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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Photo: Champions can use education and marketing techniques to help audiences implement best practices. Here, a Kenya Ministry of Health supervisor acts as an IUD champion, or "detailer," encouraging providers and community-based distributors to improve IUD services. Credit: Jennifer Wesson/FHI

Spotlight: Kenya Commits To Renewing Interest in the IUD

While overall the use of modern contraceptives in Kenya has increased steadily, levels of IUD use have dropped since the 1980s. Between 1989 and 2003 the percentage of married women using the IUD fell from about 4% to 2%. The proportion of modern-method users relying on IUDs dropped over this time from 21% to 8% as use of short-term methods increased (109, 151). Some of these shifts reflect the growing availability of other methods, such as injectables. Still, a service delivery assessment attributed the decline in IUD use to several other factors as well—poor quality of IUD services, including lack of knowledge about the IUD among some providers; providers' fear of HIV transmission from clients; clients' negative perceptions of the IUD; and providers' reluctance to provide the IUD because of rare but serious side effects and because of perceptions that providing IUD services requires a high level of skill and too much time (47, 231).

In 2001 the Kenya Ministry of Health, in coordination with 15 partner organizations, began an initiative to reintroduce the IUD into Kenya's national family planning program. By renewing interest in the IUD and strengthening reproductive health service delivery systems in general, the Ministry seeks to improve the balance and sustainability of contraceptive choices (46).

The initiative uses several approaches to address the problems identified in the service delivery assessment. These include building consensus and support among stakeholders, improving service delivery, and raising awareness and interest among family planning clients (46).

Building consensus and support among stakeholders. In 2001 the Ministry of Health and its partners sponsored a series of stakeholder meetings among policymakers, funding agencies, program managers, and service providers. The stakeholders reviewed and discussed IUD research findings and international guidelines in the Kenyan context, and they revised national family planning policies and service delivery guidelines (17 ).

Since 2001 the Ministry of Health has distributed more than 4,400 IUD advocacy kits to program managers and providers. The kits are designed to increase program managers' and providers' awareness of the safety, effectiveness, cost-effectiveness, and convenience of the IUD (46, 111, 134). With this newly gained knowledge, the managers and providers can become IUD advocates themselves and draw clients' attention to the IUD.

Improving service delivery. The initiative also focuses on maintaining stocks of IUDs, equipment, and supplies. Currently, IUD insertions number about 10,000 per year in Kenya, but that number is expected to rise. USAID is providing an additional 50,000 IUDs to public and private health care centers (17). AMKENI—a USAID-funded family planning and reproductive health project in Kenya—and several international family planning organizations are supplying complete IUD insertion kits to the health centers participating in the reintroduction initiative (134).

The initiative also is exploring new IUD counseling and training techniques. For example, the Ministry of Health and its partners tested a "detailing" approach, in which ministry supervisors used education and marketing techniques to address providers' biases against the IUD and to enhance counseling skills (45). In this approach IUD champions, or "detailers," as they would be called in the pharmaceutical industry, made two visits to each health center to discuss the IUD with providers and community-based distributors and encourage improving IUD services and education. The detailers also distributed counseling materials that highlight key messages for clients about the IUD (45). The health centers that received detailing visits showed an increase from a median of 0.3 insertions per month per center to 0.7 per month. The numbers of IUD insertions declined after the detailing intervention ended, however, indicating that continual detailing visits may be needed to sustain the increase in IUD insertions (303).

The Ministry of Health, Marie Stopes International, and the German government-owned bank Kreditanstalt für Wideraufbau Entwicklungsbank (KfW Development Bank) are exploring ways to provide IUDs at low cost to clients (113, 171). One such approach is to offer coupons to potential IUD users. A woman would give the coupon to the provider that she selects and pay only a small fee for the IUD herself. The government would reimburse the provider for the rest of the fee when the provider presented the coupon (170). Unlike a conventional approach, in which the government would pay for IUD supplies directly, this approach links payment to actual IUD insertions and encourages providers to offer high-quality services that attract clients (171, 279).

Creating demand for the IUD. The initiative works with community leaders and providers throughout Kenya to provide the public with accurate information about the IUD, address men's and women's concerns about the method in community forums, and dispel myths and misperceptions. The effort employs radio broadcasts, community fairs, and print materials. For example, at educational sessions AMKENI distributed to potential family planning clients 21,000 Swahiliand English-language brochures containing general family planning and IUD-specific information (134). As of March 2004 nearly 12,000 potential family planning clients had attended IUD educational sessions (46, 135). Between 2002 and 2005 the percentage of family planning clients choosing the IUD increased from 2% to 5% in the 68 participating facilities (5). Other countries in sub-Saharan Africa, including Ethiopia, Ghana, and Uganda, have shown interest in replicating Kenya's initiative (71).