Abstract
Objectives:
To estimate the interest in using intrauterine contraception among women seeking emergency contraception or walk-in pregnancy testing.
Methods:
We surveyed 412 women who requested emergency contraception or pregnancy testing at four family planning clinics in Pittsburgh, PA. The 41-item survey assessed knowledge of, attitudes towards, and interest in using intrauterine contraception (IUD). Data were analyzed using χ2 and Fisher's exact tests and multivariable logistic regression methods.
Results:
The response rate was 85%. Twelve percent (95% CI 9%-15%) of women surveyed expressed interest in same-day insertion of an IUD and 22% (95% CI 18%-26%) wanted more information about IUDs. Interest in same-day IUD insertion increased with higher education level, prior unwanted pregnancy, and experience with barriers to use of contraception.
Conclusion:
Same-day IUD insertion may be a reasonable way to increase the use of highly-effective contraception among women seeking emergency contraception or walk-in pregnancy testing.
Introduction
Unintended pregnancy remains common in the United States (1). While some unintended pregnancies result when no contraception is used, about half of unintended pregnancies are the result of a contraceptive method failure (2). This finding highlights the need to help couples use contraceptive methods with low rates of failure. Perfect-use failure rates describe deficits inherent in a given contraceptive method; typical-use failure rates also include failures that result from the way the method is used. Because it is difficult to remember to take a pill every day, to ensure that refills are obtained (often monthly), and other medications or gastrointestinal illness may interfere with absorption of oral contraceptives, there are dramatic differences between the rates of contraceptive failure seen with typical-use and perfect-use of birth control pills. In contrast, there is no notable difference between typical-use and perfect-use of methods such as the intrauterine contraceptive device (IUD). Typical-use failure rates of IUDs are an order of magnitude less than what is seen with use of hormonal methods such as the birth control pill (3). Although IUDs are commonly used in Europe and Asia, IUDs are used by only a small fraction of U.S. women of reproductive age (4).
It is likely that more U.S. women would use an IUD if it was easier to have one inserted. Many providers require women to schedule and attend 2 appointments: one for testing for sexually transmitted infection (STI), and a second for the insertion, despite the fact that women who have been previously screened may acquire an STI between their screening and insertion visits and any infections that are identified at the time of IUD insertion can be treated with the IUD in place (5, 6). In the post-abortal setting, women who were offered immediate IUD insertion were more likely to have an IUD inserted, and as a result were three times less likely to require a repeat abortion (7). Efforts to minimize barriers to interval insertion have also been shown to increase use of IUDs (8).
Women seeking emergency contraception (EC) and walk in pregnancy testing are at particularly high risk of unintended pregnancy (9, 10). IUDs containing copper have been shown to be a highly effective method of emergency contraception (11-15) that offers the added benefit of ongoing protection from pregnancy. The purpose of this study was to estimate interest in same-day IUD insertion among women seeking pregnancy testing or emergency contraception from family planning clinics in Pittsburgh, PA. Our hypothesis was that at least 5% of women would express interest in same-day insertion of an IUD..
Materials and Methods
Women between the ages of 15 and 44 seeking either walk-in pregnancy testing or EC at one of four family planning clinics in Pittsburgh, PA were eligible to participate in this study. Two of these clinics belong to an academic medical center, while the others are operated by Planned Parenthood. These clinics were chosen because they routinely provide services to young, low-income, predominantly minority women who are at high risk for unintended pregnancy(16). All women who registered at one of these clinics between January and October 2008 and were seeking EC or pregnancy testing were approached for potential study participation. A sample size of at least 400 women was selected to allow us to estimate 5% interest in same-day insertion of an IUD with a 95% CI of +/− 2%. The study was approved by the University of Pittsburgh's Institutional Review Board and all participants provided written informed consent.
The 41-item survey contained questions regarding women's knowledge of and attitudes towards intrauterine contraception. These items were pilot tested in the target population prior to initiation of this study. Specifically, women were asked to compare IUDs to birth control pills with regards to cost, efficacy, side-effects and risk of sexually transmitted infections. These questions offered four response options (more, less, the same, and don't know). In addition, demographic information including race and ethnicity was collected. We assessed whether women had health insurance or received “medical assistance” (a state sponsored program that provides access to health care (including contraception and IUDs) for low-income individuals). However, we did not assess whether women's private health insurance covered contraception. Subjects were also asked about their reproductive histories, current pregnancy intentions and interest in using an IUD. Women could complete the survey either before or after they had seen a clinician. However, all subjects completed the survey before receiving the results of their pregnancy test to avoid having these test results influence women's responses. Study staff recorded pregnancy test results for each subject in a secure database. Subjects received a chocolate bar as compensation for their time.
We tabulated and summarized respondents' knowledge of, attitudes towards, and interest in IUDs. Women with missing data were presumed to have no knowledge of or interest in IUDs. We used chi square and Fisher's exact tests to evaluate the significance of differences between demographic characteristics and clinical service sought (pregnancy testing or EC). We then used univariate and multivariable logistic regression models (generated using stepwise elimination when p>=0.10) to examine variables associated with attitudes towards IUDs. Variables for clinical site (Planned Parenthood vs. academic medical center) and service sought (EC vs. pregnancy testing) were retained in all multivariable models, even if p was >=0.10. Specifically, we compared responses indicating a preference for IUDs with those indicating a preference for birth control pills (i.e. when considering side effects we grouped subjects who responded IUDs produced “less” or “the same” side effects as birth control pills and compared them to subjects who responded “more” or “don't know”). In addition, we evaluated variables associated with interest in same day insertion of an IUD, including reported barriers to access to contraception, using univariate and multivariable logistic regression models similarly generated using stepwise elimination (with clinical site and service sought retained in all models). For all analyses, we used STATA version 10.0 (StataCorp, College Station, Texas).
Results
Of 485 women who sought EC or pregnancy testing at participating clinics, 412 completed surveys producing a response rate of 85%. Most respondents were young, low-income, and African American. Additional demographic characteristics of the study sample are shown in Table 1. Most respondents (85%) were seeking pregnancy testing while the other 15% were seeking emergency contraception. Women seeking these clinical services had similar pregnancy histories. The median number of prior pregnancies was 1(range=0-9); the median number of unwanted pregnancies and abortions were 0 (range=0-6, and 0-4, respectively). Women seeking emergency contraception were more likely to state they were trying to avoid pregnancy at the time they visited the clinic (87% vs. 31%, p<0.001) and less likely to be pregnant (45% vs. 4%, p<0.001) than women seeking pregnancy testing.
Table 1.
Characteristics of the study population by desired clinical service
| Pregnancy Testing (N = 349)* |
Emergency Contraception (N = 63)* |
p-value | |
|---|---|---|---|
| Age in Years | 0.22 | ||
| 15-19 | 113 (33%) | 14 (23%) | |
| 20-24 | 141 (42%) | 25 (42%) | |
| 25-29 | 56 (17%) | 17 (28%) | |
| 30-34 | 18 (5%) | 3 (5%) | |
| 35-44 | 10 (3%) | 1 (2%) | |
| Race | 0.004 | ||
| White | 96 (28%) | 29 (47%) | |
| Black | 241 (72%) | 33 (53%) | |
| Marital Status | 0.002 | ||
| Married | 26 (8%) | 0 (0%) | |
| Living with sexual partner | 119 (36%) | 13 (21%) | |
| Previously married | 23 (7%) | 3 (5%) | |
| Never married | 165 (50%) | 46 (74%) | |
| Education | 0.09 | ||
| High school or less | 214 (62%) | 30 (48%) | |
| Trade school | 43 (13%) | 12 (19%) | |
| College and above | 87 (25%) | 21 (33%) | |
| Employment Status | 0.11 | ||
| Employed (full or part time) | 168 (49%) | 38 (60%) | |
| Unemployed | 172 (51%) | 25 (40%) | |
| Health Insurance | 0.32 | ||
| Yes | 226 (65%) | 47 (75%) | |
| No | 108 (31%) | 15 (24%) | |
| Don't know | 12 (3%) | 1 (2%) | |
| Medical Assistance§ | 0.27 | ||
| Yes | 142 (42%) | 31 (49%) | |
| No | 172 (50%) | 30 (48%) | |
| Don't know | 28 (8%) | 2 (3%) | |
| Income (Annual) | 0.58 | ||
| Less than $5,000 | 79 (34%) | 12 (26%) | |
| $5,000-$20,000 | 83 (36%) | 17 (36%) | |
| $20,001-$50,000 | 62 (27%) | 16 (34%) | |
| Greater than $50,000 | 6 (3%) | 2 (4%) |
Percentages may not add up to 100% due to rounding
Respondents were able to choose more than one race
Medical assistance is a state sponsored program that provides access to health care services including contraception (and IUDs) for low-income state residents.
Overall, knowledge of and attitudes towards IUD's were similar among women seeking pregnancy testing and those seeking EC (Table 2). Most women knew very little about IUDs and only about one-third knew anyone who had ever used an IUD. In multivariable models, we found that increased education and parity were significantly associated with more positive impressions of the efficacy and cost of IUDs. Parity was also significantly associated with more positive impressions of IUD safety in terms of sexually transmitted infection.
Table 2.
Knowledge of and attitudes towards IUD's among women seeking pregnancy testing and those seeking emergency contraception
| Do you think women using IUD's are more or less likely than women using birth control pills… |
Pregnancy Testing (N = 349) n (%)* |
Emergency Contraception (N = 63) n (%)* |
p-value |
|---|---|---|---|
| …To have side effects? | 0.15 | ||
| More | 26 (8%) | 10 (16%) | |
| Less | 22 (7%) | 5 (8%) | |
| The same | 41 (12%) | 5 (8%) | |
| Don't know | 243 (73%) | 41 (67%) | |
| …To get sexually transmitted infections? | 0.04 | ||
| More | 13 (4%) | 7 (11%) | |
| Less | 4 (1%) | 1 (2%) | |
| The same | 101 (31%) | 23 (38%) | |
| Don't know | 213 (64%) | 30 (49%) | |
| …To become pregnant? | 0.59 | ||
| More | 10 (3%) | 3 (5%) | |
| Less | 57 (17%) | 14 (23%) | |
| The same | 51 (15%) | 10 (16%) | |
| Don't know | 214 (64%) | 35 (56%) | |
|
Do you think IUDs cost more or less than birth control pills, when both are used for 3 years? |
0.22 | ||
| More | 29 (9%) | 11 (18%) | |
| Less | 34 (11%) | 6 (10%) | |
| The same | 32 (10%) | 5 (8%) | |
| Don't know | 231 (70%) | 40 (65%) | |
| Knows any women who have used an IUD | |||
| Yes n(%) | 0.13 | ||
| If yes, median (range) † | 101 (31%) | 25 (41%) | |
| No | 1 (1-8) | 1 (1-9) | |
| 223 (69%) | 36 (59%) | ||
|
How many women do you know who were happy using an IUD? (median, range) † |
1.00 | ||
| 1 (1-8) | 1 (1-9) |
Percentages may not add up to 100% due to rounding
Includes only those who reported that they knew one or more women that have used an IUD
When we examined interest in using an IUD, we found that 12% (95% CI 9%-15%) of women expressed interest in having an IUD inserted that day. Interest in a same-day insertion increased slightly when the insertion would be free (16%; 95% CI 12%-20%) (Table 3). Notably, the large majority of individuals who stated they “didn't know” if they would be interested in a same-day insertion of an IUD did not know anyone who had ever used an IUD and stated they didn't know how IUDs compared to birth control pills in terms of efficacy, safety, or cost.
Table 3.
Interest in using an IUD among women seeking emergency contraception or pregnancy testing
| Pregnancy Testing (N = 349) n (%)* |
Emergency Contraception (N = 63) n (%)* |
p-value | |
|---|---|---|---|
| Ever thought about using an IUD | 0.15 | ||
| Yes | 80 (24%) | 21 (34%) | |
| Don't know | 58 (18%) | 13 (21%) | |
| No | 193 (58%) | 28 (45%) | |
|
Might want more information about IUD's |
0.59 | ||
| Yes | 65 (21%) | 14 (27%) | |
| Don't know | 60 (20%) | 8 (15%) | |
| No | 179 (59%) | 30 (58%) | |
|
Might be interested in having an IUD inserted today |
0.36 | ||
| Yes | 37 (12%) | 8 (15%) | |
| Don't know | 72 (24%) | 16 (31%) | |
| No | 196 (64%) | 28 (54%) | |
|
Might be interested in having an IUD inserted for free today |
0.30 | ||
| Yes | 49 (16%) | 9 (17%) | |
| Don't know | 71 (23%) | 17 (33%) | |
| No | 184 (61%) | 26 (50%) |
Percentages may not add up to 100% due to rounding
Interest in a same-day insertion increased with report of barriers to access to contraception such as “I couldn't get an appointment to get birth control when I needed it” (OR = 5.31, 95% CI= 2.28-12.36), and “I couldn't afford to pay for birth control or my insurance wouldn't cover it” (OR = 3.41, 95% CI= 1.45-7.99). Women who stated they had difficulty using contraception because “I didn't think I was going to have sex” (OR = 2.09, 95% CI= 1.03-4.25) were also more likely to express interest in same-day insertion of an IUD. However, women who stated they did not use contraception because “I didn't think I could get pregnant” were less likely to be interested in same-day IUD insertion (OR = 0.29, 95% CI = 0.09-0.96).
In multivariable models, adjusted for age, race, education, insurance status, parity, site, service sought, and anticipated response to a pregnancy, we found that women who had more than a high school education (OR= 2.54, 95% CI=1.18-5.50), who had given birth one or more times (OR=3.34, 95% CI=1.40-7.94), or who stated they would have (OR=6.44, 95% CI=2.47-16.78) or consider an abortion (OR=3.23, 95% CI=1.32-7.86) if they learned they were pregnant were more likely to express interest in a same-day IUD insertion. In models additionally adjusted for women's attitudes towards IUDs, we found that positive attitudes towards the efficacy of IUDs were associated with interest in a same-day insertion (OR=4.02, 95% CI=1.42-11.34). However, attitudes towards IUDs regarding cost, side effects and risk of STI were not associated with interest in a same-day insertion (Table 4).
Table 4.
Variables associated with interest in same-day insertion of an IUD among women seeking emergency contraception or pregnancy testing
| Univariate models | Multivariable model 1* |
Multivariable model 2* |
|
|---|---|---|---|
| Age | 1.03 (0.97-1.10) | 0.95 (0.87-1.04) | 0.95 (0.87-1.04) |
| Black race | 1.05 (0.53-2.07) | 0.90 (0.38-2.11) | 0.64 (0.24-1.71) |
| More than a high school education |
2.45 (1.30-4.63) | 2.54 (1.18-5.50) | 2.02 (0.87-4.72) |
| One or more births | 3.08 (1.56-6.08) | 3.34 (1.40-7.94) | 3.31 (1.28-8.56) |
| Has health insurance | 1.25 (0.63-2.50) | 0.57 (0.24-1.38) | 0.52 (0.20-1.37) |
| Pregnancy Intention* | |||
| Plan to have an abortion | 4.79 (2.20-10.47) | 6.44 (2.47-16.78) | 8.18 (2.73-24.51) |
| Don't know | 2.88 (1.34-6.17) | 3.23 (1.32-7.86) | 4.54 (1.63-12.63) |
| Clinical Site | 1.45 (0.55-3.78) | 1.11 (0.36-3.43) | 0.88 (0.25-3.07) |
| Clinical service sought |
1.38 (0.62-3.10) | 0.49 (0.18-1.35) | 0.36 (0.11-1.12) |
| Positive attitude toward side effects |
3.29 (1.70-6.35) | N/A | 2.42 (0.93-6.27) |
| Positive attitude toward STI's |
1.89 (1.02-3.51) | N/A | 0.91 (0.37-2.24) |
| Positive attitude toward efficacy |
5.09 (2.60-9.99) | N/A | 4.02 (1.42-11.34) |
| Positive attitude toward cost |
2.40 (1.24-4.66) | N/A | 0.69 (0.27-1.76) |
multivariable models contained all variables shown in column.
Of the 49 women who were interested in a same-day insertion, 11 were pregnant and 8 had unknown pregnancy results, due to difficulties in data transfer from the clinical setting to our research staff. Thus, at least 30 women (7%, 95% CI 5%-10%) would have been interested and potentially eligible for a same-day IUD insertion.
Discussion
Family planning clinics seek to reduce unplanned pregnancies and abortions. Women seeking EC and pregnancy testing are at high risk of unplanned pregnancy and abortion (9,10) and therefore may benefit greatly from the highly effective emergency and ongoing contraception provided by an IUD. This study estimated interest in same-day insertion of an IUD and found that 15% of women seeking EC from a family planning clinic expressed interest in same-day insertion of an IUD, though few women were very knowledgable about IUDs. Women seeking walk-in pregnancy testing were similar to women seeking EC in many ways. Most wanted to avoid pregnancy and a similar number of women expressed interest in using an IUD. Efforts should therefore be made to expand education about and access to IUD insertions for women seeking either emergency contraception or pregnancy testing, with consideration given to the development and evaluation of same-day insertion services. To date, few clinicians have offered IUDs to women seeking EC(17). While lack of time was cited as a major reason that British clinicians did not offer IUDs to women seeking EC (18) changes in clinic scheduling templates and/or reimbursement structure may make same-day IUD insertion feasible. If one estimates that 20% of women seeking EC will experience an unwanted pregnancy within the year without an IUD, and that with an IUD, less than 1% of these women will, the number needed to treat to prevent an unwanted pregnancy within 1 year would be 5. This implies that, if feasible, same-day insertion of an IUD would be a very effective approach to reaching family planning goals of reducing rates of unwanted pregnancy and abortion. In order for such an approach to be widely adopted, it will be important to demonstrate that it is possible to work with state and pharmaceutical patient-assistance programs to ensure that low-income women are able to pay for desired same-day services. In addition, although same-day IUD insertion has been shown to be safe post-abortion (7,8), studies are needed to confirm the safety of same-day IUD insertion in other settings with regards to STI and risk of pelvic inflammatory disease.
Previous studies have also found that many young women in the United States lack adequate knowledge of IUDs, and would benefit from education about this method of contraception (19, 20). While many people look to the internet as a source of information for their unanswered medical questions, the quality of information about IUDs available via the internet is unreliable (21) and may discourage some women from considering the IUD as a viable contraceptive option. It is therefore very important that women receive accurate information about IUDs from their health care providers. As minority and low-income women served by family planning clinics are at particularly high risk of unintended pregnancy(9,10), efforts to increase use of IUDs and other highly-effective reversible methods of contraception by this population should be a priority. In addition to being a safe and highly effective method of contraception, IUDs are also extremely cost effective (22). While providing women with information about the cost-effectiveness of IUDs relative to other methods of contraception may be of value, our study found that a positive attitude towards the cost of IUDs relative to other methods was not associated with interest in use of an IUD. A positive attitude towards the relative efficacy of IUDs compared to oral contraceptives, however, was significantly associated with interest in a same day insertion.
While our study provides new information on women's knowledge of, attitudes towards, and interest in IUDs, this work has several limitations that deserve mention. All information regarding women's reproductive histories was self-reported and therefore may be subject to bias. In addition, we did not explicitly ask women if they knew what an IUD was; therefore, it is possible that responses to all questions regarding IUDs were influenced by misperceptions. For example, some women may not have understood that a woman must undress to have an IUD inserted and that there may be some discomfort involved. We did not inform women of what was involved in IUD insertion in terms of time and potential discomfort and we did not ask women about their willingness to tolerate the potential discomfort of IUD insertion. Women who expressed interest in same-day insertion of an IUD were not asked how long they would be willing to wait to have an IUD inserted, and wait-times would likely affect the acceptability of such services. While we explored general barriers to use of contraception, we were not able to explicitly characterize the barriers that had prevented women who stated they had previously considered using an IUD from actually using one. Finally, this study was conducted exclusively in one city and with predominantly minority and low-income women which may limit the generalizability of the results to other populations. However, populations served by family planning clinics typically include high proportions of young women, minority women and women of low income.(23)
In conclusion, this study found that among women seeking walk-in pregnancy testing or emergency contraception from family planning clinics in Pittsburgh, few were knowledgeable about IUD's, but among those who were familiar with IUDs, interest in a same-day insertion was high. Overall, one in ten women surveyed were interested in a same-day IUD insertion. As many women who knew little about IUDs stated they might be interested in using an IUD, it is imperative that we develop ways to provide women seeking both EC and pregnancy testing with information about IUDs. Further study of same-day insertion of IUDs is warranted to determine whether this is a safe and effective way to increase use of highly effective contraception in the United States.
Acknowledgments
Supported in part by NICHD K23HD051585 and the RAND-University of Pittsburgh Health Initiative (RUPHI), a formal collaboration between the RAND Corporation, RAND Health, and the University of Pittsburgh Schools of the Health Sciences, and Magee-Womens Research Institute and Foundation (MWRIF).
Footnotes
Financial Disclosure: Dr. Creinin has been a consultant to Schering-Plough (Kenilworth, NJ) and has received honorarium from Bayer (Leverkusen, Germany). The other authors did not report any potential conflicts of interest.
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