This project aims to improve the health of women and infants through increased awareness and uptake of the hormonal IUD. Hormonal IUDs, which are recommended by the WHO, would have benefits for women such as reduced anemia, increased educational and employment opportunities, better sanitation, and greater control over timing and spacing of births. Reducing anemia in reproductive-age women will also lead to better birth outcomes, including reduced risk of preterm birth and better immune function and developments in neonates. Because IUDs must be inserted in clinics, this also provides an entry point for counseling and testing for other health issues, including other family planning methods and STIs. To advance these goals, this project will build capacity of health clinics and community networks to promote and market the hormonal IUD.
Benefits of IUDs
There are several reasons why this method of contraception would be beneficial for young Indian women. According to the 2006 National Family Health Survey (NFHS) report, the vast majority of Indians do not use modern methods of birth control until the desired number of children is achieved. The most common method is female sterilization. Delaying first births and spacing subsequent births is important to the health of both mother and child, especially with the young age of marriage. Delay of initial childbearing after marriage would increase educational and employment opportunities for women. This time also allows for further maturation of girls who are married in their teens, which decreases risk to both mother and baby during pregnancy and birth.
Out of the 3 spacing methods currently promoted by the Indian government (oral contraceptives, condoms, and IUDs), the hormonal IUD is the most effective, longest lasting, and easiest to use, since it only requires 3 medical visits during 5 years of use. As a long-term method, the IUD is also highly cost-effective for both patients and the medical system. These characteristics make IUDs the most commonly used reversible contraception method worldwide.
Hormonal IUDs have other non-contraceptive benefits. In 90% of women, hormonal IUDs reduce the amount of blood lost in menstruation; for about 20% menstruation ceases altogether. Menstruation is a major cause of anemia in women of reproductive age. Women that are anemic before pregnancy are usually anemic during pregnancy, which can lead to postpartum hemorrhage and other complications. Additional benefits included possible reduced risk of endometrial hyperplasia, endometrial cancer, and pelvic inflammatory disease, which can all cause infertility.
Current Status of IUDs in India
According to the 2006 NFHS, 68.8% of Indian women have knowledge of IUDs, compared to 85% for oral contraceptives and 96.6% for female sterilization; furthermore, only 51% of men have knowledge of IUDs. Only 0.4% of married 15-19 year olds have ever used an IUD, compared to 1.1% who have been sterilized. IUD use is 3.6% among married 20-24 year olds. The IUD is the least known and least used method of the 3 spacing methods available, and it is also the only of these methods that is not socially marketed.
While pills and condoms are socially marketed for birth spacing and limiting, their usage rates are also low -- 11.1% and 13.9%, respectively. To improve community attitudes about IUDs, I propose to market them not solely on their benefits as contraception, but as a method of improving preconception or intraconception health. First, project staff will identify women who have had IUDs to learn from their experiences. Project staff will then hold focus groups with young women to determine the acceptability of amenorrhea, which previous studies in India suggest is culturally acceptable. We will also have focus groups of men and older women, possibly members of the local panchayats, who are influential in family planning decisions, to determine the effectiveness of the message that hormonal IUDs should be used to improve birth outcomes for both mother and child in the future.
The project will use information from the focus groups to develop a social marketing plan to promote awareness and uptake of IUDs. The plan will include recommendations on how best to transmit messages, including through informal networks and peer to peer education. Engaging peers in education is a highly effective and sustainable practice for health programs. To ensure this method is successful, project staff will provide a train-the-trainer session for the peer education coordinator in our project area.
Project staff will also meet with health professionals responsible for inserting IUDs to ensure they are providing adequate family planning counseling, including both the positive and negative side effects of hormonal IUDs, since these are the most common reason for IUD discontinuation. Also, testing facilities for STIs will be evaluated and a risk assessment algorithm, based on the USAID model, will be recommended if facilities are inadequate. Since many young women are illiterate, we will assess the availability of visual aids used in education and counseling on IUDs and create materials if needed.