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Yacobson I, Wanga V, Ahmed K, Chipato T, Gichangi P, Kiarie J, Louw C, Morrison S, Moss M, Mugo NR, Palanee-Phillips T, Pleaner M, Scoville CW, Thomas KK, Nanda K. Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience. Contracept X 2023; 5:100092. [PMID: 37188149 PMCID: PMC10176026 DOI: 10.1016/j.conx.2023.100092] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 05/17/2023] Open
Abstract
Objectives To assess the rates of failed insertion, expulsion, and perforation when intrauterine device (IUD) insertions were done by newly trained clinicians, and to examine factors that may affect these outcomes. Study design We evaluated skill-based outcomes following IUD insertion at 12 African sites in a secondary analysis of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial. Before trial initiation, we provided competency-based IUD training to clinicians and offered ongoing clinical support. We used Cox proportional hazards regression to examine factors associated with expulsion. Results Among 2582 IUD acceptors who underwent first attempted IUD insertion, 141 experienced insertion failure (5.46%) and seven had uterine perforation (0.27%). Perforation was more common among breastfeeding women within three months postpartum (0.65%) compared with non-breastfeeding women (0.22%). We recorded 493 expulsions (15.5 per 100 person-years, 95% confidence interval [CI] 14.1─16.9): 383 partial and 110 complete. The risk of IUD expulsion was lower among women older than 24 years (aHR 0.63, 95% CI 0.50─0.78) and may be higher among nulliparous women. (aHR 1.65, 95% CI 0.97─2.82). Breastfeeding (aHR 0.94, 95% CI 0.72─1.22) had no significant effect on expulsion. IUD expulsion rate was highest during the first three months of the trial. Conclusions IUD insertion failure and uterine perforation rates in our study were comparable to those reported in the literature. These results suggest that training, ongoing support, and opportunities to apply new skills were effective in ensuring good clinical outcomes for women receiving IUD insertion by newly trained providers. Implications Data from this study support recommendations to program managers, policymakers, and clinicians that IUDs can be inserted safely in resource-constrained settings when providers receive appropriate training and support.
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Affiliation(s)
| | - Valentine Wanga
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Khatija Ahmed
- Setshaba Research Centre, Soshanguve, Gauteng, South Africa
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Tsungai Chipato
- University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Peter Gichangi
- International Centre for Reproductive Health, Nyali, Mombasa, Kenya
- University of Nairobi, Nairobi, Kenya
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - James Kiarie
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - Cheryl Louw
- Madibeng Centre for Research, Brits, North West, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Margaret Moss
- Department of O&G, Faculty of Health Sciences, University of Cape Town/Groote Schuur Hospital, Cape Town, Western Cape, South Africa
| | - Nelly R. Mugo
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Melanie Pleaner
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Caitlin W. Scoville
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Katherine K. Thomas
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - for the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium
- FHI 360, Durham, NC, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Setshaba Research Centre, Soshanguve, Gauteng, South Africa
- Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, Gauteng, South Africa
- University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
- International Centre for Reproductive Health, Nyali, Mombasa, Kenya
- University of Nairobi, Nairobi, Kenya
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
- Madibeng Centre for Research, Brits, North West, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, Gauteng, South Africa
- Department of O&G, Faculty of Health Sciences, University of Cape Town/Groote Schuur Hospital, Cape Town, Western Cape, South Africa
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Onono M, Nanda K, Heller KB, Taylor D, Yacobson I, Heffron R, Kasaro MP, Louw CE, Nhlabasti Z, Palanee-Phillips T, Smit J, Wakhungu I, Gichangi PB, Mugo NR, Morrison C, Baeten JM. Comparison of pregnancy incidence among African women in a randomized trial of intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUDs) or a levonorgestrel (LNG) implant for contraception. Contracept X 2020; 2:100026. [PMID: 32577615 PMCID: PMC7301167 DOI: 10.1016/j.conx.2020.100026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective was to address bias in contraception efficacy studies through a randomized study trial of intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUDs) and a levonorgestrel (LNG) implant. STUDY DESIGN We analyzed data from the Evidence for Contraceptive Options and HIV Outcomes Trial, which assessed HIV incidence among 7829 women from 12 sites in eSwatini, Kenya, South Africa and Zambia seeking effective contraception and who consented to be randomized to DMPA-IM, copper IUD or LNG implant. We used Cox proportional hazards regression adjusted for condom use to compare pregnancy incidence during both perfect and typical (i.e., allowing temporary interruptions) use. RESULTS A total of 7710 women contributed to this analysis. Seventy pregnancies occurred during perfect and 85 during typical use. There was no statistically significant difference in perfect use pregnancy incidence among the methods: 0.61 per 100 woman-years for DMPA-IM [95% confidence interval (CI) 0.36-0.96], 1.06 for copper IUD (95% CI 0.72-1.50) and 0.63 for LNG implants (95% CI 0.39-0.96). Typical use pregnancy rates were also largely similar: 0.87 per 100 woman-years for DMPA-IM (95% CI 0.58-1.25), 1.11 for copper IUD (95% CI 0.77-1.54) and 0.63 for LNG implants (95% CI 0.39-0.96). CONCLUSIONS In this randomized trial of highly effective contraceptive methods among African women, both perfect and typical use resulted in low pregnancy rates. Our findings provide strong justification for improving access to a broader range of longer-acting contraceptive options including LNG implants and copper IUD for African women. IMPLICATIONS STATEMENT Data from this study support recommendations to providers, policy makers and patients that all of these methods provide safe and highly effective contraception for African women.
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Affiliation(s)
- Maricianah Onono
- Kenya Medical Research Institute Center for Microbiology Research, P.O. Box 19464-00202, Nairobi, Kenya
| | | | | | | | | | | | | | - Cheryl E. Louw
- Madibeng Centre for Research, Brits, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Zelda Nhlabasti
- Family Life Association of eSwatini & ICAP at Columbia University, eSwatini
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
| | - Jenni Smit
- University of the Witwatersrand, Durban, South Africa
| | - Imelda Wakhungu
- Kenya Medical Research Institute Center for Microbiology Research, P.O. Box 19464-00202, Nairobi, Kenya
| | - Peter B. Gichangi
- International Center for Reproductive Health, Kenya
- Technical University of Mombasa, Mombasa, Kenya
| | - Nelly R. Mugo
- Kenya Medical Research Institute Center for Microbiology Research, P.O. Box 19464-00202, Nairobi, Kenya
- University of Washington, Seattle, USA
| | | | | | - for the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium
- Kenya Medical Research Institute Center for Microbiology Research, P.O. Box 19464-00202, Nairobi, Kenya
- FHI 360, Durham, USA
- University of Washington, Seattle, USA
- UNC Global Projects Zambia & University of North Carolina at Chapel Hill, Zambia
- Madibeng Centre for Research, Brits, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
- Family Life Association of eSwatini & ICAP at Columbia University, eSwatini
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
- University of the Witwatersrand, Durban, South Africa
- International Center for Reproductive Health, Kenya
- Technical University of Mombasa, Mombasa, Kenya
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