IUD insertion problems blamed on chronic shortage of trainers

A massive shortage of training supervisors is hampering efforts to teach doctors and nurses how to properly insert IUD contraceptives.

Only eight out of 300 practitioners were able to finish a course on how to insert the intra-uterine devices because there were not enough trainers to take them through the practical component.

Mainly used for birth control, an intra-uterine device (IUD) is a T-shaped plastic frame inserted into the uterus to prevent pregnancy for up to seven years but can also help with heavy periods and cramps.

Although rare, if implanted incorrectly it could push through muscle and perforate the uterus.

Last year, ACC received 51 claims relating to IUDs - 22 related to perforation.

'I feel traumatised' - patient

Tanvi Naik had low iron caused by heavy bleeding, so she opted for the insertion of a Mirena IUD in February.

"My doctor recommended that I go to see another doctor, who was apparently very qualified to have the Mirena placed in," she said.

"I went to the doctor and went into the room. She didn't ask any questions about when my last period was, if I was pregnant... No questions, just sort of straight get on the bed.

"Nothing to cover my legs or anything. She just got started with the procedure," Naik said.

The 20-year-old has been using IUDs since she was a teenager.

Gynaecologists say while mild cramping, bleeding and dizziness can happen after the procedure, symptoms usually settle within 30 minutes.

For Naik, the pain lasted 24 hours.

"I went home, and I threw up. I was in a lot of pain, like, you know, really bad cramping. [I've] had quite a few Panadols, vomited twice," she said.

"I went to bed and then the next day, I knew something was wrong, because I've had it before, and I know that this is not the kind of pain it is.

"I was nauseous. I wasn't eating. I couldn't walk. My legs were shaking," Naik said.

An urgent ultrasound revealed her uterus was perforated.

"The ultrasound showed that the IUD was inserted wrong, and one of the arms was poking into the wall of my uterus, and I've actually had a perforation," she said.

"I had to have it removed within less than 24 hours."

In a statement, the clinic responsible for Naik's procedure said it was investigating the case.

It said if she was not happy with the outcome, she would be referred to the Health and Disability Commissioner, who in the past two years, has received 16 complaints about IUD insertions.

In an email to Naik, seen by RNZ, the clinic said the doctor involved performed a high rate of procedures, but even then, perforations could occur.

The email said although the doctor was a very experienced GP and has been inserting IUDs for some time, she had been advised of a course happening later in April.

The experience made Naik reluctant to go through the process again.

"I really lost my faith in the New Zealand health care system. I'd expect a little procedure like that would be carried out with at least a bit of dignity, and allow me as a patient to feel safe, but clearly that wasn't the case.

"Now, I feel very traumatised," she said.

'It's been challenging' - Te Whatu Ora

In 2019, Te Whatu Ora contracted Family Planning NZ to carry out a national training programme to develop quality standards on IUD insertions based on international best practice.

The training had two components, an online theoretical and a practical, which required seven successful supervised observations of IUD insertion to achieve competence.

Of 300 people who took the course, only eight did the practical exams.

Through a statement, Te Whatu Ora said primary care practitioners struggled to book appointments for insertion training.

"Trainers were required to travel distances by road and sometimes by air to undertake the seven supervised observations with the trainee. This proved difficult to arrange, particularly if the patient seeking the IUD did not appear for the appointment," it said.

Last year, a new training module was put in place, run by the College of Sexual and Reproductive Health.

The "train the trainer" module saw GPs trained in IUD insertion and, in turn, they trained local practitioners.

Te Whatu Ora said so far, 31 people have attended the course, with 21 trainers requiring further work to complete it.

College of Sexual and Reproductive Health deputy chair Dr Helen Paterson said the lack of full funding on contraceptive methods slowed progress.

"If we fully funded contraception, then people would be able to see how they can provide that care and therefore they would want to go and get trained in it," she said.

Paterson said the lack of a standard procedure for IUD insertion training created a gap in knowledge.

"Sometimes, when you have things that are covered by lots of people, they maybe don't get taken up quite so well in terms of formulating training opportunities."

Women in Medicine chair and GP Dr Orna McGinn said proper training was a long time coming.

"We felt perhaps it [the training] wasn't really a priority [for the Ministry of Health]. Like inserting IUDs was just part of the skill set of GPs," she said.

"But it was never really clear to us how GPs were meant to gain that experience."

Dr McGinn said clear standards were needed.

"What's not really been prioritised by the Ministry of Health is how to develop a clear pathway to training."

She believed women would feel more comfortable having the invasive procedure done by a practitioner who has been through a standard training.

"But there's no way to enforce this currently," she said.

Te Whatu Ora said with the "train the trainer" module, it was aiming to have 300 local trainers available by 2027.