Intrauterine contraception: What will it take to shift provider practice?

OB/GYNs see IUD as effective option, but few are inserting them

A mother in her late 20s comes in your office. She says she is seeking reliable, long-term birth control as she balances the demands of a hectic work and family life. Is the intrauterine device (IUD) one of the options you offer her?

If it is not, you may be among the number of U.S. providers who do not include IUD insertions in their regular practice. According to a just-published survey of U.S. OB/GYNs, 20% of OB/GYNs had not inserted an IUD in the previous year, and of those that had, 79% had inserted 10 or fewer.1

Fear of litigation and a belief that IUDs cause pelvic inflammatory disease were associated with lower IUD use, according to the survey results. However, scientific evidence does not support these beliefs, say family planning experts.

"Many clinicians in the U.S. are unaware that the IUD is the most widely used and effective reversible method of contraception in the world today, exceeding even oral contraceptives," asserts David Grimes, MD, vice president of biomedical affairs at Family Health International in Research Triangle Park, NC. "IUDs not only provide protection against pregnancy tantamount to that achieved with tubal sterilization, but they have a range of noncontraceptive health benefits that are just beginning to be appreciated."

An estimated 106 million women worldwide use an IUD for contraception;2 however, fewer than 1% of American women at risk for pregnancy choose the method.3 What factors might influence these decisions?

To examine the "physician piece" of the U.S. puzzle, researchers mailed surveys to assess use of and attitudes toward the IUD to 811 practicing members of the Washington, DC-based American College of Obstetricians and Gynecologists. The survey response rate was 50%.

According to lead researcher Nancy Stanwood, MD, MPH, an assistant professor in the department of obstetrics and gynecology at the University of Rochester (NY) Medical Center, physicians had not been surveyed on IUD use since the 1988 introduction of the Copper T380A IUD (marketed in the United States as ParaGard Intrauterine Copper Contraceptive by Ortho-McNeil Pharmaceutical, Raritan, NJ). Stanwood conducted the research, funded by the Robert Wood Johnson Clinical Scholars Program, while completing a fellowship at the University of North Carolina at Chapel Hill.

Survey results show respondents were most restrictive about patient monogamy in their selection of IUD candidates; having less conservative criteria for selecting IUD candidates was associated with greater IUD use. Respondents with liberal criteria inserted a mean of nine IUDs in the past year, whereas those with conservative criteria inserted four.

New era dawning?

Because most OB/GYNs are inserting few IUDs, educational programs should target these physicians to expand their IUD use, the researchers conclude. Such programs should highlight modern IUD safety and the rarity of litigation, say the researchers.

The risk of liability is out of proportion to actual experience with modern IUDs, says Susan Wysocki, RNC, NP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health. Only one lawsuit has been filed against the manufacturer of ParaGard since 1988, with the lawsuit ending in a defense verdict, she states.

The tide may be turning in provider resistance to the method, says Stanwood. Younger providers are not as influenced by the negative image of the IUD cast by the Dalkon Shield controversy three decades earlier, she notes. (Numerous lawsuits forced Dalkon Shield manufacturer A.H. Robins Co. of Richmond, VA, to declare bankruptcy in 1985 after more than 4,000 product liability cases had been filed against it.) Younger survey respondents were found to insert more IUDs than their senior counterparts, even when results were controlled for activity level of practice, survey results indicate.

The growing impact of evidence-based medicine also may influence providers’ practices when it comes to the IUD, states Stanwood. Over the long run, the levonorgestrel IUD (marketed in the United States as the Mirena Levonorgestrel-Releasing Intra-uterine System by Berlex Laboratories in Montville, NJ) is the single most effective method of reversible contraception available in the world today, closely followed by the Copper T380A.4 Over seven years of wear, the cumulative probability of pregnancy is only 1.1% for the levonorgestrel IUD; for the Copper T380A, it is 1.7%.4

"With the whole push toward evidence-based medicine, I think obstetrician/gynecologists are looking at contraceptive counseling more from an evidence-based perspective and, hopefully, comparing effectiveness of one method to another," says Stanwood.

Get training in 2002

The Washington, DC-based Association of Reproductive Health Professionals (ARHP) plans 20 additional sessions in 2002 for its New Developments in Contraception: Counseling and Insertion Training Featuring the Levonorgestrel Intrauterine System. The program, sponsored with the Ithaca (NY) Center for Postgraduate Medical Education, was presented in 153 accredited continuing medical education sessions in 2001. More than 4,300 health care providers participated in the program, which has won two national awards. The program is made possible by an unrestricted educational grant from Berlex Laboratories.

In addition to provider educational sessions, the program features a patient education brochure, Birth Control: Comparing the Choices, a clinician’s handbook, videotape, and a special issue of ARHP’s monograph, Clinical Proceedings. Many of the program’s educational materials are are available for purchase on ARHP’s web site at www.arhp.org/newdev.htm.

"This program has been a highly effective tool, educating thousands of health care providers about today’s new contraceptive options," says Wayne Shields, association president and CEO. "The associated training sessions also helped clinicians fine-tune their insertion skills, a key step toward ensuring a successful experience for women who choose this new method."

Keys to successful use

The success of any new IUD is going to be based on selection of appropriate candidates, appropriate consent and teaching, and appropriate insertion, says Kirtly Parker Jones, MD, associate professor in the department of obstetrics and gynecology at the University of Utah Health Sciences Center in Salt Lake City and co-chair of the ARHP program. Since the levonorgestrel IUD represents a new method as to its side effects and insertion techniques, it was imperative that ARHP get the message out on its proper use, she says.

Women who are well informed about the benefits and disadvantages of the method are satisfied users, says Parker Jones. Patients who have been using the levonorgestrel IUD for more than a year now report light periods with decreased cramping and bleeding, she notes. Again, she stresses that its success is based on "picking the right people, doing the right counseling, and putting it in right."

Given the IUD’s history in the United States, providers need to recognize that a clinician who is passive about IUDs will insert few, if any devices, says Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville. In contrast, clinicians who are IUD advocates continue to actively insert IUDs in their practices, he reports.

A common example of why this proactive approach is important is the scenario in which a patient referred by her primary care provider for tubal sterilization ends up choosing an IUD, says Kaunitz.

Using an illustration from his own practice, Kaunitz talks about sterilization at the initial consultation, including surgical and efficacy issues. The two also discuss reversible options, including the IUD. A staff member in Kaunitz’ office, a well-educated IUD user, also has volunteered to talk with potential candidates. This firsthand counseling sometimes makes a difference, he says.

Resource

For more information on the New Developments in Contraception continuing medical education program, visit the Association of Reproductive Health Professionals web site, www.arhp.org, or write to 2401 Pennsylvania Ave., N.W., Suite 350, Washington, DC 20037-1718. Telephone: (202) 466-3825, or e-mail: arhp@arhp.org. Participants may enroll on-line; click on "New Developments in Contraception," then "Sign Up Here." Participants also may print out the on-line enrollment form and fax it to (202) 466-3826.

References

1. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: A survey of attitudes and practice. Obstet Gynecol 2002; 99:275-280.

2. Treiman K, Liskin L, Kols A, et al. IUDs — An Update. Population Reports; Series B(6). Baltimore: Johns Hopkins School of Public Health, Public Information Program; December 1995.

3. Abma JC, Chandra A, Mosher WD, et al. Fertility, family planning, and women’s health: New data from the 1995 National Survey of Family Growth. Vit Health Stat 1997; Series 12, Number 19.

4. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th revised ed. New York: Ardent Media; 1998.