JHPIEGO TrainerNews™ |
Workshop Held on Increasing Access to
the IUD
(September 2003)
An inter-agency workshop entitled, "Increasing Access to the IUD," was held on 21 July 2003 in Chapel Hill, North Carolina, USA and hosted by Family Health International's (FHI) Research to Practice Initiative in collaboration with USAID's Service Delivery Improvement Division. The following meeting summary is excerpted from the workshop's final report.
The objectives of the meeting, attended by JHPIEGO staff, were: developing new strategies; sharing recent key findings; developing a dialogue between research and service delivery agencies; and, above all, to increase the range of available contraceptive options for women.
David Grimes, FHI Vice President for Biomedical Affairs, presented a summary of recent research concerning the IUD. Reports since the mid-1980s have consistently had favorable results. In addition to being extremely effective, IUDs have now been proven to be extremely safe as well. A large randomized controlled trial in Los Angeles of the use of prophylactic antibiotics at IUD insertion found almost no pelvic inflammatory disease (PID) among IUD users, regardless of prophylaxis.(1) Follow-up studies of women discontinuing IUDs in Norway and New Zealand found no significant increase in involuntary infertility; indeed, the problem after removal was unwanted fertility. The most important study of IUDs and infertility was conducted by Hubacher and others and published in the New England Journal of Medicine in 2001.(2) This sophisticated case-control study from Mexico City showed that the copper IUD use was not associated with tubal infertility in nulligravid women (women who had never been pregnant); in contrast, past infection with Chlamydia trachomatis was associated with tubal obstruction.
Another recent contribution was Shelton's Lancet analysis showing that even in settings with high sexually transmitted infection (STI) prevalence, very little PID could be attributed to IUD use.(3) Grimes extended this example to show that the small morbidity attributable to IUD use is outweighed by the substantial morbidity and mortality of unintended pregnancy in the absence of contraception. Given the IUD's failure rate of about 2 women per 100 over ten years, Grimes noted that this efficacy is tantamount to that achieved with surgical sterilization, but without the risks, cost, and irreversibility of surgical sterilization.
Grimes presented a summary of data to address the question: Does morbidity attributable to IUDs outweigh morbidity and mortality of unintended pregnancy?
In a setting with high prevalence of STIs, about 667 women would have to receive an IUD to cause an infection in one of them. About 12 percent of such infections lead to infertility with adequate treatment, so worst-case scenario might be 25 percent. Thus, about 2700 IUD insertions might lead to one case of infertility. With a high STI prevalence, what are the obstetrical and neonatal consequences of denying 2700 women in Central Africa an IUD?
- 2160 pregnancies
- at least 400 serious obstetrical complications
- 1-2 deaths from pregnancy and childbirth
- unknown mortality and morbidity from unsafe abortion
For more information about IUDs and family planning programs, contact Ron Magarick or Harshad Sanghvi at repro@jhpiego.net.
References:1. Grimes, D. et al. Randomized controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet. 1998;351(9108):1005-1008.
2. Hubacher, D. et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. New Eng J Med. 2001;345(8):561-567.
3. Shelton, JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet. 2001;357(9254):443