IUD – A Quick Update

1. IUD – A Quick Update SAF-PAC/SRMH/CARE Kamlesh Giri April 23rd, 2013

2. Unmet Need for Modern Contraception

3. World Modern Contraceptive Prevalence by Method

4. World Map showing IUD Use

5. 18 15 8 5 1 2 Asia Europe Africa Oceania NorthAmerica Latin America & Caribbean Worldwide Use of IUDs % Use for Married Women of Reproductive Age Population Reference Bureau. 2008. Mosher WD, et al. 2004.

6. What others are saying about FP! • "[Family planning] means the difference between being empowered and feeling powerless. It means the difference between celebrating a daughter's graduation and watching her drop out of school. It even means the difference between life and death.” Melinda Gates, HuffPost Blog

7. What is an IUD? • T-shaped plastic frame with copper wire/sleeves • Highly effective in preventing pregnancy – failure rate is less than 1% • Copper T 380A lasts for 12 years once inserted • Works mainly by preventing fertilization of an egg by sperms • Most women can use IUDs, including women who have never been pregnant • Fertility returns very quickly after removal • Very effective as emergency contraception

8. IUD – Types Copper T 380A IUD Copper ions Provides protection for up to 12 years LNG IUS (hormonal) 20 mcg levonorgestrel/day Provides protection for up to 5 years

9. LNG IUS 100 Copper IUD 80 60 Cumulative pregnancy rate (%) 40 20 0 3 6 9 12 Months IUD and IUS: Return to Fertility Andersson et al. Contraception 1992;46:575 Belhadj et al. Contraception 1986;34:261

10. Copper-bearing IUD: Timing of Insertion Can insert any time reasonably sure woman is not pregnant • Within 12 days after start of menses • Later in cycle/during amenorrhea if reasonably sure not pregnant • < 48 hours postpartum (if no puerperal sepsis) • ≥ 4 weeks postpartum (if not pregnant) • Within 7 days postabortion

11. 1.4 1.3 0.6 Postpartum Salpingectomy All Sterilization TCu 380IUD IUD Efficacy: Comparable to Sterilization 5-year gross cumulative failure rate WHO. 1987. Peterson HB, et al. Am J Obstet Gynecol. 1996.

12. Side Effects and Complications • Might increase menstrual bleeding or cramps • Usually gets better after first 3 months Complications • Rare • Perforation of the wall of uterus by IUD or an instrument • Pelvic inflammatory disease (PID) may occur if the woman has Chlamydia or gonorrhea at the time of IUD insertion

13. IUDs Can Be Used by MostHIV-Positive Women • No increased risk of complications compared with HIV-negative women • No increased cervical viral shedding • MEC Category: • Initiation: not recommended if not fully controlled but can be initiated if clinically well on ARVs if other methods are not available or not appropriate • Continuation: Can continue if more appropriate methods are not available WHO. Medical Eligibility Criteria for Contraceptive Use. 2009.Morrison CS, et al. Brit J ObstetGynaecol. 2001. Richardson B, et al. AIDS. 1999.

14. Dispelling Myths: IUDs…… • Do not cause abortion • Do notcause ectopic pregnancies • Do notcause PID • Do not cause infertility • Arenot too large for small women • Are unlikely to cause discomfort for male partner • Do not travel to distant parts of the body • Are not contraindicated for HIV-positive women

15. Clinical Aspects • Counseling – foundation for FP programs • Client screening • Medical Eligibility Criteria • Pelvic exam • Insertion procedure – doctors, nurses, mid-wives, health assistants, clinic officers • Follow-up

16. IUD in Humanitarian Settings • Barriers – usual suspects • Weak health infrastructure • Lack of trained providers • Lack of good logistics support • Poor supervision of services

17. IUD in Humanitarian Settings – contd • Funding – small portion of the overall humanitarian funding pie for FP in general – and even smaller for IUD • An average of $20.8 billion in total ODA annually to 18 conflicted-affected countries in study • $509.3 million (2.4%) for reproductive health • FP represents only 1.7% of RH activities

18. IUD in Humanitarian Settings – contd • A few caveats: • SGBV is not coded as RH but rather as post-conflict peace building by ODA • Does not include $ from philanthropic organizations: e.g. Gates Foundation, Buffet Foundation • Does not include $ from multilateral organizations: WHO, UNHCR, UNOCHA, WFP

19. Supporting Access to FP-PAC • Program in 3 countries • Chad, DRC and Pakistan • Supported by Large Anonymous Donor • Emphasis on providing LARC to most underprivileged women – women in crisis and post-crisis settings • LARC as part of comprehensive FP method mix • SAF-PAC also supports RH services in Mali and Djibouti but at a smaller scale

20. Contraceptive Method Mix – SAF-PAC

21. Conclusion • Though widely used contraceptive method globally, IUDs are poorly utilized in Sub-Saharan Africa • IUDs can be safely used by nulliparous women, HIV+ women, post-partum women • IUD effectiveness comparable to permanent FP methods • IUD does not cause PIDs • IUD considered best option as an EC • Need to improve funding $ for FP in general and LARC in particular

22. Thank you • Questions?

23. Table 2. ODA disbursement in conflict-affected countries. Patel P, Roberts B, Guy S, Lee-Jones L, et al. (2009) Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries. PLoS Med 6(6): e1000090. doi:10.1371/journal.pmed.1000090 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000090