Provider and Women Characteristics as Risk Factors for Postpartum Copper IUD Expulsion and Discontinuation in Nepal.

Context: Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established.

Methods: Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion.

Results: Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks.

Conclusion: The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.