Article

Training to fit intrauterine devices/intrauterine systems for general practitioners: Is there an alternative method of service delivery?

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Abstract

Background and methodology This paper questions the traditional method of obtaining intrauterine device (IUD) and intrauterine system (IUS) training, by highlighting the pitfalls of this training, and introduces community IUD/IUS training, a new model offering significant advantages. Discussion and conclusions Traditional IUD/IUS training is not optimal for a variety of reasons including scarcity of designated IUD/IUS clinics, long distances for travel to be trained, wasted clinic appointments, a tendency towards difficult IUD/IUS fitting in these specialist clinics, and a lack of suitable doctors as IUD/IUS trainers. Community IUD/IUS training enables the trainee to be involved in patient selection, setting up an IUD/IUS clinic (probably for their own future use) and following up their own patients. Community IUD/IUS fitting has definite advantages and much to commend it.

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... 1 Further, similar challenges for IUD training have been described in other settings and countries. 13 IUD is a reversible contraceptive method that has an important impact on health care for reproductive age women as it is 99% effective on preventing pregnancies. 14 Using Comprehensive Video-Module Instruction as an Alternative Approach for Teaching IUD Insertion Juan Antonio Garcia-Rodriguez, MD, MSc; Tyrone Donnon, PhD BACKGROUND AND OBJECTIVES: Family medicine clinicians and residents have increasing educational and work demands that have made it difficult to provide and access training on specific procedures such as IUD insertion. ...
... 18 Also, a lack of technical competence with IUD insertion may prevent physicians from properly counseling patients on the advantages and disadvantages of an IUD and can contribute to women making less appropriate contraceptive decisions. 13,18,19 One of the traditional methods of IUD training in Calgary, where this study took place, is the attendance at one of the two IUD insertion teaching clinics in the city. The traditional method, or gold standard approach to teach this procedure, is a session provided by an academic gynecologist at the University of Calgary that includes instruction, demonstration, practice, and feedback. ...
Article
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Background and objectives: Family medicine clinicians and residents have increasing educational and work demands that have made it difficult to provide and access training on specific procedures such as IUD insertion. The purpose of this study was to determine whether the use of video-module instruction could provide residents with the necessary knowledge and skills to perform an IUD insertion correctly when compared with the traditional form of instruction, which is a lecture-demonstration session provided by an academic gynecologist. Methods: Thirty-nine family medicine residents participated in the study during the induction period at the beginning of their residency program in July 2012 at the University of Calgary. A randomized, two group pretest/posttest experimental research design was used to compare the procedural knowledge and skills performance (posttest only) of residents trained using an alternative instructional intervention (video-module teaching) with the traditional lecture-demonstration approach to teaching IUD insertion. Results: Both teaching methods were effective in providing procedural knowledge instruction, and the paired-samples t tests results were almost identical: t (37)=1.35. On the other hand, performance scores were significantly higher in the video-module group: t (37)=2.37, 95% CI (0.61, 8.00), with a mean difference in performance of 4.31. There were no significant differences in residents' satisfaction scores, and there was no correlation between the different scores and sex or age or between performance and level of satisfaction. Conclusions: This video-module instruction is an effective method to provide comprehensive IUD insertion training, and the psychomotor skills gain (performance component) was significantly higher than the traditional method of instruction.
... Se implementan estrategias para su utilización en atención primaria [102][103][104] . Entre las mujeres adolescentes incluidas en el proyecto CHOICE, la gran mayoría prefería un ARLD 105 . ...
Article
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Resumen: Se revisa la evidencia científica en las actividades preventivas de la atención de la mujer en relación con el seguimiento del embarazo, las actividades preventivas en la planificación y seguimiento de los métodos anticonceptivos, actividades preventivas en la menopausia, y la prevención de las fracturas osteoporóticas. Abstract: A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.
... An important factor-limiting access to IUC is the availability of providers who have the skills, time and support to train other HCPs. In the UK, a shortage of trainers has led to waiting lists for training program opportunities and hence a delay in physicians gaining the Letter of Competence in Intrauterine Techniques qualification [25]. ...
Article
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Background: Globally, 14.3% of women of reproductive age use intrauterine contraception (IUC), but the distribution of IUC users is strikingly nonuniform. In some countries, the percentage of women using IUC is <2%, whereas in other countries, it is >40%. Reasons for this large variation are not well documented. The aims of this review are to describe the worldwide variation in IUC utilization and to explore factors that impact utilization rates among women of reproductive age in different continents and countries. Study design: Published literature from 1982 to 2012 was reviewed, using Medline and Embase, to identify publications reporting diverse practices of IUC provision, including variation in the types of IUC available. Local experts who are active members of international advisory groups or congresses were also consulted to document variations in practice regulations, published guidelines and cost of IUC in different countries. Results: Multiple factors appear to contribute to global variability in IUC use, including government policy on family planning, the types of health care providers (HCPs) who are authorized to place and remove IUC, the medicolegal environment, the availability of practical training for HCPs, cost differences and the geographical spread of clinics providing IUC services. Conclusions: Our review shows that the use of IUC is influenced more by factors such as geographic differences, government policy and the HCP's educational level than by medical eligibility criteria. These factors can be influenced through education of HCPs and greater understanding among policy makers of the effectiveness and cost-effectiveness of IUC methods. Implications: Globally, 14.3% of women of reproductive age use IUC, but the percentage of women using IUC is in some countries <2%, whereas in other countries, it is >40%. This paper reviews the reasons for this diverse and highlights possible starting points to improve the inclusion of IUC in contraceptive counseling.
... The placement of an intrauterine device (IUD) requires a gynaecological examination, with a speculum. In Europe as in the United States, it is gynaecologists who most often place IUDs [1,15]. Use of a speculum for this placement facilitates performance of a Pap test, unlike visits for other means of contraception, which do not require gynaecological examinations. ...
Article
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Background In France, a Pap test for cervical cancer screening is recommended every three years for all sexually active women aged 25 to 65 years. Modes of contraception (any or no contraception, with or without a visit to a physician, and with or without a gynecological examination) may influence adhesion to screening: women who use intrauterine device (IUD) should be more up to date with their cervical cancer screening more often than those using other means of contraception. Our objectives were to analyze the association between modes of contraception and Pap tests for screening. Methods This cross sectional study is based on the CONSTANCES cohort enabled us to include 16,764 women aged 25–50 years. The factors associated with adhesion to cervical cancer screening (defined by a report of a Pap test within the previous 3 years) was modeled by logistic regression. Missing data were imputed by using multiple imputations. The multivariate analyses were adjusted for sex life, social and demographic characteristics, and health status. Results Overall, 11.2% (1875) of the women reported that they were overdue for Pap test screening. In the multivariate analysis there was no significant difference between women using an IUD and those pills or implant of pap test overdue ORa:0.9 CI95% [0.8–1.1], ORa 1.3 CI95% [0.7–2.7] respectively. Women not using contraceptives and those using non-medical contraceptives (condoms, spermicides, etc.) were overdue more often ORa: 2.6 CI95% [2.2–3.0] and ORa: 1.8 CI95% [1.6–2.1] respectively than those using an IUD. Conclusion Women seeing medical professionals for contraception are more likely to have Pap tests.
... [8][9][10][11] Bedside procedural skills training in primary care has met with various difficulties in many countries. 9,12,13 Traditionally, the skill of IUCD insertion is acquired via direct observation of the procedure performed by experienced colleagues and then attempting the procedure. The first attempt of insertion is often on a real patient. ...
Article
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Background and objectives Insertion of a intrauterine contraceptive device (IUCD) is one of the services provided at our public primary care polyclinics. We evaluate the effectiveness of a simulation workshop using low-fidelity mannequins to train primary care doctors. Methods Questionnaire feedback was collected before and after the workshop. Participants rated their confidence level in performing the insertion of IUCDs using a 10-point scale. Results A total of 37 out of 44 (84%) participants completed the survey. The median score for confidence level in performing the procedure increased from 2 out of 10 (interquartile range (IQR) 1 to 5) before the workshop to 8 out of 10 (IQR 7 to 9) after the workshop ( p < 0.01). The increase in confidence level was most pronounced among the participants with no previous experience with the procedure and those who had inserted only one or two IUCDs before the workshop. Participants rated a median score of 9 out of 10 (IQR 8 to 10) in their interest level to perform the procedure after the workshop. The overall experience of the workshop recorded a median score of 5 out of 5 using a five-point Likert scale. Conclusions Bedside procedural training has been challenging. The teaching of the procedure via a structured workshop format including a simulation of the procedure using a low-fidelity mannequin increases the confidence level of participants to perform the procedure. A similar format can be employed for training of other primary care procedural skills.
... However, there is probably a large untapped potential to improve provider attitudes towards IUDs by ensuring that all professionals involved in family planning receive regular technical updates and in-service training [106,107]. In high-income countries, OB/GYNs are more likely than general practitioners and nurses to receive regular updates on contraceptive safety, which may explain the different levels of knowledge between these professional categories. ...
Article
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Background Intra-uterine contraception (IUC) involves the use of an intra-uterine device (IUD), a highly effective, long-acting, reversible contraceptive method. Historically, the popularity of IUC has waxed and waned across different world regions, due to policy choices and shifts in public opinion. However, despite its advantages and cost-effectiveness for programmes, IUC’s contribution to contraceptive prevalence is currently negligible in many countries. This paper presents the results of a systematic review of the global literature on provider and lay perspectives on IUC. It aims to shed light on the reasons for low use of IUC and reflect on potential opportunities for the method’s promotion. Methods A systematic search of the literature was conducted in four peer-reviewed journals and four electronic databases (MEDLINE, EMBASE, POPLINE, and Global Health). Screening resulted in the inclusion of 68 relevant publications. Results Most included studies were conducted in areas where IUD use is moderate or low. Findings are similar across these areas. Many providers have low or uneven levels of knowledge on IUC and limited training. Many wrongly believe that IUC entails serious side effects such as pelvic inflammatory disease (PID), and are reluctant to provide it to entire eligible categories, such as HIV-positive women. There is particular resistance to providing IUC to teenagers and nulliparae. Provider opinions may be more favourable towards the hormonal IUD. Some health-care providers choose IUC for themselves. Many members of the public have low knowledge and unfounded misconceptions about IUC, such as the fear of infertility. Some are concerned about the insertion and removal processes, and about its effect on menses. However, users of IUC are generally satisfied and report a number of benefits. Peers and providers exert a strong influence on women’s attitudes. Conclusion Both providers and lay people have inaccurate knowledge and misconceptions about IUC, which contribute to explaining its low use. However, many reported concerns and fears could be alleviated through correct information. Concerted efforts to train providers, combined with demand creation initiatives, could therefore boost the method’s popularity. Further research is needed on provider and lay perspectives on IUDs in low- and middle-income countries. Electronic supplementary material The online version of this article (10.1186/s12978-017-0380-8) contains supplementary material, which is available to authorized users.
... Respecto a las formas de entrenamiento, las tutorías en el lugar habitual de trabajo (mentoring and coaching) de los equipos profesionales han sido propuestas como una estrategia alternativa a los talleres o cursos de capacitación tradicionales. 58 Esta estrategia intenta sortear las barreras de acceso a la capacitación que experimentan muchas/os profesionales (cupos y horarios restringidos, lucro (continuación) ...
Technical Report
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Mensajes Clave Marco general: • Los Métodos Anticonceptivos Reversibles de Larga Duración (particularmente los Dispositivos Intrauterinos y los implantes sub-dérmicos) constituyen las opciones más efectivas para las usuarias que buscan anticoncepción reversible y las más costo-efectivas para los programas. • La Organización Mundial de la Salud, así como también las principales sociedades científicas y profesionales a nivel internacional relacionadas a la salud sexual y reproductiva recomiendan ampliar el acceso a anticonceptivos altamente efectivos, de larga duración y reversibles para todas las mujeres y las adolescentes dentro de la gama completa de opciones anticonceptivas. ¿Cuál es el problema? • La utilización de métodos altamente efectivos como el DIU y el implante sub-dérmico es escasa en relación a otros métodos menos efectivos. • Existen barreras institucionales para el acceso de las mujeres a los MALD, que incluyen la variabilidad en la actitud profesional ante el método y las limitaciones en la infraestructura de los servicios y en la disponibilidad de recursos humanos. • El marco regulatorio para la disponibilidad, prescripción y provisión de MALD necesita adecuarse a las recomendaciones de los organismos internacionales en forma coordinada entre los diferentes cuerpos y estamentos del estado, y en forma articulada con las instituciones educativas y sociedades científicas. ¿Qué sabemos (a partir de revisiones sistemáticas) sobre las opciones viables para abordar el problema? • Opción 1 – Intervenciones dirigidas a mejorar el entrenamiento de obstétricas y obstétricos en la colocación, control y remoción del DIU y los implantes sub-dérmicos. • El entrenamiento de los equipos de salud para la indicación, colocación y control de DIU e implantes sub-dérmicos aumenta su tasa de utilización, y posiblemente reduzca el número de embarazos no planeados y de abortos. • Las modalidades de entrenamiento basadas en tutorías en los lugares de práctica habitual del/la profesional (on site mentoring and coaching) podrían ayudar a sortear barreras de acceso a la capacitación, y reducir el costo de traslados de las mujeres hacia los centros de mayor nivel donde habitualmente éstas se realizan. • Opción 2 – Intervenciones dirigidas a mejorar la disponibilidad de acceso de las mujeres al DIU y los implantes sub-dérmicos a partir del ordenamiento normativo y articulación de los diferentes niveles. • El marco regulatorio dentro de los estamentos del estado (salud, educación, etc.) debe estar coordinado siguiendo directrices actualizadas, basadas en evidencias científicas y orientadas a objetivos de salud. • La articulación con las sociedades profesionales y otras organizaciones de la sociedad civil favorecen la implementación de las políticas de ampliación de roles. • La articulación con el sector privado para la ampliación de roles de obstétricas y obstétricos en la colocación de DIU e implantes sub-dérmicos podría ayudar a descomprimir la demanda del sistema público de salud y mejorar la oferta de servicios en aquellos lugares donde los efectores públicos no se encuentran disponibles o accesibles.
... Current IUC and SDI training programmes might not be practical due to scarcity of designated clinics in general practice, lack of suitable caseload, lack of trainers in the community as well as other logistical problems such as distance to travel. [6] There is anecdotal evidence of long waiting lists for the practice training component of DFRSH and for LoC IUT/SDI both in and outside London. [7][8][9][10] Long waits for training might lead to attrition from the training programmes, resulting in further reduced service capacity with fewer practitioners to meet increasing demand. ...
Article
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Background: Long waiting times for training in sexual and reproductive healthcare (SRH) including long acting reversible contraception (LARC) might lead to attrition from training programmes, leading to reduced capacity for sexual health services, and reduced access to such contraception for women. Setting: General practice in London, UK. Question: Can medical educators in general practice be used as untapped potential to train other health care professionals in sexual and reproductive healthcare? Method: We conducted an online survey to find out the qualifications, skills and willingness of established educators in primary care in London to train other clinicians in sexual and reproductive healthcare, including LARC. Results: We received 124 responses from medical educators (10.1% response rate from general practitioner (GP) trainers and 59.0% of clinical supervisors for Foundation Year doctors). 86 (69.9%) had diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) qualification and further 18 (14.6%) were interested in obtaining this qualification. Eleven respondents were trained to fit intrauterine contraception only, three for contraceptive implants only and 37 were trained to fit both. 50 (40.3%) of 124 respondents were willing get involved in DFSRH training; 74% of these were willing to teach on any component of DFSRH including LARC. Discussion: There is a shortage of training places and long waiting list for clinicians who wish to train in SRH. This survey suggests there is a pool of GP educators with skills and experience in SRH and are willing to train others. This can potentially increase the training capacity and improve overall access to good contraception and LARC for women.
Article
We report a case of intrauterine device (IUD) removal five years after its insertion which was broken during the removal procedure. One of the arms of the IUD remained inside the uterus. We allowed three months for spontaneous expulsion. When this did not happen, we proceeded with a hysteroscopic removal. Because of its embebbed position in the myometrium this could not be removed during hysteroscopy and finally it was left in situ. The patient was monitored every three months for a period of 12 months. There was no problem. We report this case because doctors may find it necessary to remove the IUD in certain situations and be aware of such a breakage and various precautions to prevent this.
Chapter
IntroductionLearning OutcomesCombined Oral ContraceptiveProgestogen only PillInjectable Contraception (LARC)Sub-Dermal Implants (LARC)Legal StatusContraceptive PatchIntrauterine Contraception (LARC)Intrauterine System (LARC)Diaphragms and Cervical CapsSterilisation – Female and MaleLactational Amenorrhea MethodCondomsMale CondomFemale CondomFertility Awareness/Natural Family PlanningPersonaNew Methods Emergency ContraceptionReferencesFurther ReadingUseful Websites
Article
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Performance of procedures is an integral part of any family physician/general practitioner’s practice. Unfortunately, discrepancy occurs between the existing theoretical methods of procedural teaching and the training imparted during real daily practice, which creates gaps that need to be overcome. This article identifies and reviews teaching gaps in family medicine training and presents suggestions to overcome them with a view to forming holistic psychomotor skills based on the learner’s characteristics within the patient-centred philosophy of family medicine.
Article
To increase the uptake of long-acting reversible contraceptive methods, there is an urgent need for more health professionals to be trained to insert intrauterine devices. The author provides an up-to-date explanation of the training routes available, for both doctors and nurses. Copyright © 2009 Wiley Interface Ltd
Article
Objective To evaluate the attitude toward contraceptive methods of gynaecologists who, in Germany, are the sole prescribers of contraceptives. Methods An anonymous questionnaire was sent to 9545 gynaecologists inquiring about factors involved in their prescription of contraceptives, the contraceptives they preferred, and those they would recommend to their daughter, if they had one. Results The response rate of this survey was 21% (N = 2016). The combined oral contraceptive (COC) was the most commonly prescribed method followed by the levonorgestrel-releasing intrauterine system (LNG-IUS), the vaginal ring, the progestin-only pill (POP), the patch, and the progestin-only injectables. Of the respondents 51% would never prescribe the patch and 45% would never prescribe the hormonal implant at all; 61% would choose the LNG-IUS for themselves/for their partner; 18% would opt for a COC and 8% for the vaginal ring. Concerning their imaginary daughter, 71% would prefer a COC, 26% the ring, and 9% the LNG-IUS. The first counselling session lasted 13.8 ± 4.9 min, and the provision of information on the occasion of following visits 6.6 ± 3.2 min. Conclusion The contraceptives most prescribed by German gynaecologists were COCs, followed by the LNG-IUS, the vaginal ring, and POPs. The spectrum of contraceptives preferred for personal use differed in some ways from those prescribed to patients. Reasons for this discrepancy should be investigated.
Article
To investigate knowledge and attitudes towards intra-uterine contraception. Anonymous postal survey of 441 GPs (153 female and 288 male GPs) from the FHSA register in Stockport and Manchester. General practices in Stockport and Manchester. Main outcome measure. Response to a series of questions concerning attitudes and knowledge of intra-uterine contraception. One hundred and forty-two responses were received, giving a 35% response rate. Thirty-four percent of responding GPs did not fit intra-uterine devices (IUDs), with only 10% fitting more than 30 a year. There was a significant trend against IUD fitting by male GPs and GPs aged <40 years. Younger GPs with <10 years experience were significantly more aware of the reliability of intra-uterine contraception, but perceived IUD fitting as inconvenient for both the patient and the doctor. Female GPs had better knowledge and more positive attitudes to IUDs than male GPs. GPs may have difficulties in maintaining expertise. Primary care groups may opt to concentrate fittings in a few expert practices, or refer women to centrally based family planning clinics for IUD fitting.
Training to insert an IUD/IUS. Trends in Urology, Gynaecology & Sexual Health November
  • Dj Lee
Lee DJ. Training to insert an IUD/IUS. Trends in Urology, Gynaecology & Sexual Health November/December 2005; 10: 32–34.
Training to insert an IUD/IUS. Trends in Urology, Gynaecology & Sexual Health
  • D J Lee
Lee DJ. Training to insert an IUD/IUS. Trends in Urology, Gynaecology & Sexual Health November/December 2005; 10: 32-34.
Training to insert an IUD/IUS
  • D J Lee
  • Lee, D.J.