1. Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO), Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project Repositioning Family Planning in West Africa Repositionnement de la Planification Familiale en Afrique de l’Ouest What happened to IUD use? Solutions and lessons learnt from Ghana and Kenya H. Birungi, V. Bukusi, I. Osei, G. Addico, P. Nyarko, I.Askew, J. Gyapong

2. Contributors  Frontiers in Reproductive Health program, Population Council  Health Research Unit, Ghana Health Service  Reproductive and Maternal Health Unit, Ghana Health Service  Family Health International  Division of Reproductive Health, Ministry of Health, Kenya

3. Background  The IUD is a safe, reversible method  Requires little effort from the user once inserted & offers 10 years of protection against pregnancy  Favorable policy embracing all FP methods in most sub-Saharan countries  Steady increases in FP knowledge and use over time  High level of IUD use in other countries BUT:  Decline and stagnation in use of the IUD  Poor demand profile for the IUD WHY?

4. Observed stagnation of the IUD in the method mix (Ghana) Source: GDHS 1993-2003

5. Observed decline of the IUD in the method mix (Kenya) Source: KDHS 1993-2003

6. Poor Demand Profile – method preference for non-users (Ghana) Potential Barriers  Rumors & misconceptions  Product design  Side effects  Insufficient promotion  Insufficient providers with practical experience  Complexity of service provision  Variability in cost  No variety - only copper T available (HRU, GHS & Population Council 2003) Source: GDHS 1993-2003

7. Poor Demand Profile – method preference for non-users (Kenya) Potential Barriers  Safety concerns –Fear of increased risk for HIV/AIDS infection –Fear of increased risk for STI and complications –Fear of complications among HIV+ individuals –Fear of infertility –Myths and rumors  Service delivery –Provider biases –Inadequate equipment/supplies –Low provider skills (Stanback et al 1995, FHI) Source:KDHS 1993 -2003

8. Solutions (Ghana)  Intensify promotion of IUD using multiple strategies to dispel rumors and demystify the product - branding of product - testimonies of satisfied clients  Improve provider confidence in IUD insertion skills and create a critical mass of trained IUD providers  Review policy guidelines on who qualifies to insert the IUD  Clarify eligibility criteria with regard to nulliparous and HIV infected

9. Research to action (Ghana)  Participation in inter-agency working group  Develop information package on the IUD  Dissemination of IUD assessment to zonal district level providers  Assist service delivery organizations to utilize IUD assessment findings  Develop operations research on IUD

10. IUD re-introduction initiative (Kenya)  Increase support for IUD among policy makers, health care providers and clients  Increase the provision of quality IUD services  Create demand for the IUD

11. Solutions (Kenya)  Capacity building & service delivery  Advocacy –Advocacy partners »Professional associations and local and international NGO –Development of Advocacy Briefs »Targets: Policy makers & providers »Addressed concerns/gaps in knowledge »Endorsed by all major professional associations –Sensitization meetings »Provincial and district medical officers/health program managers –Advocacy IEC »Radio program, client pamphlets

12. Re-introduction process (Kenya)  Partnership building  Stakeholders’ meeting –Disseminate IUD assessment research –Discuss options on how best to tackle barriers –Showcase positive deviants –Inform program managers/providers of global evidence  IUD task force formed to develop a strategy based on global evidence and IUD assessment

13. Lessons Learnt  Research critical in identifying solutions  Political commitment is essential  Application of global evidence is important  Partnerships with all key stakeholders leads to better ownership