Dr Michelle Cooper - ‘Why is it taking so long to establish PPIUC in the UK?’

Posted 13 Jun 2018

Date: 13 Jun 2018

Author: Dr Michelle Cooper

Dr Michelle Cooper discusses her short oral paper presentation at this year’s Annual Scientific Meeting, exploring community sexual health providers’ views towards postpartum intrauterine contraception (PPIUC).

‘Why is it taking so long to establish PPIUC in the UK?’

This is one survey participant’s view about the implementation of PPIUC in the UK, but it certainly reflects the feelings of many others. I had the opportunity to present this work at the FSRH ASM in May 2018, and this is what it was all about.

What is PPIUC?

Postpartum intrauterine contraception or ‘PPIUC’ refers to the insertion of an intrauterine device within the first 48 hours of childbirth, after either a caesarean or vaginal delivery. Providing this service in a maternity setting reduces the need for an additional postpartum visit which can be a barrier for many women.

As well as being convenient, immediate PPIUC provision allows women to access a highly effective form of contraception before their fertility or sexual activity resumes. This may reduce their risk of experiencing an unplanned pregnancy in the months after childbirth, and encourage optimal birth spacing to reduce the maternal and neonatal complications of a short-interpregnancy interval (less than 12 months).

Why did we do it?

There is now a lot of evidence to support the safety and efficacy of PPIUC. The current FSRH “Contraception After Pregnancy” guideline recommends its availability, and yet it is not widely offered in the UK. So how can we translate this into routine practice within our labour wards?

The truth is there is limited evidence to support the practical implementation of this service, which can be challenging for many reasons. Not least is that the service itself is anchored between hospital and community services; therefore gaining the support and engagement of all potential stakeholders is key.

A few studies have explored healthcare professionals’ views towards PPIUC, but these have focussed exclusively on maternity providers. In a UK setting, community SRH staff (including GPs, practice nurses and SRH clinicians) will be important stakeholders in any PPIUC service, so we were keen to establish their views.

Firstly, we wanted to determine their overall feelings were towards PPIUC and the reasons for this. Secondly, we asked what they thought their role in a future service might be, and any potential barriers they anticipated. From our experience of implementing a PPIUC service in Edinburgh, reaching a consensus on a feasible and sustainable follow-up pathway has been especially challenging.

What did it show?

It was encouraging to find that participants felt overwhelmingly ‘positive’ (82%) about the prospect of PPIUC in the UK. Convenience; improved access to LARC; and maximising contraceptive choice for women, were seen as some of the key benefits.

Most participants said they would be happy to promote this service and conduct follow-up thread checks. SRH clinicians in particular felt their role might include training and ‘championing’ the service, both of which are essential to its success. However, a number of potential challenges were also identified. In relation to providing PPIUC aftercare, these included available staff time and funding; appropriate training; onward referral pathways and access to ultrasound.

What does it mean?

There is increasing support in the UK for PPIUC but establishing a service is certainly not without its challenges. In this respect, forewarned is definitely forearmed. Many potential issues can be overcome by increased training and education, and the development of rigorous clinical pathways. Collaboration and communication between community and hospital colleagues will be crucial for this.

So, ‘why is it taking so long to implement PPIUC in the UK?’. Well I think the answer falls along the lines of Rome not being built in a day! But we are getting there. This work is another step forward in exploring the complexities of successful service development, and in assembling evidence of the support necessary to move this agenda forward. Hopefully in the near future many more postpartum women will be able to benefit from the enhanced contraceptive choice and convenience that PPIUC offers.

Michelle is a FSRH short paper prize winner and presented her paper at the FSRH's Annual Scientific Meeting in May 2018.

Further detail of this work is available in full published in the BMJ SRH (April 2018)

For more information contact: michelle.cooper@ed.ac.uk

Read Dr Michelle Cooper's profile here