|
|
Key Points
- Ministry of Health commitment greatly facilitates IUD
reintroduction.
- Strong partnerships with professional organizations are
key to integration of IUD services into existing programs.
- Systematic provider training and attention to supply
issues are essential to build capacity.
- Advocacy efforts are needed to dispel myths, thus
increasing provider interest in and client demand for the
IUD.
- Continuous monitoring and evaluation help identify
problems and solutions.
|
Mombasa, Kenya For many years, Nancy Karisa has known that the
Copper T 380A intrauterine device (IUD) is a good contraceptive option
for many women. A registered community health nurse and unit matron at
the Port Reitz district hospital in Mombasa, Kenya, Karisa is well
acquainted with research showing that the IUD is both safe and highly
effective. What is more, it is inexpensive over the long term, an
important attribute in the resource-constrained setting where she works.
Personal experience also has made her an IUD advocate. Karisa herself
uses one. She used her first IUD for three years, then had it removed to
conceive her third child. After that child's birth, she had her second
IUD inserted and has enjoyed trouble-free contraception ever since.
The Port Reitz hospital has acquired a reputation for relatively high
IUD acceptance among clients seeking contraception. That success has
been attributed largely to the training of four (out of six) family
planning providers there to clearly explain the nature of the device to
clients, counsel about its advantages and disadvantages, and insert it.
However, tabulation of IUD acceptance rates at the hospital by a Kenya
Ministry of Health (MOH) official in February 2003 showed that while on
average 220 women received contraceptive methods each month between July
2002 and January 2003, the percentage of women selecting the IUD was
low: at best, only 4 percent.
Primary among barriers to IUD acceptance at the hospital are a
variety of myths about the device. "Some women fear that the IUD
will migrate to other parts of their body, or that the copper in it will
cause side effects," Karisa says. Still others continue to believe
despite research showing that fertility returns almost immediately
after removal that the IUD will delay or impair fertility.
Other barriers can easily arise. Providers throughout Kenya often
feel that they are not properly trained to insert IUDs. Many complain
that IUD insertion requires supplies that they lack or that it is too
time-consuming compared with provision of such contraceptives as
hormonal injectables and pills.
Aggressively confronting these and other barriers to the acceptance
and provision of IUDs is now the goal of a comprehensive effort to
"rehabilitate" the IUD in Kenya. A pilot initiative,
undertaken by the Kenya MOH in collaboration with some 15 partner
organizations,* including FHI, was officially launched on February 23,
2003, at a preconference symposium at the 5th East, Central, and
Southern African Association of Obstetrical and Gynaecological Societies
(ECSAOGS) meeting in Mombasa. The initiative's strategy, being developed
by a task force chaired by the MOH and coordinated by FHI, is to
increase support for the IUD among policy-makers, health care
professionals, and clients; increase provision of high-quality IUD
services in Kenya; enhance demand for IUDs; and collect data to
continuously monitor and improve the performance of the program. MOH
partners will collaborate to integrate the IUD into existing programs
(with little additional funding), creating a true partnership of all
family planning service providers in all 77 districts in the country
(see Professional Associations Are Vital Partners).
FHI has welcomed the opportunity to coordinate the IUD task force, as
well as to assume responsibility for advocacy, monitoring and
evaluation, and operations research for the initiative, says Dr. Maggwa
Ndugga, FHI regional director for reproductive health programs, Eastern
and Southern Africa. "We share the MOH's vision," he says,
"and ideally, the IUD rehabilitation campaign in Kenya will become
a model for activities to promote increased use of research findings and
incorporate practitioners' needs into the agenda of research
organizations."
An idea is born
The IUD has been available in Kenya for many years, and few have
disputed its attractiveness as a contraceptive method. Yet, despite a
marked and steady increase in overall contraceptive use in Kenya (from 9
percent to 39 percent among married women between 1978 and 19981),
IUD use dropped from 31 percent in 1984 to 9 percent in 1998 among
married women using contraception.2 More recently, in April
2002, an MOH review found IUD use declining in all of Kenya's provinces.
Dr. Josephine Kibaru, head of the Kenya MOH's Division of
Reproductive Health since July 2002, says that, as a practicing
gynecologist during the 1980s and 1990s, she was well aware that IUD use
was declining. And now that she is in a position to reverse that trend,
she is committed to doing so. Such a commitment is not only necessary
but also appropriate in light of the country's reproductive health
strategy for 1997 through 2010. That strategy calls for increasing
access to family planning, enhancing quality of care and affordability
of services, and reviewing and revising curricula and training to ensure
provision of high-quality reproductive health services. Although some
national policies and guidelines for IUD provision require review and
revision, they are in general "very supportive of IUD use,"
says Professor Samuel Sinei, deputy vice chancellor at Jomo Kenyatta
University in Nairobi and a practicing obstetrician and gynecologist,
who recently reviewed national IUD policy documents.
| Nicholas Bosco |
|
|
During a symposium at the 5th East, Central, and Southern
African Association of Obstetrical and Gynaecological
Societies (ECSAOGS) meeting in Mombasa, Dr. Josephine Kibaru,
head of the division of reproductive health of the Kenya
Ministry of Health, confirms the ministry's commitment to
increase IUD use in the country.
|
Dr. Masden Solomon, manager of the MOH's Division of Reproductive
Health, confirms that the MOH has the political will to reintroduce the
IUD. "The Kenya Ministry of Health seeks to develop and implement a
program with a method mix that emphasizes cost-effective, long-term
contraceptive methods," he says. "Available evidence
recognizes the critical role that the IUD has in the formulation of such
a method mix. Resources for family planning in Kenya are declining, in
part because the need to respond to the HIV epidemic is producing havoc
throughout our health care system. Meanwhile, the population entering
reproductive age and requiring family planning services is growing.
Increasing use of the IUD can both decrease our family planning program
costs ensuring program sustainability and increase contraceptive
choice for our clients."
Expanding contraceptive choice is key. While recently introduced
contraceptive methods, such as the progestin-only injectable depot-medroxyprogesterone
acetate (DMPA), have enjoyed great popularity, they like other
methods do not meet every woman's needs. A highly reliable but
reversible method, the IUD can provide long-term protection to women who
want to delay another pregnancy. Unlike hormonal methods, it does not
require resupply visits, requires little action on the part of users,
and can be used by women of any age, hypertensive women, and
breastfeeding women. The IUD is also an attractive option for women who
do not want more children but who are not ready or do not want to accept
a permanent contraceptive method.
Over time, the IUD is very inexpensive for clients and programs. In
Kenya, an IUD costs less than one year's supply of oral contraceptives
or five DMPA injections (given over a period of 15 months). And, when
all program costs (including those of staff time for all visits and
commodities, as well as the time each method will protect a woman from
pregnancy) are considered, the IUD is the least expensive reversible
contraceptive the health care system can provide.
Dr. Solomon notes that there are other, more subtle benefits of
"reintroducing" the IUD in Kenya. "The focus of the MOH
Division of Reproductive Health is to provide comprehensive reproductive
health services in general. So, the same approaches that will be used to
rehabilitate the IUD will be used to create demand for other
contraceptive methods, ultimately resulting in even more contraceptive
options for clients."
Why use is declining
Drs. Kibaru and Solomon both acknowledge that reintroducing the IUD
in Kenya will be a complex, multistep process. One of the first steps
taken by the MOH and partners two years ago was an assessment of the
need to reintroduce the IUD that considered cost, method mix and choice,
and effectiveness. They also sought to identify why IUD use was
declining.
Primary reasons for declining use many of which were revealed in
a study commissioned by the MOH in 1995 and conducted in Kenya by FHI3
were safety, service delivery, and client and partner concerns.
Among safety concerns were fears that HIV-positive women would suffer
complications if they had IUDs inserted; that IUD insertion would cause
fertility-threatening pelvic inflammatory disease (PID); and that
inserting IUDs in nonmenstruating women could inadvertently lead to
insertions in already pregnant women, resulting in harm to a fetus.
But research much of which has been conducted in Kenya has
proved these concerns to be largely unfounded. There is no increased
risk of cervical infections among HIV-positive women,4 the
risk of PID among IUD users remains low even in settings with a high
prevalence of sexually transmitted infections,5 and recent
research has shown no association between copper IUD use and tubal
infertility.6 Finally, many ways exist to rule out pregnancy
before inserting an IUD. These include a urine pregnancy test or, in the
absence of such a test, screening a nonmenstruating client for pregnancy
by obtaining a recent history of the woman's menses, sexual activity,
and pregnancy experience. A simple, six-question checklist developed by
FHI can help in this process. The checklist
(on FHI's website),
developed from guidelines prepared by the U.S. Agency for International
Development (USAID) and consistent with World Health Organization
guidelines, is available in English, French, Spanish, Creole, Hindi,
Khmer, Kiswahili, Arabic, and Nepali.
| Joseph Mboloi |
 |
| Attendees at an ECSAOGS meeting held in Mombasa,
Kenya, in February 2003 crowd around a booth where various IUDs
are displayed. |
Service delivery concerns included inadequate essential equipment and
supplies for insertions and removals at most MOH facilities and
inadequate provider skills due to gaps in preservice and in-service
training or little opportunity to practice skills due to lack of
potential IUD users. Other concerns were the need for more targeted
deployment of IUD providers to areas where they can offer their
services, and provider biases against the IUD. FHI research showed that
providers do not discuss the IUD as often as they do other methods, do
not discuss and dispel IUD rumors, rarely discuss IUD benefits, and see
IUD insertion as unacceptably labor-intensive and dependent on
availability of materials.7
Client and partner concerns about the IUD were also clarified by
taking advantage of a radio call-in show conducted by the U.S.-based
Population Council and the Kenya-based Nation Media Group. During two
programs dedicated to the IUD that were broadcast in November 2002 and
February 2003, the Kenyan public had an opportunity to question a
consultant, an obstetrician/gynecologist, a nurse-midwife, and a
satisfied IUD user. Calls from more than 20 women and men revealed that
while awareness of and knowledge about the method were high, concerns
about IUD expulsions, contraceptive failures, and the risk of PID
persisted. Such information is helping to guide advocacy efforts as the
IUD rehabilitation campaign proceeds.
Planned activities
Advocacy for the IUD constitutes the first stage of the initiative's
implementation that officially began with its February 2003 launch in
Mombasa. Subsequent stages will involve capacity building, creation of
demand, and monitoring and evaluation.
"Advocacy efforts, begun at the level of Kenya's provinces, will
extend to the district level, targeting policy-makers, service
providers, and family planning clients," says Maureen Kuyoh, deputy
director of the FHI/Kenya family planning and reproductive health
program. "These efforts are designed primarily to dispel myths and
provide accurate information to increase provider interest in and client
demand for the IUD." Advocacy tools include an IUD
advocacy kit and briefs (on FHI's website); information, education, and communication (IEC)
materials; scientific briefs and articles; and a media program.
Capacity-building efforts, to begin later in 2003, will involve
training providers and ensuring availability of expendable supplies
(such as lotions and gloves) and equipment (such as light sources and
specula). The MOH will also use a decentralized system to train trainers
to implement IUD in-service refresher courses.
Capacity will have to be built not only in the public sector (which
delivers about half of all Kenyan health services) but also in the
private sector. EngenderHealth's AMKENI Project, funded by USAID, is
charged with helping private, public, and nongovernmental facilities
build capacity for the IUD at 96 facilities in the eight districts in
which it works to improve service delivery. Of 300 targeted public- and
private-sector family planning providers at these facilities, 60 have
already been trained by AMKENI about IUD insertion and removal, says Dr.
Albert Henn, AMKENI project director.
"AMKENI welcomes the opportunity to be part of this initiative
for several reasons," Dr. Henn says. "First, in terms of
client-year contraceptive protection, the IUD can hardly be beaten by
any other method. It is also fairly low tech, so personnel like
nurse-midwives can easily be trained to provide it. Finally, we think
this initiative can work. While various misconceptions about the IUD
persist, I believe they can be eliminated once we achieve a threshold of
use."
Lessons learned from IUD provider training at such private-sector
centers are likely to guide training in the public sector. They can also
serve as an example of how the public and private sectors can benefit
from increasing collaboration in the IUD reintroduction initiative.
Building capacity also involves ensuring that a sufficient number of
IUDs and related supplies are available. Currently, about 10,000 IUDs
are inserted each year in Kenya. But, anticipating increased demand,
USAID is making available to the public sector (through the MOH) and to
the private sector (through the MOH and the USAID-supported DELIVER
Project of John Snow, Inc.) some 60,000 IUDs to ensure that no stockouts
will occur, says Dr. Mike Strong, senior health program manager at USAID/Kenya.
Expendables (such as bleach, cotton wool, and gloves) and basic
equipment (such as a proper light and a clean speculum) should not be a
problem either. "Providers who are well trained and thus motivated
to insert IUDs seldom complain that they cannot find the supplies and
equipment to perform the procedure," notes Dr. Henri van den
Hombergh, team leader of the Deutsche Gesellschaft für Technische
Zusammenarbeit (GTZ)/MOH reproductive health project. Adequate supplies
are important because, with the high prevalence of HIV in Kenya, both
clients and providers understandably want reassurance that they will not
be infected with HIV during IUD insertion or removal. With adequate
supplies and proper washing and disinfection of equipment, the extremely
small risk of such infection is eliminated, says Dr. David Grimes, FHI
vice president of biomedical affairs.
Finally, efforts will be undertaken to help managers at family
planning facilities schedule services more efficiently so that providers
feel that they have adequate time to insert and remove IUDs.
"Providers want to do a good job, but feel they are not doing a
good job when a queue of waiting clients develops," says Dr.
Strong. "In such a situation, it is tempting for them to give
injectable contraceptives that take only a few minutes."
Once IUD training and supply issues have been addressed, the
initiative will endeavor to create client demand for the device. Again,
this will be a multistep process, says Roselyn Koech, a trainer with the
MOH's Division of Reproductive Health. "Using existing MOH
channels, we will work with communities, local leaders, and providers to
respond to community concerns about the IUD. We will work to make sure
that partner organizations share our common goal, and we will develop
and integrate IEC materials with clear messages that are culturally
relevant into existing partners' community interventions, such as
behavioral change and community-based distribution (CBD) efforts."
Monitoring and evaluation is considered critical to the campaign.
"Monitoring provides information on how to make programs more
effective, and evaluation tells us whether we are meeting our
goals," says Dr. Ndugga of FHI. "We will also use operations
research to obtain information about impact, quality, client
acceptability, and cost-effectiveness. Such research can help answer
questions about the best ways to provide services that certainly will
arise during the course of the initiative, and will thus allow us to not
only take research to practice, but also use practice to guide
subsequent research."
| Nadine Burton/FHI |
 |
| Family planning services must be efficiently scheduled
to eliminate provider fears that IUD provision will lead to
lines of waiting clients such as this queue of women seeking
prenatal services in Rwanda. |
Two interventions using operations research will be tested. First, in
a pilot study for the MOH, FHI will evaluate whether having educators
promote IUDs (using the methods employed by pharmaceutical
representatives) during visits to clinic nurses and CBD workers
increases IUD acceptance. Visits will take place at 20 AMKENI clinics,
while another 20 clinics not receiving such visits will serve as
controls. Also, a project by U.K.-based Marie Stopes International and
supported by the German development bank Kreditanstalt für Wiederaufbau
(KFW) to socially market the IUD through a network of franchises will be
evaluated.
How will the initiative's success be measured? First, the process of
implementing a multipartner initiative will be documented. IUD
acceptance will be used to measure the longer-term outcome of the
project, although no targets for IUD acceptance have been set. Above
all, the goal is to enhance both the contraceptive mix and reproductive
health services for Kenyan women.
Will it work? Dr. Strong of USAID/Kenya is optimistic. "We think
we know why the IUD has languished, and we think that most pieces are in
place to reverse that trend," he says. "If we succeed in
shifting some women toward IUDs, their sharing of costs coupled with
donor and governmental funding should be sufficient to ensure the
sustainability of an increased presence of the IUD in the contraceptive
method mix."
Kim Best
* Partners with the Kenya MOH in the IUD reintroduction initiative
are (in alphabetical order): Africa Population Advisory Committee; John
Snow, Inc.'s DELIVER Project; EngenderHealth's AMKENI Project; FHI;
Family Planning Association of Kenya; Deutsche Gesellschaft für
Technische Zusammenarbeit (GTZ); PRIME Project of IntraHealth
International, Inc.; JHPIEGO; Maendeleo Ya Wanawake Organization; Marie
Stopes International; Population Council; the U.S. Agency for
International Development (USAID); and several Kenyan professional
medical associations.
References
- Central Bureau of Statistics, Ministry of Economic Planning and
Development. Kenya Fertility Survey 1977-1978.
Nairobi, Kenya: Central Bureau of Statistics, Ministry of Economic
Planning and Development, 1980; National Council for Population and
Development, Central Bureau of Statistics, and Macro International
Inc. Kenya Demographic and Health Survey 1998. Calverton, MD:
National Council for Population and Development, Central Bureau of
Statistics, and Macro International Inc., 1999.
- Kenya Demographic Health Survey 1998; Central Bureau of
Statistics, Ministry of Planning and National Development. Kenya
Contraceptive Prevalence Survey 1984. Nairobi, Kenya: Central
Bureau of Statistics and Ministry of Economic Planning and
Development, 1984.
- Stanback J, Omondi-Odhiambo, Omuodo D. Why Has IUD Use Slowed
in Kenya? Part A. Qualitative Assessment of IUD Service Delivery in
Kenya. Final Report. Research Triangle Park, NC: Family Health
International, 1995.
- Sinei S, Morrison C, Sekadde-Kigondu C, et al. Complications of
use of intrauterine devices among HIV-1-infected women. Lancet
1998;351(9111):1238-41.
- Shelton JD. Risk of clinical pelvic inflammatory disease
attributable to an intrauterine device. Lancet
2001;357(9254):443.
- Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper
intrauterine devices and the risk of tubal infertility among
nulligravid women. N Engl J Med 2001;345(8):561-67.
- Stanback.
|
|
|
Fostering strong partnerships with key implementing and
policy organizations is a key goal of the initiative to
reintroduce the intrauterine device (IUD) in Kenya. The
initiative is also building bridges to as many other people and
organizations in support of its objectives as possible.
Representatives from various professional associations, which
represent most health care providers in Kenya, are already
lending their support.
Evelyn Mutio, a nurse-midwife and honorary national secretary
of the National Nurses Association of Kenya, says the initiative
has her group's backing. "Because doctors are too busy in
general to provide IUDs and may be completely unavailable in
rural settings, nurse-midwives often are the people inserting
and removing IUDs in Kenya," she says. "I see no
problem with this IUD revival as long as nurse-midwives have the
proper preservice and in-service training to insert and remove
IUDs safely and have reliable supplies to do so. Some
nurse-midwives worry about a long queue of women waiting for
family planning services if IUD insertion becomes more common.
But they just need to be educated that over time IUD provision
will take less of their time than provision of other methods
requiring multiple visits. In Kenya, the IUD is checked by a
provider one month after insertion. After that, if there are no
problems, an IUD needs to be checked only once a year."
These annual IUD checkups, Mutio notes, provide an excellent
opportunity to perform a Pap smear to screen for cervical
cancer.
Besides nurse-midwives, most providers of family planning
services in rural settings throughout Kenya are clinical
officers. Gregory W. Miyanga, secretary-general of the Kenya
Clinical Officers' Association (KCOA), says, "Our people
are very much interested in the rehabilitation of the IUD. It is
dynamic and new, and we do not consider insertions and removals
to be time-consuming. If you have the proper training and
equipment, IUD insertion barely takes more than 10
minutes."
Gladys Okakah Koyengo, head of the department of clinical
medicine at the Kenya Medical Training College in Nairobi
which graduates about 1,000 nurses and 300 clinical officers a
year says, "I see lack of provider motivation to insert
IUDs. So changing provider attitudes is important. Once those
attitudes change, so too will clients' attitudes. Patients have
confidence in health care providers."
"Although reintroduction of the IUD in Kenya will
require the strengthening of clinics and raise issues of
supplies and expendables, we too are ready with a wide network
of skilled professionals to support and contribute to the
reintroduction of the IUD," says Dr. Joseph Karanja,
chairman of the Kenya Obstetrical and Gynaecological Society (KOGS).
"The IUD's decline really is a pity."
Among the IUD's greatest supporters are those health care
providers who have personal experience with the method.
Nurse-midwife Mutio used the IUD to space the births of her two
children. Clinical officer Miyanga's wife used an IUD for eight
years before having two children. Koyengo of the Kenya Medical
Training College has also used an IUD. "I had a wonderful
experience," she says. "No problems, no complications,
for 10 years. Taking pills was too cumbersome. I had four
children, two before the IUD, and two after. The same month I
removed the IUD, I got pregnant."
Kim Best
|
Good
Training Gives Providers Confidence to Insert IUDs
|
|
That good training builds provider confidence to offer
clients IUDs is underscored by the experience of the Family
Planning Association of Kenya (FPAK), a private nongovernmental
organization that is an affiliate of the International Planned
Parenthood Federation.
"IUD use has declined throughout Kenya, but at FPAK's 12
clinics which serve some 27,000 family planning clients each
year one of every five women seeking a contraceptive method
chooses the IUD," says Dr. Josiah Onyango, senior program
officer of service delivery at FPAK. "And that acceptance
rate has remained steady for the last five years.
"I believe there are several reasons for this. First,
FPAK providers are confident that they can safely and correctly
insert and remove IUDs because they are initially well trained
both in IUD insertion and removal and in infection prevention,
and they later benefit from training updates and supportive
supervision. FPAK providers are also well trained to describe
the characteristics of the IUD." Some contraceptive methods
may be easier than the IUD to provide, Dr. Onyango admits, but
at FPAK "we emphasize the importance of informed choice
based on a full explanation of all available contraceptive
options. Method choice is not what the provider wants, but what
is best for the client, respecting the client's
preference."
Kim Best
|
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network
|
Copyright