|Year : 2010 | Volume
| Issue : 4 | Page : 201-204
Health care delivery practices in the rural part of the Yavatmal district regarding IUD insertion
NN Ambadekar1, KZ Rathod2, Sanjay P Zodpey3
1 Additional District Health Officer, Health Department, Yavatmal, Maharastra, India
2 District Health Officer, Health Department, Yavatmal, Maharastra, India
3 Director, Public Health Education, Public Health Foundation of India, New Delhi, India
|Date of Web Publication||3-Mar-2011|
Sanjay P Zodpey
Director, Public Health Education, Public Health Foundation of India, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A cross-sectional survey of Cu T users in a rural area of the Yavatmal district was carried out using stratified sampling, to identify interventions that can improve intrauterine device (IUD) service provision processes and their acceptance. The average age at Cu T insertion was 23.8 years. Cu T acceptance with one child was 55.5%. 80.8% of Cu Ts were inserted within 10 days of menstruation, while there were no post-partum Cu T insertions. 51.8% Cu Ts were inserted in PHC's. At the time of the survey, 48.2% users already have their Cu T removed. Only 22.7% couples utilized some alternate contraception after Cu T removal. Post-discontinuation contraceptive use was lower in a tribal area. 30% Cu T acceptors received less than two health checkups. 78.8% (58.1% in a tribal area and 84.9% in a non-tribal area) beneficiaries received information about Cu T from health workers. Only 6.6% Cu T acceptors received specific advice of checking the Cu T string. Utilization of private facility was more common among tribals. Reach of health service regarding Cu T need to be improved in tribal areas. Health service providers need to be more proactive, especially about utilization of the immediate post-partum period for Cu T insertion, clients counseling, and follow up of users.
Keywords: Cu T acceptance, Health service indicators, Health care delivery practices
|How to cite this article:|
Ambadekar N N, Rathod K Z, Zodpey SP. Health care delivery practices in the rural part of the Yavatmal district regarding IUD insertion. Indian J Public Health 2010;54:201-4
|How to cite this URL:|
Ambadekar N N, Rathod K Z, Zodpey SP. Health care delivery practices in the rural part of the Yavatmal district regarding IUD insertion. Indian J Public Health [serial online] 2010 [cited 2020 Apr 7];54:201-4. Available from: http://www.ijph.in/text.asp?2010/54/4/201/77261
Use of contraceptive methods among women in developing countries has increased substantially from below 10% in 1965-70 to over 50% in recent years.  Among currently used modern contraceptives, more than 100 million women worldwide use some kind of intrauterine device (IUD). This makes IUDs the single most popular reversible contraception method.  However, the scenario in India is not encouraging. Less than 2% of women are adopting IUD as a method of contraception.  Repositioning the IUD in India's family welfare program will have several advantages. Not only are IUDs a highly effective contraceptive method (pregnancy rate < 1%), , the Cu T-380 A being used in the health program of Maharashtra, needs replacement only after 12 years. 
The quality of family planning services is an important determinant that affects the continuation/discontinuation of contraceptives.  Studies show that rural Indian women lack access to quality IUD services and follow-up. The situation is compounded by misconceptions about the methods, limited educational materials, and provider bias against the use of IUD.  In addition, emphasis on sterilization provides little motivation to health care providers to promote the IUD or other temporary contraceptive methods.
An important component of the program is promoting adequate spacing of births. In this regard, training of health care providers by using alternate methodology like the ZOE model is going on to improve skills among service providers and attitude change toward IUD. A ZOE gynecologic simulator is a model of a full-sized, adult female lower torso (abdomen and pelvis) and can be used as a training tool in training of health personnel. Against this background the present survey explored aspects of health care delivery services related to IUD use in the rural Yavatmal district, Maharashtra, with an objective to identify interventions that can improve IUD service provision processes and their acceptance. The district has a tribal population constituting about a fifth of the total population according to the 2001 census.
The present study was planned as a cross-sectional survey and was carried out in April 2009. Yavatmal district has 16 blocks, out of which 6 are tribal and 10 are non-tribal. Eight blocks (four tribal and four non-tribal) were identified using stratified sampling. There were a total of 859 beneficiaries who were inserted with a Cu T in the reference period of 2007-08 and 2008-09 according to the health service records for 31 villages in these eigth blocks. Women with Cu T insertion within 3 months of the survey were excluded from the survey. A random sample of 137 women was selected assuming a 5% margin of error and a 95% confidence level in the uncertainty and assuming a response distribution of 90%. Two female research associates trained with the structured interview schedule collected the study data. The medical officer involved in the study did a 10% verification of the interviews.
Among the Cu T users, 106 (77.4%) were from the non-tribal area, while 31 (22.6%) were from the tribal area [Table 1]. 134 (97.8%) women had post-primary education. The average age at Cu T insertion was 23.8 years, 24 years in the tribal area and 23.7 years in the non-tribal area. Most of the Cu Ts were inserted in the age group of 20 to 29 years, i.e. 123 (89%). 55.5% of couples accepted Cu T after one child, 44.5% on two or more children, but no Cu T was inserted in nulli-parous women. 83.8% Cu Ts were inserted within 10 days of menstruation, while no Cu T was inserted in the immediate post-partum period (within 48 h). In the rural area, Cu Ts were commonly inserted at government facility, i.e. 51.8% in PHC's and 11.7% in sub-centers. 27.7% of Cu T users used private health care setup for insertion, while 4.4% of Cu Ts were inserted in home or in Anganwadi centers. Utilization of private facility was more common in the tribal area. At the time of survey, 48.2% users already had Cu T removed. 21.2% Cu Ts were expelled within 3 months of insertion. Out of this, 40.9% Cu Ts were removed by health workers, 30.3% Cu Ts were removed by private gynecologist, while 28.8% Cu Ts were automatically expelled or removed by self. It was observed that only 22.7% couples utilized some other contraceptives after Cu T removal, utilization was more common in the non-tribal area. 19 (13%) of Cu T acceptors received no follow-up health checkup, while 22 (16.1%) received only one follow up health checkup. Common expectations from service providers were regular health checkup (19%), frequent guidance (24.8%), while 25.5% wish that they should get medicine. Sources of information to majority of Cu T users were health workers (78.8%) followed by relatives (32.8%). This has been reflected in motivation for Cu T acceptance, i.e. health workers were the most common source of motivation for Cu T acceptance. Only 6.6% Cu T acceptors received specific advice of checking the string. When some of the service indicators were compared between tribal and non-tribal areas, a difference was statistically significant only for the source of information.
|Table 1: Health care practices regarding Cu T services in tribal and non-tribal areas (% calculated from n in each group)|
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Health care attributes were found to be related to acceptance of family welfare services.  At present, Cu T 380 A is the IUD utilized in family welfare program in Maharashtra. It is very important to provide quality care and to inculcate suitable attitude among health care providers to utilize Cu T 380 A to its maximum potential.
Government health facilities were the common facilities observed to be utilized in the rural area, but still private gynecological facilities were utilized by the sizeable proportion of beneficiaries more so in tribal areas. This definitely reflects need for increasing the reach of health facility in the tribal area. 4.4% Cu Ts were inserted in home or in Anganwadi centers where sterility of procedure may not be maintained, indicating need to increase awareness regarding sterility of procedure among health care providers.
Specific advice of checking of IUD string [Table 2] was suggested to only 6.6% of clients by service providers, while more frequent advices were non-specific, which also means more attention is required for imparting appropriate knowledge to service providers. It was observed that approximately one-third (30%) women had less than two follow-up visits which is in contrast to WHO recommendations of two follow-up visits within 3 months of Cu T insertion.  In this regard, it was observed that the proper counseling and guidance regarding Cu T utility and follow up at the time of insertion were positively associated with continuation of Cu T.  This study also revealed that frequent guidance, health checkup, and medicine were the expectations of Cu T users from service providers.
The expulsion rate at the end of 3 months was 21.2% which was higher than other studies. ,, The situation was similar in tribal and non-tribal areas. The high expulsion rate may reflect lack of counseling at the time of insertion, inappropriate selection, and lack of quality follow-up services.
It was observed that health workers were the most common source of information regarding Cu T (78.8%) followed by relatives. Similar findings were observed by Zare et al. Regarding the source of information, a difference was significantly unfavorable to the tribal area. The observation reflects need of strengthening other IEC channels and also maximum utilization of existing field level health infrastructure in rapidly increasing awareness and utilization of IUD. Also it stresses need of increasing reach of health services in tribal at least for IUD services.
It was observed that no Cu T was inserted in the immediate post-partum period despite the guidelines that benefits of immediate (within 48 h) post-partum Cu T insertion generally outweigh the risk.  This may be because of apprehension among health care providers due to the lack of appropriate information. For women with limited access to medical care, immediate post-partum insertion offers a unique opportunity to address the need for contraception if the delivery takes place in a health-care center.
The immediate post-partum period is highly under-tapped for Cu T insertion in the Yavatmal district. It could be major intervention point for increasing Cu T coverage. A proactive role of health workers in client counseling and post-IUD follow up could lead to improvement in Cu T uptake when coupled with appropriate needs assessment in the immediate post-partum period. Although the study results may not be generalizable across the country, they are indicative of some deficiency in service factors that can be addressed to increase the utilization of IUD in family welfare services. Implementation research for IUD service utilization can pave the way for a population-level impact.
| References|| |
|1.||Annica J, Nguyen TL, Hoang TH, Vinod KD, Eriksson B. Population Policy, son preference and the use of IUDs in North Vietnam. Report Health Matters 1998;6:66-76. |
|2.||International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), India: Vol 1. Mumbai: IIPS; 2005-06. |
|3.||Copper T IUD: Safe, Effective, Reversible. 2000 Available from: http://www.fhi.org/en/rh/pubs/network/v20_1/nwvol20-1copperiud.htm. [last cited in 2010 Jan 1]. |
|4.||Penney G, Brechin S, de Souza A, Bankowska U, Belfield T, Gormley M, et al. FFPRHC Guidance. The Copper Intrauterine Device as Long-term Contraception. J Fam Plann Reprod Health Care 2004;30:29-42. |
|5.||Rakhshani F, Mohammadi M. Contraception continuation rates and reasons for discontinuation in Zahedan, Islamic Republic of Iran. East Mediterr Health J 1998;10:260-7. |
|6.||Khan ME, Patel B, Gupta R. The quality of family planning services in Uttar Pradesh from the perspective of service providers. In: Koenig MA, Khan ME, editors. Improving Quality of Care in India′s Family Welfare Programme. New Delhi: Population Council. 1999. p. 238-269. |
|7.||World Health Organization (WHO). Selected Practice Recommendations for Contraceptive Use. Geneva, Switzerland: HO, 2002. |
|8.||Aghamolaei T, Zare S, Tavafian SS, Abedini S, Poudat A. IUD Survival and Its Determinants: A Historical Cohort Study. J Res Health Sci 2007;7:31-5. |
|9.||World Health Organization (WHO). Mechanism of action, safety and efficacy of intrauterine devices. WHO Technical Report, Series 1987;753:1-91. |
|10.||Reinprayoon D, Gilmore C, Farr G, Amatya R. Twelve-month comparative multicenter study of the IUD Cut380A and ML250 intrauterine devices in Bangkok Thailand. Contraception 1998;58:201-6. |
[Table 1], [Table 2]