Knowledge of family planning and the levonorgestrel intrauterine system

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Improving knowledge of family planning is difficult in rural areas with limited resources, where cultural considerations may act as a barrier to dissemination of information. In many rural areas the family is the responsibility of the husband, even concerning such intimate matters as family planning. It was this which prompted Servet Ozgur and colleagues (pages 1226–1232) to conduct a unique experiment in Turkey to test the hypothesis that improvement of knowledge depends on the gender of the persons receiving education in family planning. The authors selected three similar villages; in the first the women were the recipients of this education, in the second the husbands and in the third both the women and their husbands. The women were interviewed by female investigators and the men by male investigators. The questions concerning knowledge of family planning may seem unusual to many practitioners but they reflect the local culture and are relevant to the local people. The results are complex and may be beset by confounding factors but in general, knowledge of men and women concerning family planning improved, whether the education was directed at the men or the women; in the women attitudes to planning the size of their families changed, but not in the men; and the women's contraceptive practices changed significantly, even in the village where only the men were exposed to the education programme. The authors conclude that in this rural setting with a low level of literacy it is consistent systematic education in family planning which is important, and not the gender of the recipients of this education.

In rural areas the intrauterine contraceptive device is an important method of family planning, but which is the best device? R. S. French and colleagues (pages 1218–1225) attempt to answer this question in their systematic review of randomised trials of the levonorgestrel intrauterine system compared with other intrauterine contraceptive devices. After investigating seven electronic databases and over four hundred publications the authors found five randomised trials which satisfied the entry criteria for the study. The levonorgestrel intrauterine system was as effective in preventing pregnancy as larger copper-bearing intrauterine contraceptive devices, and more effective than smaller copper-bearing devices; the levonorgestrel system had similar rates of continuation as the copper devices; and a reduced rate of ectopic pregnancy compared with the smaller copper devices. Expulsions were more common with the levonorgestel system than with the larger copper devices but less common than with the smaller copper devices. Removal due to amenorrhoea was more common with the levonorgestrel system, but removal due to menstrual irregularity was more common with the copper devices. The current evidence suggests that the larger copper-bearing devices are just as effective as the levonorgestel intrauterine system, last longer, and are cheaper, and in women with normal periods may be the preferred device, especially in areas with limited resources. The levonorgestrel system is better for women who already have heavy painful periods.

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