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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

Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Central Clinical School, Camperdown, Sydney, NSW 2050, Australia
Department of Obstetrics and Gynecology, University of Arizona School of Medicine, Tucson, AZ 85724, USA
Department of Adolescent Gynecology, Instituto Nacional de Perinatologia; Universidad Nacional Autónoma de México, Mexico City 11000
Sexual Health Services Surrey for Virgincare, Cobham, England KT11 1HT
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

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: (K.I. Black).

0010-7824/$ – see front matter © 2013 Elsevier Inc. All rights reserved.

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

Very few women in Canada (1%) and Australia (1.0% of women in Latin America and the Caribbean and 5.8. Germany. global rates of IUC use demonstrate enormous variability. Schering Plough and Copper TT380®) and the levonorgestrel-releasing intrauterine system (LNG-IUS. Of women of reproductive age married or in a union from the regions examined in this study. Some questions focused on the perceived efficacy. suggesting that healthcare practitioner and service provision factors have a key impact on IUC utilization. Mirena®.. use of IUCs varies greatly according to the United Nations 2011 report. In addition. in a multiple choice format where participants were directed to select one or more of the structured response(s). Respondents were asked to choose the three main benefits and barriers to IUC. The section of survey addressing HCP knowledge and attitudes to IUC provision and understanding of the WHO MEC consisted of 13 questions. From the market research panels. These questions were all. Data from Europe found that although nulliparous women constitute almost half of those in reproductive age.I. Colombia and Argentina). age. Sweden.9]. This study set out to explore HCPs’ knowledge and practice of IUC provision from 15 countries around the world. Australia. Intrauterine contraception for Nulliparous women: Translating Research into Action group) and sought to investigate knowledge and practice of IUC insertions in nulliparous women. USA.K. Black et al. HCPs were identified from existing nursing and medical market research panels of practitioners who had expressed an interest in participating in research. Canada. in both young and nulliparous women. region and work setting. 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 [13–16]. The use of intrauterine devices in nulliparous women is also recommended by national evidence-based recommendations. they make up only 10% of IUC users [10. insertion and risks associated with IUC use comparing nulliparous to parous women. from a comprehensive list of options as in Table 1. Mexico.1% of women reported using an IUC. depending on age and parity. both overall and specifically for nulliparous women. In Europe. The logistics of 651 distributing and administering the survey were undertaken by the global market research organization GfK and funded by Bayer HealthCare. Netherlands. Despite support from experts. In comparison 7. Seven initial questions addressed the HCP type of professional background and clinical practice around IUC. 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. including the National Institute of Clinical Excellence in the United Kingdom and the American Congress of Obstetricians and Gynecologists [2. They were asked to indicate which patients they would discuss the use of IUC with. individuals were selected by random sampling. Each HCP was sent an email invite to take part. 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]. / Contraception 88 (2013) 650–656 Cu-375. 12. 2. there is little uptake of intrauterine contraceptive methods (IUCs) among nulliparous women. 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. Their qualities of being user independent and highly efficacious are particularly advantageous in young nulliparous women.[Progr: insert] . 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. France. The wording of the questions is included as an electronic appendix. please specify:…. Turkey. Brazil. The questionnaire was developed by an international advisory group of 10 clinicians with expertise in IUC (INTRA. Ireland. and additional questions captured demographic characteristics of gender. except for one. Bayer Healthcare Pharmaceuticals). Materials and methods This was an online survey undertaken across 15 countries (UK.3%) were documented to be using the method [12].8% of women in USA used IUCs. The questionnaire was translated into the language of each of the countries by native speakers and tested for comprehension prior to roll out.11]. In each country. Russia. 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].

Canada was grouped with the European countries. We used the χ 2 test for univariate analysis of categorical variables.8 11.9 16.8 11.1 32.5 61. Europe and Canada.3 48.0 the risks of IUC in nulliparous women with those in parous women. 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.2 2. Latin America and the United States.0 6. / Contraception 88 (2013) 650–656 Table 2 Clinician characteristics by region of origin Healthcare practitioner Obstetrician/gynecologist General practitioner Midwife/nurse Gender Male Female Years of independent practice 0–10 11–20 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 1035 827 51.3 1460 368 34 76.7 39.5 0 49.4 30. Black et al.7 21.8 33.2.2%).1 21.1 19. Response rates varied from between 5% (Brazil) and 34% (USA).4 85. As Canada’s health system shares much in common with European systems.6 31.1 33.8 38.4%).1. Results 3.3 597 635 630 34.652 K.6 91.7 38.2 39. with an average of 18% across the 15 countries.8 39. 3. including type of HCP.7 63.8%). 1.8 3. 156 (8. 1103 (59.4 12.5 36. Australia. Perceived barriers to nulliparous IUC use by region. . and Australia.3 14. gender.1 0. Ethics approval was obtained from the University of Sydney Human Research Ethics Committee and the University of Tennessee Institutional Review Board. The demographic data.8 57.9 33. For the purposes of describing international variations.0 92.3 60.5 7.2 39. Demographic information We received 1862 responses from HCPs from 15 countries: Latin America. duration of independent practice and role in IUC insertion.7 39. USA.6%). 402 (21.5 64. The survey took approximately 15–20 min to complete.3 35.I. Analysis of the data was undertaken by using IBM SPSS Statistics 20. 201 (10. Multivariate analysis was undertaken using binary logistic regression. and practitioners were reimbursed between US $60 and US $80 for their time. countries were grouped into the regions of Europe. 3.1 26. are presented in Table 2. These Fig.

However. infertility.001). included concern about PID. that women do not like it and other reasons. HCP type and years of experience. Practitioners in Australia.001 and p=. Europe.I. ectopic pregnancy. Across all geographic regions. respectively). 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. Latin American providers remained significantly more concerned about infertility (pb.007. providers were equally concerned about PID. significantly fewer of the family planning nurses and midwives (n= 88. Around two thirds (63. / Contraception 88 (2013) 650–656 653 Fig. are presented in Figs. Perceived barriers to nulliparous IUC use by type of healthcare practitioner.2%) of HCPs believed that IUC in nulliparous women placed them at higher risk of PID compared to nonusers.027) compared to practitioners from other regions. pain.002) but were less concerned about insertion pain (pb. Canada and the United States were more concerned about difficult insertions than their Latin American colleagues (pb.K.1%) rated the risk as being higher in Fig. 2 and 3. along with how these responses varied by region. 3. The four barriers most commonly selected. Years of experience did not affect concern for difficult insertion or insertion pain. In multivariable analysis taking into account HCP type. Black et al. Perceived barriers to nulliparous IUC use by years of independent practice. 2. 48. 3. region and years of independent practice. . 1. but those in practice longer were more likely to be concerned about PID and infertility (pb. insertion difficulty.3.

6 2. Insertion risks. 63.5 47.1 48. 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 0–10 11–20 N20 a b Total N MEC 1 % MEC 2 % MEC 3 % MEC 4 % Do not know 1101 156 402 201 15 17.7 10.5 1. Black et al.7 5. 3. obstetricians and nurses were significantly more likely to have correct knowledge of WHO MEC compared to general practitioners.4 24 22. In univariate analysis.3 14. particularly in nulliparous women.7 15.5. The proportion of providers who perceived increased risk for nulliparous women compared to parous women is documented in Table 3.1%) (pb.8 14. indicating that the effect was due to HCP type (Table 4).8 8.7%) 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).9 11.8 37.4.0 2. b .3 76. Discussion This survey highlighted the ongoing misperceptions HCPs have about IUCs around infection.4 45.6 57.8 34. / Contraception 88 (2013) 650–656 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 N % 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 11.9 14.8 12.8 p=.1 31.4 43. Only HCP type remained significant in the multivariable model that included all the variables shown in the table.2 28.6 15.7 41.5 1. only half of HCPs (49.4 0 2.1 51 13.4 10.5%) and general practitioners (n= 299. 65. but that the difficulty and pain of insertion were greater. most providers felt that the risk of perforation and expulsion were similar or slightly increased in nulliparous versus parous women.2 8.654 K.2 5.6 25.5 2.7%) and lowest amongst the Australians (Table 4).4 23.2 50. 3.1 nulliparous users of IUC compared to obstetricians (n= 789. These apparent regional differences did not remain after multivariate analysis.4 10.7 36.744 Significant in bivariate analysis of correct (MEC 2) versus incorrect/do not know.9 82.001 a 1205 474 183 14. This persistent misunderstanding about the ongoing risk of PID and resultant infertility has been previously documented among HCPs. Knowledge was highest amongst the Latin Americans (57.7 1.3 p value pb.I. The risk of infertility was of greatest concern to practitioners from Latin America. expulsion risk and difficulty of insertion compared to parous women Using Likert scale questions about the details of IUC insertion.1 16. Our survey noted regional and HCP type variations.7 46.1 49. 4.7 12.3 2.01).1 50.2 1.2 5.8 10. 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.1 597 635 630 12.8 53.0 15.001 a pb.5 22. infertility and difficulty of insertion.1 41. Knowledge of WHO criteria for use in nulliparous women Overall.4 3.8 2 2.

Inherently. Madden T.20].7 cm vs. HCPs felt that. Medical eligibility criteria for contraceptive use 4th edition 2010.1016/j. [3] Winner B.25].11(3):261–76. Hum Reprod Update 2005. Peipert JF. whereas the risk of perforation and expulsion was most often regarded as the same.110(6):1493–5. It may also indicate their own expectation of their knowledge and an unwillingness to admit they do not know. although the way these guidelines are promoted and used in individual countries will vary enormously. Popul Trends 2004. We do not have information about the HCPs who declined participation in the study. There are a number of studies that compare the IUCassociated insertion pain between nulliparous and parous women [24–26]. Eur J Contracept Reprod Health Care 2008. Accessed 28/02/2012. Effectiveness of long-acting reversible contraception. Other studies found larger differences in pain scores between nulliparous and parous women [24. This survey confirms the discrepancies between HCP attitudes to IUC use in nulliparous women and the available evidence. Commissioned by the National Institute for Health and Clinical Excellence. / Contraception 88 (2013) 650–656 as Chlamydia and not the presence of an IUC [17. The study is novel. Obstet Gynecol 2007. 2013. Allsworth JE. et al. Studies of IUC insertion in nulliparous women have repeatedly documented that insertion failure is uncommon and that most insertions occur without difficulty. [11] Cibula D. ACOG Committee opinion no. 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]. but overall was around 18%. 2011. One study found that the pain was significantly greater in nulliparous women having a copper IUD inserted (mean of 2. 2. Additionally. Perpetual postponers? Women’s.8% of nulliparous women [23]. Collins J. This may well reflect greater training in the field of contraception. Eur J Contracept Reprod Health Care 2009.005. As with all quantitative surveys.19 (95% confidence interval. N Eng J Med 2012. Intrauterine device and adolescents. Women's contraceptive practices and sexual behaviour in Europe.14(3):187–95.23(6):1338–45. we used the MEC as a surrogate for knowledge about evidenced-based guidelines.114(6):1434–8. this study design does not provide in-depth analysis of IUC knowledge and practice that a qualitative study might afford. Hum Reprod 2008. [4] Mavranezouli esa/population/publications/contraceptive2011/contraceptive2011. Buckel C. 2009. Profile of long-acting reversible contraception users in Europe. More education is needed worldwide to decrease this knowledge gap. Leridon H. 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 [19.366(21):1998– December 2007.K. and its strengths are that it provides a large global survey of different types of contraceptive providers. [7] Baird DT.13(4):362–75. insertion failure occurred in only 1 of 159 nulligravid women (0. Overall. http://www. 392. ACOG Committee opinion no. 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. Supplementary data to this article can be found online at http://dx.pdf. [5] Berrington A.2013. Egozcue J. Black et al. DC: National Academies Press. insertion pain and difficulty were greater in nulliparous women. References [1] National Research Council. 22 % as moderately difficult and only 6% as very difficult [21]. [9] American College of Obstetricians and Gynecologists Committee on Gynecologic P. 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. in 95% of all women. [8] American College of Obstetricians and Gynecologists. In a Swedish study of 223 nulliparous women. Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception.who.9 cm in parous women on a 10-cm visual analogue scale).ajem. the IUC was successfully inserted as an outpatient procedure. Knowledge varied with region and HCP type in univariate analysis but only by HCP type in multivariate analysis. Washington.18]. 72% of insertions were rated as easy. particularly around the issues of PID and infertility. although overall pain scores for all women were low [26]. compared to parous women. The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline. 2005. London: RCOG Press. Although the odds ratio of the procedure being abandoned in nulliparous women compared to parous women in Australian family planning clinics was 5.06. Long-Acting Reversible Contraception Working G. 1. Obstetrician/gynecologists were the HCP group most likely to be correct and least likely to say that they did not know the correct category. [6] World Health Organization. men’s and couple’s fertility intentions and subsequent fertility behaviour. htm. Available from: http://www.I. Evers LH. Obstetrician/ gynecologists and nurses/midwives were significantly more often correct compared to general practitioners. [2] National Collaborating Centre for Women’s and Children’s Health.4%) [22]. 450: increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009. Gianaroli L.doi. including in 88. In a Brazilian study comparing nulligravid and parous women choosing the LNG-IUS. and the response rate 655 was very low in some countries. Initial national priorities for comparative effectiveness research. [12] United Nations. . Last accessed May 5th.6%) and in 2 of 477 parous women (0. 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 Zhao Q. et al.117:9–19. [10] Haimovich S. Placement failure rate in this study of nulliparous women was 6/224 (2.un.49–10.82). World contraceptive use 2011. Group LGD. 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