Recently, I had the opportunity engage in some family planning clinical work in Zimbabwe. Zimbabwe is in southern Africa, and is a country that has a complicated and fascinating history. Zimbabwe once was a prosperous country, known as the “breadbasket of Africa.” Apartheid officially ended in 1980. Shortly after that time, a military leader named Robert Mugabe came into power bringing massive corruption and dysfunction to the country and leading to a historic economic collapse in the 2000’s. Accompanying that economic collapse was a dramatic increase in maternal mortality in Zimbabwe.
Since that time, the country has been on a long, slow road to recovery. It, however, still remains a country divided between a population of well-educated and more prosperous Zimbabweans and a population in devastating poverty. The maternal mortality rates remain very high and are mostly due to hemorrhage, hypertensive diseases of pregnancy, infection and unsafe abortion. And although about 60% of Zimbabweans use “modern” contraception (mostly the pill), IUD use is almost negligible. Lack of access to contraception is a huge reason why the fertility rate is significantly higher among the poorest women in Zimbabwe.
My experience in Zimbabwe began at Parienyatwa Hospital, which used to be a private hospital during apartheid but is now a public hospital for some of Zimbabwe’s poorest populations, similar to Harare Central Hospital, the traditional public hospital of Harare. Many members of the University of Zimbabwe (UZ) faculty have been trained in IUD insertions and regularly perform them in their private practice settings. In the public sector, however, IUDs are far less commonly utilized mostly because of cost, lack of faculty supervision, and misconceptions about the risks of IUDs. Contraception, specifically contraception counseling, is also something that is routinely beyond the realm of physicians’ scope of work (except procedural contraception). Postpartum contraception counseling is done by nurses, rarely physicians. One of my goals was to emphasize how important contraception is to the health of our patients and should be to their doctors.
I brought a bunch of demo IUDs and IUD insertion models with me and started by doing some hands-on training combined with didactics. The residents were fantastic; they were very eager to learn about not just IUDs but also methods that aren’t available in Zimbabwe. We had a journal club where we discussed the evidence (or lack thereof) linking the IUD to infertility. By the end of my time there, I was able to train several residents and one nurse midwife on IUD insertions. I also got to practice insertions and removals of the 2 rod implant available in Zimbabwe, which is similar to the single rod implant we have here in the US. It was fascinating working with the residents; they have excellent clinical skills since they rely on them far more than lab values or imaging. I also recently heard that faculty will now supervise residents in a weekly family planning clinic, specifically to proctor them on IUD insertions. It was an amazing feeling to get to do some actual training by the end of my time in Zimbabwe but even more amazing to know that the UZ residents are going to continue to have access to training.
Meredith Warden MD, MPH is a Family Planning Clinical Fellow and an Ob/Gyn at the University of California, San Francisco.