Utilisation, effectiveness, and safety of immediate postpartum intrauterine device insertion: a systematic literature review

Abstract

Background: Intrauterine devices (IUDs) are highly effective contraception. IUDs inserted directly following delivery provide immediate birth control and may decrease unintended pregnancies, including short-interval pregnancies, thereby mitigating health risks and associated economic burden.

Methods: This systematic literature review included published global data on the utilisation, effectiveness, and safety of postpartum intrauterine devices (PPIUDs) of any type. English language articles indexed in MEDLINE, Embase, and Cochrane from January 2010-October 2021 were included.

Results: 133 articles met the inclusion criteria (46% interventional studies; 54% observational; n=87 from lower-income countries; n=46 from higher-income countries). PPIUD use was low in higher-income countries (6/10 000 US deliveries in 2013-2016) and varied widely in lower-income countries (2%-46%). Across both higher- and lower-income countries, in most studies (79%), >80% of women with PPIUDs had an IUD in place by 3 months; at 6 and 12 months, 76% and 54% of included studies reported that >80% of women had an IUD in place; reason for discontinuation was infrequently reported. Pregnancies were rare (96 pregnancies across 12 191 women from 37 studies reporting data) and were generally unrelated to device failure, but rather occurred in women no longer using a PPIUD. Expulsions occurred mainly in the early outpatient period and ranged widely (within 3 months: 0-41%). Abnormal bleeding, infections, or perforations were rare.

Conclusions: PPIUDs are safe and effective. Long-term follow-up data are limited. Future research elucidating reasons underlying lack of PPIUD use is warranted.

Keywords: contraceptive effectiveness; intrauterine devices; long-acting reversible contraception; patient safety.

Figure 1

Study selection flow diagram. SLR, systematic literature review.

Figure 2

Geographic distribution of included studies by economic status. World Bank Country and Lending Groups Country Classification for the fiscal year 2021. Low-income economies are defined as those with a gross national income per capita of $1035 or less in 2019; lower middle-income economies are those with a gross national income per capita between $1036 and $4045; upper middle-income economies are those with a gross national income per capita between $4046 and $12 535; high-income economies are those with a gross national income per capita of $12 536 or more. *Some studies report on more than 1 country in different economic groups.