Despite the safety and efficacy of the intrauterine device (IUD) and the reduction of cost barriers since the Affordable Care Act (ACA), only about 12% of American women use that method of contraception.1,2

Research shows that the women most likely to use an IUD or implant are ages 25 to 34 years, were born outside of the United States, live in a Western state, and report their religious affiliation as “other.”2

Researchers recently studied age and race differences in women’s knowledge and attitudes toward the IUD to find clues about why it is underused in the United States, compared with similar nations.1

“The main question behind the study came out of some work I had been doing at a homeless shelter in Philadelphia, where, very often, I saw young women interested in IUDs, and their mothers and older friends would discourage them,” says Sara Edwards, MD, principal investigator of the study and a resident at the University of Illinois at Chicago. “I wanted to look at whether older women had more negative views, based on older IUDs like the [Dalkon Shield]. We found that was not the case in our study’s population, at least.”

The Dalkon Shield, manufactured in the 1970s, was withdrawn from the market after more than 200,000 lawsuits worldwide alleged side effects of bleeding, pain, uterine perforations, pelvic inflammatory disease, sterility, ectopic pregnancies, and unplanned pregnancy. (More information is available at: https://pubmed.ncbi.nlm.nih.gov/10117045/.)

Researchers also examined data for racial differences in attitudes, education, and perceptions. “We wanted to look at everything by race because of well-documented differences in how women use contraception,” Edwards explains. “We did find some differences in our study, and the one that was the most interesting was self-reported: confidence in their knowledge of whether they felt they had sufficient knowledge about IUDs to make a decision.”

Women of all races showed the same level of knowledge about IUDs, but Black women rated their knowledge much lower. “This means we should be more reflective as clinicians in how we’re discussing these contraceptive options with our patients,” Edwards explains. “Whether we intend to or not, Black women are hearing things from their providers that make them think they know less.”

Investigators also found more negative perceptions about IUDs among Black women. The question is why this is true when Black women’s IUD knowledge is the same as white women’s IUD knowledge. “If I were to guess about why these sorts of attitudes persist, it’s probably because of real [problems] in the past,” Edwards says. “There are studies showing that non-white women more often feel like they get coercive birth control counseling in the hospital, and that kind of thing.”

While studies have not pinpointed how much providers are being coercive in contraceptive counseling, this perception should be treated as a real factor, she adds.

OB/GYNs and family planning clinicians can prevent bias from seeping into their patient conversations by making sure they have a standardized starting conversation with every patient, Edwards suggests. They could ask themselves: “Why did I suggest that to this woman? Did I have some bias?”

“I go through in a broad overview of general effectiveness of the most common forms of contraception, and I let patients drive the conversation,” Edwards says. “I think IUDs should be used more than they are, but it’s very hard to walk that line of trying to encourage someone to use something without it coming across as coercive to some patients. I let patients steer the conversation.”

To approach conversations with patients, clinicians can break down the options and ask patients when they plan to have a baby. “That makes people think, ‘Oh, maybe years,’” Edwards says. “Then, I say, ‘You might want to think about these options.’ I talk about IUDs and implants, and I say, ‘These are the options that work about as well as getting your tubes tied, but they’re all reversible.’”

Edwards also hears what patients want and do not want in a birth control method. “It might be that putting something in their uterus is scary to them, or having something implanted in their arm,” she explains. “Or maybe having hormones is something they don’t want.”

If women express interest in the IUD, Edwards speaks candidly about how the IUD’s placement can be painful, especially if they have never given birth. “If women go into it thinking it’s no big deal, then they will be unpleasantly surprised and it may be crampy going in,” Edwards says. “I tell them what to expect so it’s not a shock.”

Clinicians need to help reduce logistical barriers to IUDs, which remain common despite the no-cost mandate of the Affordable Care Act. Because of the contraceptive mandate, two-thirds of American women with private insurance do not have to pay out-of-pocket costs for IUDs. For women on Medicaid, the IUD is covered without cost-sharing.3

“It’s very common for there to be some sort of logistical barrier to IUDs, which is most frustrating,” Edwards says. Lack of peer and family support and familiarity is another barrier to IUD use. For example, many women have not heard much about the IUD and may not know women who use it, or know that most insurance plans will cover it. This can be a barrier to its adoption, she adds.

“Personally, in a residency with a lot of very hard-working, young, professional women, a vast majority of OB/GYN residents are choosing to use IUDs,” Edwards says. “We think about that [contraceptive method] much more often than the average person does.”

REFERENCES

  1. Edwards S, Mercier R, Perriera L. Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter? J Obstet Gynaecol Res 2020: doi: 10.1111/jog.14552. [Online ahead of print].
  2. Guttmacher Institute. Contraceptive Use in the United States. April 2020. https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
  3. Kaiser Family Foundation. Intrauterine devices (IUDs): Access for women in the U.S. Sept. 9, 2020. https://www.kff.org/womens-health-policy/fact-sheet/intrauterine-devices-iuds-access-for-women-in-the-u-s/