(Published September 2004)

Use of Intrauterine Contraception in the United States

Intrauterine devices (IUDs) were originally developed in Germany in the 19th century as vaginal pessaries. These rigid metal devices, introduced in the pre-antibiotic era, were associated with significant discomfort and serious infection. The design was improved over several decades, but it was not until 1959 that a report by Ishihama and Oppenheimer on their clinical experience with IUDs inspired interest in the devices and sparked the creation of several different types of IUDs.¹

For a variety of reasons, the demand for IUDs has waned over the past three decades in the United States, and fewer providers have been trained in the insertion and management of IUDs. Thirty years ago, nearly 10 percent of US women used intrauterine contraception (IUC) but less than one percent currently do, as shown in Figures 1 and 2.²

Meanwhile, intrauterine contraception is an important contraceptive method in many parts of the world outside the US, and research to develop better device designs is ongoing. As shown in Figure 3, worldwide use of IUC is much higher in Asia, Europe, and Latin America than in North America. In Germany and Denmark over 20 percent of women use IUC. In Mexico, about the same proportion of women use IUC, and the continuation rate is 75 percent at one year.² In Vietnam and Kazakhstan over 60 percent of married women use IUC.5 Currently, there are over 100 million IUC users in the world.⁵

Several factors are responsible for the lower use of IUC in the United States than in other countries, including provider and patient misconceptions, a paucity of trained and willing providers able to insert the devices, provider concerns about litigation, and restrictions imposed by product labeling.

Provider and Patient Misconceptions About Intrauterine Contraception

The persistence of such myths stems in part from misinformation presented in the professional and the lay print and electronic media. A 2002 review of the accuracy of information about copper-containing IUDs in obstetrics and gynecology textbooks from the United States and the United Kingdom found that many exaggerated the disadvantages and understated the advantages of the IUD.⁶ In addition, a majority of the US texts inaccurately reported an increased risk of pelvic inflammatory disease (PID) and ectopic pregnancy associated with the device. There is also evidence that information obtained from the Internet is misleading or inaccurate. A review of consumer-oriented websites that provide information about contraceptive options found that over half stated that IUC increases the risk of PID; about 40% of these websites reported that the risk of ectopic pregnancy is increased with IUC.⁷ Data from a survey of provider-oriented sites, which are less likely to present this misinformation, indicated that about 27 percent stated an association between IUC and PID and 23 percent an association between IUC and ectopic pregnancy.⁷¹

Misinformation is also present in the lay press. In one study, the characteristics deemed most important by the women interviewed—safety, ease and convenience, and effectiveness—were generally not seen to be characteristics of IUC; only 21%, 46%, and 31% of respondents, respectively, felt that these features closely describe IUC.⁸ Interestingly, younger subjects and Hispanic subjects, especially those born outside the US, were more likely to be interested in future IUC use than other groups. These negative patient perceptions exist despite the fact that IUC use is associated with very high user satisfaction ratings, as shown in Table 2.

Paucity of Trained and Willing Providers to Insert Devices

Despite the persistence of misinformation, providers generally have a positive perception of IUC. On a personal level, female obstetrician/gynecologists are more likely than the general population of US women to use IUC, as shown in Figure 4.¹⁰ In addition, a 2002 survey of members of the American College of Obstetricians and Gynecologists (ACOG) documented a positive attitude about IUC, with 95 percent agreeing the method is safe and 98 percent that it is effective.¹⁰ However, even though 80 percent of respondents had inserted IUC in the past year, only 21 percent of those providers had inserted more than 10 devices.¹⁰ The average number of devices inserted per provider was just seven. Thirteen percent of respondents reported they had never inserted a device during training. There was no correlation between the number of IUC devices inserted during training and the number inserted in the last year. The authors of the study believed that IUC underuse was related more to overly restrictive selection criteria than to lack of training in insertion technique.

Provider Concerns About Litigation

The 2002 survey of ACOG members found a correlation between the degree to which respondents believed that IUC is associated with PID and a lower rate of insertion.¹⁰ There also was a statistically significant correlation between fear of litigation and a lower number of IUC insertions in the previous year. The study authors suggest that a persistent belief that IUC causes PID and thus increases litigation risk is a primary reason that IUC is underused in the United States. This concern has not been substantiated by reviews of litigation experience—most lawsuits regarding IUC have been product liability suits against manufacturers rather than professional liability suits against providers.^13,14 Between 1988 and 1996 the Planned Parenthood Risk Management Group was notified of approximately 125 events per year that were involved IUC, the majority of which were minor problems.¹⁵ An analysis of earlier claims against Planned Parenthood found that only 18 (10 percent) involved IUC and only two of those resulted in unfavorable settlements that were related to failure to diagnose and treat PID rather than to IUC use itself.¹⁶ Providers can reduce the risk of litigation by providing thorough patient counseling, discussing the risks and benefits, ensuring proper insertion and follow-up, and obtaining written informed consent.

Restrictions Imposed by Product Labeling

Product labeling for IUC may restrict more widespread usage. The prescribing information for the two types of IUC available in the United States recommends use only in women who have at least one child, no history of PID, and no history of ectopic pregnancy.^17,18 However, based on current evidence, nulliparous women should not be excluded from IUC use based on their parity alone.^19,20,21 Clinicians, particularly nurse practitioners or others practicing with protocols, may feel hesitant about or be restricted from providing "off-label" prescriptions for IUC devices to nulliparous women, when IUC may be the best choice for a particular patient. The prescribing information incorrectly implies that use in nulliparous women is unsafe and therefore imposes unnecessary restrictions that prevent some clinicians from offering this method to appropriate candidates.

References

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2. Rivera R, Best K. Current opinion: consensus statement on intrauterine contraception. Contraception. 2002;65(6):385-8.
3. Gallup Survey, 1998-1999.
4. Ortho Pharmaceutical. 2003 Annual Birth Control Study.
5. Dannemiller Memorial Educational Foundation. Patient update: what to expect when having an intrauterine device (IUD) inserted. Contraceptive Rep 1998 Sep;9(4).
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7. Weiss E, Moore K. An assessment of the quality of information available on the internet about the IUD and the potential impact on contraceptive choices. Contraception. 2003;68(5):359-64.
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9. Data from Ortho Pharmaceutical Corporation's 1994 Ortho Birth Control Study.
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11. Population Reference Bureau. Family Planning Worldwide 2002 Data Sheet. 2002.
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13. Westhoff C, Marks F, Rosenfield A, et al. Clinical and legal factors influencing IUD use in the United States. In: Bardin C, Mishell D, eds. Proceedings from the Fourth International Conference on IUDs. Boston: Butterworth-Heinemann; 1994:100-8.
14. Dannemiller Memorial Educational Foundation. Patient update: modern IUDs: an update. Contraceptive Rep.1998 Nov;9(5).
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16. York SS. IUD litigation: the Planned Parenthood experience. Am J Gynecol Health. 1989;3(3-S):35-7.
17. ParaGard T 380A Intrauterine Copper Contraceptive [package insert]. North Todawanda, NY: FEI Products; 2003.
18. Mirena [package insert]. Montville, NJ: Berlex Laboratories; 2000.
19. Duenas JL, Albert A, Carrasco F. Intrauterine contraception in nulligravid vs parous women. Contraception. 1996;53(1):23-4.
20. World Health Organization. Selected Practice Recommendations for Contraceptive Use. Geneva: WHO, 2002.
21. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzman-Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345(8):561-7.