Training is essential to improve providers' knowledge of IUDs, their
technical skills in insertion and management of side effects, and their
counseling techniques.
One example of a comprehensive training program is the Green Star
Network in Pakistan. Since it began in 1995, the project has trained
more than 1,600 female physicians to insert IUDs and many others to
provide comprehensive family planning services. Administered by
Population Services International (PSI), the nationwide effort increases
access to quality family planning services for low-income clients.
Only
18 percent of married women in Pakistan use modern contraceptives, but
according to PSI more than 50 percent say they would like to limit or
space births. To increase contraceptive use, PSI began by educating
private-sector health workers, since 75 percent of Pakistanis receive
health services from private providers. Since cultural values discourage
women from visiting male doctors for pelvic exams and IUD insertions,
the network uses female physicians and encourages male doctors to refer
IUD clients to Green Star's "lady doctors."
The greatest challenge was educating physicians about the IUDs.
"Doctors had heard about the IUD but did not understand how it
worked," says Julie McBride, PSI marketing manager, who worked with
the program in Pakistan. "There were lots of myths and rumors"
among physicians, as well as clients.
While providers underwent training, PSI simultaneously conducted a
family planning campaign that featured a popular actress on radio and
television. The actress encouraged women and men to look for a green
star outside hospital clinics, a sign of quality, low-cost family
planning services. PSI has trained more than 10,000 providers to counsel
about family planning and to administer methods.
Like PSI's project, FHI's training programs also focus on both
technical and counseling skills, says Dr. Irina Yacobson, an FHI
assistant medical director who has conducted IUD training in Central
Asia, Latin America and Africa. In four former Soviet Republics where
Dr. Yacobson led training, most providers had experience inserting the
Lippes Loop, but were unfamiliar with the different insertion technique
and placement required for the Copper T.
"The general opinion (among health workers) was that the Copper
T was not a good method, that it would be expelled," she says.
"But providers were inserting the Copper T incorrectly, so that the
arms did not unfold. The arms help hold the device in place. So this
incorrect insertion caused it to fall out and enhanced the perception
that IUDs did not work well."
Another important issue was the need for better counseling.
"Women were not counseled at all about what to expect," Dr.
Yacobson says. "Providers did not talk with women during insertion.
They told them to come back in a month, but they did not tell them about
side effects or about checking the string (to be sure the IUD has not
been expelled). They spent minimal time explaining the procedure or the
side effects."
The FHI training, financed by the United Nations Population Fund,
encouraged health workers to explain the insertion process to clients --
to tell the woman what she would hear and feel as the IUD was inserted
and to explain that insertion might be uncomfortable but should not be
painful. In addition, providers learned to counsel women that their
menstrual periods might be heavier, or they might experience more
cramping the first few months following insertion.
Counseling should also include the signs of pregnancy and ectopic
pregnancy, including amenorrhea; signs of possible uterine perforation,
including abdominal pain, bowel obstruction or pelvic infection; and
symptoms of pelvic inflammatory disease -- fever, abdominal pain, and
purulent cervical discharge.
Health workers should think of the counseling process in two stages,
experts say. The first stage is to explain the available method choices
and help the client decide if the IUD is best for her. The second is to
help the client who has chosen the IUD anticipate the insertion process
and possible side effects after insertion.
"The best counseling is when we actually react to what the
client wants to discuss and what seem to be her concerns," says Dr.
Carlos Huezo, International Planned Parenthood Federation medical
director. "If a client shows interest in the IUD, one way to
approach her is to ask, 'What have you heard about the IUD? What have
you heard that makes you want to use it? What concerns do you have?'
Then, the provider can clarify."
Copyright