Background
The intrauterine device (IUD) is a safe, effective and inexpensive method of family planning. Once inserted, it requires little attention from the user and can provide protection against pregnancy for up to 10 years. In spite of these advantages, IUD use has declined relative to other contraceptive methods in Kenya. The Kenya Demographic and Health Survey (KDHS) shows that IUD use dropped from 31% among modern method users in 1984 to 15% in 1993. This decline has caused concern among family planning program managers in the east African country.
Study Design
To learn more about the declining IUD use, FHI conducted simulated client visits and in-depth interviews with providers at 12 sites throughout Kenya. The study sites represented seven of Kenya's eight provinces and included six government provincial hospitals, four government district hospitals, one Family Planning Association of Kenya (FPAK) clinic, and one Nairobi City Council clinic. The hour-long in-depth interviews were conducted by trained social scientists and covered a variety of topics related to IUD services and provider attitudes toward the method. Nurses posing as clients conducted 28 "mystery client" visits in 12 study sites, plus two pretest sites.
Results
The decline in IUD use in Kenya is due to the following five interrelated factors. The order of these factors reflects potential for effective interventions, especially training.
Poor Quality of Care. In the majority of Kenyan family planning clinics, the IUD is the most labor-intensive and materials-dependent method provided. For this reason, it is the method most sensitive to variations in quality of care. When providers are misinformed, poorly motivated, and/or overworked, IUD services suffer accordingly. In-depth interviewers reported not only that many providers were misinformed about the method but that clinics often opened late and closed early, leaving providers less time to spend with each client. Many providers also were misinformed about contraindications for IUD use and its advantages and disadvantages. Fewer than half of the providers spontaneously mentioned the IUD to simulated clients. Non-menstruating clients were often refused any service or information, and providers rarely mentioned sexually transmitted disease (STDs) and never mentioned HIV/AIDS.
Fear of HIV acquisition/transmission. Providers are genuinely worried about contracting HIV from IUD clients or spreading it from one client to another. The fear of HIV seems to prompt providers to be more rigorous in the sterilization of instruments and other aspects of aseptic technique. However, this fear may also contribute to a reluctance to offer the IUD.
Poor product image. The poor image of the IUD among clients is due in part to misinformation about the method, such as beliefs that coitus can dislodge the IUD or that the IUD can move around in the body. Providers are unable or unwilling to dispel rumors and give accurate information about the method. Either actively or passively, providers discourage clients from accepting IUDs.
Provider bias or preference. While providers do not seem to have concerns about IUD safety or efficacy, they are reluctant to provide the method. In most of the simulated client visits, providers did not volunteer information about the IUD to clients, nor did they encourage clients to use the method or clarify rumors. Program planners like the IUD because it is inexpensive and effective. However, health workers see the method as time-consuming to provide, requiring a high level of skill, concentration, and cleanliness. Providers also are concerned that they may be blamed for rare but serious side effects, including infertility.
Shifting client preferences. The rapidly increasing popularity of injectable contraceptives is an important factor in declining IUD demand. Although delayed return to fertility is a concern, clients like injectables for reasons such as privacy (from partners), ease of use, and even reduced menstrual flow.
Recommendations
The following recommendations resulted from this study:
- Training curricula for providers must emphasize, to a greater degree, both technical aspects of the method and eligibility criteria for IUD use.
- General family planning training and retraining curricula in Kenya must devote more time and energy to IUD service delivery.
- Training should include service delivery to non-menstruating clients and, in particular, guidelines to determine or rule out pregnancy.
- Given estimates that the HIV seroprevalence in Kenya is now greater than 5%, training must cover counseling on STD and HIV infection and prevention.
- Training of family planning providers should include accurate information on minimizing the risk, albeit small, of HIV infection during routine activities such as pelvic exams, IUD insertions, and injections.
- Clinic waiting time should be made productive with presentations, discussions, and audiovisual presentations on contraceptive choice, STD prevention and other reproductive health issues.
Stanback J, Omondi-Odhiambo, Omuodo D. Why Has IUD Use Slowed in Kenya? Part A. Qualitative Assessment of IUD Service Delivery in Kenya. Final Report. Research Triangle Park, NC: Family Health International, 1995.
This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development.
This document is also available as a PDF in English (306 KB), a PDF in Spanish (188 KB), and a PDF in French (79 KB).
