Series B, Number 7
Intrauterine Devices

CONTENTS

Home (Key Points)

The IUD: An Important Method with Potential
Table 1. Overview of IUDs
Figure 1. Most IUD Users Are in China
Web Table 1. Current Use of Contraceptive Methods Reported by Married Women 15-49, 1976-2005
Table 2. Estimated Worldwide Use of IUDs Among Married Women Ages 15–49, 2005

Providing High-Quality IUD Services

Spotlight: Kenya Commits To Renewing Interest in the IUD

Feature: Good Counseling Increases Client Satisfaction

Very Low Overall Risk of Infection with IUDs
Figure 2. Risk of Pelvic Inflammatory Disease (PID) Greatest in First Few Weeks After IUD Insertion

Box: Evidence Shows Many Women with HIV Can Use IUDs

Minimizing the Risk of Infection

Clinical Characteristics of IUDs
Web Box 1. Managing Problems with IUD Use

Bibliography

Credits

Go to the IUD Toolkit at http://www.iudtoolkit.org for full-text resources, including tools and best practices, on IUDs.

• Checklist: Program Plan for Providing High-Quality IUD Services
• Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International
• Counseling Aid for Communicating IUD Effectiveness

• IUD Use, STIs, and HIV-Related Conditions: 2004 WHO Medical Eligibility Criteria
• Do IUDs Increase the Risk of PID in Women with STIs?

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Providing High-Quality IUD Services

• Updating Guidelines Can Remove Medical Barriers
• Improving Providers' Practices
• Assuring Infrastructure, Equipment, and Supplies
• Training Staff To Provide IUD Services
• Improving Clients' Perceptions of IUDs

Introducing or reintroducing a contraceptive requires attention to policy and service delivery, on one hand, and to the public and potential users' knowledge and perceptions, on the other (206, 226, 264). Providing IUD services requires particular attention to service delivery factors—for example, service delivery guidelines that are up-to-date; providers who know how and why to follow guidelines; infrastructure, equipment, and supplies; a core group of competent IUD providers and a referral system that brings women to them (see 'Checklist: Program Plan for Providing High-Quality IUD Services'). But programs cannot neglect improving the perceptions of the IUD among potential clients and ensuring they know where to obtain services. A holistic approach that brings well informed clients together with good-quality services will help ensure a successful IUD program.

Updating Guidelines Can Remove Medical Barriers

Unnecessary medical barriers to contraceptive use incorrectly restrict or deny clients access to a method. These barriers often have a medical rationale, but they are not justified by the weight of scientific evidence (203). Common medical barriers to IUD use include limiting insertion to the time a woman is menstruating and requiring unnecessary multiple follow-up visits (203). Restrictions based on marital status, age, or the number of children that a woman has also are common barriers (22).

Medical barriers can be imposed at the policy level, through outdated or misinformed service delivery guidelines, or at the provider level, through individual attitudes and practices (22, 203). To ensure good quality of care, service delivery guidelines for providing contraceptives should be based on current scientific evidence. In many countries, however, national guidelines have directed providers to impose unnecessary restrictions. For example, in Burkina Faso and Kenya guidelines in the 1990s restricted IUD use to women who had had children (22).

No universal rules exist for assessing when guidelines should be reviewed and updated. The most common advice is, with each revision, to plan when the next review will take place (296). Guidelines can become quickly out-dated, however, if new evidence comes out before the scheduled review. An alternative approach is to update guidelines when new evidence becomes available.

At the local level systematically and continuously checking the world's medical literature for relevant new evidence would be time-consuming and duplicative. The World Health Organization, however, does continuously monitor medical literature, looking for new research that will affect its family planning guidance (293). A WHO Expert Working Group convenes as needed to update WHO guidance based on full reviews of medical literature including the most recent evidence.

Thus WHO guidance serves many countries as the primary basis for developing and updating national service delivery guidelines (59, 124, 230). In 2004 WHO updated its guidance for some contraceptive methods, including IUDs (181, 194). (For full text see the WHO Web site at: www.who.int/reproductive-health/publications/mec/.) In particular, the 2004 Medical Eligibility Criteria for Contraceptive Use contains several significant changes to recommendations for women with STIs and HIV-related conditions—changes that allow more women to start and continue using IUDs (see ' IUD Use, STIs, and HIV-Related Conditions: 2004 WHO Medical Eligibility Criteria').

While international standards are important and useful, so too is the involvement of key stakeholders at the country level to develop and revise national guidelines. This involvement helps to promote consensus on and ownership of the new guidelines, and it reassures providers that the local situation has been taken into account (46, 124). For example, the Kenyan Ministry of Health sponsored a series of meetings for key stakeholders, including Ministry of Health personnel, leaders of medical and other health professionals' associations, donor organizations, program managers, and representative service providers, to translate WHO guidance on IUDs into national service delivery guidelines (see 'Spotlight: Kenya Commits to Renewing Interest in the IUD'). These meetings were crucial to building a sense of shared ownership of the new guidelines and strong partnerships among the stakeholders (128). For instance, various professional associations, which represent most health care providers in Kenya, are encouraging providers to support the Ministry of Health's initiative to improve access to the IUD (17).

Improving Providers' Practices

Providers often impose their own barriers to contraceptive use. Either they are not aware of the guidelines, or they misinterpret or even ignore them when they contradict established understanding, practices, or beliefs. For example, many providers interviewed in the 1990s in Botswana, Burkina Faso, Senegal, and Zanzibar, Tanzania, said that they impose a minimum age requirement for IUD use, even though national guidelines do not (22).

When researchers from Family Health International showed family planning providers in Bangladesh, the Dominican Republic, Kenya, and Senegal a checklist of medical eligibility criteria for IUD use, the providers said it would be useful to help apply service delivery guidelines and easy to use (48). Still, posed with hypothetical scenarios, an average of 30% of these providers would ignore the checklist and would deny IUDs to women who would be, in fact, eligible for IUD insertion, based on 2004 WHO guidance. Apparently, some providers could not change their practices based solely on the guidance in the checklist.

This finding suggests that programs need to do more than distribute updated guidelines to providers. Programs should use a variety of dissemination and implementation approaches appropriate for the barriers to be overcome. For example, seminars or workshops may be sufficient if the only barrier is lack of knowledge among providers. Educational outreach through opinion leaders would be more appropriate for overcoming providers' biases against the IUD because of cultural issues or practices (286).

Providers are more likely to apply service delivery guidelines when trained how to apply them, especially when supportive supervision reinforces that training (192). In Kenya providers' knowledge, attitudes, and practices improved significantly and incrementally when they received standard training, training plus a package of printed materials, or training, printed materials, and follow-up supervision (229). Before the providers received training, 73% of them incorrectly thought that only women who had had children could use IUDs. After training, this number dropped to 46%, 41%, and 30% in the three groups. Returning to work, the trainees updated some of their colleagues who had not attended the training. The knowledge, attitudes, and practices of these providers also improved significantly but not as much as those of the directly trained providers.

Assuring Infrastructure, Equipment, and Supplies

To assure a continuing capability to offer IUDs, a health care facility needs more infrastructure, equipment, and supplies than for other reversible contraceptive methods. For example, IUD services require clean water, a private space, a bed or table, vaginal specula to inspect the cervix, forceps to clean the cervix and stabilize the uterus, a uterine sound to measure uterine depth, cotton balls, antiseptic solution, gloves, and, of course, IUDs (102, 251). In addition, a facility must have equipment to assure that, before reuse, all instruments are either (a) sterilized by autoclaving (high-pressure steam) or dry heat, or (b) high-level disinfected by boiling or steaming for 20 minutes or soaking in special chemicals (102). (Sterilization kills all microorganisms, while high-level disinfection kills all but some forms of bacteria. High-level disinfection is acceptable for processing used IUD instruments because the instruments touch only intact mucous membranes or broken skin, not the sterile tissue beneath the skin (102).) Some donors, such as UNFPA, provide IUD kits that include all necessary supplies and equipment (252).

Providing IUD services can be demanding for family planning programs with limited resources. Many clinics lack either the necessary infrastructure or the equipment and supplies. In Guatemala in 2002, for example, nearly all government clinics and health centers had the necessary infrastructure (consisting of a private space, a gynecological bed, and electricity), but about half lacked equipment and supplies (20, 65). In contrast, in Ghana nearly all family planning facilities had equipment and supplies, but only about half had the necessary infrastructure (65, 84).

Still, family planning programs can adopt innovative strategies in low-resource settings. In Bangladesh, for example, the Rural Service Delivery Program provides family planning services, including IUDs, through satellite clinics run out of rural homes without electricity or running water. The program transformed ordinary tables into gynecological beds and designed curtains to ensure privacy during pelvic exams (16). The program also adapted a portable steam sterilizer, originally designed for sterilizing hypodermic needles and syringes, for sterilizing IUD insertion equipment and supplies (13). The portable sterilizer enables health workers to fully sterilize IUD instruments and supplies beforehand at stationary clinics, instead of boiling them at the homes, which is not always possible. To be certain the instruments and supplies remain sterile during transport, health workers keep the instruments in the portable sterilizer until just before the insertion procedure. While mobile teams such as these can successfully offer IUD services, they must take special care to maintain cleanliness and avoid mistakes, since follow-up care is often difficult.

Cost-effective for programs and clients. An IUD can be used for many years, and the user does not need more supplies. Thus over time IUDs can be cost-effective for both programs and clients, even though initial costs may be higher than for other reversible contraceptive methods. In the Mombasa, Kenya, health care system, if each method were used for its full effective lifetime, the average cost per year of contraceptive protection with an IUD in 2003 would have been about US$4, compared with US$7 for tubal ligation and between US$10 and $20 for oral contraceptive pills, implants, or injectables (110). The one-time cost of IUD insertion amounted to less than other methods that involve continuing costs for supplies. Also, over the long run service delivery costs for IUDs are lower than for some other methods because the IUD requires only one revisit.

If clients are asked to pay for services, the initial fee for the IUD and its insertion may be higher than for other reversible methods. In urban clinics in Kenya, for example, clients pay about US$3 at the first visit for the IUD and insertion procedure. By comparison, a single injection of the three-month injectable depot medroxyprogesterone acetate (DMPA) or one packet of oral contraceptive pills—a month's supply—costs about $1. In many cost studies, however, the IUD becomes among the least expensive methods for clients in one to five years (30, 110, 224, 246). For clients who cannot afford to pay the initial fees all at once, programs can set up alternative payment plans such as paying the fees in installments (36).

Programs can keep down costs. There are a number of ways to provide IUD services at modest cost per client. One way is for programs to offer immediate postpartum IUD insertion (that is, insertion within the first 48 hours after delivery of the placenta) at birthing centers. In Nyeri, Kenya, for example, the Provincial General Hospital found in the 1990s that, for one year of contraceptive protection, IUD insertions at a maternal and child health clinic six or more weeks after childbirth cost about 40% more than immediate postpartum insertion in the hospital delivery room (289). This estimate took into account the greater likelihood of expulsion with immediate postpartum insertion and the average number of revisits for each type of insertion. (While expulsion is more likely with immediate postpartum insertion than with later insertion, the additional risk is not enough to favor delaying IUD insertion (see diagram in 'Expulsion Uncommon').) Postpartum insertions cost less in Kenya primarily because sterile conditions were already present in the delivery room. In contrast, staff at the clinic had to spend extra time preparing (287). A study in Lima, Peru, also found that outpatient insertions cost about 40% more than postpartum insertions in hospitals (62). The immediate postpartum period can be a convenient time for insertion, especially for women who lack easy access to family planning services.

Eliminating unnecessary routine follow-up visits also can save on costs. WHO recommends one routine visit about a month after insertion or around the time of the client's next menstrual period (269). At this visit the provider checks that the IUD is still in place, looks for any signs of infection, and finds out whether the client is satisfied or has any problems. While the client should be invited to come back any time she wants help or to have the IUD removed, further routine follow-up is not needed. Most IUD users whose problems require medical intervention have serious symptoms.

These clients come back without a scheduled routine visit (92, 100, 153). In Ecuador the Céntros Médicos de Orientación y Planificación Familiar (CEMOPLAF), a private voluntary organization that operates family planning and reproductive health clinics throughout the country, once required IUD users to return to the clinic four times in the first year after insertion. Only 30% of IUD users returned for follow-up four or more times in the first year. The average number of revisits in the first year under the four-revisit norm was 2.3 (61). Still, these IUD revisits accounted for 74% of all family planning visits and 68% of all family planning costs. In 1993 CEMOPLAF reduced the number of required routine follow-up visits from four to one. This change resulted in 29% fewer IUD revisits in 1993 than in 1992, while the number of IUD insertions remained the same (61).

Costs also can be kept down by permitting trained allied health workers to insert and remove IUDs. Studies have found that nurses, midwives, physicians' assistants, and medical students can insert and remove IUDs safely and effectively when appropriately trained (41, 55, 117), and at a lower cost to programs than when physicians insert IUDs. In Chile, China, Ecuador, Ghana, Indonesia, Nigeria, Sweden, Thailand, Turkey, the U.S., and many other countries, nurses, midwives, and other health care professionals besides physicians routinely insert IUDs (244).

Training Staff To Provide IUD Services

Good IUD services require competent health care providers. Training must cover how to insert and remove IUDs, manage potential side effects and complications, and communicate well with clients (see 'Feature: Good Counseling Increases Client Satisfaction'). To succeed, training must include practical experience.

Competency-based training works best. Competency-based training develops the skills, knowledge, and attitudes required to meet standards of competence. Training continues until each trainee is competent to provide IUD services. The approach focuses on the success of each trainee, recognizing that different providers need differing amounts of practice to reach competence. Key elements of the competency-based approach include standardization of the way that the trainers themselves provide IUD services, practice with a pelvic model, and opportunities for trainees to continue practicing until they have mastered all necessary skills (233).

JHPIEGO, an international health organization affiliated with Johns Hopkins University, has demonstrated the value of the competency-based approach for IUD skills training. In a comparative study in Thailand, a significantly higher percentage of midwives who learned through the competency-based approach achieved competence by the end of the study period than did midwives trained by conventional techniques. Midwives in the conventional training group needed an average of 6.5 insertions before achieving competence. With the new training approach, which involved practicing on pelvic models during classroom training, midwives were competent after an average of only 1.6 insertions, and 97% of the midwives achieved competence after no more than 3 insertions. Competency-based training takes less time, and therefore it costs less, than conventional approaches (122).

Practicing on models before working with clients helps trainees achieve competence faster than conventional classroom approaches. Here, family planning providers in Cambodia practice IUD insertion on pelvic models. (© Marcel Reyners, Courtesy of Photoshare)

JHPIEGO has developed an innovative approach to implement competency-based training for IUD provision, called Modified Computer-Assisted Learning (ModCal®). Trainees learn about IUD counseling, insertion, and removal at their own pace through interactive computer modules, which replace conventional classroom lectures. Clinical facilitators are available for individual coaching and follow-up. Once trainees pass ModCal's knowledge test, they move on to practical training with pelvic models and then with clients in a clinic (103).

Training a core group of providers. Conventionally, programs have trained many providers at different professional levels in IUD insertion and removal (204). Despite training, some providers have been reluctant to provide IUDs because it requires more time and effort than providing other reversible contraceptive methods (85, 108, 200, 231). Also, unless providers serve clients regularly, they quickly lose their skills and confidence.

An alternative is training a core group of providers to offer IUDs, giving them continued support and guidance, and referring clients to these providers. This approach helps ensure that providers see enough clients to maintain their IUD insertion and removal skills (196). Programs also can save money because they train fewer providers. Finally, and most importantly, this approach can assure clients of high-quality IUD services from competent providers.

To train providers who will continue to offer IUD services, programs can identify and select those who have the interest and potential for or are already providing a high volume of IUD services. Also important is selecting providers from well-located clinics that serve many people without long travel. Referral networks ensure that clients interested in the IUD reach these clinics. This approach has worked in Bangladesh, Bolivia, India, and Pakistan (204).

Improving Clients' Perceptions of IUDs

Even if programs are ready to provide IUDs, many women will miss the opportunity to choose this method if people are not aware of the IUD or have negative or incorrect perceptions. In 37 of 71 countries with data from Demographic and Health Surveys or Reproductive Health Surveys, the IUD was either the least known or the next to least known modern method (after male sterilization) among married women of reproductive age (283). In 19 sub-Saharan African countries surveyed and in Haiti and Mauritania, less than half of surveyed women had heard of the IUD. Insufficient promotion contributes to lack of awareness, especially when compared with pharmaceutical products, such as injectables, which tend to receive more attention in the mass media (137).

If people are aware of the IUD, they often have negative perceptions of it. These negative perceptions may be based on real side effects of the IUD—for example, increased bleeding with copper-bearing IUDs. Others, however, result from misinformation and have little or no basis in fact. Surveyed family planning providers around the world have reported many misperceptions among their clients, including that the IUD is large; can migrate to a woman's heart, brain, or other remote parts of her body; and can be used only by older women or women who have had children (97).

Marketing branded products and services can help attract clients, as in Pakistan's Greenstar program. Clients recognize the Greenstar logo as a symbol of affordable, high-quality family planning services.

Well-designed communication campaigns can increase people's awareness of the IUD and address negative attitudes. Involving men in such campaigns is important. They play powerful, and sometimes dominant, roles in couple's reproductive decisions (302). Some approaches found to be effective include:

• Low-cost educational materials and counseling. In Honduras rural health centers used a simple and inexpensive approach to increase demand for IUDs. Six nurse auxiliaries newly trained in IUD insertion and other reproductive health services gave 10-minute talks to clients in groups about the new services they could offer, including IUD insertion. Then they asked each client to distribute five leaflets advertising the new services to friends and neighbors. Three months later the number of IUD insertions had increased by 50% compared with the three months before the project started. The entire project, including training, supervision, and the production of 25,000 leaflets, cost only US$950 (64, 138).
• Branding. In Pakistan the Greenstar network of over 11,000 franchised private health clinics in 40 urban areas delivers high-quality family planning services including IUD services at affordable prices (133). Greenstar practitioners agree to provide high-quality family planning services, meeting standards set by the franchiser, a local nongovernmental organization called Social Marketing Pakistan. In return, Social Marketing Pakistan provides the franchisees with training and support, and it markets the Greenstar brand name to attract clients. In 1997, two years after the program started, 93% of surveyed people in low-income urban areas recognized the Greenstar logo and identified it as a symbol of affordable, high-quality family planning services (178). Greenstar providers serve an estimated 7.5 million family planning clients each year. Greenstar's efforts helped increase contraceptive prevalence among married women in Pakistan from 18% to 28% between 1995 and 2001. While overall levels of IUD use in Pakistan remain relatively low, they nearly doubled, rising from 2% to almost 4%, during this period (141).
• "Champions" to promote IUDs. Communication campaigns sometimes use champions, or advocates, to educate audiences and motivate people to consider the method. In the 1980s in Sri Lanka, teams consisting of a midwife and a satisfied IUD user recruited almost two-thirds more new IUD users over a period of 13 months than midwives working alone (60). In Kenya the Ministry of Health uses district supervisors as champions to promote more and better counseling about IUDs among providers in clinics and community-based distribution programs (see 'Spotlight: Kenya Commits To Renewing Interest in the IUD').
• Community outreach. In Egypt mobile teams consisting of a female physician, a nurse, a communication specialist, and a social worker visited rural health units periodically to provide IUD services to clients (295). In addition to increasing access to IUDs, the mobile teams also have improved women's knowledge about IUDs and their potential side effects. In Kenya local leaders and providers seek to dispel myths and misperceptions about the IUD by addressing men's and women's concerns in community forums and through radio broadcasts (see 'Spotlight: Kenya Commits To Renewing Interest in the IUD').