One Year Review of Experience with Postpartum IUD Insertions

Aims: This quality improvement project aimed to understand postpartum contraceptive initiation trends in a midwifery practice at a teaching hospital in the Intermountain West. The primary aim was to measure the uptake of intrauterine device (IUD) and other long-acting contraception (LARC) in this population. A secondary aim was to identify incidence and commonalities in adverse outcomes. This quality improvement project was developed for practice improvement to minimize IUD complications. Background: In 2011 45% of pregnancies in the United States were unintended. This rate has dropped from the previously reported rate of 49% in 2008. In the same time period, IUD use has tripled from 1.3% in 2002 to 6.8% in 2015. IUDs are an ideal method of postpartum contraception due to high efficacy (>99%) and low hormonal exposure. Anecdotally, we knew that this midwifery practice was placing a high number of IUD's, but the proportion relative to national trends was unknown. Rates of complications described in the literature find a 10.6% malposition rate, a 3-5% expulsion rate and a 0.006 % perforation rate (6/1000). Methods: A retrospective chart review of women within this practice who delivered between July 1, 2015 and June 30, 2016 was conducted. Contraceptive initiation during the first twelve months postpartum and variables associated with IUD provision were identified and measured. Variables included: brand, provider, student involvement and insertion technique. If an IUD was placed, the chart review continued for twelve months beyond placement date to identify any adverse outcomes. The final step in this quality improvement project was to communicate these data to the midwifery practice. Results: There were 426 deliveries with 361 (85%) women successfully initiating a method of contraception by twelve months postpartum. There were 46 (11%) patients who did not return One Year Review of Experience with Postpartum IUD insertions for any postpartum care after delivery. There were 150 (42%) women who selected an IUD. A total of 132 (88%) of those were placed within 3 months of delivery. A total of 23 (15%) of the IUDs placed were removed within the first year (including complications). There were 2 expulsions, 3 IUDs that were low-lying within the uterus and 2 perforations requiring surgical removal. This data-set included a total of 7 (4.6%) malpositioned IUDs. The rate of perforations was 0.013%. Conclusions: We found that both malposition and expulsion rates are lower than seen in reported literature. With our small sample size, it is not possible to conclude that the rate of perforations is higher than expected, but this should be monitored. There were no common trends in complications related to brand, provider, student involvement, or insertion technique. Implications: Future clinical implications include identifying factors contributing to high IUD (and other LARC) uptake in this practice, this may be a model to improve contraceptive care by other practices. Given we found 11% of patients do not return for postpartum care, initiation of contraception before hospital discharge might be warranted to reduce rapid repeat pregnancy and associated adverse outcomes.