Unintended pregnancy remains common in the United States.1 Although some unintended pregnancies result when no contraception is used, about half of unintended pregnancies are the result of a contraceptive failure.2 This finding highlights the need to help couples use contraceptive methods with low rates of failure. Perfect-use failure rates describe deficits inherent in a given contraceptive method; typical-use failure rates also include failures that result from the way the method is used. Because it is difficult to remember to take a pill every day and to ensure that refills are obtained (often monthly) and because other medications or gastrointestinal illness may interfere with absorption of oral contraceptives, there are dramatic differences between the rates of contraceptive failure seen with typical-use and perfect-use of birth control pills. In contrast, there is no notable difference between typical-use and perfect-use of methods such as the intrauterine device (IUD). Typical-use failure rates of IUDs are an order of magnitude less than what is seen with use of hormonal methods such as the birth control pill.3 Although IUDs are used commonly in Europe and Asia, they are used by only a small fraction of U.S. women of reproductive age.4
It is likely that more U.S. women would use IUDs if it was easier to have them inserted. Many providers require patients to schedule and attend two appointments, one for testing for sexually transmitted diseases (STDs) and a second for the insertion. This despite the facts that women who have been screened previously may acquire an STD between their screening and insertion visits and that any infections that are identified at the time of IUD insertion can be treated with the IUD in place.5,6 In the postabortal setting, patients who were offered immediate IUD insertion were more likely to have an IUD inserted and as a result were three times less likely to require a repeat abortion.7 Efforts to minimize barriers to interval insertion also have been shown to increase use of IUDs.8
Women seeking emergency contraception and walk-in pregnancy testing are at particularly high risk of unintended pregnancy.9,10 Intrauterine devices containing copper have been shown to be a highly effective method of emergency contraception11–15 that offers the added benefit of ongoing protection from pregnancy. The purpose of this study was to estimate interest in same-day IUD insertion among women and adolescent girls seeking pregnancy testing or emergency contraception from family planning clinics in Pittsburgh, Pennsylvania. Our hypothesis was that at least 5% of patients would express interest in same-day insertion of an IUD.
MATERIALS AND METHODS
Women and adolescent girls between the ages of 15 and 44 years seeking either walk-in pregnancy testing or emergency contraception at one of four family planning clinics in Pittsburgh, Pennsylvania, were eligible to participate in this study. Two of these clinics belong to an academic medical center, and the other two are operated by Planned Parenthood. These clinics were chosen because they routinely provide services to young, low-income, predominantly minority patients who are at high risk for unintended pregnancy.16 All women and adolescent girls who registered at one of these clinics between January and October 2008 and were seeking emergency contraception or pregnancy testing were approached for potential study participation. A sample size of at least 400 participants was selected to allow us to estimate 5% interest in same-day insertion of an IUD with a 95% confidence interval (CI) of ±2%. The study was approved by the University of Pittsburgh's institutional review board, and all participants provided written informed consent.
The 41-item survey contained questions regarding the respondent's knowledge of and attitudes toward intrauterine contraception. These items were pilot tested in the target population before initiation of this study. Specifically, participants were asked to compare IUDs with birth control pills with regards to cost, efficacy, side-effects, and risk of STDs. These questions offered four response options (more, less, the same, and don't know). In addition, demographic information including race and ethnicity was collected. We assessed whether participants had health insurance or received “medical assistance” (a state-sponsored program that provides access to health care, including contraception and IUDs, for low-income individuals). However, we did not assess whether participants' private health insurance covered contraception. Participants also were asked about their reproductive histories, current pregnancy intentions, and interest in using an IUD. Participants could complete the survey either before or after they had seen a clinician. However, all participants completed the survey before receiving the results of their pregnancy tests to avoid having these test results influence responses. Study staff recorded pregnancy test results for each participant in a secure database. Participants received a chocolate bar as compensation for their time.
We tabulated and summarized respondents' knowledge of, attitudes toward, and interest in IUDs. Participants with missing data were presumed to have no knowledge of or interest in IUDs. We used χ2 and Fisher exact tests to evaluate the significance of differences between demographic characteristics and clinical service sought (pregnancy testing or emergency contraception). We then used univariate and multivariable logistic regression models (generated using stepwise elimination when P≥.10) to examine variables associated with attitudes toward IUDs. Variables for clinical site (Planned Parenthood compared with academic medical center) and service sought (emergency contraception compared with pregnancy testing) were retained in all multivariable models, even if P was ≥.10. Specifically, we compared responses indicating a preference for IUDs with those indicating a preference for birth control pills (ie, when considering side effects, we grouped participants who responded IUDs produced “less” or “the same” side effects as birth control pills and compared them with participants who responded “more” or “don't know”). In addition, we evaluated variables associated with interest in same-day insertion of an IUD, including reported barriers to access to contraception, using univariate and multivariable logistic regression models similarly generated using stepwise elimination (with clinical site and service sought retained in all models). For all analyses, we used Stata 10.0 (StataCorp, College Station, TX).
Of 485 women and adolescent girls who sought emergency contraception or pregnancy testing at participating clinics, 412 completed surveys, producing a response rate of 85%. Most respondents were young, low-income, and African American. Additional demographic characteristics of the study sample are shown in Table 1. Most respondents (85%) were seeking pregnancy testing; the other 15% were seeking emergency contraception. Patients seeking these clinical services had similar pregnancy histories. The median number of prior pregnancies was 1 (range 0–9); the median number of unwanted pregnancies and abortions was 0 (range 0–6 and 0–4, respectively). Patients seeking emergency contraception were more likely to state that they were trying to avoid pregnancy at the time they visited the clinic (87% compared with 31%, P<.001) and were less likely to be pregnant (45% compared with 4%, P<.001) than those seeking pregnancy testing.
Overall, knowledge of and attitudes toward IUDs were similar among participants seeking pregnancy testing and those seeking emergency contraception (Table 2). Most participants knew very little about IUDs, and only about one third knew anyone who had ever used an IUD. In multivariable models, we found that increased education and parity were significantly associated with more positive impressions of the efficacy and cost of IUDs. Parity also was associated significantly with more positive impressions of IUD safety in terms of STD.
When we examined interest in using an IUD, we found that 12% (95% CI 9–15) of participants expressed interest in having an IUD inserted that day. Interest in a same-day insertion increased slightly when the insertion would be free (16%, 95% CI 12–20) (Table 3). Notably, the large majority of individuals who stated they “didn't know” if they would be interested in a same-day insertion of an IUD did not know anyone who had ever used an IUD and stated that they didn't know how IUDs compared with birth control pills in terms of efficacy, safety, or cost.
Interest in a same-day insertion increased with report of barriers to access to contraception, such as “I couldn't get an appointment to get birth control when I needed it” (odds ratio [OR] 5.31, 95% CI 2.28–12.36) and “I couldn't afford to pay for birth control or my insurance wouldn't cover it” (OR 3.41, 95% CI 1.45–7.99). Participants who stated that they had difficulty using contraception because “I didn't think I was going to have sex” (OR 2.09, 95% CI 1.03–4.25) were also more likely to express interest in same-day insertion of an IUD. However, those who stated that they did not use contraception because “I didn't think I could get pregnant” were less likely to be interested in same-day IUD insertion (OR 0.29, 95% CI 0.09–0.96).
In multivariable models adjusted for age, race, education, insurance status, parity, site, service sought, and anticipated response to a pregnancy, we found that participants who had more than a high school education (OR 2.54, 95% CI 1.18–5.50), who had given birth one or more times (OR 3.34, 95% CI 1.40–7.94), or who stated that they would have (OR 6.44, 95% CI 2.47–16.78) or consider an abortion (OR 3.23, 95% CI 1.32–7.86) if they learned they were pregnant were more likely to express interest in a same-day IUD insertion. In models additionally adjusted for participants' attitudes toward IUDs, we found that positive attitudes toward the efficacy of IUDs were associated with interest in a same-day insertion (OR 4.02, 95% CI 1.42–11.34). However, attitudes toward IUDs regarding cost, side effects, and risk of STD were not associated with interest in a same-day insertion (Table 4).
Of the 49 participants who were interested in a same-day insertion, 11 were pregnant and eight had unknown pregnancy test results owing to difficulties in data transfer from the clinical setting to our research staff. Thus, at least 30 participants (7%, 95% CI 5–10) would have been interested in and potentially eligible for a same-day IUD insertion.
Family planning clinics seek to reduce unplanned pregnancies and abortions. Women seeking emergency contraception and pregnancy testing are at high risk of unplanned pregnancy and abortion9,10 and therefore may benefit greatly from the highly effective emergency and ongoing contraception provided by an IUD. This study estimated interest in same-day insertion of an IUD and found that 15% of women and adolescent girls seeking emergency contraception from a family planning clinic expressed interest in same-day insertion of an IUD, although few patients were very knowledgeable about IUDs. Women and adolescent girls seeking walk-in pregnancy testing were similar to those seeking emergency contraception in many ways. Most wanted to avoid pregnancy, and a similar number expressed interest in using an IUD. Efforts therefore should be made to expand education about and access to IUD insertions for women seeking either emergency contraception or pregnancy testing, with consideration given to the development and evaluation of same-day insertion services. To date, few clinicians have offered IUDs to women seeking emergency contraception.17 Although lack of time was cited as a major reason that British clinicians did not offer IUDs to women seeking emergency contraception,18 changes in clinic scheduling templates or reimbursement structure or both may make same-day IUD insertion feasible. If one estimates that 20% of women seeking emergency contraception will experience an unwanted pregnancy within the year without an IUD and that, with an IUD, fewer than 1% of these women will, the number needed to treat to prevent an unwanted pregnancy within 1 year would be five. This implies that, if feasible, same-day insertion of an IUD would be a very effective approach to reaching family-planning goals of reducing rates of unwanted pregnancy and abortion. For such an approach to be widely adopted, it will be important to demonstrate that it is possible to work with state and pharmaceutical patient-assistance programs to ensure that low-income women are able to pay for desired same-day services. In addition, although same-day IUD insertion has been shown to be safe postabortion,7,8 studies are needed to confirm the safety of same-day IUD insertion in other settings with regard to STD and risk of pelvic inflammatory disease.
Previous studies also have found that many young women in the United States lack adequate knowledge of IUDs and would benefit from education about this method of contraception.19,20 Although many people look to the Internet as a source of information for their unanswered medical questions, the quality of information about IUDs available via the Internet is unreliable21 and may discourage some women from considering the IUD as a viable contraceptive option. It is therefore very important that women receive accurate information about IUDs from their health care providers. Because minority and low-income women served by family planning clinics are at particularly high risk of unintended pregnancy,9,10 efforts to increase use of IUDs and other highly effective, reversible methods of contraception by this population should be a priority. In addition to being a safe and highly effective method of contraception, IUDs are also extremely cost-effective.22 Although providing women with information about the cost-effectiveness of IUDs relative to other methods of contraception may be of value, our study found that a positive attitude toward the cost of IUDs relative to other methods was not associated with interest in use of an IUD. A positive attitude toward the relative efficacy of IUDs compared with oral contraceptives, however, was associated significantly with interest in a same-day insertion.
Although our study provides new information on women's knowledge of, attitudes toward, and interest in IUDs, this work has several limitations that deserve mention. All information regarding women's reproductive histories was self-reported and therefore may be subject to bias. In addition, we did not explicitly ask participants whether they knew what an IUD was; therefore, it is possible that responses to all questions regarding IUDs were influenced by misperceptions. For example, some participants may not have understood that a patient must undress to have an IUD inserted and that there may be some discomfort involved. We did not inform participants of what was involved in IUD insertion in terms of time and potential discomfort, and we did not ask them about their willingness to tolerate the potential discomfort of IUD insertion. Participants who expressed interest in same-day insertion of an IUD were not asked how long they would be willing to wait to have an IUD inserted, and wait-times likely would affect the acceptability of such services. Although we explored general barriers to use of contraception, we were not able to characterize explicitly the barriers that had prevented participants who stated that they previously had considered using an IUD from actually using one. Finally, this study was conducted exclusively in one city and with predominantly minority and low-income women and adolescent girls, which may limit the generalizability of the results to other populations. However, populations served by family planning clinics typically include high proportions of young women, minority women, and women of low income.23
In conclusion, this study found that, among women and adolescent girls seeking walk-in pregnancy testing or emergency contraception from family planning clinics in Pittsburgh, Pennsylvania, few were knowledgeable about IUDs, but, among those who were familiar with IUDs, interest in a same-day insertion was high. Overall, one in 10 women and adolescent girls surveyed were interested in a same-day IUD insertion. Because many participants who knew little about IUDs stated that they might be interested in using an IUD, it is imperative that we develop ways to provide women seeking both emergency contraception and pregnancy testing with information about IUDs. Further study of same-day insertion of IUDs is warranted to determine whether this is a safe and effective way to increase use of highly effective contraception in the United States.
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