There are lots of good reasons for women to space their babies at least two years apart. Studies show higher risks of premature birth, pregnancy complications and delivery problems, as well as higher death rates in the early years when babies are born very close together.
But in countries where there aren't a lot of family planning options, women end up getting pregnant again sooner than they'd like.
One solution might be to provide cheap and easy access to contraception immediately after childbirth, suggests a small study in India. Using a new device, researchers were able to simplify the process of inserting an IUD — a type of long-acting contraceptive device that gets embedded into the top of the uterus, an area called the fundus.
The plastic t-shaped device blocks sperm from getting to eggs and either releases hormones that prevent the ovaries from releasing eggs or contains copper that is toxic to sperm. Both kinds are more than 99 percent effective at preventing pregnancy.
The study of the new device, which is the copper variety, found that both health care providers and women who had just given birth were satisfied with the experience.
"In 10 words or less, it worked," says Paul Blumenthal, a professor of obstetrics and gynecology at Stanford University School of Medicine in California and global medical director for Population Services International, a nongovernmental group in Washington, D.C., that helps with family planning in the developing world. "Almost to a person, when the provider takes it out of the package and is able to just insert it into the fundus of the uterus without a lot of rigmarole and extra steps, you always get, 'Oh gosh, this is so simple.'"
The postpartum period offers a valuable opportunity to help women protect themselves against getting pregnant again too soon, Blumenthal says, but many women don't have access to contraception, even if they want it. According to an influential 2001 study by researchers at the Futures Group International, 95 percent of women in 27 countries said they did not want to have another baby right away. But 65 percent did not have access to family planning resources.
Things haven't changed much since then. Last year, one of the first studies to reexamine family-planning needs analyzed 22 surveys in 21 developing countries and concluded that overall, 61 percent of women still had unmet needs for family planning. That number rose to 75 percent in Liberia, Burkina Faso, Ghana, Senegal and Bihar. Across the board, at least half of subsequent children were conceived within an interval of less than two years, the study found, with short spacing most prevalent in Pakistan and Uganda.
And while IUDs have proven to be safe and effective immediately after childbirth, they can be complicated to insert. Typical inserters that come with IUDs tend to be short, flimsy and hard to maneuver, says Eve Espey, an OB/GYN and director of the Family Planning Fellowship at the University of New Mexico in Albuquerque, who was not involved with the new study.
Providers often have to either use their hands or metal forceps to place the device in the correct position, which can raise risks for damage to the device, contamination or infection for both patients and providers. Special training is required, as is careful sterilization, and some equipment may be unavailable in various places.
To make the process more appealing and more intuitive, Blumenthal and colleagues spent several years developing a new kind of inserter that is pre-loaded with the IUD. To simplify the process of putting the device in, the inserter is also extra-long: 13 .7 inches instead of 9.8 inches and with a diameter of .2 inches, double the norm. "It's basically an IUD inserter on steroids," he says.
The person doing the procedure gently presses his or her hand on the patient's abdomen to feel for the top of the uterus. Then, using the other hand, a simple motion releases the IUD into place. Longer-than-usual strings – which run from the end of the device through the cervix and into the vagina – can be seen and felt, reassuring patients and providers that the device is in there.
To assess the feasibility of using the device in practical settings, the team tested it on 80 women who chose to get an IUD within just a few hours after childbirth at two public hospitals in India during the spring of 2015.
The vast majority of IUDs ended up in the right place, the team reports today in the journal Global Health Science and Practice. About seven percent of devices were pushed out by the uterus and 10 percent were partially expelled, but these rates were comparable to other reports in the literature when studies have carefully tracked patients, Blumenthal says. And in the end, 90 percent of patients had IUDs properly implanted.
More than 90 percent of providers said the procedure was easy, and more than 90 percent of women reported feeling less pain or the same amount of pain afterward than they already felt after giving birth. There were no infections or complications. Nearly all participants said they were satisfied with the experience.
The new inserters, with IUDs included, would cost about $1 each, Blumenthal estimates, with hopes for widespread use if it proves itself in large, randomized trials, which will come next.
One potential barrier, Espey says, is that the new device will require a follow-up visit to cut the long strings a week or two after giving birth. Ideally, a second visit would not be needed.
Still, she says, an easy-to-use IUD inserter could make a big difference in developing countries where it may be difficult to sterilize equipment and many doctors lack ultrasound equipment for checking on the location of the device. "I think the impact of the device," she says, "could be substantial."