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IUD Toolkit

Up-to-date evidence and best practices related to the Intrauterine Device

Brought to you by USAID's Maximizing Access & Quality Initiative

Service Delivery

Who can provide the IUD?

In addition to physicians, other health care workers such as midwives, clinical officers, nurses, and auxiliary nurses, when appropriately trained and having shown they have the necessary skills, can provide IUD services with quality of care, safety, and client satisfaction comparable to IUD services provided by physicians (Eren et al., 1983); (Farr et al., 1998); (Villanueva et al., 2001).

Who can use the IUD?

Almost all women generally can use the IUD, including young women (under 20 years of age), nulliparous women, nulligravid women, HIV-infected women, and women with AIDS who are doing clinically well on antiretrovirals (World Health Organization, 2004a).
There are only a few conditions for which WHO recommends that the IUD should not be used (category 4), the common ones being pregnancy, postpartum or post-abortion sepsis, and current purulent cervicitis, PID, or chlamydial or gonorrheal infection (World Health Organization, 2004a). (Less common conditions for which the IUD should not be used include cervical or endometrial cancer, distorted uterine cavity, pelvic tuberculosis, and unexplained vaginal bleeding felt to reflect a serious underlying condition).

Use of IUDs by women at "increased risk" of STIs

IUDs can generally be used by women who might be judged as at "increased risk" of STIs solely because of certain epidemiologic or socio-demographic characteristics (World Health Organization, 2004a). Some examples of these characteristics include age (young), marital status (unmarried), level of education (low), or area of residence (a "high-STI setting").
If a woman has a very high individual likelihood of exposure to Chlamydia or gonorrhea (e.g., she or her partner has multiple partners), IUD use is not generally recommended, as the risks of use will generally outweigh the benefits (World Health Organization, 2004a).

Use of IUDs in the presence of Chlamydia or gonorrhea

IUDs should not be inserted in the presence of current purulent cervicitis, or chlamydial or gonorrheal infection (World Health Organization, 2004a).
If a woman already has an IUD in place presents with current purulent cervicitis or chlamydial or gonorrheal infection, she should be treated with appropriate antibiotics, but there is no need to remove the IUD (treatment of the STI is sufficient) (World Health Organization, 2004a).

Use of IUDs by HIV-infected women

IUDs can generally be used by HIV-infected women or by women at high risk of HIV. IUDs can also be used by women with AIDS who are clinically well on antiretroviral therapy, as well as by HIV-infected women who already have an IUD in place at the time AIDS manifests itself (Fisher et al., 1986).

Use of prophylactic antibiotics before insertion

Prophylactic antibiotics are generally not recommended before copper IUD insertion. However, in some unusual circumstances (such as settings with a high prevalence of STIs and limited STI screening), prophylactic antibiotics may help reduce the incidence of PID (Grimes et al., 1999); (World Health Organization, 2004b), though this still remains unproven. Risk of PID is low with IUD use, with or without prophylactic antibiotic use (Grimes et al., 1999).

Availability and access

The greater the availability of IUD services, the greater the IUD use in a given country or geographic area (Ross et al., 2002).

Modality of provision

IUD provision does not need to be limited to fixed facilities; mobile clinics can provide IUD services as well. In addition, community-based health workers can refer IUD clients to mobile or fixed facilities to increase access.

Timing of insertion

An IUD can be inserted in the first 12 days of the menstrual cycle, or at any other time, as long as a provider is reasonably sure that the client is not pregnant (White et al., 1980); (World Health Organization, 2004a). A pregnancy checklist based on criteria endorsed by WHO has been shown to be an effective tool for determining if a woman is not pregnant (Stanback et al., 1999). No additional contraceptive protection is needed after the IUD is inserted.
A woman does not need to wait until she is menstruating to have an IUD inserted (World Health Organization, 2004b); (White et al., 1980).

Postpartum insertion

Insertion of IUDs can be safely provided within the first 48 hours after delivery or otherwise at four to six weeks postpartum. Postpartum women often want reliable, long-term contraception soon after delivery (Thapa et al., 1992). For immediate postpartum insertion of the IUD, it is particularly important to provide good quality counseling to the client before labor and delivery to ensure that her decision is a voluntary and informed choice.
Postpartum IUD insertion requires different technique than interval IUD insertion. If performed by specifically trained providers, postpartum IUD insertion within 48 hours of delivery is safe and convenient, with no increased risk of infection, perforation, or bleeding. A relative disadvantage of postpartum insertion within the first 48 hours (compared to later postpartum or interval insertion) is a slightly higher risk of expulsion. Expulsion rates following postpartum IUD insertion are lowest when the IUD is inserted within 10 minutes of delivery of the placenta, when the provider is skilled and experienced, and when the IUD is placed correctly, high in the fundus (Grimes et al., 2004); (World Health Organization, 2004a); (World Health Organization, 2004b).
Providing integrated mother and child services in a single visit six weeks after birth increases the use of contraceptive methods, particularly the IUD, and substantially reduces costs for both clients and providers (Coeytaux, 1989); (Medina et al., 2001).Women who are offered the IUD before being discharged from the hospital after the birth of a child are more likely to be using it both 40 days and six months later than are women who are not offered the IUD (Foreit et al., 1993).

Postabortion insertion

Postabortion clients often want immediate protection from future pregnancy. They need good quality counseling on their contraceptive options, and easily/readily available services (Núñez et al., 2005).
IUDs can be safely inserted immediately after spontaneous or induced abortion, except in women with pelvic infections or those who have had septic abortion (Chhabra et al., 1988); (Grimes et al., 2004); (Senlet et al., 2001); (World Health Organization, 2004a); (World Health Organization, 2004b).

Follow-up visits

Only a single routine follow-up visit after IUD insertion needs to be scheduled. This visit should take place after the first menses or three to six weeks following insertion. Additional routine follow-up visits are unnecessary and can be eliminated without a significant decrease in quality of care and with substantial cost savings (Bratt et al., 1998); (Hubacher et al., 1999a); (Janowitz et al., 1994); (World Health Organization, 2004b). Rather, the client should be counseled to return at any time if she has any problems or concerns.

Medical barriers

Medical barriers (i.e., "policies or practices derived at least partly from a medical rationale that result in scientifically unjustifiable impediment to, or denial of, contraception") are a significant problem impeding wider access to modern contraception, including IUDs (Shelton et al., 1992).
Many women who request an IUD are denied their choice based on eligibility criteria that are neither scientifically justified nor consistent with national guidelines. These medically unjustified criteria include marriage and spousal consent requirements, minimum or maximum age and parity restrictions, menstruation requirement, or norms that discourage uptake by requiring too many routine follow-up visits (Miller et al., 1998); (Shelton et al., 1992); (Stanback et al., 2001).

Provider perspectives

The perspectives of providers-their attitudes, motivations, needs, as well as their knowledge and skills-are an important variable in service delivery programs that should be considered (Shelton, 2001a). For example, would a provider garner more "rewards" (e.g., greater prestige or income, or reduction of other duties) if s/he became more active in providing IUDs.
Inserting IUDs involves more work and has some other disincentives for providers. Thus, work needs to be organized accordingly to take account of these increased demands. Providers who demonstrate an interest in the IUD should be well supported.
In countries with low IUD prevalence, providers frequently do not mention the IUD in counseling sessions for family planning clients. When they do, they usually provide only minimum information about it. Lack of equipment, method stock-outs, lack of confidence in clinical skills, and lack of time are the main reasons given by providers for not offering the method (Brambila et al., 2003); (Katz et al., 2002). Even among health centers that do meet the conditions needed to provide IUD services (e.g., necessary equipment and appropriately trained staff), many do not do so (Brambila et al., 2003).

Provider myths and misconceptions

In many countries, potential providers of IUD services hold misconceptions about the IUD's mechanism of action, side effects, and eligibility criteria (e.g., erroneously believing that it can cause cancer, greatly increases risk of PID, ectopic pregnancy, and infertility, or is inappropriate for HIV-infected women). Many also believe, incorrectly, that the IUD moves through the body or that it interferes with sexual relations because it can be felt by partners or can cause pain during intercourse (Gyapong et al., 2003); (Katz et al., 2002).

Cost considerations

The IUD, among the reversible methods, is the most cost-effective-in terms of both cost per unit time of protection and all program costs (including materials and staff time for initial and follow-up visits) (Chiou et al., 2003); (Hubacher et al., 1999b); (Trussell, 1974).
Providing an IUD to a woman before she is discharged from a hospital after delivering a baby is less than half as expensive as providing the method at outpatient visits (Foreit et al., 1993).