Contraception 88 (2013) 650 656

Original research article

Global survey of healthcare practitioners beliefs and practices around

intrauterine contraceptive method use in nulliparous women
Kirsten I. Black a,, Pamela Lotke b , Josefina Lira c , Tina Peers d , Nikki B. Zite e
a

Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Central Clinical School, Camperdown, Sydney, NSW 2050, Australia
b
Department of Obstetrics and Gynecology, University of Arizona School of Medicine, Tucson, AZ 85724, USA
c
Department of Adolescent Gynecology, Instituto Nacional de Perinatologia; Universidad Nacional Autnoma de Mxico, Mexico City 11000
d
Sexual Health Services Surrey for Virgincare, Cobham, England KT11 1HT
e
Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, TN 37920, USA
Received 14 January 2013; revised 28 May 2013; accepted 2 June 2013

Abstract
Background: Despite the efficacy and safety of intrauterine contraceptive methods (IUCs), healthcare providers (HCPs) are sometimes
reluctant to recommend their use, particularly in nulliparous women. This study sought to understand the global practitioner perceived
impediments to IUC provision.
Study Design: We developed an online survey for HCPs administered across 4 regions comprising 15 countries. We sought their attitudes to
IUC provision; their perceived barriers to IUC use, particularly in nulliparous women; as well as their knowledge of the World Health
Organization Medical Eligibility Criteria (WHO MEC) for contraceptive use.
Results: We received 1862 responses from HCPs in 15 countries grouped into 4 regions, with an average country response rate of 18%. For
analysis, the results were grouped into these regions: Latin America, 402 (21.6%); USA, 156 (8.4%); Europe and Canada, 1103 (59.2%); and
Australia, 201 (10.8%). The two most frequently identified perceived barriers to IUC use in nulliparous women were difficulty of insertion
(56.6%) and pelvic inflammatory disease (PID) (49.2%), but responses differed by region and HCP type. Only 49.7% recognized the correct
WHO MEC category for IUC use in nulliparous women.
Discussion: The results of this survey confirm that, across the four regions, the two main barriers to IUC provision for nulliparous women are
concern about the difficulty of insertion and PID. Providers knowledge of the WHO MEC was lacking universally. A global effort is
required to improve understanding of the evidence and knowledge of available guidelines for IUC use.
2013 Elsevier Inc. All rights reserved.
Keywords: Nulliparous; Intrauterine contraception; Intrauterine device; Healthcare practitioners; Knowledge

1. Introduction
It is increasingly recognized that unintended pregnancies
in young and adolescent women would be best prevented

All authors are members of the INTRA group, an independent panel

of physicians with expert interest in intrauterine contraception, the formation
of which was facilitated by Bayer HealthCare. The market research company
GfK is acknowledged for conducting the field research with funding from
Bayer HealthCare. This publication and its content were solely the
responsibility of the authors. All authors have acted as consultants to
Bayer HealthCare and received consultancy honoraria unrelated to the
creation of this paper.
Corresponding author. Tel.: +61 295157696; fax: + 61 295153359.
E-mail address: kirsten.black@sydney.edu.au (K.I. Black).

0010-7824/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2013.06.005

through a strategy that encourages greater uptake of methods

that are less user dependent [1,2]. The long-acting reversible
methods which include intrauterine devices and implants
provide highly effective contraception without the need for
daily adherence. The CHOICE study in St. Louis, MO, USA,
demonstrated that these methods are acceptable and more
reliable than pill, patch or ring contraceptive methods in
young women [3]. They are also highly cost-effective [4]. In
addition, in many countries, the mean age at first birth is
rising, and increasing numbers of women are delaying
childbearing into their 30s [5,6]. This means that there is a
growing pool of women who are nulliparous and who desire
long-term effective methods of contraception.
International guidance supports the use of intrauterine
devices, including the copper devices (Cu-IUD, Multiload

K.I. Black et al. / Contraception 88 (2013) 650656

Cu-375, Schering Plough and Copper TT380) and the

levonorgestrel-releasing intrauterine system (LNG-IUS,
Mirena, Bayer Healthcare Pharmaceuticals), in both
young and nulliparous women. The Medical Eligibility
Criteria (MEC) produced by the World Health Organization
(WHO) state that the benefits of use of IUC methods in
nulliparous women outweighs the risks (category 2) [7]. The
use of intrauterine devices in nulliparous women is also
recommended by national evidence-based recommendations, including the National Institute of Clinical Excellence
in the United Kingdom and the American Congress of
Obstetricians and Gynecologists [2,8,9]. Their qualities of
being user independent and highly efficacious are particularly advantageous in young nulliparous women.
Despite support from experts, there is little uptake of
intrauterine contraceptive methods (IUCs) among nulliparous women. Data from Europe found that although
nulliparous women constitute almost half of those in
reproductive age, they make up only 10% of IUC users
[10,11]. In addition, global rates of IUC use demonstrate
enormous variability, suggesting that healthcare practitioner
and service provision factors have a key impact on IUC
utilization. Of women of reproductive age married or in a
union from the regions examined in this study, use of IUCs
varies greatly according to the United Nations 2011 report.
In Europe, 12.1% of women reported using an IUC. In
comparison 7.0% of women in Latin America and the
Caribbean and 5.8% of women in USA used IUCs. Very few
women in Canada (1%) and Australia (1.3%) were
documented to be using the method [12].
Surveys of healthcare provider (HCP) attitudes from
several countries suggest that misunderstandings of the risks
and benefits of IUC are common and result in reluctance to
provide these methods to nulliparous women [1316]. These
studies found that concern over pelvic inflammatory disease
(PID) and infertility has lingered even though the modern
intrauterine methods show no additional risk of either of
these complications [17]. There are no comparative international data about HCPs views on IUC use in nulliparous
women nor any information about what issues may be of
concern to contraceptive providers from different settings.
This study set out to explore HCPs knowledge and practice
of IUC provision from 15 countries around the world.

2. Materials and methods

This was an online survey undertaken across 15 countries
(UK, France, Australia, USA, Mexico, Russia, Turkey,
Canada, Germany, Netherlands, Sweden, Brazil, Ireland,
Colombia and Argentina). The questionnaire was developed
by an international advisory group of 10 clinicians with
expertise in IUC (INTRA; Intrauterine contraception for
Nulliparous women: Translating Research into Action
group) and sought to investigate knowledge and practice of
IUC insertions in nulliparous women. The logistics of

651

distributing and administering the survey were undertaken

by the global market research organization GfK and funded
by Bayer HealthCare.
The questionnaire was translated into the language of
each of the countries by native speakers and tested for
comprehension prior to roll out. In each country, HCPs were
identified from existing nursing and medical market
research panels of practitioners who had expressed an
interest in participating in research. From the market
research panels, individuals were selected by random
sampling. Each HCP was sent an email invite to take part.
A series of screening questions excluded practitioners with a
relationship to a pharmaceutical company and sought to
involve only those who saw more than 20 patients in a
month for advice about contraception. Seven initial
questions addressed the HCP type of professional background and clinical practice around IUC, and additional
questions captured demographic characteristics of gender,
age, region and work setting.
The section of survey addressing HCP knowledge and
attitudes to IUC provision and understanding of the WHO
MEC consisted of 13 questions. Respondents were asked
to choose the three main benefits and barriers to IUC, both
overall and specifically for nulliparous women, from a
comprehensive list of options as in Table 1. They were
asked to indicate which patients they would discuss the use
of IUC with, depending on age and parity. Some questions
focused on the perceived efficacy, insertion and risks
associated with IUC use comparing nulliparous to parous
women. The wording of the questions is included as an
electronic appendix. These questions were all, except for
one, in a multiple choice format where participants were
directed to select one or more of the structured response(s).
We used a Likert scale question to ask HCPs to compare

Table 1
Perceived barriers to IUC provision in nulliparous women
Response options offered to HCP when asked What are the three main
barriers for you when considering intrauterine contraception as an option for
nulliparous women?
Lack of efficacy
Concerns about pelvic inflammatory disease
Concerns about infertility
Concerns about difficult insertion
Concerns about insertion pain for the woman
Concerns about ectopic pregnancy
Women do not like it
Concerns about expulsion
The age of the woman
Lack of training
The woman may not be monogamous
Ethical/religious concerns about the mode of action
of intrauterine contraception
Disruption of normal menstruation
Financial cost is too high
Concerns over legal risks
Other, please specify:..[Progr: insert]

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K.I. Black et al. / Contraception 88 (2013) 650656

Table 2
Clinician characteristics by region of origin

Healthcare practitioner
Obstetrician/gynecologist
General practitioner
Midwife/nurse
Gender
Male
Female
Years of independent practice
010
1120
N20
Role in IUC insertion
I insert myself
I refer to a colleague for insertion
Other

Total
N

Europe/Canada
%

USA
%

Latin America
%

Australia
%

1205
474
183

57.4
30.4
12.5

64.1
19.9
16.0

92.5
7.5
0

49.8
38.8
11.4

1035
827

51.3
48.7

63.5
36.5

61.7
38.3

60.7
39.3

597
635
630

34.1
32.8
33.1

21.2
39.7
39.1

33.3
35.6
31.1

26.9
33.8
39.3

1460
368
34

76.7
21.8
11.4

85.3
14.1
0.6

91.0
6.2
2.8

57.2
39.8
3.0

the risks of IUC in nulliparous women with those in

parous women.
The survey took approximately 1520 min to
complete, and practitioners were reimbursed between US
$60 and US $80 for their time. Analysis of the data was
undertaken by using IBM SPSS Statistics 20. We used the
2 test for univariate analysis of categorical variables.
Multivariate analysis was undertaken using binary logistic
regression. For the purposes of describing international
variations, countries were grouped into the regions of
Europe, Australia, Latin America and the United States. As
Canadas health system shares much in common with
European systems, Canada was grouped with the European
countries. Ethics approval was obtained from the University
of Sydney Human Research Ethics Committee and the
University of Tennessee Institutional Review Board.

3. Results
3.1. Demographic information
We received 1862 responses from HCPs from 15
countries: Latin America, 402 (21.6%); USA, 156 (8.4%);
Europe and Canada, 1103 (59.2%); and Australia, 201
(10.8%). Response rates varied from between 5% (Brazil)
and 34% (USA), with an average of 18% across the 15
countries. The demographic data, including type of HCP,
gender, duration of independent practice and role in IUC
insertion, are presented in Table 2.
3.2. Barriers to IUC use in nulliparous women
HCPs when asked What are the three main barriers for
you when considering intrauterine contraception as an option
for nulliparous women? identified a variety of issues. These

Fig. 1. Perceived barriers to nulliparous IUC use by region.

K.I. Black et al. / Contraception 88 (2013) 650656

653

Fig. 2. Perceived barriers to nulliparous IUC use by type of healthcare practitioner.

included concern about PID, infertility, insertion difficulty,

pain, ectopic pregnancy, that women do not like it and other
reasons. The four barriers most commonly selected, along
with how these responses varied by region, HCP type and
years of experience, are presented in Figs. 1, 2 and 3.
Across all geographic regions, providers were equally
concerned about PID. In multivariable analysis taking into
account HCP type, region and years of independent practice,
Latin American providers remained significantly more
concerned about infertility (pb.002) but were less concerned
about insertion pain (pb.027) compared to practitioners from
other regions. Practitioners in Australia, Europe, Canada and
the United States were more concerned about difficult
insertions than their Latin American colleagues (pb.001).

Years of experience did not affect concern for difficult

insertion or insertion pain, but those in practice longer were
more likely to be concerned about PID and infertility (pb.001
and p=.007, respectively).
3.3. Risk of PID
Practitioners were specifically asked the level of risk they
thought a nulliparous woman with intrauterine contraception
has of PID and subsequent infertility compared to a woman
not using intrauterine contraception. Around two thirds
(63.2%) of HCPs believed that IUC in nulliparous women
placed them at higher risk of PID compared to nonusers.
However, significantly fewer of the family planning nurses
and midwives (n= 88, 48.1%) rated the risk as being higher in

Fig. 3. Perceived barriers to nulliparous IUC use by years of independent practice.

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K.I. Black et al. / Contraception 88 (2013) 650656

Table 3
HCP perceived risks of IUC use in nulliparous women compared to parous women

Risk of perforation in nulliparous

Risk of expulsion in nulliparous

Ease of placement in nulliparous

Experience of pain at insertion of nulliparous women

Scale

Lower than in parous women

The same as in parous women
Higher than in parous women
Lower than in parous women
The same as in parous women
Higher than in parous women
Easier than in parous women
The same as in parous women
More difficult than in parous women
N/A
Less pain than in parous women
The same as in parous women
More pain than in parous women

212
845
805
536
646
680
45
191
1429
197
37
296
1529

11.4
45.4
43.2
28.8
34.7
36.5
2.4
10.3
76.7
10.6
2.0
15.9
82.1

nulliparous users of IUC compared to obstetricians (n= 789,

65.5%) and general practitioners (n= 299, 63.1%) (pb.01).
3.4. Insertion risks, expulsion risk and difficulty of insertion
compared to parous women
Using Likert scale questions about the details of IUC
insertion, most providers felt that the risk of perforation and
expulsion were similar or slightly increased in nulliparous
versus parous women, but that the difficulty and pain of
insertion were greater. The proportion of providers who
perceived increased risk for nulliparous women compared to
parous women is documented in Table 3.
3.5. Knowledge of WHO criteria for use in
nulliparous women
Overall, only half of HCPs (49.7%) recognized that IUC
use in nulliparous women was a category 2 under the WHO
classification system of medical eligibility for contraception
use (MEC) (Table 3). In univariate analysis, obstetricians
and nurses were significantly more likely to have correct
knowledge of WHO MEC compared to general practitioners.

Knowledge was highest amongst the Latin Americans

(57.7%) and lowest amongst the Australians (Table 4).
These apparent regional differences did not remain after
multivariate analysis, indicating that the effect was due to
HCP type (Table 4).
4. Discussion
This survey highlighted the ongoing misperceptions
HCPs have about IUCs around infection, infertility and
difficulty of insertion, particularly in nulliparous women.
Our survey noted regional and HCP type variations.
Midwives and family planning nurses were the HCP type
least concerned about PID and least likely to believe that
IUC increased the chance of infertility compared to a woman
not using a device. The risk of infertility was of greatest
concern to practitioners from Latin America. This persistent
misunderstanding about the ongoing risk of PID and
resultant infertility has been previously documented among
HCPs, despite the fact that there is strong evidence PID and
infertility are caused by sexually transmitted infections such

Table 4
Clinician knowledge of the WHO MEC for IUC use in nulliparous women: univariate associations

Region
Europe/Canada
USA
Latin America
Australia
HCP type
Ob/gyn
General practitioners
Midwives/nurses
Years of experience
010
1120
N20
a
b

Total
N

MEC 1
%

MEC 2
%

MEC 3
%

MEC 4
%

Do not know

1101
156
402
201

15
17.9
14.2
5.5

47.2
50.6
57.7
46.8

12.7
5.8
10.2
5.0

2.4
0
2.2
1.5

22.6
25.6
15.7
41.3

p value
pb.001 a

pb.001 a
1205
474
183

14.9
11.8
14.8

53.1
41.1
49.7

12.8
8.4
3.3

2.5
1.5
1.1

16.8
37.1
31.1

597
635
630

12.7
15.3
14.1

48.1
50.1
51

13.4
10.2
8.7

1.8
2
2.4

24
22.4
23.8

p=.744

Significant in bivariate analysis of correct (MEC 2) versus incorrect/do not know.

Only HCP type remained significant in the multivariable model that included all the variables shown in the table.

K.I. Black et al. / Contraception 88 (2013) 650656

as Chlamydia and not the presence of an IUC [17,18]. This

concern is especially a barrier to IUC use in nulliparous
women who may be considered at high risk if they are single
or have multiple sexual partners [19,20].
Overall, HCPs felt that, compared to parous women,
insertion pain and difficulty were greater in nulliparous
women, whereas the risk of perforation and expulsion was
most often regarded as the same. Studies of IUC insertion in
nulliparous women have repeatedly documented that
insertion failure is uncommon and that most insertions
occur without difficulty. In a Swedish study of 223
nulliparous women, 72% of insertions were rated as easy,
22 % as moderately difficult and only 6% as very difficult
[21]. Placement failure rate in this study of nulliparous
women was 6/224 (2.7%) insertions. In a Brazilian study
comparing nulligravid and parous women choosing the
LNG-IUS, insertion failure occurred in only 1 of 159
nulligravid women (0.6%) and in 2 of 477 parous women
(0.4%) [22]. Although the odds ratio of the procedure being
abandoned in nulliparous women compared to parous
women in Australian family planning clinics was 5.19
(95% confidence interval, 2.4910.82), in 95% of all
women, the IUC was successfully inserted as an outpatient
procedure, including in 88.8% of nulliparous women [23].
There are a number of studies that compare the IUCassociated insertion pain between nulliparous and parous
women [2426]. One study found that the pain was
significantly greater in nulliparous women having a copper
IUD inserted (mean of 2.7 cm vs. 1.9 cm in parous women
on a 10-cm visual analogue scale), although overall pain
scores for all women were low [26]. Other studies found
larger differences in pain scores between nulliparous and
parous women [24,25]. A study documenting LNG-IUS
insertions in nulliparous women in Sweden reported that
insertion was moderately painful in 72% and severely
painful in 17% [21].
Only half of the HCPs knew the correct WHO MEC
category for IUC use in nulliparous women. Knowledge
varied with region and HCP type in univariate analysis but
only by HCP type in multivariate analysis. Obstetrician/
gynecologists and nurses/midwives were significantly more
often correct compared to general practitioners. Obstetrician/gynecologists were the HCP group most likely to be
correct and least likely to say that they did not know the
correct category. This may well reflect greater training in
the field of contraception. It may also indicate their own
expectation of their knowledge and an unwillingness to
admit they do not know.
The study is novel, and its strengths are that it provides a
large global survey of different types of contraceptive
providers. The limitations of the study include that it was an
online survey that may have canvassed only those
practitioners with a particular interest in contraception and
those who participated were necessarily technologically
savvy. We do not have information about the HCPs who
declined participation in the study, and the response rate

655

was very low in some countries, but overall was around 18%.
As with all quantitative surveys, the respondents were
somewhat limited in their choice of answers and may have
been forced to choose responses that did not entirely accurately
reflect their views. Inherently, this study design does not
provide in-depth analysis of IUC knowledge and practice that a
qualitative study might afford. Additionally, we used the MEC
as a surrogate for knowledge about evidenced-based guidelines, although the way these guidelines are promoted and used
in individual countries will vary enormously.
This survey confirms the discrepancies between HCP
attitudes to IUC use in nulliparous women and the available
evidence, particularly around the issues of PID and
infertility. More education is needed worldwide to decrease
this knowledge gap. Access to international and national
evidence informed guidance could reassure HCP about the
safety of IUC use and could potentially lead to increased
uptake in nulliparous women.
Supplementary data to this article can be found online at
http://dx.doi.org/10.1016/j.ajem.2013.06.005.
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