Research

Increasing Access and Safeguarding Health: The Impact of IUD Revisit Norms in Ecuador

Background

Providing follow-up services to acceptors of family planning is considered to be an essential element of quality of care. Most programs recommend that intrauterine device (IUD) acceptors return for routine follow-up visits, in order to detect and treat medical problems related to IUD use. However, programs have questions about the number and timing of visits that are appropriate in order to detect problems and assure quality care. Excessive visits are costly to programs, which must screen large numbers of clients to detect the relatively few who require treatment, thereby reducing access for other potential acceptors. Revisits also represent real and opportunity costs to users, who pay with their money and their time. The Centros Medicos de Orientación y Planifición Familiar (CEMOPLAF), an Ecuadorian family planning NGO, employed a follow-up norm that recommended four IUD revisits; the first at eight days post-insertion, the second thirty-five days later, the third three months after the second, and a final revisit nine months after insertion. CEMOPLAF management believed that this norm exceeded the optimal number of revisits required for a quality service, and wanted to reduce unnecessary revisits, while safeguarding the health of the women using IUDs. CEMOPLAF wanted to make sure that reducing the required number of visits would not result in an unacceptable number of undetected and untreated IUD-related problems. Problems were defined as expulsions, suspected pregnancies and suspected pelvic inflammatory disease (PID).

Table 1 shows estimated number of problems per 100 women. Table 1

Estimated Number of First Year Problems for Women Receiving IUDs

Problems per 100 Women

Expulsion 3.7

Suspected Pregnancy 2.1

Suspected PID 2.1

Total 7.9

Research Objectives

The study was designed to evaluate the impact on safety and costs of IUD revisit norms that recommend fewer routinely scheduled visits.

Study Design

The study, carried out by FHI and the Population Council through the INOPAL program, used information from client interviews and clinic records to model the probability of an IUD acceptor returning to the clinic for a scheduled revisit, and the likelihood that an IUD-related problem would be detected at that revisit. The proposed norm of one revisit was compared with the current norm of four first-year revisits. The two key indicators measured were the number of IUD-related problems not detected at a follow-up visit, and the costs to CEMOPLAF and clients of follow-up visits.

Results

Nearly 5,000 women making IUD revisits were interviewed. Few women complied fully with the four-visit norm; most clients made a first visit at about the time indicated, but subsequent revisits declined rapidly after the first appointment, as did the probability of returning at the time specified by the norm. The modeling exercise showed that reducing the number of required revisits from four to one would capture 66% of problems compared to 73% under the four visit norm (see Table 2) but would save CEMOPLAF and clients U.S.$33,000 in financial and opportunity costs.

Table 2

Estimated Detection Rates Under Two Different Revisit Norms
	Four Revisit Norm	One Revisit Norm
Expulsion	71%	65%
Suspected Pregnancy	67%	57%
Suspected PID	83%	78%
Total	73%	66%

Impact

CEMOPLAF held a dissemination meeting in Quito in early 1993 to present study findings to an audience which included representatives of MOH, Social Security, USAID, other family planning NGOs, and USAID Cooperating Agencies. Based on the study results and on the recommendations made at the meeting, CEMOPLAF implemented a new follow-up norm of one recommended visit at fifteen days after insertion, since most problems occur within the first weeks after IUD insertion. Clients who experience side effects or have concerns about the IUD are encouraged to make re-visits at any time. The impact on volume of revisits was almost immediate: while the number of insertions remained constant between 1992 and 1993, revisits declined by 29% after changing the norm. Further declines may occur as clients become accustomed to making revisits (after the initial one) only if they have problems. CEMOPLAF believes that this change in policy has reduced program and user costs with minimal impact on detection of medical problems, increased access for additional users, and improved overall quality of care.

August 1994

This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development.