A qualitative exploration of emergency contraception users' willingness to select the copper IUD

Abstract

Background

The copper T intrauterine device (IUD) is an effective but underutilized method of emergency contraception (EC). This study investigates the factors influencing a woman's decision around which method of EC to select.

Study Design

In-depth interviews with 14 IUD and 14 oral EC users aged 18–30 years accessing public health clinics.

Results

Emergency contraception users associated long-term methods of contraception with long-term sexual relationships. Women were not aware of the possibility of using the copper IUD for EC. Cost was identified as a major barrier to accessing IUDs. Perceived side effects and impact on future pregnancies further influenced the EC method a participant selected.

Conclusions

Women think about contraception in the context of each separate relationship and not as a long-term individual plan. Most women were unaware of the copper IUD for EC. Furthermore, there is little discussion between women and their health-care providers around EC.

1. Introduction

The unintended pregnancy rate in the United States is the highest among developed countries. An estimated 30% of women aged 15–44 years will have an unintended birth, and the rate is even higher among women living at or below the poverty level [1]. The wide availability of oral emergency contraception (EC) has not reduced unplanned pregnancy or abortion rates [2]. Although the copper T intrauterine device (IUD) is a highly effective method of EC, knowledge and use among women in the United States remain low [3,4].

There is little literature investigating women's willingness to use the copper IUD as a method of EC and what factors might influence their decision-making process. Qualitative research methods are an effective approach for developing a comprehensive understanding about how women conceptualize issues around EC and unintended pregnancy. This approach allows for a broader awareness of women's contraceptive decision-making process within their social context [5]. This study investigated what factors influence women's decisions about using the copper IUD as a form of EC.

2. Methods

Participants enrolled in a prospective clinical trial about the use of the copper IUD vs. oral levonorgestrel EC were offered participation in a qualitative component. The larger clinical trial enrolled women aged 18–30 years presenting for EC within 120 h of unprotected intercourse at family planning clinics in Salt Lake City, UT. At trial enrollment for the larger study, participants were queried regarding willingness to participate in the qualitative study involving individual, in-depth interviews. Up to three attempts were made to contact each interested individual to schedule an interview or participation in a focus group. Individual interviews were conducted at one of the family planning clinics where the study was conducted. Interview questions inquired about knowledge of contraceptive methods, long-term contraceptive consideration and past experiences with EC.

Interviews were audio-recorded, transcribed and independently analyzed by two investigators (C.J.F. and R.L.W.). Interviews were read and reread, and categories and themes were identified and coded [6]. Line-by-line analysis was also conducted on large paragraphs of data to gain a fuller understanding about the interview information [7]. The researchers collected data until information saturation was achieved. Study staff were prepared to conduct interviews in English and Spanish. Approval was obtained from the University of Utah Institutional Review Board.

3. Results

Participants were selected to create equal groups of copper IUD and oral EC users. Semistructured individual interviews (lasting on average 45 min) were conducted with 14 copper IUD users and 14 oral EC users. All interviews were conducted in English. Researchers were not able to schedule any focus groups with a sufficient number of participants. There were no significant differences in demographic data between participants who were interviewed and those who failed to attend scheduled interviews.

Demographic and descriptive characteristics about study participants are displayed in Table 1. Of the 14 oral EC users, two initially selected the copper IUD as their preferred method of EC; however, they received oral EC due to the practitioners' inability to insert the copper IUD. The remaining 12 women in this group initially selected oral EC. Half of oral EC and 21% of copper IUD users had no previous experience with EC, while 21% of oral EC and 35% of copper IUD participants used EC four or more times prior to the study. Please refer to Table 2 for participant reason for EC use.

Table 1. Participant demographics.

Variable	IUD	Oral EC
Age (years), mean (SD)	22.4 (2.9)	22.7 (3.8)
Race/ethnicity, n (%)
White	12 (85.7)	10 (71.4)
Pacific Islander	2 (14.3)	0
Latina	0	4 (28.6)
Income ($), n (%)
<20,000	12(85.7)	10 (71.4)
20–40,000	2 (14.3)	2 (14.3)
40–80,000	0	2 (14.4)
Number of previous times used EC, n (%)
0	3 (21.4)	7 (50)
1–3	4 (28.6)	3 (21.4)
4 or more	5 (35.7)	3 (21.4)
Not specified	2 (14.3)	1 (7.1)
Insurance coverage for BC, n (%)
Yes	5 (35.7)	4 (28.6)
No	1 (7.1)	1 (7.1)
Do not know	3 (21.4)	4 (28.6)
No insurance	5 (35.7)	5 (35.7)

Table 2. Reason for EC.

	IUD	Oral EC
No birth control refill	6	0
Missed pills	1	1
No method used	3	9
Condom broke/slipped	3	2
Withdrawal method failed	1	2

Three major themes emerged from the interview data: long-term methods associated with long-term relationships, contraceptive cost and knowledge, side effects and pregnancy considerations. These themes are explored below.

3.1. Long-term methods associated with long-term relationships

The type of EC participants selected related to their relationship status. Women who identified as being in a long-term relationship were more likely to select the copper IUD as a form of EC due to its ability to act as a long-term contraceptive method. Women not currently engaged in a long-term relationship did not identify long-term contraception as necessary due to either infrequent sexual activity or the perception that their short-term relationship did not warrant the effort of investigating long-term options.

It is just based on where you are in life too I guess, and like if you don't know, if you are like in a serious relationship you probably want a more serious form of birth control, but if you are not, you probably won't go to a lot of measures to figure out what there is and you will stick with condoms (#1, copper IUD).

When I first started this [study], you know they said you could either do the IUD or the Plan B [oral levonorgestrel] the day you come in, I was really tempted to do the IUD, I think it is also, I am not really in a relationship right now so there is not really a point to do that (#1, oral EC).

3.2. Cost

The cost of a method emerged as a significant factor in women's decision-making process. While participants may have had prior interest in IUDs as a form of birth control, the high upfront cost was presented as a substantial barrier. Frequently, the cost of a copper IUD prevented further investigation into its possible benefits and risks.

When I first actually heard about the IUD, I was interested in it, but it was really expensive up front. Over the long run it becomes more cost effective, but people don't think about it that way. (#2, copper IUD).

I thought about it [IUD] for a really long time, probably like starting couple of years ago even, and what kept me from getting it back then was the cost. So had I been able to afford it, I would have gotten it longer, like earlier (#3, copper IUD).

Oral EC users did not identify the cost of oral levonorgestrel as too high or high enough to prevent access. Therefore, they expressed comfort with continued reliance on oral EC as either a secondary or main form of contraception.

Birth control can be pricey and condoms are pricey and so it's kind of a big thing. You don't want to get pregnant, but then you don't want to spend all this money on buying everything so, that's why we usually do the pull-out [method] because of price (#2, oral EC).

3.3. Knowledge, side effects and pregnancy considerations

Although most participants held some knowledge of IUDs as an effective, long-term method of contraception, none had prior knowledge of the copper IUD's ability to function as a form of EC. Therefore, enrollment in the larger EC study served as their initial exposure to the dual role of the copper IUD:

I did not even know that was possible. I thought it [IUD] was just a long-term protection. I didn't know it could count like kind of for the morning after pill (#4, copper IUD).

The possible side effects of an EC method contributed to a woman's decision about which option to select. Participants with prior experience with oral EC were satisfied with its ability to prevent pregnancy and did not identify experiencing negative immediate or long-term side effects with this option. Fear of the potential side effects of the copper IUD contributed further to a woman's decision to select oral EC:

I felt like the IUD is kind of scary, like we are going to place it inside you and there are all these risks that may or may not happen and that kind of scared me personally (#3 oral EC).

Participants wanted to prevent, or at minimum delay, pregnancy. How a participant perceived the copper IUD's impact on her ability to become pregnant in the future factored into her decision-making process. Women selecting oral EC often viewed the copper IUD as potentially harmful to her ability to become pregnant in the future:

Yeah but it [IUD] kind of freaked me out because they said when you take it out it could take up to a year to get pregnant, like up to a year to get pregnant (#4, oral EC).

I didn't want to do anything that would affect having a baby in the future (#5, oral EC).

Conversely, women selecting the copper IUD viewed it as a long-term method with no long-term effects on pregnancy:

With the IUD you can still take it out whenever you want and get pregnant right away, so it's long-term but it's still really flexible. You know, you can change your mind really easily (#5, copper IUD).

4. Discussion

In this study, while no single factor determined a woman's choice of EC method, our findings reveal that multiple factors contribute to a woman's decision-making process. Women presenting for EC may not be aware of the role of the copper IUD as EC method. Once informed, they have to incorporate this into their decision about which method to select. In our study, some of the factors that influence EC method choice include relationship status, cost and concern about side effects. These factors are consistent with a study of women accessing abortion services who reported the most frequent barriers to contraceptive use include worry about side effects and cost [8].

Couples in casual sexual relationships may be less likely than those in more stable or long-term relationships to be prepared for sexual activity and therefore may not have a preconsidered contraceptive method [9]. The association of long-term contraceptive methods with long-term relationships is troubling. How a woman defines her desire for pregnancy as either wanted or not and her subsequent actions are significantly affected by perceived partner support and relationship longevity [10]. By rejecting long-term effective contraceptive methods, women in casual relationships are more likely to experience unintended pregnancy without partner support and relationship stability.

Although not identified as a major theme, most participants did not identify their health-care providers as primary sources of information on EC in general or of the copper IUD as a form of EC. Furthermore, several nulliparous participants identified their health-care providers as a barrier to obtaining an IUD due to their unwillingness to insert an IUD. While such barriers as the lack of health insurance coverage certainly prevent numerous women from accessing reliable forms of contraception, inaccurate information from healthcare providers may further inhibit adequate access to EC. Findings from a study investigating contraception knowledge suggest that a significant level of misinformation persists among health-care providers [11]. A recent Kaiser Family Foundation study on EC reports that few women have discussed any form of EC with their health-care providers [12]. These findings suggest the need for increased discussion about EC between providers and patients.

While no participant identified pregnancy as a current or short-term goal, the ability to become pregnant in the future weighed heavily on participants' interpretation of the benefits and risks of both the copper IUD and oral EC. Participants possessing less knowledge of the copper IUD could not identify a justification for selecting this long-term method of contraception when presenting at clinics for EC. Participants selecting oral EC articulated specific reasons for selecting this method of EC. Our findings support previous research indicating a disconnect between the desire to avoid pregnancy and acceptance of a long-term or consistent contraceptive method [13,14].

Policy-maker and practitioner perspectives may favor the long-term benefits of the copper IUD and its ability to decrease unintended pregnancy. However, oral EC continues to be the preferred EC option for many women. This reasoning is due in part to the timing of future pregnancy, concern regarding side effects and lack of accurate IUD knowledge. Research indicates that increased knowledge of the IUD leads to more positive attitudes and willingness to utilize the IUD [15]. While it has many benefits, the copper IUD is primarily viewed as a long-term contraceptive method and not as a form of EC. Increased education and discussion both with women and health-care providers may increase familiarity and comfort with the IUD as a form of EC.