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韓國農村에서의 效果的 IUD施術方案에 關한 硏究

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 (A) study on a feasible method of IUD service in rural Korea. 
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[영문] Introduction The intra-uterine device (IUD) has been clinically proven to be an effective contraceptive method, and it is now being adopted as a main weapon in the population control program of many developing countries including Korea. In applying the IUD in the field, a main concern is how to efficiently increase the number of IUD accepters who may in turn contribute toward lowering community birth rates through continuous use. It has been noted that, as experienced elsewhere, IUD acceptance is greatly influenced by seasonal factors (planting, harvest, raining, drought, etc.), geographic factors (distance between a village and a clinic, public transportation system, etc.), personnel factors of the clinic (medical qualification, sex and personality of a physician, etc.), characteristics of the townships (level of exposure to family planning program and to other communicationmedia, etc.). Since 70% of the Korean population resides in rural areas, there was a need to explore the most feasible and efficient IUD service program taking the above factors into account. Purpose of the Study The study was designed to fad out the acceptability and effectiveness of the various types of IUD services in a rural setting combining three major variables, namely, medical qualifications of inserter, time of insertion, and place of insertion in order to answer the following questions: 1. To what extent can a program be intensified if IUD services are made available to nearby villages by sending out mobile teams consisting of a physician and/or nurse? 2. What is the difference in acceptance rates for insertions made any time during the menstrual cycle compared with insertions made on specific days? 3. What is the difference in the rate of IUD insertion according to a physician's sex? 4. What is the difference in the IUD acceptance rate and in the frequency rate of side effects caused by IUD insertion when insertion is performed by a physician, by a nurse or by a nurse with a physician's screening? Study Design To help answer the above questions, the following different types of services were provided to the study population: 1. Insertion of the IUD by physicians on limited days, taking into consideration the ovulation period of each patient, at stationary clinics by male or female physicians. 2. Insertion by a paramedical person on limited days with accepters being screened by a visiting physician, at village stationary clinic. 3. Insertion by a physician any time of the month without consideration of the ovulation periodat mobile clinic. 4. Insertion by a paramedical person at any time of month with accepters being screened by a physician. 5. And, finally, both screening and insertion done by a paramedical person at any time of the month. The study area was Koyang Gun (county) including six Myuns (townships)-Wondang, Jido, Joong, Shindo, Byuckje, Songpo-which have about 76,810 inhabitants with 10,073 eligible women in 13,947 households. Study Procedure To implement this design, the following steps were taken: 1) Before-Survey: Before the IUD field services were provided, a survey of the Koyang study population was conducted during a period of April 21 to May 8, 1965 by a cluster sampling method. 1,609 eligible couples were interviewed as to their fertility for the past 5 years, and then knowledge, attitude, and practice of family planning. 2) Set-up of the New IUD Field Services: In addition to the existing four IUD clinics in Koyang County, three field units for IUD service were newly organized in those townships where the medical facilities were not available, namely, (1) a stationary clinic in Songpo providing IUD insertion by a nurse-midwife after screening by a physician and (2) a mobile service in Shindo, Byuckje with IUD service by a physician and by a nurse respectively. 3) Training of Nurses for IUD Insertion: Two qualified nurse-midwives were selected from among the family planning workers and were given a training course, under the supervision of Obstetrics and Gynecology specialists in Severance Hospital, Yonsei University College of Medicine. 4) Size of Loop: Three different sizes of Lippes loop were used; namely, the medium sized loop (27.5 mm) for normal uterus, the small sizes (25 mm) for atrophied uterus, and the large sited (30 mm) for hypertrophied uterus or for reinsertion after spontaneous expulsion. 5) Field Educational Service: Advertising leaflets with the IUD clinic schedule were distributed by family planning workers directly to eligible couple i while in the village for home-visiting or group meetings. Family planning workers also handed out leaflets to Richiefs, asking them to distribute the leaflets to eligible couples in their villages. Results This report was based on the data obtained from the above study activities up to the end of July 1966, and some of the salient results were as follows: 1. Increase of Total IUD Acceptance Rates in Koyang County: As of July 31, 1966, the total number of insertions were 2,213, which is about 22.0% of the total eligible couples (10,073) in Koyang County, indicating an increase of 12.0%from 10.0% which was the level of IUD insertions in April, 1965 or before the program. The main reason for such increase was the increase in the acceptance rates of Shindo(from 7.3% to 22.3%) and Byuckje (from 10.5% to 24.8%) with the activities of the mobile service and in Songpo (from 8.2% to 24.4%) with a stationary clinic, implying that the IUD program could be intensified if IUD services are extended to the village from the Headquarters either by mobile services or stationary services. 2. Sex Difference of the Physician in IUD Services: According to the results of the before-survey done in 1965, 84% of the eligible women wanting IUD in the future preferred to have IUD insertion by a female physician, but only 4% by a male physician, 9% by nurses and midwives. However, when we examine our actual experience in the IUD clinic of the Health Center, where IUD services were conducted by a male physician on Tuesday and by a female physician on Friday each week, we note that, from May 1965 to December 1965, 137 out of 259 insertions (52.9%) were inserted by a male physician and 122 (47.1%) by a female physician. In the IUD services at village level for the same period, we see that the number of insertions done in a village stationary clinic where a pre-insertion examination was done by a male physician once a week was net much different from the number of insertions made by a female physician in the village mobile service once a week. Therefore, we could state that there is not much problem of embarrassment which might prevent women from coming into IUD services operated by male physicians, but the problem is whether a physician, regardless of sex, has an interest in IUD service itself. 3. IUD Insertions by Time in Relation to Menses: As to the time of IUD insertion within the menstrual cycle, first of all, about 40% out of the total insertions were made during the period of post-partum amenorrhea and other 60% of the total insertions were inserted during the menstruation Period in both stationary and mobile IUD services. In the mobile service where the IUD insertion was made at the time of visit regardless of menstrual cycle, 52.1% or 108 out of 174 insertions were done after the 10th day of the cycle rather than requesting postponement until the proper day of the next cycle. When we asked for a revisit from those women who came in after the 10th day of the menstrual cycle, about half of them failed to come back. At the stationary clinic, for an example, where the IUD was inserted within the first 10 days of the cycle, 34 out of 159were asked to revisit because of Poor timing of their first visit. Only 47% or 16 out of those 34 cases came back for insertion of the IUD at the proper time, and 53% or 18 of them failed to revisit the clinic up to December 1965. When we apply this rate of failure to revisit (53%) to the mobile services, we should have loot 57 out of 108 cases inserted after the 10th day of the cycle. In other words, about 20% or 57 out of the total number of insertions (290 cases) were saved from failure to insert due to insertion being performed regardless of when in her cycle the woman first visited the clinic 4. Possibility of Using Paramedical Personnel for IUD Insertion: As Part of the mobile service from May 1965 a nurse inserted 162 IUDs without a Physician's supervision and another nurse inserted 189 IUDs in the village stationary clinic after screening by a physician, while a private practitioner inserted 190 IUDs in the mobile service for the same period. (from May 1965 to April 1966). Therefore, the problem here apart from the legal aspects is not so much in the insertion itself but rather in the pre-insertion examination during which all contra-indicated cases must be identified as well as the identifying of side effects after insertion such as pregnancy, expulsion and removal. 5. The Over-all Evaluation of the Study in terms of an IUD Termination Rate: Even though there is a considerable variation in the relative ranking of the termination rates between the inserters and between the different times of insertion, the lowest rate was obtained for postpartum cases when the insertion was made by the specialist in Obstetrics and Gynecology; a somewhat higher termination was obtained in the same cases with insertion by a nurse. This suggests to us that the best recommendation to clients for IUD insertion would be to visit the Obstetrics and Gynecology specialist during the postpartum period, and if this feasible, then not is to see a trained nurses during the same period. This also leads to there commendation to the Government that the IUD services should be integrated into the general maternal health program, especially with the post-natal care program in the community. In short, when IUD services are extended to remote areas using medical and paramedical personnel, IUD acceptance rate as well as its use-effectiveness rate are considerably increased. This increase, in turn, can contribute markedly to the reduction of fertility in the rural population of Korea.
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