IUD POSTPLACENTA

IUDPOSTPLACENTA
Biran Affandi
Klinik
Kli
ik Raden
R d Saleh
S l h
DepartmentofObstetrics&Gynecology
F lt f M di i
FacultyofMedicine,UniversityofIndonesia/
U i
it f I d
i /
Cipto Mangunkusumo GeneralHospital
Jakarta
k
Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010

Objectives:
1.Toupdatepostpartum
1
T
d t
t t
contraception
2 To review IUD
2.ToreviewIUD
POSTPLACENTA
3.To discuss medical barriers
3.Todiscussmedicalbarriers
Affandi B.IUDPostplacenta .Rapat Persiapan TOT IUDPascapersalinan .BKKBNPusat ,Jakarta,28Desember 2010

MillenniumDevelopmentGoals
1.Eradicateextremepovertyandhunger
1
E di
dh
2.Achieveuniversalprimaryeducation
3.Promotegenderequality&empowerwomen
4.Reducechildmortality
5.Improvematernalhealth
6.CombatHIV/AIDS,malaria&otherdiseases
7.Ensureenvironmentalsustainability
8.Develop a global partnership for development
8.Developaglobalpartnershipfordevelopment
MDGs

challenges are not new;

new; what is new is that they involve
concrete, timetime-bound & quantitative targets for action by 2015.
Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

GOAL5ImproveMaternalHealth

TARGET6
Reducebythreequarters,between1990and
2015,thematernalmortalityratio

Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

 Maternalmortalityisan
indicatorofgrossinequality,
human rights abuse and
humanrightsabuseand
developmentfailure.
Allmaternalhealthproblems
arepreventableaslongasthe
bl
l
h
government pays attention and
governmentpaysattentionand
prioritizesmaternalhealth.
Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010

AffandiB.KesehatanReproduksidanUpayaKesehatanMaternaldiIndonesia,QuoVadis?OrasipadaPITXVIIIPOGI,Jakarta,7Juli2010

Ofthe11countriesthatcontributeto65
percenttoglobalmaternaldeath,fivearein
l b l
l d h fi
i
AsiancountriesincludingIndonesia,
Bangladesh,Pakistan,IndiaandAfghanistan.
Ahighmaternalmortalityrateisan
g
y
indicatorofthestatusofpoorfunctioningof
a countrysshealthsystemincludinglackof
acountry
health system including lack of
supportiveandprotectivelegalandpolicy
environment.
Dr.S.T.Mathai,UNFPA,TheJakartaPost,13Jan.,2010

Affandi B.Kesehatan Reproduksi dan Upaya Kesehatan Maternaldi Indonesia,QuoVadis?Orasi pada PITXVIIIPOGI,Jakarta,7Juli 2010

GOAL5ImproveMaternalHealth
p
Target6:Reducebythreequarters,between
1990and2015,thematernalmortalityratio

Indicators:
Maternalmortalityratio
g
y
Percentageofbirthsattendedbyskilled
healthpersonnel
Contraceptiveprevalencerate
AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010

Threeprongedstrategy
toreducingmaternalmortality
Familyplanningtoensurethateverybirthis
Family planning to ensure that every birth is
wanted
Skilledcarebyahealthprofessionalwith
Skilled care by a health professional with
midwiferyskillsforeverypregnantwoman
d i
duringpregnancyandchildbirth
d hildbi th
EmergencyObstetricCare(EmOC)toensure
timelyaccesstocareforwomenexperiencing
p
complications.
UNFPA,2009
AffandiB.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta,22Sept.2010

PERENCANAANKELUARGA
1. Seorangwanitatelahdapatmelahirkan,segera
setelahiamendapathaidyangpertama
(
(menarche)
h )
2. Kesuburanseorangwanitaakanterusberlangsung,
sampai mati haid (menopause)
sampaimatihaid(menopause)
3. Kehamilandankelahiranyangterbaik,artinya
risikopalingrendahuntukibudananak,adalah
p g
,
antara2035tahun
4. Persalinanpertamadankeduapalingrendah
risikonya
i ik
5. Jarakantaraduakelahiransebaiknya24tahun
Affandi, 1984
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

POLA PERENCANAAN KELUARGA

POLAPERENCANAANKELUARGA

Fase
M
Menunda
d
Kehamilan

Fase

Fase

M j
Menjarangkan
k
Kehamilan

Tidak Hamil
lagi

2 4
2

20

35

Affandi, 1984
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

PEMILIHANKONTRASEPSIRASIONAL
Fase

Fase

menunda
Kehamilan

Fasee
Fas

Menjarangkan
Kehamilan

Tidak hamil
lagi

2 4
2

Pil
IUD
Sederhana
Suntikan
Implant
Affandi, 1984

20

IUD
Suntikan
MiniPil
Pil
Implant
Sederhana

IUD
Suntikan
MiniPil
Pil
Implant
Sederhana
Steril

35

Steril
IUD
Implant
Suntikan
Sederhana
Pil

Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

80

CONTRACEPTIVEPREVALENCE
INDONESIA 19702007
INDONESIA,1970
2007

70

60 %

61 4 %
61.4

57 %

60
48 %

50
40
26 %

30
20
5 % (?)

10
0

1970 1980 1987 1997 2002 2007

Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand,2023January2010

CurrentContraceptiveUsers
Indonesia March 2006
Indonesia,March2006
METHODS

USERS

INJECTABLES

9 743 550
9,743,550

35 2
35.2

PILLs

7,796,474

28.1

IUDs

5 218 196
5,218,196

18 8
18.8

IMPLANTABLES

3,156,705

11.4

STERILIZATION

1 515 406
1,515,406

55
5.5

278,473

1.0

OTHERS
TOTAL

27 708 804
27,708,804

100 0
100.0

BKKBN, 2007
Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010

BIRTHRATE

STILL HIGH ! ! !
4 5 5 Million/year
4.5
Affandi B.UnsafeAbortion:IndonesianExperience.1stInternationalCongressonWomenHealth&UnsafeAbortion,Bangkok,Thailand ,2023January2010

FAKTA
1.PascasalinOVULASIdapat
p
terjadidalamwaktu21hari
2.PascakeguguranOVULASI
dapatTERJADIdalamwaktu
11hari
Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30(3):181189

Affandi B.Kontrasepsi Terkini dan IUDPascaplasenta .Pertemuan Koordinasi Peningkatan KBPascapersalinan di Rumah Sakit ,Makassar31Agustus 2010

SimplifiedClassificationofEligibility
Criteria(WHO)
(
)

AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010

12.Theuseofprogestogenonlymethodsinthefirst6
weekspostpartumdoesnotappeartohaveanadverse
p p
pp
effectonbreastmilkvolume(GradeB).
13.Theuseofprogestogenonlymethodswhen
b
breastfeedingprovidesover99%efficacy(GradeB).
f di
id
99% ffi
(G d )
14.Theproblematicbleedingassociatedwithprogestogen
only methods appears to be more acceptable than that
onlymethodsappearstobemoreacceptablethanthat
experiencedbywomenwhoarenotbreastfeeding
(GradeB).
Aftercounselling,breastfeedingwomenmaychooseto
useaprogestogenonlymethodofcontraceptionbefore
6 weeks postpartum if other contraceptive methods are
6weekspostpartumifothercontraceptivemethodsare
unacceptable.
Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

17.DMPAusebefore6weekspostpartumis
not usually recommended (Grade C)
notusuallyrecommended(GradeC).
18.TroublesomebleedingcanoccurwithDMPA
useintheearlypostpartumperiod(GradeC).
DMPAwillnotrequiretheinjectionuntilDay
21postpartum,butiftheriskofimmediate
subsequentpregnancyishighitmaybegiven
beforethistime.
Contraceptive choices for breastfeeding women. Journal of Family Planning and Reproductive Health Care 2004; 30: 181189
Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181
189

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Breastfeedingwomenmaychooseto
useaprogestogenonlyimplantbefore
Day 28 without the need for
Day28withouttheneedfor
additionalcontraceptiveprotection.
IMPLANTwillnotberequireduntil
Day 28 postpartum, but if the risk of
Day28postpartum,butiftheriskof
immediatesubsequentpregnancyis
high it ma be gi en before this time
highitmaybegivenbeforethistime.

C
Contraceptivechoicesforbreastfeedingwomen.JournalofFamilyPlanningandReproductiveHealthCare2004;30:181189
i
h i
f b
f di
J
l f
il l
i
d
d i H l hC
2004 30 181 189

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Statement,WHOGeneva,22Oct.2008:
Progestinonlycontraceptiveuseduringlactation
1. Useofprogestinonlymethods,withtheexceptionofthe
l
levonorgestrel
l bearingIUD,isnotusuallyrecommendedfor
b
ll
d df
womenwhoarelessthan6weekspostpartumandbreastfeeding,
unlessothermoreappropriatemethodsareunavailableor
unacceptable.
2. Beyond6weekspostpartum,thereisnorestrictionfortheuseof
progestin only contraceptive methods among breastfeeding
progestinonlycontraceptivemethodsamongbreastfeeding
women.
3. ThelevonorgestrelbearingIUDisnotusuallyrecommendedfor
th fi t 4
thefirst4postpartumweeks,unlessothermoreappropriate
t t
k
l
th
i t
methodsareunavailableorunacceptable.Beyond4weeks
postpartum,thereisnorestrictiononitsuse.
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

IUDCu
AffandiB.PerkembanganKontrasepsi,TeknikPenapisandanKBPostpartum,BPMPPKB,Balikpapan,24Juni2010

 ThepostpartuminsertionofIUDshas
anumberofadvantages,including
b
f d
l d
ease of insertion, availability of skilled
easeofinsertion,availabilityofskilled
personnelandappropriate
f ili i
facilities,andconvenienceforthe
d
i
f h
woman.
Practitionershavebeenconcerned
aboutthepossibilityofhigher
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
expulsion,
expulsion,infectionandperforation
infection and perforation
rates.
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

 Postplacental (preferablywithin
(preferably within
10minutesafterexpulsionofthe
placenta)andimmediate
postpartum insertion during the
postpartuminsertionduringthe
firstweekafterdelivery(but
preferablywithin48hours)are
convenient effective and safe
convenienteffectiveandsafe
timestoinsertcopperIUDs.
{ManagingContraception20052007,page92}

Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

Teknik Pemasangan AKDR

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Fundal placement

ThewaytheIUDisinsertedismoreimportantthan
thedesignofthedevice.
DifferencesinIUDexpulsionratesbetweencenters
Diff
i IUD
li
b
participatinginthetrialsweregenerallygreaterthan
expulsion rates for different IUDs;
expulsionratesfordifferentIUDs;
FHIdatashowthatemphasisneedstobegiventothe
fundal placementofthedevice.
placement of the device.
Theprovidershouldbeabletofeelthedevicethrough
theabdominalanduterinewallsatthetimeof
insertion.
Retrainingisnecessaryforthoseindividualswho
reporthighexpulsionrates
www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

Teknik Pemasangan AKDR

Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

 Allowthewomantorest.
Besureshegetscomplete
postpartumcare.
t t
Providepostinsertion
P id
i
i
instructions.
instructions

Expulsion
Afterbirth,astheuterusreturnstonormal
size(involution),uterinecontractionsexpel
p
y
retainedplacentalandbloodclotsandmay
haveasimilareffectonanyforeignbody
introduced into the uterus.
introducedintotheuterus.
IUDsinsertedwithin10minutesofplacenta
expulsionhaveamuchlowerexpulsionrisk
li h
hl
li
ik
thanthoseinsertedlaterinthepostpartum
period. www.fhi.org/en/rh/pubs/factsheets/iud_pp.htm
Affandi B.PostpartumContraception&MedicalBarrier.DepartmentofObstetrics&Gynecology,UniversityofIndonesia,Jakarta, 22Sept.2010

BarrierThatPreventContraceptive
Success
Barriertoeffectivefamily
planning services
planningservices

Outcomewhenbarrier
areovercome
Accesstoservice
Contraceptive
preference
f
Qualityservices
Quality services

MAQExchangecurriculum(Online)MaximizingAccessandQualityinitiative,WashingtonDC,2001

Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010

Medical barriers
Medicalbarriers
weredefinedas "practices,derivedat
p
,

leastpartlyfromamedical
rationale,thatresultina
scientifically unjustifiable
scientificallyunjustifiable
p
,
,
impedimentto,ordenialof,
contraception"

SheltonJD,etal.Lancet,1992;340:13341335

Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

MedicalBarriersthatrestrict
accesstofamilyplanningservices
f
1 Providerbias
1.
Provider bias Whentheprovideris
When the provider is
fororagainstaspecificmethod
2 Overlyrestrictiveeligibilitycriteria
2.
O l
t i ti
li ibilit it i
Whocangetwhatcontraceptive
3. Unnecessaryprocesshurdles
Requirementsthat,fromtheuser's
pointofview,makeitdifficultto
obtainacontraceptive
SheltonJD,etal.Lancet,1992;340:13341335

Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

4.Inappropriatecontraindications
Medical conditions that restrict the
Medicalconditionsthatrestrictthe
useofsomecontraceptives
5 Overly restrictive regulations
5.Overlyrestrictiveregulations
Nationallawsandclinicorhospital
regulations
regulations
6.Providerlimitation Whocan
provide what method
providewhatmethod
7.Inappropriatemanagementofside
effects Actionstakenbythe
Actions taken by the
providertohelptheusertoleratea
contraceptive method
contraceptivemethod

Shelton JD et al Lancet 1992;340:13341335

SheltonJD,etal.Lancet,1992;340:1334
1335

Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

Checklists
ReduceMedicalBarriers
Medicalbarriersoftenpreventclientsfromusingtheir
desiredmethodoffamilyplanning.
Thepregnancy,COC,DMPA,andIUDchecklistscan
effectivelyincreaseaccesstofamilyplanningwhile
helping ensure client safety
helpingensureclientsafety.
Introductionofchecklistsintoservicedeliverysettings
g
shouldincludecarefultrainingonhowtousethe
checklistsaswellasthemedicaleligibilitycriteriaon
whichtheyarebased.
Affandi B.Perkembangan Kontrasepsi,Teknik Penapisan dan KBPostpartum,BPMPPKB,Balikpapan,24Juni 2010

Knowingisnot
enough,wemustapply
Willingisnotenough,we
mustdo
td
Goethe
G h
Affandi B.PostpartumContraception&MedicalBarrier.BuildingMomentumMDGs4&5,RSIABudiKemuliaan ,Jakarta,28Sept.2010