'Rehabilitating' the IUD: Initiative in Kenya is a potential model for activities to promote research utilization for better services.

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 is 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 article, page 17).

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 1981 (1)), 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 of 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.

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 FHI [I.sup.3]--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, 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, and Nepali at http:// www.fhi.org/en/RH/Pubs/servdelivery/ checklists/pregnancy/index.htm.

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 inservice 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 (available at http://www.fhi.org/en/RH/ Pubs/servdelivery/kenyabriefs/index.htm); 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 Dentsche Gesellschaft fur 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 communitybased 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."

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 fur 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."

References

(1.) 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.

(2.) 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.

(3.) Stanback J, Omondi-Odhiambo, Omuodo D. Why Has IUD Use Slowed in Kenya? Port A. Qualitative Assessment of IUD Service Deliver,/ in Kenya. Final Report. Research Triangle Park, NC: Family Health International, 1995.

(4.) Sinei S, Morrison C, Sekadde-Kigondu C, et el. Complications of use of intrauterine devices among HIV-1-infected women. Lancet 1998;351(9111):1238-41.

(5.) Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet 2001;357(9254):443.

(6.) Hubacher D, Lara-Ricalde R, Taylor DJ, et el. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67.

(7.) Stanback.

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 fur 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 severn Kanyan professional medical associations.