IUD protocols for international training.

PIP: A review of 9 reference protocols for IUD training in the US and in developing countries revealed conflicting instructions on antibiotic prophylaxis, postpartum insertion of IUDs, management of complications, and sterilization and disinfection procedures. The protocols only agreed on the contraindication status of pregnancy and active gynecological or chlamydial infections (all listed as absolute contraindications) which were just 2 of 32 different contraindications. US physicians considered some conditions to be contraindications to IUD use, but they usually are not applicable to women in developing countries. In developing countries with maternal mortality rates 2 times greater than those in developed countries, 8 contraindications may be inappropriate: prior expulsion of or perforation by an IUD, IUD insertion during the postpartum period, prior pregnancy with and IUD in place, prior ectopic pregnancy, copper allergy, coagulopathy, valvular heart disease, and Wilson's disease. The only inappropriate contraindication addressing infection (1 of 8) was a distant history of pelvic inflammatory disease. This history should not exclude IUD use in a woman not at risk of sexually transmitted diseases. Contraindications referring to cancer of the reproductive tract should be consolidated in a statement warning against hormonal contraceptive and IUD use in women, especially those over 35, who have recent, undiagnosed, irregular vaginal bleeding, until the cause has been determined. The reviewers also discussed justifications for other contraindications, including those related to menstrual blood loss, small uterus, structural abnormality of the uterus, severe vasovagal reactivity or fainting and severe cervical stenosis, no access to services, and future fertility. THis analysis indicated a need to simplify, rationalize, and update current IUD protocols as well as make them consistent. This will improve service quality and reduce unnecessary medical obstacles to contraception.^ieng

Medical barriers to access to family planning.

PIP: Medical barriers to family planning (FP) are identified as contraindications, eligibility, process hurdles, the provider of contraception, provider bias, and regulation. These obstacles to FP are considered practices which may have a medical rationale in some manner but are scientifically unjustified. The denial or interference in obtaining contraception is unacceptable. Examples are given of barriers, i.e., eligibility criteria such as lack of headaches or history of diabetes. Obstacles that deter oral contraception (OC) are a by-product of testing requirements, repeat visits, and long waits. OC provision does not require a physician's prescription; a trained technician can perform similar functions. When a provider such as community-based distributor is limited in provision of methods, women are not given the right to choose from a full menu. Medical barriers occur due to the ignorance about the safety of contraceptives, the benefits of FP, and the role of health professionals in service delivery. Clinics tend to be curative rather than preventive. In place of careful thinking, there are rules in a hierarchical medical system suitable for treatment of complicated life-threatening illness. Barriers are complicated, interrelated, and situational. The solutions suggested are 1) informing the health community and mobilizing medical leadership, 2) defining and treating the FP seeker as a client and not a medical patient, and 3) engaging in more epidemiological research to assess the risk/benefits of contraceptive use and operations research to evaluate ways to reduce medical restrictions. The position that obstacles are an example of quality of care does not support the Bruce-Jain FP quality of care framework. Health and FP services may be integrated but contraceptive usage should not be at the expense of health care. The obstacles are not just in developing countries where it would appear that access to FP far outweighs the risks of maternal mortality from pregnancy. Providers are not the target is creating a win-win-win situation for the client, the provider, and organized public health.^ieng