Clinical training. To be effective, training must include practical experience in performing pelvic exams, IUD insertions, and removals (319, 436). The World Health Organization (WHO) advises that most trainees need to perform at least 50 to 60 pelvic examinations and 10 to 15 IUD insertions under supervision before they have the skill and self-confidence to practice alone (126). The training should be flexible, however, to allow for as many insertions as needed. Training also should emphasize the management of side effects. Practical training should be done in small groups to assure adequate supervision (126, 287). Special training is needed for postpartum IUD insertion. When health care providers return to their jobs, they need to continue inserting and removing IUDs regularly in order to maintain their skills (287, 319).

The best training is competency-based—that is, each trainee is trained until competent to provide IUD services. The competency-based approach recognizes that different providers will need differing amounts of practice before they are competent. The approach also requires training programs to recognize that some providers will not achieve competence during a training course and therefore cannot be certified as competent (571).

The value of the competency-based approach for training in IUD insertion has been demonstrated. The Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO) has developed competency-based training for trainers of IUD insertion (614). In a comparative study in Thailand, a higher percentage of the midwives who learned from these trainers achieved competency during the training course than midwives whose trainers were trained by conventional techniques. Also, the clients of these midwives were more satisfied with the services that they received, and the training cost less. Among the key elements of the JHPIEGO approach are standardization of the way the trainers themselves provide IUD services, practicing insertion on a pelvic model until competent before practicing with actual clients, and assessing clinical skills before the course to ascertain where each trainee needs to improve. Even with the conventional training, the Thai midwives needed an average of just 6.5 practices with clients. With the new training approach, however, midwives were competent after an average of only 1.6 practices with clients, and 98% of the midwives achieved competence after only three practices with clients (571).

Thorough training in IUD insertion along with careful counseling and follow-up lead to longer IUD use. In areas of Sri Lanka where doctors and public health midwives received refresher training that emphasized insertion technique, counseling, and follow-up, rates of discontinuation due to expulsion or complications were significantly lower than where there was no special training (107, 353).

Training in communication. As noted, family planning providers who offer IUDs must be able to counsel clients accurately and empathetically. To do so, they themselves need both training in counseling techniques and accurate information about IUDs. Providers themselves may believe some of the false rumors about IUDs—that the IUD can travel to the heart or brain, or that the IUD string can become wrapped around a man's penis during intercourse, for example. Effective training identifies trainees' misperceptions and addresses then directly. The result can be a new and positive attitude toward IUDs (593). Program managers, ministry officials, and other decision-makers also need updates on IUDs. Without such updates, they may not be aware that recent scientific findings show the modern IUD to be a safe, highly effective, and comfortable method for many women.

The role of nurses, midwives, and paramedics. In Chile, China, Ecuador, Ghana, Indonesia, Nigeria, Sweden, Thailand, Turkey, the US, and many other countries, nurses, midwives, or paramedical workers routinely insert IUDs (51, 203, 268, 270, 351, 429, 436, 448, 482). Studies in a number of countries have found that with appropriate training these health care personnel provide safe and effective IUD services (18, 35, 268, 293, 313, 353, 436, 439, 448, 482, 484). A WHO study in the Philippines and Turkey, for example, found that assistant nurse-midwives and doctors inserting IUDs were equally able to identify eligibility criteria and complications of IUD use. Furthermore, rates of expulsion, pregnancy, medical removal, and continuation were similar in the clients of the two types of providers (439). A Brazilian study also found no significant differences in complication or continuation rates between women randomly assigned for IUD insertion to a doctor or to a nurse (35). Where nurses, midwives, or paramedical workers provide IUD services, doctors should be readily available for supervision, consultation, and, when necessary, diagnosis and treatment of complications.

Community health workers, trained traditional midwives, and other briefly trained health care personnel also can play an important role in IUD services. With appropriate training they can tell women about IUDs and other methods and help in counseling about routine side effects, recognizing complications, and referring women for medical care when necessary (125, 436). Satisfied IUD users also can be helpful in spreading the word about IUDs. In Sri Lanka, where midwives were teamed with satisfied IUD users, they recruited an average of two-thirds more new clients than midwives alone (107, 353).

Now that long-lasting second-generation copper IUDs have become available and research has identified the appropriate users, attention is focusing more on improving the way that programs provide IUDs. As with all family planning methods, it is essential to help the client decide whether the IUD suits her needs or, if the IUD is not medically appropriate, to encourage her to choose another method. At the same time, well-trained providers are needed to insert and remove IUDs properly and to help whenever the user has a problem. When the right women are using IUDs with the right program support, the result is effective, safe contraception and satisfied users.