Intrauterine contraceptive device; family planning; professional nurses; primary healthcare; qualitative research; reproductive health; health system barriers; service delivery barriers; long-acting reversible contraceptives (LARCs); Eastern Cape Province; South Africa
Long-acting reversible contraceptives (LARCs), particularly the intrauterine contraceptive device (IUCD), are globally recognized as safe, highly effective, and reversible methods that significantly reduce unintended pregnancies across the reproductive life course.1 Despite their proven efficacy, global utilization of IUCDs remains uneven, reflecting the influence of complex social, organizational, and health system factors beyond clinical effectiveness.2 As a cornerstone of reproductive health, IUCDs empower individuals to make informed decisions regarding childbearing while contributing to improved maternal and child health outcomes.3 Their attributes, including cost-effectiveness, long-term protection, non-hormonal options, and immediate reversibility, make them particularly suitable for women across all reproductive age groups.4
Globally, increasing attention has been directed toward strengthening IUCD provision within primary healthcare systems as part of broader public health strategies aimed at reducing unintended pregnancies, unsafe abortions, and maternal mortality.5 These efforts align with global development priorities, particularly Sustainable Development Goals (SDGs) 3 and 5, which focus on ensuring healthy lives and reducing maternal mortality, and on gender equality and universal access to reproductive health services, respectively. Achieving these goals depends heavily on equitable access to quality family planning services and informed contraceptive choices.6 In this context, healthcare providers, particularly professional nurses, play a crucial role in facilitating IUCD uptake, as they are central to client counselling, IUCD insertion, follow-up care, and the management of side effects and potential complications (citation). Evidence suggests that healthcare providers’ perceptions and attitudes toward IUCDs significantly influence both their recommendations and women of childbearing age’s acceptance of the method.7 Adequate knowledge and positive attitudes among nurses are therefore essential to dispel myths, address misconceptions, and support informed decision-making among women.
Across Africa, however, the uptake of IUCDs remains relatively low despite high rates of unintended pregnancies. This gap is often attributed to systemic challenges such as inadequate training of healthcare providers, limited resources, cultural beliefs, and persistent misconceptions about contraceptive methods.8 These barriers are further compounded by health system constraints, including workforce shortages and inconsistent service delivery, which hinder the effective integration of IUCD services into routine care.9
In South Africa, although family planning services are widely available within primary healthcare settings, the provision and uptake of IUCDs remain suboptimal. Structural challenges such as staff shortages, heavy workloads, and insufficient infrastructure continue to affect the quality and accessibility of reproductive health services.10 These challenges are more pronounced in rural and underserved areas, where women face significant barriers to accessing a full range of contraceptive options.
The situation in the Eastern Cape Province is particularly critical, especially in rural areas such as the OR Tambo region, where limited human resources, inadequate training opportunities, and fragmented service delivery12 are prevalent. These issues negatively affect the provision of IUCD services and restrict women’s ability to make informed reproductive health choices.11
A qualitative, exploratory, descriptive study design was utilised for this research. The study involved fourteen professional nurses, aged 25 to 35 and older, who were purposefully selected from four community healthcare (CHC) facilities in the King Sabata Dalindyebo Sub-District of OR Tambo for face-to-face interviews. Only those professional nurses who were directly involved in family planning and could provide Intrauterine Contraceptive Devices (IUCD), including nurses working in the maternity unit and offering family planning services after postpartum delivery, were included in the study.
The OR Tambo District has one of the highest adolescent pregnancy rates in the country, with around 27% of young women aged 15–19 either having given birth or being pregnant. The CHCs selected for data collection were Baziya, Ngangelizwe, Mbekweni, and Mqanduli, which serve as primary access points for IUCD insertion, staffed by trained professionals focused on improving contraceptive service delivery.
To be eligible for selection, professional nurses had to meet the following criteria: (A) Professional nurses who were inserting IUCDs.
(B) Professional nurses working in family planning units at community healthcare centers. (C) Professional nurses trained in IUCD services, practicing at the CHC facility, who can communicate in English. Professional nurses who were outside the family planning brackets were excluded from the study. Professional nurses are undergoing community service. IUCD-trained Professional nurses who are on leave.
The interviews were conducted by the researcher, who served as the principal investigator for the study. The number of participants was determined based on the principles of information saturation. Each participant voluntarily answered each question before moving on to the next. The study included professional nurses who had received both informal and formal training in IUCD insertion, representing a range of backgrounds in knowledge, education, management, and practice.
The lead researcher, trained in qualitative methods, conducted face-to-face semi-structured interviews using an interview guide based on the literature review and study objectives.12 The interview guide included thirteen open-ended questions that examined participants’ knowledge, attitudes, and practices regarding IUCD provision, while allowing for further exploration of emerging topics. Interviews were conducted in English in private rooms at the facilities and lasted approximately 30 to 45 minutes.
All interviews were audio-recorded with participants’ permission. The data collection process continued until data saturation was reached, at which point no new information emerged from subsequent interviews. This approach ensured a comprehensive understanding of the participants’ perspectives and experiences.13
Audio recordings were transcribed verbatim and anonymized by replacing participants’ names and facility identifiers with codes for confidentiality. Transcripts were reviewed for accuracy and securely stored on password-protected devices accessible only to the researcher and supervisors. Data analysis was conducted using Braun and Clarke’s six-phase thematic analysis, with NVivo software.14
To evaluate the accuracy and reliability of the data, the criteria of credibility, transferability, dependability, and confirmability were systematically applied.12
The interview transcripts were analysed using a systematic inductive thematic analysis. Data were collected through individual face-to-face interviews, which were transcribed verbatim. Initially, the principal investigator transcribed the interviews, generated codes and themes, and subsequently reviewed, interpreted, and described them. Additionally, the researcher analyzed the codes and themes, making necessary adjustments and consolidations. The analytical process aimed to refine the ideas into their fundamental concepts, which were articulated as distinct themes. Data analysis began after additional interviews and concluded once thematic saturation was reached. An independent researcher, fluent in both Oromic and English, reviewed the transcripts to ensure accuracy and preserve the original meaning during translation.
Ethical clearance was received from the Walter Sisulu University Faculty of Health Sciences Research Ethics Committee WSU HREC 183/2025 from 1 August 2025. Permission was also granted by the Eastern Cape Department of Health, the OR Tambo District Department of Health, and the management of the Community Health Centres in the King Sabata Dalindyebo sub-district. Professional nurses who met the inclusion criteria of the study were notified of the purpose of the study as it attempted to improve knowledge, attitude, and practise of professional nurses regarding the use of IUCD contraceptives in selected CHC facilities in KSD sub-district or O. R Tambo district. Written informed consent was obtained prior to data collection, including permission to record interviews. To ensure confidentiality, participants’ names and identifiers were replaced with unique codes, and all data were securely stored on password-protected devices accessible only to the researcher and supervisors. Findings are reported in aggregate form to protect participants’ identities.
The study included 14 professional nurses, predominantly female,13 with only one male participant refer to table 1. Most were aged 25–35 years,8 indicating a relatively young workforce, and the majority had 1–10 years of experience,7 reflecting a mix of early- and mid-career professionals. In terms of IUCD training, most participants had received informal training,9 while only a few had formal training2 or no training,3 highlighting gaps in structured professional development. The table below provides additional details on the participants’ demographics.
Three main themes emerged from participants’ experiences regarding health system and service delivery barriers to the uptake of IUCDs in selected facilities within the KSD sub-district refer to table 2.
| Theme | Categories |
|---|---|
| Theme 1: Limited knowledge and clinical competence regarding IUCD services. |
|
| Theme 2: Positive attitudes towards IUCDs |
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| Theme 3: Reduced confidence in providing IUCD services |
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3.2.1. Theme 1: limited formal training and insufficient clinical competence
Participants reported a lack of formal training and limited exposure, as well as core knowledge gaps and misconceptions about IUCDs. Throughout the interviews, nurses reported receiving minimal formal education on IUCDs.
Participants 3 and 4. For example, the nurses admitted, “I don’t have extensive knowledge about IUCDs because I haven’t received any formal training. Participant 4 explained, “I cannot offer it now because I don’t know how to insert it … No, I’m not trained.” (Participant 4)”.
Participants displayed basic knowledge of IUCDs, though inconsistently. Many accurately described IUCDs as long-acting contraceptive devices.
Participant 5 explained, “An IUCD is an intrauterine contraceptive device. It is inserted into a woman’s uterus … It is a long-term contraceptive method – safe and effective (about 99.9% safe) … It helps women avoid frequent clinic visits”.
Participant 7 described the IUCD as “a contraceptive that is inserted via the cervix into the uterus … the one I know of that is a non-hormonal contraceptive that lasts for five years”.
Participant 9: correctly distinguished hormonal vs non-hormonal types: “IUCD is a device … We have two types … I only know the copper one, the Copper IUCD.”
Participant 1: cited benefits and limitations: for instance, one noted that IUCDs allow “long spacing between children, and you don’t go to the clinic often … You insert it once, and it lasts for about five years. You then come in for a check-up after six weeks.”
Participant 2: observed that IUCDs “last a long time” and help reduce clinic visits, an advantage over short-term methods.
Nevertheless, some knowledge gaps and misconceptions emerged. For example, Participant 6 and Participant 8 confessed minimal understanding: “I know that this is one of the methods considered … It can last up to five years … That’s all I know”.
Others were unsure about contraindications. Several said they could not mention any or could list only basic criteria, for example, avoiding IUCDs during pregnancy. This knowledge gap likely stems from the limited training cited above. Constructivist analysis recognizes that nurses’ IUCD “knowledge” is socially constructed through scant training and experience, rather than grounded in full biomedical guidelines. There is a significant issue with service delivery and clinical awareness at the four primary healthcare (PHC) facilities in the KSD Sub-District. The Eastern Cape is particularly affected by high rates of health challenges in this predominantly rural area. One major concern is the notably high incidence of unintended pregnancies, especially among adolescents. Recent statistics indicate that the OR Tambo District has one of the highest rates of adolescent pregnancies in the country, with approximately 27% of young women aged 15–19 either having given birth or currently being pregnant. This situation reflects a pressing public health concern. There is currently no statistical report available regarding the insertion of long-term contraceptives, specifically IUCD. Despite professional nurses attending in-service training, the program coordinators are not providing the necessary support to these institutions, which contributes to the ongoing problem of teenage pregnancy in the KSD municipality.
3.2.2. Theme 2: Positive attitudes towards IUCDs
Participants’ explanations indicated a generally positive perception of IUCDs and a willingness to recommend them, although some expressed reservations or discomfort regarding their use. Many nurses articulated favorable attitudes toward IUCDs and acknowledged their advantages in contraceptive care.
These participants clearly valued the long-term benefits of IUCDs. Another said she felt comfortable recommending IUCDs:
Participant 1 For example, stated, “I recommend it, especially for children still at school, because she will only come after five years … she can attend university and graduate without incurring daily expenses.”
Participant 5: “I feel comfortable because it saves time and reduces clinic congestion”.
Participant 8 was enthusiastic: “I would happily recommend the IUCD because it lasts longer, meaning clients don’t have to visit the clinic often. … We all know there are long queues, so to avoid that, I’d recommend the IUCD.”
Several nurses expressed hesitations or a lack of confidence. A key sub-theme was “lack of confidence due to inadequate training.
Participant 7 admitted, “Since I am not trained, I don’t feel comfortable recommending IUCD because I won’t be able to offer it myself.”
Reflecting this, another participant, 11, stated, “No. We do not offer IUCDs in our facility because we are not trained to do so.”
The results indicate that most professional nurses hold predominantly positive views about IUCDs, particularly recognising their effectiveness in reducing both teenage pregnancies and unintended pregnancies. However, these positive opinions often depend on the nurses’ self-assessment of their competence and their access to adequate training. In some cases, a lack of skills and uncertainty led to hesitation in actively encouraging clients to consider IUCDs. These insights suggest that the confidence of nurses plays a significant role in the contraceptive options they present to clients. The findings of this research indicate that enhancing training and support for nurses could positively influence their attitudes and strengthen their advocacy for IUCDs.
3.2.3. Theme 3: Constrained clinical practices related to IUCDs
Participants also reported receiving health education provided to the client before and after IUCD insertion and follow-up procedures.
Participant 1 first asks how much Participant knows about IUCDs. Then, provide information, check for STIs, and explain that the IUCD can remain in place for several years …”.
Participant 7 should inform clients before insertion about the procedure and what they should expect after insertion.” These statements suggest that nurses strive to educate clients, consistent with their positive attitudes.
Several nurses acknowledged that much IUCD-specific counselling does not take place because IUCD insertions are rare.
As Participant 6 noted in a frustrated tone, “Because I’ve never inserted it … I don’t do any counselling pertaining to IUCDs.”
Participant 1. “We do them occasionally, but the clients are few.”
Other participants had never inserted an IUCD themselves.” Participant 4 reported. “I’ve never inserted one … I don’t insert IUCDs.”
Participant 7, a nurse, stated clearly, “We don’t perform IUCD since we are not trained.”
Participant 1 admitted: “We improvise most of the time … we don’t have the proper instruments.”
Participant 1addressed that “Most of the time, we refer patients to the hospital because we don’t insert IUCDs here.”
Participant 2 confirmed that” We don’t have enough equipment … we improvise sometimes.”
These quotes show that the clinical practice of IUCD insertion was rare and non-existent at many sites. When insertions did occur, PNs improvised due to equipment shortages. The results indicate that the actual implementation of IUCD-related clinical practices varies widely across facilities. While nurses mentioned offering general contraceptive counselling, their ability to provide specific counselling and perform IUCD insertions was frequently limited by a lack of training and resources. Numerous participants had never conducted an IUCD insertion, even though they recognized its theoretical advantages. This discrepancy between understanding and actual practice reveals lost opportunities for broadening access to long-acting contraceptive methods. These findings underscore the need for practical skill development to translate knowledge and favourable attitudes into standard clinical procedures.
A qualitative, exploratory, and descriptive study was conducted to examine professional nurses’ perspectives on their knowledge, attitudes, and practices regarding the use of Intrauterine Contraceptive Devices (IUCDs) in selected primary healthcare facilities within the KSD Subdistrict of the OR Tambo District.
The study identified barriers to IUCD contraceptive utilization, categorized into three areas: limited formal training and inadequate clinical competence, positive attitudes towards IUCDs, and constrained clinical practices related to IUCDs. The findings suggest that participants believe their knowledge, attitudes, and practices as professional nurses are hindered by insufficient formal training and clinical competence in providing IUCDs. Both knowledge, attitudes, and practices (KAP) and clinical competence are essential for effectively delivering necessary information to women within the reproductive health system.
Most PNs reported relying on informal training or observation rather than engaging in structured training.15 This observation reinforces prior research that identified inadequate training among healthcare providers as a significant barrier to the uptake of long-acting reversible contraceptives. The absence of formal education, training, and practical experience not only impacts technical skills, such as IUCD insertion, but also diminishes nurses’ confidence in offering comprehensive contraceptive services. As illustrated in this study, participants who lacked formal training expressed uncertainty about insertion procedures and the management of complications. The limited availability of services at the facility level, especially in the KSD Sub-district, Eastern Cape, is concerning, as it has recently been identified as a hotspot for teenage pregnancy. The occurrence of unwanted pregnancies can significantly hinder service delivery, resulting in harmful outcomes for affected individuals.16
The knowledge gap in training represents a significant barrier to the effective provision of IUCDs. PNs are critical sources of information, as they guide childbearing women in selecting the most appropriate contraceptive options for their individual needs.15 Given their vital role in reproductive health, it is essential that nurses receive comprehensive training to improve service delivery outcomes. The training participants exhibited foundational knowledge of IUCDs, particularly regarding their effectiveness, long-term contraceptive protection, and their ability to reduce the frequency of clinic visits. This suggests that nurses are aware of the theoretical benefits of IUCDs. However, this knowledge was often incomplete and accompanied by misconceptions, especially regarding contraindications and clinical management. The inconsistency in knowledge reflects a gap between theoretical understanding and clinical competence, which may compromise the quality of counselling and limit clients’ informed decision-making. These findings support the notion that knowledge alone is insufficient without practical training and continuous professional development.
The study further found that nurses generally held positive attitudes towards IUCDs, recognizing their value in preventing unintended pregnancies and reducing the burden on healthcare services. Many PNs expressed willingness to recommend IUCDs, particularly for young women and those seeking long-term contraception. However, these positive attitudes were often conditional on perceived competence. PNs who lacked training reported reduced confidence and reluctance to recommend IUCDs, highlighting the strong link between knowledge, skills, and attitudes. This suggests that improving provider competence may not only enhance service delivery but also strengthen positive attitudes and advocacy for IUCD use.17
In clinical practice, the findings revealed a significant gap between knowledge and actual service delivery. Although nurses reported providing general contraceptive counselling, IUCD-specific counselling and insertion were limited or absent in many facilities. In several cases, clients were referred to hospitals due to the unavailability of trained staff or necessary equipment. This indicates missed opportunities to expand access to long-acting contraceptive methods at the primary healthcare level. The inconsistency in service provision underscores systemic challenges within the healthcare system, including inadequate infrastructure, insufficient supplies, and a shortage of human resources.18
Faced with organizational constraints, such as staff shortages and high patient workloads, IUCD service delivery is affected.19 Nurses reported being overwhelmed by clinical demands, leaving little time to provide comprehensive contraceptive counseling or perform IUCD insertions. These findings reflect broader health system challenges in resource-constrained settings, where competing priorities often limit the implementation of specialized services. The shortage of equipment and reports of improvisation during procedures further raise concerns about the quality and safety of IUCD services.
Finally, our results highlight that IUCD underutilization is not solely a client-related issue but is strongly influenced by provider and system-level factors. The interaction between inadequate training, limited confidence, and organizational barriers restricts the availability and accessibility of IUCD services. Addressing these challenges requires a multifaceted approach, including strengthening pre-service and in-service training, improving resource allocation, and ensuring supportive supervision within primary healthcare settings.20
The findings suggest that targeted interventions are needed to enhance nurses’ competence and confidence in IUCD provision. Structured training programmers, mentorship, and continuous professional development could improve both knowledge and practical skills. Additionally, strengthening health system support, including adequate staffing, equipment, and supply chains, is essential to ensure consistent service delivery.
Future research should explore intervention strategies to improve provider capacity and examine their impact on IUCD uptake in similar settings. There is also a need for broader studies to assess how systemic factors influence contraceptive service delivery across different regions. Additionally, evaluating the effectiveness of training programs for professional nurses, as well as the screening procedures utilized, could provide insights into improving their skills in identifying and managing side effects associated with IUCDs. This research could also assess the quality of health education provided to patients following the insertion of these contraceptive devices.
This study was conducted in 4 Community healthcare clinics in a single rural sub-district; the findings may not apply to other contexts. The qualitative design and purposive sampling limit statistical generalizability. Self-reported interviews may introduce response bias, including social desirability. Excluding other healthcare providers involved in IUCD service delivery may also limit perspectives. While researcher subjectivity was acknowledged, reflexivity and peer debriefing enhanced trustworthiness. The small sample size of 14 and practical constraints suggest that findings should be interpreted within their specific context.
This study reveals that while nurses in Eastern Cape primary healthcare facilities generally have positive attitudes toward IUCD use, significant knowledge and skill gaps remain. Inadequate training and limited practical experience hinder their ability to provide effective IUCD counselling and insertion. As a result, many facilities rely on referrals instead of offering comprehensive services on-site. Barriers like staff shortages and high workloads further complicate the integration of IUCD services. Addressing these issues requires policy-driven solutions focused on training, professional development, and resource allocation to enhance provider competence and support health systems, ultimately improving IUCD uptake and reproductive health outcomes.
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Walter Sisulu University WSU HREC 183/2025 on 01 August 2025.
For studies involving human subjects, Informed Consent Statement: Informed consent was obtained from all participating subjects.
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