The effect of a postpartum IUD intervention on counseling and choice: Evidence from a cluster-randomized stepped-wedge trial in Sri Lanka

Mahesh Karra, Erin Pearson, Elina Pradhan, Ranjith de Silva, Arnjali Samarasekera, David Canning, Iqbal Shah, Deepal Weerasekera, Hemantha Senanayake, Mahesh Karra, Erin Pearson, Elina Pradhan, Ranjith de Silva, Arnjali Samarasekera, David Canning, Iqbal Shah, Deepal Weerasekera, Hemantha Senanayake

Abstract

Background: The International Federation of Gynaecology and Obstetrics (FIGO), in collaboration with the Sri Lankan College of Obstetrics and Gynaecologists (SLCOG), launched an initiative in 2014 to institutionalize immediate postpartum IUD (PPIUD) services as a routine part of antenatal counseling and delivery room services in Sri Lanka. In this study, we evaluate the effect of the FIGO-SLCOG PPIUD intervention in six hospitals by means of a cluster-randomized stepped-wedge trial.

Methods/design: Six hospitals were randomized into two groups of three using matched pairs. Following a 3-month baseline period, the intervention was administered to the first group, while the second group received the intervention after 9 months of baseline data collection. We collected data from 39,084 women who delivered in these hospitals between September 2015 and January 2017. We conduct an intent-to-treat (ITT) analysis to determine the impact of the intervention on PPIUD counseling and choice of PPIUD, as measured by consent to receive a PPIUD, as well as PPIUD uptake (insertion following delivery). We also investigate how factors related to counseling, such as counseling timing and quality, are linked to choice of PPIUD.

Results: We find that the intervention increased rates of counseling, from an average counseling rate of 12% in all hospitals prior to the intervention to an average rate of 51% in all hospitals after the rollout of the intervention (0.307; 95% CI 0.148-0.465). In contrast, we find the impact of the intervention on choice of PPIUD to be less robust and mixed, with 4.1% of women choosing PPIUD prior to the intervention compared to 9.8% of women choosing PPIUD after the rollout of the intervention (0.027; 95% CI 0.000-0.054).

Conclusions: This study demonstrates that incorporating PPIUD services into postpartum care is feasible and potentially effective. Taking the evidence on both counseling and choice of PPIUD together, we find that the intervention had a generally positive impact on receipt of PPIUD counseling and, to a lesser degree, on choice of the PPIUD. Nevertheless, it is clear that the intervention's effectiveness can be improved to be able to meet the demand for postpartum family planning of women.

Trial registration: ClinicalTrials.gov, NCT02718222 . Registered on 11 March 2016 (retrospectively registered).

Keywords: 44 cluster-randomized controlled trial; Counseling; FIGO; Family planning; Immediate postpartum IUD (PPIUD); Intervention; Sri Lanka; Stepped-wedge design; Uptake.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Trends in PPIUD counseling rates standard errors are shown as error bars. Approximate intervention start dates in Group 1 (red) and Group 2 (black) hospitals are shown by the green and orange vertical lines, respectively. For exact dates of intervention, please see Additional file 1: Table S1
Fig. 2
Fig. 2
Trends in choice of PPIUD. Standard errors are shown as error bars. Approximate intervention start dates in Group 1 (red) and Group 2 (black) hospitals are shown by the green and orange vertical lines, respectively. For exact dates of intervention, please see Additional file 1: Table S1
Fig. 3
Fig. 3
Forest plot of estimates from main analyses. 95% confidence intervals are shown as error bars

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