Abstract:
OBJECTIVES : To assess the rates of failed insertion, expulsion, and perforation when intrauterine device
(IUD) insertions were done by newly trained clinicians, and to examine factors that may affect these
outcomes.
STUDY DESIGN : We evaluated skill-based outcomes following IUD insertion at 12 African sites in a secondary
analysis of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial. Before trial
initiation, we provided competency-based IUD training to clinicians and offered ongoing clinical support.
We used Cox proportional hazards regression to examine factors associated with expulsion.
RESULTS : Among 2582 IUD acceptors who underwent first attempted IUD insertion, 141 experienced insertion
failure (5.46%) and seven had uterine perforation (0.27%). Perforation was more common among
breastfeeding women within three months postpartum (0.65%) compared with non-breastfeeding women
(0.22%). We recorded 493 expulsions (15.5 per 100 person-years, 95% confidence interval [CI] 14.1─16.9):
383 partial and 110 complete. The risk of IUD expulsion was lower among women older than 24 years (aHR
0.63, 95% CI 0.50─0.78) and may be higher among nulliparous women. (aHR 1.65, 95% CI 0.97─2.82). Breastfeeding (aHR 0.94, 95% CI 0.72─1.22) had no significant effect on expulsion. IUD expulsion rate was highest during the first three months of the trial.
CONCLUSIONS : IUD insertion failure and uterine perforation rates in our study were comparable to those reported in the literature. These results suggest that training, ongoing support, and opportunities to apply new skills were effective in ensuring good clinical outcomes for women receiving IUD insertion by newly trained providers.
IMPLICATIONS : Data from this study support recommendations to program managers, policymakers, and clinicians that IUDs can be inserted safely in resource-constrained settings when providers receive appropriate training and support.
Description:
ACKNOWLEDGEMENTS : We thank the women who participated in this study for their motivation and dedication and the communities that supported this work. We also want to thank Sister Modiege Didi Maria Mojapelo (Refilwe Bophelo Clinic/NGO, Lanseria, South Africa), who served as one of the ECHO clinical trainers and certified ECHO clinicians in nine South African sites. The ECHO Trial is dedicated to the memory of Ward Cates.
