Provision of the levonorgestrel intrauterine system in Nigeria: Provider perspectives and service delivery costs

Background: Several organizations in Nigeria are leading pilot introduction programs of the levonorgestrel intrauterine system (LNG-IUS). We conducted a qualitative assessment of providers' experiences across the five programs and an analysis of service delivery costs in one program. Methods: We conducted 20 in-depth interviews (IDIs) with providers. We used project expenditure records to estimate incremental direct service delivery costs of introducing the LNG-IUS in 40 social franchise clinics supported by the Society for Family Health (SFH). We then compared the direct service delivery costs per couple years of protection (CYP) for the LNG-IUS to other family planning methods. Results: Providers appreciated the therapeutic benefits of the LNG-IUS, especially reduction of heavy bleeding. They said that women generally accepted bleeding changes with counseling but noted complaints about spotting and mixed acceptability of amenorrhea. Providers indicated being comfortable with both the insertion and removal process and believed their equipment and infection prevention protocols were adequate. Lack of awareness among women, limited availability, current pricing, and resistance to uterine placement among some women were perceived as barriers. The estimated direct service delivery cost of introducing the LNG-IUS in pilot settings, inclusive of up-front provider training costs, was USD 34 per insertion. Direct service delivery costs at a 'steady state' (i.e., without training costs included for any method) of the LNG-IUS per CYP was similar to that of other contraceptive methods distributed in Nigeria. Conclusion: Providers' positive experiences with the LNG-IUS and direct service delivery costs per CYP that align with those for other methods suggest that the LNG-IUS could be an important addition to the method mix in Nigeria. Product introduction strategies will need to address both the supply and the demand sides, as well as consider appropriate pricing of the LNG-IUS relative to other methods and particularly the copper IUD.