Comparative Study of Safety and Efficacy of IUD Insertions by Physicians and Nursing Personnel in Brazil1 KAREN

To assess whether trained nursing personnel could provide IUD services as safely and 4fecfively as physicians in Brazil, an experimental study was conducted at the main clinic of the Center for Research on Integrated Maternal and Child Care in Rio de Janeiro. From November 1984 through April 1986, a fatal of 1 711 women who requested IUD insertion at the clinic were randomly assigned to have a Copper-T 200 IUD inserted by one of the clinic’s 11 physicians or 13 nurses. All of the physicians and nursing staff members who provided fhese services had taken the Center’s standard clinical family planning training course. Of 860 insertions attempted by the physicians and nurses, 1.3% and 3.3%, respectively, were unsuccessful. Statistically, this difference was very significant V < 0.01). Also, mainly because the cervix was small and undiluted, nulliparous women had a relatively high insertion failure rate of 8.0%‘ as compared to 1.5% for primiparas and 1 .O% for multiparas. The overall rateof complications at insertion was 1.8%‘ these complications including diapkoresis, vomiting, syncope, cervical laceration, and one case of perforation of the uterus; no significant diflerence was found between the complication rates for insertions performed by physicians as compared to nurses. However, 9.0% of the study subjects reported severe pain during IUD inserfion, with significantly higher percentages reporting pain if the IUD was inserted by a physician, or if the subject was nulliparous, had preinsertion symptoms, or had a history of pelvic inflammatoy disease (PlD) or sexually transmitted disease (STD). It was also found that the nurses had a dramatically high insertion failure rate (11.6%) with nulliparous subjects, while the physicians‘ failure rate with suck subjects was a significantly lower 3.4%. No significant difference was found in the groups served by nurses and physicians with regard to posfinsertion complaints or termination of use within 12 months of insertion. These findings suggest that future training, besides preparing nursing personnel in IUD insertion, should emphasize preparation in taking the client’s medical kisto y and diagnosing ejcisting medical symptoms that could be associated with IUD insertion complications. In addifion, if a nulliparous woman requests an insertion, it should be performed by a physician or more experienced nursing staff member with close medical supervision. Because of high rates of reported pain at insertion, suck women, as well as those with medical symptoms associated with IUD insertion complications and those with a kistoy of PID or STD, should be considered candidates for extra care and counseling. Finally, because a kigk rate of removal was related to medical symptoms reported by users after insertion, women with postinserfion symptoms should be carefully evaluated and counseled about options for treatment or possible IUD removal.