Helping postpartum women in Mali achieve their fertility intentions: Perspectives from the dedicated PPIUD pilot program

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The West African country of Mali has one of the world’s highest fertility rates and one of the lowest rates of modern contraceptive prevalence (mCPR). In Mali, more than 1 in 4 women have an unmet need for family planning (FP). This gap between method demand and access is particularly acute for postpartum women, with nearly 70% reporting an unmet need. In 2016, PSI-Mali piloted a new healthcare device to help address this gap. The dedicated postpartum (PP) intrauterine device (IUD) inserter replaces the technique of using Kelly forceps for voluntary IUD insertion for women in the post-placental and immediate postpartum period, i.e. within 48 hours post-delivery. The dedicated PPIUD inserter is designed to facilitate easier insertion, with the aim of improving the PPIUD experience for clients and providers.

This case study documents PSI-Mali’s programmatic approach to introducing the dedicated PPIUD inserter and shares insights on the perspectives of providers using the inserter and on trends in voluntary PPIUD uptake during the program pilot. Primary and secondary data were collected during visits in July 2017 to 5 health facilities (3 public, 2 private) in Bamako that were participating in the PPIUD inserter pilot, including interviews with 10 trained providers.

Service uptake trends reveal an overall increase in the voluntary uptake of PPIUD services coinciding with the introduction of the dedicated inserter as compared to before the pilot began when forceps were used for immediate postpartum insertion. Trends in inserter-assisted service uptake vary across facilities and between sectors. Despite a lower number of total deliveries, a higher proportion of postpartum clients of private sector facilities where the inserter was in use chose a voluntary PPIUD before discharge as compared to the rate at public sector facilities participating in the pilot.

Qualitative findings show strong acceptability and preference among providers for the dedicated PPIUD inserter versus the forceps insertion technique. Providers cited ease, speed, and reduced associated risks as benefits of the dedicated inserter. Analysis of client data from 2016 and 2017 shows that clients choosing a voluntary PPIUD service at pilot-participating facilities had lower levels of education than the general population of Malian women, suggesting that the pilot program is effectively reaching clients with lower education levels, and, by association, lower socio-economic status. While clients choosing PPIUD from private sector facilities using the dedicated inserter included a broad age range, 45% of public sector PPIUD clients were 30 to 39 years of age, suggesting the need for further examination of whether postpartum family planning (PPFP) counseling is more proactively offered to older or multiparous women.

Further research is needed to fully understand the reasons that clients choose a PPIUD and the causal factors behind the differences in patterns of uptake between public and private facilities. Recommendations stemming from this case study include the need to ensure consistent availability of PPIUD in the postpartum method mix and the need to increase community sensitization, with a focus on male involvement, and sensitization during antenatal counseling to PPIUD as a postpartum FP option. If demand increases and providers have the capacity and motivation to meet that demand, voluntary PPIUD services present an excellent opportunity to respond to the high unmet need for postpartum family planning in Mali.