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

Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study

BACKGROUND

The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost.

METHODS

We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC.

RESULTS

Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day.

CONCLUSIONS

This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.

Women's Contraceptive Perceptions, Beliefs, and Attitudes: An Integrative Review of Qualitative Research

INTRODUCTION

Unintended pregnancy rates will remain high until researchers explore the lived experience of women's relationships with contraception. This integrative review examines the extant qualitative literature on women's contraception to illuminate common themes in women's perspectives through the lens of the feminist poststructuralist framework.

METHODS

A literature review of PubMed and CINAHL databases was completed for English-language studies conducted in the United States from January 2008 through September 2018 that qualitatively examined women's perceptions, beliefs, and attitudes regarding contraception. Reports, dissertations, mixed-methods research, and literature reviews were excluded. The sample, methods, and findings of 19 studies were reviewed. Themes were identified using the 5 major tenets of the feminist poststructuralist framework: discourse, power, language, subjectivity, and agency.

RESULTS

Themes of power imbalance between partners and health care providers; societal and communal discourses on femininity and motherhood; distrust of hormonal contraception; the ability to enhance personal agency through contraceptive decision making; and a need for open, patient-focused communication arose from the 19 studies included in the review.

DISCUSSION

Using a feminist poststructuralist framework to examine women's contraceptive perceptions illuminates and magnifies the many ways in which contraceptive beliefs and use are dependent on gender roles and power dynamics. Gaps in knowledge specific to older women and exploration of women's subjectivity should be addressed. Clinicians should evaluate the power structures inherent to their practice while providing woman-focused, evidence-based contraceptive education.

Re-Examining Genetic Screening and Oral Contraceptives: A Patient-Centered Review

The World Health Organization classifies combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation but advises against routine thrombophilia screening before initiating combined oral contraceptives (COCs) on the grounds of high screening costs and low prevalence. From the perspective of patient-centered care, we examine cost, prevalence, and other published arguments for and against thrombophilia screening before initiating COCs. Our patient-centered review draws on relevant empirical evidence concerning the advantages and disadvantages of thrombophilia screening, while placing the discussion in the broader context of evolving attitudes toward genetic testing and a shifting policy landscape that provides many women direct access to COCs and/or thrombophilia screening. Given variation in prior probabilities of thrombophilia, expected exposure to other risk factors for venous thromboembolism, attitudes towards risk, expected reactions to a positive test result, ability to pay, and concerns about genetic discrimination, we conclude that the current one-size-fits-most approach is not consistent with patient-centered care. Instead, we advocate for greater patient and provider education concerning the implications of thrombophilia screening. Moreover, we recommend offering patients optional thrombophilia screening before initiating COCs.

Knowledge of and Interest in the Copper Intrauterine Device Among Women Seeking Emergency Contraception

OBJECTIVE

Emergency contraception (EC) includes hormonal pills (levonorgestrel or ulipristal acetate) and the copper IUD (Cu-IUD). The Cu-IUD is more effective for EC than hormonal pills but remains underused, possibly because of lack of knowledge or interest. The objective of this study was to examine knowledge of and interest in the Cu-IUD for EC among Canadian women seeking EC.

METHODS

The study used a cross-sectional convenience survey of English-speaking women presenting for EC at two sexual health clinics in Toronto. The anonymous paper-based survey was completed in the waiting room. The main outcome measures were women's knowledge of and interest in the Cu-IUD for EC. Demographic and reproductive health data were also collected.

RESULTS

Between January and December 2013, 124 surveys were completed. Mean age of respondents was 26 years (SD ± 6.9). Most were single (85%), and over one half had completed postsecondary education. Overall, 77% had heard of the Cu-IUD, but only 21% were aware of its use for EC. Over 50% were aware that the Cu-IUD is hormone-free and may be used for long-term contraception. Women were less familiar with the window of administration of the Cu-IUD for EC (26%) and its efficacy (6%). In total, 23% (28 of 124) of women were interested in the Cu-IUD, including eight women scheduled to receive one that day.

CONCLUSION

Women presenting for EC were unaware of the Cu-IUD but were moderately interested in it once informed. Public education and routine counselling about the Cu-IUD at EC visits may increase the uptake of this method.

Access to the copper IUD as post-coital contraception: results from a mystery caller study

OBJECTIVE

To assess access to the copper IUD as post-coital contraception (PCC) and identify barriers to obtaining this contraceptive method.

STUDY DESIGN

We used a "mystery caller" approach to survey primary care, family planning, and Ob/Gyn clinics in nine U.S. cities, identified via online search. A single researcher called 199 clinics, assuming the role of a patient seeking the copper IUD for PCC. Using a standard script, the researcher collected information regarding access to the copper IUD and respondent's knowledge of the copper IUD's indication for PCC. The primary outcome was availability of the copper IUD as PCC. Secondary outcomes included any provision of the copper IUD, awareness of the copper IUD's indication for use as PCC, and offering accurate information regarding the copper IUD as PCC. Fisher's exact test was used to compare outcomes by clinic type.

RESULTS

Two thirds (68%) of primary care clinics, 87% of family planning clinics, and all Ob/Gyn clinics offered the copper IUD (p<.001). Only 11% of primary care clinics, however, were aware of the copper IUD's use as PCC, as compared with 63% of family planning clinics and 24% of Ob/Gyn clinics (p<.001). Few primary care or Ob/Gyn clinics offered the copper IUD as PCC, while 49% of family planning clinics did so (p<.001).

CONCLUSION

Access to the copper IUD as PCC is limited and varies by clinic type. Knowledge gaps exist regarding the use of the copper IUD as PCC, as well as regarding the general medical guidelines for copper IUD placement.

IMPLICATIONS

A majority of primary care and Ob/Gyn clinics do not offer the copper IUD as PCC, and only about half of family planning clinics do so. Barriers included lack of knowledge, unavailability of device, unavailability of an appointment with a trained provider, and outdated IUD provision protocols.

Choice of Emergency Contraceptive and Decision Making Regarding Subsequent Unintended Pregnancy

OBJECTIVES

To prospectively evaluate (1) pregnancy desirability, (2) stated intentions should pregnancy occur among emergency contraception (EC) users, and (3) explore differences between women selecting the copper T380 intrauterine device (Cu IUD) or oral levonorgestrel (LNG) regarding hypothetical pregnancy plans and actual pregnancy actions during subsequent unintended pregnancies.

STUDY DESIGN

In this prospective observational trial, women received the Cu IUD or oral LNG for EC without cost barriers. At baseline, participants completed a visual analogue scale measuring pregnancy desirability (anchors: 0, "trying hard not to get pregnant"; 10, "trying hard to get pregnant") and self-reported plans (abortion, adoption, parenting, and unsure) if the pregnancy test were to come back positive. Pregnancies were tracked for 12 months, and actions regarding unintended pregnancies were compared between EC method groups.

RESULTS

Of 548 enrolled women, 218 chose the Cu IUD and 330 the oral LNG for EC. Pregnancy desirability at baseline was low, with no difference between EC groups (IUD group: 0.51, SD ± 1.60; LNG group: 0.68, SD ± 1.74). Fifty-four (10%) women experienced unintended pregnancies. Pregnancy plans from baseline changed for 27 (50%) women when they became pregnant. EC groups did not differ in hypothetical pregnancy intention (p = 0.15) or in agreement of hypothetical pregnancy intention with actual pregnancy action (p = 0.80).

CONCLUSIONS

Women presenting for EC state high desire to prevent pregnancy regardless of method selected. When considering a hypothetical pregnancy, half of women had a plan for how they would respond to that situation, but when confronting an actual unintended pregnancy, half altered their plan.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier NCT00966771.

Recent advances on anti-HIV vaginal delivery systems development

A review of the recent outcomes regarding technologies to prevent vaginal transmission of HIV, mainly by using antiretroviral (ARV) drugs formulated as microbicides. An introduction about the HIV transmission mechanisms by the vaginal route is included, together with the recent challenges faced for development of successful microbicide products. The outcomes of clinical evaluations are mentioned, and the different formulation strategies studied to-date, with the requirements, advantages, disadvantages and limitations of each dosage-form type, are presented. Finally, the recent attempts to apply various types of nanotechnologies in order to develop advanced microbicide-products and overcome existing limitations, are discussed.

U.S. Men's Perceptions and Experiences of Emergency Contraceptives

Research suggests that men should be included in reproductive health decision making to help enhance positive health outcomes for their partners. Men affect the use of contraception and what method is used. Men's decisions may be affected by different factors such as gender, education, and the nature of their sexual relationship. A qualitative study was conducted to explore males' experiences and perceptions about emergency contraception (EC), and the meanings males assign to EC. Semistructured in-depth focus groups were held with 15 men who engage in heterosexual activity recruited from a university setting in the United States. Participants expressed egalitarian views of the contraception decision-making processes, a sense of responsibility regarding reproductive decision making, and that society has a negative stigma toward those who use EC. However, there was a lack of knowledge regarding the copper intrauterine device, which was not viewed as a method of EC. Exploring the role and needs of men in reproductive health care discussions and research is an important and growing area. Recommendations are provided for health care practitioners, policy, and future research around men and EC.

Emergency contraception - potential for women's health

Emergency contraception (EC) is a safe and effective method which is used to prevent unwanted pregnancy after unprotected sexual intercourse. Many of the unwanted pregnancies end in unsafe abortions. The search for an ideal contraceptive, which does not interfere with spontaneity or pleasure of the sexual act, yet effectively controls the fertility, is still continuing. Numerous contraceptive techniques are available, yet contraceptive coverage continues to be poor in India. Thus, even when not planning for a pregnancy, exposure to unprotected sex takes place often, necessitating the use of emergency contraception. This need may also arise due to failure of contraceptive method being used (condom rupture, diaphragm slippage, forgotten oral pills) or following sexual assault. Emergency contraception is an intervention that can prevent a large number of unwanted pregnancies resulting from failure of regular contraception or unplanned sexual activity, which in turn helps in reducing the maternal mortality and morbidity due to unsafe abortions. However, a concern has been expressed regarding repeated and indiscriminate usage of e-pill, currently the rational use of emergency contraception is being promoted as it is expected to make a significant dent in reducing the number of unwanted pregnancies and unsafe abortions. In fact, since the introduction of emergency contraception, the contribution of unsafe abortion towards maternal mortality has declined from 13 to 8 per cent.

IUDs as EC? Limited awareness and high reported acceptability: evidence from Argentina

BACKGROUND

We explored knowledge and attitudes regarding the copper intrauterine device (IUD) as emergency contraception (EC) among women in Buenos Aires, Argentina.

STUDY DESIGN

We interviewed a convenience sample of women attending a family planning center at a public hospital. Participants were asked about knowledge and use of contraceptives, including EC (pre-script). Then they were given information about the IUD as EC and subsequently asked about acceptability of using the copper IUD as EC (post-script), the primary outcome in this analysis.

RESULTS

We analyzed data on 273 women. While only 1.83% of participants knew the IUD served as EC at baseline, 79.85% said they would be willing to use the device as such if the need arose after given relevant information. Multivariate results from a pre-script revealed that women with low levels of education and those born outside of Argentina were less knowledgeable about EC pills. Only previous use of the IUD was associated with high levels of IUD knowledge. Post-script, results indicated that being Argentine [odds ratio (OR)=2.15, 95% confidence interval (CI) 1.21, 3.81] and previous IUD use (OR=2.12, 95% CI=1.07, 4.19) were positively associated with considering the IUD as EC. Nulliparity was negatively associated with willingness to use the IUD as EC (OR=0.44, 95% CI 0.22, 0.86).

CONCLUSION

We examined acceptability of the copper IUD as EC in a Latin American setting and found that, while prior levels of knowledg'e were low, acceptability of the IUD as EC was high. Implications for programming and policy include outreach and education regarding this highly effective method and advocacy to change existing regulations in Argentina prohibiting the use of IUD as EC.

IMPLICATIONS

After given information about the IUD as a method of EC, women interviewed said they would be willing to use the IUD EC despite their limited prior knowledge of this method. With more widespread information and availability of the IUD as EC, more women may opt for this highly effective method, which can provide additional protection against unwanted pregnancy for up to 10 years.

Obstetrician-gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations

OBJECTIVES

Use of intrauterine devices (IUDs) by US women is low despite their suitability for most women of reproductive age and in a variety of clinical contexts. This study examined obstetrician-gynecologists' practices and opinions about the use of IUDs in adolescents, nulliparous women and other patient groups, as well as for emergency contraception.

DESIGN

A survey questionnaire was sent to a computer-generated sample of 3000 fellows who were reflective of the American College of Obstetricians and Gynecologists (College) membership.

RESULTS

After exclusions from the 1552 returned surveys (51.7% response rate), 1150 eligible questionnaires were analyzed. Almost all obstetrician-gynecologists (95.8%) reported providing IUDs, but only 66.8% considered nulliparous women, and 43.0% considered adolescents appropriate candidates. Even among obstetrician-gynecologists who recalled reading a College publication about IUDs, only 78.0% and 45.0% considered nulliparous women and adolescents appropriate candidates, respectively. Few respondents (16.1%) had recommended the copper IUD as emergency contraception, and only 73.9% agreed that the copper IUD could be used as emergency contraception. A total of 67.3% of respondents agreed that an IUD can be inserted immediately after an abortion or miscarriage. Fewer (43.5%) agreed that an IUD can be inserted immediately postpartum, and very few provide these services (11.4% and 7.2%, respectively). Staying informed about practice recommendations for long-acting reversible contraception was associated with broader provision of IUDs.

CONCLUSIONS

Although most obstetrician-gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for long-term use, despite evidence-based recommendations.

IMPLICATIONS

This study shows that obstetrician-gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.

Microbicides for the Treatment of Sexually Transmitted HIV Infections

Approximately 34 million people were living with human immunodeficiency virus (HIV-1) at the end of 2011. From the last two decades, researchers are actively involved in the development of an effective HIV-1 treatment, but the results intended are still doubtful about the eradication of HIV. The HIV-1 virus has gone from being an "inherently untreatable" infectious agent to the one liable to be affected by a range of approved therapies. Candidate microbicides have been developed to target specific steps in the process of viral transmission. Microbicides are self-administered agents that can be applied to vaginal or rectal mucosal surfaces with the aim of preventing, or reducing, the transmission of sexually transmitted infections (STIs) including HIV-1. The development of efficient, widely available, and low-cost microbicides to prevent sexually transmitted HIV infections should be given high priority. In this review, we studied the various forms of microbicides, their mechanism of action, and their abundant approaches to control the transmission of sexually transmitted infections (STIs).

The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception

Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper intrauterine device (IUD), the most effective method of EC, continues to provide contraception as effective as sterilization for up to 12 years, and it should be offered as the first-line method of EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an important role in reducing rates of unintended pregnancy. The EC visit should include access to the copper IUD as optimal care but should ideally include access to all highly effective methods of contraception.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Emergency contraception

This review will focus on the available methods for emergency contraception (EC), efficacy, side effects and mechanisms of action. Copper intrauterine device (IUD) has been shown to be the most effective method for EC which can be continually used for regular contraception. However, this possibility is seldom used and may be little known. Among the hormonal EC methods 1.5 mg levonorgestrel is the most widely used EC pill while the more recently developed Ulipristal acetate (UPA) has been shown to be the most effective option. This is probably due to a more pronounced prevention of follicular rupture compared with other hormonal EC methods. Knowledge is needed to better advise lactating women and obese women on optimal EC method. Furthermore a possible interaction of UPA with regular hormonal contraception and possibilities for "bridging" from EC to regular contraception needs to be explored. To increase efficacy future studies should focus on EC methods that target the endometrium.

The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience

BACKGROUND

Intrauterine devices (IUDs) have been studied for use for emergency contraception for at least 35 years. IUDs are safe and highly effective for emergency contraception and regular contraception, and are extremely cost-effective as an ongoing method. The objective of this study was to evaluate the existing data to estimate the efficacy of IUDs for emergency contraception.

METHODS

The reference list for this study was generated from hand searching the reference lists of relevant articles and our own article archives, and electronic searches of several databases: Medline, Global Health, Clinicaltrials.gov, Popline, Wanfang Data (Chinese) and Weipu Data (Chinese). We included studies published in English or Chinese, with a defined population of women who presented for emergency contraception and were provided with an IUD, and in which the number of pregnancies was ascertained and loss to follow-up was clearly defined. Data from each article were abstracted independently by two reviewers.

RESULTS

The 42 studies (of 274 retrieved) that met our inclusion criteria were conducted in six countries between 1979 and 2011 and included eight different types of IUD and 7034 women. The maximum timeframe from intercourse to insertion of the IUD ranged from 2 days to 10 or more days; the majority of insertions (74% of studies) occurred within 5 days of intercourse. The pregnancy rate (excluding one outlier study) was 0.09%.

CONCLUSIONS

IUDs are a highly effective method of contraception after unprotected intercourse. Because they are safe for the majority of women, highly effective and cost-effective when left in place as ongoing contraception, whenever clinically feasible IUDs should be included in the range of emergency contraception options offered to patients presenting after unprotected intercourse. This review is limited by the fact that the original studies did not provide sufficient data on the delay between intercourse and insertion of the IUD, parity, cycle day of intercourse or IUD type to allow analysis by any of these variables.