Feasibility and Safety of IUD Insertion by Mid-Level Providers in Sub-Saharan Africa

Felix G. Mhlanga, University of Zimbabwe Jennifer E. Balkus, University of Washington Devika Singh, Microbicide Trials Network Catherine Chappell, Magee-Women's Research Institute and Foundation Betty Kamira, Makerere University-Johns Hopkins University Ishana Harkoo, Centre for AIDS Programme of Research in South Africa Daniel Szydlo, Fred Hutchinson Cancer Research Center Shorai Mukaka, University of Zimbabwe Jeanna Piper, National Institute of Allergy and Infectious Diseases Sharon L. Hillier, University of Pittsburgh Medical Center

First published online:

| DOI: https://doi.org/10.1363/45e8019
Abstract / Summary

The copper IUD is safe and effective, but underutilized in Sub-Saharan Africa, in part because of a lack of trained providers. The World Health Organization recommends training mid-level providers—including nurses and midwives—to insert IUDs; however, the safety of such task shifting has not been evaluated in Sub-Saharan Africa.


Data were drawn from baseline surveys and study charts of 535 sexually active women aged 18–45 who used a copper IUD while participating in an HIV-prevention clinical trial conducted from August 2012 through June 2015 in Malawi, South Africa, Uganda and Zimbabwe. IUDs were inserted by study physicians, nurses and midwives trained as part of the trial, and by local nonstudy providers. Chi-square and Fisher's exact tests were used to compare women's experiences of adverse events—such as irregular bleeding, pelvic pain or device expulsion—by provider type.


Half (54%) of women reported experiencing an adverse event; the most common were irregular bleeding and pelvic pain (45% and 25%, respectively). Compared with women who had received an IUD from a study physician or study nurse, greater proportions of women who had received one from a nonstudy provider reported any adverse event (76% vs. 49% and 51%, respectively), irregular bleeding (57% vs. 41% and 45%) and pelvic pain (35% vs. 15% and 32%); the difference between study physicians and nurses was significant only for pelvic pain. Expulsion rates were comparable for study nurses and nonstudy providers (12.3 and 11.9 per 100 woman-years, respectively), but lower for study physicians (7.3 per 100 woman-years).


The findings support task shifting of IUD insertion to mid-level providers to improve IUD access in Sub-Saharan Africa.

Author's Affiliations

Felix G. Mhlanga is senior lecturer, and Shorai Mukaka is medical officer—both with the University of Zimbabwe College of Health Sciences Clinical Trials Unit, Harare, Zimbabwe. Jennifer E. Balkus is assistant professor, Department of Epidemiology and Department of Global Health, University of Washington, Seattle, WA, USA. Devika Singh is safety researcher at the Microbicide Trials Network, Seattle, WA, USA. Catherine Chappell is assistant professor, Obstetrics, Gynecology and Reproductive Services, Magee-Women's Research Institute and Foundation, Pittsburgh, PA, USA. Betty Kamira is medical officer, Makerere University-John Hopkins University, Kampala, Uganda. Ishana Harkoo is medical officer, Centre for AIDS Programme of Research in South Africa, Durban, South Africa. Daniel Szydlo is statistical research associate, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. Jeanna Piper is senior officer, Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA. Sharon L. Hillier is Richard Sweet Professor of Reproductive Infectious Disease, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; for the MTN-020/ASPIRE study team.


The views expressed in this publication do not necessarily reflect those of the Guttmacher Institute.