Family Health Intl- Training and Reference Guide for a Screening Checklist to Initiate use of the Copper IUD

Publication date: 2008

Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD This Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD was developed by Family Health International (FHI), a nonprofit organization working to improve lives worldwide through research, education, and services in family health. Similar guides, providing training and reference materials on other FHI provider checklists, are also being published. This guide was produced under FHI’s Contraceptive and Reproductive Health Technologies Research and Utilization (CRTU) program, which is supported by the U.S. Agency for International Development (USAID) under the terms of Cooperative Agreement No. GPO-A-00-05-00022-00. The contents of this publication do not necessarily reflect the views of USAID. Authors: Monique Peloquin Mueller, Christine Lasway, Irina Yacobson, Katherine Tumlinson Technical Review: Irina Yacobson, John Stanback, Erin McGinn, Jennifer Wesson, Kirsten Krueger Field Test: Angela Akol, Violet Bukusi, Marsden Solomon, Maureen Kuyoh Project Manager: Christine Lasway Copyediting: Mary Bean Production Coordinator: Karen Dickerson Design and Layout: Dick Hill, HillStudio ISBN: 1-933702-13-3 © 2008 by Family Health International Family Health International P.O. Box 13950 Research Triangle Park, North Carolina 27709 USA Telephone: 1.919.544.7040 Fax: 1.919.544.7261 Web site: http://www.fhi.org E-mail: publications@fhi.org Introduction 4 Training Module 7 Session One: Welcome and Introductions 10 Session Two: Rationale and Purpose of the IUD Checklist 14 Session Three: Design of and Instructions for Using the IUD Checklist 24 Session Four: Wrap-Up 33 Optional Session: Summary of Research Findings 34 Training Handouts 37 Scenario Exercises for Participants 37 Answer Guide to Scenarios 39 Quick Reference Charts 49 The IUD Checklist 51 Reference Guide 55 Adapting the Checklist to the Local Context 57 Basic Evidence-Based Information on IUDs 59 Annotated Bibliography 69 Appendix 73 Supplementary Training Schedules 73 Sample Energizers 79 Sample Certificate of Attendance 80 Table of Contents 4 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Introduction This training and reference guide was developed for family planning service providers interested in using the Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, commonly referred to as the “IUD Checklist”. Designed to serve as both a training and reference tool, the guide is composed of two parts: a training module and a collection of essential, up-to-date reference materials on the copper intrauterine device (IUD). This guide is part of a series to train on other checklists, including the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), and the checklist entitled How to Be Reasonably Sure a Client is Not Pregnant. The IUD Checklist was developed to assist service providers in screening clients who have already been counseled about contraceptive options and who have made an informed decision to use the copper IUD. This simple job aid is based on guidance provided in the Medical Eligibility Criteria for Contraceptive Use (WHO 2004) and supports the application of these guidelines into service delivery practice. Research findings have established that the IUD is safe and effective for use by most women, including those who have not given birth and those living with or at risk of HIV infection. For some women, IUD insertion is not recommended because of the presence of certain medical conditions, such as pelvic inflammatory disease (PID) or cervical cancer. The IUD Checklist provides a series of questions to screen for these medical conditions to determine if a woman is medically eligible for IUD insertion. The IUD Checklist also provides a series of questions to rule out pregnancy. This is a required practice before initiating an IUD because IUD insertion in a pregnant woman may result in a septic miscarriage. Pregnancy can be reliably determined with pregnancy tests, but in many areas of the world these tests often are either unavailable or unaffordable. In such cases, clients who are not menstruating at the time of their visit (occasionally referred to in this guide as “nonmenstruating women”, for the sake of simplicity) are often denied contraception by providers who rely on the presence of menses as an indicator that a woman is not pregnant. Usually, these women are required to wait for their menses to return before they can initiate a contraceptive method, thus putting them at risk of an unwanted pregnancy. The pregnancy-related questions on the IUD Checklist are taken directly from the checklist entitled How to Be Reasonably Sure a Client is Not Pregnant. This checklist, referred to as the “Pregnancy Checklist”, has been shown to be 99 percent effective in ruling out pregnancy. 5 Purpose of the Training and Reference Guide This publication is intended to provide program managers, administrators, trainers, and service providers with: n a training module on how to use the IUD Checklist; n an overview of the IUD Checklist and guidance for adapting it for local use; n information on the most current research regarding the validity, effectiveness and use of the IUD Checklist; and n current, essential, evidence-based information on the IUD. Intended Users of this Guide This guide can be used by: n trainers, facilitators, program managers and administrators responsible for training service providers to use the IUD Checklist; n service providers who need to apply the IUD Checklist in their practice and are responsible for teaching themselves how to use it; n policy-makers and program managers interested in introducing the IUD Checklist for use in their community. Intended Participants of the Training Training on the IUD Checklist would benefit both clinical and non-clinical service providers who counsel clients about IUDs or who provide clients with this contraceptive method, including: n family planning providers; n providers appropriately trained in conducting pelvic exams, such as physicians, midwives, clinical officers, nurses, or auxiliary nurses; n non-clinical health workers, such as counselors or assistants, who can be trained to use the first two sets of screening questions. A clinical service provider would then complete the checklist based on the results of the pelvic exam. Note: This guide focuses exclusively on how to use the IUD Checklist. In order to provide quality services, providers who offer or plan to offer the Copper IUD to their clients may also need training or information on additional topics, such as IUD insertion techniques, details on various contraceptive methods, and family planning counseling techniques. For more comprehensive, evidence-based information on the IUD, please visit www.iudtoolkit.org. Introduction 6 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD How to Use this Guide Using the guide as a training tool This guide provides a curriculum for training service providers to use the IUD Checklist. Training on the IUD Checklist can be completed in approximately six hours. Facilitators are free to adapt the training to better serve the needs of their particular audience and may add or delete activities or use the information provided to create their own training. Additional tools that may assist the facilitator in adapting the training include a CD-ROM and training schedules for different types of audiences. The CD-ROM is located in the pocket inside the back cover, and the training schedules may be found in the section entitled Supplementary Training Schedules, page 73. Using the guide as a reference tool This guide also provides reference information that supplements the training. This information includes recommendations on adapting the checklist to the local context, basic evidence-based information on the IUD, and an annotated bibliography. 7 Learning Objectives By the end of the training, participants will have learned or become familiar with: n the rationale, purpose, and design of the IUD Checklist; n the medical eligibility criteria to screen clients for IUD initiation; and n proper use of the checklist. Number of participants No more than 30 people are recommended per training. Time A minimum of six hours is required to complete all four sessions. This includes the Optional Session but does not include breaks. Structure of the Module Each training session has four components: n Objective — a short description of the purpose and learning objective(s) for the session n Time — anticipated length of the session n Training Steps — basic steps that guide the trainer through the activities n Facilitator’s Resource — detailed information to convey to participants, as indicated in the training steps Training Module Session Time Topic Training Method 1 30 minutes Welcome and introductions Exercise A: Peel the Cabbage Large group activity; group discussion 2 20 minutes Rationale and purpose of the IUD Checklist Facilitator presentation 10 minutes Exercise B: Demonstrating the Benefits of Using the Pregnancy Checklist Small group activity 40 minutes Exercise C: Review of the WHO Medical Eligibility Criteria Large group activity 3 40 minutes Design of and instructions for using the IUD Checklist Facilitator presentation 170 minutes Exercise D: Practice Using the IUD Checklist Small group activity 4 15 minutes Wrap-up Group discussion Optional Session 25 minutes Summary of Research Findings Facilitator presentation Training Module 8 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Training Materials Facilitators will need the following materials: n flip chart paper n tape n markers n colored pencils for all participants (red and green are recommended) n training handouts, found on pages 37-54 and on the CD-ROM, including: • the Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD • two versions of the Quick Reference Chart (one with the medical eligibility categories colored in and one with no color) • Scenario Exercises for Participants • Answer Guide to Scenarios Advance Preparation for Trainers In order to understand the purpose, content, and approach of the training, we recommend that facilitators master the information in this guide, as well as the materials on the CD-ROM. Facilitators should also be very familiar with the training handouts used in conjunction with the participant exercises. Some sessions require advance preparation, such as photocopying, preparing flip charts, or preparing components for exercises. Facilitators should know their audience and adapt the training accordingly. Due to the technical nature of the subject matter, it is highly likely that questions about IUDs will arise that are beyond the scope of the information provided in the training portion of this guide. The information provided in the reference guide or on the CD-ROM may help facilitators to address some of these questions. Because this guide is not intended to comprehensively answer all questions around IUD provision, additional training may be required. In those limited cases where the facilitator does not have a clinical background, it is recommended that someone with a clinical background be present to answer technical questions. Key information for the facilitator is noted throughout the training module with the following symbol. 9Training Module The CD-ROM accompanying this module provides information on all four screening checklists to enhance the training for a variety of participant groups. The CD-ROM contains the following materials. 1. Suggested schedule for a combined training on all four checklists 2. PowerPoint presentations for orienting different audiences on the checklists: • PowerPoint presentation A: How to Use Screening Checklists to Initiate Use of Contraceptives (for facilitators) • PowerPoint presentation B: Screening Checklists to Initiate Use of Contraceptives — Tools for Service Providers (for policy-makers and program managers) 3. Handouts for participants: • Scenario Exercises for Participants • Answer Guide to Scenarios • Quick Reference Charts • Four Screening Checklists • Certificate of Attendance (sample) 4. Electronic versions of all four Training and Reference Guides 5. Basic, essential, evidence-based information on COCs, DMPA, and IUDs: • Medical Eligibility Criteria for Contraceptive Use, WHO 2004 • Selected Practice Recommendations for Contraceptive Use, WHO 2004 • PowerPoint presentation C: Overview of COCs • PowerPoint presentation D: Overview of Injectables — DMPA and NET-EN • PowerPoint presentation E: Overview of the IUD • PowerPoint presentation F: Hormonal Contraceptives — Considerations for Women with HIV and AIDS The CD-ROM Training and Reference Guides for Family Planning Screening Checklists © 2008 10 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Objectives: To present the learning objectives of the training. To facilitate introductions among participants and facilitator(s). To develop a common understanding of training expectations and group norms. To “break the ice” and help participants become engaged in the training. Training Steps: 1. Welcome the participants and introduce yourself and any other facilitators. Provide an opportunity for participants to also introduce themselves. You may choose to have participants do this by stating their name and area of expertise or by using the icebreaker activity in the shaded box below. The icebreaker activity will also help you to better understand your audience. 2. Ask participants to state what they expect to learn from the workshop. Write their expectations on flip chart paper and save them for later. These expectations will be valuable at the end of the workshop as an evaluation tool. 3. Ask participants to suggest guidelines, or norms, to be followed by the group during the training session. Group norms could include: switching off mobile phones, respecting others’ right to speak, etc. 4. Launch the training by discussing the title of the IUD Checklist and the learning objectives of the training. Highlight any relevant expectations that were previously expressed by participants. 5. Conduct Exercise A (page 12) to engage participants in an introductory discussion of their current practices for screening women who wish to start using an IUD. 30 minutes Session One: Welcome and Introductions Icebreaker Activity Each participant talks to the person next to them for five minutes to find out: a) their name, b) the name of their organization and the nature of their work, and c) why they are attending the training today. Participants should then present this information back to the group. 11 6. Explain that the Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, which we will often refer to as the “IUD Checklist”, was developed to help providers correctly determine that a woman has no conditions which would prevent her from safely receiving an IUD. 7. Explain that participants will review the IUD Checklist and will practice using it later in the training. In so doing, they will discover the answers to the following questions. • Why was the IUD Checklist developed? • How should service providers use the IUD Checklist? • What is the basis for the IUD Checklist? • How does the IUD Checklist work? Training Module Exercise A: Peel the Cabbage Advance Preparation Prior to the training, write the following three questions at least four times, each on a different piece of paper. You should have at least 12 pieces of paper. Mix the pages up and then layer and crumple them so that they resemble a cabbage. Include additional questions on additional pieces of paper, as appropriate. Also write these three questions on the flip chart, each on a different page, and tape them up for all to see. Name one practice that you follow to determine if a woman can safely receive an IUD. Name one approach to ruling out pregnancy prior to IUD insertion. Name one health condition that prevents women from having an IUD inserted. Objective: Participants will discuss their current practices for screening women who wish to start using an IUD. 1. Toss “the cabbage” to one of the participants. The person holding the cabbage must peel off the top layer and answer the question. After answering the question, the participant “tosses the cabbage” to another participant to answer the next question. If this question has already been asked, the participant cannot repeat the same answer. Continue tossing the cabbage until all the questions are answered. Possible answers are given below. Name one practice that you follow to determine if a woman can safely receive an IUD. Answers could include: medical histories, questions about the presence of certain symptoms, laboratory tests, the IUD Checklist, etc. Name one approach to ruling out pregnancy prior to IUD insertion. Answers could include: a pregnancy test, presence of menses, pelvic exam, Pregnancy Checklist, etc. Name one health condition that prevents women from having an IUD inserted. Answers could include: current pelvic inflammatory disease (PID), cervical cancer, sexually transmitted infections (STIs), etc. 12 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 2. If appropriate for your audience, you may chose to make the exercise fun by having the group give some form of mild “penalty” to participants who cannot answer their question. This might include such things as raising one hand, bending their head to one side or standing on one foot until the cabbage is completely peeled. Let the participants be creative. 3. Conclude the exercise by telling participants that they will have the opportunity to see whether their answers were correct or not at the end of Exercises B and C in Session Two. Remember that participants may already have extensive knowledge and practical experience in family planning. Make an effort to incorporate participants’ questions, knowledge, and experiences into your training session, as appropriate. Training Module 13 14 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Session Two: Rationale and Purpose of the IUD Checklist Objective: To learn why and how the checklist was developed. Training Steps: 1. Hold up a copy of the IUD Checklist to show participants, but do not distribute it until later in the session, at the end of Exercise C. Check to see if they are already familiar with the checklist, by asking the following questions. n How many of you currently use this checklist to decide if a woman can safely have an IUD inserted? n For those who use the checklist, do you find it useful in your work? How? 2. Explain what the IUD Checklist is and why it was developed. If appropriate for your audience and if needed, you may also choose to discuss the research on the IUD and Pregnancy Checklists, located in the Optional Session, page 34. 3. Engage participants in a discussion on how service providers should use the IUD Checklist. Ask participants the following question to emphasize the use of this job aid to improve efficiency in their daily work. n In your daily work, how easy is it to use your national guidelines/protocols to determine if a woman can safely have an IUD inserted? 4. Discuss the basis for the three sets of questions on the IUD Checklist. n First, explain the concept of the Pregnancy Checklist questions, what they are, and why they were developed. n Then, perform Exercise B (page 15) to help participants understand the usefulness of the Pregnancy Checklist questions for ruling out pregnancy among women who are not menstruating at the time of their visit. n Next, introduce the WHO Medical Eligibility Criteria and explain its purpose. n Finally, perform Exercise C (page 17) to help participants better understand how the categories work in relation to the use of IUDs. If there are national guidelines or protocols for family planning provision, it is important to link the checklists to these documents to promote utilization of the checklist. 70 minutes Exercise B: Demonstrating the Benefits of Using the Pregnancy Checklist Advance Preparation In advance of the training, write each of the following statements on a separate piece of paper. The statements represent six circumstances that prevent a woman from becoming pregnant and one that does not. n Client 1: “I’ve not had sexual intercourse since my last menstrual period.” n Client 2: “I always use condoms during intercourse, but I want to start using something else.” n Client 3: “I just started my menses six days ago.” n Client 4: “I have a 3-week-old baby.” n Client 5: “Five days ago, I had a miscarriage.” n Client 6: “I am fully breastfeeding my 5-month-old baby. Since having my baby, I have not had my menstrual period.” n Client 7: “It has been two weeks since I had my last menstrual period.” Objective: Participants will gain a better understanding of the benefits of using the Pregnancy Checklist by visually comparing the number of women who would potentially receive contraception at the time of their visit when providers do and do not use the checklist. This exercise is based on studies of the Pregnancy Checklist done in Kenya, Guatemala, Mali, Senegal, and Egypt. 1. Ask seven participants to come to the front of the room. They will represent seven female clients seeking an IUD who are not menstruating at the time of their visit. 2. Tell the rest of the participants they will act as providers and will be asked to determine as they would usually do (i.e., based on their current practices) if these women are not pregnant. For example, participants might suggest that the client would be: • sent home with condoms and asked to return when they are menstruating, or to return four weeks later for an exam if they are not menstruating, whichever comes first; • given a pregnancy test; • given a pelvic or abdominal exam; or • asked more questions. Training Module 15 3. Distribute the above statements, one to each client. Have the first volunteer “client” read their statement out loud, then ask the group acting as providers if pregnancy can be ruled out for this client — Yes or No, and why. Require participants to explain their answers and correct any mistakes as you go along. 4. Repeat the exercise for all seven clients. 5. Conclude the exercise by stating that clients 1-6 represent the six questions on the Pregnancy Checklist that allow pregnancy to be ruled out. Emphasize that if these questions were not asked, these clients would not be able to receive an IUD right away. Point out that the Pregnancy Checklist prompts providers to inquire about all six of these conditions when facing a client. Explain that for client 7 pregnancy has not been ruled out. Since it has been two weeks since her last menstrual period, there is a possibility she might be pregnant. However, the Pregnancy Checklist cannot determine that this woman is, in fact, pregnant. 16 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 17 Exercise C: Review of the WHO Medical Eligibility Criteria Advance Preparation n Prior to the training, make sufficient photocopies of both Quick Reference Charts (pages 49-50) and the IUD Checklist (pages 51-54) to distribute to each participant. n You will also need green and red pens or markers for each participant. n In addition, you may want to prepare a flip chart page containing the informa- tion in the box below. Category 1: No restrictions for use. Category 2: Generally use; some follow-up may be needed. Category 3: Usually not recommended; clinical judgment and continuing access to clinical services are required for use. Category 4: Should not be used. Objective: Participants will review the Quick Reference Chart to become familiar with relevant conditions that have been studied and determined to either be safe or not safe for IUD insertion and use. 1. Give each participant a blank copy of the Quick Reference Chart, along with a green and a red pen/marker. 2. Present the information in the box above and explain how the categories are grouped into two colors: GREEN — representing categories 1 and 2, and RED — representing categories 3 and 4. 3. Ask participants to use the green or red pens/markers to color in the rectangles to the right of the conditions listed on the chart. Choose a maximum of four conditions, such as diabetes, high blood pressure, HIV/AIDS, and endometrial cancer. Have them use GREEN if they think the condition falls under category 1 or 2 and RED if they believe the condition falls under category 3 or 4. They should choose the color based on their knowledge, assumptions or best guess. At your discretion, participants can work individually, in pairs, or as a group. Allow them 10 minutes to complete this task. (If no colored pencils or markers are available, have participants write a “G” for green or an “R” for red in the rectangles.) Training Module 17 4. Now, give each participant a copy of the color version of the Quick Reference Chart and ask them to compare their own answers to it. Allow about 10 minutes for them to assess whether their answers were correct or incorrect. Note that the color version has four colors, one for each category. To make this activity simpler, only two colors are being used instead of four. Clarify to participants that light red/pink is red and light green is green. 5. Ask volunteers to share which color or category they assigned to each condition. Correct any misinformation as you go along. Discuss significant issues affecting medical eligibility for IUD insertion (page 22). 6. Distribute a copy of the IUD Checklist. Ask participants to compare questions seven through twenty of the IUD Checklist with the conditions colored in red on the Quick Reference Chart. Participants will quickly see that the checklist questions only ask about category 3 and 4 conditions (red categories). Explain that these questions were written to identify women who should not have an IUD inserted or who will require additional evaluation by a higher level provider before inserting an IUD. Category 1 and 2 conditions (green categories) are not addressed on the checklist because research shows that women with these conditions can have an IUD safely inserted. 18 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 19 Facilitator’s Resource: Why was the IUD Checklist developed? n The IUD Checklist was developed to help family planning providers determine quickly and with confidence whether a client may safely have an IUD inserted as their contraceptive method of choice by screening women for certain medical conditions. n Screening is necessary because some medical conditions preclude safe IUD insertion. Most women who want to initiate use of an IUD can safely and effectively do so. Some women need further evaluation and/or treatment before having an IUD inserted. For example, a woman who recently had gonorrhea should not have an IUD inserted unless it is determined through further evaluation that she is not currently infected. A few women should not have an IUD inserted under any circumstances, such as those who have current pelvic inflammatory disease (PID) or cervical cancer. n Screening for IUD initiation should also include ruling out pregnancy, because IUD insertion in a pregnant woman could result in a septic miscarriage. n Training on the IUD Checklist would benefit both clinical and non-clinical service providers who counsel clients about IUDs or who provide clients with this contraceptive method, including: • family planning providers; • providers appropriately trained in conducting pelvic exams, such as physicians, midwives, clinical officers, nurses, or auxiliary nurses; • non-clinical health workers, such as counselors or assistants, who can be trained to use the first two sets of screening questions. A clinical service provider would then complete the checklist based on the results of the pelvic exam. How should service providers use the IUD Checklist? n As a screening/decision-making tool • The IUD Checklist can be used as a screening tool to help a provider determine whether a woman (1) is a good candidate for IUD use, (2) will need further evaluation, or (3) should choose another family planning method. It is not a diagnostic tool, such as a blood test, which can determine whether a woman has a particular disease or condition. • The IUD Checklist should only be used with women who have made an informed decision to have an IUD inserted. In order to make an informed decision, all women should be counseled about their contraceptive options by providers who are properly trained in counseling techniques and in Training Module 20 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD providing information on various contraceptive methods. The checklist itself is not a counseling tool, but may be used after counseling has been completed. n As a job aid for using resources more efficiently • The IUD Checklist can save time for both providers and clients by asking simple questions to rule out pregnancy and eliminating the need for most nonmenstruating clients to make another appointment. • Evidence-based practice guidelines can be lengthy and sometimes complicated. Use of the IUD Checklist provides a way to apply these same guidelines in a simple, efficient, and timely manner. What is the basis for the IUD Checklist? n The IUD Checklist is composed of three sets of questions to determine if the client is medically eligible to use an IUD. Questions 1-6 allow providers to be reasonably sure that the client is not pregnant. The next two sets of questions (questions 7-13 and 14-20) allow the provider to identify women who may have contraindications for IUD insertion other than pregnancy. n All three sets of questions on the IUD checklist are based on the WHO Medical Eligibility Criteria for Contraceptive Use (MEC). The WHO MEC is a set of recommendations to support the development of guidelines for providing contraceptives. It is updated by a WHO expert working group every three to four years (or as needed) in order to reflect the latest clinical and epidemiological data. The Quick Reference Chart on page 50 is a condensed version of the information contained in the WHO MEC (2004). n First we will discuss the questions designed to rule out pregnancy, and then we will discuss the questions related to other medical eligibility issues. n Pregnancy-Related Questions (Questions 1-6) • The first set of questions on the IUD Checklist (questions 1-6) is taken directly from another checklist entitled How to Be Reasonably Sure a Client is Not Pregnant (Pregnancy Checklist). Ruling out pregnancy prior to IUD insertion is essential because IUD insertion in a pregnant woman could result in a septic miscarriage. Also, the pregnancy-related questions help to address a medical barrier that women often encounter when seeking an IUD at a time when they are not menstruating. In countries where resources are limited and pregnancy tests are often unavailable or unaffordable, many providers worry that these women may be pregnant (unless they are within four weeks postpartum). Many of these clients are sent home, often without contraception, to await menses. Those who are unable to return — often because of time and money constraints — risk unintended pregnancy. 21 • The questions from the Pregnancy Checklist help providers to be reasonably sure a woman is not pregnant or to decide that another approach is required to rule out pregnancy. Each question describes a situation that effectively prevents a woman from getting pregnant. The checklist is not a diagnostic tool for determining if a woman is pregnant. (Note that women in whom pregnancy was not ruled out by questions 1-6 are not necessarily pregnant.) n Other Medical Eligibility Questions (Questions 7-20) • The WHO MEC takes various individual characteristics (e.g., age, breastfeeding status) or health conditions (e.g., diabetes, hypertension) that may or may not affect eligibility for the use of each contraceptive method and classifies them into four categories. Category Recommendation 1 No restriction for use of method 2 Advantage of using method outweighs theoretical or proven risk: method generally can be used, but follow-up may be required 3 Theoretical or proven risk outweighs the advantages of using method: method not recommended except if other more appropriate methods are not available/acceptable 4 Method should not be used • The IUD checklist includes questions related to categories 3 and 4 only. These two categories include conditions for which the method is either not recommended or should not be used. Category 1 and 2 conditions are not addressed on the checklist because research shows that women with these conditions can have an IUD safely inserted. • The IUD checklist incorporates two screening approaches: medical/personal history and pelvic examination. This is why questions 7-13 solicit answers from the client, whereas questions 14-20 are answered by the provider himself/herself, based on the results of the pelvic exam. Training Module 22 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD n Significant Issues Affecting Medical Eligibility The following is a brief summary of some significant issues affecting medical eligibility for IUD insertion. These issues should be discussed during Step 5 of Exercise C and may also be reemphasized during discussion of the scenarios. The following information was taken from the research which informed the development of the WHO MEC. Additional information may be found in the reference section of this guide (pages 59-68) and in the guidance provided on the IUD Checklist itself. • Use of the IUD by nulliparous women In the past, concerns had been raised about whether IUD use was associated with infertility. These concerns led to the recommendation that nulliparous women should not receive an IUD. Subsequently, nine well designed studies, conducted between 1985 and 2002, examined this issue specifically. These studies, which were reviewed by the WHO Working Group, suggest that there is no increased risk of infertility. The recommendation has therefore been changed to allow nulliparous women to receive an IUD. • Use of the IUD by women with pelvic inflammatory disease (PID) Current PID is a contraindication for IUD insertion. If a woman presents with PID, she should be treated with antibiotics and may have an IUD inserted when she is cured. A woman who is already using an IUD and who subsequently develops PID does not need to have her IUD removed, but can be treated for PID with the IUD in place if she chooses to continue using her IUD. Research has shown that there is no difference in clinical outcomes of PID when treated with the IUD left in place or taken out. • PID and Sexually Transmitted Infections (STIs) There is a potentially small increase in the risk of PID if an IUD is inserted in a woman with current gonorrhea or chlamydial infection. However, it is important to understand that women with gonorrhea or chlamydia may develop PID with or without an IUD. It has been shown that IUD insertion in women with current infection may increase this risk slightly, by 0.15 to 0.30 percent. Therefore, the recommendation is to treat any current cervical infection and provide condoms until the infection has cleared. Then, if the woman still wishes to use an IUD, insert the device and provide careful follow-up. Identifying women who are at risk for an STI and determining appropriate next steps may be difficult. Women should be considered at high individual risk of infection if they have certain factors, such as multiple partners, a partner with multiple partners, or if their partners have symptoms of an 23 STI or were recently diagnosed with an STI. (Note: In countries where polygamous marriage is practiced, this risk is impacted by the sexual behaviors of each of the partners in the marriage. In other words, whenever the husband or any of the wives has more than one partner, the risk of contracting an STI increases.) Women at high individual risk generally should not have an IUD inserted. When contraceptive methods other than the IUD are not available or acceptable to a woman, she should be counseled about risk, checked for STI symptoms and have the IUD inserted if there are no symptoms. (If possible, testing for current gonorrhea or chlamydial infection can be done, but is not mandatory.) Women should also be counseled to return in approximately four weeks after insertion to check for signs of infection, or be told to return immediately if she experiences symptoms of pelvic infection, such as low abdominal pain, vaginal discharge or fever. • Use of the IUD by women with HIV infection and AIDS Human immunodeficiency virus (HIV) is a virus that attacks the immune system, making it difficult for the body to fight infection and disease. HIV is the virus that eventually causes acquired immunodeficiency syndrome (AIDS), which increases a person’s risk of developing certain cancers and infections. AIDS is the last and most severe stage of the HIV infection. IUDs can generally be initiated and used by HIV-infected women or by women at high risk of HIV. Women who have AIDS should not have an IUD inserted unless they are clinically well on antiretroviral (ARV) therapy. However, women who develop AIDS while using an IUD can continue using the device even if they are not receiving ARV therapy. IUD use has not been found to increase the risk of acquiring or transmitting HIV. There is some evidence showing no increased risk of complications, such as PID, for HIV-positive women compared to non-infected women. The risk of complications does increase in a woman with AIDS who is not on ARV therapy, and therefore the difference in status between HIV and AIDS should be considered. Questions may be likely about these and other medical eligibility criteria. Details provided in the WHO MEC, on the IUD Checklist, and in the reference section of this guide may assist in providing answers to these questions. Training Module 24 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Session Three: Design of and Instructions for Using the IUD Checklist Objectives: To understand the design of the IUD Checklist. To practice using the IUD Checklist in different scenarios to ensure that participants are comfortable using it. Training Steps: 1. Discuss the checklist’s design and explain how to use the checklist. Then ask participants if they have any questions, and clarify anything they did not understand. 2. Conduct Exercise D (page 25) to allow everyone in the group to practice administering the checklist. 3 hours and 30 minutes Design of and Instructions for Using the IUD Checklist Exercise D: Practice Using the IUD Checklist Advance Preparation Prior to the training: n photocopy the Scenario Exercises for Participants (pages 37-38); n make sure you are familiar with the information provided in the Answer Guide to Scenarios (pages 39-48); n make photocopies, if desired, of the Answer Guide to distribute at the end of the session; n prepare a flip chart page containing the following questions: • Is this client a good candidate for receiving an IUD during today’s visit? • Why or why not? • What course of action would you take next? (For example: counsel, refer, provide an IUD, send the client home with condoms to await menses, administer a pregnancy test, etc.) • Did you experience any problems applying the checklist to your scenarios? Objective: To help participants become comfortable using the IUD checklist. 1. Introduce the scenario exercises and explain that participants will be grouped into pairs. Each pair will receive two scenarios. Within each pair, one participant will play the role of the client and the other will play the provider administering the checklist. Participants will then switch roles for the second scenario and repeat the process. This way, everyone will have a chance to practice using the checklist and to experience both roles. 2. Explain that after they role-play their scenarios, each pair should discuss and be able to answer the questions on the flip chart. 3. Divide the participants into pairs and distribute two scenarios to each pair. Participants will have 10 minutes to role-play each scenario and 10 minutes to answer the questions on the flip chart (40 minutes total). Give the following instructions, according to the role the participants will play: For participants acting as providers • Make sure you have read and understood the checklist questions and explanations before administering the checklist to the client. • Ask the client the checklist questions and follow instructions to determine if the client can receive an IUD. • Trust the client’s response. Training Module 25 • Base your decisions on the IUD Checklist questions only, and not on any assumptions about the client. Doing so could lead you to the wrong conclusion and cause you to unnecessarily deny your client access to contraception. • You may answer questions or define terms, if necessary. However, do not make substantive changes to the checklist questions; for example, do not separate one question into two questions or combine two questions into one. For participants acting as clients • Read the scenario carefully and answer the checklist questions based on the situations outlined in the scenario. • If a situation is not specifically described in the scenario, you should answer “NO”. For example, if the scenario does not specify that the woman’s last menstrual period started within the past seven days, you, as a client, should answer NO to that question. 4. Reconvene the group and discuss each scenario with the whole group. Depending on the number of participant pairs, this part of the exercise may take between one and a half to two hours. For each scenario, ask a participant pair to share their answers to the questions on the flip chart. If they do not answer questions 1 or 2 correctly, or if additional possibilities exist in answer to question 3, solicit responses from the other participants, or provide it from the answer guide. 5. For each checklist question, discuss any concerns participants have about its phrasing or clarity. Help the group find ways to explain or rephrase the question without changing its meaning. Be familiar with the information in the Adapting the Checklist to the Local Context section of this guide, page 57. 6. When discussing a scenario in which pregnancy cannot be ruled out, emphasize that the client should be told she is not necessarily pregnant, but that, due to her responses, another approach will be needed to rule out pregnancy (either a pregnancy test, a pelvic exam, or awaiting her next menses). If she has to wait to rule out pregnancy, always provide her with an interim form of protection against pregnancy, such as condoms. 7. After all the scenarios have been discussed, the Answer Guide to Scenarios (pages 39-48) may be distributed to the participants for their future reference. 26 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 8. A course of action has been outlined for each scenario. However, if any adaptations are made to the scenarios and/or checklist, it should be recognized that the course of action may change somewhat as well. 9. The scenarios have been designed to work with any provider training group. To further adapt the training to meet the needs of a specific audience, scenarios may be modified by the facilitator or by another qualified person. Additional scenarios may also be created. Optional approaches for conducting scenarios n Ask one or more of the participant pairs to role-play in front of the larger group. Have the whole group discuss each scenario before going on to the next one. n Instead of role-playing in pairs, ask participants to work individually, each one developing a response to their scenario(s). Then have some participants present their response to the larger group. n Ask participants to work individually and then find two or three people who had the same scenario. They should discuss their responses and see how they differ. These small groups could then share with the larger group. 27Training Module 28 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Facilitator’s Resource: How does the IUD Checklist work? n The IUD checklist is designed to use the provider’s time as efficiently as possible. Notice that instructions for all sets of questions on the checklist state: “As soon as the client answers YES to any question, stop, and follow the instructions below.” This means that if the client answers “YES” to any question, the provider is finished with that set of questions. Therefore, depending on the client’s responses, the questioning may proceed question by question, OR the provider may discover the woman is not a good candidate early in the questioning. n The IUD Checklist consists of 20 questions, as well as instructions for providers based on a woman’s responses. The first set of questions is meant to identify women who are not pregnant (questions 1-6, related to pregnancy). The second and third sets of questions are meant to determine if the woman has no conditions which could preclude safe insertion of an IUD (questions 7-20, related to medical eligibility). Each of the checklist questions is explained in more detail on the reverse side of the checklist. Providers should refer to these explanations to understand the intent of the questions. n Pregnancy-Related Questions • “Yes” response — If a woman answers “YES” to any one question and is free from signs and symptoms of pregnancy, providers can be 99 percent sure she is not pregnant. As instructed on the checklist, continue with the screening. However, if the client answered “YES” to question one, read the guidance provided and follow the instructions to delay insertion until four weeks after delivery of her baby. • “No” response — If a woman answers “NO” to all questions, she has not been protected from pregnancy. To rule out pregnancy in these women, the provider will need to do a pregnancy test, conduct a pelvic exam, or have the woman return when she is menstruating. If the client is sent home to await her menses, always provide her with condoms to use in the meantime. n Medical Eligibility Questions Based on History • “Yes” response — If a woman answers “YES” to any one of these questions, she is not medically eligible for an IUD; however, some of these women may become medically eligible after further evaluation. See the instruction box at the bottom of this set of questions and follow the guidance provided there. • “No” response — If a woman answers “NO” to all questions, proceed with the pelvic exam with the assistance of the third set of questions. 29 n Medical Eligibility Based on Pelvic Exam Only those providers trained to conduct a pelvic exam will continue with this set of questions. Unlike the previous two sets of questions, in which the client gives the answer, this set of questions is designed for the provider to answer based on his/her observations during the pelvic exam. • “Yes” response — If the provider determines the answer is “YES” to any one of these questions, the client cannot receive an IUD now without further evaluation. Follow the guidance provided with the relevant checklist question to determine next steps. • “No” response — If the provider determines the answers are “NO” to all the questions, the client is medically eligible to receive an IUD. The provider may insert the IUD. n Generally, the conditions asked about on the checklist are serious enough that a woman would know if she has them because she would have had to seek medical attention for them. This is why several of the questions begin with “Have you ever been told …”, “Do you have…”, and “Have you ever had…”. If a woman has not been told she has a condition, providers should assume she does not have it. n Providers should make an effort to build trusting relationships with clients before administering the IUD Checklist. For example, the provider might wish to convey to the client the necessity of answering as accurately and as honestly as possible, in order to avoid possible complications from IUD use. The majority of women will answer honestly to the best of their ability. Training Module 30 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Example A woman answers “NO” to questions 1 and 2, but then answers “YES” to question 3 because she has abstained from sexual intercourse since her last menstrual period. The provider should now stop asking questions because a “YES” response to any of the questions indicates a circumstance under which it is highly unlikely that a woman could be pregnant. First, be reasonably sure that the client is not pregnant. If she is not menstruating at the time of her visit, ask the client questions 1-6. As soon as the client answers YES to any question, stop, and follow the instructions below. YES 1. Have you had a baby in the last 4 weeks? NO YES 2. Did you have a baby less than 6 months ago, are you fully or nearly-fully breastfeeding, and have you had no menstrual period since then? NO YES 3. Have you abstained from sexual intercourse since your last menstrual period or delivery? NO YES 4. Did your last menstrual period start within the last 12 days? NO YES 5. Have you had a miscarriage or abortion in the last 12 days? NO YES 6. Have you been using a reliable contraceptive method consistently and correctly? NO If the client answered NO to all of questions 1-6, pregnancy can not be ruled out. The client should await menses or use a pregnancy test. If the client answered YES to any one of the questions 1−6, and she is free from signs or symptoms of pregnancy, you can be reasonably sure that she is not pregnant. Proceed to questions 7-13. However, if she answers YES to question 1, the insertion should be delayed until 1 week after delivery. Ask her to come back at that time. 31 Optional information: If participants are curious and asking questions about the design elements of the checklist, such as arrows and colors, an explanation is provided below for your use in addressing these questions. It is important to note that while these design elements provide visual cues, they are secondary to the main instructions on the checklist, which participants must follow. • The arrows next to the “YES” responses and the straight lines next to the “NO” responses offer cues as to how to proceed through the questions. The arrows indicate the provider should end the questioning and jump directly to the instruction box below that set of questions. The straight lines indicate the provider must proceed to the next question. • Generally, if the client’s response falls in the GREEN boxes, she is a good candidate, and if her response falls in the RED box, she is probably not a good candidate. However, for the eligibility questions, ALL of the client’s answers must fall in the green boxes for the woman to be a good candidate, whereas for the pregnancy questions ONE answer in the green boxes is sufficient for her to be a good candidate. Training Module 32 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 33 Session Four: Wrap-Up Objectives: To summarize what was accomplished during the training session. To address any remaining issues. To thank participants for their attention and participation. Training Steps: 1. Briefly summarize the objectives and accomplishments of the training. 2. Show participants the flip chart page containing the expectations they expressed at the beginning of the training. Ask participants if these expectations have been met. 3. Engage participants in a wrap-up discussion, by asking the following questions: • Was the IUD Checklist easy to use? • Was it easy to explain questions to the client? • What problems did you encounter while using the checklist? • Do you foresee any barriers to using the checklist in your work? How could these barriers be overcome? • What would help you to use the checklist in your work? • Do you have any suggestions for improving the checklist or for getting more providers to use it? • What did you find helpful about the training? • Could the training be improved in any way? If so, how? This is a good way to end the training, because it allows you to address any issues or concerns that participants may have. Also, FHI requests that you compile these responses and forward them to our staff at publications@fhi.org for future improvements to this guide. 4. Thank the participants for their time and energy. Tell them whom they should contact for more information or materials. 5. Distribute certificates of attendance to each participant. 15 minutes Training Module 34 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Objective: To understand the research surrounding the need for and the effectiveness of the IUD and Pregnancy checklists. Training Steps: 1. Summarize the research on the acceptability of the IUD Checklist. 2. Summarize the research on the rationale for the Pregnancy Checklist. 3. Summarize the research validating the Pregnancy Checklist. Facilitator’s Resource: Research on the acceptability of the IUD Checklist n A field test to examine the acceptability of the IUD Checklist among providers was conducted in four countries (Bangladesh, the Dominican Republic, Kenya, and Senegal). A total of 16 focus groups, involving 135 active family planning providers, were held to solicit providers’ points of view. n Results: • Providers found the checklist easy to use and thought it would enhance identification of eligible IUD users. • Nevertheless, many providers relied on prior outdated knowledge of IUD eligibility, rather than follow the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69 percent of the time. n Conclusions: • The IUD checklist is a useful job aid for providers, but training on the WHO medical eligibility criteria should precede its introduction to ensure that the checklist is correctly used. Research on the rationale for the Pregnancy Checklist n The checklist was developed to reduce barriers to contraception for women who are not menstruating at the time of their visit. Research on menstruation requirements has been done in several countries. • Kenya — an estimated one-third of all new clients were sent home without a contraceptive method because of a menstruation requirement (Stanback et al. 1999). Optional Session: Summary of Research Findings 25 minutes 35 Summary of Research Findings • Ghana — 76 percent of health care providers said they would send a client home if she was not menstruating at the time of her visit (Twum-Baah and Stanback 1995). • Cameroon — only one-third of nonmenstruating clients received hormonal contraceptive methods because providers were unsure of clients’ pregnancy status (Nkwi et al. 1995). • Jamaica — 92 percent of clients were required to be menstruating or to have a negative pregnancy test at the time contraceptives were provided (McFarlane et al. 1996). n Additional research evaluated whether using the checklist reduced the number of women denied contraceptives because they were not menstruating at the time of their visits. • In Guatemala, 16 percent of nonmenstruating women were denied their contraceptive choice when no checklist was used. After providers began using the checklist, only 2 percent of women were denied (Stanback et al. 2005). • In Senegal, the situation was similar; fewer women were denied their contraceptive method of choice after providers were introduced to the checklist — 11 percent were denied without the checklist versus 6 percent when the checklist was available (Stanback et al. 2005). Research on the validity of the Pregnancy Checklist n The Pregnancy Checklist has been extensively tested to ensure that it is valid and that women identified by the checklist as not pregnant truly are not pregnant. Research has been done in Kenya, Guatemala, Mali, Senegal, and Egypt. Those studies posed several questions to determine the checklist’s validity. Does the checklist accurately predict that a woman is not pregnant? Yes — Researchers compared the checklist results with a pregnancy test and found that more than 99 percent of the time the checklist was correct in ruling out pregnancy. In the very rare cases where the checklist ruled out pregnancy but the client was actually pregnant, the reasons included contraceptive failure or inaccurate answers given by the client. Does the checklist accurately predict that a woman is pregnant? No — Most women who are identified as possibly pregnant are, in fact, not pregnant. Researchers gave pregnancy tests to women who answered no to all questions and found that less than 15 percent were actually pregnant. If pregnancy is not ruled out by the checklist, the woman should be referred for additional evaluation or a pregnancy test, or should await menses. Training Module 36 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD n Optional information: At the end of the Pregnancy Checklist, it states that “If the client answered YES to at least one of the questions and she is free of signs or symptoms of pregnancy, provide client with desired method.” Research shows that the six questions are much more reliable in determining whether a woman is not pregnant than are signs and symptoms. If a provider is trained to do so, signs and symptoms should be assessed in addition to, but not instead of, administering the checklist. If a provider is not trained to assess signs and symptoms of pregnancy, the provider should feel confident that pregnancy has been ruled out based on the questions alone. (Symptoms may include nausea, mood changes, and missed menstrual period(s), and signs may be uterine softness and breast tenderness.) Emphasize that the Pregnancy Checklist was developed to RULE OUT pregnancy and to minimize barriers women face in seeking contraception. The Pregnancy Checklist CANNOT be used to diagnose pregnancy. 37 1 IUD Scenario You are a 23-year-old woman who gave birth to your first child six weeks ago and you have abstained from sexual intercourse since the delivery. You and your husband are faithful to each other. 2 IUD Scenario You are a 30-year-old woman who is married, monogamous, and has three children. You know that you are HIV positive, but have had no symptoms and feel healthy. You have been using a reliable contraceptive method consistently and correctly. 3 IUD Scenario You are a 32-year-old woman who wants no more children. You and your husband are both faithful. You report recently having had unexplained bleeding after intercourse with your husband. Your last menstrual period started four days ago. 4 IUD Scenario You are a 31-year-old monogamous, married woman. You gave birth to your fifth child four months ago, have been exclusively breastfeeding the child, and have not yet started your menses. 5 IUD Scenario You are a 30-year-old woman with five children. You had a miscarriage four days ago. You are married and faithful to your husband. However, your husband often travels for work, and you think he is with other women when he is away from home. 6 IUD Scenario You are a 26-year-old woman who gave birth to your first child three weeks ago. You and your husband want to wait at least two or three years before having another baby. 7 IUD Scenario You are a 28-year-old divorced woman who has two children. You have one primary sexual partner, and a second casual partner. You had your last menstrual period six days ago. 8 IUD Scenario You are a 33-year-old married woman with three children. You do not want to risk getting pregnant again, since you were recently diagnosed with endometrial cancer. You have abstained from sexual intercourse since your last menstrual period. 9 IUD Scenario You are a 25-year-old woman with one child who is five months old. You are fully breastfeeding and have not had a menstrual period. You are living with your Training Handout Scenario Exercises for Participants Training Module 38 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD boyfriend, and you both want to wait three to four years to have another child. You have no other partners and think your boyfriend is also faithful. However, you worry about his health, since you have noticed that he recently had a penile discharge. 10 IUD Scenario You are a 26-year-old woman who has been diagnosed with AIDS and you do not want to have any children and pass on your disease. You are not taking antiretroviral treatments. You have been using contraceptive pills consistently and correctly, but you are afraid you may forget to take a pill, and you want to switch to another method that is easier to use. 11 IUD Scenario You are a 34-year-old married woman with four children. Neither you nor your husband has ever had an STI. You admit that you recently had sex with someone other than your husband and you did not use a condom. But it only happened a couple of times. 12 IUD Scenario You are a 21-year-old married woman with no children. You and your husband do not want any children right now, but you are nervous because you are not using contraception. You are menstruating at the time of your visit. 13 IUD Scenario You are a 27-year-old divorced woman with two children. Two months ago you were treated for gonorrhea. Your menstrual period started seven days ago. 14 IUD Scenario You are a 35-year-old woman in a monogamous marriage with two children. During the pelvic examination, the provider notes that you have cervical motion tenderness. Your menstrual period started seven days ago. 15 IUD Scenario You are a 29-year-old woman in a faithful relationship with your boyfriend and you feel that you have enough children already. You started your menstrual period 12 days ago. The provider will note during the pelvic examination that you have an ulceration on your outer genitals. 16 IUD Scenario You have been using condoms consistently and correctly for the past six months. During the pelvic exam, the provider was not able to determine the position of the uterus. 39Training Module IUD Scenario 1 You are a 23-year-old woman who gave birth to your first child six weeks ago and you have abstained from sexual intercourse since the delivery. You and your husband are faithful to each other. 1. Is this client a good candidate for receiving an IUD during today’s visit? Yes. 2. Why or why not? This client is eligible because she would answer “YES” to question 3, making it likely she is not pregnant. 3. What course of action would you take next? You may insert the IUD. Be sure to remind the client to come back to the clinic approximately one month after her IUD insertion for a follow-up visit. At that time, you should check for signs of infection and make sure that she has adapted well to the method. IUD Scenario 2 You are a 30-year-old woman who is married, monogamous, and has three children. You know that you are HIV positive, but have had no symptoms and feel healthy. You have been using a reliable contraceptive method consistently and correctly. 1. Is this client a good candidate for receiving an IUD during today’s visit? Yes. 2. Why or why not? HIV infection is not a contraindication for IUD insertion or continuing IUD use. As the guidance for question 13 indicates, a woman with HIV infection who has not developed AIDS may be an appropriate candidate for IUD insertion. 3. What course of action would you take next? You may insert the IUD. Be sure to remind the client to come back to the clinic approximately one month after her IUD insertion for a follow-up visit. At that time, you should check for signs of infection and make sure that she has adapted well to the method. Note: You may choose to ask a follow-up question, such as “What would you do if this client returns in a few years having developed AIDS?” The answer is that the client can continue IUD use regardless of AIDS status, and therefore no action would need to be taken. Training Handout Answer Guide to Scenarios 40 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD IUD Scenario 3 You are a 32-year-old woman who wants no more children. You and your husband are both faithful. You report recently having had unexplained bleeding after intercourse with your husband. Your last menstrual period started four days ago. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance for question 7 indicates that unexplained vaginal bleeding could be the sign of an underlying condition, such as malignancy (cancer), or a pregnancy-related problem. 3. What course of action would you take next? An IUD should not be inserted until the client’s condition has been further evaluated. Underlying conditions that preclude IUD insertion should be ruled out. If you do not have the capacity to rule out pregnancy or a malignancy, the client should be referred to a higher-level provider or specialist for evaluation and diagnosis. In either case, the woman should be counseled about other contraceptive methods available to her until a determination of her eligibility for the IUD is made. She should also be provided with a contraceptive method, such as condoms, to use in the meantime. IUD Scenario 4 You are a 31-year-old monogamous, married woman. You gave birth to your fifth child four months ago, have been exclusively breastfeeding the child, and have not yet started your menses. 1. Is this client a good candidate for receiving an IUD during today’s visit? Yes. 2. Why or why not? This client is eligible because she would answer “YES” to question 2, making it likely she is not pregnant. 3. What course of action would you take next? You may insert the IUD. Be sure to remind the client to come back to the clinic approximately one month after her IUD insertion for a follow-up visit. At that time, you should check for signs of infection and make sure that she has adapted well to the method. 41Training Module IUD Scenario 5 You are a 30-year-old woman with five children. You had a miscarriage four days ago. You are married and faithful to your husband. However, your husband often travels for work, and you think he is with other women when he is away from home. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance for question 10 indicates that a woman whose partner has more than one sexual partner is at high individual risk of sexually transmitted infections. Unless an STI can be reliably ruled out, these women are not good candidates for an IUD, as they may be at higher risk of PID following IUD insertion. 3. What course of action would you take next? You should counsel the client about other contraceptive options. If, after counseling, she still wishes to have an IUD inserted and laboratory tests are available, you can test her to determine if she has a gonorrheal or chlamydial infection. If she has either of these infections, you can treat her and, after treatment is completed, you may provide her with an IUD. You should counsel the client to use condoms during the time of testing and treatment to be sure she does not become reinfected by her husband. She also should be counseled to refer her husband for treatment. If there is no other acceptable contraceptive method available for the client, and you cannot test for STIs, you may insert the IUD and follow her closely to be sure she does not develop PID. IUD Scenario 6 You are a 26-year-old woman who gave birth to your first child three weeks ago. You and your husband want to wait at least two or three years before having another baby. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? Although the client answered “YES” to question 1, making it highly likely she is not pregnant, women who are between 48 hours and 4 weeks postpartum have 42 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD higher risk of uterine perforation during IUD insertion. The IUD is also more likely to be expelled if it is inserted during this time. 3. What course of action would you take next? You should request that the client come back for IUD insertion once she is four weeks postpartum. Explain to her that there is no need for contraception during the waiting time, since there is no risk of pregnancy during the first four weeks postpartum. IUD Scenario 7 You are a 28-year-old divorced woman who has two children. You have one primary sexual partner, and a second casual partner. You had your last menstrual period six days ago. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? Question 9 identifies this client as possibly being at high individual risk of STI, since she has more than one sexual partner. There is a possibility that this woman currently has an STI and, unless it can be reliably ruled out, she is not a good candidate for IUD insertion. IUD insertion increases risk of PID in women with current sexually transmitted infections. 3. What course of action would you suggest next for this client? You should counsel the client about other contraceptive options. If, after counseling, she still wishes to have an IUD inserted and laboratory tests are available, you can test her to determine if she has a gonorrheal or chlamydial infection. If she has either of these infections, you can treat her and, after treatment is completed, you may provide her with an IUD. You should counsel the client to use condoms during the time of testing and treatment to be sure she does not become reinfected, and you should counsel her to refer her partner for treatment. If there is no other acceptable contraceptive method available for the client and you cannot test for STIs, you may insert the IUD and follow her closely to be sure she does not develop PID. 43Training Module IUD Scenario 8 You are a 33-year-old married woman with three children. You do not want to risk getting pregnant again, since you were recently diagnosed with endometrial cancer. You have abstained from sexual intercourse since your last menstrual period. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance for question 8 indicates that women who have any type of cancer in their genital organs have an increased risk of infection, perforation and bleeding at IUD insertion and therefore are not good candidates. 3. What course of action would you take next? This client should be counseled about other contraceptive methods that may be appropriate for her. Until she decides on another method, she should be provided with condoms to use. Note: Endometrial cancer requires surgery that will leave the woman sterile, but in the meantime she should be provided with the contraceptive method of her choice, other than an IUD. IUD Scenario 9 You are a 25-year-old woman with one child who is five months old. You are fully breastfeeding and have not had a menstrual period. You are living with your boyfriend, and you both want to wait three to four years to have another child. You have no other partners and think your boyfriend is also faithful. However, you worry about his health, since you have noticed that he recently had a penile discharge. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance for question 12 points out that recent penile discharge in a sexual partner may be a sign that he has a sexually transmitted infection. Having a partner with an STI puts a woman at high individual risk of STI herself. Unless an STI can be reliably ruled out, this client is not a good candidate for the IUD, since women with STIs are at higher risk of PID following IUD insertion. 44 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 3. What course of action would you take next? You should counsel the client about other contraceptive options. If, after counseling, she still wishes to have an IUD inserted and laboratory tests are available, you can test her to determine if she has a gonorrheal or chlamydial infection. If she has either of these infections, you can treat her and, after treatment is completed, you may provide the client with an IUD. You should counsel the client to use condoms during the time of testing and treatment to be sure she does not become reinfected, and you should counsel her to refer her partner for treatment. If there is no other acceptable contraceptive method available for the client, and you cannot test for STIs, you may insert the IUD and follow her closely to be sure she does not develop PID. IUD Scenario 10 You are a 26-year-old woman who has been diagnosed with AIDS and you do not want to have any children and pass on your disease. You are not taking antiretroviral treatments. You have been using contraceptive pills consistently and correctly, but you are afraid you may forget to take a pill and you want to switch to another method that is easier to use. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance provided for question 13 states that if a woman answers “YES” to this question, she should be asked if she is taking ARVs. A woman who has AIDS is not an appropriate candidate for an IUD unless she is doing clinically well on ARVs. As this client is not on ARV treatment, she is at increased risk of STIs and PID because of a suppressed immune system. An IUD may further increase that risk. 3. What course of action would you take next? You should counsel this client about other contraceptive methods that may be appropriate for her. Because she wants a method that doesn’t require a daily routine, counsel her about implants, injectables, and sterilization. Until she decides on another method, she should be provided with condoms to use. She should also receive counseling regarding ARV treatment, if possible. 45 IUD Scenario 11 You are a 34-year-old married woman with four children. Neither you nor your husband has ever had an STI. You admit that you recently had sex with someone other than your husband and you did not use a condom. But it only happened a couple of times. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? According to the guidance provided for question 9, a woman who has more than one sexual partner is at high individual risk of sexually transmitted infections. This woman is at high individual risk since she reports unprotected sex with a casual partner. Unless an STI can be reliably ruled out, this client is not a good candidate for the IUD, as she is at higher risk of PID following IUD insertion. 3. What course of action would you take next? You should counsel the client about other contraceptive options. If, after counseling, she still wishes to have an IUD inserted and laboratory tests are available, you can test her to determine if she has a gonorrheal or chlamydial infection. If she has either of these infections, you can treat her and, after treatment is completed, you may provide the client with an IUD. You should counsel the client to use condoms during the time of testing and treatment to be sure she does not become reinfected, and you should counsel her to refer her partners for treatment. If there is no other acceptable contraceptive method available for the client, and you cannot test for STIs, you may insert the IUD and follow her closely to be sure she does not develop PID. IUD Scenario 12 You are a 21-year-old married woman with no children. You and your husband do not want any children right now, but you are nervous because you are not using contraception. You are menstruating at the time of your visit. 1. Is this client a good candidate for receiving an IUD during today’s visit? Yes. 2. Why or why not? Neither young age nor absence of children is a contraindication for IUD use. Since the client is menstruating at the time of the visit, you can be reasonably sure that she is not pregnant. Training Module 46 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 3. What course of action would you take next? Insert the IUD. Be sure to remind the client to come back to the clinic approximately one month after her IUD insertion for a follow-up visit. At that time, you should check for signs of infection and make sure that she has adapted well to the method. IUD Scenario 13 You are a 27-year-old divorced woman with two children. Two months ago you were treated for gonorrhea. Your menstrual period started seven days ago. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance provided for question 11 states that having an STI in the past three months requires further evaluation before proceeding, because there is a possibility the client may have a current infection. A client with chlamydia and/ or gonorrhea infection is at higher risk of PID if an IUD is inserted. 3. What course of action would you take next? You should counsel the client about other contraceptive options. If, after counseling, she still wishes to have an IUD inserted and laboratory tests are available, you can test her to rule out gonorrheal infection. If she has been reinfected, retreat and, after treatment is completed, you may provide the client with an IUD. You should counsel the client to use condoms during the time of testing and treatment to be sure she does not become reinfected, and you should counsel her to refer her partner for treatment. If there is no other acceptable contraceptive method available for the client, and you cannot test for STIs, you may insert the IUD and follow her closely to be sure she does not develop PID. IUD Scenario 14 You are a 35-year-old woman in a monogamous marriage with two children. During the pelvic examination, the provider notes that you have cervical motion tenderness. Your menstrual period started seven days ago. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? The guidance provided for question 15 states that pain in a client’s lower 47 abdomen when the cervix is moved is a sign of cervical infection (cervicitis) and possible PID. Women with current cervicitis or PID should not have an IUD inserted. 3. What course of action would you take next? The client should be treated for PID. If you are not sure how, or don’t have the means to treat it, you should refer the client to a higher-level provider or specialist. She should also be counseled about other contraceptive options that can be provided immediately. If she still wants an IUD, the insertion can be done after she is cured from PID. Until she is cured, the client should be advised to use condoms. IUD Scenario 15 You are a 29-year-old woman in a faithful relationship with your boyfriend and you feel that you have enough children already. You started your menstrual period 12 days ago. The provider will note during the pelvic examination that you have an ulceration on your outer genitals. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? A genital ulcer may indicate a sexually transmitted infection, such as syphilis or chancroid. While ulcerative STIs are not contraindications for IUD insertion, they do indicate that a woman is at high individual risk for STIs in general, and there is a possibility of coinfection with other STIs, such as gonorrhea or chlamydia. Since gonorrhea and chlamydia are often asymptomatic among women, any woman at high individual risk is generally not considered an appropriate IUD candidate. For general purposes, pregnancy is ruled out if the client started her last menstrual period within the past seven days. When considering eligibility for the copper IUD however, the time frame is extended to 12 days, due to the additional contraceptive effectiveness of the IUD. If the copper IUD is inserted before day 12 of the menstrual cycle, the possibility of pregnancy is very low. 3. What course of action would you take next? The client should be treated for ulcerative STIs (according to your clinic guidelines, using either the laboratory or the syndromic approach). If you can rule out gonorrhea and chlamydia through laboratory tests, the client can receive an IUD. The client should be advised to use condoms during the time of diagnosis and treatment. Counsel her about other contraceptive options and counsel her to refer her partner for treatment. Training Module 48 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD IUD Scenario 16 You have been using condoms consistently and correctly for the past six months. During the pelvic exam, the provider was not able to determine the position of the uterus. 1. Is this client a good candidate for receiving an IUD during today’s visit? No. 2. Why or why not? As stated in the guidance for question 20, the inability to determine the position of the uterus may increase the risk of uterine perforation. 3. What course of action would you take next? If you cannot determine the position of the client’s uterus, you should not insert the IUD. Counsel her about other contraceptive options or, depending on your experience with IUD insertions, refer her to a more experienced provider. The client should be provided with condoms to use in the meantime. 49Training Module CO N D IT IO N D M PA D M PA / N ET -E N CU -IU D A ge M en ar ch e to 3 9 ye ar s 40 y ea rs o r m or e M en ar ch e to 1 7 ye ar s 18 y ea rs to 4 5 ye ar s M or e th an 4 5 ye ar s M en ar ch e to 1 9 ye ar s 20 y ea rs o r m or e N ul lip ar ou s Br ea st fe ed in g Le ss th an 6 w ee ks p os tp ar tu m * 6 w ee ks to 6 m on th s po st pa rt um 6 m on th s po st pa rt um o r m or e Sm ok in g Ag e < 35 y ea rs Ag e ≥ 35 y ea rs , < 1 5 ci ga re tt es /d ay Ag e ≥ 35 y ea rs , ≥ 1 5 ci ga re tt es /d ay H yp er te ns io n H is to ry o f h yp er te ns io n w he re b lo od p re ss ur e: CA N N O T be e va lu at ed Is c on tr ol le d an d CA N b e ev al ua te d Sy st ol ic 1 40 - 15 9 or d ia st ol ic 9 0 - 9 9 Sy st ol ic ≥ 1 60 o r d ia st ol ic ≥ 1 00 H ea da ch es N on -m ig ra in ou s (m ild o r s ev er e) M ig ra in e w ith ou t a ur a (a ge < 3 5 ye ar s) M ig ra in e w ith ou t a ur a (a ge ≥ 3 5 ye ar s) M ig ra in es w ith a ur a H is to ry o f d ee p ve no us th ro m bo si s Su pe rfi ci al th ro m bo ph le bi tis Co m pl ic at ed v al vu la r h ea rt d is ea se Is ch em ic h ea rt d is ea se /s tr ok e D ia be te s N on -v as cu la r d is ea se Va sc ul ar d is ea se o r d ia be te s o f > 2 0 ye ar s M al ar ia N on -p el vi c tu be rc ul os is Th yr oi d di se as e Ir on d efi ci en cy a ne m ia Si ck le c el l a ne m ia CO N D IT IO N D M PA D M PA / N ET -E N CU -IU D Kn ow n hy pe rl ip id em ia s Ca nc er s Ce rv ic al En do m et ria l O va ria n Ce rv ic al e ct ro pi on Br ea st d is ea se U nd ia gn os ed m as s ** ** Fa m ily h is to ry o f c an ce r Cu rr en t c an ce r U te ri ne fi br oi ds w ith ou t c av it y di st or tio n En do m et ri os is Tr op ho bl as t d is ea se (m al ig na nt g es ta tio na l) Va gi na l bl ee di ng pa tt er ns Irr eg ul ar w ith ou t h ea vy b le ed in g H ea vy o r p ro lo ng ed , r eg ul ar a nd ir re gu la r U ne xp la in ed b le ed in g Ci rr ho si s M ild Se ve re Cu rr en t s ym pt om at ic g al l b la dd er d is ea se Ch ol es ta si s Re la te d to th e pr eg na nc y Re la te d to o ra l c on tr ac ep tiv es H ep at iti s Ac tiv e Cl ie nt is a c ar rie r Li ve r t um or s ST Is /P ID Cu rre nt p ur ul en t c er vi ci tis , c hl am yd ia , g on or rh ea Va gi ni tis Cu rre nt p el vi c in fla m m at or y di se as e (P ID ) O th er S TI s (e xc lu di ng H IV /h ep at iti s) In cr ea se d ris k of S TI s Ve ry h ig h in di vi du al ri sk o f e xp os ur e to S TI s H IV H ig h ris k of H IV o r H IV -in fe ct ed A ID S N o an tir et ro vi ra l t he ra py (A RV ) N ot c lin ic al ly w el l o n A RV th er ap y Cl in ic al ly w el l o n A RV th er ap y U se o f: G ris eo fu lv in Ri fa m pi ci n O th er a nt ib io tic s Q ui ck R ef er en ce C ha rt fo r t he W H O M ed ic al E lig ib ili ty C ri te ri a fo r C on tr ac ep tiv e U se – to in iti at e u se of co m bi ne d o ra l c on tra ce pt ive s ( DM PA s), de po t-m ed ro xy pr og es te ro ne ac et at e ( DM PA ), no re th ist er on e e na nt at e ( NE T- EN ), co pp er in tra ut er in e d ev ice (C u- IU D) * Br ea st fe ed in g do es n ot a ffe ct in iti at io n an d us e of th e IU D . R eg ar dl es s o f b re as tfe ed in g st at us , p os tp ar tu m in se rt io n of th e IU D is Ca te go ry 2 u p to 4 8 ho ur s p os tp ar tu m , C at eg or y 3 fro m 4 8 ho ur s t o fo ur w ee ks , a nd C at eg or y 1 fo ur w ee ks a nd a ft er . ** E va lu at io n sh ou ld b e pu rs ue d as so on a s p os si bl e. Ca te go ry 1 Th er e ar e no re st ric tio ns fo r u se . Ca te go ry 2 G en er al ly u se ; s om e fo llo w -u p m ay b e ne ed ed . Ca te go ry 3 U su al ly n ot re co m m en de d; c lin ic al ju dg m en t a nd c on tin ui ng ac ce ss to c lin ic al se rv ic es a re re qu ire d fo r u se . Ca te go ry 4 Th e m et ho d sh ou ld n ot b e us ed . Source: Adapted from Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization. Third edition, 2004. Available: http://www.who.int/reproductive-health/publications/MEC/ © 1 0/ 20 06 Training Handout Quick Reference Charts 50 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD CO N D IT IO N D M PA D M PA / N ET -E N CU -IU D A ge M en ar ch e to 3 9 ye ar s 40 y ea rs o r m or e M en ar ch e to 1 7 ye ar s 18 y ea rs to 4 5 ye ar s M or e th an 4 5 ye ar s M en ar ch e to 1 9 ye ar s 20 y ea rs o r m or e N ul lip ar ou s Br ea st fe ed in g Le ss th an 6 w ee ks p os tp ar tu m * 6 w ee ks to 6 m on th s po st pa rt um 6 m on th s po st pa rt um o r m or e Sm ok in g Ag e < 35 y ea rs Ag e ≥ 35 y ea rs , < 1 5 ci ga re tt es /d ay Ag e ≥ 35 y ea rs , ≥ 1 5 ci ga re tt es /d ay H yp er te ns io n H is to ry o f h yp er te ns io n w he re b lo od p re ss ur e: CA N N O T be e va lu at ed Is c on tr ol le d an d CA N b e ev al ua te d Sy st ol ic 1 40 - 15 9 or d ia st ol ic 9 0 - 9 9 Sy st ol ic ≥ 1 60 o r d ia st ol ic ≥ 1 00 H ea da ch es N on -m ig ra in ou s (m ild o r s ev er e) I C M ig ra in e w ith ou t a ur a (a ge < 3 5 ye ar s) I C I C M ig ra in e w ith ou t a ur a (a ge ≥ 3 5 ye ar s) I C I C M ig ra in es w ith a ur a I C H is to ry o f d ee p ve no us th ro m bo si s Su pe rfi ci al th ro m bo ph le bi tis Co m pl ic at ed v al vu la r h ea rt d is ea se Is ch em ic h ea rt d is ea se /s tr ok e D ia be te s N on -v as cu la r d is ea se Va sc ul ar d is ea se o r d ia be te s o f > 2 0 ye ar s M al ar ia N on -p el vi c tu be rc ul os is Th yr oi d di se as e Ir on d efi ci en cy a ne m ia Si ck le c el l a ne m ia CO N D IT IO N D M PA D M PA / N ET -E N CU -IU D Kn ow n hy pe rl ip id em ia s Ca nc er s Ce rv ic al I C En do m et ria l I C O va ria n I C Ce rv ic al e ct ro pi on Br ea st d is ea se U nd ia gn os ed m as s ** ** Fa m ily h is to ry o f c an ce r Cu rr en t c an ce r U te ri ne fi br oi ds w ith ou t c av it y di st or tio n En do m et ri os is Tr op ho bl as t d is ea se (m al ig na nt g es ta tio na l) Va gi na l bl ee di ng pa tt er ns Irr eg ul ar w ith ou t h ea vy b le ed in g H ea vy o r p ro lo ng ed , r eg ul ar a nd ir re gu la r U ne xp la in ed b le ed in g I C Ci rr ho si s M ild Se ve re Cu rr en t s ym pt om at ic g al l b la dd er d is ea se Ch ol es ta si s Re la te d to th e pr eg na nc y Re la te d to o ra l c on tr ac ep tiv es H ep at iti s Ac tiv e Cl ie nt is a c ar rie r Li ve r t um or s ST Is /P ID Cu rre nt p ur ul en t c er vi ci tis , c hl am yd ia , g on or rh ea I C Va gi ni tis Cu rre nt p el vi c in fla m m at or y di se as e (P ID ) I C O th er S TI s (e xc lu di ng H IV /h ep at iti s) In cr ea se d ris k of S TI s Ve ry h ig h in di vi du al ri sk o f e xp os ur e to S TI s I C H IV H ig h ris k of H IV o r H IV -in fe ct ed A ID S N o an tir et ro vi ra l t he ra py (A RV ) I C N ot c lin ic al ly w el l o n A RV th er ap y I C Cl in ic al ly w el l o n A RV th er ap y U se o f: G ris eo fu lv in Ri fa m pi ci n O th er a nt ib io tic s Q ui ck R ef er en ce C ha rt fo r t he W H O M ed ic al E lig ib ili ty C ri te ri a fo r C on tr ac ep tiv e U se – to in iti at e o r c on tin ue us e o f c om bi ne d o ra l c on tra ce pt ive s ( DM PA s), de po t-m ed ro xy pr og es te ro ne ac et at e ( DM PA ), no re th ist er on e e na nt at e ( NE T- EN ), co pp er in tra ut er in e d ev ice (C u- IU D) I/C (I ni tia tio n/ Co nt in ua tio n) : A w om an m ay fa ll in to e ith er o ne c at eg or y or a no th er , d ep en di ng o n w he th er sh e is in iti at in g or c on tin ui ng to u se a m et ho d. F or e xa m pl e, a c lie nt w ith c ur re nt P ID w ho w an ts to in iti at e IU D u se w ou ld b e co ns id er ed a s C at eg or y 4, a nd sh ou ld n ot h av e an IU D in se rt ed . H ow ev er , i f s he d ev el op s P ID w hi le u si ng th e IU D , s he w ou ld b e co ns id er ed a s C at eg or y 2. T hi s m ea ns sh e co ul d ge ne ra lly c on tin ue us in g th e IU D a nd b e tr ea te d fo r P ID w ith th e IU D in p la ce . W he re I/ C is n ot m ar ke d, a w om an w ith th at c on di tio n fa lls in th e ca te go ry in di ca te d – w he th er o r n ot sh e is in iti at in g or c on tin ui ng u se o f t he m et ho d. * Br ea st fe ed in g do es n ot a ffe ct in iti at io n an d us e of th e IU D . R eg ar dl es s o f b re as tfe ed in g st at us , p os tp ar tu m in se rt io n of th e IU D is Ca te go ry 2 u p to 4 8 ho ur s p os tp ar tu m , C at eg or y 3 fro m 4 8 ho ur s t o fo ur w ee ks , a nd C at eg or y 1 fo ur w ee ks a nd a ft er . ** E va lu at io n sh ou ld b e pu rs ue d as so on a s p os si bl e. Ca te go ry 1 Th er e ar e no re st ric tio ns fo r u se . Ca te go ry 2 G en er al ly u se ; s om e fo llo w -u p m ay b e ne ed ed . Ca te go ry 3 U su al ly n ot re co m m en de d; c lin ic al ju dg m en t a nd c on tin ui ng ac ce ss to c lin ic al se rv ic es a re re qu ire d fo r u se . Ca te go ry 4 Th e m et ho d sh ou ld n ot b e us ed . Source: Adapted from Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization. Third edition, 2004. Available: http://www.who.int/reproductive-health/publications/MEC/ © 1 0/ 20 06 51Training Module Training Handout The IUD Checklist Continued on page 54 Determining Current Pregnancy Questions 1–6 are intended to help a provider determine, with reasonable certainty, whether a client is not pregnant. If a client answers “yes” to any of these questions and there are no signs or symptoms of pregnancy, it is highly likely that she is not pregnant. An IUD should never be inserted in a woman who is pregnant as it may result in a septic miscarriage. However, if a client answers “yes” to question 1, IUD insertion should be delayed until four weeks postpartum. There is an increased risk of perforating the uterus when IUDs are inserted after 48 hours and up to four weeks postpartum. However, IUDs can be inserted by a trained professional within the first 48 hours after the client has given birth. Assessing Medical Eligibility for the IUD 7. Do you have bleeding between menstrual periods that is unusual for you, or bleeding after intercourse (sex)? Unexplained vaginal bleeding may be a sign of an underlying pathological condition, such as genital malignancy (cancer), or a pregnancy-related problem. All these possibilities must be ruled out before an IUD can be inserted. If necessary, refer the client to a higher-level provider or specialist for evaluation and diagnosis. Counsel the client about other contraceptive options available and provide condoms to use in the meantime. 8. Have you been told that you have any type of cancer in your genital organs, trophoblastic disease, or pelvic tuberculosis? There is a concern about the increased risk of infection, perforation, and bleeding at insertion in clients with genital cancer. Clients with trophoblastic disease may require multiple uterine curettages, and an IUD is unwise in this situation. There is also an increased risk of perforation. Clients with known pelvic tuberculosis may have a higher risk of secondary infection and bleeding if an IUD is inserted. If a woman has any one of these three conditions, she should not have an IUD inserted. Counsel her about other contraceptive options available and provide condoms to use in the meantime. Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD Research findings over the past 20 years have established that intrauterine devices (IUDs) are safe and effective for use by most women, including those who have not given birth, who want to space births, and those living with or at risk of HIV infection. For some women, IUDs are not recommended because of the presence of certain medical conditions, such as genital cancer and current cervical infection. For these reasons, women who desire to use an IUD must be screened for certain medical conditions to determine if they are appropriate candidates for the IUD. Family Health International (FHI), with support from the U.S. Agency for International Development (USAID), has developed a simple checklist (see next page) to help health care providers screen clients who were counseled about contraceptive options and made an informed decision to use an IUD. The checklist is based on the guidance included in the Medical Eligibility Criteria for Contraceptive Use (WHO, 2004). It consists of a list of 20 questions designed to identify medical conditions and high-risk behaviors that would prevent safe IUD use or require further screening, as well as provide further guidance and directions based on clients’ responses. A health care provider should complete the checklist before inserting an IUD. In some settings the responsibility for completing the checklist may be shared – with a counselor completing questions 1–13 and an appropriately trained health care provider, including a physician, midwife, clinical officer, nurse, or auxiliary nurse, determining the answers to the remaining questions during the pelvic exam. Clients who are ruled out because of their response to some of the medical eligibility questions may still be good candidates for an IUD after the suspected condition is excluded through appropriate evaluation. This checklist is part of a series of provider checklists for reproductive health services. The other checklists include the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, the Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), and the checklist on How to be Reasonably Sure a Client is Not Pregnant. For more information about the provider checklists, please visit www.fhi.org. 52 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Ch ec kli st fo r S cre en in g C lie nt s W ho W an t t o I ni tia te U se of th e C op pe r I UD If th e cl ie n t a n sw er ed Y ES to a n y o n e o f q u es tio n s 1– 6 an d sh e is fre e o f s ig n s o r sy m pt o m s o f p re gn an cy , yo u ca n be re as o n ab ly su re th at sh e is n o t p re gn an t. Pr o ce ed to qu es tio n s 7– 13 . H o w ev er , if sh e an sw er s Y ES to qu es tio n 1, th e in se rt io n sh o u ld be de la ye d u n til 4 w ee ks af te r de liv er y. A sk he r to co m e ba ck at th at tim e. Fi rs t, be re as on ab ly su re th at th e cl ie nt is n ot p re gn an t. If sh e is no t m en str ua tin g at th e tim e of h er v isi t, as k th e cl ie nt q ue sti on s 1 –6 . A s so o n as th e cl ie n t a n sw er s Y ES to a n y qu es tio n , st o p, an d fo llo w in st ru ct io n s be lo w . To de te rm in e if th e cl ie n t i s m ed ic al ly el ig ib le to u se an IU D , as k qu es tio n s 7– 13 . A s so o n as th e cl ie n t a n sw er s Y ES to a n y qu es tio n , st o p, an d fo llo w in st ru ct io n s be lo w . N O 7. D o yo u ha v e bl ee di ng b et w ee n m en str ua l p er io ds th at is u nu su al fo r y ou , o r b le ed in g af te r in te rc ou rs e (se x )? YE S N O 8. H av e yo u be en to ld th at y ou h av e an y ty pe o f c an ce r i n yo ur g en ita l o rg an s, tr op ho bl as tic di se as e, o r p el vi c tu be rc ul os is? YE S N O 9. W ith in th e la st 3 m on th s, ha v e yo u ha d m or e th an o ne se x u al p ar tn er ? YE S N O 10 . W ith in th e la st 3 m on th s, do y ou th in k yo ur p ar tn er h as h ad a no th er se x u al p ar tn er ? YE S N O 11 . W ith in th e la st 3 m on th s, ha v e yo u be en to ld y ou h av e an S TI ? YE S N O 12 . W ith in th e la st 3 m on th s, ha s y ou r p ar tn er b ee n to ld th at h e ha s a n ST I o r d o yo u kn ow if he h as h ad a ny sy m pt om s – fo r e x am pl e, p en ile d isc ha rg e? YE S N O 13 . A re y ou H IV - po sit iv e an d ha v e yo u de v el op ed A ID S? YE S If th e cli en t a n sw er ed N O to a ll o f q u es tio n s 1– 6, pr eg n an cy ca n n o t b e ru le d o u t. Th e cl ie n t sh o u ld aw ai t m en se s o r u se a pr eg n an cy te st . YE S 1. H av e yo u ha d a ba by in th e la st 4 w ee ks ? N O YE S 2. D id y ou h av e a ba by le ss th an 6 m on th s a go , a re y ou fu lly o r n ea rly -fu lly b re as tfe ed in g, an d ha v e yo u ha d no m en str ua l p er io d sin ce th en ? N O YE S 3. H av e yo u ab sta in ed fr om se x u al in te rc ou rs e sin ce y ou r l as t m en str ua l p er io d or d el iv er y? N O YE S 4. D id y ou r l as t m en str ua l p er io d sta rt w ith in th e pa st 12 d ay s? N O YE S 5. H av e yo u ha d a m isc ar ria ge o r a bo rti on in th e la st 12 d ay s? N O YE S 6. H av e yo u be en u sin g a re lia bl e co nt ra ce pt iv e m et ho d co ns ist en tly a nd c or re ct ly ? N O 53 © 2 00 7 Training Module N O 14 . Is th er e an y ty pe o f u lc er o n th e vu lv a, v ag in a, o r c er vi x? YE S N O 15 . D oe s t he c lie nt fe el p ai n in h er lo w er a bd om en w he n yo u m ov e th e ce rv ix ? YE S N O 16 . Is th er e ad ne x a te nd er ne ss ? YE S N O 17 . Is th er e pu ru le nt c er vi ca l d isc ha rg e? YE S N O 18 . D oe s t he c er vi x bl ee d ea sil y w he n to uc he d? YE S N O 19 . Is th er e an a na to m ic al a bn or m al ity o f t he u te rin e ca v ity th at w ill n ot a llo w a pp ro pr ia te IU D in se rti on ? YE S N O 20 . W er e yo u un ab le to d et er m in e th e siz e an d/ or p os iti on o f t he u te ru s? YE S If th e an sw er to a ll o f q u es tio n s 14 – 20 is N O , yo u m ay in se rt th e IU D . If th e an sw er to a n y o f q u es tio n s 14 – 20 is Y ES , th e IU D ca n n o t b e in se rte d w ith o u t fu rth er ev al u at io n . Se e ex pl an at io ns fo r m or e in str uc tio ns . If th e cl ie n t a n sw er ed N O to a ll o f qu es tio n s 7– 13 , pr o ce ed w ith th e PE LV IC EX A M . If th e cl ie n t a n sw er ed Y ES to qu es tio n 7 o r 8, an IU D ca n n o t b e in se rt ed . Fu rt he r ev al u at io n o f t he co n di tio n is re qu ire d. If th e cl ie n t a n sw er ed Y ES to a n y o f q u es tio n s 9– 12 , sh e is n o t a go o d ca n di da te fo r an IU D u n le ss ch la m yd ia an d/ o r go n o rr he a in fe ct io n ca n be re lia bl y ru le d o u t. If sh e an sw er ed Y ES to th e se co n d pa rt o f q u es tio n 13 an d is n o t c u rr en tly ta ki n g A RV dr u gs , IU D in se rt io n is n o t u su al ly re co m m en de d. If sh e is do in g cl in ic al ly w el l o n A RV s, th e IU D m ay ge n er al ly be in se rt ed . H IV - po sit iv e w o m en w ith o u t A ID S al so ge n er al ly ca n in iti at e IU D u se . D ur in g th e pe lv ic ex am , th e pr ov id er sh ou ld d et er m in e th e an sw er s t o qu es tio ns 1 4– 20 . 54 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Continued from page 51 Note: Questions 9–12 are intended to identify clients at high individual risk of sexually transmitted infections (STIs), because there is a possibility that they may currently have chlamydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, clients at high risk are not good candidates for IUD insertion. IUD insertion may increase risk of pelvic inflammatory disease (PID) in these clients. They should be counseled about other contraceptive options and provided with condoms for STI protection. However, if other contraceptive methods are not available or acceptable and there are no signs of STI, an IUD still can be inserted. Careful follow-up is required in such cases. 9. Within the last 3 months, have you had more than one sexual partner? Clients who have multiple sexual partners are at high risk of contracting STIs. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 10. Within the last 3 months, do you think your partner has had another sexual partner? Clients whose partners have more than one sexual partner are at high risk of contracting STIs. Unless chlamydia and/ or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. In situations where polygamy is common, the provider should ask about sexual partners outside of the union. (See note regarding questions 9–12.) 11. Within the last 3 months, have you been told you have an STI? There is a possibility that these clients currently have chlamydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 12. Within the last 3 months, has your partner been told that he has an STI or do you know if he has had any symptoms – for example, penile discharge? (Note: There are two parts to this question. Answering “yes” to either part or both parts of the question restricts IUD insertion.) Clients whose partners have STIs may have these infections as well. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note regarding questions 9–12.) 13. Are you HIV-positive and have you developed AIDS? This is a two part question, and both parts must be asked together. If the woman answers “yes” to both parts, ask whether she is taking ARVs and make sure she is doing clinically well. If she is, she may be a candidate for the IUD. If she is not, an IUD is usually not recommended unless other more appropriate methods are not available or not acceptable. There is concern that HIV-positive clients who have developed AIDS and are not taking ARVs may be at increased risk of STIs and PID because of a suppressed immune system. IUD use may further increase that risk. If the woman is HIV-positive but has not developed AIDS, the IUD may generally be used. Pelvic Examination 14. Is there any type of ulcer on the vulva, vagina, or cervix? Genital ulcers or lesions may indicate a current STI. While an ulcerative STI is not a contraindication for IUD insertion, it indicates that the woman is at high individual risk of STIs, in which case IUDs are not generally recommended. Diagnosis should be established and treatment provided as needed. An IUD can still be inserted if co-infection with gonorrhea and chlamydia are reliably ruled out. 15. Does the client feel pain in her lower abdomen when you move the cervix? Cervical motion tenderness is a sign of PID. Clients with current PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use and other contraceptives. 16. Is there adnexa tenderness? Adnexa tenderness or/and adnexa mass is a sign of a malignancy or PID. Clients with genital cancer or PID should not use an IUD. Diagnosis and treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. 17. Is there purulent cervical discharge? Purulent cervical discharge is a sign of cervicitis and possibly PID. Clients with current cervicitis or PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use. 18. Does the cervix bleed easily when touched? If the cervix bleeds easily at contact, it may indicate that the client has cervicitis or cervical cancer. Clients with current cervicitis or cervical cancer should not have an IUD inserted. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. If, through appropriate additional evaluation beyond the checklist, these conditions may be excluded, then the woman can receive the IUD. 19. Is there an anatomical abnormality of the uterine cavity that will not allow appropriate IUD insertion? If there is an anatomical abnormality that distorts the uterine cavity, proper IUD placement may not be possible. Cervical stenosis also may preclude an IUD insertion. 20. Were you unable to determine the size and/or position of the uterus? Determining size and position of the uterus is essential before IUD insertion to ensure high fundal placement of the IUD and to minimize the risk of perforation. © Family Health International, 2007 P.O. Box 13950, Research Triangle Park, NC 27709 USA Fax: (919) 544-7261 • http://www.fhi.org 55 Reference Guide The purpose of this reference guide is to provide essential information that supplements the training module. This information includes: n recommendations on adapting the checklist to the local context; n basic evidence-based information on the copper IUD; and n an annotated bibliography. The facilitator should anticipate — and be well prepared to answer — questions that are likely to arise and that are beyond the scope of the IUD Checklist. The checklist is intended solely to help providers decide if clients may or may not safely initiate use of the copper IUD. However, participants may well inquire about such issues as IUD side effects or IUD use by specific client populations, such as women who are at risk of HIV or who are living with AIDS, etc. This guide does not attempt to provide comprehensive information about the copper IUD, and trainers should consult other resources as needed. It is recommended to have a clinician with experience in IUD insertion cofacilitate the training, if possible. Reference Guide 56 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD 57 The IUD Checklist can be adapted to meet the specific needs of a local area or program, or to align with national guidelines that may apply. However, before the adapted version is finalized and put into use, we strongly recommend that any changes be reviewed by an expert who understands the medical basis for the checklist. Likewise, the corresponding training module should be adjusted to reflect any changes. The intent of each question is explained on the reverse side of the checklist to help with these adaptations. The following are examples of situations in which adaptation may be needed. n Adapting the checklist to the local language and style Whenever necessary, the checklist should be translated and the style adapted to meet the cultural and linguistic needs of the intended users of the checklists and their clients. In addition to English, the checklist has been produced in French, Spanish, Kiswahili and several other languages. These checklists are available on FHI’s web site, www.fhi.org. n Adapting for local culture Some of the questions on the checklist deal with personal issues and may need to be asked in a sensitive manner. For example, question 5 asks about miscarriage and abortion. To help ensure that the client feels safe and comfortable answering honestly, it may be useful to rephrase the question to “Have you lost a pregnancy in the last 12 days?”. n Adapting the checklist for comprehension Adaptations may also be made if the questions are too technical to be understood. Be careful, however, not to inadvertently change the intent of the question, because even small changes in wording can cause significant changes in meaning. For audiences with low literacy levels, it may be helpful to develop materials that convey key messages through illustrations with simple captions. Illustrations also should be appropriate for the local target audience. Adapting the Checklist to the Local Context Reference Guide 58 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD The purpose of the IUD Checklist is to safely allow more women to receive this contraceptive method. Poor adaptations could prevent eligible women from receiving an IUD. The following are examples of poorly adapted checklist questions. Original Question Poorly Adapted Question Reason Changes to the approach/structure of the question Did you have a baby less than 6 months ago, are you fully or nearly- fully breastfeeding, and have you had no menstrual period since then? Are you fully or nearly fully breastfeeding and have you had no menstrual period since you gave birth? The structure of the question is changed in this example. The original question identifies women who are experiencing lactational amenorrhea, which is defined by the three criteria in the question, and can be used to effectively prevent unintended pregnancy. Removing “Did you have a baby less than 6 months ago?” removes one of the criteria, so this question can no longer be used to identify women with lactational amenorrhea. Are you HIV-positive and have you developed AIDS? Are you HIV-positive? Do you have AIDS? This adaptation has separated the original question into two different parts. By doing so, the most important aspect of the original question could be misinterpreted. An HIV-positive client who has not developed AIDS is eligible to receive an IUD, but with this poor adaptation she may be prevented from receiving it. 59Reference Guide Evidence-Based Information on IUDs FACT SHEET: Intrauterine Device — TCu-380A An intrauterine device (IUD) is a small device inserted into a woman’s uterine cavity to prevent pregnancy. The IUD containing copper (TCu-380A) is the most commonly used and is effective for up to 12 years. Primary mechanisms of action Prevents fertilization by: n impairing viability of sperm n interfering with sperm movement Characteristics of IUDs n Highly effective n No constant supplies needed n Easy to use n Does not interfere with intercourse n Rapid return to fertility n Have beneficial non-contraceptive effects (protection from endometrial cancer and ectopic pregnancy) n Provider needed to initiate and discontinue use n May cause minor pain or discomfort during insertion and removal procedures n Has common side effects n Complications are rare (i.e., pelvic inflammatory disease and uterine perforation) n Small risk of expulsion (woman needs to check for IUD strings after menses) n No protection against sexually transmitted infections, including HIV Possible side effects (generally not signs of a health problem) n Pain or cramping during menses n Prolonged and heavy menstrual bleeding n Bleeding or spotting between monthly periods Who can have an IUD inserted n Women of any parity or reproductive age, including young and nulliparous women n Women who have no health conditions that preclude the use of an IUD Who should not have an IUD inserted (for a complete list, see WHO eligibility criteria) Women who have the following conditions (contraindications): n pregnancy 60 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD n septic infection following childbirth or abortion (if insertion is immediately postpartum or postabortion) n unexplained vaginal bleeding (before evaluation) n cervical, endometrial, or ovarian cancer n current pelvic inflammatory disease n current purulent cervicitis (gonorrhoea or chlamydia) n malignant gestational trophoblastic disease n known pelvic tuberculosis n uterine fibroid or other anatomical abnormalities resulting in distortion of the uterine cavity, which is incompatible with IUD insertion IUD use by women with HIV and AIDS n An IUD can be provided to a woman with HIV if she has no symptoms of AIDS. n An IUD generally should not be initiated in a woman with AIDS who is not taking antiretroviral drugs (ARVs). n A woman who develops AIDS while using an IUD can continue to use the device. n A woman with AIDS who is doing clinically well on ARV therapy can both initiate and continue IUD use, but follow-up may be required. n Women with HIV who choose to use an IUD should be counselled about dual method use and consider using condoms in addition to the IUD. Provide follow-up and counseling for n Any client concerns or questions n Common side effects n Any signs of complications; counsel the woman to come back immediately if any of the following symptoms develop: • bleeding or severe abdominal cramping during the first three to five days after insertion (perforation) • iregular bleeding or pain in every cycle (possible dislocation, partial expulsion, or perforation) • fever and chills, unusual vaginal discharge, or low abdominal pain (possible infection) • missing strings (possible expulsion) • missing or delayed menstrual period (possible pregnancy) Dispelling myths regarding IUDs IUDs do not: n migrate from the woman’s uterus to other parts of her body n prevent a woman from having children after it is removed n require a “rest” period (a new IUD can be inserted the same day the existing IUD is removed) 61Reference Guide Evidence-Based Information on IUDs No More Waiting! Using a Checklist to Rule out Pregnancy is an Effective Way to Increase Access to Contraceptives Summary Nonmenstruating women need not wait for the onset of their menses to initiate their contraceptive method of choice. Several research studies conducted in vari- ous countries show that a simple checklist developed to help providers rule out pregnancy among such clients is correct 99 percent of the time and is effective in reducing the proportion of clients denied contraceptive services. Using this check- list offers an effective and inexpensive alternative to laboratory tests and increases women’s access to essential family planning services. Family planning providers are required to determine whether a woman might already be pregnant before initiating use of her contra- ceptive method of choice. When pregnancy tests are unavailable or unaffordable, health providers often rely on the presence of menstruation as an indicator to rule out pregnancy. When women do not present with menses at the time of their visit, they are sent home — often without any contraception — to await the onset of menses. This is because providers fear that contraception can harm an unrecognized pregnancy. Data analyzed from family plan- ning programs in Cameroon, Ghana, Jamaica, Kenya and Senegal have found that a significant proportion of new, nonmenstruating clients (25% to 50%) are denied their desired method as a result of their menstrual status.1 Clients sent home because of such menstruation requirements risk unplanned pregnancies, if they are unable to return due to time and financial constraints. If the client answered NO to all of the questions, pregnancy cannot be ruled out. Client should await menses or use a pregnancy test. If the client answered YES to at least one of the questions and she is free of signs or symptoms of pregnancy, provide client with desired method. Figure 1 NO 1. Did you have a baby less than 6 months ago, are you fully or nearly-fully breastfeeding, and have you had no menstrual period since then? YES NO 2. Have you abstained from sexual intercourse since your last menstrual period or delivery? YES NO 3. Have you had a baby in the last 4 weeks? YES NO 4. Did your last menstrual period start within the past 7 days (or within the past 12 days if you are planning to use an IUD)? YES NO 5. Have you had a miscarriage or abortion in the past 7 days (or within the past 12 days if you are planning to use an IUD)? YES NO 6. Have you been using a reliable contraceptive method consistently and correctly? YES How to be Reasonably Sure a Client is Not Pregnant Ask the client questions 1-6. As soon as the client answers YES to any question, stop, and follow the instructions. 62 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Family Health International (FHI) developed a simple checklist to rule out pregnan- cy among such clients with a reasonable degree of certainty. The checklist consists of six questions that providers ask clients while taking their medical history. If the client answers “yes” to any of these questions, and there are no signs or symp- toms of pregnancy, then a provider can be reasonably sure that the woman is not pregnant. (See Figure 1.) The six questions are based on criteria established by the World Health Organization (WHO) that indicate conditions that effectively prevent a woman from getting pregnant. Checklist Correctly Rules Out Pregnancy A study to test the validity of the checklist against a standard pregnancy test was first conducted in Kenya2 in 1999 and later repeated in Egypt in 2005. In both studies, the checklist correctly ruled out pregnancy 99% of the time. In addition, each of the six individual questions indicated a high predictive value in ruling out pregnancy. As a result, both studies concluded that in low resource settings, where pregnancy tests are not available, nonmenstruating women should not leave a fam- ily planning clinic without an effective method, given that providers can be reason- ably sure a woman is not pregnant as determined by a “yes” response to any of the six questions on the checklist. Checklist Allows Signficantly More Women Access to Contraceptives An operations research study was conducted in Guatemala, Mali, and Senegal from 2001 to 2003 to deter- mine the impact of the checklist on family planning servic- es.3 The study results showed that where denial of services to nonmenstruating family planning clients was a prob- lem, introduction of the pregnancy checklist significantly reduced denial rates and improved access to contraceptive services. Among new family planning clients, denial of the de- sired method due to menstrual status decreased signifi- cantly — from 16 percent to 2 percent in Guatemala and from 11 percent to 6 percent in Senegal. In Mali, denial rates were essentially unchanged, but were low from the start. (See Figure 2.) Uses of the Pregnancy Checklist Beyond Family Planning Although originally developed as a tool for family plan- ning providers, the pregnancy checklist may prove useful to other health providers in low-resource settings who also need to rule out pregnancy. For example, providers who prescribe and pharmacists who dispense medica- tions that should be avoided during pregnancy, including certain antibiotics or anti-seizure drugs, can adapt the pregnancy checklist for use in their settings. Figure 2 Percentage of all new fam- ily planning clients denied their desired method as a result of their menstrual status, before and after the checklist intervention, in Guatemala, Mali, and Senegal, 2001-03 1. Stanback J, Thompson A, Hardee K, Janowitz B. Menstruation requirements: a significant barrier to contraceptive access in developing countries. Stud Fam Plann 1997;28(3):245-50. 2. Stanback J, Qureshi Z, Sekadde-Kigondu C, Gonzalez B, Nutley T. Checklist for ruling out pregnancy among family planning clients in primary care. Lancet 1999;354(9178):566. 3. Stanback J, Diabate F, Dieng T, Duarte de Morales T, Cummings S, Traoré M. Ruling out pregnancy among family planning clients: the impact of a checklist in three countries. Stud Fam Plann 2005;36(4):311-15. This brief was produced by Family Health International’s CRTU (Contraceptive and Reproductive Health Technologies Research and Utilization) program. Financial assistance for this work was provided by the US Agency for Interna- tional Development (USAID). The contents do not necessarily reflect USAID views and policy. Read more about the Pregnancy Checklist and download electronic copies at www.fhi.org. For more information or to order hard copies, please e-mail publications@fhi.org. 20 15 10 5 0 Pe rc en t n Before Intervention n After Intervention Guatemala Mali Senegal 63Reference Guide Evidence-Based Information on IUDs IUDs: A Resurging Method Programs and providers are now making IUDs more available. Reasons for this resurgence include: n recognition of the IUD’s many advantages; n new research findings on safety — resulting in liberalized guidance from WHO; and n a new program strategy, focusing on developing a core of skilled providers mo- tivated to offer IUDs. Main positives For Copper-T380A IUDs, positives include very high effectiveness, potentially 10+ years of use, low cost of commodity, convenience, suitability for a wide variety of women and very high client satisfaction generally. Main negatives Most women report no or negligible side effects. However, an important minority have significant pain, bleeding, spotting or expulsion. In addition, for women at risk of gonorrhea and chlamydia, IUD use increases the possibility of pelvic infection. Program requirements are extensive, including skilled providers, good counseling, supplies, equipment, and time and place to perform insertions. New evidence on safety A study in Kenya found that HIV+ and HIV- women adopting IUDs had similar rates of complications.1 A study in Mexico found that IUDs were not associated with infertility.2 Accumulated evidence from a number of studies indicates that the abso- lute increase in risk of pelvic inflammatory disease (PID) associated with the IUD is quite low, even where STIs are relatively common. Broadened eligibility based on WHO guidance In response to such new evidence, WHO, in late 2003, changed the medical eligi- bility classification for the IUD from category 3 to 2 (“generally use the method”) for HIV+ women and for those with successfully treated AIDS. Also, increased STI risk is now a category 2 unless a woman has a “very high individual likelihood of exposure” to gonorrhea or chlamydia. Mechanism of action Contrary to the common belief that the IUD works by preventing implantation, in fact the IUD works predominantly by inhibiting sperm from reaching the egg and by altering the egg, thus preventing fertilization. Unjustified medical barriers Common barriers include restrictions on eligibility related to age or parity (in fact, IUDs can be used by women of any age or parity), restricting insertion to the men- strual period, withholding insertion because of a vaginal discharge and mandating excessive follow-up visits (actually, one check-up, 3 to 6 weeks after insertion or after the next menstrual period, is recommended). 64 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Current problems with IUD programming In a number of countries the IUD is the leading method. However, in many others it is a minor method. Contributing factors to underutilization include: stigma and aftermath of the IUD issues of the 1970s and ’80s; exaggeration of the legitimate concern about STIs and the relationship to PID; provider perspective (notably, that providing IUDs is a lot of work that requires skill and confidence, as well as mod- erately extensive equipment and supplies); and poor management of common side effects. New program approach As with any program effort, the focus should include guidelines, training, supplies and logistics, communication, supervision, organization of work, etc. In the past, programs have often tried, unsuccessfully, to advance IUD use by very broad-based approaches, such as training many providers across various skill levels. In principle, someone with minimal training can insert an IUD. In actual practice, however, such providers may lack confidence, experience and proficiency, or may lose these attributes rapidly without a large volume of IUD clients. An alternative approach is to focus on a smaller number of skilled providers and support expansion through those providers who perform well. Evidence collected on the national level in Bolivia (where IUDs are the number one method), as well as from smaller efforts in Bangladesh, India and Pakistan, supports this approach. In any case, a key step is to become acquainted with providers’ views and gain insight into what might moti- vate them to provide IUDs. Many programs have not taken the IUD seriously because of an incorrect view that STIs are too common in their client population to offer this method. Such concerns can be addressed by building on the new WHO guidance and the new research findings and by removing common medical barriers. 1Morrison CS, et al. Is the intrauterine device appropriate contraception for HIV-1-infected women? Br J Obstet Gynaecol 2001;108(8):784-90. 2Hubacher D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8)561-67. Source: The preceding Global Health Technical Brief is reprinted from the MAQ website (Maximizing Access and Quality), a USAID initiative. 65 Evidence-Based Information on IUDs Intrauterine Devices: Safe, Effective, and Underused Summary Intrauterine devices (IUDs) are the most popular form of reversible contraception in the world. IUDs are extremely safe and effective, and they can be used by women as a long-term method. They are also among the most cost-efficient reversible methods of contraception. IUDs do not increase a woman’s risk of pelvic inflammatory disease (PID), which can lead to infertility. Rather, pre-existing sexually transmit- ted infections (STIs) increase the risk of infection and subsequent infertility. Clinicians other than physi- cians can be trained to evaluate candidates and insert IUDs safely. Proper technique and timing is essential to minimize the risk of early expulsion and infection. Overview Intrauterine devices (IUDs) are among the most reliable and cost-effective contraceptives available. Though little-used in the United States, they are the most popular form of reversible contraception world- wide. Globally, 12 percent of all married women of reproductive age use an IUD. This is surpassed only by nonreversible surgical sterilization (19%). The most popular IUD in most countries is the 380A (copper T). The copper T is approved for 10 years of use and may be effective for upwards of 12 years. Another type of IUD is hormonal. The most common hormonal IUD is the levonorgestrel (LNg) intrauterine system. The effectiveness of both devices rivals that of surgical sterilization and may surpass that of Norplant. Although the initial cost of an IUD is relatively high, with a seven- to 10-year ser- vice life, IUDs are among the most cost-effective forms of contraception. Additional costs incurred during use tend to be minimal. IUDs require insertion in a clinical setting by trained personnel and require a follow-up visit after one month. Some protocols require three additional follow-up visits in the first year; however, a recent study in Mexico (Hubacher, et al., 1999) found no significant difference in rates of PID between clients who had two follow- up visits (at one month and 12 months), and clients who had four follow-up visits in the first year. Women of any reproductive age, including those who have never had children (nul- liparous), can use IUDs. However, nulliparous women and women under 20 years of age have a higher risk of expulsion. IUDs may be inserted at any time during Key Points IUDs are extremely safe, effective, and econom- ical. They have a service life of five to 10 years and produce very few side effects. In general, the associated risk of PID is very low. While the initial cost of an IUD is relatively high, due to the need for clinical visits and trained inserters, the cost of continuing use is minimal. Proper insertion techniques are of paramount importance and reduce the risks of PID and expulsion of the device. An IUD should not be used by a woman who has experienced an STI within the past three months. The presence of STIs during IUD insertion can lead to PID. In populations with a high prevalence of STIs, prophylactic administration of antibiotics may reduce the incidence of PID. Reference Guide 66 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD the menstrual cycle, as long as the provider is reasonably sure the woman is not pregnant. Contraindications for IUD use are few and relate mainly to the presence of genitourinary infection. Women with genitourinary infection after childbirth or abortion, women with an ongoing STI or PID, and women who have had an STI or PID within the past three months should not have an IUD inserted. On the other hand, many of the contraindications for other family planning methods do not ap- ply to IUDs. For example, women who smoke, breastfeed (after six weeks for LNg), or take antibiotics, can use an IUD. In general, women report fewer side effects with IUDs than with oral, implantable, or injectable contraceptives. However, complaints of intermenstrual bleeding and cramping, especially during the first month of IUD use, are common and may lead to removal. The copper T is associated with an increase in heavy and prolonged menstrual bleeding, dysmenorrhea, and intermenstrual spotting and cramping during the first few menstrual cycles after insertion. These effects are the primary reasons for discontinuation, but they generally decrease over time and are less common among older and parous users. In contrast, the primary reasons for discontinuation of the LNg intrauterine system are infrequent or absent menstruation. IUDs do not increase the risk of ectopic pregnancy. However, up to half of the few pregnancies that do occur among IUD users are ectopic. Continuation rates for the copper T and LNg interuterine system are similar. A recent literature review by Fortney, et al. (1999), cites a number of articles on continua- tion rates. While study results varied, continuation rates were generally around 80 percent after the first year and between 38 percent and 50 percent after five years. In one nonclinical survey, the five-year continuation rate was as high as 68 percent. Insertion Trained clinicians other than physicians can insert IUDs safely. Proper technique is essential to reduce the risk of expulsion and infection. Insertion under hygienic con- ditions significantly reduces the risk of infection. Between two percent and 10 percent of users spontaneously expel their IUD within the first year. Expulsion rates are highest in the first three months after insertion, and women younger than 20 years of age have the highest expulsion rates. A woman who has expelled an IUD has a 30 percent chance of subsequent expulsion. Infertility Risk Historically, the most important adverse effect associated with the IUD was PID, which can cause infertility. However, recent studies have found the causal relation- ship suspect. A study among 1,895 women (Hubacher, et al., 2001) found tubal infertility was not associated with prior IUD use, regardless of the duration. Further- more, the study found that tubal infertility was not associated with the reason for IUD removal, or the presence or absence of gynecological problems related to IUD use. However, past exposure to chlamydia was strongly associated with infertility. 67 STIs And PID PID in IUD users is related to poor insertion techniques and the presence of an STI at the time of insertion. PID is usually caused by a pathogen ascending from the vagina or cervix into the upper reproductive tract (uterus, fallopian tubes, ovaries), which can be facilitated by insertion of an IUD. The risk of PID is significantly in- creased in the first month after IUD insertion, but after the first three months of use, the risk in IUD users is comparable to that in nonusers. Another recent study (Shelton, 2001) modeled the risk of PID based on the assump- tion that PID among IUD users results from insertion in the presence of cervical gonorrhea or chlamydia and occurs within the first few months after insertion. Fully symptomatic PID attributable to IUD use was uncommon, even in populations with a high prevalence of STI. The author estimated that the risk of clinical PID due to IUD use was 0.15 percent, or less than one in 600 women. With a high overall prevalence of gonorrhea or chlamydia of 30 percent, the PID risk increased to 0.3 percent. Antibiotic Prophylaxis Administering antibiotics prior to IUD insertion may reduce the likelihood of an un- scheduled return visit to the clinic. While the reason is unclear, it has been suggest- ed that antibiotics may reduce the risk of subclinical endometritis, which can cause pain or bleeding. However, antibiotics may not significantly reduce the likelihood of PID or premature IUD discontinuation. A study evaluating antibiotic prophylaxis before IUD insertion (Grimes and Schulz, 1999) found that while the use of antibiotics significantly reduced the number of unscheduled return visits to the clinic, there was no statistically significant effect on rates of PID or premature IUD discontinuation. However, in populations with a high prevalence of STIs, antibiotic prophylaxis may offer a benefit. In settings where the prevalence of gonorrhea and chlamydia was high, prophylactic antibiotics prior to IUD insertion reduced the incidence of both PID and unscheduled return visits by one-third. Clinics operating in areas with high STI rates might want to consider these benefits. Family Health International. Network 2000;20(1):1–20. Fortney JA, Feldblum PJ, Raymond EG. Intrauterine devices — the optimal long-term contraceptive method? J Reprod Med 1999;44(3):269-74. Grimes D, Schulz K. Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception 1999;60(2):57-63. Stewart GK. Intrauterine devices (IUDs). In Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology, 17th ed. New York: Ardent Media, Inc; 1998. Hubacher D, Fortney J. Follow-up visits after IUD insertion — are more better? J Reprod Med 1999;44(9):801–6. Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67. Morrison CS, Sekadde-Kigondu C, Miller WC, et al. Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates. Contraception 1999;59(2):97-106. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD. Unpublished paper. Family Health International, 1999. © Family Health International, 2003. This work was supported by the U.S. Agency for International Development (USAID). The contents do not necessarily reflect USAID views and policy. For more information, contact FHI’s Research to Practice initiative at rtop@fhi.org. PB-02-03E Reference Guide 68 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Choice Comes with Strings: IUCDs in an era of STIs/HIV Erin McGinn, M.A.1 Violet Bukusi, M.B.A.2 Joshua Kimani, M.D., M.P.H. Family Health International, 1Research Triangle Park, NC, and 2Nairobi, Kenya True or False ? 1. IUCDs cause pelvic inflammatory disease (PID), which can lead to infertility. 2. IUCDs are not appropriate for young women, or women who have never given birth (nulliparous). 3. IUCDs are contra-indicated for HIV-positive women. False False False IUCDs: Good method with a bad reputation IUCDs are one of the safest, most effective, and convenient contraceptive methods available, yet they regularly suffer a bad reputation. Of major concern is the erroneous assumption that IUCDs can lead to infertility, or that that they are not appropriate for young, nulliparous, or HIV+ women. IUCDs in a high STI setting Pelvic inflammatory disease (PID), which can lead to infertility, is caused by STIs such as chlamydia or gonnorrhea. Between 10 and 40 percent of women with chlamydia or gonnorhea develop PID.1 The IUCD itself contributes very little to PID.2 Even in high STI settings, the additional risk of developing PID from IUCD insertion is extremely low.3 IUCD use among HIV+ women Studies conducted in East Africa on IUCD use among HIV-positive women demonstrated: n no increased cervical shedding of HIV n no significant differences in complications, including pelvic inflammatory disease (PID) between HIV-positive and HIV-negative clients.6 WHO’s Medical Eligibility Criteria for Contraceptive Use The evidence on the safety of IUCDs for women at risk of STIs and HIV has led to the WHO changing its international guidelines on Medical Eligibility Criteria for Contraceptive Use.7 What does this mean for programs? n Need for revision of national service delivery policies and guidelines to reflect the new WHO changes n Update pre- and in-service training materials (e.g., curricula, reference manuals) n Inform, educate and communicate with providers and/or clients incorporating evidence-based key messages regarding the IUCD. Key messages for training/IEC materials IUCDs are: n Extremely safe, even for HIV-positive women n Effective (99.2% in first year) n Low-cost for client and health system n Appropriate for birth spacing n Low-maintenance; one-month follow-up visit and yearly thereafter Risks are minimal and manageable Dr. Jim Shelton, USAID, recently modeled the risks of inserting IUCDs in a clinic setting with an STI prevalence of 10 percent (considered high). He estimated that with simple screening criteria, the risk of developing PID that is directly attributable to IUCD insertion would be one in 667 women. Even without screening, the risk would be one in 333 women.2 Other reproductive health risks in perspective Women in sub-Saharan Africa face many reproductive health risks due to unplanned, unwanted, or mistimed pregnancies. Access to effective contraceptives, including the IUCD, is essential. Number of deliveries not attended by a skilled provider4 1 in 2 Women who do not receive antenatal care during pregnancy4 1 in 3 Lifetime risk of maternal mortality4 1 in 16 Risk of death from unsafe abortion5 1 in 147 Risk of PID attributable to IUD insertion (without screening)3 1 in 333 Category 1: There is no restriction for the use of the contraceptive method. Category 2: The advantages of using the method generally outweigh the theoretical or proven risks. The method may generally be used, but careful follow-up may be required. Category 3: The theoretical or proven risk usually outweighs the advantages of using the method. Use of the method is not usually recommended unless other more appropriate methods are not available or acceptable; it requires clinical judgment and access to clinical services for follow-up. Category 4: The method should not be used. 1. Rees E. The treatment of pelvic inflammatory disease. Am J Obstet Gynecol 1980; 138: 1042-47; Stamm WE, Guinan ME, Johnson C, Starcher T, Holmes KK, McCormack WM. Effect of treatment regimens for Neisseria gonorrhoeae on simultaneous infection with Chlamydia trachomatis. N Engl J Med 1984; 310: 545-49; Platt R, Rice PA, McCormack WM. Risk of acquiring gonorrhoea and prevalence of abnormal adnexal findings among women recently exposed to gonorrhoea. JAMA 1983; 250: 3205-09. 2. Hubacher D, Lara-Ricalde R, Taylor D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67. 3. Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet 2001;357(9254):443. 4. WHO/UNICEF/UNFPA. Maternal mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva, World Health Organization. In press. Available: http://www.who.int/reproductive-health/publications/maternal_mortality_2000. 5. Berer M. Making abortions safe: a matter of good public policy and practice. Bull World Health Organ 2000;78(5):580-89. 6. Morrison, CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate contraception for HIV-1 infected women? Br J Obstet Gynaecol 2001;108(8):784-90. 7. World Health Orgnization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva, Switzerland: World Health Orgnization, 2003. Available: http://www.who.int/reproductive-health/publications/MEC_3/index.htm. Shelton, Lancet, 2001 Funding for FHI’s Research to Practice Initiative provided by USAID. The contents do not necessarily reflect USAID views and policy. Implementing Best Practices, Uganda, June 2004. WHO Medical Eligibility Criteria for Use of Copper IUCDs STIs & HIV 2nd Ed. (2004) 3rd Ed. (2004) Category Category Initiation Continuation Current purulent cervicitis, chlamydia or gonorrhea Vaginitis Increased risk of STIs High individual risk of STIs New High risk of HIV HIV-infected AIDS No ARV or no clinical improvement on ARV AIDS No ARV or no clinical improvement on ARV New High Risk Setting of 10% Cervical Infection Simple Screening Questions No Screening 1 in 667 get PID due to IUD (0.15%) 1 in 333 get PID due to IUD (0.3%) ­ ­ 69 Shelton J, Angle M, Jacobstein R. Medical barriers to access to family planning. Lancet 1992;340:1334-1335. While well-intentioned and based partly on medical rationale, some service delivery practices are unnecessary and can prevent access to family planning services for women and men who could safely use methods. There are six types of medical barriers: inappropriate or out-of-date contraindications; too-stringent eligibility criteria; unnecessary physical exams and laboratory tests; provider biases; limiting contraception provision to physicians only; and government regulations that limit the types of contraceptives available. To reduce medical barriers, providers must work as a group to assess all service delivery practices, to determine whether they are essential to provision of contraception. The medical community should develop standard guidelines on contraceptive use. Family planning should be viewed as less medical: Women and men should be seen as clients, not patients, and increased emphasis should be placed on delivery of methods through community-based, over-the-counter and social marketing outlets. Additional research should be conducted to assess contraceptive risks and benefits, to evaluate ways to reduce unnecessary restrictions and to understand clients’ perceptions of family planning methods and services. Stanback J, Diabate F, Dieng T, Duarte de Morales T, Cummings S, Traoré M. Ruling out pregnancy among family planning clients: the impact of a checklist in three countries. Stud Fam Plann 2005;36(4):311-315. Women in many countries are often denied vital family planning services if they are not menstruating when they present at clinics, for fear that they might be pregnant. A simple checklist based on criteria approved by WHO has been developed to help providers rule out pregnancy among such clients, but its use is not yet widespread. Researchers in Guatemala, Mali, and Senegal conducted operations research to determine whether a simple, replicable introduction of this checklist improved access to contraceptive services by reducing the proportion of clients denied services. From 2001 to 2003, sociodemographic and service data were collected from 4,823 women from 16 clinics in the three countries. In each clinic, data were collected prior to introduction of the checklist and again three to six weeks after the intervention. Among new family planning clients, denial of the desired method due to menstrual status decreased significantly — from 16 percent to 2 percent in Guatemala and from 11 percent to 6 percent in Senegal. Multivariate analyses and bivariate analyses of changes within subgroups of nonmenstruating clients confirmed and reinforced these statistically significant findings. In Mali, denial rates were essentially unchanged, but they were low from Reference Guide Annotated Bibliography 70 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD the start. Where denial of services to nonmenstruating family planning clients was a problem, introduction of the pregnancy checklist significantly reduced denial rates. This simple, inexpensive job aid improves women’s access to essential family planning services. Stanback J, Nakintu N, Qureshi Z, Nasution M. Does assessment of signs and symptoms add to the predictive value of an algorithm to rule out pregnancy? J Fam Plann Reprod Health Care 2006;32(1):27-29. A WHO-endorsed ‘pregnancy checklist’ has become a popular tool for ruling out pregnancy among family planning clients in developing countries. The checklist consists of six criteria excluding pregnancy, all conditional upon a seventh ‘master criterion’ relating to signs or symptoms of pregnancy. Few data exist on the specificity of long-accepted signs and symptoms of pregnancy among family planning clients. A study based on a previous observational study in Kenya (n=1,852) found that signs and symptoms of pregnancy were rare (1.5 percent), as was pregnancy (1 percent). Signs and symptoms were more common (18.2 percent) among the 22 clients who tested positive for pregnancy than among the 1,830 clients (1.3 percent) who tested negative, but did not add significantly to their predictive value. Although the ‘signs and symptoms’ criterion did not substantially improve the ability of the checklist to exclude pregnant clients, several reasons (including use of the checklist for IUD clients) render it unlikely that the checklist will be changed. Stanback J, Nutley T, Gitonga J, Qureshi Z. Menstruation requirements as a barrier to contraceptive access in Kenya. East Afr Med J 1999;76(3):124-126. A study was conducted in Kenya in 1996 to determine whether menstruation requirements pose a barrier to new clients seeking family planning services. Data were collected from eight public-sector health centers and one hospital in two provinces. Health providers tracked the menstrual status of women using a simple tally sheet. Forty-five percent of the women seeking services were not menstruating. Among the 345 nonmenstruating women, 51 percent were breastfeeding and amenorrheic, while 49 percent were between menstrual periods. Providers considered nonmenstruating women pregnant unless they were within six weeks postpartum. Women were told to go home and await the onset of menses or to have a pregnancy test at another facility. Researchers estimated that 78 percent of nonmenstruating women were sent home without their chosen method, and that up to one-third of all women were turned away. In most cases, pregnancy could have been ruled out with a simple checklist. Policy-makers should consider adopting national guidelines that remove the unnecessary menstruation requirement. 71 Stanback J, Qureshi Z, Sekadde-Kigondu C, Gonzalez B, Nutley T. Checklist for ruling out pregnancy among family-planning clients in primary care. Lancet 1999;354(9178):566. Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to nonmenstruating clients. In Kenya, a trial (n=1,852) of a simple checklist to exclude pregnancy showed a negative predictive value of more than 99 percent. Use of this simple tool could improve access to services and reduce unwanted pregnancies and their sequelae. Stanback J, Thompson A, Hardee K, Janowitz B. Menstruation requirements: a significant barrier to contraceptive access in developing countries. Stud Fam Plann 1997;28(3):245-250. Some family planning clinics require women seeking hormonal contraception or IUDs to be menstruating before they can receive their chosen method. Studies in Ghana, Kenya, Cameroon, Senegal, and Jamaica have found that menstruation requirements negatively affect access to services for clients who could safely use contraceptives. As many as one-fourth to one-half of new clients seeking contraceptive services are sent home to await the onset of menses. These clients risk an unplanned pregnancy, and many are unable to return to the clinic because of time and money constraints. Because pregnancy is a contraindication to contraceptive use, health providers have used menstruation as a proxy for expensive pregnancy tests. Another rationale for menstruation requirements is timing — hormonal methods are usually initiated and IUDs typically inserted during menses. In addition, some providers believe pregnant women may use contraceptives to induce abortion. While many providers believe that women know about menstruation requirements, data from Kenya and Cameroon show that clients do not. Denial of contraceptive methods to nonmenstruating women is a serious obstacle to services that could be reduced by using a simple checklist to rule out pregnancy. Wesson J, Gmach R, Gazi R, Ashraf A, Méndez JF, Olenja J, Nguer R, Janowitz B. Provider views on the acceptability of an IUD checklist screening tool. Contraception 2006;74(5):382-388. A field test to examine the acceptability of the IUD Checklist among providers was conducted in four countries (Bangladesh, the Dominican Republic, Kenya, and Senegal). A total of 16 focus groups, involving 135 active family planning providers, were held to solicit providers’ points of view. Providers found the checklist easy to use and thought it would facilitate identification of eligible IUD users. Nevertheless, many providers relied on prior knowledge of IUD eligibility, Reference Guide 72 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD rather than the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69 percent of the time. The IUD checklist is a useful job tool for providers, but training and effective dissemination of the World Health Organization medical eligibility criteria should precede its introduction to ensure that it is correctly used. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva, Switzerland: Reproductive Health and Research, 2004. This document was developed by the WHO expert working group which brought together participants from 18 countries, including representatives of many agencies and organizations. The document is important for improving access to quality care in family planning, as it reviews the medical eligibility criteria used for selecting appropriate methods of contraception for a variety of clients. The document provides recommendations for appropriate medical eligibility criteria based on the latest clinical and epidemiological data and is intended to be used by policy- makers, family planning program managers and the scientific community. It aims to provide guidance to national family planning and reproductive health programs in preparing guidelines for the service delivery of contraceptive methods. World Health Organization. Selected Practice Recommendations for Contraceptive Use. Second Edition. Geneva, Switzerland: Reproductive Health and Research, Family and Community Health, 2004. Selected Practice Recommendations for Contraceptive Use is one of two evidence- based guidelines on contraceptive use published by WHO. This document provides guidance for using contraceptive methods safely and effectively once they are deemed to be medically appropriate. It is the companion guideline to WHO’s Medical Eligibility Criteria for Contraceptive Use. The document is intended to be used by policy-makers, program managers, and the scientific community. It aims to support national programs in preparing service delivery guidelines. 73 Appendix Supplementary Training Schedules A. Combined Training Schedule for All Four Provider Checklists FHI has produced a series of four easy-to-use checklists designed to assist clinical and non-clinical family planning service providers in screening women who want to initiate use of COCs, DMPA/NET-EN, or the IUD. The fourth checklist helps providers rule out pregnancy among nonmenstruating women seeking to initiate the contraceptive method of their choice. It is recommended that service providers be trained on how to use all four checklists, unless a particular checklist is not applicable to their scope of work. A training and reference guide has also been produced for each checklist. Familiarity with all four guides is necessary for conducting a combined training. The schedule on pages 74 and 75 is recommended for a combined training and follows the same structure used in the individual training guides. The Notes section of the outline will assist facilitators in determining what to include and how to adapt a section. Facilitators should carefully consider the training needs of participants when adapting the training. Appendix 74 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD Session Overview and Schedule (Combined Training) Time: 9 hours Session Time Topic Notes 1 40 minutes Welcome and Introductions Exercise A: Peel the Cabbage Adapt from any of the checklist trainings. Use the questions: • What practice is currently used to determine if a woman is medically eligible to receive contraception? (Consider COCs, DMPA and IUD.) • How is pregnancy ruled out? • Can you name some conditions that prevent women from using COCs, DMPA or an IUD? (Create a separate list of conditions for each contraceptive method.) 2 20 minutes Rationale and Purpose Adapt from the COC, DMPA or IUD checklist trainings. • Show all four checklists, but do not distribute them to participants at this time. • Emphasize that all checklists were designed to assist providers in safely screening women for contraceptive eligibility and, therefore, to reduce barriers to contraceptive use. The Pregnancy Checklist may have other purposes as well. • Note that the checklists were designed for a variety of providers and can be used in a variety of settings. The IUD Checklist differs from the others in that it requires that some of the questions be administered by a provider trained to conduct a pelvic exam. 60 minutes Exercise B: Review of the WHO Medical Eligibility Criteria (MEC) Note: In the IUD Guide, Exercises B and C are reversed so that they follow the order in which they occur on the IUD Checklist. More specifically, in the IUD Guide, Exercise B covers use of the Pregnancy Checklist and Exercise C covers the WHO medical eligibility criteria (MEC). • Follow steps 1-6 under Exercise B for COCs and DMPA and Exercise C for IUDs, with the following exceptions: Step 3: Choose a maximum of four conditions for each of the three contraceptive methods and allow a total of 20 minutes to complete the task. The following conditions are suggested for the exercise. COCs and DMPA: diabetes, high blood pressure, HIV/AIDS, and endometrial cancer. IUDs: nulliparous, STI, PID, and HIV and AIDS. Step 4: Allow 20 minutes for participants to assess whether their answers were correct or incorrect. Step 6: Distribute a copy of the COC, DMPA, and IUD checklists and complete the step. • Additional IUD discussion points should be brought up at this point (see Significant Issues Affecting Medical Eligibility in Session 2, Facilitator’s Resource, IUD Guide). 10 minutes Exercise C: Demonstrating the Benefits of Using the Pregnancy Checklist Additional detail on the research related to the Pregnancy Checklist can be found in the Optional Session. 75 Session Overview and Schedule (Combined Training) Time: 9 hours Session Time Topic Notes 1 40 minutes Welcome and Introductions Exercise A: Peel the Cabbage Adapt from any of the checklist trainings. Use the questions: • What practice is currently used to determine if a woman is medically eligible to receive contraception? (Consider COCs, DMPA and IUD.) • How is pregnancy ruled out? • Can you name some conditions that prevent women from using COCs, DMPA or an IUD? (Create a separate list of conditions for each contraceptive method.) 2 20 minutes Rationale and Purpose Adapt from the COC, DMPA or IUD checklist trainings. • Show all four checklists, but do not distribute them to participants at this time. • Emphasize that all checklists were designed to assist providers in safely screening women for contraceptive eligibility and, therefore, to reduce barriers to contraceptive use. The Pregnancy Checklist may have other purposes as well. • Note that the checklists were designed for a variety of providers and can be used in a variety of settings. The IUD Checklist differs from the others in that it requires that some of the questions be administered by a provider trained to conduct a pelvic exam. 60 minutes Exercise B: Review of the WHO Medical Eligibility Criteria (MEC) Note: In the IUD Guide, Exercises B and C are reversed so that they follow the order in which they occur on the IUD Checklist. More specifically, in the IUD Guide, Exercise B covers use of the Pregnancy Checklist and Exercise C covers the WHO medical eligibility criteria (MEC). • Follow steps 1-6 under Exercise B for COCs and DMPA and Exercise C for IUDs, with the following exceptions: Step 3: Choose a maximum of four conditions for each of the three contraceptive methods and allow a total of 20 minutes to complete the task. The following conditions are suggested for the exercise. COCs and DMPA: diabetes, high blood pressure, HIV/AIDS, and endometrial cancer. IUDs: nulliparous, STI, PID, and HIV and AIDS. Step 4: Allow 20 minutes for participants to assess whether their answers were correct or incorrect. Step 6: Distribute a copy of the COC, DMPA, and IUD checklists and complete the step. • Additional IUD discussion points should be brought up at this point (see Significant Issues Affecting Medical Eligibility in Session 2, Facilitator’s Resource, IUD Guide). 10 minutes Exercise C: Demonstrating the Benefits of Using the Pregnancy Checklist Additional detail on the research related to the Pregnancy Checklist can be found in the Optional Session. Session Time Topic Notes 3 30 minutes Design of and Instructions for Using the Checklists All the checklists have the same basic design and instructions for use. Therefore, the training presented in this guide can be easily adapted to apply to all the checklists. Note: • The Pregnancy Checklist contains one set of questions, the COC and DMPA Checklists contain two sets, and the IUD Checklist contains three sets. 3-6 hours Exercise D: Practice Using the four checklists Provide participants the opportunity to use the COC, DMPA and IUD checklists. The time will vary depending on the number of scenarios selected. To save time, do not independently practice the Pregnancy Checklist, since it is incorporated into the other checklists. Review the optional approaches for conducting the scenarios as potential time-saving tools. The option chosen should be the most appropriate for the needs of the participants. 4 20 minutes Wrap-up Modify as needed from this or any of the trainings. Appendix 76 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD B. Training Para-Professionals on the IUD Checklist The term “para-professional” is used here to designate service providers who are physically located in the same facility where IUDs are provided but who have no training in performing pelvic exams or IUD insertion. Some of these para-professionals can be trained to conduct a limited screening for an IUD insertion. Facilitators preparing training sessions for para-professionals in the use of the IUD Checklist should simplify the training content for this audience. Lecture sessions should generally be avoided, and the training should be practical in nature to ensure that para-professionals understand the checklist tool and are comfortable using it correctly. The outline below, which follows the same structure used in the individual training guides, is intended as a suggestion only. The Notes section of the outline will assist facilitators in determining what to include and how to adapt the different sections. Facilitators should carefully consider the training needs of participants when adapting the training. Session Overview and Schedule (Para-professionals) Time: 2 hours Session Time Topic Notes 1 15 minutes Welcome and Introductions Icebreaker Activity Use Session 1 from this guide. Do not perform Exercise A: Peel the Cabbage. 2 20 minutes Rationale and Purpose Exercise B: Demonstrating the Benefits of Using the Pregnancy Checklist Training Steps: • Distribute copies of the IUD Checklist and the Quick Reference Chart to each participant. • Briefly and in simple language explain what the IUD Checklist is and why it was developed. Clearly explain that the third set of questions is intended for skilled providers. • Perform Exercise B: Demonstrating the Benefits of Using the Pregnancy Checklist to illustrate how the checklist can be effective in ruling out the possibility of pregnancy in women who are not menstruating at the time they are seen by the para-professional. • Use the Quick Reference Chart to illustrate that many women, even those with certain medical conditions, can safely have an IUD inserted. Allow five minutes for participants to familiarize themselves with the Quick Reference Chart. Do not perform Exercise C: Review of the WHO Medical Eligibility Criteria. 77 Session Time Topic Notes 3 20 minutes Design of and Instructions for Using the IUD Checklist • Briefly and simply explain the design of the IUD Checklist and go over instructions for using it. • Discuss with participants what is expected of them once the first two sets of questions have been administered. For example, what are some ways of transitioning a client to the final screening portion (pelvic exam) if they have been deemed eligible thus far? • What should the next step be if the client is not eligible? If pregnancy is not ruled out? • After this, ask participants if they have any questions or need any items clarified. 45 minutes Exercise D: Practice Using the IUD Checklist Review the optional approaches for conducting the scenarios as potential time-saving tools. The option chosen should be the most appropriate for the needs of the participants. Do not use scenarios 14, 15, or 16 because they are related to pelvic exams and are only relevant to providers who actually insert IUDs. 4 15 minutes Wrap-up Modify as needed from this training. Appendix 78 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD C. Introducing Provider Checklists to Policy-makers and Program Managers A slide presentation (Powerpoint presentation B) with expanded notes can be found on the CD-ROM that accompanies this training and reference guide. This presentation is targeted to policy-makers and program managers who may be interested in introducing the checklists in their service delivery settings. The presentation focuses on introducing all four checklists and includes an explanation of their rationale and a discussion of general issues regarding their use. It does not go into detail on how to use the checklists. Also included is a section that can be adapted to issues specific to local areas, such as checklist dissemination and resources. 79 Sample Energizers Energizers* are highly recommended during training sessions, in particular during trainings involving lectures. In this training, an energizer is recommended between sessions two and three. n Coconut The facilitator shows the group how to spell out C-O-C-O-N-U-T by using full movements of the arms and the body. All participants then try this together. n The sun shines on. Participants sit or stand in a tight circle with one person in the middle. The person in the middle shouts out “the sun shines on.” and names a color or articles of clothing that some in the group are wearing. For example, “the sun shines on all those wearing blue” or “the sun shines on all those wearing socks” or “the sun shines on all those with brown eyes”. All the participants who have that attribute must change places with one another. The person in the middle tries to take one of their places as they move, so that there is another person left in the middle without a place. The new person in the middle shouts out “the sun shines on.” and names a different color or type of clothing. n Body writing Ask participants to write their name in the air with a part of their body. They may choose to use an elbow, for example, or a leg. Continue in this way, until everyone has written his or her name with several body parts. n Football cheering The group pretends that they are attending a football game. The facilitator assigns specific cheers to various sections of the circle, such as ‘Pass’, ‘Kick’, ‘Dribble’ or ‘Header’. When the facilitator points at a section, that section shouts their cheer. When the facilitator raises his/her hands in the air, everyone shouts “Goal!” *Adapted from International HIV/AIDS Alliance. 100 ways to energise groups: games to use in workshops, meetings and the community. Brighton, UK: International HIV/AIDS Alliance, 2002. Appendix 80 Training and Reference Guide for a Screening Checklist to Initiate Use of the Copper IUD N am e of Sponsoring O rganization certifies that N am e of Participant has successfully com pleted training on the Checklist for Screening Clients W ho W ant to Initiate U se of the Copper IU D (D ate) (Place) N am e of Person issuing certificate N am e of Person issuing certificate Title Title Sponsoring O rganization Sponsoring O rganization Sample Certificate of Attendance 81

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