Hladky, Katherine J. MD; Allsworth, Jenifer E. PhD; Madden, Tessa MD, MPH; Secura, Gina M. PhD, MPH; Peipert, Jeffrey F. MD, PhD
Unintended pregnancy remains epidemic in the United States, encompassing nearly half of the six million annual pregnancies and disproportionately affecting young, lower income, and minority women.1 The National Survey for Family Growth reports that the majority of women using reversible contraception choose oral contraceptive pills and condoms.2 These methods have higher failure and discontinuation rates than long-acting, reversible contraception and require significant patient compliance.3 The National Survey for Family Growth reported an increase in the use of intrauterine contraception from 2% in 2002 to 5.5% in the 2006–2008 cycle. However, intrauterine contraception use remains low when compared with use of less effective, reversible methods.2
Multiple studies have shown that women value safety, effectiveness, and ease of use in a birth control method,4,5 characteristics inherent to intrauterine contraception. Low utilization in the United States is likely attributable to a variety of factors, including patients' misconceptions4,5 and providers' reluctance to encourage use.6,7 Previous studies of women's knowledge about intrauterine contraception indicate significant discrepancies between the respondents' perception of intrauterine contraception and actual intrauterine contraception characteristics.5,8 A large, previous study of women's knowledge about intrauterine contraception focused on women's attitudes about the copper intrauterine contraception only, because this research was performed before the levonorgestrel intrauterine system was available in the United States.5 The U.S. Food and Drug Administration approved the levonorgestrel intrauterine system in 2000. In this study, we sought to improve our understanding of women's knowledge, attitudes, specific beliefs, and misperceptions about intrauterine contraception by using a mail survey administered to a random sample of a large, diverse population of reproductive-aged women in the Saint Louis area.
MATERIALS AND METHODS
We conducted a postal survey of St. Louis, Missouri area women's knowledge of intrauterine contraception. From February to May 2008, we sent surveys to 12,500 randomly selected households in the St. Louis City and County using the U.S. Postal Service. We developed the survey instrument at our institution and piloted it among 700 women participating in a separate contraceptive study. This study was approved by the Washington University in St. Louis Human Research Protections Office before administering the survey. Participant consent was implied by return of the completed survey. The postal survey was administered by the University of Wisconsin Survey Center.
Using the eight-page instrument, we obtained demographic information, including age, race or ethnicity, highest education level, type of insurance (private, Medicaid, Medicare, or military), average income, receipt of government assistance, such as welfare, unemployment, and food stamps, obstetric history, and past and current use of contraceptive methods. An additional 27 questions focused on respondent's knowledge of intrauterine contraception, including respondent's awareness of effectiveness, safety, and misperceptions about intrauterine contraception, such as an association between intrauterine contraception and infection or infertility. Questions about contraceptive knowledge and use did not differentiate between types of intrauterine contraception or assess timing or duration of use of a contraceptive method. Knowledge about the effectiveness of all contraceptive methods was assessed by asking about estimated failure rates with 1 year of typical use. Respondents were asked to choose the most appropriate category of the number of women out of 100 (or percentage) to become pregnant within 1 year of typical use (less than 1%, 1–5%, 6–10%, and more than 10%) for each method. Typical use failure rates as described by Trussell et al3 were used to define “correct” answers.
We estimated that 1,200 completed surveys would provide a diverse sample of women in St. Louis City and County, with an estimated maximum margin of error ±4% with the percentages of contraceptive use. Potential participant households were randomly sampled from a list of U.S. Postal Service residential addresses purchased from Genesys Sampling Systems. The sample comprised 12,500 addresses, half from St. Louis City and half from St. Louis County. Twenty-four percent of households were estimated to have a resident female of reproductive age. Given an expected response rate of 40% from eligible households, a total of 12,500 area households were sampled to obtain our goal of 1,200 completed surveys. Oversampling of the city was performed in an attempt to increase response rates from underserved populations. Women eligible to participate were aged 18–45 years, literate in English, and willing to return the survey. One woman from each household was invited to participate.
The initial mailing contained an introductory letter, the survey instrument, a postage-paid return envelope, a $2 cash incentive, and a postcard for return by ineligible households. A reminder postcard followed the first mailing. The second and third mailings were sent to nonresponding addresses only, which excluded nondeliverable addresses and ineligible households. The second and third mailings contained a modified introductory letter, survey, envelope, and ineligibility postcard. Return of the postcard indicating a household without an eligible participant prompted removal of this address from future mailings, and the household was documented as successfully screened. Each mailed survey contained a unique identifier so that subsequent mailings would not be sent to a household that had already responded. This identifier was not attached to any of the information returned in the survey. Returned surveys contained no identifying information about respondents.
The survey was weighted for nonresponse using weighting cell adjustments based on geographic regions within strata as well as mode or method of contact. Weights were trimmed before poststratification. Weight trimming is a part of the weighting process to ensure that the effect of the sampling weights are not centered on one particular case, and also to limit the variability of estimates that could have otherwise been inflated with untrimmed weights. We created a total of 36 poststratification cells by crossing two strata (city compared with county), three age groups, two race groups (African American compared with other race), and three levels of education. An iterative proportional fitting algorithm was applied to the weights to calibrate them to Saint Louis area control totals, which came from U.S. census data. The estimated number of women in the target population was 179,009 for the county and 69,628 for the city.
Descriptive analyses included demographic characteristics, past and current contraceptive use and satisfaction, and knowledge of intrauterine contraceptives. Univariable and multivariable logistic regressions were used to assess likelihood of accurate knowledge of contraceptive effectiveness by previous method used, and to determine if the number of previously used contraceptive methods affected accuracy of knowledge of method effectiveness. All statistical analyses were performed using Stata 10.0.
Figure 1 shows the outcomes of the 12,500 mailed surveys; 1,665 (13.3%) completed surveys were returned, 3,644 (29.1%) surveys were mailed to an ineligible household confirmed by return of the ineligibility postcard, and an additional 1,134 surveys (9.1%) were returned as having an undeliverable address. This provided a 46.9% contact rate for the survey mailing. The percent of returned surveys in each mailing was 9.2%, 3.6%, and 3.0% for the first, second, and third mailings, respectively. Reported intrauterine contraception use and user satisfaction with intrauterine contraception did not differ between mailing (P=.99 for trend). Seventy-eight percent of the total surveys received were returned after the first mailing.
Table 1 shows the characteristics of respondents by experience with intrauterine contraception. Overall, the mean age was 31.9 years, the majority had pursued education past high school, and 81.6% had some type of health insurance at the time of survey participation. A total of 129 (7.7%) respondents were currently using or had previously used intrauterine contraception, and 78.7% of respondents had heard of intrauterine contraception. Past and current contraceptive use patterns of the respondents are presented in Table 2. Women who were current or previous users of intrauterine contraception were slightly older, with a mean age of 32.4 years, and were more likely to be parous or to be receiving government assistance than respondents who had never used intrauterine contraception. Only 28% of respondents reported that they had spoken with their health care provider about intrauterine contraception. Women who reported discussing intrauterine contraception with their health care provider were more likely to report current or past use (adjusted odds ratio [OR] 13.4, 95% confidence interval [CI] 6.5–27.8) after controlling for age, race, gravidity, education, insurance, and receipt of government assistance. However, 49% of women who had spoken with a health care provider about intrauterine contraception had not used the method. Fifty-four percent of past intrauterine contraception users and 61% of current intrauterine contraception users reported being satisfied with this method of birth control (Table 2). Among respondents who had used an intrauterine contraceptive and were not satisfied with the method, common reasons for dissatisfaction included change in menstrual bleeding (32% past users, 37% current users) and discomfort with device (19% previous users, 12% current users). Of previous intrauterine contraception users who reported dissatisfaction with the method, 17% reported that it was because of concerns about an adverse outcome related to intrauterine contraception effect such as infection or pelvic pain.
Respondent's knowledge about intrauterine contraception was modest. Most respondents (79%) had heard of intrauterine contraception, were aware that intrauterine contraception is used to prevent pregnancy (85%), and indicated that intrauterine contraception does not prevent acquisition of a sexually transmitted infection (98%). The most commonly cited reasons to use intrauterine contraception included prevention of pregnancy (59%), convenience (36%), and favorable side effect profile (28%). Additional questions focused on respondent's specific knowledge about intrauterine contraception safety, side effects, and identification of appropriate candidates for intrauterine contraception use. Respondents could indicate if they were unsure of the answer to each question. Never-users were more likely than past and current intrauterine contraception users to answer “do not know” to each of the knowledge questions. Forty-nine percent of respondents agreed that intrauterine contraception is safe, only 8% indicated this statement was incorrect, and an additional 43% were unsure. Common misperceptions about intrauterine contraception included concerns that intrauterine contraception increases the risk of an ectopic pregnancy, cancer, or a sexually transmitted infection (Table 3). Thirty-eight percent of respondents believed tampons cannot be used with intrauterine contraception. At least 40% of women were uncertain who was an appropriate candidate for intrauterine contraception, only 46% thought that nulliparous women could receive intrauterine contraception, and less than 30% of respondents believed that women with a new partner (27%), women with a history of a sexually transmitted infection (28%), or adolescents (23%) would be candidates for intrauterine contraception. Specific knowledge about the safety and expected side effects of intrauterine contraception was limited and was higher in current or past users of intrauterine contraception (Tables 3 and 4).
Overall, knowledge of contraceptive effectiveness was poor; 55%–84% of respondents reported incorrect answers for the likelihood of pregnancy in 1 year with typical use of reversible methods of contraception. The majority of respondents (61%) underestimated the effectiveness of intrauterine contraception, and most overestimated the effectiveness of combined hormonal contraceptive methods and barrier contraception (Table 3). Current intrauterine contraception use was associated with increased knowledge about intrauterine contraception effectiveness; after controlling for age, race, gravidity, and history of abortion, current intrauterine contraception users were more than seven times more likely to accurately identify intrauterine contraception effectiveness (OR 7.6, 95% CI 3.2–18.0) when compared with those respondents who had not used intrauterine contraception. Experience with other contraceptive methods such as condoms, oral contraceptive pills, the contraceptive patch, and depot medroxyprogesterone acetate did not improve knowledge about intrauterine contraception effectiveness. However, current implant users and ever-users of the contraceptive vaginal ring were more likely to accurately identify intrauterine contraception effectiveness (OR 4.9, 95% CI 1.1–23.0 and OR 2.5, 95% CI 1.6–4.1, respectively).
In this study, we attempted to gain greater understanding of reproductive-aged women's knowledge about intrauterine contraception. We found that most respondents are aware of intrauterine contraception and approximately half believe intrauterine contraception to be safe. However, specific knowledge of intrauterine contraception is limited, even among intrauterine contraception users. Nevertheless, efforts to dispel myths and promote the safety and efficacy of intrauterine contraception appear have a positive effect on intrauterine contraception use. In the 1980s, the combination of concerns about the Dalkon Shield9 and research studies reporting an increase in the risks of infertility and infection10 caused a reduction in the use of intrauterine contraception in the United States from almost 10% of reproductive-aged women11 to less than 1%.2 Subsequent studies have disproved the association between intrauterine contraception and infection and infertility.12,13 The most recent National Survey for Family Growth data show that 5.5% of reproductive-aged women using reversible contraception chose intrauterine contraception.2 Attitudes about intrauterine contraception safety are also shifting to reflect greater favorability; a 1996 study by Forrest5 reported only 21% of respondents believed intrauterine contraception to be safe, whereas our findings show 49% of respondents believed intrauterine contraception to be safe and only 8% thought intrauterine contraception was not safe. In addition, our study revealed at least half of respondents did not believe intrauterine contraception increases risk of a sexually transmitted infection, and only one third thought an intrauterine contraception increases the risk of infertility.
Our findings and the existing literature indicate a need for further education of providers and patients. Obstetrician-gynecologists are reluctant to place intrauterine contraception in young, nulliparous, unmarried women6,7,14 despite current recommendations from the American College of Obstetricians and Gynecologist and the Centers for Disease Control and Prevention.15–17 The persistent deficits in provider knowledge affects patient counseling and subsequent provision of intrauterine contraception; however, younger health care providers and those with greater experience with intrauterine contraception placement during residency training are more likely to insert intrauterine contraception once in practice.7 Additionally, lack of knowledge about intrauterine contraception may contribute to low utilization of this method by patients. Whitaker et al18 evaluated the effect of a brief educational video on adolescent females' knowledge of and attitude toward intrauterine contraception and found improved attitude toward intrauterine contraception after this intervention. Additionally, a recent study from Secura et al19 showed that among women entering a prospective cohort study on contraception, those who are provided with education about intrauterine contraception and implants and provided with no-cost contraception are more likely to choose intrauterine contraception and implants.
Our study offers a contemporary evaluation of reproductive-aged women's knowledge about intrauterine contraception, including specific beliefs and misperceptions regarding safety and side effects, and provides potential avenues for targeted education. Our findings reveal need for improvement in knowledge for all women, regardless of contraceptive history. Strengths of this study include a random sampling strategy and a large, diverse sample of reproductive-aged women. Potential limitations of the study include the collection of self-reported data, which are subject to recall and social desirability bias. Only 18% of respondents reported a history of abortion, which is lower than expected given national estimates, suggesting participants may have been unwilling to divulge certain information. However, the 5.1% of respondents who reported current intrauterine contraception use is similar to 5.5% reported from the most recent National Survey for Family Growth data, leading us to believe underreporting of intrauterine contraception use is unlikely in this study. We did not assess timing or duration of contraceptive method use, nor did we differentiate between types of intrauterine contraception, which may affect reported satisfaction or side effects. There is also the possibility of a response bias, because women who had used intrauterine contraception may have been more likely to complete the survey. This potentially could result in an overestimation of knowledge about intrauterine contraception, which would strengthen our findings. Response bias also may account for the low satisfaction rates noted for past and current intrauterine contraception users, because dissatisfied users may have been more likely to respond. Because we only surveyed a single geographic region, our results may not be generalizable to other areas in the United States. However, given the diversity of our study population, we believe the results are likely generalizable to other urban, racially diverse areas.
Our data indicate that women's attitudes toward intrauterine contraception have improved in comparison to data of previous studies. However, persistent efforts to improve provider and patient education are strongly needed. Educational interventions should include all reproductive-aged women, regardless of past contraceptive experience.
1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90–6.
2. Mosher WD, Jones J. Use of contraception in the United States: 1982–2008: data from the National Survey of Family Growth. Vital Health Stat 2010;29:1–77.
3. Trussell J. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception 2008;78:85.
4. Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006;108:1417–22.
5. Forrest JD. U.S. women's perceptions of and attitudes about the IUD. Obstet Gynecol Surv 1996;51:S30–4.
6. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99:275–80.
7. Madden T, Allsworth JE, Hladky KJ, Secura GM, Peipert JF. Intrauterine contraception in Saint Louis: a survey of obstetrician and gynecologists' knowledge and attitudes. Contraception 81:112–6.
8. Schrager S, Hoffmann S. Women's knowledge of commonly used contraceptive methods. WMJ 2008;107:327–30.
9. Sivin I. Another look at the Dalkon Shield: meta-analysis underscores its problems. Contraception 1993;48:1–12.
10. Cramer DW, Schiff I, Schoenbaum SC, Gibson M, Belisle S, Albrecht B, et al. Tubal infertility and the intrauterine device. N Engl J Med 1985;312:941–7.
11. Darney PD. Time to pardon the IUD? N Engl J Med 2001;345:608–10.
12. Kronmal RA, Whitney CW, Mumford SD. The intrauterine device and pelvic inflammatory disease: the Women's Health Study reanalyzed. J Clin Epidemiol 1991;44:109–22.
13. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmán-Rodríguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561–7.
14. Espey E, Ogburn T, Espey D, Etsitty V. IUD-related knowledge, attitudes and practices among Navajo Area Indian Health Service providers. Perspect Sex Reprod Health 2003;35:169–73.
15. American College of Obstetricians and Gynecologist. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007;110:1493–5.
16. ACOG Committee on Practive Bulletins-Gynecology. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 59, January 2005. Intrauterine device. Obstet Gynecol 2005;105:223–32.
17. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Farr S, Folger SG, Paulen M, Tepper N, et al. U S. medical eligibility criteria for contraceptive use, 2010: adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Recomm Rep 2010;59 (RR-4):1–86.
18. Whitaker AK, Terplan M, Gold MA, Johnson LM, Creinin MD, Harwood B. Effect of a brief educational intervention on the attitudes of young women toward the intrauterine device. J Pediatr Adolesc Gynecol 2010;23:116–20.
19. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol 2010;203:115 e1–7.