The Training Resource Package for Family Planning
IUDs Module
Copper-Bearing Intrauterine Devices (IUDs):
Facilitator’s Guide to the Training Resource Package
Table of Contents
I. What is the Training Resource Package for IUDs? ..............................................................4
II. What is the Purpose of the Training Resource Package for IUDs? ....................................4
III. Who Can Use the Training Resource Package for IUDs? ...................................................4
IV. Using the Training Resource Package IUDs Module to Develop Training........................4
V. Using the Training Resource Package for Pre-Service Training ........................................9
VI. Overview of the Design of the Technical Resource Package Module for IUDs
(see Diagram, next page) .................................................................................................................9
a. The Learning Objectives ........................................................................................................9
b. Illustrative Module Session Plan with Illustrative Training Schedule.................................10
c. Facilitator’s Guide ................................................................................................................11
d. Presentation (PowerPoint slides) .........................................................................................11
e. Handouts ..............................................................................................................................12
f. Evaluation Tools ...................................................................................................................12
g. References ............................................................................................................................14
VII. Clinical Practicum ...............................................................................................................18
a. Selecting a Clinical Training Site ........................................................................................18
b. Steps in Developing a Clinical Training Site .......................................................................18
c. Selecting a Clinical Trainer ..................................................................................................19
d. Clinical Procedure Skills Training .......................................................................................19
e. How Much Clinical Practice is Needed for Certification?...................................................21
f. What is the Proper Length of Clinical Training and Ration of Trainers to Trainees? .........21
g. Steps for Guiding a Clinic-Based Practicum .......................................................................21
h. Training Follow-up ..............................................................................................................22
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Appendices
Appendix A: Adult Learning ...................................................................................................24
Appendix B: Using Case Studies .............................................................................................28
Appendix C: Facilitating Role Plays........................................................................................30
Appendix D: Illustrative Training Schedule ...........................................................................36
Appendix E: Demonstration and Return Demonstration .........................................................40
Appendix F: Illustrative Competency-based Skills Checklist for IUD Counseling
and Clinical Skills ....................................................................................................................41
Appendix G: Illustrative Competency-based Skills Checklist for Infection
Prevention Related to IUD Insertion or Removal ....................................................................52
Appendix H: The Copper-Bearing IUDs (IUDs): Answer Keys for Preand Post-Test and Applied Learning Case Studies ..................................................................57
Appendix I: Sample Course Evaluation ...................................................................................60
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Illustrative IUDs Module Diagram
*The technical information for these materials is based on the Family Planning: A Global Handbook for Providers
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Intrauterine Devices (IUDs):
Facilitator’s Guide to the Training Resource Package
I. What is the Training Resource Package for Combined Oral Contraceptives?
This Facilitator’s Guide will help you make effective use of The Training Resource Package
(TRP) for Intrauterine Devices (IUDs). The TRP for IUDs is part of a global resource package
for trainers, supervisors, and program managers. It contains high quality user-friendly materials
and resources for designing, conducting and evaluating training for family planning (FP)
providers. The resource package is specifically designed for mid-level providers but also
contains more advanced materials for physicians and can be adapted for use with lower-level
community health workers.
II. What is the Purpose of the Training Resource Package for IUDs?
This training manual was developed for use in training physicians, nurses, and midwives. It is
designed to actively involve the trainees in the learning process. Sessions include PowerPoint
presentations, simulation skills practice in the form of role plays, discussions, case studies,
practice on an anatomical model, and clinical practice using objective competency-based skills
checklists.
At the end of this module, the trainee will be able to describe IUDs as an effective FP method,
counsel and screen clients seeking IUDs, respond to rumors and misconceptions about IUDs,
provide services for IUD clients, recognize and manage common side effects and complications,
and provide follow up care for IUD acceptors.
III. Who can use the Training Resource Package for IUDs?
The training materials are designed to be used by clinical trainers and pre-service educators with
a thorough understanding of adult learning principles and the ability to provide clinical training
on FP topics in pre-service or in-service settings.
IV. Using the Training Resource Package IUDs Module to Develop Training
All of the parts needed to develop a curriculum for IUDs are included in the TRP for IUDs. The
diagram following the Table of Contents shows how the different elements of the TRP fit
together. They are there to be adapted to fit the circumstances in the country where they will be
used, the trainers who will be conducting training, and the level of expertise and skills of the
trainees. The TRP can be adapted to fit any kind of training. The module can be used as a standalone module or as part of a comprehensive course in family planning. If the training TRP is
used as part of a comprehensive course you may want to reduce the time allocated for each
individual by eliminating some activities, such as the counseling role plays of contraceptive
effectiveness. Doing the role play once will be sufficient. The TRP can be used as a resource for
refresher training or for training new providers. The following six steps can be used as to
develop effective training using the TRP materials.
Step 1: Assess Training Needs
Before devoting time and resources to developing a training program, verify that a lack of skills
and knowledge is a primary cause of the performance problem or challenge that you are facing.
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A training program can address only knowledge and skills deficits; it does not address any of the
other factors that influence workers’ performance. Engage stakeholders in the assessment of the
performance challenge. If a knowledge and skills deficit is identified, also ensure that the factors
workers need to transfer new knowledge and skills to the job are in place (or will be in place at
the completion of training). Engaging stakeholders and ensuring support for improved
performance are often overlooked but critical components of a training program.
Creating a shared vision, identifying challenges and opportunities, and planning actions as a
team are key strategies for improving workplace practices using a systems approach. A Training
Needs Assessment (TNA) identifies gaps between how health workers are currently performing
(the actual performance) and how you would like them to perform (the desired performance).
Root causes of identified gaps can be linked directly to the absence of one of the five key
performance factors:
1. Clear job expectations;
2. Clear and immediate performance feedback;
3. Adequate physical environment, including proper tools, supplies, and workspace;
4. Motivation and incentives to perform as expected; and
5. Skills and knowledge required for the job.
A training course can address only the fifth key performance factor. A clear TNA can assist
trainers and health care administrators to decide if a training intervention is appropriate to
address an identified gap. There are several reasons for conducting a TNA:

To determine whether training is really needed;

To determine causes of poor performance;

To determine content and scope of a training;

To determine desired training outcome;

To provide a baseline for measurement; and

To gain management support.
A TNA aims to identify providers’ gaps in Knowledge, Attitudes and Skills (KAS) between the
present performance and the desired performance. A discrepancy between what exists and what
is needed is often stated in terms of what is necessary to perform a job or series of tasks.
The baseline/criteria often used to identify the desired performance are:

Job descriptions, and

National standards and guidelines.
It may also be necessary to interview other stakeholders, like managers or supervisors, to
determine desired performance.
The KAS standards proposed need to be so specific and clear that they are observable and
measurable.
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Once the KAS standards are determined, a TNA is conducted to identify providers’ gaps in KAS
Step 2: Review national standards and guidelines
The goal of training is to improve Knowledge, Attitudes and Skills (KAS) to meet the needs for
health care provision. Thus, clinical training should be based on the country’s clinical standards
and guidelines. Linking the training to the national standards and guidelines is important in:

Making the training relevant to the current clinical situation;

Making the training consistent with the national standards and guidelines;

Providing a basis, or standard, for training evaluation and follow up; and

Providing a basis for choosing and strengthening a site for clinical practicum.
Step 3: Determine the Knowledge, Attitude and Skills (KAS) needed to provide IUDs
Before turning to the TRP, determine the KAS necessary on the part of the provider. It may also
be necessary to interview other stakeholders, like managers or supervisors, to determine desired
performance. The KAS standards proposed need to be so specific and clear that they are
observable and measurable. Once the KAS standards are determined, a TNA is conducted to
identify providers’ gaps in KAS. Keep in mind that the KAS needed for a physician may not be
the same KAS needed for a nurse, midwife or CHW.
What is KAS?

Knowledge, which consists of the information and understanding necessary to perform a
job or task;

Skills, which consist of the practical, hands-on activities necessary to perform the job or
task; and

Attitudes, which consist of the opinions and beliefs associated with performing a job or
task.
Step 4: Write your training goal and learning objectives and assess learners
To develop an effective training program, follow the steps of the instructional design process,
including writing a training goal based on a performance needs assessment, defining job tasks and
the skills and knowledge required to do the tasks, determining who should participate in the training,
assessing the learners’ instructional needs, writing learning objectives, and determining how to
evaluate learning.
When assessing learners and their work environment, be sure to:

Identify local policies, service delivery guidelines, and record-keeping practices related to
your training goal and objectives so you may adapt content accordingly (i.e., the
maximum number of pill packs that health workers may distribute to new or continuing
clients).

Identify job aids and resources that trainees use or will be using at their work sites so that
you can obtain and distribute these during the training and include them in training
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presentations and activities (i.e., screening checklists, client brochures, record-keeping
forms).

Collect local myths or misconceptions related to the training topic so you can prepare to
respond to them and use them as examples.
Step 5: Identify pieces of the IUDs TRP module related to your learning objectives

Look in the Diagram of the Pieces of the TRP (found immediately after the table of contents
in this document) and their contents pertaining to your training goal, objectives, and intended
trainees.

Review the learning objectives for the TRP for IUDs.

Select the pieces of the IUD TRP that address your learning objectives.
Step 6: Review and adapt IUDs TRP materials

Go to the appropriate section of the website to review the session plans, presentations,
role plays, and other activities.

Ensure that you are utilizing the principles of Adult Learning found in Appendix A.

The session plan and the primary presentation are the key documents of the IUDs
module. Review the session plan and the PowerPoint Presentation.

Based on the level of your trainees, decide which slides and activities address your
learning objectives. If your trainees are nurses, midwives or lower level health workers,
use the basic presentation. Consider eliminating the more technical slides on medical
eligibility for lower level health workers. If your trainees are physicians, consider adding
the advanced slides in the appropriate places. If you are using the materials for refresher
training, you may want to select slides that have new information, such as the WHO
Medical Eligibility slides. Download the materials you want to use and adapt the
presentations and other module materials as appropriate. Revise slides as needed.

Use only the content directly related to the learning objectives; including extraneous
information in training reduces learning.

Create a new session plan or combine sections of different session plans as needed to
coordinate the pieces of your curriculum.

Combine the slides you copied into a new set, and revise details of role play scenarios to
match your trainees’ culture. Cut and paste portions of the modules’ session plans to
create a new session plan for your training, ensuring an appropriate mix of activities that
taps into trainees’ experience, keeps trainees engaged, and presents new knowledge and
skills in a logical order.
Step 7: Create a training schedule
Modify the Illustrative Training Schedule (found in Appendix D) that indicates starting and ending
times of activities, breaks, and meals. Select and include additional activities such as:
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
Welcoming the trainees and establishing a climate for learning

Providing introductions

Setting ground rules with input from the trainees

Describing the general structure of the training

Reviewing the agenda and plans for the day

Gathering feedback on what worked and what needs improvement

Ice-breakers and energizers, warm-up and wrap-up activities

Homework assignments
IUDs Module
Links to a collection of warm-ups and wrap-ups are available here.

Create a schedule based on the time needed for each training session, taking into account
the learning objectives addressed, the activities that will be conducted, the time needed
for role play practice, and the prior knowledge and skills of trainees.

Choose ice-breakers, energizers, warm-ups, and wrap-ups that complement the activities
selected to accomplish the learning objectives.
Step 8: Gather needed materials and prepare for training

Obtain and copy the counseling tools, screening checklists, and other job aids that
trainees will be using.

Obtain IUD insertion and removal equipment, anatomical models (both hand held and
larger pelvic models) and supplies needed: a computer projector for displaying the
presentation, flip charts, markers and pens, etc.

Thoroughly review the content, making sure it is clear, until you feel comfortable
presenting information and giving instructions for group activities.
Step 9: Pre-Test the Curriculum

Hold a trainers’ workshop to finalize the curriculum, including; objectives, content,
module/ material, training site, materials or aids.

Work closely with the trainees, their supervisors, clinical trainers, and others to ensure
that the logistics of the training pre-test event are well organized.

As a training is piloted, a secretary should keep good notes of the training times, content,
methodologies, time management, and feedback from participants. The trainer should
record all learning activities, exercises, or content that need to be changed, as well as
reactions from trainees.

As part of evaluating the training, tests are given to trainees to evaluate their progress
after certain training topics. Feedback on content, methodology, handouts, time allocation
and training site, materials, and training aids from trainees are collected.
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
IUDs Module
After the pilot test is conducted and evaluated, trainers should meet to revise the
curriculum. Changes should be made to the training curriculum to address problem areas
(methodology, materials, pre- and post-course tests).
V. Using the TRP for Pre-service Training
Teachers and curriculum developers may use TRP resources for developing a new course or to
create teaching materials for an existing pre-service curriculum. While many of the activities
involved in developing in-service training also apply to pre-service curricula, (for example, task
analysis of job responsibilities, defining prerequisite skills and knowledge), developing preservice curricula involves a distinctive set of coordinated activities. Describing how to use the
TRP in this process would require more extensive instructions than this guide can currently
provide. (Detailed advice on using the TRP for pre-service education will be included in a future
revision of this guide).
VI. Overview of the Design of the TRP module for IUDs
Like all of the modules in the TRP, the IUD Module is a complete package of learning resources
needed to address the learning objectives of the module, including a session plan, PowerPoint
presentations, and accompanying activities and resources. The module is designed for generic
groups of health workers. The IUD module materials should be tailored and adapted according to
the education and training background and learning needs of the identified trainees.
The module is designed for the providers in developing countries who most often are tasked with
providing FP services—primarily nurses and nurse-midwives, as well as primary care
physicians—and assume trainees will have at minimum a nurse’s level of clinical training.
In order to understand the design of all of the modules, it is helpful to see the diagram on page two.
The basic design includes the following:
a. The Learning Objectives
By the end of the training, trainees should be able to:
1. List the key messages about IUDs
2. Describe the characteristics of IUDs in a manner that clients can understand, including:
a.
b.
c.
d.
e.
f.
What IUDs are and how they work (mechanism of action)
Effectiveness
Side effects
Non-contraceptive health benefits
Other characteristics (STI/HIV protection, ease of use, return to fertility)
Possible health risks (complications)
3. Demonstrate the ability to:
a.
b.
c.
d.
e.
Screen clients for medical eligibility for IUD use
Explain to clients how IUDs are inserted and removed
Explain when to return to the clinic
Address common concerns, misconceptions, and myths
Conduct follow-up for IUD clients in a way that enhances continuing safety,
satisfaction, and acceptance
4. Describe when to initiate IUDs (postpartum, switching from another method)
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5. Explain how to manage side effects
6. Identify new conditions that may require a client to switch to another method or to
temporarily stop IUD use
7. Identify clients in need of referral for IUD-related complications
b. Illustrative Module Session Plan with Illustrative Training Schedule
The session plan summarizes how the resources and documents in the module should be
used to achieve the learning objectives. Each section of the session plan addresses a
module topic, such as characteristics of the method or medical eligibility, and is linked to
one or more slides in the primary presentation. All the module materials and resources
are listed on the first few pages of each session plan, with links to the module files. The
IUDs Module is divided into four sessions:

Session I is on the characteristics of IUDs and includes key points for providers and
clients, effectiveness, mechanism of action, health benefits of IUDs and side effects.

Session II contains information on who can and who cannot use IUDs, medical
eligibility for the use of IUDs, and information on screening for contraceptive use.

Session III is on providing IUDs. It includes information on when women can start
using an IUD, how an IUD is inserted and removed, counseling IUD users, correcting
rumors and misconceptions, follow up visits, management of side effects, warning
signs of complications, and problems that may require stopping use of an IUD or
switching to another method.

Session IV is on providing instructions on how to insert and remove a copper-bearing
IUD and for preventing infection during insertion and removal. Participants practice
inserting and removing the IUD on anatomical models.
The Illustrative Training Schedule provides a snapshot of the breakdown of the module
by day, time, and topic covered. For example:
Time
Topic
DAY 1
Method
Resources
8:00-8:15
Welcome and Introduction
Discussion
Basic Slide Set: Session I, Slide 2
8:15-8:45
Pre-test
Test
Evaluation Tool: The Copper-Bearing
Intrauterine Devices (IUDs) Pre-Test
Time
8:00-10:00
Topic
DAY 2
Method
Resources
Session III, continued
Role Plays
Handouts #9-11
Case Studies
Handouts #12-13
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c. Facilitator’s Guide
The Facilitator’s Guide is this guide and contains information on the module design, a
description of the materials, learning objectives, how to conduct role plays, pre- and posttest answer key, and case studies, and how to conduct clinical training.
The IUD module includes a set of role play scenarios that enable trainees to practice
using the knowledge and skills they are learning. Each role play describes a typical client
scenario and the tasks specific to that scenario. In addition, Facilitating Role Plays in
Appendix C includes instructions for setting up and facilitating role plays, role play
observation checklists, and general instructions for the observer, provider, and client roles.
In addition to role plays, the module also includes two case studies with progressive case
descriptions, questions, and answer keys that enable trainees to analyze a situation and
think through how to apply their newly learned technical information. See Using Case
Studies in Appendix B for instructions.
d. Presentation (PowerPoint slides)
The PowerPoint presentation includes technical information on IUDs. There are three
types of slides:
Slides conveying most of the technical information are pale blue/green:
.
Pale blue/green slides with a pink header are primarily pictorial slides. Many of them come
from WHO’s Decision-Making Tool for Family Planning Clients and Providers. They are
useful for all trainees, but are especially useful for trainees of low-literacy.
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The pale blue advanced slides present research that supports the recommendations in the
Global Handbook and the Training Resource Package and can be included or excluded by
the facilitator as appropriate. They are especially appropriate for physicians who may desire
additional information from supporting research studies.
e. Handouts
Job aids
The IUDs Module includes job aids that describe how and when to perform important
provider tasks—for example, screening checklists and job aids for explaining method
effectiveness. Learning activities in the modules give trainees opportunities to practice
using these job aids so they can more easily incorporate use of these tools at the
workplace.
Counseling tools
The TRP for IUDs activities can be used with a variety of counseling approaches and job
aids. The term counseling tool in TRP materials refers to the counseling tool or job aid
that trainees will be using. Examples include WHO’s Decision-Making Tool for Family
Planning Clients and Providers, Balanced Counseling Strategy counseling cards, a REDI
tool, or other approaches and tools. Facilitators should incorporate activities that enable
trainees to use the counseling tool or job aids that they use at work (or will use after the
learning intervention).
Games and activities
Most modules contain review games that are enjoyable ways for trainees to review
module content. In addition to games, role plays, and case studies, TRP modules also
contain other small or large-group activities that keep trainees engaged and enable them
to apply new knowledge and skills.
f. Evaluation Tools
The TRP for IUDs contains several options for evaluating trainees including pre- and
post-tests which contain objective questions, with instructions for scoring the tests. The
module also contains competency-based skills checklists and an optional review games
and instructions for evaluating role plays and case studies.
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Pre- and Post-tests
The pre-test knowledge evaluation should be given at the beginning of the course and
again at the end of the course (post-test). The trainee’s pre- and post-test scores should be
compared to measure changes in knowledge. The pre-test contains the same test items as
the post-test. The pre- and post-tests are objective and comprised of true/false and
multiple choice questions. Instructions are given on how to score the tests. There are also
two case studies included with the post-test. Grade the case studies separately. The case
studies are a good way to determine whether trainees are able to apply the knowledge
they have gained.
Competency-based Skills Checklists
Trainers may observe trainees practicing and applying skills, tools, and techniques during
the session. This can be done through, direct observation of clinical skills, role plays,
simulations, or case studies.
A competency-based checklist is developed by breaking down the clinical skill or activity
to be taught into its essential steps. Each step is then analyzed to determine the most
efficient and safe way to perform and learn it. These checklists make learning the
necessary steps or tasks easier and evaluating the learner’s performance more objective.
In addition to using checklists to learn a skill, trainees and trainers keep track of progress
in the clinical area by using checklists. The checklists contain enough detail to permit the
trainer to evaluate and record the overall performance of the skill or activity.
Using checklists in competency-based clinical training:

Ensures that trainees have mastered the clinical skills and activities, first with
models and then with clients;

Ensures that all trainees will have their skills measured according to the same
standard; and

Forms the basis for follow-up observations and evaluations.
Criteria for satisfactory performance by the trainees are based on the knowledge,
attitudes, and skills demonstrated and practiced during training. In preparing for formal
evaluation by the trainer, trainees can familiarize themselves with the content of the
checklist by critiquing each other’s skills.
When evaluating the performance of a trainee, the trainer will judge each step of the skill
to be:
1 = Needs Improvement: Step or task not performed correctly or out of sequence (if
necessary) or is omitted
2 = Competently Performed: Step or task performed correctly in proper sequence (if
necessary) but participant does not progress from step to step efficiently
3 = Proficiently Performed: Step or task efficiently and precisely performed in the
proper sequence (if necessary)
Not observed: Step, task, or skill not performed by the trainee during evaluation by
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the trainer.
An Illustrative Competency-based Skills Checklist for IUD Counseling
and Clinical Skills can be found in Appendix F and an Illustrative Competency-based
Skills Checklist for Infection Prevention Related to IUD Insertion or Removal can be
found in Appendix G.
Course Evaluations
The course evaluation is an important first step in determining the success of a training
program. Trainees reactions help determine the effectiveness of a program and how it can
be improved.
The Course Evaluation can’t measure the ability to apply the learning, changes in
attitudes or beliefs, organizational impact, or the trainer’s technical knowledge. A Sample
Course Evaluation can be found in Appendix I.
Rapid evaluations can be done quickly determine trainee’s reactions to the day’s session.
Ask the following:
1. How valuable was today’s session for you using a 5-point scale?
2. What are the most important things you learned today?
3. How do you plan to apply those ideas to your job?
I f you choose not to use the course evaluation form a quick alternative at the end of
training (or during) is to put up two flip charts. On one flip chart write, “Here are some
things we found especially useful in the training.” On the other write, “Here are some
suggestions for how the training could be even better.” Make sure the trainer leaves the
room while the trainees are writing.
Review Exercises and Games
An interesting way to measure what trainees have learned is through the use of review
exercises and games. One of these can be found under the evaluation tools section of the
website.
g. References
The main references for the IUDs module as well as for other modules of the TRP are the
World Health Organization’s four cornerstones of family planning guidance:
1. Family Planning: A Global Handbook for Providers (2011 update).This book serves
as a quick-reference resource for all level of health care workers. It provides practical
guidance on delivering family planning methods appropriately and effectively.
2. The Medical Eligibility Criteria for Contraceptive Use (4th edition 2010. This
resource provides guidance on whether people with certain medical conditions can
safely and effectively use specific contraceptive methods.
3. Decision Making Tools for Family Planning Clients and Providers
4. The Selected Practice Recommendations for Contraceptive Use (2nd Edition 2005)
and the Selected Practice Recommendations for Contraceptive Use: 2008 Update.
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Other resources related to IUDs:
 Knowledge for Health, IUD Toolkit
http://www.k4health.org/toolkits/iud

New Attention to the IUD: Expanding Women’s Contraceptive Options
http://www.populationreports.org/b7/

IUD Guidelines for Family Planning Service Programs: A Problem-Solving Reference
Manual (Jhpiego, 2006.)
http://www.k4health.org/toolkits/iud/iud-guidelines-family-planning-serviceprograms-problem-solving-reference-manual
 Intrauterine Devices (IUDs), Second Edition (Pathfinder International, 2008.)
Trainer’s Guide: http://www.k4health.org/toolkits/iud/intrauterine-devices-iudssecond-edition-trainers-guide
Participant’s Guide: http://www.k4health.org/toolkits/iud/intrauterine-devices-iudssecond-edition-participants-guide
 Global Postpartum Intrauterine Contraceptive Device (PPIUCD) Learning Resource
Package (LRP) (Jhpiego/ACCESS FP, 2010. Includes reference manual, trainers guide
and learners guide.)
http://www.k4health.org/toolkits/ppfp/postpartum-intrauterine-contraceptive-deviceppiud-services
 The Postpartum Intrauterine Device: A Training Course for Service Providers,
Trainer’s Manual (EngenderHealth/The ACQUIRE Project, 2008)
http://www.engenderhealth.org/files/pubs/acquire-digitalarchive/10.0_training_curricula_and_materials/10.2_resources/
PPIUD_TM_complete_updated.pdf
 TCu380A Intrauterine Contraceptive Device (IUD): Specification, Prequalification
and Guidelines for Procurement, 2010
Can be obtained from WHO Press (tel.: +41 22 791 3264; fax: +41 22 791 4857;
email: bookorders@who.int).
Selected research articles for use by facilitators as needed:
Anteby E, Revel A, Ben-Chetrit A, et al. Intrauterine device failure: relation to its location
within the uterine cavity. Obstet Gynecol 1993;81(1):112-114
Bluestone J, Chase R, Lu ER. IUD Guidelines for Family Planning Service Programs: A
Problem-Solving Reference Manual. Baltimore, MD: Jhpiego, 2006.
Browne H, Manipalviratn S, Armstrong A. Using an intrauterine device in
immunocompromised women. Obstet Gynecol 2008;112:667–9.
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Chi IC, Wilkens L, Rogers S. Expulsions in immediate postpartum insertion of Lippes Loop
D and copper T IUDs and their counterpart delta devices: An epidemiological analysis.
Contraception, 1985; 32(2):119-134
DeMaeyer EM, Dallman P, Gurney JM, et al. Preventing and Controlling Iron Deficiency
Anaemia through Primary Health Care. A Guide for Health Administrators and Programme
Managers. Geneva: World Health Organization, 1989.
Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review.
Contraception. 2009 Jun;79(6):418-23.
Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory
disease: an international perspective. Lancet. 1992 Mar 28;339(8796):785-788.
Farr G, Amatya R. Contraceptive efficacy of the copper T380A and the multiload Cu250
IUD in three developing countries. Adv Contracept 1994;10:137-49.
Grimes D, Lopez LM, Schulz K, et al. Immediate post-partum insertion of intrauterine
devices. Cochrane Database Syst Rev. 2010 May 12;(5):CD003036.
Hubacher, D. et al. Use of copper intrauterine devices and the risk of tubal infertility among
nulligravid women. New England Journal of Medicine 2001;345(8):561-567.
Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects.
Contraception 2007;75: S8–S11.
Heikinheimo O, Lahteenmaki P. Contraception and HIV infection in women. Hum Reprod
Update. 2009 Mar-Apr;15(2):165-76.
Hubacher, D. et al. Use of copper intrauterine devices and the risk of tubal infertility among
nulligravad women. New England Journal of Medicine 2001;345(8):561-567.
Kulier R, Helmerhorst FM, O'Brien P, et al. Copper containing, framed intra-uterine devices
for contraception. Cochrane Database Syst Rev 2006;3:CD005347.
Larsson C, Milsom I, Jonasson K, et al. The long-term effects of copper surface area on
menstrual blood loss and iron status in women fitted with an IUD. Contraception
1993;48(5):471-80.
Morrison CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate
contraception for HIV-1-infected women? Br J Obstet Gynaecol 2001;108(8):784-90.
Mueller MP, Lasway C, Yacobson I, Tumlinson K. Training and Reference Guide for a
Screening Checklist to Initiate Use of the Copper IUD. Research Triangle Park, NC: Family
Health International, 2008.
O’Hanley K, Huber DH. Postpartum IUDs: keys for success. Contraception 1992;45(4):35161.
Ortiz ME, Croxatto HB. Copper-T intrauterine device and levonorgestrel intrauterine system:
biological bases of their mechanism of action. Cotraception 2007 Jun;75(6 Suppl):S16-30.
Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of intrauterine device on
cervical shedding of HIV-1 DNA. AIDS 1999;13(15):2091-97.
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Salem R. New Attention to the IUD: Expanding Women’s Contraceptive Options To Meet
Their Needs. Population Reports, Series B, No. 7. Baltimore: Johns Hopkins Bloomberg
School of Public Health, Center for Communications Programs, The INFO Project, 2006.
Available: http://www.k4health.org/pr/b7/index.shtml
Shelton J. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device.
Lancet 2001;357(9253):443.
Sivin I. Alternative estimates of ectopic pregnancy risks during contraception. Am J Obstet
Gynecol. 1991;165(6 Pt 1):1900.
Sivin I. Dose and age dependent ectopic pregnancy risks with intrauterine contraception.
Obstet Gynecol, 1991;78(2):291-8.
Sivin I, Greenslade F, Schmidt F, et al. The Copper T 380 Intrauterine Device: A Summary of
Scientific Data. New York: The Population Council, 1992.
Solter C. Intrauterine Devices (IUDs): Participant’s Manual. Watertown, MA: Pathfinder
International, 2008.
Stanback J , Shelton JD. Pelvic inflammatory disease attributable to the IUD: modeling risk
in West Africa. Contraception 2008;77(4):227–9.
Stringer EM, Kaseba C, Levy J, et al. A randomized trial of the intrauterine contraceptive
device vs. hormonal contraception in women who are infected with the human
immunodeficiency virus. Am J Ob Gyn August 2007; 197(2): 144: e2 – e8.
TCu380A Intrauterine Contraceptive Device (IUD): Specification, Prequalification and
Guidelines for Procurement, 2010. Geneva: WHO, UNFPA, and FHI, 2011.
Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397-404.
United Nations (UN). World Contraceptive Use 2010. New York: UN, Department of
Economic and Social Affairs, Population Division, 2010.
Wesson J, Gmach R, Gazi R, et al. Provider views on the acceptability of an IUD checklist
screening tool. Contraception 2006;74(5):382-8.
World Health Organization (WHO). Mechanism of action, safety and efficacy of intrauterine
devices. Report of a WHO Scientific Group. Geneva: WHO, 1987.
WHO Special Programme of Research Development and Research Training in Human
Reproduction. Long-term reversible contraception: twelve years of experience with the
TCu380A and TCu220C. Contraception 1997;56(6):341-52.
Zhang J, Feldblum P, Chi, IC, et al. Risk factors for Copper T IUD expulsion: an
epidemiological analysis. Contraception 1992;46(5):427-33.
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VII.
IUDs Module
Clinical Practicum
a. Selecting a Clinical Training Site
The success of a competency-based training program depends upon having a site where
trainees are exposed to adequate numbers of cases and are practicing in a supportive
environment that reinforces standards taught in the training program.
Clinical sites should be selected based on the following criteria:

Patient mix and volume;

Equipment, supplies, and drugs;

Available physical facility

Staff (number of staff, skills needed);

Transportation accessibility; and

Other training activities. (If there are other trainings going on, predict possible obstacles/
barriers. What are possible solutions?).
b. Steps in Developing a Clinical Training Site
1. Discuss the process that will be needed to prepare the site for a clinic practicum with
the clinic staff.
2. Select an appropriate team to make the site assessment.
3. The purpose of the assessment will be to determine what needs to be done to prepare
the site for a clinical practicum.
4. Brief the assessment team on what you plan to do.
5. Discuss the steps in the performance analysis.
6. Decide what you will need at the facility to make it a practicum site.
 Patient mix and volume

Equipment, supplies, and drugs

Supportive staff

Protocols and correct procedures

Transportation

Clinical supervisors
7. Conduct an analysis of the current situation in the facility.

Site assessment–what is currently available?

Look at existing performance data and review records.

Use inventory checklists.

Use observation checklists to observe procedures and staff performance.
8. Define the gap between the current situation at the facility and what is needed to
make it a good practicum site.
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
Meet with assessors and clinic staff.

Define what will be needed.
IUDs Module
9. Perform a cause analysis.

Work with clinic staff to find the reasons for the gap.
10. Select interventions.

Work with the staff to decide on interventions and prioritize them.
11. Plan interventions

Create an action plan.

Include who will do it, the resources needed, a deadline, and determine how to monitor
progress.
12. Make the changes.
13. Monitor and supervise the changes.
c. Selecting a Clinical Trainer
In addition to meeting the criteria for a good clinical training site, expert clinical trainers
are needed. Good service providers do not necessarily make good clinical trainers.
Clinical trainers must perform clinical procedures perfectly and should also be trained to
effectively transfer knowledge, attitudes and skills to trainees. There are various terms
used to describe clinical trainers: preceptor, tutor, coach, and mentor. A clinical trainer
may be a physician, midwife or nurse, but is always an experienced clinician. In selecting
a clinical trainer, some important characteristics include:

Demonstrated proficiency in skills to be taught

Good interpersonal communication skills (both with clients and with trainees)

Professional attitude

A desire to be a clinical trainer

The patience and commitment to give the time needed

The ability to create dynamic training activities (not just to demonstrate a procedure)

Willingness to provide post-training support if needed

The humility to acknowledge that they are not always right
d. Clinical Procedure Skills Training
Clinical trainers should determine competency in the provision of methods by assessing a
learner’s KAS throughout the learning intervention against a set of criteria captured on a
validated knowledge assessment tool and skills checklist. As a general rule, learners
should:

Be introduced to the procedure

Observe demonstrations on models and clients
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
Have opportunities to practice the required procedures on anatomical models in a
simulated setting

Be coached and receive constructive feedback
During the learning process, the clinical trainer determines whether and when the learner
is competent to practice the relevant procedures on clients in a supervised clinical setting.
Competency-based Training (CBT) is very different from the traditional education most of
us received. Competency-based training is learning by doing. It focuses on the specific
knowledge, attitude and skills that are needed to carry out a procedure, task or activity. All
clinical training should be competency-based. In CBT, clinical skills are developed in the
class room, in a simulated setting, using an anatomical model, before the trainee comes in
contact with an actual patient in a clinical setting.
In the CBT approach, actions required to complete each clinical task are detailed in
checklists that then serve as guides for both instructors and trainees. The checklists of tasks
for each skill are derived from evidence-based internationally accepted standards. They are
very specific and even include the communication and recording activities required. CBT
checklists can be found in each of clinical training modules in the TRP.
The CBT checklists are used in a variety of ways in training. On arrival, the trainer should
assess the participant’s learning needs by assessing his/her performance with a checklist.
The checklist should be filled out and given to the trainee to use as a learning guide during
the training. Participants can verify the validity of the items on the checklist as they observe
the trainer performing the skill. Later each participant uses the checklist to guide
development, integration and proper sequence of each task within the skill as he/she
develops clinical competency. Periodically during the CBT course the participant is
observed by the trainer to assess progress. Trainees may also observe and critique each other
using the checklist. When the trainee can demonstrate the ability to perform all of the
actions on the checklist with 100% accuracy, the trainee can advance to actual clinical
practice.
During the practicum, the clinical trainer must again determine whether the learner can
safely, effectively, and independently perform the procedures. Only then can a learner be
considered qualified to provide the method(s) at their workplace. Newly qualified
trainees should be instructed to refer complicated cases to more experienced providers,
unless they can perform those under supervision. Trainees should not be left alone in
clinical practice until they are considered to be competent and have support in their
clinics.
A skilled trainer’s judgment is the most important factor in determining a trainee’s
competence. Competence carries more weight than the number of procedures performed.
Trainers must enable every participant to achieve competency and provide additional
practice of skills if necessary. Using competency-based checklists ensures that trainees
have mastered clinical and counseling skills and activities, first with models and then
with clients. Checklists also ensure that all participants will have their skills measured
according to the same standard and forms the basis for follow-up observations and
evaluations. After a trainee demonstrates competency, they can work with clients, and
checklists can be used again to assess their performance.
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Certification of a trainee's competency means that a trainee is competent to perform a
procedure independently, without supervision. The institution that provides the training,
whether it is a government or NGO institution may provide some type of certification. The
institution assumes the responsibility for assuring that a trainee is competent to
independently perform a procedure. The institution may choose to provide either
competency certificates or simply certificates of attendance.
e. How Much Clinical Practice is Needed for Certification?
For the purpose of planning training events, trainers should arrange for three to five cases
per trainee to ensure an adequate number of clients are available during the practicum.
The actual number of supervised client procedures completed by each learner will vary
based on how quickly the learner develops mastery of the required skills. Every learner is
different. Each learner acquires competency at a different rate. Providers who have
already been providing services may acquire skills much more quickly than new service
providers or students. For this reason, we suggest that certification be given based on
competency, rather than the number of procedures performed.
Practicums (or simulations of client visits) can be used to assess the competence of
service providers and provide them an opportunity to practice using their new knowledge
and skills under the supervision of an experienced provider. This practice may occur in a
clinic-based practicum or in a simulated setting (see below). Although a clinic setting is
not comparable to what the providers encounter in their facilities and communities, the
interactions between the clients and the provider are similar to what occurs in the facility
or community setting.
f. What is the Proper Length of Clinical Training and Ration of Trainers to Trainees?
There is no absolute number of days for clinical training and no perfect ratio of trainers to
trainees. The number of participants should be limited based on the number of clients
expected and complexity of the skills being learned. There should be a balance between
practice on models versus practice on clients and models should be available in clinics
where clinical training is held. For procedures that require a high level of skills and the
potential to do harm to the patient (such as IUD or implant insertion), a clinical trainer
should always be present. For skills like counseling, once the trainer is satisfied that the
trainee is performing the skill correctly, the training may continue to practice without
direct one-on-one supervision.
g. Steps for Guiding a Clinic-Based Practicum
1. Orient the trainee to the space where they will be seeing clients for visits. Ensure that
they know where to access the supplies that they need during their interactions with
clients.
2. Pre-screen clients to ensure that their reason for visiting the clinic is to receive FP
services. Ideally it would be most efficient to identify those who express an interest in
the contraceptive method(s) that the provider has learned to provide (e.g., clients
interested in an IUD if the provider is learning to offer IUDs).
3. Before initiating any interaction with a client, inform the client that this is a learning
activity for the trainee that will occur under the close observation of an experienced
provider/supervisor who is prepared to intervene as needed. Ask the client’s
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permission for the trainee to conduct the session and request that she/he initial the
observation checklist to indicate her/his approval. The supervisor should also initial
the observation form to verify that the client’s permission was obtained.
4. Use a competency-based skills checklist similar to the one in Appendix F to
document the trainer’s observations of the interactions that the trainees have with
clients. Adapt the checklist as needed to include specific tasks and sub-tasks related to
IUDs. During the course of each trainee’s interaction with a client, check YES, NO,
or NA (not applicable) next to the item described in the checklist. Use the space on
the second page of the checklist to make detailed notes about your observations.
5. If at any time during the trainee’s interaction with the client it appears that the client’s
care is being compromised, intervene in the interaction or the procedure to ensure the
client’s safety is maintained at all times. Decide whether the trainee should receive a
passing score (if she demonstrated overall competence) for this interaction and note
that on page two of the checklist.
6. Immediately after the conclusion of the client interaction, meet with the trainee to
discuss your observations. Provide reinforcement for the items or tasks that the
trainee completed correctly and offer constructive feedback for items or tasks that the
trainee needs to improve. As indicated, instruct the trainee to read pages from the
counseling tool or job aids booklet to review key information or tasks that need
improvement. Share your overall score of the interaction with the trainee, indicate
passed/failed in the space provided, and ask the trainee to sign the checklist.
h. Training Follow-up
For training to be truly successful, trainees must be able to use their new skills and
knowledge and apply them when they return to their jobs. Only when the trainees have
been able to apply the new skills and knowledge that they have acquired during training,
has the transfer of knowledge really been achieved. Following-up with trainees once they
return to work is essential in order to:

Determine whether the trainee is correctly providing the service with his/her newly
acquired skills and knowledge;

Help the trainee solve problems and clarify misunderstandings that might have
developed since the training;

Obtain feedback from the trainee that might improve future trainings;

Ensure that the clinic environment supports the use of the trainee’s new skills. This
includes making sure that equipment is in place, that clinical standards support the
newly acquired skills, and that clinic management and systems (especially financial)
support the trainee’s use of new skills.
The competency based checklists included in each module can be used to evaluate
clinical skills during training follow up. In addition, it is useful to review client records to
assess the type and mix of clients the trainee is seeing; ensure that clinical equipment,
supplies and commodities are in place; interview the trainee about how the training can
be improved; and interview the clinic manager or supervisor about the trainee’s
performance.
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Appendices
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Appendix A: Adult Learning
Adult Learning
A noted educator, Dr. Malcolm Knowles, devised a theory of adult learning. Before Dr. Knowles
published his theory, most educators assumed that adults learned just as children did and that the
teacher’s role was to teach and the learner’s role was just to learn. The teacher was to take full
responsibility for the teaching/learning process. S/he made all of the decisions about what should be
learned; how it should be learned was purely a result of the teacher's knowledge and expertise. In
the 1960's, Dr. Knowles and others theorized that children and adults learned differently and he
made the following assumptions that characterized adults as learners:
Adults as Learners
1. Adults have a need to know why they should learn something.
Adults are motivated to learn when they are convinced that learning the new knowledge,
attitude, or skill is important. Learning is a more meaningful experience for adults if they
can understand why they "need to know.”
2. Adults have a deep need to be self-directing.
“The psychological definition of an 'adult' is one who has achieved a self-concept of being in
charge of his or her own life, of being responsible for making his or her own decisions, and
living with the consequences.” Adults have a strong need to take responsibility for their own
lives, including deciding what they want to learn. Dr. Knowles speculates that when adult
learners are treated as children, they withdraw from the learning situation. However, selfdirected learning doesn't necessarily mean learning without help. Adults often need help in
making the transition from seeing themselves as dependent learners to becoming selfdirected learners. Trainers are still responsible for the plan or approach, but throughout the
training, the trainer involves the participant.
3. Adults have a greater volume and different quality of experience than youth.
The longer we live, the more experiences we have. This affects learning in several ways.
Adults bring to the learning experience a wealth of experience which can be used to enrich
their learning and that of other participants.
Adults have a broader base of experience to which to attach new ideas and skills and give
them richer meaning. Tying learning activities to past experiences can make them more
meaningful and will help participants remember them better.
Adult learners come together in a group having had a wide range of experiences. They will
have a wide range of differences in background, interests, abilities, and learning styles.
Because of these differences, adult learning must be more individual and more varied. A wise
trainer will find out what the trainees already know and build on these experiences.
There is a potential negative effect of greater experiences--"it tends to cause people to
develop habits of thought and liaises to make presuppositions to be less open to new ideas.”
This potentially negative effect must be taken into account in planning learning experiences.
Techniques must be developed to try to counter this tendency.
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4. Adults become ready to learn when they experience in their life situation a need to
know or to be able to do in order to perform more effectively and satisfyingly.
Adults learn best when they choose voluntarily to make a commitment to learn. In order for
them to choose voluntarily, the trainer needs to help them understand why the information is
included or why they need to develop a particular skill.
5. Adults enter into a learning experience with a task-centered orientation to learning.
Children learn through a process of acquiring subject matter needed to pass tests, so the
content of courses for children needs to be organized into subject-matter courses such as
history or science divided into specific periods of time. In adult education the content needs
to be organized around life tasks, problems or situations. The content should focus much
more on "how-to" and "problem-solving." In this way participants will see the program as
much more relevant to their lives and will learn the content with the intention of using it.
6. Adults are motivated to learn by both extrinsic and intrinsic motivations.
Almost all adults are motivated to learn something. Allen Lough, who conducted research on
how adults learned in real life, could not find a single subject who had not engaged in at least
one major learning project (a minimum of seven hours of intentional learning) in the
preceding year, and the average learning projects were over seven.
Adult learners respond to extrinsic (external) motivators such as wage increases, promotion,
or praise from their boss, but they also respond to intrinsic (internal) motivators such as the
need for recognition and self-esteem, natural curiosity, an innate love of learning, broadened
responsibilities, and achievement.
The only difficulty is that participants may not be motivated to learn what we wish to teach
them which is why it is important to develop in them a need or wish to know.
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A variety of activities, based on the characteristics of adult learning, can be used in the teaching
process. Some are listed below:
Adults have a need to know why they should learn something.
 Provide real or simulated experiences through which the learners experience the benefits
of knowing and the costs of not knowing.

Start training by creating a climate of mutual trust and by discussing expectations with
the learner.

Allow participants to engage in self-diagnosis by using questionnaires and assessment
instruments both before and during training.

Help participants see how the training will help them.
Adults have a deep need to be self-directing.
 Allow for as much choice as possible in making decisions during the learning experience.

Create a mechanism for mutual planning. Help adults diagnose their needs. Set
objectives and design learning activities suited to their needs.
Adults have a greater volume and different quality of experience than youth.
 Encourage participants to share their experiences.

Try to link new learning activities to the participants' experiences.
Adults become ready to learn when they experience in their life situation a need to know or be
able to do in order to perform more effectively.
 Any training course will be more effective if the content is related to meeting their need for
knowledge or a particular skill. Often participants are sent by their organization/ company
and do not "choose to attend." When participants are "sent" for training, there are two
mechanisms for reducing their resistance:
1. State publicly that you realize there may be some participants who are not in the
course because they want to be and that you are sorry because this gets in the way of
learning, and
2. Explain that since they have no choice but to be in the course, to try to find some
value in learning what the course has to offer.

Participants should be told why a particular topic or session is included and why they are
expected to learn a particular skill or adopt a certain attitude.
Adults enter into a learning experience with a task-centered orientation to learning.
 Case studies and role play techniques help participants feel they are working with "real"
problems and accomplishing "real" tasks.

Developing and carrying out "re-entry" plans help participants learn how to apply the
lessons learned.
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Adults are motivated to learn by both extrinsic and intrinsic motivators.
 As trainers, we can set the stage and do much to orchestrate an environment conducive to
learning, however, it is also an internal process.

Positive reinforcement enhances learning.

Link training with promotions, added responsibility, power, and esteem.
How Adults Learn
1. Adults have many previous experiences that are pertinent to any educational activity.
Ignoring them causes resistance to learning.
2. Adults have a great many preoccupations other than what you may be trying to teach them.
If you waste their time, they will resent it.
3. Adults are faced with real decisions to make and real problems to solve. If training does not
help them with either, it may be wasted.
4. Adults react to authority by habit according to their experiences. You cannot force someone
to learn.
5. Adults are proud and self-directing. Learning is most efficient when it is the learner's idea,
and meeting his specific needs.
6. Adults have real things to lose. Learning must enhance their position, their esteem, or their
self-actualization. Otherwise there is too much risk.
Source: Donaldson, L, Scannell E. Human Resource Development. Reading, MA: Addison-Wesley Publishing
Company, 1986.
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Appendix B: Using Case Studies
Why use case studies?
Case studies allow trainees to carefully analyze a situation and make well considered decisions about
how to apply the technical information they have learned. Analyzing case studies gives trainees the
opportunity to apply new knowledge and skills in situations similar to those they will face in their
workplace, which helps ensure that the knowledge and skills are transferred to the job.
In addition, case studies facilitate transfer of knowledge and skills by allowing trainees to:

Employ different techniques for accomplishing both familiar and unfamiliar tasks

Approach problem-solving using new strategies

Become comfortable following new practice recommendations by collaborating with
other professionals who may have similar reservations (or enthusiasm) for change

Practice in a safe environment

Receive targeted feedback and support, which is the key to achieving that a high level of
proficiency and attaining workplace performance expectations
Preparing for the activity
1. Read the case studies. Carefully review the details of the cases and study the answers to
the sets of questions that the trainees will be discussing. Choose situations that suit the
objectives of the training and match the needs of the trainees.
2. Adapt the activity to make it relevant. Adapt the cases so that they reflect the cultural
practices, conditions, and circumstances that trainees will encounter at their work sites.
3. Anticipate and know how to address issues. Review the technical information in Family
Planning: A Global Handbook for Providers (CCP and WHO, 2011) related to the issues
addressed in the case study so that you are prepared to address questions that trainees might
raise.
4. Familiarize yourself with the related tools and job aids. Which tools are the trainees
expected to use when solving the case? Make sure that you are familiar with the material
and be prepared to describe proper use of the tool or job aid—whether it is a screening
checklist for medical eligibility, a client brochure that describes the characteristics of a
particular method, or pages from the counseling tool.
5. Decide how you will introduce and use the case study. If this is the first time that
trainees are working through a case study, you should conduct at least part of the activity
with the entire group. As trainees become more familiar with the expectations, divide
them into smaller groups or pairs so that each trainee has more responsibility for
resolving the case. If you have several small groups, you may want to assign each group
to a different set of questions. Ensure that each small group reports back to the larger
group so that all trainees can reflect on and benefit from the lessons learned in other
groups. Alternatively, you can assign the case studies as “homework” that trainees can
work on—either individually or in groups—outside of the classroom.
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6. Practice giving instructions to the trainees. Make sure you can provide clear, simple
guidelines so that the activity is easy to understand.
7. Prepare copies of resources. Make sure that you have copies of the necessary resources
available for the trainees. Ensure that trainees have copies of the tools or job aid(s).
Conducting the activity
1. Introduce the activity using the slide that describes the case. Emphasize that case
studies provide trainees with an opportunity to analyze a case and to make well-considered
decisions about how to apply the technical information they have learned to situations
similar to those they will encounter in the workplace. Provide step-by-step instructions that
clearly describe how you (the facilitator) and the trainees are expected to analyze the case
study. Tell the group how much time they have to complete each portion of the activity.
2. Encourage trainees to work as a team and take advantage of all the available resources
when answering the questions. Groups should consider each question in the set one at a
time and use their job aids, counseling tools, fact sheets, study notes, and PowerPoint slides
from the presentation to arrive at the most complete response. Each group should select a
spokesperson who will report their answers to the larger group.
3. Describe the case. Use the PowerPoint slide (or a prepared flipchart) to display the
description of the case. Ask one trainee to read the client description aloud. Ask trainees if
they have any questions.
4. Provide support and feedback as trainees work through the sets of questions. Each
small group should answer their assigned questions independently. Move from group to
group, and listen to the suggestions the trainees are making, offer encouragement, suggest
strategies, and redirect trainees who are moving towards or have given an incorrect
response. If multiple facilitators are available, assign one facilitator to each small group.
5. Ask spokespersons to report back. After the groups complete their analysis and
questions, ask the spokesperson from each group to share their answers with the entire
group so that all the trainees have an opportunity to learn the correct answers to each set
of questions. As each group reports, encourage other trainees to comment and offer
additional feedback.
6. Use the answer key to guide the discussion. Each case study has an answer key that can
help you process the reports, comments, and feedback. As necessary, intervene if neither
the spokesperson nor the trainees can suggest the correct response. It is imperative that
trainees know whether their answers to the case questions are correct.
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Appendix C: Facilitating Role Plays
Why use role plays?
Role plays allow trainees to apply new technical knowledge and skills in situations that simulate
those they encounter at work, which helps facilitate transfer of learning to the workplace for
improved on-the-job performance. Unlike case studies, in which trainees carefully analyze a situation
before responding, role plays require trainees to react to situations in the moment when applying
technical information and procedures they have learned.
In addition, role plays help facilitate transfer of learning by giving trainees opportunities to:

Practice in a safe, non-threatening environment where it is permissible to make mistakes

Work in small groups and observe the facilitator or an experienced trainee demonstrate
the provider role, which helps trainees to be comfortable trying out new approaches

Become confident using job aids and tools to facilitate performance of work tasks

Receive targeted feedback and support after each time they role-play a provider; such
immediate feedback is crucial for trainees to achieve a high level of proficiency and
attain workplace performance expectations
Note: Many learning activities in the modules involve brief role-playing. These instructions apply
to activities involving multiple role plays conducted in small groups of three trainees.
Preparing for the activity
1. Read the role-play scenarios. Carefully review the details on the client and observer
information sheets for each role play and become familiar with the key issues. Select the
role plays that suit the objectives of your training session and represent situations that are
most similar to what trainees will encounter at their workplaces.
2. Adapt the activity to make it relevant. If necessary, adapt role plays to make them
more consistent with the situations that providers are likely to encounter in their
workplace (e.g., type of facility, titles of job aids, cultural practices and names of clients).
For example, if most of the trainees work in a hospital, the scenario should reflect this. It
is also important to keep the cultural practices of clients in mind. For example, if women
tend to come to appointments with their husbands or mothers-in-law, make sure that the
scenarios provide for this.
3. Anticipate and know how to address issues. Study the relevant technical information in
Family Planning: A Global Handbook for Providers (CCP and WHO, updated 2011) so that
you are ready to address issues that trainees might raise during the role-playing activities. For
CHWs, keep explanations simple as well as accurate.
4. Familiarize yourself with relevant tools and job aids. Will trainees be practicing using
a checklist for screening clients who want to initiate a particular contraceptive method?
Will they be working with pages from the counseling tool? Will they share an
informational brochure with a new method user? Be prepared to demonstrate proper use
of counseling tools or other job aids.
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5. Decide how you will introduce and use the role plays. If it is the first time that the
trainees are taking part in a multiple role-playing activity, conduct a demonstration so that
they become familiar with the expectations related to the roles and support materials.
Choose one role play to use for the demonstration. Practice playing the role of the provider
and prepare two other facilitators (or trainees) to take on the supporting roles of the client
and observer during the demonstration. Also practice explaining how to conduct the role
plays. (Note that the eligible methods section of the observer information sheet is omitted
in the CHW role plays to reduce the amount of information that CHWs need to process
during the activity.) Ensure that there are at least three role play scenarios so that the
trainees in a small group will not need to repeat a role play during a round.
6. Prepare copies of resources. Make enough copies of the provider, observer, and client
instructions and the role play observation checklist for clinicians or CHWs for each small
group. Ensure that trainees have copies of the counseling tools or job aid(s).
Conducting the activity
1. Introduce the activity using the slide that outlines the role-play instructions.
Emphasize that role-playing provides trainees with an opportunity to apply their new
knowledge, skills, and tools in situations that simulate actual client interactions.
2. Identify specific learning objectives. Describe the objectives that are associated with the
role-play activity. For example: Trainees will demonstrate their ability to screen clients who
have decided to use a specific contraceptive method.
3. Ask trainees to break into groups of three. Direct the members of each group to choose
who will play the role of client, provider, or observer. Remind the groups that each
trainee will play each role during the activity. Distribute copies of the instructions for the
client, provider, and observer roles, or create flip charts that describe the general
expectations for each role. Review the expectations for each role with the trainees.
4. Provide a demonstration. In addition to showing how the activity is conducted, the
demonstration will help trainees feel more comfortable trying out new approaches.
Prepare for the demonstration as suggested in item 5 above.
5. Distribute role-play materials to trainees taking on the client and observer roles. Give
each “client” a copy of the scenario information sheet that includes the client description and
responses to share with the provider. Give the “observer” a scenario information sheet
describing the case-specific issues they should watch for and a role play observation checklist.
Ask the clients and observers not to share any information about the role play with the person
who is playing the provider, except the client’s name, age, and gender.
6. Give the groups 15 minutes to conduct the role play. Circulate among the groups to
answer any questions that may arise and provide guidance as needed.
7. Instruct each group to discuss the role play. After the small groups have finished with
the role play, ask the groups to take five minutes to talk about what happened during the
role play from the perspective of the provider (self-assessment), the client (personal
satisfaction with the interaction), and the observer (objective assessment using the Role
Play Observation Checklist). The groups should discuss the following questions among
themselves:
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
What was going on between the provider and client?

What did the provider do in this situation that was effective?

What might the provider consider doing differently?

How well did the provider attend to the items on the Role Play Observation Checklist
and the case specific observations included in the role play description?
Post a prepared flip chart of the discussion questions where each small group can see it, or
display the PowerPoint slide that shows these questions. Encourage trainees to provide
constructive criticism during their discussions and to take breaks as needed between role
plays.
8. Rotate roles and substitute new role plays. Trainees should rotate roles within their
small groups. If the small groups are each working on different role plays, the groups can
pass their role play materials to the next group.
9. Process the activity. After the groups have completed three rounds of role plays (each
team member has had an opportunity to play each role once), conduct a discussion in the
large group using the following questions:
While playing the role of the provider:

How did it feel to integrate new content, techniques, and job aids into your
interaction?

What worked well? What still feels awkward and requires more practice?

What did you think about the length of the counseling sessions?

Did the client raise issues or questions that you did not know how to answer?
While playing the role of the client

Did the provider adequately address your main reason for coming to the clinic?

Were you able to understand and use the information the provider gave you?

Did the provider address all of your concerns?

Were you comfortable asking questions?

After being a client, what changes will you make the next time you role-play the
provider?
While playing the role of the observer

Did the provider create a comfortable environment? Did the provider build
adequate rapport with his/her client?

Can you share some examples of interesting interactions and creative solutions
that you observed in the role plays?
10. If desired and time allows, ask the trainees to form new small groups and complete
another set of role plays, using different role-play scenarios and switching roles after the
first and second rounds.
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11. After the final round of role-plays (each team member has had an opportunity to play
each role twice), repeat the large group discussion. Use the questions in step 9 to
conduct another debriefing with the trainees.
12. Conclude the activity by reminding trainees of the importance of their interactions
with clients. Counseling is an essential component of FP services. When done well, FP
counseling sessions can ensure that providers meet the needs of their clients.
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Provider Instructions for Role Plays
Pretend that you are meeting the client for the first time. Ask the client for his or her name, gender
(male or female) and age. Pretend that there is a health center nearby to which you can refer the client,
if needed. Remember to:
 Assess the client’s reproductive health (RH) goals, concerns, and fertility intentions.
 Address the primary and secondary reasons for the client’s visit.
 Facilitate the client’s decision-making process.
 Integrate information and services related to other RH issues as appropriate.
 Help the client act on her or his decision(s).
Apply your prior experience along with what you have learned from the training and use job aids and tools
as appropriate to address the client’s concerns.
Observer Instructions for Role Plays
Prior to the start of the interaction:
 Review the Role Play Observation Checklist so that you are familiar with the behaviors that you are
observing and where they appear on the checklist.
 Review the case-specific issues on the observer information sheet for the role play.
While observing the interaction between the provider and client, remember to:
 Use the observation checklist to take notes on what happens during the interaction.
 Record how well the provider addresses the case-specific issues in the space provided.
 Be prepared to give feedback to the provider regarding how well he or she addressed the client’s
needs.
Pay particular attention to whether the provider:
 Helped the client deal with anxiety
 Facilitated communication with a partner
 Allowed the client to make an informed decision
 Ensured that the client met the medical eligibility criteria for the method she chose
 Helped the client carry out her decision
Client Instructions for Role Plays
Prior to the start of the interaction:
 Read the client information sheet and make sure you understand your character’s situation.
 Pick a name for your character. Tell the provider your name, age, and whether you are male or
female.
During the interaction, offer information only when the provider asks relevant questions. Use the
information given in your client information sheet to respond to the provider’s questions. Feel free to
ask questions of the provider.
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Role Play Observation Checklist
Case: ____________________________ Provider: _______________________________ Client: _______________________________ Observer: _______________________________ Date: ___________________________
Overall: Communicate Effectively and Maintain Rapport
Yes
No
N/A
Help Client Make an Informed Decision or Address a Problem
Yes
Shows respect and avoids judging client ...............................................
Asks client if he or she has any questions about methods of interest ........
Maintains relaxed, friendly and attentive body postures and eye contact
Asks client to choose a method .................................................................
Uses simple, clear language ...................................................................
Uses screening checklist to determine if client can use the method ..........
Uses open-ended and probing questions correctly ..................................
Agrees on decision or plan in partnership with client ...............................
Listens carefully to client (paraphrases and reflects) ..............................
Asks client about feelings (and shows empathy) ....................................
Encourages client participation ...........................................................
Explains what will occur during visit and procedures ............................
Ensures client understanding and corrects misunderstandings ...............
Uses job aids appropriately ....................................................................
Offers to involve client’s partner ............................................................
Records data according to protocols .......................................................
Establish Rapport and Assess Client’s Needs and Concerns
Greets client appropriately .....................................................................
Ensures confidentiality and privacy and that client is comfortable .........
Asks about reason for visit .....................................................................
Asks about client’s partner(s), children, family, sexual behavior, health
Asks about plans to have children, desire for FP (e.g., spacing, limiting) ..
Explores STI risk and what client does to avoid STIs.................................
Identifies areas to evaluate during physical exam (if indicated) ............
Provide Information and Options Related to Client’s Concerns
Advises on preventing STIs (i.e., abstain, fewer partners, use condoms)
Advises on achieving desired pregnancy as safely as possible ...............
Explains benefits of FP and healthy spacing ...........................................
Helps client identify FP methods suited to her or his needs ....................
Gives information on FP methods of interest..........................................
Responds to other client questions or concerns ......................................
Last revised: 6 September 2012
No
Provide Assistance to Support Client’s Decision
Gives contraceptive method and condoms for dual-method use, if needed ..
Explains and/or demonstrates correct use ..................................................
Asks client to explain or demonstrate correct use, and reinforces client’s
understanding and/or corrects client’s demonstration ...................................
Reminds client about side effects and reasons for returning .....................
Gives treatment, supplies, medications (as indicated) ..............................
Role plays or rehearses negotiation skills and helps client plan approach .
Arranges follow-up, resupply, and referral to other services, as needed .....
Case-Specific Observations or Questions:
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
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N/A
The Training Resource Package for Family Planning
IUDs: Appendix D
Appendix D: Illustrative Training Schedule
Total Time: Approximately 13 hours of instruction time
Time
Topic
DAY 1
Method
Resources
Welcome, Introduction and
8:00-8:15am
Objectives
Discussion
Basic Slide Set: Session I, Slide 2
and Handout #1
8:15-8:45am Pre-test
Test
Evaluation Tool: IUD Pre-Test
8:45-10:15am Session I: Characteristics of IUDs (2 hrs., 10 min.)
What are IUDs? Key Points for
Discussion
Basic Slide Set: Session I, Slides 3-4
Providers and Clients
Copper IUDs
Discussion
Basic Slide Set: Session I, Slide 5
Effectiveness
Discussion
Basic Slide Set: Session I, Slide 6
and Optional Advanced Slide 2
Relative Effectiveness
Lecturette
Basic Slide Set: Session I, Slide 7
Method Effectiveness
Role Play
Handouts #2 and #3
Explaining How IUDs Work
Brainstorming
Basic Slide Set: Session I, Slide 8
Characteristics of IUDs
Work Group
Activity
Basic Slide Set: Session I, Slide 9
Copper IUDs: Health Benefits
Discussion
Basic Slide Set: Session I, Slide 10
and Optional Advanced Slide 3
Copper IUDs: Side Effects
Lecturette
Basic Slide Set: Session I, Slide 11
Copper IUDs: Counseling about
Side Effects
Lecturette
Basic Slide Set: Session I, Slide 12
IUDs Fact Sheet
Brainstorming
Handout #4
10:15-10:30am
10:30am12:00pm
Tea Break
Session II: Who Can and Cannot Use IUDs (1 hr, 35 min.)
Copper IUD is Safe for Most
Lecturette
Basic Slide Set: Session II, Slide 2
Women
Who Can and Cannot Use the
Lecturette
Basic Slide Set: Session II, Slide 3
IUD
Medical Eligibility Criteria
Basic Slide Set: Session II, Slides
Brainstorming
(MEC); Categories 1-4
4-8 and Handouts #5-6
IUD Use by Women with HIV
and AIDS
IUD Use by Postpartum
Women
Discussion
Basic Slide Set: Session II, Slide 9
and Advanced Optional Slides 4-5
Lecturette
Basic Slide Set: Session II, Slide 10
Understanding the Checklist for
IUD screening
Experiential
Learning
Exercise
Basic Slide Set: Session II, Slide 11
and Handouts #6-7
IUD Eligibility Checklist
Brainstorming
Handouts #6-7
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The Training Resource Package for Family Planning
Time
Topic
DAY 1, continued
Method
Brainstorming
Handouts #6-7
IUD Eligibility Checklist (3)
Brainstorming
Handouts #6-7
Lunch
Session III: Providing IUDs (5 hrs)
Timing of IUD Insertion
Lecturette
(15 min.)
Correcting Rumors and
Misconceptions (20 min.)
What Will Happen When You
Get Your IUD (20 min.)
Explaining the IUD Insertion
Procedure (10 min.)
Post-Insertion Instructions
(10 min.)
Complications of IUDs
(10 min.)
Complications of IUDs,
continued (10 min.)
2:45-3:00pm
3:00-4:30pm
Resources
IUD Eligibility Checklist (2)
12:00-1:00pm
1:00-2:45pm
IUDs: Appendix D
Basic Slide Set: Session III, Slide 2-3
Brainstorming
Basic Slide Set: Session III, Slide 4
and Handout #8
Brainstorming
Basic Slide Set: Session III, Slide 5
Discussion
Basic Slide Set: Session III, Slide 6
Discussion
Basic Slide Set: Session III, Slides 7
Discussion
Basic Slide Set: Session III, Slide 8
Lecturette
Basic Slide Set: Session III, Slide 9
and Optional Advanced Slides 6-8
Tea Break
Signs of Possible IUD
Complications
Explain Removal Procedure to
Client
Managing IUD Side Effects or
Complications: Heavy,
Prolonged or Irregular Bleeding
Managing IUD Side Effects or
Complications: Cramping and
Mild Pain
Managing IUD Side Effects or
Complications: Severe Pain in
Lower Abdomen (Rare)
Managing IUD Side Effects or
Complications: Suspected
Perforation
Managing IUD Side Effects or
Complications: Missing Strings
Managing IUD Side Effects or
Complications: Suspected
Pregnancy
Last revised: 6 September 2012
Lecturette
Basic Slide Set: Session III, Slide 10
Discussion
Basic Slide Set: Session III, Slide 11
Brainstorming
Basic Slide Set: Session III, Slide 12
Lecturette
Basic Slide Set: Session III, Slide 13
Lecturette
Basic Slide Set: Session III, Slide 14
Lecturette
Basic Slide Set: Session III, Slide 15
Lecturette
Basic Slide Set: Session III, Slide 16
Lecturette
Basic Slide Set: Session III, Slide 17
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The Training Resource Package for Family Planning
Time
8:00-10:00am
Topic
IUDs: Appendix D
DAY 2
Method
Resources
Session III: Providing IUDs, continued
Role Plays
Handouts #9-11
Case Studies
Handouts #12-13
Copper IUDs: Summary,Posttest, Applied Learning Case
Studies and Course Evaluation
Basic Slide Set: Session III, Slide 18
and Evaluation Tools: Post-test,
Applied Learning Case Studies, and
the COCs Course Evaluation
10:00-10:15am
Tea Break
10:15-12:15
Session IV: Practicing IUD Insertion and Removal (5 hrs)
Optional Additional Content Slide
Session Overview
Lecturette
Set: Session IV, Slide 2
IUD Insertion Procedure:
Optional Additional Content Slide
Lecturette
Instruments and Supplies
Set: Session IV, Slide 3
IUD Insertion Procedure:
Optional Additional Content Slide
Lecturette
Instruments and Supplies (2)
Set: Session IV, Slide 4
IUD Insertion Procedure:
Optional Additional Content Slide
Preventing Infection during
Lecturette
Set: Session IV, Slide 5 and Handout
IUD Insertion
#14
IUD Insertion Procedure:
Optional Additional Content Slide
Preventing Infection during
Lecturette
Set: Session IV, Slide 6 and Handout
IUD Insertion (2)
#15
IUD Insertion: Procedure
Optional Additional Content Slide
Lecturette
Overview
Set: Session IV, Slide 7
Optional Additional Content Slide
IUD Insertion Procedure Step 1 Lecturette
Set: Session IV, Slide 8 and Handout
#16
Optional Additional Content Slide
IUD Insertion Procedure Step 2 Lecturette
Set: Session IV, Slide 9 and Handout
#17
Optional Additional Content Slide
IUD Insertion Procedure Step 3 Lecturette
Set: Session IV, Slides 10-20 and
Handout #14
IUD Insertion Procedure Steps
Optional Additional Content Slide
Lecturette
4-7
Set: Session IV, Slides 21-24
Optional Additional Content Slide
IUD Insertion Procedure Step 8 Lecturette
Set: Session IV, Slide 25
IUD Insertion Procedure Steps
Optional Additional Content Slide
Lecturette
9-13
Set: Session IV, Slides 26-29
IUD Insertion Procedure Step
Optional Additional Content Slide
Lecturette
14
Set: Session IV, Slide 30
Optional Additional Content Slide
Removing an IUD
Lecturette
Set: Session IV, Slides 31-32
12:15-1:15pm
Lunch
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The Training Resource Package for Family Planning
Time
1:15-3:15pm
Topic
DAY 2
Method
Resources
Session IV: Practicing IUD Insertion and Removal, continued
Demonstration/
Pelvic Examination
Return
Demonstration
Demonstration/
Loading the Copper T 380A in
Return
the Sterile Package
Demonstration
Demonstration/
Insertion and Removal
Return
Demonstration
3:15-3:30pm
3:30-4:30pm
IUDs: Appendix D
Tea Break
Infection Prevention Procedures
in IUD Insertion and Removal
Last revised: 6 September 2012
Demonstration/
Return
Demonstration
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The Training Resource Package for Family Planning
IUDs: Appendix E
Appendix E: Demonstration Return Demonstration
The Five-Step Method of Demonstration and Return Demonstration is a training technique useful
in the transfer of skills. The technique is used to make sure that participants become proficient in
certain skills. It can be used to develop skills in IUD insertion, pill dispensing, performing a
general physical examination, performing a breast or pelvic examination, etc. In short, it can be
used for any skill which requires a demonstration. The following are the "five steps:"
1. Overall Picture: Provide participants with an overall picture of the skill you are helping
them develop and a skills checklist. The overall picture should include why the skill is
necessary, who needs to develop the skill, how the skill is to be performed, etc. Explain
to the participants that these necessary skills are to be performed according to the steps in
the skills checklist, on models in the classroom and practiced until participants become
proficient in each skill and before they perform them in a clinical situation.
2. Trainer Demonstration: The trainer should demonstrate the skill while giving verbal
instructions. If an anatomical model is used, a participant or co-trainer should sit at the
head of the model and play the role of the client. The trainer should explain the
procedure and talk to the role playing participant as s/he would to a real client.
3. Trainer/Participant Talk-Through: The trainer performs the procedure again while the
participant verbally repeats the step-by-step procedure.
Note: the trainer does not demonstrate the wrong procedure at any time. The remaining
participants observe the learning participant and ask questions.
4. Participant Talk-Through: The participant performs the procedure while verbalizing
the step-by-step procedure. The trainer observes and listens, making corrections when
necessary. Other participants in the group observe, listen, and ask questions.
5. Guided Practice: In this final step, participants are asked to form pairs. Each participant
practices the demonstration with their partner. One partner performs the demonstration
and talks through the procedure while the other partner observes and critiques using the
skills checklist. The partners should exchange roles until both feel competent. When
both partners feel competent, they should perform the procedure and talk-through for the
trainer, who will assess their performance using the skills checklist.
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IUDs: Appendix F
Appendix F: Illustrative Competency-based Skills Checklist for IUD
Counseling and Clinical Skills
Date of Assessment ____________
Dates of Training ________________________
Place of Assessment: Facility _______________ Classroom ____________________
Name of Facility _____________________________________________________
Type of Facility:  MOH/Gov’t
 NGO
 Other
Level of Facility:  Primary
 Secondary
 Tertiary
Name of the Service Provider _____________________________________________
Name of the Assessor __________________________________________________
This assessment tool contains the detailed steps that a service provider should follow in
counseling and providing client instructions for IUDs. The checklist may be used during training
to monitor the progress of the trainee as s/he acquires the new skills and it may be used during
the clinical phase of training to determine whether the trainee has reached a level of competence
in performing the skills. It may also be used by the trainer or supervisor when following up or
monitoring the trainee. The trainee should always receive a copy of the assessment checklist so
that s/he may know what is expected of her/him.
Instructions for the Assessor
1. Always explain to the client what you are doing before beginning the assessment. Ask for the
client's permission to observe.
2. Begin the assessment when the trainee greets the client.
3. Use the following rating scale:
1= Needs Improvement. Step or task not performed correctly or out of sequence (if
necessary) or is omitted.
2= Competently Performed. Step or task performed correctly in proper sequence (if
necessary) but participant does not progress from step to step efficiently.
3= Proficiently Performed. Step or task efficiently and precisely performed in the proper
sequence (if necessary).
Not observed: Step, task, or skill not performed by the trainee during evaluation by the
trainer.
4. Continue assessing the trainee throughout the time s/he is with the client, using the rating
scale.
5. Observe only and fill in the form using the rating numbers. Do not interfere unless the trainee
misses a critical step or compromises the safety of the client.
6. Write specific comments when a task is not performed according to standards.
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7. Use the same copy for several observations.
8. When you have completed the observation, review the results with the trainee. Do this in
private, away from the client or other trainees.
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The Training Resource Package for Family Planning
TASK/ACTIVITY
INITIAL INTERVIEW
IUDs: Appendix F
CASES
1
2
3
1
2
3
COMMENTS
Greets client in a friendly and respectful manner.
Maintains eye contact with the client.
Concentrates fully on what the client is saying.
Asks what MCH/FP service she is seeking and
respond to any general questions she may have.
Provides general information about MCH services and
FP methods available.
Explains what to expect during clinic visit.
Asks client if she has a method in mind.
Asks client her feelings about or experience with a
method.
Helps client to make an informed choice: e.g.,
• Asks client about reproductive goals, to space
or limit births
• Explores any attitudes or religious beliefs that
may favor or rule out one or more methods
• Briefly explains contraceptive choices available
• Briefly explains benefits/advantages of each
• Briefly explains risks/disadvantages of each
• Asks client if she has any questions and
responds to these
• Asks client which method she prefers
METHOD-SPECIFIC COUNSELING
Ensures necessary privacy.
Obtains necessary biographical data (name, address,
age, etc.).
If the client chooses IUDs:
• Asks her what she knows about IUDs. Corrects
any myths, rumors or misinformation she may
express
• Asks if she has used IUDs in the past. What was
her experience?
• Gives client an IUD to look at and handle.
• Explains advantages of the IUD, including non-
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TASK/ACTIVITY
IUDs: Appendix F
CASES
COMMENTS
contraceptive benefits.
• Briefly explains how IUDs work.
• Explains potential common side effects of the
IUD. Stress that she may experience some (or
possibly none) of these and that they can all be
managed:
– Some cramps for several days
– Some spotting for a few weeks
– Longer and heavier periods
– Bleeding or spotting between periods
– More cramps or pain during periods
• Reassures client that most side effects are not
serious and will decrease or stop after a few
months of use.
• Describes the insertion process and what the
client should expect during and after the
procedure.
• Responds to any questions or concerns the
client may have.
• Explains that s/he will ask the client some
questions and performs a pelvic examination to
insert the IUD.
CLIENT SCREENING
1
2
3
Screens client using Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD.
Asks all questions on checklist and record responses.
1.
Have you had a baby in the last 4 weeks?
2.
Did you have a baby less than 6 months ago,
are you fully or nearly-fully breastfeeding,
and have you had no menstrual period since
then?
Have you abstained from sexual intercourse
since your last menstrual period or delivery?
3.
4.
5.
6.
Did your last menstrual period start within the
past 12 days?
Have you had a miscarriage or abortion in the
last 12 days?
Have you been using a reliable contraceptive
method consistently and correctly?
If the client answered YES to any one of questions 1–6 and she is free of signs or symptoms of
pregnancy, you can be reasonably sure that she is not pregnant. Proceed to questions 7–14.
However, if she answers YES to question 1, the insertion should be delayed until 4 weeks after delivery.
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CASES
COMMENTS
Ask her to come back at that time.
If the client answered NO to all of questions 1-6, pregnancy cannot be ruled out. The client should await
menses or take a pregnancy test.
To determine whether the client is medically eligible to use an IUD, ask questions 7-14. As soon
as the client answers YES to any question, stop and follow the instructions after question 14.
7.
8.
9.
10.
11.
12.
13.
14.
Do you have bleeding between menstrual
periods that is unusual for you, or bleeding
after intercourse (sex)?
Have you been told that you have any type of
cancer in your genital organs, trophoblastic
disease, or pelvic tuberculosis?
Have you ever been told that you have a
rheumatic disease such as lupus?
Within the last 3 months, have you had more
than one sexual partner?
Within the last 3 months, do you think your
partner has had another sexual partner?
Within the last 3 months, have you been told
you have an STI?
Within the last 3 months, has your partner
been told that he has an STI, or do you know
if he has had any symptoms – for example,
penile discharge?
Are you HIV-positive, and have you
developed AIDS?
If the client answered NO to all of questions 7–14, proceed with the pelvic exam. During the pelvic
exam, the provider should determine the answers to questions 15–21.
If the client answered YES to any of questions 7–9, an IUD cannot be inserted. Further evaluation of the
condition is required.
If the client answered YES to any of questions 10–13, she is not a good candidate for an IUD unless
chlamydia and/or gonorrhea infection can be reliably ruled out.
If she answered YES to the second part of question 14 and is not currently taking ARV drugs, IUD
insertion is not usually recommended. If she is doing clinically well on ARVs, the IUD may generally be
inserted. HIV-positive women without AIDS also generally can initiate IUD use.
15. Is there any type of ulcer on the vulva,
vagina, or cervix?
16. Does the client feel pain in her lower
abdomen when you move the cervix?
17. Is there adnexa tenderness?
18. Is there purulent cervical discharge?
19. Does the cervix bleed easily when touched?
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TASK/ACTIVITY
CASES
COMMENTS
20. Is there an anatomical abnormality of the
uterine cavity that will not allow appropriate
IUD insertion?
21. Were you unable to determine the size and/or
position of the uterus?
If the answer to all of questions 15–21 is NO, you may insert the IUD.
If the answer to any of questions 15–21 is YES, the IUD cannot be inserted without further evaluation.
See explanations for more instructions.
Physical Examination Prior to IUD Insertion
1
2
3
Ensures that high-level disinfected (HLD)
instruments are prepared on an HLD tray
Asks client to empty her bladder and rinse the skin
area around her vagina if possible.
Explains the procedure to the client
Washes hands and air dries hands or uses a clean
towel.
Checks the client for signs of anemia
Palpates the lower abdomen to check for
tenderness, swelling or other abnormalities
Puts new exam (disposable) or HLD or sterile
(reusable) gloves on both hands
Performs visual exam of external genitalia -- checking for
ulcers, lesions, sores, or discharge
If no problems found, proceeds to bimanual exam.
problems found, performs speculum exam next.
If
Performs bimanual exam checking for checking for
cervical, adnexal, or uterine abnormalities that would
preclude insertion
Removes and disposes of gloves correctly
Puts new exam (disposable) or HLD or sterile (reusable)
gloves on both hands
Performs speculum exam, checks for purulent vaginal
discharge, ulcers, lesions or sores. Locates cervix checking
for purulent cervicitis, bleeding, erosions, narrowing of the
cervical canal or any other vaginal problems that might
preclude insertion at this time
Makes appropriate findings based decision on whether or
not to proceed with insertion and explains decision to client
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CASES
COMMENTS
If decision is to NOT insert the IUD at this time,
then terminates exam and explains reasons to
client and makes recommendations for other
method and for any necessary treatment needed.
If decision is to go ahead with insertion, proceeds
with the procedures that follow
IUD INSERTION
1
2
3
1
2
3
1
2
3
Loads the IUD inside the sterile package according to
package instructions/protocols
Puts new examination (disposable) or HLD or sterile
(reusable) gloves on both hands.
Inserts vaginal speculum (and vaginal wall elevator if
using single valve speculum).
Swabs cervix and vagina with antiseptic at least twice.
Waits for two minutes if using an iodophor.
Gently grasps cervix with tenaculum or Vulsellum
Forceps.
Sounds uterus using no touch technique.
Sets blue depth gauge on the loaded IUD inserter to
the depth of the sound.
Inserts the IUD using the withdrawal technique.
Cuts strings and gently removes tenaculum.
POST-INSERTION TASKS
Places used instruments in chlorine solution for
decontamination.
Disposes of waste materials according to guidelines.
Removes reusable gloves and places them in chlorine
solution.
Washes hands with soap and water.
Completes the client record.
POST-INSERTION COUNSELING
Teaches client how and when to check for strings, if
she wants.
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CASES
COMMENTS
Assures the client that she can have the IUD removed
at any time.
Explains in a non-alarming way the warning signs,
stressing the rarity of these:
• Some bleeding and severe abdominal cramping
within a few days post-insertion.
• Irregular bleeding or pain every cycle.
• Fever, unusual vaginal discharge, low
abdominal pain.
• Missing IUD strings, missed period.
Discusses what to do if the client experiences any side
effects or problems.
Asks client a few questions to ensure that she
understands and remembers key instructions.
Observes the client for at least 15 minutes before
sending her home.
Reassures client that s/he is available to see her if she
has any problems or questions or needs advice.
Plans for a return visit after her first monthly bleed or
in 3-6 weeks.
Documents/records the visit according to local clinic
guidelines.
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RETURN VISIT COUNSELING
IUDs: Appendix F
CASES
1
2
3
1
2
3
1
2
3
COMMENTS
Greets the client in friendly and respectful manner.
Ensures privacy.
Asks the following questions:
• Have you been happy using the IUD?
• Have you had any concerns or problems?
• Has your health changed in any way since you
had your IUD inserted?
• Do you have any questions you would like me
•
to answer?
How are you protecting yourself from STIs?
(Explains dual protection)
• Do you need some condoms?
• May I examine you?
FOLLOW UP EXAMINATION
(3-6 WEEKS AFTER INSERTION)
Explains to the client why and how she will do the
pelvic examination.
Prepares the client while ensuring dignity and privacy.
Performs a pelvic examination and checks to make
sure the string is visible and that there is no partial or
complete expulsion.
Checks for pelvic infection.
Explains findings and reassures the client.
PRE-REMOVAL COUNSELING
Greets the client in friendly and respectful manner.
Establishes the purpose of the visit.
Asks the client her reason for removal and answers
any questions she may have.
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CASES
COMMENTS
Reviews the client’s present reproductive goals (e.g.,
does she want to continue spacing or limiting births?).
Describes the removal procedure and she should
expect during the removal and afterwards.
REMOVAL OF IUD
1
2
3
1
2
3
1
2
3
Washes hands thoroughly with soap and water and
dries with a clean cloth or allows to air dry.
Puts new examination (disposable) or HLD or sterile
(reusable) gloves on both hands.
Performs bimanual exam.
Inserts vaginal speculum and looks at length and
position of strings.
Swabs cervix and vagina with antiseptic.
Grasps strings close to the cervix and pulls gently but
firmly to remove the IUD.
POST-REMOVAL TASKS
Places used instruments in chlorine solution for
decontamination.
Disposes of waste materials according to guidelines.
Removes reusable gloves and places them in chlorine
solution.
Washes hands with soap and water.
Records IUD removal in client record.
POST-REMOVAL COUNSELING
Discusses what to do if the client experiences any
problems (e.g., prolonged bleeding or abdominal or
pelvic pain).
Asks the client to repeat the instructions.
Answers any questions.
Reviews general and method-specific information
about family planning methods, if the client wants to
continue spacing or limiting births.
Assist the client in obtaining new contraceptive
methods or provides temporary (barrier) method until
method of choice can be started.
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CASES
COMMENTS
Observes the client for five minutes before sending
her home.
Comments: ________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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The Training Resource Package for Family Planning
IUDs: Appendix G
Appendix G: Illustrative Competency-based Skills Checklist for
Infection Prevention Related to IUD Insertion or Removal
Date of Assessment ____________
Dates of Training ________________________
Place of Assessment: Facility _______________ Classroom ____________________
Name of Facility _____________________________________________________
Type of Facility:  MOH/Gov’t
 NGO
 Other
Level of Facility:  Primary
 Secondary
 Tertiary
Name of the Service Provider _____________________________________________
Name of the Assessor __________________________________________________
This assessment tool contains the detailed steps in infection prevention that a service provider
should accomplish when performing IUD insertion or removal. The checklist may be used during
training to monitor the progress of the trainee as s/he acquires the new skills and during the
clinical phase of training to determine whether the trainee has reached a level of competence in
performing the skills. The checklist may also be used by the trainer or supervisor when following
up or monitoring the trainee. The trainee should always receive a copy of the assessment
checklist so that s/he may know what is expected of her/him.
Instructions for the Assessor
1. Always explain to the client what you are doing before beginning the assessment. Ask for the
client's permission to observe.
2. Begin the assessment when the trainee greets the client.
3. Use the following rating scale:
1= Needs Improvement. Step or task not performed correctly or out of sequence (if
necessary) or is omitted.
2= Competently Performed. Step or task performed correctly in proper sequence (if
necessary) but participant does not progress from step to step efficiently.
3= Proficiently Performed. Step or task efficiently and precisely performed in the proper
sequence (if necessary).
Not observed: Step, task, or skill not performed by the trainee during evaluation by the
trainer.
4. Continue assessing the trainee throughout the time s/he is with the client, using the rating
scale.
5. Observe only and fill in the form using the rating numbers. Do not interfere unless the trainee
misses a critical step or compromises the safety of the client.
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6. Write specific comments when a task is not performed according to standards.
7. Use the same copy for several observations.
8. When you have completed the observation, review the results with the trainee. Do this in
private, away from the client or other trainees.
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PRIOR TO IUD INSERTION
IUDs: Appendix F
CASES
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
COMMENTS
Prepare a bucket containing 0.5% chlorine solution for
decontaminating instruments.
Wash hands thoroughly and dries them.
Put new examination or HLD surgical gloves on both
hands.
Arrange instruments and supplies on HLD disinfected
or sterile tray.
DURING CLIENT ASSESSMENT AND IUD
INSERTION
If rectovaginal exam is performed: immerse both
gloved hands in 0.5% chlorine solution. Remove
gloves by turning them inside out and dispose of them
properly.
Puts on gloves correctly.
Asks client if she has a method in mind.
Load TCu 380A in sterile package.
FOLLOWING IUD INSERTION
Places all instruments in 0.5% chlorine solution for
only 10 minutes immediately following the procedure.
Reusable gloves are decontaminated in 0.5% chlorine
for 10 minutes.
Wipes down exam table with chlorine between clients.
CLEANING INSTRUMENTS
Collects all supplies needed, including large and
small brushes, detergent, and large basin
Wears utility gloves.
Completely disassembles instruments and/or
opens jaws of jointed items.
Washes all surfaces with a brush or cloth until
visibly clean.
Thoroughly cleans serrated edges.
Rinses all surfaces with clean water.
Dries by air or towels before further processing.
HIGH-LEVEL DISINFECTION OF
INSTRUMENTS BY BOILING
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CASES
COMMENTS
Completely submerges items in water.
Starts timing when boiling begins.
Keeps at rolling boil for 20 minutes.
Air dries equipment.
Boiled items removed using HLD forceps.
HIGH-LEVEL CHEMICAL DISINFECTION
1
2
3
1
2
3
1
2
3
Uses one of the following:
• Chlorine 0.5% for 20 minutes
• One part 35%-40% formaldehyde to four
parts water) for 20 minutes
• Glutaraldehyde (Cidex) for 20 minutes
• Hydrogen peroxide 6% (one part 30% to
four parts water) for 20 minutes
• Prepares fresh solution
• Immerses items completely
• Rinses items with boiling water and allows
to air dry
• Stores items in HLD container
STERILIZATION BY AUTOCLAVE
Decontaminates, cleans, and dries instruments.
Disassembles items.
Wraps instruments.
Arranges packs loosely in autoclave.
Puts holes in drums in open position.
Heats water until steam escapes from pressure
valve only.
Follows directions for operating autoclave
Sterilizes for 30 minutes for wrapped items and
20 minutes for unwrapped items at 121° C (250°
F) and 106 kPa (15 lbs/in2)
After autoclaving, opens the lid and lets
instruments dry for 30 minutes before removing.
STERILIZATION BY DRY HEAT
Decontaminates, cleans, and dries instruments
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COMMENTS
Puts instruments on traps or wraps loosely
Begins timing after temperature has been reached
• 170° C (340° F): 60 minutes
• 160° C (320° F): 120 minutes
• 150° C (300° F): 150 minutes
• 140° C (285° F): 180 minutes
• 121° C (250° F): Over night
After cooling, removes instruments with HLD
forceps.
WASTE DISPOSAL
Needles are disposed of in a separate container
filled with 0.5% chlorine
1
2
3
Medical waste is removed daily
Medical waste is destroyed by burning
SUM
SUM/TOTAL
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The Training Resource Package for Family Planning
IUDs: Appendix H
Appendix H: The Copper-Bearing IUDs (IUDs): Answer Keys for
Pre- and Post-Test and Applied Learning Case Studies
Participant Name________________________________________________________
Instructions: Circle the letter(s) for all that apply. (Some questions may have more than one
correct answer.) Follow specific directions for each section. There is a total of 50 points.
Scoring: Score each correct answer by 1. Multiply total correct answers by 2 to get total
percentage. It is recommended that a passing score is 80% and above.
1. Which of the following contraceptive methods are less effective than copper IUDs?
a. Oral contraceptives
b. DMPA
c. Female Sterilization
d. Contraceptive implants
e. All of the above
2. Copper IUDs prevent pregnancy primarily by:
a. Preventing the fertilized egg from attaching to the uterine lining.
b. Interfering with sperm movement.
c. Suppressing ovulation.
d. Damaging sperm.
3. In counseling a woman about the advantages of the copper IUD, you would inform her
that the IUD:
a. Is permanent
b. Is highly effective
c. Has few side effects for most women
d. Does not interfere with sexual intercourse
e. Is effective in preventing anemia
4. Which of the following conditions are precautions, would indicate that a woman should
not have an IUD inserted:
a. Pregnancy
b. Three or more children
c. Has AIDS and is not on antiretroviral therapy
d. History of candidiasis
e. Retroverted uterus
f. Current pelvic infection
5. Prior to IUD insertion, a pelvic exam is performed to:
g. Determine uterine position and size
a. Rule out anteflexion
b. Rule out pregnancy
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c. Rule out presence of infection, masses, and tumors
6. Post-insertion IUD instructions should include:
a. Client should return for first check up one week after insertion
b. Client should return for first check up three to six weeks after insertion
c. Client should return any time she has problems, questions or wants another
method
d. Removal when the IUD has been in place for one year
7. The following are warning signs that you should teach to an IUD client, which indicate
that she may be having a problem with her IUD and should seek medical attention:
a. Cramping with menses
b. Increased length of menstrual cycle
c. Missing IUD string
d. Irregular bleeding or pain every cycle
e. Unusual vaginal discharge and low abdominal pain
8. IUD clients should be counseled:
a. Before the insertion
b. After the insertion
c. During each follow up visit
d. All of the above
True or False
Check off either "True" (T) or "False" (F) in the space provided.
9.
IUDs provide protection against sexually transmitted infections.
T ___
F ___
10.
IUDs are 99 percent effective in preventing pregnancy.
T ___
F ___
11.
Women can initiate IUD use 24 hours after giving birth.
T ___
F ___
12.
Fertility returns immediately after an IUD is removed.
T ___
F ___
13.
A woman can remove her IUD without the help of a healthcare
provider.
T ___
F ___
14.
The chance that an IUD will be expelled from a woman’s body
increases with her age and number of births.
T ___
F ___
15.
A physical exam for an IUD client must include abdominal,
speculum, and bimanual exams.
T ___
F ___
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16.
If a woman becomes pregnant with an IUD, it should be left in
place unless a problem develops.
T ___
F ___
17.
An IUD can be inserted in a woman who is ovulating.
T ___
F ___
T ___
F ___
T ___
F ___
T ___
F ___
18.
19.
20.
Following IUD insertion, heavy, yellow vaginal discharge is
common.
An IUD may be inserted at any time during the menstrual cycle,
if the provider is reasonably certain that the client is not
pregnant.
It is better to change all IUDs after two years, because leaving
them in the uterus for a longer period may lead to development
of complications.
Fill in the Blank
Complete the following sentences with one of these words. (Words may be used more than
once.)
Headaches
Blood clots
Nausea
Ectopic
pregnancy
Cramping
Perforation
PID
Acne
Infertility
Amenorrhea
Anemia
Irregular
bleeding
Heavy/prolonged Expulsion
bleeding
Pregnancy
21. The side effects associated with using an IUD are heavy/prolonged bleeding, cramping,
and irregular bleeding (or spotting).
22. Rare complications of IUD use include PID and perforation.
23. Partial or unnoticed expulsion of an IUD can result in pregnancy.
24. One health benefit of IUD use is reduced risk of ectopic pregnancy.
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Appendix H: Applied Learning Case Studies Answer Key
Case 1: Shinta is a 25-year-old mother of one child. She is engaged to be married this month
and she does not want to have more children right away. Shinta is HIV positive, but she feels
healthy. She and her fiancé are mutually faithful. She has come to the clinic somewhat
informed about IUDs and expresses interest in using this contraceptive method.
a) Does Shinta fit the medical eligibility criteria for IUDs? Why or why not?
Yes, Shinta is eligible. According to the eligibility criteria, HIV infection is not a contraindication
for IUD use.
b) Assuming Shinta has made an informed choice to start using an IUD, what are three key
counseling messages Shinta’s health care provider should share with her?
(Any three of the following):
• Review method characteristics (how the IUD works, length of protection, health
benefits, return of fertility, that it requires a trained provider to insert and remove,
possible complications)
• Explain expected side effects, such as prolonged/heavy bleeding and cramping
• Explain that these side effects are not a sign of illness, and that they usually
become less after the first several months after insertion
• Counsel her that IUDs provide no protection from STIs, and that she should use
condoms in addition to the IUD to avoid becoming reinfected with HIV or other
STIs, and to prevent passing the infection to her partner
• Explain the examinations required before having the IUD inserted (abdominal and
pelvic exams)
• Describe the IUD insertion procedure in terms that she can understand
• Explain that she can return any time she has questions or concerns, or wants the
IUD removed for any reason.
Case 2: Shinta has been using her IUD for six months. She has returned to the clinic because
she has been diagnosed with AIDS. She is not taking any antiretroviral drugs.
a) Does Shinta fit the medical eligibility criteria for IUDs? Why or why not?
Yes. An AIDS diagnosis without ARV treatment is a Category 3 for initiation, but a Category 2
for continuing use of an IUD. If a woman develops AIDS while she has an IUD in place, it does
not need to be removed. Shinta may continue using her IUD.
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The Training Resource Package for Family Planning
IUDs: Appendix I
Appendix I: Sample Course Evaluation
Instructions: Rate each of the following statements as to whether or not you agree with them,
using the following key:
1 Strongly disagree
2 Somewhat disagree
3 Neither agree nor disagree
4 Somewhat agree
5 Strongly agree
Overview
• The objectives of the module were clearly defined.
1 2 3 4 5
• The material was new to me.
1 2 3 4 5
• The trainer understood the material being presented.
1 2 3 4 5
• The time spent on this module was sufficient.
1 2 3 4 5
• Time for discussion and questions was sufficient.
1 2 3 4 5
• The material in this module has provided me with sufficient
information to conclude the safety and effectiveness of IUDs.
1 2 3 4 5
• The module has offered me the skills to provide IUD services,
including counseling, appropriate client screening and selection, and
management and follow-up of clients.
1 2 3 4 5
• The pre-/post-test accurately assessed my course learning.
1 2 3 4 5
Meeting Conditions/Locations
• The training was held on a convenient day and time.
1 2 3 4 5
• Necessary supplies were available.
1 2 3 4 5
Training Methods and Materials
• The trainers' presentations were clear and organized.
1 2 3 4 5
• I learned practical skills in the role plays and case studies.
1 2 3 4 5
• Class discussion was helpful.
1 2 3 4 5
• The trainers encouraged my questions and input.
1 2 3 4 5
Course Length
The length of the course was (circle your answer):
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Too long
Too short
Just right
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What topics in this training do you think would be most useful to you in your work?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
On which topics would you have liked more information or preferred to spend more time on?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What was the least useful aspect of this training?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
On which topics would you have liked less information or preferred to spend less time?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Suggestions
What suggestions do you have to improve the training? Please feel free to refer to points above.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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