Every Saturday The CSPH highlights news or recent research in the field of human sexuality. This week we’re looking at a recent study from Contraception, which examines individual’s interest levels in trying intrauterine devices (IUDs) if they are informed that these are self-removable.
IUDs, while convenient, cost-effective, reversible, long-lasting, and highly—over 99%—effective, represent only a small portion of all contraceptives used in the United States. The authors of this study sought to understand part of the reasons behind this low number by addressing one commonly cited concern of women not using IUDs: that the device requires insertion and removal by a medical provider. In their study, the researchers proposed to examine the interest of women in using the contraception if they were informed that they could remove the device themselves at home, a practice that is already undertaken by many women and is understood to pose little health risk to the individual.
For this study, English- or Spanish-speaking individuals seeking abortion services—either the procedure itself or follow-up appointments—in clinic waiting rooms in or near six U.S. cities were invited to participate in this computer-guided survey. Participants were asked about their contraceptive attitudes, preferences, and risk behaviors, and were then assessed for their opinions on IUDs. Initially asked about their interest in the device in general, respondents were then asked that if there were, hypothetically, a new IUD that the medical provider stated was safe to remove at home, whether they would be more or less likely to consider it. They were then questioned about whether they would consider removing it themselves and about which factors of the scenario influenced their answer. Participants were offered $20 for completing this study. Ultimately, of the 983 eligible women, 61% opted to complete the study.
Although the researchers asked about numerous aspects of contraceptive choice, the bulk of the study focused on self-removal of IUDs, with participants reporting a range of responses. One-fourth of those surveyed stated they would be interested in an IUD they could remove themselves, slightly less than one-third said this factor did not affect them, and one-third said it would make them less likely to use one. However, among the women who were already considering using an IUD (36% of the sample), self-removal made them 39% more interested in using the IUD, versus 23% who said it would do the opposite. For those who reported self-removal making them more interested in an IUD, they listed that it would be “less of a hassle” (53%); would make it easy to test if they liked it (51%); would make them feel more in control (50%), and would mean they would not have to go to a doctor (47%). Those who were put off by self-removal cited that it would make them feel less safe (58%) and that they were concerned it was more likely to fall out (47%).
As the investigators found, the idea of being able to remove an IUD oneself tended to be an encouraging factor for those women who were already interested in IUDs; this population was three times more likely to be interested in a self-removing option than those not predisposed to being interested. For those who had no initial interest, the idea of self-removal was actually discouraging. The researchers also noted, however, that there may have been misunderstandings in the study that affected these numbers: namely, that because the hypothetical IUD in question was new and specified as self-removable, as opposed to the IUDs currently on the market, it may have been viewed as more likely to fall out or of poorer quality.
There were a number of limitations on this study that affect how far we could reasonably accept its findings. Primarily among these, beyond the potential for misunderstanding that may have skewed results, was that there were several moments in this study where bias could have occurred. Selection bias—where the individuals who participate are systematically different from those who do not—may have featured, as there was no analysis provided that listed the comparative demographics of those who did and did not participate. They were also offered a financial incentive, which may have been a significant amount to some individuals, over-representing people with financial need in the study. Though this study addressed age, race/ethnicity, and pregnancy status, it never mentioned socioeconomic status (SES), insurance coverage, or any other factors related to class. This is a clear oversight, both because these are key factors for demographic comparisons and also because they affect the experiences of the participants and limit the context in which we can understand their opinions. Cost is often cited as a deterrent from getting an IUD, as it has a more substantial up-front price than many other types of contraception, and its coverage varies by insurance. As well, SES is linked to education, and thus affects how individuals understand or feel about different contraceptive options.
Despite these limitations, this study brings up some interesting new ideas for medicine that cannot be ignored. A self-removing IUD could lessen a number of the access barriers that exist for many individuals who would like to use this form of contraception: a second doctor’s appointment can be impossible for individuals who cannot afford to take time off work, commute, require child care, or lack health insurance. Enlightening individuals to this more accessible way of using this highly successful birth control measure could have significant impacts for individuals who might have found it too challenging before this information. As well, this study emphasizes the importance in education and physician-patient communication, so that clinicians can ensure that patients know how to make self-removal safe, including what side effects to anticipate for the IUD initially so that they do not remove the device prematurely out of discomfort.
Ultimately, what makes this topic so interesting is that it gives more reproductive choices and power to the people using it, and that is always an exciting thing. To read more about this study, see the March 2012 edition of Contraception.
