5. % Use for Married Women of Reproductive Age
18
15
8
Asia
Europe
5
Africa
Latin
America
& Caribbean
1
2
Oceania
North
America
Population Reference Bureau. 2008.
Mosher WD, et al. 2004.
6. • "[Family planning] means the difference between
being empowered and feeling powerless. It means
the difference between celebrating a daughter's
graduation and watching her drop out of school. It
even means the difference between life and death.”
Melinda Gates, HuffPost Blog
7. • T-shaped plastic frame with copper wire/sleeves
• Highly effective in preventing pregnancy – failure
•
•
•
•
•
rate is less than 1%
Copper T 380A lasts for 12 years once inserted
Works mainly by preventing fertilization of an
egg by sperms
Most women can use IUDs, including women
who have never been pregnant
Fertility returns very quickly after removal
Very effective as emergency contraception
8. Copper T 380A IUD
• Copper ions
• Provides protection for up
to 12 years
LNG IUS (hormonal)
• 20 mcg levonorgestrel/day
• Provides protection for up
to 5 years
9. Cumulative pregnancy rate (%)
LNG IUS
100
Copper IUD
80
60
40
20
0
3
6
Months
9
12
Andersson et al. Contraception 1992;46:575
Belhadj et al. Contraception 1986;34:261
10. •
•
•
•
•
Can insert any time reasonably sure woman is not
pregnant
Within 12 days after start of menses
Later in cycle/during amenorrhea if reasonably sure
not pregnant
< 48 hours postpartum (if no puerperal sepsis)
≥ 4 weeks postpartum (if not pregnant)
Within 7 days postabortion
11. 5-year gross cumulative failure rate
1.4
TCu 380
IUD
1.3
0.6
All
Sterilization
Postpartum
Salpingectomy
WHO. 1987.
Peterson HB, et al. Am J Obstet Gynecol. 1996.
12. • Might increase menstrual bleeding or cramps
• Usually gets better after first 3 months
Complications
• Rare
– Perforation of the wall of uterus by IUD or an
instrument
– Pelvic inflammatory disease (PID) may occur if
the woman has Chlamydia or gonorrhea at the
time of IUD insertion
13. • No increased risk of complications compared
with HIV-negative women
• No increased cervical viral shedding
• MEC Category:
• Initiation: not recommended if not fully
controlled but can be initiated if clinically well
on ARVs if other methods are not available or
not appropriate
• Continuation: Can continue if more
appropriate methods are not available
WHO. Medical Eligibility Criteria for Contraceptive Use. 2009.
Morrison CS, et al. Brit J Obstet Gynaecol. 2001.
Richardson B, et al. AIDS. 1999.
14. •
•
•
•
•
•
Do not cause abortion
Do not cause ectopic pregnancies
Do not cause PID
Do not cause infertility
Are not too large for small women
Are unlikely to cause discomfort
for male partner
• Do not travel to distant parts of the body
• Are not contraindicated for HIV-positive women
15. • Counseling – foundation for FP programs
• Client screening
– Medical Eligibility Criteria
– Pelvic exam
• Insertion procedure –
doctors, nurses, mid-wives, health
assistants, clinic officers
• Follow-up
16. • Barriers – usual suspects
– Weak health infrastructure
– Lack of trained providers
– Lack of good logistics support
– Poor supervision of services
17. • Funding – small portion of the overall
humanitarian funding pie for FP in general
– and even smaller for IUD
• An average of $20.8 billion in total ODA
annually to 18 conflicted-affected countries
in study
– $509.3 million (2.4%) for reproductive health
– FP represents only 1.7% of RH activities
18. • A few caveats:
– SGBV is not coded as RH but rather as postconflict peace building by ODA
– Does not include $ from philanthropic
organizations: e.g. Gates Foundation, Buffet
Foundation
– Does not include $ from multilateral
organizations:
WHO, UNHCR, UNOCHA, WFP
19. • Program in 3 countries
– Chad, DRC and Pakistan
– Supported by Large Anonymous Donor
– Emphasis on providing LARC to most underprivileged
women – women in crisis and post-crisis settings
• LARC as part of comprehensive FP method mix
• SAF-PAC also supports RH services in Mali and
Djibouti but at a smaller scale
21. • Though widely used contraceptive method
•
•
•
•
•
globally, IUDs are poorly utilized in Sub-Saharan
Africa
IUDs can be safely used by nulliparous women, HIV+
women, post-partum women
IUD effectiveness comparable to permanent FP
methods
IUD does not cause PIDs
IUD considered best option as an EC
Need to improve funding $ for FP in general and
LARC in particular
23. Table 2. ODA disbursement in conflict-affected countries.
Patel P, Roberts B, Guy S, Lee-Jones L, et al. (2009) Tracking Official Development Assistance for Reproductive Health in ConflictAffected Countries. PLoS Med 6(6): e1000090. doi:10.1371/journal.pmed.1000090
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000090
Editor's Notes
At least 215 million women want to prevent or delay pregnancy but are not using effective contraceptives either due to lack of information, social pressures, or due to insufficient access to contraceptive options. Access to family planning improves child and maternal health and reduces number of abortions.
This slide shows the distribution of modern contraceptive use globally. The most common types of contraception are permanent or long-acting methods: 34% practicing modern methods choose female sterilization – these are high in China, India and also the United States (30%) Among reversible contraceptive methods, IUD is the most common method25% choose IUDs – the highest percentage coming from Asia, substantially contributed by the government supported program in China (40% IUD use)The IUDs high prevalence can be attributed to favorable government sponsored programs in China, as well as in countries like Egypt, Vietnam and a few previous Soviet Republic Independent States
This map shows IUD prevalence in different parts of the world. Clearly China and the adjoining geographic regions have a high prevalence rate of over 30% of IUD use. Certain countries in Europe and Latin America also have a high prevalence of IUD use.
What are the movers and shakers in this field saying about family planning in general? Here is a quote from Melinda Gates, of the Gates Foundation, taken from the HuffPost Blog: “Family Planning means the difference between being empowered and feeling powerless. It means the difference between celebrating a daughter’s graduation and watching her drop out of school. It even means the difference between life and death”.
So, What is an IUD? As most of you know, it is a long acting contraceptive device. It is a plastic frame shaped as the letter T with copper wire or sleeve around the stem and arms of the T. In the US it is marketed as ParaGuard and internationally as Copper T-380 A. A variation of this is the Mirena – a hormone (progesterone) containing IUD. In this presentation we will be focusing on the Copper T-380 A because of its relevance to our international programs Together with the Implants – it is referred to as the LARC – long acting reversible contraceptive It is a highly effective method – with failure rates less than 1% It is effective for 12 years once inserted in the uterus Copper is toxic to sperms and works by preventing fertilization of egg by spermsMost women can use IUDs including those who have never been pregnant And fertility returns very quickly after removal Very effective as emergency contraception
Copper T-380 A Copper ions are toxic to sperms as mentioned ealierLNG IUS – marketed as Mirena IUD –Levoneorgestrel Intra-uterine System It works similar to other hormonal methods like implants
When can one insert an IUD? It can be inserted safely: Within 12 days after menses Later in cycle – during amenorrhea if reasonably sure woman is not pregnant Within 48 hours postpartum – if no infections 4 weeks after delivery within 7 days postabortion This is the only reversible contraceptive method that can be used immediately after childbirth
As with all contraceptive methods, IUDs have their own share of side-effects Some women may experience minimal side effects while others might experience more severe side effects Increased menstrual bleeding or uterine cramps are common side effects In most cases these side effects get better after first 3 months of useComplications with IUD are rarePerforation of the uterine wall is a recognized complication – most small perforations repair on their own with minimal intervention. IUD does not cause PID – Chlamydia or gonorrhea cause PID! To quote Dr. Hatcher. Client screening is important to minimize this risk.
Family Planning Counseling is the foundation for all family planning programs – whether it is community based or facility based the stronger the counseling practice, the more stable a family planning program unfortunately, counseling for family planning tends to be neglected in many programs adversely affecting the program Counseling offers an opportunity to clients to understand the options available and make an informed decision or choice Client Screening – WHO provides technical guidance in outlining clinical conditions that are contraindications to different contraceptive methods. The Medical Eligibility Criteria is integrated into a user-friendly tool – the MEC Wheel for contraceptives – a sample is available here for review Pelvic exams are an integral part of an IUD screening – women in most cultures shy away from pelvic exams, if they can help it. But it is also true that providers tend to avoid pelvic exams because it is more labor intensive, with extra steps in service provision as well as instruments processing and preparation Almost all countries where we work allow doctors, nurses, mid-wives, clinical officers and health assistants to insert and remove IUDs. Post-partum IUD insertion requires special training to qualify as PP IUD provider. IUDs are placed high up in the uterus under the dome of the uterus. Expulsions are more common with improperly placed IUD. Good training helps to reduce this common cause of IUD expulsion Follow-up: A single follow up 4-6 weeks after insertion is recommended. Regular follow ups are not required for IUD clients. They can return to clinic if they have any issues or questions. They are advised to come back if they feel that IUD has been expelled. Or if they are having any side effects!
How does IUD performin humanitarian settings? IUDs are part of the broader method-mix that we persevere to provide in humanitarian settings (as we do in development setting) The barriers to services reflect what we find in most low-resource settings – but more severe making it an even bigger hurdle to overcome Here are some of the usual suspects: The overall health system/infrastructure is weak, at times with almost no national system level support in crisis affected areas IUDs are facility based or clinic-based services. There is always a shortage of trained providers as it requires clinicians to provide services, and they are hard to find, even in normal settings in developing countries, let alone in humanitarian settings. The challenge then is to find clinicians in crisis settings, train them quickly to meet service demands without compromising on quality of care, at the same time recognize that high turn-over of staff is the expected norm Logistics supply of FP commodities is a critical component for services and almost always weak – for numerous reasons, e.g. poor roads, poor political will, problem of the ‘last-mile’ coverage, lack of reliable supply-chain-management system, etc. Supervision of services is limited if present, and providers have to make it on their own with little feedback, reward or punishment
Reproductive Health care hasn’t yet gained prominence as a life-saving intervention in humanitarian settings. Consequently, the funding for RH intervention is crisis-setting is very limited. Study: Official Development Assistance (ODA) for Reproductive health in Conflict-Affected CountriesThese figures are based on study conducted by RAISE Initiative with data from 18-conflict affected countries analyzed for 2003, 2004, 2005, and 2006 of funds disbursed by Official Development Assistance (ODA). Two data sources were analyzed for the study: The Creditor Reporting System and the Financial Tracking System databases. Findings: An average of US$20.8 Billion in total ODA was disbursed annually to the 18 conflicted-affected countries included in the study, of which US$509.3 million (2.4%) was allocated to reproductive health. This represents an annual average of US$1.30 disbursed per capita in the 18 sampled countries for RH activities Family planning activities represents only 1.7% of annual ODA disbursement for RH activities annuallyReference: Tracking Official Development Assistance for RH in Conflict-Affected Countries – Preeti Patel, Bayard Roberts, S. Guy, Louise Lee-Jones, LesongConteh
Study: Official Development Assistance (ODA) for Reproductive health in Conflict-Affected Countries SGBV is not coded as Reproductive Health but rather as post-conflict peace building by ODA Does not include money from philanthropic organizations e.g. Gates Foundation, Buffet Foundation, etc. nor from these multilateral organizations: WHO, UNHCR, UNOCHA (office for the coordination of humanitarian affairs), and WFPReference: Tracking Official Development Assistance for RH in Conflict-Affected Countries – Preeti Patel, Bayard Roberts, S. Guy, Louise Lee-Jones, LesongConteh
Supporting Access to Family Planning and Postabortion Care in emergencies or SAF-PAC is supported by a large anonymous donor with CARE programs in Chad, DRC and Pakistan. Program emphasis is on providing long acting reversible contraceptives to populations who are either in crisis or post-crisis settings. LARC is provided as part of a comprehensive FP method mix – considered as important aspect of good quality FP services SAF-PAC also supports RH services in Mali and Djibouti but at a smaller scale
This is a method mix graph for our programs form Phase Iin the 3 countries, Chad, DRC, and Pakistan As you can see IUD uptake is quite high in Pakistan in the method mix while it is very low in DRC and Chad However, it is encouraging to see a very high uptake of Implants, which though not IUDs, but still part of LARC methods
In Conclusion Though widely used contraceptive method globally, IUDs are poorly utilized in Sub-Saharan AfricaIUDs can be safely used by nulliparous women, HIV+ women, post-partum women IUD effectiveness comparable to permanent FP methods IUD does not cause PIDs or pelvic inflammatory disease IUD considered best option as an EC Need to improve funding $ for FP in general and LARC in particular
