Training is essential to improve providers' knowledge of IUDs, their technical skills in insertion and management of side effects, and their counseling techniques.
One example of a comprehensive training program is the Green Star Network in Pakistan. Since it began in 1995, the project has trained more than 1,600 female physicians to insert IUDs and many others to provide comprehensive family planning services. Administered by Population Services International (PSI), the nationwide effort increases access to quality family planning services for low-income clients.
Only 18 percent of married women in Pakistan use modern contraceptives, but according to PSI more than 50 percent say they would like to limit or space births. To increase contraceptive use, PSI began by educating private-sector health workers, since 75 percent of Pakistanis receive health services from private providers. Since cultural values discourage women from visiting male doctors for pelvic exams and IUD insertions, the network uses female physicians and encourages male doctors to refer IUD clients to Green Star's "lady doctors."
The greatest challenge was educating physicians about the IUDs. "Doctors had heard about the IUD but did not understand how it worked," says Julie McBride, PSI marketing manager, who worked with the program in Pakistan. "There were lots of myths and rumors" among physicians, as well as clients.
While providers underwent training, PSI simultaneously conducted a family planning campaign that featured a popular actress on radio and television. The actress encouraged women and men to look for a green star outside hospital clinics, a sign of quality, low-cost family planning services. PSI has trained more than 10,000 providers to counsel about family planning and to administer methods.
Counseling needs
Like PSI's project, FHI's training programs also focus on both technical and counseling skills, says Dr. Irina Yacobson, an FHI assistant medical director who has conducted IUD training in Central Asia, Latin America and Africa. In four former Soviet Republics where Dr. Yacobson led training, most providers had experience inserting the Lippes Loop, but were unfamiliar with the different insertion technique and placement required for the Copper T.
"The general opinion (among health workers) was that the Copper T was not a good method, that it would be expelled," she says. "But providers were inserting the Copper T incorrectly, so that the arms did not unfold. The arms help hold the device in place. So this incorrect insertion caused it to fall out and enhanced the perception that IUDs did not work well."
Another important issue was the need for better counseling. "Women were not counseled at all about what to expect," Dr. Yacobson says. "Providers did not talk with women during insertion. They told them to come back in a month, but they did not tell them about side effects or about checking the string (to be sure the IUD has not been expelled). They spent minimal time explaining the procedure or the side effects."
The FHI training, financed by the United Nations Population Fund, encouraged health workers to explain the insertion process to clients -- to tell the woman what she would hear and feel as the IUD was inserted and to explain that insertion might be uncomfortable but should not be painful. In addition, providers learned to counsel women that their menstrual periods might be heavier, or they might experience more cramping the first few months following insertion.
Counseling should also include the signs of pregnancy and ectopic pregnancy, including amenorrhea; signs of possible uterine perforation, including abdominal pain, bowel obstruction or pelvic infection; and symptoms of pelvic inflammatory disease -- fever, abdominal pain, and purulent cervical discharge.
Health workers should think of the counseling process in two stages, experts say. The first stage is to explain the available method choices and help the client decide if the IUD is best for her. The second is to help the client who has chosen the IUD anticipate the insertion process and possible side effects after insertion.
"The best counseling is when we actually react to what the client wants to discuss and what seem to be her concerns," says Dr. Carlos Huezo, International Planned Parenthood Federation medical director. "If a client shows interest in the IUD, one way to approach her is to ask, 'What have you heard about the IUD? What have you heard that makes you want to use it? What concerns do you have?' Then, the provider can clarify."
-- Barbara Barnett
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