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. 2023 Mar 30:5:100092.
doi: 10.1016/j.conx.2023.100092. eCollection 2023.

Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience

Irina Yacobson  1 , Valentine Wanga  2 , Khatija Ahmed  3   4 , Tsungai Chipato  5 , Peter Gichangi  6   7   8 , James Kiarie  9 , Cheryl Louw  10   11 , Susan Morrison  2 , Margaret Moss  12 , Nelly R Mugo  2   13 , Thesla Palanee-Phillips  14 , Melanie Pleaner  14 , Caitlin W Scoville  2 , Katherine K Thomas  2 , Kavita Nanda  1 ; Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium
Affiliations

Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience

Irina Yacobson et al. Contracept X. .

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.

Keywords: Copper intrauterine device; Expulsion; IUD; Insertion; Provider training; Uterine perforation.

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Figures

Fig. 1
Fig. 1
Summary of the IUD insertion attempts, failures, and expulsions over the course of the ECHO trial. *Contributed to the total number of IUD insertion attempts over the course of the trial (N = 3081). IUD = intrauterine device.
Fig. 2
Fig. 2
Cumulative incidence of the intrauterine device expulsion (time to first expulsion; 95% CI). CI = confidence interval; IUD = intrauterine device.
See this image and copyright information in PMC

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