Study on Quality of IUD Services Provided by Trained Professionals at Teaching Institutes

Abstract

Objective

Access the completeness in IUD services provided by trained professionals and find out the weak links.

Materials and Methods

Study was conducted on 100 IUD trained professionals of tertiary care hospital and nursing teaching institute. All were given questionnaire that was duly filled by them. Data obtained were analysed. Protocols of case selection, pre-insertion counselling, insertion process and follow-up were assessed.

Results

All the four criteria were assessed on score of ten. Study group could not get ten points under any of the set criteria. Average of 53% case selection, 31.4% pre-insertion counselling, 42.5% insertion protocols and 46.1% follow-up counselling criteria were observed by study group. Highest compliance of protocols was seen among postgraduate students.

Conclusion

Although IUD training is given to all medical professionals and IUD facility is available up to subcentres but the study shows that completeness in services is still lacking. Ensuring ideal place for IUD insertion, proper case selection, use of specific instruments for insertion and observance of insertion protocols are very vital for the success of IUD.

Introduction

Family planning is continuous need of society. Use of family planning methods by eligible couples is vital to control fertility. Among the currently available temporary and reversible contraceptive methods, IUD is the most convenient, effective and efficient contraceptive [1]. It was introduced in National Family Welfare Program in form of Lippe’s loop in 1965. IUD is available in all government health institutions of Rajasthan [2]. Good IEC and capacity building is also in place but optimal contraceptive use is still a challenge. Current utilisation is only 1.6%, and contraceptive prevalence rate is 58.1% [3] (NFHS III).

IUD is facing huge defamation in society despite good quality and convenience of use. Over the years, no significant change in numbers of IUD users is visible in Rajasthan [4] (CMIS Raj).

Health care providers play a key role in providing information and method of correct use of contraceptive. They also help in removing myths and misbeliefs. Therefore, it is important that health care providers themselves have correct knowledge. Current study is an attempt to access practices, quality of service and behaviour of IUD service providers of state level teaching institutes in Jaipur city.

Objective

1. Access completeness in IUD service provided by trained professionals.

2. Identify the weaker link.

Materials and Methods

Target Group

Sample size of 100, comprising faculty of medical teaching institute, postgraduate students, trained nursing staff, nursing tutors and nursing students (twenty each) was taken. They were either routinely inserting IUD or they were providing IUD training to medical professionals.

Method

To observe the practices and procedure of IUD insertion, study was conducted at SMS Medical College and associated group of hospitals and Government nursing college, Jaipur, Rajasthan. Participants were asked to fill questionnaire after consent. Anonymity of participants was maintained. Relevant information was extracted. Data were analysed on the following points (Table 1):

1. Criteria of case selections.

2. Pre-insertion counselling.

3. Cu T insertion protocols.

4. Follow-up advice.

Table 1.

Assessment criteria

S. no.	Case selection (one point each)	Pre-insertion counselling (2 points each)	Observance of SOPs (one point each)	Follow-up (2 points each)
1	Obstetrics history	Detailing Cu T	Hand washing	Sharing common side effects
2	Menstrual history	Explaining the procedure	Sterile equipments	Process of checking the string and follow-up
3	H/o Abnormal vaginal bleeding	Counselling on change in bleeding pattern	Painting and draping	What to do if string is missing
4	H/o gonorrhoea Chlamydial, etc.	Counselling about dysmenorrhoea	Per vaginal examination	What to do if period is missed
5	H/o contact	Removing myths and misbeliefs	Uterine sounding	Sharing duration of effectivity and return of fertility
6	PS examination for ulcer, discharge, etc.		No touch loading
7	Adnexal tenderness		Insertion by withdrawal
8	Cervical bleeding on touch		Telling what is happening step by step
9	Anatomical abnormality		Alert her before a step that may cause discomfort
10	Consent		Allowing her to rest till she is comfortable

All processes were assessed on a scale of ten.

Observation

Among the respondents, eighty were in practice of inserting IUD. Sixty-nine per cent of respondents had more than 1 year experience in IUD insertion. Twenty-five per cent of practicing respondents had received additional special training in IUD insertion. Nursing students had no practical experience in IUD insertion. Their feedback was solely based on theory classes (Table 2).

Table 2.

Experience and training status of participants

Participants	Experience of applying Cu T routinely			Additional IUD training status
	< 1 year	1–5 years	> 5 years	Received	Not received
College faculty	0	5	15	17	3
PG students	11	9	0	0	20
Nursing faculty	0	10	10	0	20
Nursing students	0	0	0	0	20
Nursing staff	0	9	11	8	12
Total	11	33	36	25	75
Percentage	11	33	36	25	75

Skill of respondents was assessed on the basis of points acquired in four criteria by all five categories of study groups (Fig. 1).

Fig. 1.

Average score of assessment criteria among study groups

Selection of Case

Proper case selection is very crucial for the success of all contraceptive methods. It helps in minimising the future complications. Completeness of case selection was assessed on pre-decided ten criteria based on history taking and physical examination.

None of the study group could meet all the criteria of selection of cases. Average score of medical college faculty and students was 7–8, while score of nursing group was below 5 on scale of ten.

Pre-Insertion Counselling

Sharing contraceptive details, procedure of application and prior sorting of the fears and myths during pre-insertion counselling, is expected to increase acceptance and compliance. In current study, average score of pre-insertion counselling in all the respondents was less than 5. Lowest score was observed among nursing students.

Standard Operative Procedures

Key to the success of any procedure is observance of protocols. Flawless execution is expected to ensure better patient compliance, minimal complications and good name to the procedure. Score obtained in observance of insertion protocols in entire study group was ranging from 2.6 to 6.

Follow-up of IUD Cases

Continuation of IUD is mainly dependent on regular follow-up and timely identification and management of complications. Specific follow-up instructions relieve the anxiety and ensure timely intervention, if needed. Average score of follow-up advice was found good among medical faculty and postgraduate students was found to be very low in nursing group (Fig. 2).

Fig. 2.

Completeness in observance of inclusion criteria

Considering perfection in case selection for IUD, 60% of medical college faculty and 50% of postgraduate students mentioned more than 70% criteria. Seventy per cent of nursing staff and 65% of nursing students mentioned less than 50% of selection criteria. Pre-insertion counselling was addressed by 50% of total respondents. Only 30% doctors and 35% postgraduate students mentioned more than 7 criteria of pre-insertion counselling.

Regarding the observance of protocols of IUD insertion, only 35% of the doctors and 30% of postgraduate students mentioned more than 7 points of the set criteria. Follow-up counselling was visible in 50% of doctors and less than 20% of nursing group. Seventy per cent of medical faculty had follow-up score more than 5. PG students, nursing staff and nursing students gave follow-up advice to some extent. But very poor response was seen in nursing faculty.

Discussion

IUD is one of the important contraceptive for spacing. Acceptance of a contraceptive method is dependent on the quality of services we provide. Three components namely individual perception, influencing factors and likelihood of action are to be addressed to achieve optimal outcome (Rosen stock’s Health Belief Health Promotion model [5] In view of this model, quality of IUD service was assessed in relation to selection of case, pre-insertion counselling, observance of insertion protocols and regular follow-up by service providers. This was done with the assumption that compromised quality of IUD services might be responsible for poor uptake of IUD in state.

Earlier studies have shown significant associations between higher quality of care and higher contraceptive prevalence and likelihood of use [6]. Positive link between the provision of more intensive client counselling and/or information about method and side effects is associated with lower rates of contraceptive discontinuation [7]; follow-up of the IUD acceptors is also important to improve acceptance and to find out the complications if any [8].

In current study, attempt was made to access the quality of IUD services with reference to provider attitude, knowledge and practices. Criteria which have crucial impact on acceptance, comfort, convenience and health of client were included. Steps vital for infection prevention, preparation of patient, actual process of IUD insertion and follow-up of the client were taken care of.

Key to the success of IUD is proper case selection. It includes history taking and complete physical examination. On reviewing the formats, complete history was taken by all respondents but only 50% mentioned physical examination for the case selection. Category-wise analysis showed that against highest expected pre-insertion counseling score of ten average score observed in all the groups was less than 5. Lowest score was observed among nursing students. Many pre-insertion counselling details were found missing, indicating thereby that most of the queries, apprehensions and worries of client were left unattended. Facts concerning side effects, complication and future fertility were also not mentioned. Not sharing the side effects adds negative impression to procedure as patients conceives them as complication. Similar findings were observed in earlier studies also [9, 10].

On analysing the compliance of individual components of insertion protocol, hand washing percentage was 43% only. Other measures to prevent the infection were seen in 50–60% respondents. Basic steps of insertion as uterine sounding, no touch loading, etc., were also seen in around 50% respondents only. Low compliance of protocols is a serious concern. Steps to console and comfort the patients were missing in most of the formats. These factors increase the possibility of complications resulting in bad name to method.

Specific follow-up instructions relieve the anxiety of client and helps in minimising the rumours and myths about IUD. Post-insertion counselling although mentioned by most of the respondents was incomplete. Vital issues like return of fertility were mentioned in only 20% formats. Action points on missed periods, PID, missed string, etc., were poorly addressed.

Although IUD is universally used contraceptive and is available from tertiary level hospitals to subcentre still on analysing the formats, it came out very clearly that providers knowledge on IUD is satisfactory [11] but the compliance of protocols, counselling and follow-up advice are poorly addressed. Providers need to be proactive in discussing IUD and clarifying the misconception. More than half of the health care providers have never attended any specific training on IUD insertion [12]. In addition, providers need opportunity to improve their skill and should receive education and training focusing on medical safety and acceptability of IUD [13]. To ensure quality services and increase the acceptance rate of IUD in Rajasthan, there is need to ensure the availability of trained staff at government health facilities and there is need of refresher training that too on communication skills.

Conclusion and Recommendations

1. Although IUD training is imparted to all medical professionals and IUD facility is available up to subcentres, the study shows that completeness in service delivery is still lacking.

2. Ensuring ideal place for IUD insertion, proper case selection, use of specific instruments for insertion, observance of SOPs and counselling is very vital for the success of IUD.

3. Nurses scored lowest in all four study criteria. Need is to evaluate and strengthen their existing training programs on IUD.

4. IUD counselling needs to be more comprehensive and client centred.

Noopur Prasad

is currently Principal specialist in Obstetrics and Gynaecology in Mahila Chikitsalaya, SMS Medical College and group of Hospital, Jaipur. She has worked as Project Director Maternal health, Rajasthan, and has seven years working experience in HIV AIDS in various capacities. She has published a book on HIV AIDS scenario of Rajasthan. She has been involved in planning, capacity building, monitoring and evaluation of state level public health issues.

Compliance of Ethical Standards

Conflict of interest

All of the author declare that they have no conflict of interest or financial conflict.

Informed Consent

Informed consent was obtained from all the individual participants.

Ethical Approval

All procedures performed in study involving human participant were in accordance with the ethical standards of institutional research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.