Contraceptive Update: Contraceptive Pearls
(November 2002)

The "Contraceptive Pearls" offer answers to commonly asked questions about family planning. These "Pearls" were prepared by Dr. James D. Shelton, Senior Medical Scientist, Office of Population and Reproductive Health, United States Agency for International Development (USAID). They are reprinted with permission. To view archives of Jim Shelton's Pearls online, visit Jim Shelton's Pearls online

How Many IUD Insertions to Reach Competence?

Question: We do a fair amount of IUD training in our program, but finding enough clients desiring IUDs is always an issue for such training. How many IUDs is one required to insert under supervision to be properly trained in this technique?

Answer: There is no "magic" number of repetitions that will ensure mastery of any clinical skill by all learners. Many factors can either facilitate or hinder learning (e.g., the experience of the learner, the teaching techniques, etc.) Using competency-based training, the learner is supervised and assessed until competency is demonstrated regardless of how many procedures are performed.

One technique to reduce actual human insertions is the so-called "humanistic" approach that uses anatomic models together with individual feedback and assessment before the learner progresses to actual human insertions.

The effectiveness of this approach was demonstrated in a Thai study in collaboration with JHPIEGO comparing a traditional 6-week IUD course (which did not include anatomic models) to a 2-week course incorporating the use of models and competency-based training. With the humanistic approach, 70 percent of the 150 participants were judged competent after just two insertions with clients, and 100 percent by six insertions. By contrast, of the participants taught without models, 50 percent obtained competency only after an average of 6.5 insertions and 10 percent never achieved competency even after 15 insertions.

Reference: Limpaphayom K et al. 1997. The effectiveness of model-based training in accelerating IUD skill acquisition. British Journal of Family Planning 23(2):58-61.

Quick Start for Oral Contraceptives (OCs)

Question: I've heard there is a new procedure for initiating OC taking called "Quick Start." Can you tell me about it?

Answer: Yes, rather than traditional approaches of starting OCs during the menstrual period or on the first Sunday, with Quick Start (or Quickstart) the woman takes her first pill on the actual day of her first visit. Some places such as the Columbia-Presbyterian Clinics in New York even employ an approach where women take the first pill immediately under "direct observation." The rationale for Quick Start is to improve acceptability and use by eliminating the time period women would be waiting for their menstrual periods.

Notably, two small observational studies in the US have found improved continuation rates with Quick Start. There also does not appear to be an increase in side effects.

References: 

1. Westhoff CL et al. Quickstart: A novel oral contraceptive initiation method. Paper Presented at 129th APHA Meeting, 2001.
2. Lara-Torre E and Schroeder B. Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills. Contraception 66:81-85, 2002.

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