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Obstetrics & Gynecology 2006;108:1417-1422
© 2006 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Young Pregnant Women’s Knowledge of Modern Intrauterine Devices

Nancy L. Stanwood, MD, MPH and Karen A. Bradley, MD

From the University of Rochester Medical Center, Rochester, New York.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX: Selected Questions...
 REFERENCES
 
OBJECTIVE: Modern intrauterine devices (IUDs) are safe, effective, and reversible, but only 2.1% of U.S. women use IUDs. We aimed to estimate young pregnant women’s knowledge of IUDs.

METHODS: We surveyed 190 women, aged 14–25 years, presenting for prenatal or abortion care about their contraceptive history, plans, and knowledge. We asked if they had heard of IUDs and queried them on IUD characteristics.

RESULTS: The women were, on average, 20 years old, 27% had education past high school, and 47% had delivered a child. Half were in prenatal care, and 91% had not planned their current pregnancy. Fifty-two percent wished to wait 4 or more years before their next pregnancy, and 27% did not want to be pregnant ever again. Safety and efficacy were the most important factors in choosing a contraceptive method. Fifty percent had heard of IUDs, 71% did not know about IUDs’ safety, and 58% did not know about IUDs’ efficacy. Respondents who knew of IUDs were older (21 versus 19 years, P<.001) and more likely to be parous (55% versus 39%, P=.04).

CONCLUSION: Young women choosing contraception after a pregnancy would benefit from counseling about the relative safety and effectiveness of IUDs, allowing them to make fully informed contraceptive decisions.

LEVEL OF EVIDENCE: II-2

In the United States, the rate of unintended pregnancy is endemically high.1 Approximately half of the 6 million annual pregnancies are unintended and almost half of these are ended in abortion, for 1.3 million abortions in 2000.1,2 The United States has the highest rates of abortion and adolescent pregnancy of any Western developed country. Most teen pregnancies (80%) are unintended, with 45% ending in abortion.1 Although a higher percentage of teen pregnancies are unintended, women in their 20s contribute the largest absolute number of unintended pregnancies.1 And although contraceptive behavior improves with age,6,7 U.S. women in their early 20s who become pregnant did not intend to 39% of the time.1

For teens and women in their early 20s who have recently given birth or had an abortion, delaying another pregnancy is crucial to helping them reach their educational and employment goals and enabling them to be good parents to the children they may have. However, in the first 2 years postpartum, up to one third of teenaged mothers become pregnant again. Of women who present for abortion, 55% are mothers.11 In Finland, 18% of parous women having abortions are within the first year postpartum.12 Of women having abortions, 45% have had one before.11 Helping teens and young women chose an effective method of postpartum or postabortal contraception is critical in the public health effort to decrease unintended pregnancies, abortions, and repeat abortions.

In one recent survey, the majority of currently or recently pregnant women stated that the ideal contraceptive would be nonpermanent and would not need frequent thought.13 Contraceptive effectiveness studies confirm their opinion. Teenagers and young women have higher continuation rates and lower repeat unintended pregnancy rates postpartum when they use a method that does not require frequent or coital behavior.10,14,15 Such methods currently available in the United States are the 3-month depomedroxyprogesterone acetate injection and the modern intrauterine devices (IUDs), the copper T380A, and the levonorgestrel-releasing system.

Earlier surveys of women show that effectiveness and safety are the most important factors to women when choosing a contraceptive method.16 However, little is known about what the current generation of pregnant young women wants in a contraceptive method and what affects their plans for contraception after delivery or abortion. With use of intrauterine contraception increased to 2.1% in the United States,17 we are interested to know what young women in the United States know of modern IUDs.

In the current study, we aimed to estimate the contraceptive experience and beliefs of young pregnant women presenting for prenatal or abortion care, with particular attention to their knowledge of modern IUDs.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 APPENDIX: Selected Questions...
 REFERENCES
 
We approached women presenting for prenatal or abortion care at two hospital-based clinics and asked if they would complete an anonymous self-administered written questionnaire. The clinics provide general reproductive health care to a population in which the majority has Medicaid for health insurance. We conducted the prenatal survey from August to September 2003 and the abortion survey from February to June 2005, offering participation to most patients presenting for care during the respective study periods. We did not track the rate of nonresponse. The survey cover page asked women to identify themselves as being in our age range and being pregnant. We included respondents in the analysis who were aged 13–25 years and pregnant. The survey instrument included 28 multiple choice questions covering demographics as well as reproductive and contraceptive history, knowledge, and plans. Most women completed the survey before they met with their clinician at that visit. For a nonrandom but representative sample of the population, we aimed to have 200 women total, with half in prenatal and half in abortion care. The Research Subjects Review Board at the University of Rochester approved this study and granted it exemption from consent.

We performed univariate analyses of the data as well as bivariate analyses (t test, Fisher exact, and {chi}2) assessing associations between demographic factors and knowledge of IUDs. We categorized contraceptive method effectiveness by the World Health Organization’s (WHO) criteria.18 More effective methods are male or female sterilization, IUD, or hormone injection. Effective methods are pills, patch, or ring. Less effective methods are condoms, diaphragm, withdrawal, natural family planning, or spermicides.


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 APPENDIX: Selected Questions...
 REFERENCES
 
We surveyed 190 women, aged 14–25 years. Half were in prenatal care and half were presenting for abortion. Women were, on average, 20 years old, 27% (95% confidence interval [CI] 21–34%) had education past high school, 47% (95% CI 39–55%) had delivered a child, and 91% (95% CI 86–95%) reported the current pregnancy as unintended. Those women in abortion care and those in prenatal care were of similar age (20.4 versus 19.6 years, P=.05), but those in abortion care were more likely to have education past high school (73% versus 23%, P=.04) and to already have children (59% versus 38%, P<.001). As expected, women presenting for abortion had a high (99%) rate of unintended pregnancy, but the prenatal group also had a high rate, with 84% reporting the current pregnancy as unintended (P=.002).

We asked women what they felt was important in selecting a contraceptive method. They reported effectiveness and safety as the two most important characteristics, with 68% (95% CI 61–75%) choosing effectiveness and 48% (95% CI 41–56%) choosing safety. Fewer chose ease of use (23%, 95% CI 17–30%) or lack of weight gain (14%, 95% CI 9–19%) as important. Forty-one percent (95% CI 34–49%) chose partner preference as the least important issue in choosing a contraceptive method.

Subjects were experienced users of contraception. Ninety-five percent (95% CI 91–98%) had used condoms in the past, and 72% (95% CI 65–79%) had used pills. Forty-eight percent (95% CI 38–54%) had used the highly effective depo-medroxyprogesterone, and almost half (46%, 95% CI 40–56%) had used the highly ineffective method of withdrawal. Twenty-three percent (95% CI 17–31%) had tried the contraceptive patch, and only two women (1%, 95% CI 0.1–3.8%) had used an IUD in the past.

We asked women what method of contraception they were using at the time they conceived their current pregnancy. Subjects having abortions were significantly more likely to have been using contraception compared with all women in prenatal care (86% versus 61%, P<.001) and compared with those in prenatal care with unintended pregnancies (86% versus 73%, P=.02). The overall patterns of contraceptive use at conception in the abortion or prenatal groups were significantly different, with those in the abortion group more likely to use dual method (condoms and hormonal) and more likely to use nothing due to a perceived low risk of pregnancy (Table 1). These findings are consistent with national data on contraceptive use and unintended pregnancy.1,11


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  		Table 1. Contraceptive Method Used at Time of Conception

 

In planning for their next pregnancy, most women wanted to wait several years. Although 9% (95% CI 5–14%) wanted another pregnancy within 2 years, 52% (95% CI 44–59%) wished to wait 4 or more years until their next planned pregnancy, and 27% (95% CI 20–34%) never wanted another child. The two groups (abortion or prenatal) had no difference in their plans for timing another pregnancy. Thus, 78% (95% CI 72–84%) need postpregnancy contraception for 4 or more years to reach their family planning goal.

We asked women what method of contraception they planned to use after the current pregnancy to achieve their family plans. For all abortion and most prenatal women, this response was given before contraceptive counseling by the clinician. More women having abortions planned to use pills or an IUD, and more prenatal women planned to use the patch or depomedroxyprogesterone acetate injection (P=.04; Table 2). When categorized according to the World Health Organization for method effectiveness,18 32% (95% CI 25–40%) of women planned for a more effective method, 54% (95% CI 47–62%) an effective method, and 13% (95% CI 9–19%) a less effective method. These proportions were not significantly different by age, parity, type of care (abortion or prenatal), or the effectiveness of the method used at the time of conception if the current pregnancy was unintended.


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  		Table 2. Planned Postpartum Method of Contraception

 

Half of women (95% CI 43–57%) had heard of intrauterine devices, 25% (95% CI 19–32%) knew someone using an IUD for contraception, and 20% (95% CI 14–26%) had heard of both types of IUDs. Of women who had heard of IUDs, 58% (95% CI 47–69%) did not know about their efficacy, and 71% (95% CI 60–80%) did not know about their safety (Table 3). Over half (55%, 95% CI 44–65%) knew that IUDs could be used for a year or more. Women who knew of IUDs were slightly older (21 versus 19 years, P<.001) and were more likely to be parous (55% versus 39%, P=.04) than those who did not know about IUDs. This knowledge was not associated with education or type of care.


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  		Table 3. Knowledge About Modern Intrauterine Device Safety and Effectiveness Among Respondents Who Had Heard of Intrauterine Devices (n=92)

 

Overall 13% (95% CI 8–20%) of women planned to use an IUD after the current pregnancy, with parous women being more likely than nulliparous women (20% versus 6%, P=.01). Planning to use an IUD was not associated with age, education, or type of care.


   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
APPENDIX: Selected Questions...
 REFERENCES
 
We found that the majority of these young pregnant women in prenatal or abortion care wanted to postpone another pregnancy for 4 or more years and wanted a safe and effective method of contraception to reach this goal. Half of women had heard of IUDs, but few of these women were familiar with the safety or effectiveness of modern IUDs. Half of women planned to use a method categorized by the WHO18 as effective, and one third chose a more effective method. Overall, 13% planned to use an IUD after the current pregnancy.

The percentage of women using contraception who use an IUD varies among countries and in the United States over time. The percentage of women using an IUD also has an inverse relationship to the rate of female sterilization. Currently in the United States, 2.1% of contracepting women use an IUD, and 17% have been sterilized.17 In contrast, of western European women using contraception, 14% use an IUD and 6% have been sterilized.19 In the United States, use of IUDs went from 7% in 1982 to 0.8% in 1995, whereas sterilization in the same years went from 23% to 28%.6 This shift in IUD use was driven by the debacle with the deeply flawed Dalkon Shield. The two modern IUDs in the United States—the copper T380A and the levonorgestrel-releasing system—are distinctly different from the Dalkon Shield in design and drug delivery, are highly cost-effective,20,21 and have impressive safety and efficacy profiles.

Although U.S. clinicians have been traditionally reluctant to provide IUDs to younger women, younger age in itself is not a contraindication to use of an IUD. The World Health Organization categorizes recommendations for contraception in specific conditions on a scale of 1 to 4. A classification of 1 has no restrictions on use of the method, 2 is "where the advantages outweigh the theoretical or proven risks," 3 is "where the risks usually outweigh the advantages," and 4 is an unacceptable health risk.26 For IUDs, WHO gives a level 1 recommendation for women over the age of 20 and a level 2 for menarche to age 20. In this section, the guidelines states, "IUDs do not protect against STI/HIV. If there is risk of STI/HIV..., the correct and consistent use of condoms is recommended."26 We base our clinical practice on these recommendations, and we teach patients about the option of an IUD for contraception and strongly encourage condom use. In our abortion service, we offer immediate postabortal IUD insertion.27

In counseling pregnant women about contraception, it is important to consider how long until they would wish to be pregnant again. The typical use failure rates for contraceptive methods are reported as cumulative over 1 year. Most of our respondents wish to postpone pregnancy for 4 or more years. With typical use, those who take oral contraceptive pills over 4 years have up to a 28% chance of an unintended pregnancy, whereas those who choose a copper T380A IUD have a 1.1% chance.28,29 This relative difference is important to include in contraceptive counseling.

Modern evidence is reassuring about the safety of IUDs. The risk of insertion-related upper genital tract infection is 3 in 1,000 and occurs in the first 20 days of use.30 After this time, the risk of upper genital tract infection for IUD users is based on sexual exposure, not use of the device.30 A case control study of tubal factor infertility found that prior use of a copper IUD was not associated with infertility, but that positive Chlamydia antibody was.25 It is unknown if a woman wearing an IUD who gets gonorrhea or Chlamydia cervicitis is more likely to develop upper genital tract infection than a woman with the same infection who is not wearing an IUD. However, some studies suggest that the levonorgestrel IUD may actually protect against upper genital tract infection,31,32 perhaps by thickening cervical mucus.

This study is limited by its cross-sectional design; therefore, we can find associations but not conclude causality. The findings are from an academic obstetrics and gynecology residency practice and an adolescent maternity program and thus may not be generalizable to other populations. Although we do not have information on nonrespondents, during recruitment the majority of women approached agreed to participate. Subjects reported what method they planned to use, but we do not know what these women actually used for contraception. However, in our abortion service, approximately 25% get an IUD, 25% get depomedroxyprogesterone acetate, 20% start pills, and 10% start the patch. Thus, more women may adopt a highly effective method after care and counseling than had planned to before counseling. The two components of the survey (prenatal and abortion) were conducted at different times (fall 2003, spring 2005). Because there was little secular change in contraceptive care during this time, we feel it is unlikely that this temporal difference introduced significant biases.

Young women with unintended pregnancies are well served by effective, long-term methods of contraception that separate contraceptive performance from compliance. Although taking one pill is easy, taking one consistently every day for 4 years provides 1,460 chances to miss a pill, 47 chances to miss the monthly trip to the pharmacy, 47 chances to lack the co-pay to fill the prescription, and three chances to delay getting a renewed prescription from the clinician. Modern IUDs do not require on-going contraceptive work by the woman to be effective. Young women choosing contraception after a pregnancy would benefit from counseling on the relative safety and effectiveness of IUDs, allowing them to make fully informed contraceptive decisions.


   APPENDIX: Selected Questions From the Survey Instrument
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX: Selected Questions...
REFERENCES
 

  1. What’s the MOST IMPORTANT thing to you when you choose a method of birth control?
    1. It does not cost too much
    2. It works really well
    3. My doctor or nurse recommends it
    4. It’s easy to use
    5. It won’t mess up my periods
    6. My boyfriend likes it
    7. It’s safe
    8. My friends recommend it
    9. It won’t make me gain weight

  2. What’s the NEXT MOST important thing to you when you choose a method of birth control?
  3. What’s the LEAST important thing to you when you choose a method of birth control?
  4. Please check the box of the ALL methods of birth control you have EVER tried?
  5. What were you using for birth control when you got pregnant this time?
  6. Which method do you think you want to use after this baby comes?
  7. Which method do you think works the BEST at keeping you from getting pregnant?
  8. Which method do you think works the NEXT BEST at keeping you from getting pregnant?
  9. Which method do you think works the WORSE at keeping you from getting pregnant?
  10. Before today, had you ever heard about the Intrauterine Devices (IUDs)?
  11. Do you know anyone who uses an IUD for birth control?
  12. If you know something about an IUD, how well do you think it works for birth control?
    1. As well as the Pill
    2. As well as the 3-month DepoProvera shot
    3. As well as getting your tubes tied
    4. Not sure

  13. If you know something about an IUD, how safe do you think it is for your overall health?
    1. As safe as the Pill
    2. As safe as the 3-month DepoProvera shot
    3. As safe as getting your tubes tied
    4. Not sure

  14. How many kinds of IUDs do you know about?
    1. One, the copper one
    2. One, the hormone one
    3. Two, the copper and the hormone one
    4. None

  15. Do you know how long the IUDs work?
    1. 1 year
    2. 2 years
    3. 5 to 10 years
    4. Not sure

  16. What side effects do you think the IUDs have? (Check all that apply)
    1. Change your periods
    2. Make you gain weight
    3. Change your hair
    4. Not sure


   Footnotes
 
See related article on page 1411.

Funding for this study came from the Kenneth J. Ryan Training Grant in Abortion and Contraception. Dr. Stanwood received salary support from the National Institutes of Health Women’s Reproductive Health Research Grant (K12 HD01332–05), and she was a consultant for FEI Women’s Health, the manufacturer of the ParaGard IUD.

The authors thank Jacqueline Nasso, CNM, for her assistance with collecting surveys.

Corresponding author: Nancy L. Stanwood, MD, MPH, 601 Elmwood Avenue, URMC Box 668, Rochester, NY 14642-8668; e-mail: nancy_stanwood{at}urmc.rochester.edu.

doi:10.1097/01.AOG.0000245447.56585.a0


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 APPENDIX: Selected Questions...
 REFERENCES
 
1. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24–9.[Medline]

2. Finer LB, Henshaw SK. Abortion incidence and services in the United States in 2000. Perspect Sex Reprod Health 2003;35:6–15.[Medline]

3. Wulf D. Sharing responsibility: women, society and abortion worldwide. New York (NY): Alan Guttmacher Institute; 1999.

4. Darroch JE, Singh S, Frost JJ. Differences in teenage pregnancy rates among five developed countries: the roles of sexual activity and contraceptive use. Fam Plann Perspect 2001;33:244–50, 281.

5. Cheyne KL. Adolescent pregnancy prevention. Curr Opin Pediatr 1999;11:594–7.[Medline]

6. Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States: 1982–1995. Fam Plann Perspect 1998;30:4–10, 46.

7. Glei DA. Measuring contraceptive use patterns among teenage and adult women. Fam Plann Perspect 1999;31:73–80.[Medline]

8. Templeman CL, Cook V, Goldsmith LJ, Powell J, Hertweck SP. Postpartum contraceptive use among adolescent mothers. Obstet Gynecol 2000;95:770–6.[Abstract/Free Full Text]

9. The Alan Guttmacher Institute. Teen sex and pregnancy: facts in brief. New York (NY): Alan Guttmacher Institute; 1999.

10. Stevens-Simon C, Kelly L, Kulick R. A village would be nice but...it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. Am J Prev Med 2001;21:60–5.[Medline]

11. Henshaw SK, Kost K. Abortion patients in 1994–1995: characteristics and contraceptive use. Fam Plann Perspect 1996;28:140–7, 158.

12. Vikat B, Kosunen E, Rimpela M. Risk of postpartum induced abortion in Finland: a register-based study. Perspect Sex Reprod Health 2002;34:84–90.[Medline]

13. Cwiak C, Gellasch T, Zieman M. Peripartum contraceptive attitudes and practices. Contraception 2004;70:383–6.[Medline]

14. Trussell J, Kost K. Contraceptive failure in the United States: a critical review of the literature. Stud Fam Plann 1987;18:237–83.[Medline]

15. Zibners A, Cromer BA, Hayes J. Comparison of continuation rates for hormonal contraception among adolescents. J Pediatr Adolesc Gynecol 1999;12:90–4.[Medline]

16. Grady WR, Klepinger DH, Nelson-Wally A. Contraceptive characteristics: the perceptions and priorities of men and women. Fam Plann Perspect 1999;31:168–75.[Medline]

17. Mosher WD, Martinez G, Chandra A, Abma J, Willson S. Use of contraception and use of family planning services in the United States, 1982–2002. Hyattsville (MD): National Center for Health Statistics; 2004.

18. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed. Geneva, Switzerland: World Health Organization; 2000.

19. Spinelli A, Talamanca IF, Lauria L. Patterns of contraceptive use in 5 European countries. European Study Group on Infertility and Subfecundity. Am J Public Health 2000;90:1403–8.[Abstract/Free Full Text]

20. Trussell J, Leveque JA, Koenig JD, London R, Borden S, Henneberry J, et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health 1995;85:494–503.[Abstract/Free Full Text]

21. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, et al. Economic analysis of contraceptives for women. Contraception 2003;68:3–10.[Medline]

22. Chi IC. A bill of health for the IUD: where do we go from here? Adv Contracept 1994;10:121–31.[Medline]

23. Ronnerdag M, Odlind V. Health effects of long-term use of the intrauterine levonorgestrel-releasing system: a follow-up study over 12 years of continuous use. Acta Obstet Gynecol Scand 1999;78:716–21.[Medline]

24. Sivin I, Stern J. Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. International Committee for Contraception Research (ICCR). Fertil Steril 1994;61:70–7.[Medline]

25. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzman-Rodriguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561–7.[Abstract/Free Full Text]

26. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 3rd ed. Geneva, Switzerland: World Health Organization; 2004. Available at: http://www.who.int/reproductive-health/publications/mec/mec.pdf. Retrieved September 15, 2006.

27. Stanwood NL, Grimes DA, Schulz KF. Insertion of an intrauterine contraceptive device after induced or spontaneous abortion: a review of the evidence. BJOG 2001;108:1168–73.[Medline]

28. Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89–96.[Medline]

29. Sivin I, el Mahgoub S, McCarthy T, Mishell DR Jr, Shoupe D, Alvarez F, et al. Long-term contraception with the levonorgestrel 20 mcg/day (LNg 20) and the copper T 380Ag intrauterine devices: a five-year randomized study. Contraception 1990;42:361–78.[Medline]

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32. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49:56–72.[Medline]




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Are Young, Pregnant Women in the U.S. Savvy About IUDs?
Journal Watch Women's Health, January 25, 2007; 2007(125): 3 - 3.
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