Community Forum

RH Resources

Program Examples by Region



Site Map

Adolescent Reproductive Health

Cervical Cancer

Family Planning

Gender and Sexual Health

Harmful Traditional Health Practices



Men and Reproductive Health

Refugee Reproductive Health

Reproductive Tract Infections

Safe Motherhood

Family Planning

 Overview/Lessons Learned | Contraceptive Methods | Key Issues
Annotated Bibliography | Program Examples | Links | Presentations

Annotated Bibliography

This is page 3 of the Family Planning Annotated Bibliography. This page contains:

To access more bibliographic entries, visit page 1, page 2, or page 4, or return to the complete list of topics covered in the Family Planning Annotated Bibliography. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.


Intrauterine devices

Chi, I-cheng. What we have learned from recent IUD studies: a researchers perspective. Contraception (48):81-107 (August 1993).
This review of research was one of the first to conclude that IUD use is not associated with an increased risk of pelvic inflammatory disease. Other key findings were: (1) IUDs are not abortifacients; (2) newer copper IUDs are highly effective and long-lasting; (3) IUDs can be safely used by most lactating women with lower removal rates for bleeding and/or pain than for nonlactating women; and (4) immediate post-placental IUD insertion reduces the risk of expulsion often associated with postpartum insertion.

Family Health International (FHI). Intrauterine devices. Network 16(2) (Winter 1996).
(Available online at www.fhi.org/en/fp/fppubs/network/v16-2/index.html)
This issue focuses on the safe provision of IUDs in family planning programs in developing countries. Key articles emphasize the importance of proper training (including current scientific knowledge, insertion practice, and counseling techniques), how IUDs work, and key precautions to minimize PID risk. A special counseling section presents short, practical answers to questions commonly asked about Copper IUDs and reviews the current WHO Eligibility Criteria for Use of Copper IUDs.

Farley, T.M.M. et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. The Lancet 339(8796):785-788 (March 28, 1992).
This article reviewed World Health Organization's IUD clinical trial data to explore the incidence and patterns of PID risk with use of an IUD. Twelve studies, involving nearly 2,300 IUD users—using a total of 10 different device types—from around the world were included. Overall, the rate of PID among IUD users was very low (1.6 case per 1,000 women-years of use). After adjusting for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times (9.7 per 1,000 women-years of use) and low and stable thereafter (1.4 cases per 1,000 women-years of use). After the 20 days following insertion, the risk of PID remained very low, even among users who had an IUD in place for eight years or more. These findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of STDs. Because of the increased risk with insertion, IUDs should be left in place up to their maximum life span, and not routinely replaced earlier, provided there are not medical reasons to discontinue use and the woman wishes to continue with the device.

Farr, G. et al. Non-physician insertion of IUDs: clinical outcomes among TCu380A insertions in three developing-country clinics. Advances in Contraception 14(1):44-57, (March 1998).
Demand for IUDs and IUD-related services affects family planning service delivery, especially in developing countries, where physicians are spending more time than ever before to evaluate IUD candidates and perform insertions. Insertion by trained non-physicians is increasing in several countries. This analysis looked at the experience of 367 IUD acceptors collected at clinics in Nigeria, Turkey, and Mexico. Physicians performed 193 insertions; non-physicians performed 174 insertions. Women having their IUD inserted by a non-physician were more likely to experience a pain-free insertion, but also were more likely to have the IUD removed for bleeding and pain, or to experience an expulsion, than were women who had the IUD inserted by a physician. Discontinuation rates were similar between the two groups. Trained non-physicians can probably insert the TCu380A safely and acceptably, but researchers stress the importance of competency-based training, especially in correct IUD placement, to reduce the number of expulsions.

Kishen, M. Gynefix. IPPF Medical Bulletin 32(1) (February 1998).
This article reports on experience with the newly approved Gynefix frameless IUD in a family planning clinic in the United Kingdom. Some 56% of the 210 Gynefix insertions were in nulliparous women; 25% of insertions were for postcoital contraception. The need for proper provider training for insertion is emphasized. The author suggests that despite the higher cost of the new Gynefix IUD (four times the cost of a Copper T 380 in the UK), it should be considered by nulliparous women who have experienced pain or spontaneous expulsion with a framed IUD.

Ladipo O.A. et al. Prevention of IUD-related pelvic infection: the efficacy of prophylactic doxycycline at IUD insertion. Advances in Contraception 7:43-54 (1991).
The risk of PID among IUD users is likely caused by bacterial contamination of the endometrial cavity at the time of IUD insertion. Previous research suggested that use of prophylactic antibiotics at the time of IUD insertion could reduce the risk of developing PID. In this randomized clinical trial of 1485 women in Ibadan, Nigeria, where the effectiveness of 200 mg of doxycycline (versus placebo) given orally at the time of IUD insertion was evaluated, the rate of PID infection in the doxycycline-treated group was not significantly lower than in the placebo group. Also, no significant differences in the rate of unscheduled IUD-related visits to clinic were found. Both groups experienced low incidence of PID-related complaints, however, indicating that this population was at lower risk of PID than originally thought. Careful screening of prospective IUD users and aseptic conditions during IUD insertion were thought to have reduced the risk of PID without the use of prophylactic antibiotics, and may be more cost-effective interventions than expensive prophylactic antibiotic therapy.

Luukkainen, T. and Toivonen, J. Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties. Contraception 52(5): 269-276 (November 1995).
This article reviews the performance, safety, and therapeutic use of the the levonorgestrel-releasing IUD. It states that the local release of levonorgestrel results in the strong suppression of endometrial growth, which in turn results in a significant reduction of menstrual blood loss or amenorrhea, and for the disappearance of dysmenorrhea. Although irregular spotting is common during the first two three months of use, blood loss and number of bleeding days per cycle are significantly reduced. The authors state that the levonorgestrel-releasing IUD is an effective and well-tolerated treatment for women with menorrhagia, and that it protects against ectopic pregnancy and pelvic inflammatory disease. In addition, the failure rate (0.0 to 0.2 per 100 women-years) is not dependent on the user's age.

PATH (Program for Appropriate Technology in Health). IUDs: Do new devices reduce bleeding and expulsion rates? Outlook 17(1) (April 1999). (Available online at www.path.org/outlook/html/17_1.htm#iud).
This article reviews three new, modern IUDs specifically designed to reduce the incidence of side effects most troublesome to users (especially young women) – bleeding, pain, and expulsion.  The results of three studies are used to compare the pregnancy, expulsion, and bleeding/pain rates of a Copper T IUD (the TCu380A) with two modified IUDs (the Cu-Safe 300 and the Cu-Fix). Data presented suggest that the modified devices provide comparable pregnancy protection to the Copper T and may provide an alternative for women who have experienced difficulty with other IUDs.

PATH (Program for Appropriate Technology in Health). IUDs: Safe and Effective for Many Women. Outlook 10(2) (September 1992).
This article summarizes presentations and discussions from an international conference held in March 1992 to evaluate the safety, effectiveness, and reversibility of modern IUDs. Key points are that modern devices (Copper T 380A and Multiload 375) are extremely effective and safe when clients are appropriately screened and high quality insertion procedures are used. Newer devices (levonorgestrel releasing IUD and frameless IUDs) are discussed. Safe and gentle insertion procedures for Copper T380A insertion are detailed.

Sinei, Samuel K, Charles S Morrison, et al. Complications of use of intrauterine devices among HIV-1-infected women. The Lancet 351 (April 25, 1998).
This article investigates whether women infected with HIV-1 have a higher risk of short-term complications with IUD use than women who are not infected with HIV-1. Complications including pelvic inflammatory disease and IUD expulsion are investigated. The study found low rates of overall and infection-related complications among HIV-1 infected women during the four months after insertion. The study concludes that although more information is needed, IUDs may be a safe contraceptive method for appropriately selected HIV-1-infected women with continuing access to medical services.

Van Os, W. and Edelman D. New Directions in IUCD Development. Advances in Contraception 14: 41-44 (March 1998).
This article reports on recent developments to improve IUDs through reducing expulsion and removal for complaints such as bleeding and pain. Special attention is placed on the GyneFix frameless IUD, which recently became available in Europe. This device and its predecessors (the Copper-Fix 390 and FlexiGard) have been studied since 1984. Results of a study of 1,039 GyneFix insertions by experienced practitioners are discussed. The cumulative 3-year rates per 100 women were 0.5 for pregnancy, 0.7 for expulsion, and 3.8 for removal for bleeding and or pain. No serious complications were reported. Confirmation of these early promising results is needed.

Wildemeersch, D. et al. GyneFIX. The frameless intrauterine contraceptive implant -- an update for interval, emergency and postabortal contraception. British Journal of Family Planning 24(4) (January 1999).
This article reviews the clinical experience with the GyneFix IUD for interval, emergency, and post-abortal contraception. The GyneFix IUD is a frameless IUD consisting of six copper sleeves threaded on a length of suture material. Research has found that this specific design minimizes the side-effects and discomfort commonly experienced with other conventional IUDs. The article reports that the pregnancy rate with GyneFix is lower than those of the most effective high-load copper devices currently used. Additionally, a properly inserted GyneFix implant is rarely expelled. The article concludes that due to its design and insertion requirements, GyneFix could assist in reducing the number of unintended pregnancies and induced abortions.

World Health Organization (WHO). Intrauterine Devices, Technical and Managerial Guidelines for Services. World Health Organization (1997). Cost: Sw.fr. 54--/US$48.60, in developing countries: Sw.fr. 37.80.
This 175-page book addressed primarily at managers of clinic-based services provides detailed guidelines for providing IUDs through family planning programs. The book provides information needed to update policies and practices, including counseling and screening of clients, infection prevention, and follow-up care. The newer copper-bearing IUDs, which have been shown in clinical and epidemiological studies to offer advantages in terms of safety, acceptability, and life span, are featured. Annexes provide additional guidance in procurement of IUDs and other supplies, calculation of contraceptive prevalence, insertion and removal procedures, and assessing client satisfaction.

World Health Organization (WHO). IUDs: What health workers need to know. Geneva: WHO (1997). Available on request.
This booklet is aimed at health workers and provides an overview of IUDs and the major points important to their safe provision. Topics covered include: IUDs and how they work, effectiveness and safety, client concerns, appropriate screening for IUD use, and basic elements of high quality services. Although IUDs are used by over 100 million women, many women still have questions about the method, particularly about safety. This booklet will help address those concerns.

Top of page

Male condoms

De Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. The New England School of Medicine, 331(6) (August 11, 1994).
This prospective multi-country European collaborative study evaluated HIV-negative subjects whose only risk of HIV infection was a stable heterosexual relationship with an HIV-infected partner. Every six months the couples were interviewed, tested for HIV, and counseled about safe sex practices. Couples were followed for up to 20 months. Of the 256 couples who continued to have vaginal or anal intercourse for at least three months after enrollment, only 124 used condoms consistently for vaginal and anal intercourse. Among these couples, none of the sero-negative partners became infected with HIV, despite a total of about 15,000 episodes of intercourse. Among the 121 couples who used condoms inconsistently, the rate of infection was 4.8 per 100 person-years (95 percent CI, 2.5-8.4). The authors conclude that consistent use of condoms for heterosexual intercourse is highly effective in preventing transmission of HIV.

Family Health International (FHI). The Latex Condom -- Recent Advances, Future Directions. Research Triangle Park: FHI. (1998).
This monograph summarizes information on various issues related to condoms, including latex condom manufacturing, quality assurance, performance in human use, acceptability and user behavior, and the interrelationships among these issues. Recent advances in condom design and technology are discussed, including development of several non-latex alternatives for men and women. This information will be particularly helpful for researchers, manufacturers, regulatory officials and public health officials, and anyone who helps to promote or provide condoms.

Lisken, L. et al. Condoms now more than ever. Population Reports H(8) (September 1990).
This publication provides an extensive review of condom use and effectiveness for pregnancy and disease prevention in both developed and developing countries. Reviews of studies concerning condom failure are described. Strategies for how to promote condoms more widely are discussed, and program examples are provided. A practical guide for how to counsel condom users also is provided. This issue of Population Reports is useful for policy makers, family planning and STD program managers, and public health officials interested in increase correct and consistent condom use.

PATH (Program for Appropriate Technology in Health). Condoms protect against STDs and HIV: correct and consistent use is key. Outlook 12(4) (December 1994).
This article discusses issues related to the protective effect that latex condoms have against sexually transmitted diseases, especially HIV. Concerns about condom effectiveness, such as permeability, breakage, and slippage, are discussed. The importance of ensuring condom quality and the importance of correct and consistent use for reducing STD risk are emphasized.

Richters, J. et al. Why do condoms break or slip off in use? An exploratory study. International Journal of STD and AIDS (6) (January/February 1995)
This study reports on condom experience in 108 men (age 18-62 years) attending three sexually transmitted disease clinics in Australia. The overall breakage rate was 4.9%, while 3.1% reported a condom slipping off their penis. On multivariate analysis, condom breakage was related to: (1) having a male sexual partner; (2) infrequent condom use, and (3) method of putting on a condom. Factors associated with slippage included: (1) young age, (2) being circumcised, and (3) having less lifetime experience with condoms. Few men used inappropriate lubricants and no association was found between lubricant type and breakage. Almost half the men reported deliberately removing a condom after the beginning of intercourse, nearly 20% had done so three times or more. Condom counseling protocols should be strengthened to reflect the real life user issues related to successful condom use.

Top of page

Hormonal contraception, IUDs, and HIV risk

Allen, S. et al. Human immunodeficiency virus infection in urban Rwanda: demographic and behavioral correlates in a representative sample of child-bearing women. Journal of the American Medical Association 266(12): 1657-1663 (1991).
This article presents the findings of a study which examined the incidence and predictors of HIV disease in prospective cohorts of HIV-1–infected and HIV-1–uninfected women in urban Rwanda. A cross-sectional analysis of the responses to questionnaires administered to 3,702 women aged 18 to 35 years was performed, and the relationships between three demographic predictors of HIV infection -- marital status, partner income, and duration of union -- were evaluated. Infection rates were higher in women who were single, among  women in steady relationships that began after 1981, and in 33% of the women reporting more than one lifetime sexual partner. Having a male partner who drank alcohol or who had a higher income were significant risk factors, but use of oral contraceptives and having an uncircumcised partner were not. The article concludes that, in Rwanda, the epidemic of AIDS has spread beyond the high-risk groups to the general populations of women without known risk factors. For most of the women studied, a steady male partner was the source of their HIV risk and therefore a key target for intervention efforts.

Costello Daly, C. et al. Contraceptive methods and the transmission of HIV: implications for family planning. Genitourinary Medicine 70:110-117 (1994).
This article reviews published evidence for associations between HIV and individual contraceptive methods including oral contraceptives (OCs), injectable hormonal contraceptives, IUDs, spermicidal preparations, and the female condom. The authors discuss the program and policy implications of associations between specific contraceptive methods and HIV transmission. They also state that many unanswered questions remain, and that additional studies are needed to determine whether there is an association between individual contraceptive methods and HIV infection. The article recommends that large-scale studies involving low-risk women using contraceptives for extended periods be conducted to evaluate the impact of contraceptive use among the majority of users. The possibility of behavioral differentials between users of different contraceptives should be carefully evaluated. The study notes that additional research about the sites of virus entry, infectivity, and local defense mechanisms in the female genital track also is needed. Given that contraceptive use is being promoted worldwide (including areas where HIV incidence is increasing), additional knowledge about the effect of individual contraceptives on HIV transmission is needed.

Martin, H.L. et al. Hormonal contraception, sexually transmitted diseases, and the risk of heterosexual transmission of human immunodeficiency virus type 1. The Journal of Infectious Diseases 178:1053-1059 (1998).
This study examines the associations between methods of contraception, sexually transmitted diseases (STDs), and incidence of HIV-1 infection among female sex workers attending a municipal STD clinic in Mombasa, Kenya. Data presented include demographic and behavioral characteristics, prevalence and incidence of STDs and other genital tract conditions, and univariate associations between demographic characteristics and sexual behavior during follow-up and HIV-1 seroconversion. The study reports that demographic and behavioral factors significantly associated with HIV-1 infection include type of workplace (such as a bar or dance club), condom use, and parity. In multivariate models, vulvitis, genital ulcer disease, vaginal discharge, and Candida vaginitis were significantly associated with HIV-1 seroconversion. Women using depo medroxyprogesterone acetate (Depo, "the shot") were found to have an increased incidence of HIV-1 infection, and the article explores several possible reasons for this.

Mati, J.K.G. et al. Contraceptive use and the risk of HIV infection in Nairobi, Kenya. International Journal of Gynecology and Obstetrics 48:61-67 (1995).
Sexual exposure to HIV is a major determinant of a woman's risk of HIV infection. However, factors such as sexually transmitted disease have been shown to alter the probability of infection after exposure. The objective of this study was to determine the prevalence of HIV-1 infection among women attending family planning clinics in Nairobi, and the association between contraceptive use and HIV infections. Data for the study were collected through the use of history, clinical examinations, and laboratory tests for 4,404 women. Use of oral contraceptives (OCs), injectables, IUDs, and condoms were measured. The study found no significant association between past or current OC use and risk of HIV infection, suggesting that any independent association between OC use and HIV risk is not large. Prevalence of HIV was slightly elevated among women who had used OCs the longest (more than two years). However, the dose-response relationship was nonlinear and non-significant. The study also did not find a significant association between the use of injectables or IUDs and HIV. In spite of the high level of HIV/AIDS awareness in this population, the study found that condom use was low.

Mostad, S.B. et al. Hormonal Contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. The Lancet 350(9082): 922-927 (September 27, 1997).
This article investigates whether use of hormonal contraceptive (oral contraceptives and injectables), vitamin A deficiency, or other variables such as certain sexually transmitted diseases and immunosuppression were risk factors for cervical and vaginal shedding of HIV-infected cells. The study documents and presents data illustrating several positive correlates of HIV-1 shedding in cervical and vaginal secretions, most notably in women using hormonal contraceptives or with vitamin A deficiency. The article concludes that these factors may be important determinants of sexual or vertical transmission of HIV-1, and that they are important to public health because they are easily modified by simple interventions.

PATH (Program for Appropriate Technology in Health). Hormonal contraception, IUDs, and HIV risk. Outlook 17(1) (April 1999). (Available online at www.path.org/outlook/html/17_1.htm#featureHormonal).
This article summarizes several studies that have investigated whether hormonal contraceptives and IUDs increase a woman's risk of HIV infection. Some of the studies suggest that oral contraceptives and injectables, which contain high levels of progestins, may increase a woman's risk of HIV by promoting certain physiological changes. Other studies found no association or were inconclusive due to various statistical or methodological concerns. IUDs may be a concern because of their tendency to increase menstrual bleeding and upper genital tract infections, which may put users at higher risk of HIV transmission. Program implications also are discussed.

Plummer, F.A. et al. Cofactors in male-female sexual transmission of human immunodeficiency virus type 1. The Journal of Infectious Diseases 163:233-239 (February 1991).
Facilitation of HIV-1 transmission by concomitant STDs, frequent heterosexual intercourse, and injections in STD clinics have all been postulated as explanations for the heterosexual epidemic of HIV-1 in Africa. The study examined demographic variables, contraceptive use, STDs, and sexual practices as possible factors causing seroconversion to HIV-1 in a group of African prostitutes. Statistical analyses performed by the author confirm independent associations between HIV-1 infection and oral contraceptive use, condom use, genital ulcers, and C. trachomatis, thus concluding that, with the exception of condoms, all three factors appear to facilitate HIV-1 transmission. The study hypothesizes and discusses several potential mechanisms by which oral contraception could facilitate HIV-1 acquisition, either by direct effect on the genital tract or through systemic effect. The article concludes by arguing strongly for the inclusion of STD control in AIDS control programs.

Top of page

Copyright 1997-2000, PATH.

Home | About RHO | Topic Areas | RH Resources | Search | Contact