For health care workers who travel between clinics in rural areas, adequately preparing the instruments that will be used to provide IUD services has long been a serious concern.

In Bangladesh, providers in rural areas had trouble transporting equipment, obtaining fuel and clean water, and finding the time needed to boil and cool instruments (boiling is the process recommended by national guidelines).

Now an innovation in the form of a portable, easy-to-use steam sterilizer is addressing this problem. This low-tech steam sterilizer allows health workers to fully sterilize IUD instruments before a visit to a rural clinic, so that they no longer have to rely on boiling the instruments at the clinic itself.

The steam sterilizer, which represents a unique step toward providing safer IUD services in Bangladesh, is a design that has broad-reaching applications to infection prevention programs around the world.

Infection Prevention and IUD Services

IUDs are a very popular method, used by nearly 500,000 women in Bangladesh alone.

However, one concern with IUD use is the potential risk for post-insertion pelvic inflammatory disease (PID), a serious disease that can lead to chronic lower abdominal pain, ectopic pregnancy, infertility, and even death.

Studies have demonstrated that there is an increased risk of PID for a period of roughly one month following IUD insertion. This increase is presumably related to the introduction of bacteria into the uterus during the insertion procedure.

Proper processing of IUD instruments and supplies and strict attention to aseptic technique can help reduce the risk of post-insertion PID.

Development of the Steam Sterilizer

AVSC International was one of several organizations that worked with Bangladesh's National IUD Task Force to develop the simple, portable steam sterilizer for IUD instruments and supplies.

The Task Force was organized in 1993 by the Bangladesh Ministry of Health and Family Welfare (MOHFW) to address inadequacies in IUD service provision in Bangladesh.

Processing of instruments and supplies was one area identified as needing attention - particularly in Bangladesh's "satellite clinics."

Satellite Clinics

The Directorate of Family Planning of the Bangladesh MOHFW began the Satellite Clinic Program in 1988 to increase access to family planning and other maternal and child health services in rural Bangladesh.

These satellite clinics consist of designated homes in rural areas which are visited on a regularly scheduled basis by a health care worker. Under this program, IUD insertions and other services are provided at the satellite clinics.

Although the MOHFW guidelines recommend boiling of IUD instruments at the satellite clinic sites, this is often impractical for rural health care workers who may have difficulty finding the fuel and clean water needed for boiling. The results of one evaluation indicated that instruments were being properly processed only 25% of the time, primarily due to logistical difficulties.

The Task Force recognized that finding a better way to process IUD insertion instruments was of special concern in these satellite clinics.

A Practical Solution

By adapting a currently available portable steam sterilizer, the Task Force was able to develop a practical solution to the problem of inadequate instrument processing for IUD insertion.

The Task Force adapted the steam sterilizer from one originally designed for sterilizing hypodermic needles and syringes in the World Health Organization's Expanded Programme on Immunization.

The adapted sterilizer allows for sterilization to take place at a stationary clinic - or at a health care worker's home - before the worker visits a satellite clinic. Heat for the sterilization process can be provided by an electric or gas burner or by a portable stove, depending on the resources available at the stationary service site or the home of the health care worker.

The two standard racks that were a part of the original sterilizer can be used for sterilization of reusable gloves and cotton balls. After they are processed, these items can be removed from the sterilizer and transported to satellite clinics in plastic bags.

Metal compartments that hold IUD insertion instruments were specially designed and built to fit into the steam sterilizer. Three compartments, each of which contains a full set of IUD insertion instruments, can be sterilized at one time. Sterile instruments can be left in the sterilizer and transported to the satellite clinic in a specially designed backpack carrying case.

Easy and Convenient to Use

With assistance from AVSC, the adapted steam sterilizer was tested in both laboratory and field conditions, and these tests have confirmed the effectiveness of the device.

Studies in Bangladesh have indicated that health care workers find the sterilizer easy and convenient to use and transport to satellite clinics.

The National Technical Committee in Bangladesh has approved the IUD instrument sterilizer for use. It is currently being used at some nongovernmental service sites, and plans for expansion to all MOHFW sites are now underway. Global public-sector distribution of the sterilizer is currently under discussion.

An Important Development

Although boiling IUD-insertion instruments is an acceptable process, it is often difficult to accomplish in rural, low-resource settings. In addition, boiling is not practical for some IUD supplies, such as cotton balls.

In the satellite clinics in Bangladesh, using the steam sterilizer before visiting the clinics can help providers ensure that supplies and instruments are adequately processed. This way providers no longer need to rely on the limited resources that may be available at each satellite clinic.

The steam sterilizer is portable, durable, and easy to use - proving that the sterilization of IUD instruments and other supplies can be easily accomplished without complex technology.

An important development in providing safer IUD services in Bangladesh, the steam sterilizer has equally important potential in other low-resource settings around the world.

This article is based on "Adaptation and Validation of a Portable Steam Sterilizer for Processing IUD Insertion Instruments and Supplies in Low-Resource Settings," to be published in the August 1997 issue of the American Journal for Infection Control. Dr. Mark Barone, medical associate for AVSC, and Dr. Abu Jamil Faisel, country representative for AVSC's Bangladesh office, are two of the authors of the journal article. Karen Levin is a project assistant for AVSC International.