Study identifies ways to increase IUD use in developing countries

Boosting demand for intrauterine devices, commonly referred to as IUDs, and improving access to them can significantly increase their use in developing countries, where they have traditionally been an unpopular method of birth control, a new study says.

Researchers at the nonprofit Population Services International and the Stanford University School of Medicine show how they were able to provide these long-acting, reversible contraceptives to more than a half-million women in 13 countries.

The group’s “experience with promoting a contraceptive previously believed to be unsuitable for these contexts should encourage both public and private providers,” the researchers wrote in their paper, which appears in this month’s issue of Contraception.

Paul Blumenthal, MD, professor of obstetrics and gynecology and director of the Stanford Program for International Reproductive Education and Services, is the study’s lead author. The other authors are with PSI, a Washington, DC-based organization dedicated to improving the health of people in the developing world.

Long-acting reversible contraceptives, such as IUDs, are known to be a safe, effective and inexpensive form of birth control. The IUD does not have widespread popularity, though: A 2005 United Nations report showed that IUDs were used by 7.6 percent of women of reproductive age in developing countries, compared to 14.5 percent of women in developed ones.

Experts believe there are a variety of factors that prevent more women in developing countries from using IUDs. Among others are “myths and rumors about the IUD, uncertainty or inadequate information about where a woman could get one, and an inadequate number of providers trained and ready to provide a quality service,” Blumenthal said.

Women in these countries may face hurdles with other forms of birth control, as well. Access is common problem. “Clients often have to go a long distance to get their method, and even then might get to the clinic only to find out it’s out of stock,” said Blumenthal.

Project director Dana Tilson added, “When contraceptives are available in these settings, they are often limited to one or two options, all requiring frequent, repeat visits to continue.”

In an effort to, in Tilson’s words, “give women access to a range of choices that were previously unavailable” and to improve reproductive health, the researchers launched a two-year, 13-country initiative to promote and provide IUDs.

The project began in 2009 and focused on Cambodia, El Salvador, Guatemala, India, Kenya, Madagascar, Myanmar, Nepal, Nicaragua, Nigeria, Uganda, Tanzania and Zambia. The countries were chosen, Blumenthal said, because of their low IUD usage numbers, and because PSI identified them as areas with opportunities for significant improvement.

The initiative focused on both creating demand and improving service delivery. A group of community “mobilizers” conducted outreach in many of the countries, going door to door or arranging group meetings to educate women on family planning options and linking them with local providers. Media activities, including radio and TV spots, printed educational materials and billboards, were also done in many areas to address misconceptions about reversible contraceptives and to educate women on the potential benefits of using them.

Project leaders also improved access by training local clinic staff on counseling, complication management, side effects, removals and referrals, and by offering IUD insertion at a variety of clinics throughout each of the countries. Outreach clinic event days were held in six countries, during which IUD insertions were offered to local women over a one- to three-day period.

Between January 2009 and December 2010, 575,601 women across the 13 countries were provided with IUDs. The typical woman who received an IUD was in her 20s, married, had at least one living child and was primary-school educated. Twenty-four percent of women who received an IUD said they previously had been using no modern birth-control method.

Blumenthal believes a “success at this scale has not been previously reported.” And he and his colleagues noted in the paper that the fact that so many women opted for an IUD indicates increased use is likely to occur “once barriers of provider training and negative perceptions of IUDs are overcome.”

The authors also emphasized the importance of linking demand creation and service delivery. “By creating demand through ‘marketing’ but then also ensuring that there’s a high-quality, reliable provider within easy reach of the client, we have shown that IUDs can be acceptable to women and provided at scale,” said Blumenthal.

This initiative is ongoing, with the number of countries being expanded. Project leaders are now refining marketing approaches, focusing on providing IUDs to women immediately after they have delivered a baby, and working with various ministries of health to revise outdated guidelines, which will make access easier for women. Project directors are also turning their attention to post-abortion care, aiding women who have experienced unsafe abortions and ensuring they have access to contraception.

The project was a collaborative effort between Stanford and PSI: Blumenthal assisted by providing technical advice, guidance and oversight, while PSI received the funding and implemented the projects. Funding came from grants to PSI’s Women’s Health Project from an anonymous donor, the United States Agency for International Development and the Strategic Alliance for International NGOs, which is funded by the Dutch Foreign Ministry and KfW Entwicklungsbank, a German government-owned development bank.

Information about the Stanford Department of Obstetrics and Gynecology, which also supported this work, is available at

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