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Perceptions of intrauterine contraception among women seeking primary care
Contraception 88 (2013) 269 – 274
Original research article
Perceptions of intrauterine contraception among women seeking primary care Lisa S. Callegari a, b,⁎, Sara M. Parisi c , Eleanor Bimla Schwarz c, d, e a
Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA b Department of Epidemiology, University of Washington, Seattle, WA, USA c Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA d Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA e Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA Received 13 November 2012; revised 22 January 2013; accepted 10 February 2013
Abstract Background: Intrauterine contraception (IUC) is safe, highly effective and has few medical contraindications. Primary care providers see many women with chronic conditions who might benefit from IUC. Study Design: We surveyed women aged 18–50 who visited one of four primary care clinics in Pennsylvania between October 2008 and April 2010 to investigate perceptions of IUC and to identify factors associated with accurate perceptions. Key independent variables included patient characteristics, including knowing other women who had used IUC, and having discussed IUC with a provider. Logistic regression was used to examine the association between independent variables and accurate perceptions. Results: The study population included 1626 eligible respondents. Only 19.5% of women knew that IUC is more effective than oral contraceptive pills, 57.4% knew that IUC does not increase the risk of sexually transmitted infections and 28.7% knew that IUC is more costeffective than oral contraceptive pills. Among women who had never used IUC, accurate perceptions were associated with higher levels of education, knowing one or more women who had used IUC and having discussed IUC with a health care provider. Conclusions: Many women seeking primary care have inaccurate perceptions of IUC and may benefit from counseling about the advantages of this approach to preventing unintended pregnancy. Published by Elsevier Inc. Keywords: Attitudes; Contraception; Counseling; Intrauterine devices; Primary care; Progesterone releasing
1. Introduction High rates of unintended pregnancy continue to pose a significant public health challenge in the United States [1]. Fifty percent of all US pregnancies are unintended, and approximately half of those occur in women who report using contraception at the time of conception [1,2]. Efforts are therefore needed to promote contraceptives that are less likely to fail and are easier for women to use. One proposed strategy for lowering rates of unplanned pregnancy is to increase use of highly effective reversible contraceptives such as intrauterine contraception (IUC) [3,4]. ⁎ Corresponding author. Seattle HSR&D Center, Puget Sound Veterans Administration, University of Washington, 1400 Seattle, WA 98101. Tel.: +1-206-277-3129; fax: +1-206-768-5343. E-mail address: [email protected] (L.S. Callegari). 0010-7824/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.contraception.2013.02.004
Rates of IUC use in the US are lower than those in many other industrialized countries for a number of reasons, including patient and provider knowledge and attitudes, practice patterns and cost [4]. Misperceptions about IUC persist among both patients and providers [5], despite a large body of evidence supporting the safety and acceptability of currently available IUC [6–8]. Recently, a large prospective cohort study found IUC to be 20 times more effective than other more commonly used methods such as oral contraceptive pills (OCPs) [9]. IUC does not increase risk of transmission of sexually transmitted infections (STIs), pelvic inflammatory disease or infertility [10] and is more costeffective than OCPs when used for 2 or more years [11]. Women seeking primary care from internists and family physicians are more likely to have chronic medical conditions that increase the potential morbidity of an unintended pregnancy compared to women who only see obstetrician
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gynecologists [12–15]. These women may benefit from IUC which, unlike estrogen-containing contraceptives, has few medical contraindications [16,17]. Primary care providers, however, are less likely to provide contraceptive counseling than obstetrician gynecologists [13,18] and less likely to discuss IUC [19]. Previous studies suggest that many women have inaccurate views about the risks and benefits of IUC [5,20–23], which may influence contraceptive decision making. A recent study from Saint Louis found that most women underestimated the effectiveness of IUC and overestimated the risk of infection and infertility [20]. The only previous study conducted in a primary care setting found that 79% of participants knew that IUC was safe but did not investigate perceptions of effectiveness or cost [23]. Our study therefore seeks to more fully describe perceptions of IUC among women seeking primary care and to identify patient characteristics and experiences associated with accurate perceptions of IUC. Given the controversy surrounding whether contraceptive counseling influences women's knowledge and behavior [24–28], we also explored the role provider counseling plays in establishing accurate perceptions of IUC.
2. Materials and methods 2.1. Data collection All women aged 18–50 years who visited one of four primary care clinics in western Pennsylvania between October 2008 and April 2010 were invited to complete a survey online or by phone 7–30 days after their visit as part of a larger study evaluating the use of clinical decision support. This study has been previously described [24,29]. Briefly, study clinics included three community-based family practice clinics and one academic general internal medicine clinic. All clinics provide care to both publicly and privately insured patients. Participants provided signed informed consent and received instructions on how to access the survey at the time of their clinic visit. Participants who completed the survey received a US$10-gift card. This study was approved by the University of Pittsburgh Institutional Review Board. 2.2. Survey The 75-question survey assessed patient characteristics such as age, education, race, marital status, annual household income, insurance status, receipt of Medicaid and number of prior pregnancies, live births and abortions. Information on participants' ability to conceive was also obtained. Participants were asked to specify what contraception they used the last time they had sex and during the last 3 months as well as contraceptives they had ever used. Women's perceptions about IUC were assessed with a series of questions that compared IUC to OCPs, including (a)
whether women using IUC are more or less likely to become pregnant than women using OCPs; (b) whether women using IUC are more or less likely than women using OCPs to get STI; and (c) whether IUC costs more or less than OCPs when both are used for 3 years or longer. Responses to these three knowledge questions were dichotomized into accurate versus inaccurate perceptions. Specifically, accurate perceptions of IUC included stating that, compared to OCPs, IUC is more effective in preventing unintended pregnancy, more cost-effective and does not increase risk of STIs. Participants were also asked whether they had ever discussed IUC with a provider and the number of women they knew who had used IUC. 2.3. Statistical analysis We excluded from this analysis participants who were unable to conceive due to tubal ligation, partner vasectomy, hysterectomy or menopause at the time of their survey and women who did not provide information about current or past IUC use. We divided respondents into women who had (a) never used IUC; (b) previously used IUC; or (c) were currently using IUC. We compared the baseline characteristics of these three groups using chi-squared tests and one-way analysis of variance. We then compared perceptions of IUC among these three groups. Among the subgroup of women who had never used IUC, we used multivariable logistic regression to examine the relationships between accurate perceptions of IUC and receipt of provider counseling, knowing someone who had used IUC, patient demographics and reproductive characteristics. Variables were selected for inclusion in the multivariable models (a) a priori (age, education, marital status, parity) and/or (b) by significance at the pb .05 level in bivariate analyses. Finally, we performed a multivariable logistic regression model predicting the receipt of provider counseling about IUC, using variables selected a priori (age, race, education, marital status, parity, income and prior abortion). All analyses were conducted using Stata 12.0 (StataCorp. College Station, TX, USA). 3. Results A total of 1965 (19%) eligible women visited the primary care clinics and completed surveys. As reported by Lee et al. [24], women who completed surveys were similar to those who did not in age and marital status. However, women who completed surveys were more likely to be White, have more education and be established clinic patients [24]. We excluded women who were unable to conceive at the time of their survey (n= 323) or who did not provide information about current or past IUC use (n= 16), producing a sample for this analysis of 1626 (Fig. 1). Of these, 1451 (89.2%) had never used IUC, 94 had previously used IUC (5.8%) and 81 (5.0%) were current users. The majority of participants saw physicians (96%); however, 4% were seen by a nurse practitioner.
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Patients eligible to fill out the survey (n=10,177)
Patients who consented to fill out the survey (n=3,589)
Patients who completed the survey (n=1,965) Unable to conceive (n=323) Did not provide information on current or past IUC use (n=16) Study population (n=1,626) Fig. 1. Flowchart of study selection methods.
On average, participants were 33 (SD=9.1) years of age. Most participants were White, had at least some college education and were insured. Table 1 describes participant characteristics by IUC use. Compared to prior and never IUC users, current users were more likely to have given birth (63.8% vs. 39.4% and 43.3%, p= .001) and to have had an abortion (22.5% vs. 11.8% and 7.1%, pb .001). Current IUC users were more educated and more likely to have higher incomes. Only 19.5% of women knew that IUC was more effective than OCPs, whereas 57.4% accurately perceived no increase in STI risk with IUC compared to OCPs. Less than a third (28.7%) knew that IUC costs less than OCPs when used for 3 or more years. Current IUC users were more likely than past or never users to report accurate perceptions of IUC (Table 2). Almost all current users knew someone else who had used IUC (92.6%), compared to one third of prior or never users. Only 14.8% of women who had never used IUC reported having ever discussed IUC with a health care provider. Among women who had never used IUC, bivariate analyses for each of the three knowledge questions revealed that educational attainment, knowing one or more women who had used IUC and having discussed IUC with a provider were associated with greater odds of accurate perceptions (Table 3). Parity was associated with decreased odds of accurate perceptions about IUC effectiveness and risk of STIs. Being married or cohabitating and being 36 years of age or older were both associated with decreased odds of accurate perceptions of IUC effectiveness. In the multivariable models, knowing someone who had used IUC, provider counseling and educational attainment remained significantly associated with all three outcomes (Table 3). In the model predicting accurate perceptions of IUC effectiveness, age over 36 years remained a significant association but marital status did not.
We also analyzed factors associated with having previously discussed IUC with a provider. In a multivariable model adjusted for age, race and marital status, history of Table 1 Characteristics of respondents by history of IUC use Current
Past
Never
n=81 (%)
n=94 (%)
n= 1451 (%)
Age (N=1608) 18–25 years 14 (17.5) 32 (34.4) 362 (25.2) 26–35 years 33 (41.3) 29 (31.2) 493 (34.4) 36 + years 33 (41.3) 32 (34.4) 580 (40.4) Mean age (SD) 33.7 (8.1) 32.1 (9.3) 33.3 (9.1) Race (N= 1620) White 74 (91.4) 80 (86.0) 1337 (92.5) Black 1 (1.2) 6 (6.5) 45 (3.1) Other 6 (7.4) 7 (7.5) 64 (4.4) Education (N= 1619) High school or less 3 (3.7) 19 (20.4) 185 (12.8) Some college 27 (33.3) 32 (34.4) 432 (29.9) Bachelors 14 (17.3) 19 (20.4) 374 (25.9) Masters/Higher 37 (45.7) 23 (24.7) 454 (31.4) Have health insurance 80 (98.8) 88 (95.7) 1390 (96.7) (N= 1610) Received Medicaid 13 (16.1) 18 (19.4) 140 (9.7) (N= 1614) Income (N=1461) bUS$20,000/year 13 (17.3) 24 (28.2) 165 (12.7) US$20–49,999/year 20 (26.7) 29 (34.1) 355 (27.3) US$50–79,999/year 13 (17.3) 16 (18.8) 375 (28.8) ≥ US$80,000/year 29 (38.7) 16 (18.8) 406 (31.2) Marital status (N= 1622) Married/Cohabitating 55 (67.9) 48 (51.6) 817 (56.4) Single/Separated/ 26 (32.1) 45 (48.4) 631 (43.6) Divorced/Widowed Parity (N=1587) 0 29 (36.3) 57 (60.6) 801 (56.7) ≥1 51 (63.8) 37 (39.4) 612 (43.3) Prior abortion (N=1577) 18 (22.5) 11 (11.8) 99 (7.1)
p value
.13
.40 .11
.003
.50 .004
b .001
.08
.001 b .001
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Table 2 Awareness about and perceptions of IUC by history of IUC use
Awareness about IUC Ever discussed IUC with a provider (N= 1626) Know ≥ 1 person who used IUC (N=1625) Perceptions of IUC⁎ IUC more effective (N=1625) IUC does not increase STI risk (N=1625) IUC costs less over 3 years of use (N=1625)
Current
Past
Never
p value
n= 81 (%)
n=94 (%)
n= 1451 (%)
53 (65.4) 75 (92.6)
46 (48.9) 29 (30.9)
215 (14.8) 482 (33.3)
b.001 b.001
59 (72.8) 60 (74.1) 60 (74.1)
13 (13.8) 43 (45.7) 17 (18.1)
245 (16.9) 830 (57.2) 390 (26.9)
b.001 .001 b.001
⁎ Compared to OCPs.
abortion was associated with having been counseled about IUC by a health care provider [odds ratio (OR) 2.16, 95% CI=1.42–3.29], as was history of giving birth (OR 1.84, 95% CI=1.32–2.56). Other factors associated with provider counseling about IUC included household income of less than US$50,000 per year (OR 1.65, 95% CI=1.21–2.28) and higher educational attainment (college degree or more) (OR 1.44, 95% CI=1.06–1.96).
4. Discussion This study of more than 1600 women seeking primary care found that most had inaccurate perceptions of IUC. However, those women who had discussed IUC with a provider were more likely to have accurate views. Health care providers therefore have a critical role to play in providing women with high quality counseling that enables them to make informed decisions about their contraceptive options. Our results are consistent with other studies in highlighting significant misperceptions of IUC [20–22]. We found that most women did not know that IUC is more effective
than OCPs. Given the substantial failure rates with typical use of OCPs [30,31], this finding is concerning regardless of whether it reflects underestimation of IUC's effectiveness or overestimation of OCPs' effectiveness. Whereas data from the 1990s indicated that few women believed IUC was safe [5], we found that just over half of women accurately reported that IUC does not increase STI risk over OCPs. Our study joins other recent data [23] in suggesting some improvement over time in perceptions of IUC safety; however, many women remain misinformed. Over two thirds of women did not know that IUC is more costeffective than OCPs when used for 3 or more years. While women's out-of-pocket contraceptive cost may vary widely by insurance plan, perceptions of the cost-effectiveness of available contraceptives may influence some women's decision making. Our study also identified several key factors associated with having accurate perceptions of IUC's effectiveness, cost and safety among those women who had never used IUC. First, having discussed IUC with a provider was associated with having accurate perceptions. This finding is consistent with recent studies demonstrating that women who are
Table 3 Characteristics associated with accurate perceptions of IUC among women who have never used IUC Effectiveness of IUC
Ever discussed IUC with provider Know 1 + person who used IUC Age 18–25 26–35 36+ years Race White Black Other College degree or more Married/Cohabitating Prior birth Prior abortion
Effect of IUC on STI risk
Cost of IUC
Bivariate
Adjusted⁎
Bivariate
Adjusted⁎
Bivariate
Adjusted⁎
2.09 (1.49–2.93) 3.66 (2.75–4.86)
2.12 (1.55–2.88) 4.26 (3.23–5.62)
2.13 (1.55–2.92) 2.73 (2.16–3.47)
1.50 (1.13–1.98) 2.32 (1.85–2.92)
1.78 (1.31–2.42) 3.38 (2.65–4.31)
1.65 (1.25–2.18) 3.46 (2.73–4.37)
Ref 1.06 (0.76–1.48) 0.47 (0.32–0.67)
Ref 0.80 (0.56–1.15) 0.39 (0.26–0.59)
Ref 1.51 (1.14–2.00) 0.87 (0.67–1.14)
Ref 1.20 (0.91–1.67) 0.84 (0.61–1.15)
Ref 1.20 (0.88–1.63) 1.14 (0.85–1.54)
Ref 0.86 (0.62–1.21) 0.93 (0.66–1.33)
Ref 1.07 (0.49–2.33) 1.14 (0.60–2.17) 1.70 (1.28–2.28) 0.70 (0.53–0.93) 0.69 (0.52–0.92) 1.08 (0.64–1.84)
– – – 1.63 (1.21–2.20) 0.84 (0.62–1.17) 1.03 (0.73–1.45) –
Ref 0.71 (.39–1.28) 0.95 (0.57–1.57) 1.95 (1.58–2.41) 0.98 (0.79–1.21) 0.79 (0.64–0.98) 0.83 (0.55–1.25)
– – – 1.58 (1.27–1.97) 0.97 (0.76–1.25) 0.88 (0.68–1.15) –
Ref .89 (0.45–1.78) 1.35 (0.79–2.30) 1.82 (1.43–2.33) 0.93 (0.74–1.18) 0.97 (0.76–1.23) 1.00 (0.63–1.59)
– – – 1.69 (1.31–2.07) 1.06 (0.81–1.40) 1.01 (0.76–1.35) –
Ref=reference group. ⁎ Multivariable logistic regression models adjusted for age, education, marital status, parity, ever discussed IUC with provider, know 1 or more people who used IUC, N= 1565.
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counseled by a provider about a method have a higher likelihood of using the method [20,24,25] and that provider counseling can significantly improve contraceptive knowledge [32,33]. However, few of the women we studied had discussed IUC with a provider. We found that parous women were more likely than nulliparous women to have discussed IUC with a provider, consistent with prior studies indicating that clinicians preferentially recommend IUC to parous women [19,34,35] despite evidence-based recommendations that IUC should be a first-line option for nulliparous women [6,36]. In addition, knowing other women who had used IUC was highly predictive of having accurate perceptions, suggesting that social networks may also be an important source of information about IUC. Although the role of social networks in influencing IUC perceptions has not been specifically examined, one study found that clinic staff's disclosing personal experiences with IUC to patients was associated with increased IUC uptake [37]. Our findings should be considered in light of several limitations. As with any survey, response bias is a potential concern. Responders were more likely to be White, have more education and be established clinic patients. Overall, our sample was less racially diverse, more educated, wealthier and less likely to have had an abortion than the general population, which limits the generalizability of our findings. We were also unable to determine whether women or their providers had initiated discussions about IUC. Cross-sectional data do not allow determinations of causality; therefore, women who were more knowledgeable about IUC may have been more likely to initiate discussions about IUC with their providers rather than provider counseling having led to more accurate perceptions of IUC. Our study highlights the critical need to educate reproductive-aged women who seek primary care about the advantages of IUC. Expanding IUC use among women with higher rates of medical comorbidities could reduce unintended pregnancy and prevent needless maternal and perinatal morbidity. Encouragingly, we found provider counseling to be associated with more accurate perceptions of IUC. This suggests that efforts to increase the quantity and quality of IUC counseling in primary care settings may be a successful strategy to increase IUC uptake and decrease rates of unintended pregnancy. Future research is needed to identify best practices in counseling women with chronic medical conditions about IUC. References [1] Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85. [2] 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. [3] Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011;83:291–4.
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Original research article
Perceptions of intrauterine contraception among women seeking primary care Lisa S. Callegari a, b,⁎, Sara M. Parisi c , Eleanor Bimla Schwarz c, d, e a
Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA b Department of Epidemiology, University of Washington, Seattle, WA, USA c Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA d Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA e Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA Received 13 November 2012; revised 22 January 2013; accepted 10 February 2013
Abstract Background: Intrauterine contraception (IUC) is safe, highly effective and has few medical contraindications. Primary care providers see many women with chronic conditions who might benefit from IUC. Study Design: We surveyed women aged 18–50 who visited one of four primary care clinics in Pennsylvania between October 2008 and April 2010 to investigate perceptions of IUC and to identify factors associated with accurate perceptions. Key independent variables included patient characteristics, including knowing other women who had used IUC, and having discussed IUC with a provider. Logistic regression was used to examine the association between independent variables and accurate perceptions. Results: The study population included 1626 eligible respondents. Only 19.5% of women knew that IUC is more effective than oral contraceptive pills, 57.4% knew that IUC does not increase the risk of sexually transmitted infections and 28.7% knew that IUC is more costeffective than oral contraceptive pills. Among women who had never used IUC, accurate perceptions were associated with higher levels of education, knowing one or more women who had used IUC and having discussed IUC with a health care provider. Conclusions: Many women seeking primary care have inaccurate perceptions of IUC and may benefit from counseling about the advantages of this approach to preventing unintended pregnancy. Published by Elsevier Inc. Keywords: Attitudes; Contraception; Counseling; Intrauterine devices; Primary care; Progesterone releasing
1. Introduction High rates of unintended pregnancy continue to pose a significant public health challenge in the United States [1]. Fifty percent of all US pregnancies are unintended, and approximately half of those occur in women who report using contraception at the time of conception [1,2]. Efforts are therefore needed to promote contraceptives that are less likely to fail and are easier for women to use. One proposed strategy for lowering rates of unplanned pregnancy is to increase use of highly effective reversible contraceptives such as intrauterine contraception (IUC) [3,4]. ⁎ Corresponding author. Seattle HSR&D Center, Puget Sound Veterans Administration, University of Washington, 1400 Seattle, WA 98101. Tel.: +1-206-277-3129; fax: +1-206-768-5343. E-mail address: [email protected] (L.S. Callegari). 0010-7824/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.contraception.2013.02.004
Rates of IUC use in the US are lower than those in many other industrialized countries for a number of reasons, including patient and provider knowledge and attitudes, practice patterns and cost [4]. Misperceptions about IUC persist among both patients and providers [5], despite a large body of evidence supporting the safety and acceptability of currently available IUC [6–8]. Recently, a large prospective cohort study found IUC to be 20 times more effective than other more commonly used methods such as oral contraceptive pills (OCPs) [9]. IUC does not increase risk of transmission of sexually transmitted infections (STIs), pelvic inflammatory disease or infertility [10] and is more costeffective than OCPs when used for 2 or more years [11]. Women seeking primary care from internists and family physicians are more likely to have chronic medical conditions that increase the potential morbidity of an unintended pregnancy compared to women who only see obstetrician
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gynecologists [12–15]. These women may benefit from IUC which, unlike estrogen-containing contraceptives, has few medical contraindications [16,17]. Primary care providers, however, are less likely to provide contraceptive counseling than obstetrician gynecologists [13,18] and less likely to discuss IUC [19]. Previous studies suggest that many women have inaccurate views about the risks and benefits of IUC [5,20–23], which may influence contraceptive decision making. A recent study from Saint Louis found that most women underestimated the effectiveness of IUC and overestimated the risk of infection and infertility [20]. The only previous study conducted in a primary care setting found that 79% of participants knew that IUC was safe but did not investigate perceptions of effectiveness or cost [23]. Our study therefore seeks to more fully describe perceptions of IUC among women seeking primary care and to identify patient characteristics and experiences associated with accurate perceptions of IUC. Given the controversy surrounding whether contraceptive counseling influences women's knowledge and behavior [24–28], we also explored the role provider counseling plays in establishing accurate perceptions of IUC.
2. Materials and methods 2.1. Data collection All women aged 18–50 years who visited one of four primary care clinics in western Pennsylvania between October 2008 and April 2010 were invited to complete a survey online or by phone 7–30 days after their visit as part of a larger study evaluating the use of clinical decision support. This study has been previously described [24,29]. Briefly, study clinics included three community-based family practice clinics and one academic general internal medicine clinic. All clinics provide care to both publicly and privately insured patients. Participants provided signed informed consent and received instructions on how to access the survey at the time of their clinic visit. Participants who completed the survey received a US$10-gift card. This study was approved by the University of Pittsburgh Institutional Review Board. 2.2. Survey The 75-question survey assessed patient characteristics such as age, education, race, marital status, annual household income, insurance status, receipt of Medicaid and number of prior pregnancies, live births and abortions. Information on participants' ability to conceive was also obtained. Participants were asked to specify what contraception they used the last time they had sex and during the last 3 months as well as contraceptives they had ever used. Women's perceptions about IUC were assessed with a series of questions that compared IUC to OCPs, including (a)
whether women using IUC are more or less likely to become pregnant than women using OCPs; (b) whether women using IUC are more or less likely than women using OCPs to get STI; and (c) whether IUC costs more or less than OCPs when both are used for 3 years or longer. Responses to these three knowledge questions were dichotomized into accurate versus inaccurate perceptions. Specifically, accurate perceptions of IUC included stating that, compared to OCPs, IUC is more effective in preventing unintended pregnancy, more cost-effective and does not increase risk of STIs. Participants were also asked whether they had ever discussed IUC with a provider and the number of women they knew who had used IUC. 2.3. Statistical analysis We excluded from this analysis participants who were unable to conceive due to tubal ligation, partner vasectomy, hysterectomy or menopause at the time of their survey and women who did not provide information about current or past IUC use. We divided respondents into women who had (a) never used IUC; (b) previously used IUC; or (c) were currently using IUC. We compared the baseline characteristics of these three groups using chi-squared tests and one-way analysis of variance. We then compared perceptions of IUC among these three groups. Among the subgroup of women who had never used IUC, we used multivariable logistic regression to examine the relationships between accurate perceptions of IUC and receipt of provider counseling, knowing someone who had used IUC, patient demographics and reproductive characteristics. Variables were selected for inclusion in the multivariable models (a) a priori (age, education, marital status, parity) and/or (b) by significance at the pb .05 level in bivariate analyses. Finally, we performed a multivariable logistic regression model predicting the receipt of provider counseling about IUC, using variables selected a priori (age, race, education, marital status, parity, income and prior abortion). All analyses were conducted using Stata 12.0 (StataCorp. College Station, TX, USA). 3. Results A total of 1965 (19%) eligible women visited the primary care clinics and completed surveys. As reported by Lee et al. [24], women who completed surveys were similar to those who did not in age and marital status. However, women who completed surveys were more likely to be White, have more education and be established clinic patients [24]. We excluded women who were unable to conceive at the time of their survey (n= 323) or who did not provide information about current or past IUC use (n= 16), producing a sample for this analysis of 1626 (Fig. 1). Of these, 1451 (89.2%) had never used IUC, 94 had previously used IUC (5.8%) and 81 (5.0%) were current users. The majority of participants saw physicians (96%); however, 4% were seen by a nurse practitioner.
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Patients eligible to fill out the survey (n=10,177)
Patients who consented to fill out the survey (n=3,589)
Patients who completed the survey (n=1,965) Unable to conceive (n=323) Did not provide information on current or past IUC use (n=16) Study population (n=1,626) Fig. 1. Flowchart of study selection methods.
On average, participants were 33 (SD=9.1) years of age. Most participants were White, had at least some college education and were insured. Table 1 describes participant characteristics by IUC use. Compared to prior and never IUC users, current users were more likely to have given birth (63.8% vs. 39.4% and 43.3%, p= .001) and to have had an abortion (22.5% vs. 11.8% and 7.1%, pb .001). Current IUC users were more educated and more likely to have higher incomes. Only 19.5% of women knew that IUC was more effective than OCPs, whereas 57.4% accurately perceived no increase in STI risk with IUC compared to OCPs. Less than a third (28.7%) knew that IUC costs less than OCPs when used for 3 or more years. Current IUC users were more likely than past or never users to report accurate perceptions of IUC (Table 2). Almost all current users knew someone else who had used IUC (92.6%), compared to one third of prior or never users. Only 14.8% of women who had never used IUC reported having ever discussed IUC with a health care provider. Among women who had never used IUC, bivariate analyses for each of the three knowledge questions revealed that educational attainment, knowing one or more women who had used IUC and having discussed IUC with a provider were associated with greater odds of accurate perceptions (Table 3). Parity was associated with decreased odds of accurate perceptions about IUC effectiveness and risk of STIs. Being married or cohabitating and being 36 years of age or older were both associated with decreased odds of accurate perceptions of IUC effectiveness. In the multivariable models, knowing someone who had used IUC, provider counseling and educational attainment remained significantly associated with all three outcomes (Table 3). In the model predicting accurate perceptions of IUC effectiveness, age over 36 years remained a significant association but marital status did not.
We also analyzed factors associated with having previously discussed IUC with a provider. In a multivariable model adjusted for age, race and marital status, history of Table 1 Characteristics of respondents by history of IUC use Current
Past
Never
n=81 (%)
n=94 (%)
n= 1451 (%)
Age (N=1608) 18–25 years 14 (17.5) 32 (34.4) 362 (25.2) 26–35 years 33 (41.3) 29 (31.2) 493 (34.4) 36 + years 33 (41.3) 32 (34.4) 580 (40.4) Mean age (SD) 33.7 (8.1) 32.1 (9.3) 33.3 (9.1) Race (N= 1620) White 74 (91.4) 80 (86.0) 1337 (92.5) Black 1 (1.2) 6 (6.5) 45 (3.1) Other 6 (7.4) 7 (7.5) 64 (4.4) Education (N= 1619) High school or less 3 (3.7) 19 (20.4) 185 (12.8) Some college 27 (33.3) 32 (34.4) 432 (29.9) Bachelors 14 (17.3) 19 (20.4) 374 (25.9) Masters/Higher 37 (45.7) 23 (24.7) 454 (31.4) Have health insurance 80 (98.8) 88 (95.7) 1390 (96.7) (N= 1610) Received Medicaid 13 (16.1) 18 (19.4) 140 (9.7) (N= 1614) Income (N=1461) bUS$20,000/year 13 (17.3) 24 (28.2) 165 (12.7) US$20–49,999/year 20 (26.7) 29 (34.1) 355 (27.3) US$50–79,999/year 13 (17.3) 16 (18.8) 375 (28.8) ≥ US$80,000/year 29 (38.7) 16 (18.8) 406 (31.2) Marital status (N= 1622) Married/Cohabitating 55 (67.9) 48 (51.6) 817 (56.4) Single/Separated/ 26 (32.1) 45 (48.4) 631 (43.6) Divorced/Widowed Parity (N=1587) 0 29 (36.3) 57 (60.6) 801 (56.7) ≥1 51 (63.8) 37 (39.4) 612 (43.3) Prior abortion (N=1577) 18 (22.5) 11 (11.8) 99 (7.1)
p value
.13
.40 .11
.003
.50 .004
b .001
.08
.001 b .001
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Table 2 Awareness about and perceptions of IUC by history of IUC use
Awareness about IUC Ever discussed IUC with a provider (N= 1626) Know ≥ 1 person who used IUC (N=1625) Perceptions of IUC⁎ IUC more effective (N=1625) IUC does not increase STI risk (N=1625) IUC costs less over 3 years of use (N=1625)
Current
Past
Never
p value
n= 81 (%)
n=94 (%)
n= 1451 (%)
53 (65.4) 75 (92.6)
46 (48.9) 29 (30.9)
215 (14.8) 482 (33.3)
b.001 b.001
59 (72.8) 60 (74.1) 60 (74.1)
13 (13.8) 43 (45.7) 17 (18.1)
245 (16.9) 830 (57.2) 390 (26.9)
b.001 .001 b.001
⁎ Compared to OCPs.
abortion was associated with having been counseled about IUC by a health care provider [odds ratio (OR) 2.16, 95% CI=1.42–3.29], as was history of giving birth (OR 1.84, 95% CI=1.32–2.56). Other factors associated with provider counseling about IUC included household income of less than US$50,000 per year (OR 1.65, 95% CI=1.21–2.28) and higher educational attainment (college degree or more) (OR 1.44, 95% CI=1.06–1.96).
4. Discussion This study of more than 1600 women seeking primary care found that most had inaccurate perceptions of IUC. However, those women who had discussed IUC with a provider were more likely to have accurate views. Health care providers therefore have a critical role to play in providing women with high quality counseling that enables them to make informed decisions about their contraceptive options. Our results are consistent with other studies in highlighting significant misperceptions of IUC [20–22]. We found that most women did not know that IUC is more effective
than OCPs. Given the substantial failure rates with typical use of OCPs [30,31], this finding is concerning regardless of whether it reflects underestimation of IUC's effectiveness or overestimation of OCPs' effectiveness. Whereas data from the 1990s indicated that few women believed IUC was safe [5], we found that just over half of women accurately reported that IUC does not increase STI risk over OCPs. Our study joins other recent data [23] in suggesting some improvement over time in perceptions of IUC safety; however, many women remain misinformed. Over two thirds of women did not know that IUC is more costeffective than OCPs when used for 3 or more years. While women's out-of-pocket contraceptive cost may vary widely by insurance plan, perceptions of the cost-effectiveness of available contraceptives may influence some women's decision making. Our study also identified several key factors associated with having accurate perceptions of IUC's effectiveness, cost and safety among those women who had never used IUC. First, having discussed IUC with a provider was associated with having accurate perceptions. This finding is consistent with recent studies demonstrating that women who are
Table 3 Characteristics associated with accurate perceptions of IUC among women who have never used IUC Effectiveness of IUC
Ever discussed IUC with provider Know 1 + person who used IUC Age 18–25 26–35 36+ years Race White Black Other College degree or more Married/Cohabitating Prior birth Prior abortion
Effect of IUC on STI risk
Cost of IUC
Bivariate
Adjusted⁎
Bivariate
Adjusted⁎
Bivariate
Adjusted⁎
2.09 (1.49–2.93) 3.66 (2.75–4.86)
2.12 (1.55–2.88) 4.26 (3.23–5.62)
2.13 (1.55–2.92) 2.73 (2.16–3.47)
1.50 (1.13–1.98) 2.32 (1.85–2.92)
1.78 (1.31–2.42) 3.38 (2.65–4.31)
1.65 (1.25–2.18) 3.46 (2.73–4.37)
Ref 1.06 (0.76–1.48) 0.47 (0.32–0.67)
Ref 0.80 (0.56–1.15) 0.39 (0.26–0.59)
Ref 1.51 (1.14–2.00) 0.87 (0.67–1.14)
Ref 1.20 (0.91–1.67) 0.84 (0.61–1.15)
Ref 1.20 (0.88–1.63) 1.14 (0.85–1.54)
Ref 0.86 (0.62–1.21) 0.93 (0.66–1.33)
Ref 1.07 (0.49–2.33) 1.14 (0.60–2.17) 1.70 (1.28–2.28) 0.70 (0.53–0.93) 0.69 (0.52–0.92) 1.08 (0.64–1.84)
– – – 1.63 (1.21–2.20) 0.84 (0.62–1.17) 1.03 (0.73–1.45) –
Ref 0.71 (.39–1.28) 0.95 (0.57–1.57) 1.95 (1.58–2.41) 0.98 (0.79–1.21) 0.79 (0.64–0.98) 0.83 (0.55–1.25)
– – – 1.58 (1.27–1.97) 0.97 (0.76–1.25) 0.88 (0.68–1.15) –
Ref .89 (0.45–1.78) 1.35 (0.79–2.30) 1.82 (1.43–2.33) 0.93 (0.74–1.18) 0.97 (0.76–1.23) 1.00 (0.63–1.59)
– – – 1.69 (1.31–2.07) 1.06 (0.81–1.40) 1.01 (0.76–1.35) –
Ref=reference group. ⁎ Multivariable logistic regression models adjusted for age, education, marital status, parity, ever discussed IUC with provider, know 1 or more people who used IUC, N= 1565.
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counseled by a provider about a method have a higher likelihood of using the method [20,24,25] and that provider counseling can significantly improve contraceptive knowledge [32,33]. However, few of the women we studied had discussed IUC with a provider. We found that parous women were more likely than nulliparous women to have discussed IUC with a provider, consistent with prior studies indicating that clinicians preferentially recommend IUC to parous women [19,34,35] despite evidence-based recommendations that IUC should be a first-line option for nulliparous women [6,36]. In addition, knowing other women who had used IUC was highly predictive of having accurate perceptions, suggesting that social networks may also be an important source of information about IUC. Although the role of social networks in influencing IUC perceptions has not been specifically examined, one study found that clinic staff's disclosing personal experiences with IUC to patients was associated with increased IUC uptake [37]. Our findings should be considered in light of several limitations. As with any survey, response bias is a potential concern. Responders were more likely to be White, have more education and be established clinic patients. Overall, our sample was less racially diverse, more educated, wealthier and less likely to have had an abortion than the general population, which limits the generalizability of our findings. We were also unable to determine whether women or their providers had initiated discussions about IUC. Cross-sectional data do not allow determinations of causality; therefore, women who were more knowledgeable about IUC may have been more likely to initiate discussions about IUC with their providers rather than provider counseling having led to more accurate perceptions of IUC. Our study highlights the critical need to educate reproductive-aged women who seek primary care about the advantages of IUC. Expanding IUC use among women with higher rates of medical comorbidities could reduce unintended pregnancy and prevent needless maternal and perinatal morbidity. Encouragingly, we found provider counseling to be associated with more accurate perceptions of IUC. This suggests that efforts to increase the quantity and quality of IUC counseling in primary care settings may be a successful strategy to increase IUC uptake and decrease rates of unintended pregnancy. Future research is needed to identify best practices in counseling women with chronic medical conditions about IUC. References [1] Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85. [2] 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. [3] Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011;83:291–4.
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