Women must be fully informed about the intrauterine device (IUD) before choosing it, and health care workers must be adequately trained to insert the device, if the IUD is to be used properly.
"Many providers are not comfortable with the method," says Dr. Roberto Rivera, FHI corporate director for international medical affairs, who notes that good training can improve access to the method. "For wide-scale IUD use, providers need to have a commitment that they are doing something for the benefit of the client, to improve the health and life of the woman. Then they are willing to spend whatever time is necessary to help the client select the method of her choice and provide it under the conditions that are required."
Providing the IUD takes more time than do many other methods. Good IUD services require good client screening and counseling, a pelvic exam, assuring that no pregnancy or infection is present, good insertion technique, proper follow-up, and management of side effects. The IUD is the most widely-used modern, reversible contraceptive method worldwide, with about 100 million users, although 70 percent are in China. In only four developing countries do as many as 15 percent of married women of reproductive age use IUDs: Vietnam (33 percent), Egypt (28 percent), Tunisia (17 percent) and Jordan (15 percent).
The number of IUD users "should increase by 25 percent or more in the coming decade, if due attention is given to keeping the medical, scientific, and programmatic communities informed about the characteristics of IUDs in comparison to other methods," write Drs. Parker Mauldin and Sheldon Segal, both of the Population Council, in proceedings from the latest international IUD conference.1
IUDs will continue to be underutilized in many countries until health workers are trained in three essential aspects of IUD use: the latest scientific information on the device, proper insertion methods, and good counseling techniques. These areas overlap but necessary attention must be given to each. Other factors also limit women's access to IUDs. These include national policies, restrictive protocols on who may do insertions and required number of follow-up visits, fear among potential users, and in some areas, maintaining a steady supply of IUDs.
Scientific updates
An IUD must be obtained through health care services. If a provider explains it fully, women are more likely to use it. To do this, health workers must understand how the method works, its efficacy rates, potential side effects, and how to insert and remove it.
Worldwide, two matters in particular have limited IUD use, says Dr. Rivera of FHI: Fears of infection and concerns about bleeding and pain. "These problems do exist, but the frequency and severity have been highly exaggerated," he says.
The IUD devices in use today by most programs do not themselves cause infection and pelvic inflammatory disease. "Infections associated with the IUD are due to the actions of the provider, through improper screening of potential users and poor insertion technique," says Dr. Tapani Luukkainen, a visiting scholar at FHI from the University of Helsinki and a leading expert on IUDs. "Infection is not due to the IUD."
If a woman is at high risk for sexually transmitted diseases (STDs), she should not use the IUD. If she has a cervical infection, it should be cured before the IUD is inserted. It is very important that all insertions be done under strictly aseptic conditions.
The newer models of IUDs generally have lower rates of bleeding and pain than do the early models.2 Also, insertions done well are less likely to cause pain and bleeding.
The first step in changing providers' views on the IUD is wide-scale dissemination of correct information. Various organizations are attempting to provide such information. FHI, for example, has recently developed a presentation on IUDs with slides, lecture script and resource materials that can be used in medical schools and training courses. (A copy of this IUD module is available at no charge to family planning trainers in developing countries who provide a written explanation of need to FHI.)
Needs vary
Training efforts on IUD use are expanding, including a national project in Indonesia and a three-year program in four Central Asian countries. Training is also intensifying in Brazil and the Philippines, to name just a few countries. The emphasis varies from country to country, depending on many factors. These include the current image of IUDs among providers and potential users, the needs of the national training structures and the health-care infrastructure, national policies, and supplies.
In the Central Asian countries, trainers are emphasizing the importance of giving the client the information she needs to choose the method. "Our biggest challenge is having the physicians recognize that women should be given information about IUDs and other methods currently available so they can make an informed choice," says Beverly Tucker of FHI. "Historically, physicians in the former Soviet Union would mandate what contraceptive method women used." Tucker is coordinating this UNFPA-funded project in Tajikistan, Kazakstan, Kyrgyzstan and Uzbekistan, all formerly part of the Soviet Union.
Where IUDs have been available in these countries, they have been well accepted. But until recently, contraceptive supplies have been very limited, and few family planning workers have received good training. The new training initiative covers counseling techniques and scientific information on several methods, but with clinical training only on IUDs. In Uzbekistan and Tajikistan, which border Afghanistan, obstetrician-gynecologists will be trained in IUD insertion, including postpartum and postabortion techniques. They will in turn train others. In Kyrgyzstan and Kazakstan to the north, a vast area about the size of India, midwives will be trained in IUD insertion as well.
In Brazil, where only 2 percent of married women of reproductive age use IUDs, the government has recently made IUDs a part of the official family planning program. "For many years, IUDs were seen as a very bad method in this country," says Dr. Juan Díaz, who has worked with IUDs in Brazil for almost 20 years. The Catholic Church did not support the method, and many stories circulated about the IUD leading to infection.
Over the years, Dr. Díaz and his colleagues at the Centra de Pesquisas e Controle des Doencas Materno-Infantis de Campinas (CEMICAMP) have provided the IUD and trained other providers in IUD use. "Gradually, women began accepting IUDs, and these happy women began telling their friends," he says. "Word of mouth is extremely important for acceptance." But the increased use was localized. With the change in national policy, more physicians receive training at more locations, including two new centers in northern Brazil where the method was rarely used before.
"The work of convincing physicians is easier now," says Dr. Díaz. "Anywhere physicians obtain a certain amount of training, they begin offering it and demand increases. To improve access, we need training, training, training."
In Kenya, researchers recommend that training focus on improved quality of care, including motivating family planning workers to take a client's best interests to heart. Despite sharp increases in contraceptive use in Kenya in the last 10 years, the number of IUD users has remained about the same. As a proportion of all modern contraceptive use, IUD use has dropped from 31 percent to 15 percent.
To assess the factors causing this decline in popularity, researchers conducted in-depth interviews with 24 providers and made 28 simulated client visits at 14 clinics. "Nurses posing as clients reported that many providers were rushed and unfriendly, and that many were not well informed about the IUD," reports John Stanback of FHI, who coordinated the study. Providers did not often mention IUDs as a choice available to clients, nor did they attempt to dispel common rumors.
The Kenya study concluded that several interrelated factors account for the stagnant level of IUD use, including poor quality of care, poor product image, provider bias or preference, and shifting client preferences. Accurate information can address some of these issues. For example, some Kenyans are reluctant to use copper IUDs that have tarnished in their packages, thinking that the greenish color can be dangerous. This oxidation process can occur in properly packaged and stored devices and does not affect IUD safety or effectiveness.
National efforts
Two ambitious national training efforts are under way in the Philippines and Indonesia. In the Philippines, IUDs had never been widely available until the government, with UNFPA assistance, recently began a large-scale training project. Between 1990 and 1994, thousands of health workers were trained, and IUD use in the Philippines increased substantially, explains Cathy Solter, who worked on the project. In one region, for example, the number of new acceptors quadrupled in three years, from 4,000 in 1990 to 17,000 in 1992, says Solter, now with the U.S.-based Pathfinder International.
"There was resistance to the training and complaints that the IUDs were too large for Filipino women -- complaints that were not correct," says Solter. The training had to address various myths about IUDs. For example, the IUD cannot circulate through the body if the uterus is perforated, as some say, nor can the IUD string get wrapped around a man's penis during intercourse. "Once they were trained, the providers' bias went the other way. They loved the method."
Many of those trained in the Philippines were midwives working in rural clinics. "They knew the women in the villages," says Solter. "They were constantly worried about the supply stream for pills. And there were few services for sterilization. With the IUD, once they put it in properly, they knew they didn't have to worry about these clients again. They really like it as a method."
In Indonesia, recent studies by the National Family Planning Coordinating Board (BKKBN) and others found that training for long-term methods needed improvement. A national five-year effort recently began to improve training, focusing on IUDs and Norplant. Funded by the U.S. Agency for International Development and coordinated by Pathfinder International, it involves government and nongovernmental organizations, professional associations and other groups.
Hundreds of clinicians will be trained as trainers in Indonesia. They in turn will train thousands of providers, about half of them midwives. Indonesia is already one of the world's largest users of the IUD, but IUD use has declined from 13 percent of married women of reproductive age in 1991 to 10 percent in 1994.
Insertion and counseling
Regardless of the specific country's situation, training projects should include certain basic components and approaches. These involve three general areas -- scientific and counseling knowledge, skills acquisition using anatomical models, and clinical practice.
"Providers have to obtain a certain level of competence in knowledge and skills before going on to clinical practice," says Patricia MacDonald of the Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO), a U.S.-based group that coordinates IUD training projects throughout the world.
Training health workers about the method covers scientific information, clinical skills, and techniques for counseling potential clients. For example, a provider must not only understand the relationship between IUDs and STDs, but also how to discuss a client's history of STDs in a sensitive way so as to get accurate information. In the past, training has emphasized the medical aspects of IUDs more than the impact on the clients. But that is changing.
"Women need to be counseled on what to expect during insertion, what you're getting ready to do," says the Pathfinder's Solter, a nurse-midwife herself. "We need to let women know what to expect from IUDs, particularly extra bleeding during menstruation. It is also important to encourage women to return to the clinic if they have any problems or questions." New training curricula are putting more emphasis on client behavior and attitudes, asking the trainees how they think clients would feel about particular steps in the process.
Studies have found that most women stop using the IUD because of personal, not medical, reasons. For example, a study of 2,748 users in 14 countries found that the most common reasons given for discontinuation were planned pregnancy (32 percent) and a husband or family opinion against IUD use (26 percent). Effective counseling about IUD use, especially among illiterate women, may encourage better continuation rates, concluded Dr. Carlos Petta of CEMICAMP, and his colleagues at FHI, who conducted the analysis.3
In the skills acquisition stage of IUD training, experts agree that the crucial element is having sufficient anatomical models with which to work. In the Philippines project, there were not enough models. Some trainees had to spend evenings to get their turn, says Solter. "It was extremely important for everyone to use the models. People have no business inserting IUDs in women without working with a model first."
Following skills acquisition, trainees get clinical experience under the supervision of an experienced clinician. Some of the most important practical elements are:
screening the clients with a preliminary pelvic exam to rule out pregnancy, pelvic inflammatory disease (PID) and endocervical infection
STD screening by personal history and sociodemographic risk factors, such as having multiple partners or a partner with multiple partners
counseling that emphasizes changes in menses, heavier bleeding with copper-bearing IUDs, and situations that would require a return visit to the clinic, such as abdominal pain, pain with intercourse, abnormal vaginal discharge, pelvic pain with fever, or a change in the IUD string (missing, shorter or longer).
Training must emphasize aseptic conditions. IUD insertion should not be done unless aseptic procedures can be followed, including handwashing by the inserter, careful preparation of the cervix, sterile IUDs and equipment, and correct decontamination of the instruments.
Midwives and nurses can insert IUDs safely with appropriate training. Studies have found that they are at least as careful as doctors in performing insertions.4 "Often, nurses or midwives are better at insertion because they are not as rushed and approach it more conscientiously," says Dr. Pouru Bhiwandi, a former FHI medical director who recently conducted insertion training in the Central Asian republics on the FHI-UNFPA project.
An appropriate follow-up schedule should be encouraged. One follow-up visit one month after insertion is sufficient unless there is a problem. Thereafter, there is no need for a fixed follow-up schedule. Research has found that multiple follow-up visits take time away from serving more clients and result in discovering only a very small number of problems that would not have caused women to return on their own.5 Users, however, must understand which symptoms require a return visit to the clinic.
Finally, after providers have gained knowledge, acquired skills and demonstrated competence in clinical practice, each individual should consider listing the specific problems he or she will face and ways to overcome these barriers. "These might be a lack of equipment and supplies for infection prevention, problems with client flow or clinic overcrowding, or the attitude of other providers," explains MacDonald of JHPIEGO.
-- William R. Finger
Footnotes
Mauldin WP, Segal SJ. IUD use throughout the world: Past, present and future. Proceedings from the Fourth International Conference on IUDs. Ed. Bardin CW, Mishell DR. (Newton, MA: Butterworth-Heinemann, 1994) 1-10.
Sivin I, Greenslade F, Schmidt F, et al. The Copper T 380 Intrauterine Device, A Summary of Scientific Data. (New York: The Population Council, 1992) 16-17.
Petta CA, Amatya R, Farr G, et al. An analysis of the personal reasons for discontinuing IUD use. Contraception 1994;50(4):339-47.
Eren V, Ramos R, Gray RH. Physicians vs. auxiliary nurse-midwives as providers of IUD services: A study in Turkey and the Philippines. Stud Fam Plann 1983;14(2):43-47.
Janowitz B, Hubacher D, Petrick T, et al. Should the recommended number of IUD visits be reduced? Stud Fam Plann 1994;25(6):362-67.
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