Expanding Contraceptive Choice: Lessons from Nigeria’s Scale Up of the Hormonal IUD

By Kendal Danna, Technical Advisor, Sexual and Reproductive Health, PSI

The hormonal intrauterine device (IUD) is a long-acting reversible method that offers unique contraceptive and lifestyle benefits for users. Despite decades of popularity in the United States and Europe, it has remained out of reach for women in lower resource settings. The recent inclusion of hormonal IUD in USAID and UNFPA product catalogs—at the lowest price ever available to the public sector—along with the development of national strategies for scaling up this method in countries like Nigeria, Zambia, and Madagascar constitute major milestones.

Population Services International (PSI) has been a leader in supporting government efforts to expand hormonal IUD in markets like Nigeria and around the world, through our former USAID-funded project SIFPO2 project and the LEAP Initiative, led by FHI360. We spoke with Dr. Kayode Afolabi of the Nigerian Federal Ministry of Health and Dr. Anthony Nwala of PSI local partner Society for Family Health (SFH) about these exciting steps forward and why now is the time for hormonal IUD scale up.

Learn more about PSI’s contribution to the global evidence base to catalyze these achievements on the hormonal IUD Portal and in several peer reviewed publications from PSI projects Expanding Effective Contraceptive Options (EECO), Support for International Family Planning and Health Organizations 2 and the Learning about Access and Potential of the LNG-IUS (LEAP) Initiative.

Nigeria has taken the lead in scaling up affordable access to the hormonal IUD. Why was it important to integrate this new method into the national health strategy?

Dr. Afolabi: It is necessary to expand the method mix to make more family planning (FP) options available for Nigerians of reproductive age. Evidence shows that introduction of a new method mix into the FP program has a positive rebound effect on uptake and consequently on the modern Contraceptive Prevalence Rate. The hormonal IUD is highly acceptable to women in Nigeria but scale up has been hindered by the previously prohibitive price that made it out of reach for most women.

Dr. Nwala: Many women desire a hormonal method because they perceive them as highly effective but shy away due to side effects. The hormonal IUD provides a favorable choice due to its low side effects.

What evidence gathered over the past few years do you feel was most influential in the decision to scale up the hormonal IUD in Nigeria?

Dr. Nwala: PSI and SFH have contributed both operational learning and research evidence to the Government’s efforts to increase the method mix in Nigeria. The SIFPO2 project, which supported the introduction of the method at SFH facilities, sought to understand users experience and providers’ perception with the new hormonal IUD. Through the LEAP Initiative, we are generating timely, actionable evidence to help determine if and how the method could play a catalytic role in increasing contraceptive use. Consumer and market insights generated from these studies, such as method acceptability to both users and providers, along with the high continuation rate and user satisfaction greatly informed the decision to scale up.

Dr. Afolabi: We know that more women are getting interested in hormonal IUD because of its non-contraceptive benefits. However, the method was previously only available in private sector facilities at a very high price. Hence, the Government of Nigeria decided to introduce it in public health facilities to address the challenge of inaccessibility. We intend to leverage the National Free Commodities Policy — which provides free public sector contraceptive services — to facilitate scale up. The support from the donor community and manufacturers of hormonal IUD is also a critical factor in the Government’s decision.

The global hormonal IUD landscape has changed substantially over the past few years. How have these global efforts impacted the decision to scale up this method in Nigeria?

Dr. Afolabi: The provision of hormonal IUD at the lowest subsidized price has served as an incentive to the Federal Ministry of Health. The rapidly changing global landscape also helped to open a strong and broad collaboration among all major players including government, donors, manufacturers, UN agencies and in-country implementing partners in market shaping and equity of access to the hormonal IUD. This also influenced Nigeria’s Financing and Fiscal Space Analysis for FP. Another notable impact is that this global effort and support influenced Nigeria’s financial commitment to the FP2030 Partnership, which the Honorable Minister of Health has approved.

Dr. Nwala: This changing landscape also created an avenue for effective procurement and registration of affordable brands, such as AVIBELA, which has been registered and procured in Nigeria for private sector use by SFH. The availability of donated product from the International Contraceptive Access (ICA) Foundation has also made the method accessible to more Nigerian women.

Nigeria adopted the National Strategic Plan to scale up the hormonal IUD in 2021. Could you describe what went into this process, the results so far, and key lessons for the future.

Dr. Afolabi: We held several stakeholder meetings involving all levels of government, implementing partners, civil society organizations, faith-based organizations and the organized private sector to brainstorm on the best approach to introducing hormonal IUD into the public health sector, including the roles and responsibilities of key stakeholders. Following these efforts, the strategy was costed, and approval was sought and obtained to allow subsequent implementation of the strategies identified in the National Strategic Plan. The inclusiveness of all stakeholders, along with the costing and broad-based accountability framework, added value to the success of the process. These are key lessons for the future.

What role can other stakeholders play in support of the Nigerian Federal and State Ministries of Health to make this scale-up of access successful and more equitable?

Dr. Afolabi: It is vital to build synergy among stakeholders to support ongoing efforts by the Federal and State Ministries of Health in the areas of forecasting, procurement, storage and distribution of hormonal IUD. The Ministry and other stakeholders should work towards filling the pipeline with not just hormonal IUD, but all other methods and ensure effective Last Mile Distribution and uninterrupted availability of contraceptives. Supply chain support must be aligned with the existing national system to avoid duplication of efforts or creation of parallel systems and to ensure optimization of investment. All implementing partners are to key into the existing system. Technical assistance and support for capacity building for service providers and program officers are essential.

Dr. Nwala: Exploring various means of improving the efficiency and cost effectiveness of this rollout, such as on the job, digital and/or hybrid training approaches will also enable greater capacity building of providers at scale. Bringing quality points of care closer to women in need of FP, in both the public and private sectors, and ensuring access to hormonal IUD and other FP commodities at various price points is critical to ensuring equitable access across the total market.

What do you feel is the role of the private sector in scaling up access to the hormonal IUD?

Dr. Afolabi: The evidence shows that more than 60% of clients access health services from the private sector, which is a low hanging fruit for increasing access to family planning services. The private sector is also vital for creating awareness and sensitizing members of the public on hormonal IUD. The private sector could also be supportive in financial, technical and material support, including the provision of Hormonal IUD.

What challenges do you see with hormonal IUD scale-up? How do you think we can overcome or address these barriers?

Dr. Afolabi: Some key challenges include the inadequate number of service providers trained on hormonal IUD as well as the attrition of trained staff. Improper storage in some facilities may lower its efficacy and lead to high failure rates. Myths and misconceptions also impact demand. Integrating the hormonal IUD into various data generation and management tools including the National FP Dashboard will be instrumental in ensuring adequate monitoring of national stock levels and strengthening the FP supply chain.

Dr. Nwala: Additional solutions include integrating hormonal IUD with other important services, such as cervical cancer screening and other reproductive health initiatives. New digital and hybrid provider training models could also offer an easy and cost-effective option to catalyze scale-up. We are currently evaluating new training approaches through the LEAP Initiative and the USAID-funded Research for Scalable Solutions (R4S). Our partnership with the USAID MOMENTUM Private Healthcare Delivery project will expand this training approach to an additional 135 private providers and build demand through a blend of in-person communication and media campaigns. PSI and SFH will continue to make these tools available and collaborate with global partners to broaden method choice and access to hormonal IUD for women everywhere.

Photo credit: Medicines360

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