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It is a good contraceptive with a bad reputation in some countries.
The Copper T intrauterine device (IUD) is safe and reversible, requires
little effort on the part of the user once inserted, and offers 10 years
of prevention against pregnancy. However, in some countries family
planning clients are reluctant to use IUDs, health workers are reluctant
to provide them, or programs do not have the supplies or trained staff
needed to offer them.
Fears about side effects, concerns about infection and infertility,
lack of technical training for providers, and the time and costs
involved in providing services combine to discourage use of IUDs in some
countries. "The IUD is quite an effective method and has a lower
rate of complications than hormonal methods," says Dr. Carlos
Huezo, medical director of the International Planned Parenthood
Federation (IPPF). "Therefore, it is regrettable that its use is
low in many countries. We need to create an awareness of the safety of
the IUD and how effective it is."
Worldwide, approximately 13 percent of all women of reproductive age
use the IUD, making it the second most popular contraceptive (19 percent
use female sterilization, the leading method). However, most IUD users
are in a few countries, especially China, where a fifth of the world's
population lives. While studies show the Copper T IUD is nearly as
effective as male or female sterilization, the IUD is often ignored or
overlooked. One reason is misinformation on the part of both clients and
providers.
Myths and rumors
An international mail survey being conducted by IPPF and the World
Health Organization (WHO) has found that inaccurate information about
IUDs is a barrier to use worldwide. Dr. Huezo says preliminary data
about clients' questions and concerns revealed that rumors are
commonplace. The survey was sent to national institutions providing
family planning services in 75 countries.
"The most common misconception was that IUDs work by causing an
abortion," says Dr. Huezo. "We also heard that the IUD causes
cancer. This was a quite common perception, but it came as a surprise to
researchers. Another concern is that the IUD moves outside the uterus
and can travel as far as the heart or brain."
IPPF and WHO are preparing a list of these misconceptions for
providers and responses providers can give to address clients' concerns.
For example, no scientific evidence indicates IUDs cause cancer. In
fact, research suggests the devices reduce the risk of endometrial and
cervical cancers. Although the IUD can be expelled through the vagina or
very rarely can perforate the uterus during insertion, the IUD does not
travel outside the uterus to other organs. IUDs prevent fertilization.
Although the specific mechanisms are not fully understood, studies show
the IUD effectively interrupts the reproductive process before
implantation and pregnancy, suggesting that it does not act as an
abortifacient.
"If we want to increase the acceptability of the IUD, or any
other method, it is important to provide information and education to
the community, the clients and potential clients," Dr. Huezo said.
"It is also very important to update knowledge among the service
providers -- not only those who directly provide (contraception) but
those who provide other reproductive health services."
Up-to-date information is important. A study in Jamaica found that
private physicians often denied family planning methods, basing their
decisions on out-of-date information rather than current scientific
evidence.1 Twenty-nine percent of physicians required their
patients take a rest after using an IUD -- before inserting another IUD
or using another method -- and 11 percent required a blood test before
IUDs were inserted. Neither is medically necessary.
Incorrect or out-of-date information extends to concerns about
infection prevention. Some health workers are reluctant to recommend the
IUD because they incorrectly believe it causes pelvic inflammatory
disease (PID), a serious condition that can lead to infertility or
death.
PID risks can be reduced by screening clients at high risk of
sexually transmitted diseases. Women at risk of sexually transmitted
diseases should consider another contraceptive option, such as condoms.
"If an infection follows insertion, perhaps the woman had an
infection, such as gonorrhea, that was present in the lower reproductive
tract and was introduced into the upper tract," says Dr. Irina
Yacobson of FHI, who has conducted IUD training in several countries.
Leaving the IUD in place for its recommended life span can also help
minimize infection risks. Providers should also use sterile insertion
procedures, and encourage condom use if women have sex with potentially
infected men.
Another barrier has been the requirement that women be menstruating
before they receive an IUD, to be sure that they are not already
pregnant. FHI has developed a simple checklist to help providers rule
out pregnancy in nonmenstruating clients, and has trained providers in
Kenya on how to use the checklist.
Side effects
For some clients, fear of IUD side effects is a deterrent to IUD use
and a major reason for discontinuation. While IUD users generally report
fewer side effects than users of hormonal or traditional methods, when
side effects do occur, they can prompt client requests for IUD removal.2
Intermenstrual bleeding and cramping are the most common complaints
during the first months of IUD use. An FHI study in Thailand found that
during the first 12 months, intermenstrual bleeding and painful periods
were the side effects most often cited by IUD users.3 In
Bangladesh, 40 percent of the 3,678 users surveyed had their IUD
removed, with about one-fifth of the removals due to menstrual problems.4
And in Nepal, women mistakenly thought increased bleeding and cramping
during the first few months of IUD use were symptoms that the IUD was
migrating outside the uterus and would eventually pierce the heart.5
A recent FHI study in Latin America, Asia and Africa found that
factors contributing to discontinuation among 321 copper IUD users were
expulsion (3.1 percent) and bleeding and pain (4.5 percent). Researchers
also found that women younger than age 20 had higher expulsion rates
than older women.6
Women should be counseled about side effects and what they mean
before an IUD is inserted. If menstrual changes occur during the first
few months of use, providers should reassure the woman that these side
effects are normal and will usually diminish over time. It is not
medically necessary to remove the IUD unless the woman also complains of
fever, abdominal tenderness or unusual vaginal discharge -- signs of PID
-- or severe pain -- a sign of uterine perforation or partial expulsion.
Health workers can also help women cope with side effects by prescribing
nonsteroidal anti-inflammatory drugs, such as ibuprofen. For example,
doctors can recommend 400 milligrams of ibuprofen four times a day until
bleeding stops for women with menstrual bleeding problems and pain.
However, if the woman cannot tolerate side effects and requests IUD
removal, providers should comply and offer another method.
FHI research suggests that providers may be able to predict removals
for bleeding or pain at the one-month follow-up visit. Scientists
analyzed data from international studies and found that among 2,625
women, 89 had IUDs removed for bleeding or pain during the first year of
use. Women who were not breastfeeding at the time of insertion were
nearly three times as likely as breastfeeding women to request removal.
Women living in West Asia or North Africa were nearly three times as
likely to seek removals as their counterparts in other countries.
Researchers concluded that several factors, which could be identified at
the one-month visit, predicted IUD removal: reports of intermenstrual
bleeding since last menses, excessive menstrual flow and not
breastfeeding or stopping breastfeeding.7
Economic barriers
For clients and family planning programs, the cost of any method is
always a concern. In addition to the cost of an IUD itself, clients must
often travel long distances to clinics and pay for transportation, miss
a day's work and find child care. Family planning clinics must consider
the costs of staff time for counseling, insertion and follow-up visits.
Even the materials needed for IUD insertion can be expensive. For
instance, in an FHI study in Kenya, some clients seeking an IUD were
asked to bring gloves or cotton wool with them.8
While initial costs of IUD insertion may be high, the long-term use
of the method makes it very cost-effective over time. An FHI study in
Thailand compared contraceptive methods based on couple-years of
protection (CYP) and found the IUD's cost, including follow-up visits,
was about U.S. $0.86 per CYP after five years of use. The CYP
costs of subdermal implants and injectables were U.S. $5.65 and $5,
respectively.9 A study has shown similar cost-savings among
U.S. women over five years.10
The cost of visits is important to consider. The number of
recommended follow-up visits often varies from clinic to clinic, ranging
from two to five during the 12 months following insertion. Some women
return only because of scheduled visits, not because they are
experiencing problems. Follow-up visits that are too frequent can lead
to clinic overcrowding and divert staff and financial resources from
women in need of medical care.
To learn whether follow-up visits could reduce program costs without
compromising client health, FHI analyzed visits among IUD users in nine
countries, looking specifically at visits for women who had no symptoms
or mild symptoms but required some type of medical care. Of the more
than 11,000 follow-up visits, less than 11 percent required care
(treatment of side effects or IUD removal). Less than 1 percent required
both treatment and removal.11
Among the women with mild symptoms or no symptoms, nearly two-thirds
said they likely would have returned to the clinic without a scheduled
follow-up visit (most cited personal reasons or possible pregnancy as
the reason). Women with severe or moderate symptoms said they would have
returned to the clinic whether or not they were scheduled to.
Researchers concluded that health workers spend time seeing healthy,
satisfied IUD users, who really do not need medical services.
In Ecuador, FHI and the Population Council explored the impact of
reducing the number of IUD follow-up visits on program costs and client
quality of care. Researchers asked more than 3,300 new acceptors at the
20 clinics administered by the Centro Médico de Planificación Familiar
(CEMOPLAF) why they made follow-up visits -- to report health problems
or simply because they were told to return. CEMOPLAF required four
visits within the first year of use.
In analyzing answers, they found that IUD follow-up visits accounted
for 74 percent of all clinic visits and 64 percent of all clinic costs.
While most clients made their first follow-up visit, the number who kept
their second, third and fourth appointments declined rapidly. Of the
women diagnosed with medical problems, including expulsion and PID,
three-fourths said they would have returned without an appointment.12
As a result, CEMOPLAF adopted a new policy to require one IUD visit
no sooner than 15 days after insertion. Also, women were encouraged to
return any time they had a problem. Although the number of IUD
insertions remained the same, the number of first-year follow-up visits
declined by 36 percent. Reducing the number of follow-up visits allowed
staff time to care for more urgent problems.
-- Barbara Barnett
References
- McDonald OP, Hardee K, Bailey W, et al. Quality of
care among Jamaican private physicians offering family planning
services. Adv Contracept 1995;11(3):245-54.
- Cleland J, Ali M. Quality of care and
contraceptive continuation. In Ersheng G, Shah I, eds. Progress
of Social Science Research on Reproductive Health: Anthology of
Treatises of the International Symposium on Social Science Research
on Reproductive Health, Shanghai, People's Republic of China,
October 11-14, 1994. Beijing: China Population Publishing House,
1997.
- Reinprayoon D, Gilmore C, Farr G, et al.
Twelve-month comparable multicenter study of the TCu 380A and ML250
intrauterine devices in Bangkok, Thailand. Contraception
1998;58(4):201-6.
- Akhter HH, Faisel AJ, Ahmen YH, et al. An IUD
study to assess follow-up needed for removal or reinsertion. Summary
Bibliography of BIRPERHT Studies. Dhaka: Bangladesh Institute of
Research for Promotion of Essential & Reproductive Health and
Technologies, 1994.
- Nepal Ministry of Health and University Research
Corporation. Developing Strategies to Increase IUD Use in Urban
Areas, Population Council Operations Research Database Project
Summaries. New York: Population Council, 1993.
- Rivera R, Chen-Mok M, McMullen S. Analysis of
client characteristics that may affect early discontinuation of the
TCu-380A IUD. Contraception 1999;60(3):155-60.
- Stanback J, Grimes D. Can intrauterine device
removals for bleeding or pain be predicted at a one-month follow-up
visit? Contraception 1998;58(6):357-60.
- Stanback J, Omondi-Odhiambo, Omuodo D. Final
Report, Why Has IUD Use Slowed in Kenya, Part A, Qualitative
Assessment of IUD Service Delivery in Kenya. Research Triangle
Park, NC: Family Health International, 1995.
- Janowitz B, Kanchanasinith K, Auamkul N, et al.
Introducing the contraceptive implant in Thailand: impact on method
use and costs. Int Fam Plann Perspect 1994;20(4):132-36.
- Trussell J, Leveque JA, Koenig JD, et al. The
economic value of contraception: a comparison of 15 methods. Am J
Public Health 1995;85:494-503.
- Janowitz B, Hubacher D, Petrick T, et al. Should
the recommended number of IUD visits be reduced? Stud Fam Plann
1994;25(6):362-67.
- Foreit J, Bratt J, Foreit K, et al. Cost control,
access and quality of care: the impact of IUD revisit norms in
Ecuador. J Health Popul Dev Countries 1998;1(2):11-18.
For more information, visit Family Health International's Website at www.fhi.org
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