Beyond the Barriers: Strategies for “Jumpstarting” the IUD in Africa

1. Beyond the Barriers: Strategies for “Jumpstarting” the IUD in Africa Roy Jacobstein, M.D., M.P.H. Clinical Director ACQUIRE/EngenderHealth Erin McGinn, M.A. Associate Director, FITS Family Health international

2. Why Bother? • High unmet need in Africa for modern FP (lifetime risk of MM 1/16) • IUD “Underutilized” in Africa • IUD very effective and very safe • IUD availability increases choice • Low cost to programs/clients

3. Historical trends – IUDs were “popular” once

4. Global Context: How Many Women Use IUDs? In the world? 145 Million; CPR 13.9% In “Developing Countries”? 131 Million; CPR 15% Excluding China? 35 Million; CPR 5.8% D. Sub-S. Africa? <1 million; CPR 1%

5. Current IUD Use in Sub-Saharan African • East Africa: 0.6% • Middle Africa: 0.2% • Southern Africa: 1.8% • Western Africa: 1.3% (Japan: 2.2%; India: 1.6%; U.S.: 0.7% )

6. IUDs: An Excellent Method • Highly effective / comparable to FS • “Reversible sterilization” • 12-13 yrs with CU-T • Cheaper and easier to provide • Quickly and completely reversible

7. IUDs: An Excellent Method (cont.) • Very safe for most women, including: • Postpartum, postabortion, or interval • breastfeeding • young • nulliparous • Recent/new findings about IUD’s safety in relation to: • PID • Infertility • HIV/AIDS

8. Programmatic Considerations • More cadres can provide (because nonsurgical) • Potentially most cost-effective method • Greater availability = greater choice • Good option for HIV+ women • Good for both “spacers” and “limiters” YET…

9. “The IUD has the worst reputation of all contraceptives …except among those using it”

10. So What (to do)?: Have a MAQ Mini-U Session on the IUD?

11. Challenges to Revitalizing IUD Service Delivery

12. Service Delivery Challenges “In health care, invention is hard, but dissemination is harder”* “Mastering the generation of good changes is not the same as mastering the use of good changes”* *Berwick, JAMA, April 16, 2003, Vol 289, no. 15

13. Service Delivery Challenges: Intrinsic Nature of IUD A clinical method, ergo: • Must be provided in “medicalized” settings and systems • Highly provider-dependent • Prone to medical barriers • Marked by myths, fears, ignorance

14. Service Delivery Challenges: Nature of “Medicalized” Settings • Hierarchical • Conservative • Curative-oriented • Pace of change generally slow (then & now, here & there)

15. The Slow Pace of Change in Medical Settings: Some Reasons • Lack of perceived need for change • Lack of provider motivation (lack of perceived benefit) 3. Ignorance • of latest scientific findings • of risks and benefits (of IUD, etc.) • of concept of relative risk

16. Slow Pace of Change in Medical Settings: Some Reasons (cont.) • Medical/Clinical Orientation versus Epidemiological/Public Health Orientation • Primum non nocere • “Harm of doing” greatly feared • “Harm of not-doing” greatly overlooked • Focus on individual, not groups (of individuals) • Curative versus preventive orientation • Client and socio-cultural factors

17. What are Major Medical Barriers to IUD Use? • Provider bias against (or for) IUD • Limitations on which provider cadres are allowed to provide the IUD • Inappropriate eligibility restrictions • Age (“Not for the young”) • Parity (“No nullips need apply”) • “Must be menstruating” • “Can’t be post-partum or post-abortion”

18. What are Major Medical Barriers to IUD Use? (cont.) • Process hurdles • Mandatory and unnecessary F/U • Marriage / spousal consent requirements • Unsubstantiated “contraindications” • Can’t have vaginal discharge • “IUD not good for HIV+ women” • “Not suitable for Africa”

19. Understanding Change

20. The Diffusion of Innovations 1) an innovation – 2) its communication through certain channels 3) over time 4) among the members of a social system

21. The Three Main “Clusters of Influence” in Innovation Diffusion • What: Perceptions of the innovation • Who: Characteristics of the adopters • How: Contextual factors, e.g.,: • Communication • Leadership • Management/supervision • Policies and guidelines

22. I. Perceptions of the Innovation (The “What”) The five most influential properties of given innovation: Benefit • perceived Compatibility • perceived Simplicity • perceived “Trialability” • perceived Observability • perceived

23. II. Characteristics of Adoptersof Innovations (“The Who”)

24. What Are These? Why Are They Here?

25. Characteristics of Early Adopters • Opinion leaders • Socially well-connected • Cross-pollinators (of ideas) • Resources & risk tolerance to try new things • Watched by others (thus crucial to dynamics of spread) • Often chosen as leaders & representatives

26. So What (to do)?: New Opportunities • New findings about IUD safety • Updated/new WHO MEC – new policies/guidelines • Renewed donor interest in IUD • Potential/actual greater country interest in IUD (HSR, cost and HCD considerations) • Integration opportunities increasing

27. Revitalizing the IUD:In-Country Efforts

28. Kenya – The innovator

29. Trends in Modern Method Use in Kenya – Currently Married Women: 1984-2003

30. Qualitative Assessment of IUD Service Delivery in Kenya (1995) • Decline of IUD in Kenya due to: • Poor quality of care • Fear of HIV acquisition/transmission among providers • Poor product image among clients • Provider bias or preference for other methods • Shifting client preferences

31. The Kenya IUD Re-introduction Initiative (2002 – present) • Increase support for the IUD among policy makers, health care professionals and clients • Increase the provision of quality IUD services • Enhance demand for IUDs

32. Holistic Approach • National Working Group: Ministry of Health, USAID, DFID, AMKENI (EngenderHealth), FPAK, Professional organizations, JHPIEGO, GTZ/MOH, IntraHealth, Africa Population Advisory Committee, Population Council • Consensus building • Updated MoH FP Policies and Guidelines • 600 IUD kits distributed • 100 service providers have received intensive training related to IUD counseling, insertion and removal • Improved Service Delivery (AMKENI Sites)

33. Holistic Approach (cont’d) • Advocacy/Demand Creation • Advocacy towards policy-makers/providers • 4000 kits disseminated • Provincial CMEs or “sensitization” meetings • 600+ public and private sector providers reached • Education of 500 CBD/field agents • IEC materials distributed to clients (21,000 pamphlets) • Community information sessions • reached 12,000+ people

34. Experimental components… • IUD Checklist Field-Tested • “Academic Detailing”

35. IUD Checklist

36. “Academic detailing” • Based on model of pharmaceutical representatives • Seeks to: • Educate • Motivate • Change behavior Results: • Small, but significant impact on IUD uptake only in CBD/Clinic group

37. Comparative costs of pregnancy prevention

38. Results thus far…

39. Increased Services • IUD services available in 70% of AMKENI sites, up from 19%.

40. Increased IUD Uptake

41. Scale-up in Kenya • Extension to Kenya’s Kisii District/Nyanza Province (MoH/ACQUIRE Project)

42. Scale-up in Kenya • “Innovation” – adding a communications / marketing component to increase client interest/demand (in progress) • Will be called the “Stand Up” marketing campaign • Will build on the testimonial approach • Urges clients to take a “second look” at the IUD

43. The Early Adopters… • Uganda, Ethiopia, Mali, Ghana … • Kenya also playing a role model for early adopters • Research • Kenya’s IUD initiative highlighted at regional IBP meeting (Uganda, June, 2004) • Documentation of initiative is informing other countries in region and feeding into thinking at the HQ level here in the US

44. IUDs in Uganda • Broader focus on FP/LAPMs • Including costing analysis • Exploring mechanisms to involve private sector (midwives)

45. IUDs in other places… • Mali: Focus on cities, then expand out. • Ghana: Operations research looking at promotional campaigns and mobile services vs static services • Ethiopia, Guinea, Nigeria, Tanzania

46. Are we here?

47. Or are we here?

48. Are we here? MAQ IUD Toolkit

49. Take Home Messages: What to do? • Take a holistic approach (supply/demand) • Understand individual perspectives of health care institutions, providers, clients, communities (and intervene accordingly) • Avoid the “empty vessel syndrome” • Many IUD issues universal—but so is need for local buy-in • Identify and support/nurture early adopters/champions (individuals and org. units)

50. Be Realistic / Be Patient • Change will be slow • Change will be incremental • Change takes (a lot) of time “There’s no quick fix”