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Acceptability of the intrauterine device among women in El Salvador
Abstract
This article describes a cross-sectional study which investigated the comprehension and apprehension among rural Salvadoran women with regard to the intrauterine device (IUD). Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
... Fear of insertion, Fear of the design of the IUD, partner disappointment, rumors and myths as a baby will be born with IUD, the IUD can get lost in the body, embeds in the uterus, limited supply, time to discuss about the methods, provider discouragement, training needs, demand generation and promotion, cost etc were mentioned for low utilization of the method. [5,6,7] Many studies were conducted to investigate those factors which determine the prevalence of modern contraceptive methods in group and at individual method level. To the best of the investigators knowledge none of the studies assess the usage of LARC methods among women who are using modern contraceptive to limit the number of children. ...
... These countries represent few part of the world and thus the prevalence of long acting reversible contraceptive methods (implants and IUD) is very low in most of the countries in this world. [2,6,8] In almost all countries of the world the prevalence of implant is less than 10%. [2] The prevalence of LARCs is lowest in sub-Saharan Africa with rate below 2% among women of reproductive age while the use of SARCs is very popular in this region. ...
... Over all, the participants in this study had a poor comprehension of IUD efficacy and adverse effect. [6] In a qualitative study conducted in El Salvador, the most common reason for negative impression about IUD among clients was fear which was generally based on rumors and myths. Based on providers view about the rumors and myths, cancer, a baby will be born with the IUD in its body, an IUD can get lost in a women's body and IUD becomes embedded in the uterus were mentioned. ...
... Counseling by a trained provider or community health worker was the most important enabling factor for women to adopt a vaginally inserted contraceptive method (McDonald-Mosley et al. 2010;Shapiro 2016;Vakilian et al. 2018;Harris and Angel 2020;Miller et al. 2018;Nanda et al. 2018;K. Thapa et al. 2019;Makins et al. 2018;Hayes and Kilboume-Brook 2016a;Machado et al. 2013;Gottert et al. 2015;Shapiro et al. 2014;Wasim et al. 2018;Zafar et al. 2019;Eluwa et al. 2016;Karra et al. 2019;Somesh Kumar et al. 2014;Huber-Krum et al. 2019). ...
... Effective in-person contraceptive counseling was an important factor for adoption and a unique enabler for continuation of the copper IUD(McDonald-Mosley et al. 2010;Vakilian et al. 2018; K. Thapa et al. 2019;Makins et al. 2018;Gottert et al. 2015;Wasim et al. 2018;Zafar et al. 2019;Eluwa et al. 2016;Karra et al. 2019;Somesh Kumar et al. 2014;Huber- Krum et al. 2019;Karra et al. 2017;Gedeon et al. 2015;A. Kumar et al. 2018;Malik et al. 2014;Animen, Lake, and Mekuriaw 2018;Blumenthal et al. 2016;Santhya et al. 2014;Azmat et al. 2013; Radwan et al. 2019;Ambadekar, Rathod, and Zodpey 2010; Elkhateeb et al. 2020;Mazzei et al. 2019;Puri et al. 2020). ...
Most vaginally inserted methods have limited availability and use despite offering characteristics that align with many women's stated preferences (e.g., nonhormonal and/or on demand). The objective of this review was to identify enablers and barriers to women's adoption and continuation of vaginally inserted contraceptive methods in low‐ and middle‐income countries (LMICs). We searched three databases (PubMed, Embase, and Web of Science) and 18 websites using keywords related to five vaginally inserted contraceptive methods (diaphragm, vaginal ring, female condom, copper intrauterine device [IUD], hormonal IUD) and terms associated with their adoption and continuation. Searches were limited to resources published between January 2010 and September 2020. Studies eligible for inclusion in our review presented results on women's use and perspectives on the enablers and barriers to adoption and continuation of the vaginally inserted contraceptive methods of interest in LMICs. Relevant studies among women's partners were also included, but not those of providers or other stakeholders. Data were coded, analyzed, and disaggregated according to a framework grounded in family planning (FP) literature and behavioral theories common to FP research and program implementation. Our initial search yielded 13,848 results, with 182 studies ultimately included in the analysis. Across methods, we found common enablers for method adoption, including quality contraceptive counseling as well as alignment between a woman's preferences and a method's duration of use and side effect profile. Common barriers included a lack of familiarity with the methods and product cost. Notably, vaginal insertion was not a major barrier to adoption in the literature reviewed. Vaginally inserted methods of contraception have the potential to fill a gap in method offerings and expand choice. Programmatic actions should address key barriers and enable voluntary use.
... Despite the IUD's reliability and efficacy, knowledge among women of the device as a method of EC is low [9,10]. Numerous studies have examined women's acceptability and knowledge of the IUD as a method of regular contraception [11][12][13][14][15][16][17][18]. However, few explore acceptability of IUD as a form of EC [9,10,19,20], and to our knowledge, none have done so in a Latin American setting. ...
Background
We explored knowledge and attitudes regarding the copper intrauterine device (IUD) as emergency contraception (EC) among women in Buenos Aires, Argentina.
Study Design
We interviewed a convenience sample of women attending a family planning center at a public hospital. Participants were asked about knowledge and use of contraceptives, including EC (pre-script). Then they were given information about the IUD as EC and subsequently asked about acceptability of using the copper IUD as EC (post-script), the primary outcome in this analysis.
Results
We analyzed data on 273 women. While only 1.83% of participants knew the IUD served as EC at baseline, 79.85% said they would be willing to use the device as such if the need arose after given relevant information. Multivariate results from a pre-script revealed that women with low levels of education and those born outside of Argentina were less knowledgeable about EC pills. Only previous use of the IUD was associated with high levels of IUD knowledge. Post-script, results indicated that being Argentine (OR = 2.15, 95% CI 1.21, 3.81) and previous IUD use (OR = 2.12, 95% CI = 1.07, 4.19) were positively associated with considering the IUD as EC. Nulliparity was negatively associated with willingness to use the IUD as EC (OR = 0.44, 95% CI 0.22, 0.86).
Conclusion
We examined acceptability of the copper IUD as EC in a Latin American setting and found that while prior levels of knowledge were low, acceptability of the IUD as EC was high. Implications for programming and policy include outreach and education regarding this highly effective method and advocacy to change existing regulations in Argentina prohibiting the use of IUD as EC.
To survey a cross-section of reproductive-age Salvadoran women in order to assess the factors that influence their decision to use depot-medroxyprogesterone acetate (DMPA), an injectable form of contraception.
Reproductive-age women at three rural Salvadoran health clinics were asked to participate in a study to assess their current and past experiences using DMPA contraception. Verbal informed consent was obtained, and research coordinators administered a 23-question survey.
Surveys were completed in 425 women with an average age of 27.36 years. Average duration of DMPA contraception use was 2.89 years. The majority (84%) of past and present users were very satisfied with DMPA contraception, most commonly because they did not have to remember to use it daily (44.9%). The side effects of DMPA appear to be a significant indicator of whether women heard about and wanted to use other forms of long-term reversible contraception, such as an intrauterine device (IUD) or implant.
The main reason Salvadoran women chose to use DMPA is because they do not have to think about it on a daily basis. However, many women do not like the side effects and may be open to explore using other long-term reversible methods of contraception, such as IUDs or implants. It is possible that with increased access to educational information about IUD use, safety, and effectiveness, more women would use this form of long-term contraception as opposed to sterilization.
In order to gain an understanding of Salvadoran health care providers' clinical knowledge, attitudes, and practice toward the intrauterine device (IUD), Ministry of Health providers completed a self-administered, anonymous survey. Surveys were completed by 135 participants. The majority (94.7% and 97.0%) agreed the IUD is a safe and effective form of contraception. Only 46.6% of participants had ever received training in IUD placement, and 32.0% of them had ever inserted more than 10 IUDs. The majority of providers (54.2%) believed that the IUD was associated with a higher rate of infection than is described in the literature. Lack of formal training and knowledge about persistent infection rates associated with IUDs may contribute to low IUD placement by Salvadoran providers. Health care providers surveyed are open to learning more about the IUD and sharing the information with their patients.
Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates.
We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine women's group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28?931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309.
From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% CI 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls.
Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women's groups.
Context: While the IUD is a safe and cost-effective method, use is very low in some countries, and the reasons for this are not well understood. Methods: To examine the reasons that the IUD is little used in El Salvador, data were collected in 1999 via three techniques. In-depth interviews were conducted with 30 providers; simulated clients made a total of 40 clinic visits; and 10 focus groups were conducted separately with sterilized women, current or past IUD users and users of other clinical family planning methods. Results: Most family planning clients who had never used an IUD reported a negative impression of the method, mainly because of fear resulting from rumors and myths they had heard. In contrast, nearly all IUD users viewed the method positively. Most providers interviewed reported a positive attitude. Providers agreed that rumors and myths are the biggest barrier to IUD promotion, yet simulated clients reported that providers spontaneously tried to dispel myths in only about half of visits. Most providers said they discussed the IUD with clients, but many focus-group participants said they received information only on pills and injectables. According to simulated clients, providers spontaneously mentioned pills and injectables more than any other method. While 23 of the 30 providers interviewed had been trained in IUD insertion, many felt they did not have enough practical experience. Conclusions: Three main barriers impede IUD use in El Salvador: rumors and myths about the method; insufficient attention to the method during counseling sessions; and insufficient provider experience with it.
Incluye bibliografía e índice
Compared with other contraceptive methods such as sterilization and oral contraceptives, the prevalence of IUD use in Latin American countries is relatively low. This study evaluated the clinical performance of the TCu 380A IUD in six Latin American clinics to determine whether its performance was a determining factor in its low prevalence, and to provide efficacy and safety data based on local data sets to Latin American service providers. The 12-month unintended pregnancy rate ranged from 0.0 to 1.7 per 100 women and the 12-month discontinuation rates for all reasons, from 3.3 to 21.0 per 100 women. Statistically significant differences in discontinuation rates were observed among clinics, and could be explained, in part, by the different sociodemographic and clinical characteristics of women attending the clinics. The overall performance and acceptability of the TCu 380A IUD was considered satisfactory and comparable to those reported from other countries. Thus, the low prevalence of IUD use in Latin America is probably related to barriers to its use rather than its clinical performance.
To assess obstetrician-gynecologists' clinical use of the intrauterine device (IUD), their attitudes toward the IUD and how they select IUD candidates, and to test the hypotheses that limited residency training in IUDs, fear of litigation, and a belief that IUDs cause pelvic inflammatory disease decrease IUD use.
We performed a national mailed survey of 811 practicing obstetrician-gynecologists obtained from systematic sampling of ACOG membership listings to assess use of and attitudes toward the IUD.
The survey response rate was 50%. Most respondents agreed that the copper IUD is safe (95%) and effective (98%). However, 20% of respondents had not inserted an IUD in the past year, and of those who had, most (79%) reported inserting 10 or fewer. Fear of litigation and a belief that IUDs cause pelvic inflammatory disease were associated with lower IUD use; the number of IUDs inserted during residency was not. In selecting IUD candidates, respondents were most restrictive about patient monogamy. Having less conservative criteria for selecting IUD candidates was associated with greater IUD use. Respondents with liberal criteria inserted a mean of nine IUDs in the past year, whereas those with conservative criteria inserted four.
Because most obstetrician-gynecologists are inserting few IUDs, educational programs should target these physicians to expand their IUD use. Such programs should highlight modern IUD safety and the rarity of litigation. The number of IUDs inserted in residency may be less important than the development of less restrictive, more evidence-based criteria for selecting IUD candidates.
According to a survey of 5865 ever-married women 15-49 years in Sri Lanka, the island nation has relatively good immunization coverage, increasing contraceptive use, and declining fertility. In the 1960s and 1970s, the total fertility rate dropped from over 6.0 to 3.4. A "marriage boom" in the late 1970s contributed to a temporary fertility increase to a 3.7 child average. The 1987 Contraceptive Prevalence Survey showed that Sri Lankan fertility resumed its decline in the 1980s, recording an average total fertility rate of 2.8 children between 1982-86. Contraceptive prevalence also increased. An estimated 62% of married women 15-49 were currently using contraception in 1987 compared to 55% in 1982 and only 32% in 1974. 21% of the married women used rhythm, withdrawal, or prolonged abstinence as their methods, but 30% were protected by sterilization. Relatively small percentages chose oral contraception, condoms, or the IUD and injection. The women were less likely to use methods which necessitated repeat clinic or pharmacy visits. This preference most likely reflects the type of family planning services available. Nearly 80% of the married women indicated they did not want any more children; 69% in this age group were contracepting. Nearly all Sri Lankan pregnant mothers received prenatal care, and 87% of births during the 1982-86 period were assisted by medically trained personnel.
The total fertility rate of women in El Salvador has declined from an average of 6 children per woman in the 1970s to 4.4 in 1985, according to the Demographic and Health Survey report by Westinghouse's Institute for Resource Development. 5200 women aged 15-49, from areas covering 75-80% of the country, were surveyed. Contraceptive usage has risen from 34 to 47%. The usual method chosen is sterilization, by 70% of women. Only 7% of married women use the pill, 3% the IUD, 3% rhythm or withdrawal. Rural women, making up the majority of the population, accounted for a decline in total fertility from 8.4 to 5.9 children. In the capital San Salvador, fertility has risen from 2.6 to 3.3 children, reflecting migration of rural people into the city. The instability in El Salvador is probably responsible for a lowered life expectancy from 60 to 57 years, and for heavy out migration in the 1980s. Vaccination rates have improved recently to 47% of children under 5 years.
Maternal health is not simply a question of provision of good obstetric care and midwifery in district hospitals or health centres. It is a public health issue for which community interventions must be implemented. By ‘community interventions’ we mean activities which take place beyond health facilities such as skilled birth attendants attending home deliveries; outreach workers or community volunteers providing advice family planning nutritional supplements or drugs such as antibiotics or misoprostol; community health promotion such as work with women’s groups; and collaboration with traditional birth attendants (TBAs). Community interventions have the potential to improve preventive care in remote communities to reduce delays in seeking care and to support primary care services and referral systems. (excerpt)
National Family Health Survey Final Report General Summary: FESAL
- Fesal
FESAL. National Family Health Survey Final Report General Summary: FESAL 2008. http://www.fesal.org.sv. Published February 2009. Accessed October 7, 2009.