After falling in and out of favor, the intrauterine device (IUD) is once again gaining popularity among women in the United States and worldwide.

In the late 1960s and early 1970s, the IUD was used by one out of 10 reproductive-age women in the United States. But by the mid-1990s, the IUD had mostly disappeared from use, according to a new paper on the IUD’s rocky history.1

One particular IUD nearly ended the contraceptive: The Dalkon Shield.

“For people who were around in the 1970s or early 1980s, and for those of us who studied birth control, the Dalkon Shield looms so hard over the history of IUDs,” says Elizabeth Watkins, PhD, dean of the graduate division, vice chancellor of student academic affairs, and professor of history of health sciences at the University of California, San Francisco.

The Dalkon Shield consisted of a five-pronged, crablike shield. It contained small amounts of copper and was attached at the base to a string. Its marketing campaign emphasized its safety over traditional contraceptive pills, according to the Embryo Project Encyclopedia.2

Within a few years, 2.2 million women used the Dalkon Shield, making it the most popular IUD in the United States in the 1970s. But problems emerged, including septic infections. Investigators found that the string attached to the device would fray, disintegrate, and draw bacteria into the uterus, leading to septic infection, miscarriage, and death.2

Women also reported that the IUD did not prevent pregnancy, which was confirmed by a 1973 study from the Centers for Disease Control and Prevention (CDC). Researchers found that the Dalkon Shield was correlated to increased pregnancy-associated complications and other health problems requiring hospitalization and resulted in 18 known deaths. After more studies confirmed the IUD’s ineffectiveness at preventing pregnancy and its health risks, the manufacturer pulled it from the market.2

“There were thousands of lawsuits against the company, which later filed for bankruptcy,” Watkins says.

By 1995, only 0.8% of American women on contraceptives used the IUD. But 20 years later, that percentage shot up to almost 12% using a device. The IUD’s ranking in preferred contraceptive methods rose from 10th to fourth. The top three methods are the pill, female sterilization, and the male condom.1

The IUD’s rehabilitated image largely is due to physicians and researchers. The Affordable Care Act’s elimination of an upfront cost for IUD insertion for people with insurance meant more women could afford and access IUDs, Watkins says.

Between 1986 and 1988, there were no IUDs on the market in the United States, Watkins says. Family planning organizations sought to change this. In 1988, the copper IUD (Paragard) was approved for marketing in the United States. Mirena, the first hormonal IUD, was marketed in Finland in 1990, then a decade later in the United States.

“The story I tell is about one physician who took it upon herself to spread the gospel of long-acting reversible contraceptives [LARCs]. Her name is Eve Espey,” Watkins explains.

In the early 1990s, Espey was a staff physician for the Indian Health Service. She was concerned about how few birth control options were available to girls in the teen clinic. She personally used the new Paragard copper IUD and wondered why other physicians were not enthusiastic about the method, so she researched it for her master’s in public health thesis.1

“Dr. Espey looked at the literature and found out that research articles, even in the 1980s, should have supported IUD use, but because of the Dalkon Shield, it passed a pall over IUDs,” Watkins says. “She realized IUDs were safe, so she worked with the American College of Obstetricians and Gynecologists to get them to promote the use of LARCs.”

There is ongoing debate over whether LARCs should be promoted as first-line contraceptives, over all others. “There’s a lot of concern about coercive use, contraception where women don’t have control, and it requires a physician to remove them,” she says. “There’s a backlash against directive counseling because of concerns that young women and women of color will be forced into this choice.”

Some of this concern is based on historic paternalism, in which people involved in population control, from 50 and 60 years ago, did not believe women in underdeveloped countries would be able to take a daily contraceptive pill. They were looking for other solutions, Watkins explains. “And they believed economic development was tied to women’s fertility, instead of education and job opportunities. IUDs gained in popularity in the 1960s.”

By the 1970s, almost 10% of women were using IUDs. After the Dalkon Shield, IUDs fell out of favor.

Current IUDs marketed in the United States are both safe and highly effective at preventing pregnancy. Confidence in IUDs has risen among physicians and women.

“There should be a menu of contraceptive options,” Watkins says. “Clearly, the long-lasting ones are the most effective.”

REFERENCES

  1. Watkins ES. The comeback of the IUD in 21st-Century USA. J Hist Med Allied Sci 2021;jrab004. doi: 10.1093/jhmas/jrab004. [Online ahead of print].
  2. Horwitz R. The Dalkon Shield. The Embryo Project Encyclopedia. Jan 10, 2018. https://embryo.asu.edu/pages/dalkon-shield