Fostering Change in Medical Settings: A Holistic Programming Approach to “Revitalizing” IUD Use in Kenya

  • Roy Jacobstein
Part of the The Springer Series on Demographic Methods and Population Analysis book series (PSDE, volume 33)


This paper discusses strategies to accelerate the rate, extent, and sustainability of change in medical care settings, using as a case example a 2-year technical assistance project mounted by EngenderHealth to “revitalize” use of the IUD in Kisii District of Kenya’s Nyanza Province. This project followed a holistic programming model, which holds that a coordinated package of programmatic activities among the supply, demand, and policy/advocacy program areas can be not only efficacious, but mutually reinforcing. Attention was also paid to four important crosscutting elements in reproductive health programming: the fundamentals of care (safety, quality, and choice); use of local data for decision making; gender equity; and stakeholder participation. IUD use rose with each program intervention, e.g., training, community and male engagement, and district-wide multimedia demand creation campaigns. At project close in 2007, 142 IUDs were being inserted monthly at the 13 project sites, up from a baseline average of 28 insertions monthly, an increase of 507 %. Despite district restructuring and transfer of skilled staff, increased annual levels of IUD provision (over 300 %) were sustained for 30 months after project close. Other positive changes generated district-wide included: improvements in the supervision system; implementation of a CBD program, with increased linkages between the community and project sites; increased male engagement in FP; 33 % more new clients for all FP methods at project sites; and greater use of other RH services.


Family Planning Contraceptive Method Pelvic Inflammatory Disease Medical Setting Family Planning Service 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



 Many staff from both the Kisii District Ministry of Health, the ACQUIRE Project, the RESPOND Project, and EngenderHealth worked on the IUD revitalization effort in Kisii. Too numerous to acknowledge individually, they contributed the knowledge and expertise of a number of professional disciplines including medicine, midwifery, nursing, communication, marketing, and project management and evaluation. Appreciation is also given to the many community leaders and volunteers who worked to increase access, quality, and use of FP among women and men in Kisii. The continuing encouragement and commitment of Patricia MacDonald and Carolyn Curtis of USAID was indispensible in allowing this project to proceed and succeed.


  1. ACQUIRE Project. (2006). Revitalizing the IUD in Kenya (Acquiring knowledge no. 2). New York: EngenderHealth/The ACQUIRE Project.Google Scholar
  2. ACQUIRE Project. (2007). The ACQUIRE Project’s program model for FP/RH service delivery. New York: EngenderHealth/The ACQUIRE Project. Accessed 30 Jan 2011.
  3. ACQUIRE Project. (2008a). Programming for IUD services: Experience and lessons learned in field implementation and global leadership (Acquiring knowledge no. 14). New York: EngenderHealth/The ACQUIRE Project.Google Scholar
  4. ACQUIRE Project. (2008b). Revitalizing underutilized family planning methods: using communications and community engagement to stimulate demand for the IUD in Kenya (Acquiring knowledge no. 7). New York: EngenderHealth/The ACQUIRE Project.Google Scholar
  5. Alnakash, A. H. (2008). Influence of IUD perceptions on method discontinuation. Contraception, 78(4), 290–293.PubMedCrossRefGoogle Scholar
  6. Bertrand, J. T., Hardee, K., Magnani, R. J., & Angle, M. A. (1995). Access, quality of care and medical barriers in family planning programs. International Family Planning Perspectives, 21(2), 64–74.CrossRefGoogle Scholar
  7. Berwick, D. M. (2003). Disseminating innovations in health care. Journal of the American Medical Association, 289(15), 1969–1975.PubMedCrossRefGoogle Scholar
  8. Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], & ORC Macro. (2004). Kenya demographic and health survey 2003. Calverton: CBS, MOH, & ORC Macro.Google Scholar
  9. Doyal, L. (2000). Gender equity in health: Debates and dilemmas. Social Science & Medicine, 51(6), 931–939.CrossRefGoogle Scholar
  10. EngenderHealth. (2006). Performance needs assessment: Lessons learned from EngenderHealth/The ACQUIRE Project. Unpublished report prepared for EngenderHealth/The ACQUIRE Project, New York.Google Scholar
  11. Farley, T. M., Rosenberg, M. J., Rowe, P. J., Chen, J. H., & Meirik, O. (1992). Intrauterine devices and pelvic inflammatory disease: An international perspective. The Lancet, 339(8796), 785–788.CrossRefGoogle Scholar
  12. Fischer, S. (2005). Translating research into practice: Reintroducing the IUD in Kenya. Research Triangle Park: Family Health International.Google Scholar
  13. Hubacher, D., Lara-Ricalde, R., Taylor, D. J., Guerra-Infante, F., & Guzmán-Rodríguez, R. (2001). Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. The New England Journal of Medicine, 345(8), 561–567.PubMedCrossRefGoogle Scholar
  14. Jacobstein, R. (2007). Long-acting and permanent contraception: An international development, service delivery perspective. Journal of Midwifery & Women's Health, 52(4), 361–367.CrossRefGoogle Scholar
  15. Jacobstein, R. (2009). Fostering change in medical settings: Some considerations for family planning programs. International Planned Parenthood Federation (IPPF) Medical Bulletin, 43(3), 3–4.Google Scholar
  16. Jacobstein, R., Bakamjian, L., Pile, J. M., & Wickstrom, J. (2009). Fragile, threatened, and still urgently needed: Family planning programs in sub-Saharan Africa. Studies in Family Planning, 40(2), 147–154.PubMedCrossRefGoogle Scholar
  17. Kaneshiro, B., & Arby, T. (2010). Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device. International Journal of Women’s Health, 9(2), 211–220.CrossRefGoogle Scholar
  18. Kenya National Bureau of Statistics (KNBS) (2009). Kenya 2009 population and housing census highlights. Available at: Accessed 3 Apr 2011.
  19. Kenya National Bureau of Statistics (KNBS) & ICF Macro. (2010). Kenya demographic and health survey 2008–09. Calverton: KNBS & ICF Macro.Google Scholar
  20. Kisii District Ministry of Health (MOH). 2005. Report on a performance needs assessment on revitalization of family planning and the IUCD, Kisii, Kenya. Unpublished report prepared for USAID/The ACQUIRE Project, New York.Google Scholar
  21. Milsom, I., Andersson, K., Jonasson, K., Lindstedt, G., & Rybo, G. (1995). The influence of the gyne-T 380S IUD on menstrual blood loss and iron status. Contraception, 52(3), 175–179.PubMedCrossRefGoogle Scholar
  22. Mishell, D. R. (1998). Intrauterine devices: Mechanisms of action, safety, and efficacy. Contraception, 58(3), 45S–53S.PubMedCrossRefGoogle Scholar
  23. Morrison, C. S., Sekadde-Kigondu, C., Sinei, S., Weiner, D., Kwok, C., & Kokonya, D. (2001). Is the intrauterine device appropriate contraception for HIV-1-infected women? British Journal of Obstetric Gynecology, 108(8), 784–790.Google Scholar
  24. Nanda, G., Switlick, K., & Lule, E. (2005). Accelerating progress towards achieving the MDG to improve maternal health: A collection of promising approaches. Washington, DC: World Bank.Google Scholar
  25. Peters, D. H., El-Saharty, S., Siadat, B., Janovsky, K., & Vujicic, M. (Eds.). (2009). Improving health service delivery in developing countries: From evidence to action. Washington, DC: World Bank.Google Scholar
  26. Peterson, H. B., & Curtis, K. M. (2006). The World Health Organization’s global guidance for family planning: An achievement to celebrate. Contraception, 73(2), 113–114.PubMedCrossRefGoogle Scholar
  27. Pourbohloul, B., & Kieny, M.-P. (2011). Complex systems analysis: Towards holistic approaches to health systems planning and policy. Bulletin of the World Health Organization, 89, 242.PubMedCrossRefGoogle Scholar
  28. RamaRao, S., Lacuesta, M., Costello, M., Pangolibay, B., & Jones, H. (2003). The link between quality of care and contraceptive use. International Family Planning Perspectives, 29(2), 76–83.PubMedCrossRefGoogle Scholar
  29. Republic of Kenya, Ministry of Public Health and Sanitation, Division of Reproductive Health. (2008). Kenya comparative assessment of long-acting and permanent methods activities, final report. Nairobi: Government of Kenya.Google Scholar
  30. Richardson, B. A., Morrison, C. S., Sekadde-Kigondu, C., Sinei, S. K., Overbaugh, J., Panteleeff, D. D., Weiner, D. H., & Kreiss, J. K. (1999). Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS, 13(15), 2091–2097.PubMedCrossRefGoogle Scholar
  31. Rogers, E. (2003). Diffusion of innovations (5th ed.). New York: The Free Press.Google Scholar
  32. Ross, J., and Smith, E. (2010). The family planning effort index: 1999, 2004, and 2009. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1.Google Scholar
  33. Salem, R. (2006). New attention to the IUD: Expanding women’s contraceptive options to meet their need (Population reports, series B, no. 7). Baltimore: INFO Project, Johns Hopkins Bloomberg School of Public Health.Google Scholar
  34. Shelton, J. D. (2000). The harm of “first, do no harm”. Journal of the American Medical Association, 284(21), 2687–2688.PubMedCrossRefGoogle Scholar
  35. Shelton, J., Angle, M., & Jacobstein, R. (1992). Medical barriers to access to family planning. The Lancet, 340(8831), 1334–1335.CrossRefGoogle Scholar
  36. Sinei, S. K., Morrison, C. S., Sekadde-Kigondu, C., Allen, M., & Kokonya, D. (1998). Complications of use of intrauterine devices among HIV-1-infected women. The Lancet, 351(9111), 1238–1241.CrossRefGoogle Scholar
  37. Sivin, I. (1989). IUDs are contraceptives, not abortifacients: A comment on research and belief. Studies in Family Planning, 20(6), 357–359.CrossRefGoogle Scholar
  38. Sivin, I. (1991). Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception. Obstetrics and Gynecology, 78(2), 291–298.PubMedGoogle Scholar
  39. Skjeldestad, F. E. (2008). The impact of intrauterine devices on subsequent fertility. Current Opinion in Obstetrics and Gynecology, 20(3), 275–280.PubMedCrossRefGoogle Scholar
  40. Speidel, J. J., Sinding, S., Gillespie, D., Maguire, E., & Neuse, M. (2009). Making the case for U.S. International family planning assistance. Baltimore: The Bill & Melinda Gates Institute for Population and Reproductive Health.Google Scholar
  41. Stanback, J., & Shelton, J. D. (2008). Pelvic inflammatory disease attributable to the IUD: Modeling risk in West Africa. Contraception, 77(4), 227–229.PubMedCrossRefGoogle Scholar
  42. Stanback, J., & Twum-Baah, K. A. (2001). Why do family planning providers restrict access to services? An examination in Ghana. International Family Planning Perspectives, 27(1), 37–41.CrossRefGoogle Scholar
  43. Stanback, J., Thompson, A., Hardee, K., & Janowitz, B. (1997). Menstruation requirements: A significant barrier to contraceptive access in developing countries. Studies in Family Planning, 28(3), 245–250.PubMedCrossRefGoogle Scholar
  44. Thonneau, P. F., & Almont, T. (2008). Contraceptive efficacy of intrauterine devices. American Journal of Obstetrics and Gynecology, 198(3), 248–253.PubMedCrossRefGoogle Scholar
  45. Townsend, J. W., & Jacobstein, R. (2007). The changing position of IUDs in reproductive health services in developing countries: Opportunities and challenges. Contraception, 75(Suppl), S35–S40.PubMedCrossRefGoogle Scholar
  46. Trussell J. (2007). Contraceptive efficacy. In R. A. Hatcher, et al. (Eds.), Contraceptive technology (19th Rev. ed.). New York: Ardent Media.Google Scholar
  47. Tumlinson, K., Steiner, M., Rademacher, K., Olawo, A., Solomon, M., & Bratt, J. (2011). The promise of affordable implants: Is cost recovery possible in Kenya? Contraception, 83(1), 88–93.PubMedCrossRefGoogle Scholar
  48. United Nations (UN). (2011). World contraceptive use 2010. New York: United Nations, Department of Economic and Social Affairs, Population Division.Google Scholar
  49. United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), World Health Organization (WHO), & World Bank. (1997). Long-term reversible contraception: Twelve years of experience with the TCu380A and TCu220C. Contraception, 56(6), 341–352.Google Scholar
  50. Westoff, C. F., & Cross, A. R. (2006). The stall in the fertility transition in Kenya (DHS analytical studies 9). Calverton: ORC Macro.Google Scholar
  51. Whitehead, A. N. (1929). Process and reality: An essay in cosmology. New York: The Free Press.Google Scholar
  52. WHO. (2010a). Medical eligibility criteria for contraceptive use (4th ed.). Geneva: Department of Reproductive Health and Research, WHO.Google Scholar
  53. WHO. (2010b). Review of priorities in research: Hormonal contraception and IUDs and HIV infection. Report of a technical meeting, Geneva 13–15 Mar 2007.Google Scholar
  54. WHO, UNICEF, UNFPA, & World Bank. (2010). Trends in maternal mortality: 1990–2008. Estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: WHO.Google Scholar
  55. World Health Organization (WHO). (2004). Selected practice recommendations for contraceptive use (2nd ed.). Geneva: Department of Reproductive Health and Research, WHO.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.EngenderHealthNew YorkUSA

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