Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat, India

This 38-page report details an operations research study carried out to explore the strategy of using behaviour change communication (BCC) to increase use of the Intra Uterine Device (IUD) in rural and urban areas in Vadodara District in the state of Gujuarat, India. The specific hypothesis being tested was that, by improving the demand for the IUD and simultaneously strengthening the technical competencies and counselling skills of the providers, IUD use would increase. The study was carried out by the United States Agency for International Development (USAID)-funded FRONTIERS Program of the Population Council, in collaboration with the Department of Health and Family Welfare, Government of Gujarat, and the Center for Operations Research and Training, Vadodara. These collaborators were motivated by the observation that, although the IUD is a highly effective (and relatively inexpensive) contraceptive method, it is unpopular worldwide; India is no exception, with less than 2% of women adopting this family planning method.

In order to test their hypothesis, researchers first engaged in a diagnostic and preparatory phase that involved formative research designed to understand the users' perspectives about the IUD and its use, as well as prevailing myths and misperceptions about the contraceptive. Similarly, informal discussions and focus group discussions (FGDs) with providers helped in understanding providers' perspectives and their problems in promoting the IUD and personal biases against the IUD, if any. The findings were used for preparing BCC materials and counselling aids, which were then field-tested for language, clarity, and acceptability of the messages and then modified, if required. These materials included:

• A client leaflet containing information about the IUD, how it works, who can use it, advantages, side effects, and myths associated with IUD use. This leaflet was used for awareness raising in the community by distributing it widely through health workers as well as anganwadi (nutrition) workers.
• A provider leaflet designed to help providers remember the steps of IUD insertion and removal.
• An IUD chart featuring a graphical representation of the steps of the "no-touch" IUD insertion and removal technique.
• An IUD flip chart containing information designed to help providers in counselling. The size of the booklet was small so that the providers could easily carry it in their purse during field visits.
• Two posters imparting key messages about the IUD that were displayed at the sub-centres (SCs), primary health centres (PHCs), Vadodara municipal corporation clinics (VMCs), and anganwadi centres (government-sponsored child-care and mother-care centres).

Following the development of a training curriculum, staff from 41 facilities (5 PHCs, 30 sub-centres, and 6 VMCs) were trained, including 10 medical officers and 67 paramedical workers. All the paramedics that participated in the study were trained in IUD insertion and removal and were regularly providing the device. Hence, the training was largely a refresher course in terms of technical skills; however, more comprehensive training on counselling skills and use of job aids for effective communication with clients was incorporated into the capacity-building sessions.

Drawing on the fact that one anganwadi worker is assigned per 1,000 people, and she usually resides within the community, anganwadi workers were asked to participate in disseminating information regarding the IUD. The anganwadi worker conducts one meeting every month with pregnant women, lactating mothers, and newly married women to counsel them about nutrition, safe delivery practices, and family planning; as part of the study, a total of 300 group meetings were conducted each month in the study area with emphasis on the IUD. Male workers were asked to conduct group meetings with husbands and educate them about the IUD.

In order to create a positive programmatic environment where contraceptive choice is emphasised and valued, the Medical Officers in Charge (MOICs) of the clinics were asked to signal to workers during monthly meetings that there is a commitment to provide all methods - including the IUD - not just sterilisation. Project staff regularly visited the clinics and reviewed the monthly service statistics to assess the method mix of the clinic.


The impact of the intervention was evaluated 9 months after introduction of the interventions. The methodology involved a pre- and post-intervention design with no control group. The key dependent variable considered for the study was use of the IUD among clients. However, given the short intervention period available and the fact that behaviour change is a continuous process that passes through a series of stages, a major increase in the adoption of the IUD was not expected. Instead, researchers anticipated changes in process variables, such as increased positive perception and knowledge of the IUD at the community level and a decrease in myths about the device.

Researchers found that knowledge of providers on the critical steps for providing IUD services increased significantly, from 5% to 40%, and the proportion of women having poor knowledge (score of <7 out of 29) decreased significantly from 81% to 47%. Though the proportion believing in myths decreased significantly from the baseline, the prevalence of these myths was still high at endline. The proportion of IUD users who reported the quality of IUD services received to be good (score of = 25 out of 34) increased from 26% to 73%. A majority (92%) of providers used the IEC materials developed during the project when counselling clients, and 95% of them stated that their performance improved because of the IEC materials. Due to continuous monitoring and supportive supervision by the medical officers, over-reporting of IUD cases decreased significantly from 42% to 2%. Comparison of month-wise IUD insertion rates during the intervention period (2007), compared with 2006 showed significant improvement after adjusting for over-reporting.

In short, researchers found that demand generation activities and provision of good-quality IUD services, together with a supportive programmatic environment - when carried out simultaneously - showed increased acceptance of the IUD. They contend that "The intervention could be easily integrated into the existing system....[T]he IEC and counseling aids developed for the study have been well accepted by health care providers, clients and national and state government officials." Specifically, the state government is considering printing the information, education, and communication (IEC) materials and counselling aids for the entire state. The IEC Division of the Ministry of Health and Family Welfare (MOHFW) has accepted a revised version of these IEC materials and has sent the CD to all the state governments with the request that they get it translated into local languages and then use it for dissemination of knowledge and as a counseling aid.