or manuscript preparation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Further details are provided in the Methods section.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.