Formative research is needed to evaluate the counseling for immediate postpartum LARC, particularly for the post-placental IUD when there is a finite and clinically significant window of time for placement. The importance of this decision-making process is highlighted by providers’ concern for the potential coercion during labor and the higher risk of expulsion that comes with a post-placental IUD.
This study investigated the counseling that women received for the placement of a postpartum IUD, and characterized the decision-making process when choosing a postpartum IUD. It also assessed if there were changes in these perspectives and the recall of experiences about the counseling for post-placental IUD. Women were eligible to participate if they were admitted to Weiler Hospital for delivery, desired an IUD as their contraceptive method, spoke English, and were able to give informed consent. Our research utilized in-person semi-structured interviews prior to hospital discharge. Follow-up interviews were conducted to check for consistency of themes. All interviews were audio-recorded and transcribed. Delivery and demographic data were abstracted from the medical record.
The in-depth interviews focused on three main domains – the counseling experience, the decision-making process, and the placement experience. Within counseling experience, we sought to learn about timing and location of counseling, comprehension and recall of content of counseling, feeling of any pressure or coercion in the counseling, and if the woman had specific interactions that could speak to trust or mistrust of clinicians and the healthcare system. Related to the decision-making process, we explored reasons for contraceptive choice and timing of placement, previous contraceptive choices, personal satisfaction with their choice, and who else was involved in the decision making process. We also explored the woman’s experience with placement of the device, if applicable.
We conducted 25 in-depth interviews. 7 follow-up interviews confirmed consistency of themes. The participants varied in age and parity. 19 women had a vaginal delivery and 6 had a cesarean section. 17 women had an IUD placed immediately post-placental, and 8 women opted for interval placement. Our findings show that women prefer antepartum counseling, but find intrapartum counseling acceptable and a reinforcement of what they heard from their antepartum provider. Women who opted for immediate placement placed particular importance on convenience, avoiding a potentially painful procedure, and the immediacy of contraceptive coverage. Women who opted for delayed placement wanted time for the body to cleanse and heal. The risk of expulsion was interpreted differently in each group. Those women who had immediate placement were not concerned by the higher risk of expulsion, whereas those who opted for interval placement wanted to avoid this risk.
Our study has several limitations. The population of the Bronx may not be generalizable to other populations. Not all women will have as easy a time securing replacement device should they have an expulsion. There is the potential for recall bias. Biases held by the interviewer and the coders could also have influenced the conduct of the interviews and the analysis of the transcripts. The findings from this investigation help us understand and improve counseling for postpartum contraception. This counseling should address the issues that women feel are part of the decision making process by comparing and contrasting the immediacy and convenience of immediate placement with the desire to let the body cleanse and heal prior to placement. It should also include a discussion about the placement experience, and address the higher rate of expulsion. Intrapartum counseling should reinforce the themes of antepartum counseling, and at all times we must respect a woman’s autonomy to decide when she does or does not want an IUD placed.