IUD insertion by nurse-midwives increases use.

Over a 15-year period, intrauterine device (IUD) prevalence more than doubled in Turkey after recommendations from a collaborative operations research effort influenced ratification in 1983 of the national family planning law that, among other changes, allowed trained nonphysicians to provide IUD services.

Before that, in the 1970s, only physicians could provide IUDs, and most physicians were male. But many women were uncomfortable being examined or having an IUD inserted by a male physician, thus limiting acceptance and use of the IUD.

Together, the Ministry of Health (MOH) and researchers in the Public Health Department of Hacettepe University in Ankara,Turkey, recognized this problem. Supported by the World Health Organization (WHO) Programme in Human Reproduction,the researchers began studying whether trained nonphysicians--particularly nurse-midwives--could adequately provide IUD services.

"The lead investigator from Hacettepe University had the foresight to involve the Ministry of Health in the project from the outset,"says Dr. Iqbal Shah of the Department of Reproductive Health and Research at WHO. Furthermore, the Director General of Maternal and Child Health and Family Planning at the time was a coinvestagator of the project, facilitating wide dissemination of results and mobilizing support for research utilization, he says.

In 1979, 13 female nurse-midwives from a district near Ankara learned to provide IUD services using a training program designed specifically for this research. The program involved use of a specially developed WHO manual for providing IUD services, followed by practice. Nurse-midwives in training used pelvic models, gave real pelvic examinations, and performed supervised IUD insertions. (1) Researchers then determined how well the trained nurse-midwives provided IUD services, compared with six male and two female physicians. (2) After 238 IUD insertions by physicians and 257 by nurse-midwives, no significant differences were found in terms of IUD expulsions, IUD removals, pregnancies, losses to follow-up, and referrals to obstetrician-gynecologists.

Study findings were published in February 1983 and disseminated to the MOH, policymakers, and the medical community in Turkey. Findings from a similar, unpublished WHOsupported study of some 200 nurse-midwives were also disseminated, with a recommendation that legislation be changed to allow nonphysicians with appropriate training to provide IUD services. Policy-makers and the medical community showed some resistance, but the MOH and Hacettepe University countered with several advocacy meetings to convince the two groups of the proposal's merits. (3)

The resistance eventually weakened. On May 24, 1983, the second anti-natalist population planning law, which included a provision allowing nonphysicians to provide IUD services, went into effect.

"In my opinion, if we had not performed this operations research on these sensitive issues, it would have been either impossible or too hard to change the existing population planning law" to include that provision, says Dr. Ayse Akin, the lead investigator from Hacettepe University.

Training of nurse-midwives to provide IUD services was added to regular national training programs, and in the 15 years after the law was ratified, IUD prevalence among contracepting women steadily increased from 9 percent to 20 percent, says Dr. Akin.

The studies that influenced ratification of the population planning law in Turkey, which also included research from the Philippines, (4) focused on the Lippes loop IUD. FHI and others have conducted similar studies on Copper T IUD provision in Turkey, Mexico, Nigeria, Brazil, and Thailand, showing that nonphysicians with proper training can also safely provide services involving this type of IUD. (5)

References

(1.) Akin A, Gray RH, Ramos R. Training auxiliary nurse-midwives to provide IUD services in Turkey and the Philippines. Stud Fam Plane 1980; 11(5):178-87.

(2.) Eren N, Ramos R, Gray RH. Physicians vs. auxiliary nurse-midwives as providers of IUD services: a study in Turkey and the Philippines. Stud Fam Plann 1983;14(2):43-47.

(3.) Akin A, Ozvarius SB, Fisek N. Integrating an Expanded Range of Reproductive Health Services in Primary Health Care: Turkey's Experience. International Council on Management of Population Programmes. Available: http://www icomp.org.my/Country/inno78.htm.

(4.) Akin, Gray, Ramos; Eren.

(5.) Farr G, Rivera R, Amatya R. Non-physician insertion of IUDs: clinical outcomes among TCu380A insertions in three developing-country clinics. Adv Contracept 1998;14(1):45-57; Lassner KJ, Chen CHC, Kropsch LAJ, et el. Comparative study of safety and efficacy of IUD insertions by physicians and nursing personnel in Brazil. Bull Pan Am Health Organ 1995;29(3):206-15; Wright NH, Sujpluem C, Rosenfield AG, et el. Nurse-midwife insertion of copper T in Thailand: performance, acceptance, and programmatic effects. Stud Fam Plann 1977;8(9):237-43.