Event 3: Programs Increasing Access to IUDs and IUSs in the USA and in Lower- and Middle-Income Countries (LMIC)
Moderator: Ricky Lu, Jhpiego
Tessa Madden, CHOICE
Anita Makins, FIGO
Caitlin Quade, Family Planning Elevated
International actions to increase access:
Kate Rademacher
Tabitha Sripipatana
Anna Hazelwood
Jim Sailer
Susan Ontiri
Q&A
(last updated February 9, 2021)
Q: Anita Makins mentioned some FIGO resources during her talk. How can I see those?
A: You can download the complete list of FIGO publications here. (PDF)
Q: Has there been any work in IUD trainings using virtual platforms?
Dr. Makins: Yes - we recently held virtual training session on PPFP/PPIUD counselling & insertion at the FIGO Kigali Regional Conference in Dec 2020. The video link will be available on the FIGO website.
Ms. Rademacher: We are about to launch a study (FHI 360 and PSI) in partnership with the MOH in Nigeria looking at a virtual platform to train on hormonal IUS for copper IUD- experienced providers. Stay tuned!
Q: Is FIGO considering work on PPIUD with hormonal IUS vs copper IUDs?
Dr. Makins: Regarding FIGO and PPFP and IUS - there are no current plans. The PPIUD project closed in December 2020 and no funding as yet to continue it in any format.
Q: Can you talk about the access to removal of their IUDs for people receiving PPIUD in the FIGO project?
Dr. Makins: All women who had PPIUD as part of the FIGO project had access to removal through their regular family planning clinics as they would have if they had had it inserted as an interval IUD. The technique is no different.
Q: Does the cost effectiveness study [for FIGO PPIUD] capture cost of maintaining services over time to account for staff attrition, ongoing need for training, supervision and quality improvement?
Dr. Makins: Yes, these costs were all included. Salary costs of hospital clinical staff were not included as thee were staff which were already working in the system whether or not they were counselling on PPFP or placing PPIUDs for those women consenting for it. But the costs pf training, supervision and QI were included.
Q: Was there an assessment done on the number of women who reported "Missing Thread" post PPIUD insertion follow up?
Dr. Makins: Yes – the results are published in our paper: FIGO postpartum intrauterine device initiative: Complication rates across six countries in the International Journal of Gynecology & Obstetrics. Missing threads occurred in about 30% of women at the 6 week follow up. We have anecdotal evidence that this reduced by half at 1 year follow up, which makes sense as women will start menstruating once they stop fully breast feeding and so the threads are more likely to come down.
Q: If you give more than simulation training and help supervise procedures on real patients, how do you deal with issues of malpractice and privileges?
Ms. Quade: Our clinical trainer’s liability coverage [as a member of university faculty] extends to her training & proctoring visits in the community clinics. I know this is a significant barrier to proctoring in other settings.
Q: Does FPE (Family Planning Elevated) provide contraceptives to its client clinics?
Ms. Quade: Yes, FPE does provide contraceptives to our participating clinics. Some of these we stock directly (IUDs, barrier methods) and for the remaining methods, we reimburse clinics for dispensing either through an on-site or community pharmacy.
Q: Caitlin, can you speak to how the FPE program plans to sustain the work in each of your clinics especially when there is staff and provider turnover? How long will you be collecting data on patient satisfaction from your clinic partners and how do you plan to address declining rates in method provision or patient dissatisfaction, if any?
Ms. Quade: The need for continued technical training and support at clinics (particularly once the FPE program concludes) has informed our plan to shift in our final year to a train-the-trainer approach, building the capacity of clinicians within health organizations to train their incoming providers and staff. We’re also excited to build a community of practice in contraceptive care for FPE “graduates” so that they can continue connecting with our team and each other to discuss complex cases that arise. Regarding data collection, while our EHR data collection will extend a year after the program concludes (both at control and intervention sites), our client exit surveys will be collected just during the program implementation period. Our complete evaluation plan can be found on the Open Science Framework if you’re interested in digging deeper!
Q: Jim, as the market for LNG IUS evolves in LMIC, how do you see the role of the ICA foundation moving forward?
Mr. Sailer: ICA Foundation has been going through a strategic planning process, the results of which will be announced over the coming months. In the future, we believe that ICAF will continue to provide LNG IUS at no charge to organizations seeking to expand their method mix. More information for organizations in LMICs that wish to add the LNG IUS to the method mix can be found here. We hope that this stimulates more interest and demand in this important method, as has happened in countries like Nigeria, Kenya, and Zambia. We are paying close attention to the countries that are focus of donor efforts. At the same time, we feel it is important to provide access to this method for countries that may not be at the top of the international donor agenda, but still may have significant need (e.g. we have many significant projects in Latin/South America).
Q: Were there any demographic segments significantly *not* selecting LNG-IUS?
Ms. Rademacher: For LEAP, we have data on users who chose implants, copper IUD and hormonal IUS in Nigeria and Zambia. Publication coming soon!
Q: Are there any experiences with PPIUD in the rural low resource settings especially during desire for removals and especially when staff turnover for various reasons is very high?
Dr. Lu: These are field realities across LMIC and some programs have explored optimizing task shifting/sharing, on-site facility based mentoring to work with more than 1 provider (which is usually a limitation of group based centralized in-service training) and bolstering referral services when there is need, for example to remove misplaced or missing IUDs.
Q: A question for Susan Ontiri: When was your questionnaire re bleeding pattern post insertion of IUS conducted? How late after and what proportion of women were followed up?
Ms. Ontiri: 63% of the women were followed up, an average of 5 months post-insertion.