IUDs Become More Popular in the United States


The Intrauterine Device (IUD) is a highly effective form of birth control used by many women worldwide.  Once an IUD is inserted by a health care provider it can offer 5 to 10 years of pregnancy prevention with no further action by the user (such as taking a pill every day or using a condom with every act of intercourse).  As a result, the failure rates under typical use and perfect use are nearly identical and show that fewer than 1 percent of women using this method will become pregnant in the first year of use. 

Nonetheless, this method has been relatively unpopular in the United States over the last few decades. 

A new study, Renewed Interest in Intrauterine Contraception in the United States: Evidence and Explanation, however, suggests that the IUD is gaining popularity among American women of all ages.  The study looks at data from the 2006–08 National Survey of Family Growth (NSFG) which found that approximately 2.1 million American women used the IUD, which is the highest level of use since the 1980s.  This means that in 2006–08,  5.5 percent  of women using contraception were using an IUD compared to 2.0 percent in 2002 and 1.3 percent in 1995 (when use was at its lowest).  

The authors of the study suggest a number of reasons for this renewed interest in IUDs including product improvements, new guidelines, more trained providers, a better reputation, and increased access.

Product Improvements

Today, women have a choice of the CuT380A (also known as the Copper-T or Paraguard) and the LNG IUS (the levonorgestrel intrauterine system, sold under the name Mirena) which was approved by the FDA in 2000.  The Copper-T last ten years while Mirena lasts five.  New research has demonstrated that these modern devices are highly safe, that their efficacy comes close to that of surgical sterilization, but that they are instantly reversible if a woman decides she wants to get pregnant.   All of which should make them a popular choice.

New Guidelines

When I was first learning about various contraceptive methods, so that I could be a Peer Sexuality Educator at UMass, I was told that IUDs were intended for older women who had already had children.  As such, we barely even mentioned them in the contraceptive education class that was mandatory for any woman who wanted to get birth control from the University’s health center. 

This opinion was not unique to my program; it was likely based on the practice guidelines published by the American College of Obstetricians and Gynecologists (ACOG).  These guidelines are used by providers to help determine whether a patient is a good candidate for a given contraceptive method.  According to the authors of the study, the 1987 and 1992 bulletins were rather negative when it came to IUDs.  In fact, they started with a statement about product liability and its impact on the IUD.  Moreover, the guidelines suggested that IUDs were best suited for older, monogamous women who had already had children, had no history of pelvic inflammatory disease (PID) or ectopic pregnancy, and “ ‘are not candidates for the ‘slightly more effective’ oral contraceptive pill.’ ”

In contrast, the 2005 bulletin begins by saying:

“ ‘Intrauterine devices (IUDs) offer safe, effective, long-term contraception and should be considered for all women who seek a reliable, reversible contraception that is effective before coitus.’”  

These new guidelines are echoed by the World Health Organization and the U.S. Centers for Disease Control and Prevention (CDC).  Both organizations issued similar eligibility criteria which support the use of IUDs among wide populations, including women under 18 and those who have not had children. 

More Providers

The study notes that a greater number of providers are aware of the evidence supporting the safety and efficacy of IUDs, in part due to the new guidelines and, in part, due to concerted efforts by organizations such as the Association of Reproductive Health Professionals and the Society of Family Planning.  The study also explains that a greater number of clinicians have been trained in the insertion and removal of IUDs.   

Interestingly, the authors also point to an increase in family planning training programs in general and note that family planning fellowships for post-residency training have been established at many universities over the last several years.

A Better Reputation

When they hear the term IUD, many women, even those of us who are too young to really remember it, think instantly of the Dalkon Shield.  Introduced in the early 1970s, this popular IUD caused increased risk of Pelvic Inflammatory Disease and left many of its users infertile.  Though it was pulled from the market in 1974, the lawsuits around it continued for many years and damaged the reputation of all IUDs. 

The study suggests that the method’s reputation is improving now that there are “no widespread medico-legal controversies or negative media attention.”  It also suggests that direct-to-consumer marketing has increased demand and that as more women use the device positive word of mouth spreads. 

Mirena has certainly had a widespread ad campaign that seems designed to remind women that IUDs are not just safe and effective but reversible.  In each of the commercials I’ve seen, the women have a few kids running around and say they don’t want any more, that is until the commercial fast forwards a few years and we see that she’s changed her mind and now has another happy, healthy child. 

Increased Access

Finally, the authors note that access to IUDs has increased through a number of factors.  They point to the ARCH Foundation (Access and Resource in Contraceptive Health) which is a not-for-profit foundation that is funded by the manufacturer of the LNG IUS and provides financial assistance to low-income women who want to use that method.  They also note that “many states have Medicaid family planning expansion programs (‘waivers’) that increase the income cutoff below which women can receive benefits, including access to all FDA-approved contraceptives.”  And, finally, they explain that many states have passed contraceptive equity laws that require insurance plans to cover contraceptive methods. This is particularly important for IUDs, because while they are cost effective over time, they have an upfront cost that can be quite high (insertion of Mirena, for example, can cost over $800).  

A woman’s decision about what birth control method to use is based on so many personal factors – how often she is having sex, whether she can safely take hormones, how good she is at remembering to take a pill, her relationship with her current sexual partner(s), her comfort with her own body, what her insurance will cover or what she can afford without it, when and whether she wants kids…the list goes on and on.  Therefore, what is most important is that women have access to as many safe and effective options to prevent unintended pregnancies as possible.  It is good to know that a new generation of IUDs has emerged and a new generation of women is using them. 

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  • robin-marty

    My insurance won’t pay for any birth control, it’s all out of pocket til you hit your deductible. For this to be worth it cost-wise, we would have to have sex at least once a day every day for each of those ten years that it can be effective, in comparison to a 25 cent condom.

    Which is probably why we are still in post partum birth control paralysis.

  • martha-kempner

    A few months after my sister had my nephew, she called me having just gotten a new diaphragm. Apparently, her insurance wouldn’t cover it. My nephew, by the way, had spent a week or so in the NICU. To quote my sister: “It just cost them $36,000 for me to have a baby, you would really think they’d spring for the 30 bucks to make sure I didn’t do it again.”

    Compared to a prenatal care and childbirth, even $800 seems like a steal for the insurers. If only they’d learn.

  • pbelden

    Robin, check whether you live in one of the states where insurers are required to cover contraception.  http://www.guttmacher.org/statecenter/spibs/spib_ICC.pdf  If you do you might be in luck.  Or if your employer has more than 15 employees and covers other precription drugs then you are also likely in luck.  You can call the National Women’s Law Center at 1-866-PILL4US or email info@nwlc.org.  There are a few other ways in which employers in other states are often required to cover contraception.  See http://www.nwlc.org/resource/contraceptive-equity-laws-your-state-know-your-rights-use-your-rights-consumer-guide-0

     

    “The federal law against sex discrimination in employment, Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000e-2(a)(1), has been interpreted to prohibit employers who offer otherwise comprehensive health benefits to their employees, including coverage of prescription drugs and devices generally, from excluding coverage of prescription contraceptives. This law covers all private employers with 15 or more employees, as well as state and local governments as employers. See U.S. Equal Employment Opportunity Commission, Commission Decision on Coverage of Contraception (Dec. 14, 2000),http://www.eeoc.gov/policy/docs/decision-contraception.html; Erickson v. Bartell Drug Co., 141 F. Supp. 2d 1266 (W.D. Wash. 2001). Thus, if you obtain your health insurance through your employee benefits plan, and you work for a government or for a private employer with at least 15 employees, you have a right to contraceptive coverage under federal law if your plan covers other prescription drugs and devices. If you live in Arkansas, Iowa, Minnesota, Missouri, Nebraska, North Dakota, or South Dakota, a federal court decision may implicate your Title VII protection. In re Union Pacific Railroad Employment Practices Litigation, 479 F.3d 936 (8th Cir. 2007). For more information on how to assert this right, see the National Women’s Law Center’s guide for employees, Take Action: Get Your Prescription Contraceptives Covered.”

  • equalist

    I was in the 1% that has an IUD failure (I was pregnant two months after coming off the pill, which I thought was funny because they tell you not to bother trying to conceive until around 7 months after coming off the pill).  I’ve also gotten pregnant while using condoms alone, and with the pill.  After the IUD thing though, I told my doctor, cut it, tie it, burn it, whatever it takes.  And if this doesn’t work, just yank the whole damn thing out!

    As for cost though, I think for low income women (at least in my state) it’s a really good option.  It’s covered by medicaid here, has a good effectiveness rate, and it’s a good long term contraceptive, whereas family planning medicaid only covers contraceptives for two years after the birth of a child.  When you’re on the pill under that program, you’re tossed back to figuring out how to pay for it on your own, whereas long term methods like the IUD, you’re covered for a good while.

  • elburto

    Access to IUDs is still fraught with difficulties in the US, compared to how we have it here in Europe. I volunteer on a sexual health site, and the vast majority of people are under the impression that IUDs aren’t suitable for them, that they’re dangerous, and that they interfere with sex (blame that on their ignorance-only education). The FDA still prohibit Bayer from including any info or advice in Mirena’s packaging, or on the US website, that indicates the device is suitable for nulliparous women and girls.

    Once people have been shown when devices are safe, heard happy testimonials from satisfied users, they then try to get one. But, due to years of misinformation and ignorance, healthcare professionals are no better informed than would-be users. They very often refuse to fit them in nulliparous women, the few that will are often woefully inexperienced which leads to complications like expulsion, and so the whole “IUDs are bad” cycle continues.

    Another problem I’ve bone across, with Mirena, is practitioners charging for an office visit for the woman to be sounded. This is completely unnecessary as mirena has a sounding device built in to the applicator. It won’t work if there isn’t sufficient room. These costs all add up, with some paying up to $1500.

    I’m working hard to help people realise it’s a good choice, and often refer them to non-American websites and literature so they can have access to accurate, up-to-date info.

  • equalist

    When I got my IUD put in, my OBGYN tried for quite a while to convince me to stay on the pill, but in years of going on and off the pill due to lack of funds, I’d noticed that within six months of starting the pill each time I’d gained close to 100 lbs, and within six months of coming off of the pill each time I’d lost between 50-75 of that weight.  It’d become clear that the weight gain was if not caused by the hormonal methods, then at least exacerbated by it, so I was ready for something different.  Having gotten pregnant while using condoms twice, I was reluctant to go with another barrier method, so the IUD seemed like a great fit for me.  I did notice that the practitioner that did the insertion may have been in the category you describe.  I became pregnant two months after the insertion, and when I went back to him for prenatal care (admittedly in a panic, because that just wasn’t supposed to happen, and knowing there’s both a fetus and a medical device in there at the same time is rather worrying) he didn’t have any information and had a hard time looking up information on actual failure rates for the devices and other information.

  • prochoiceferret

    For this to be worth it cost-wise, we would have to have sex at least once a day every day for each of those ten years that it can be effective

     

    That sounds like a CHALLENGE!

  • prochoiceferret

    It’d become clear that the weight gain was if not caused by the hormonal methods, then at least exacerbated by it, so I was ready for something different.

     

    That’s why I find the IUD, and specifically Paraguard, so interesting—complete contraception without buggering up your hormone balance! Of course, some women may not the cramping or (heavy) flow of an “au naturel” cycle, and there’s always the matter of (not) blocking STIs, but for all those for whom those aren’t an issue, this seems almost like an ideal form of birth control. Would that there were something similarly effective, convenient, long-lasting, and reversible for men.

  • robin-marty

    And THAT’s really why we aren’t doing the IUD. Cost effectively, if we DO decide we want one last kid, we need to do it in the next two or three years — a long time in birth control land, but not long enough to make an IUD cost effective for us (and no, my state has no coverage mandate, I just checked the list). I’m too “old” to wait five more years, and $1000 is a lot of money for a two year block. So if we’re going to invest a lot of cash, we might as well just do the vasectomy and skip a third kid all together. Which is fine I think, but man, if I had known we really were done I would have just let them tie my tubes when I was getting my csection and have this all overwith.