Intrauterine Device Use in America: Cultural Barriers Propagated by Fear and Misinformation

The intrauterine device (IUD) is the most popular form of reversible contraception in the world. The United States, however, has extremely low usage rates due to negative beliefs about the safety of its use. This article explores the reason for these false beliefs and why they are only found within the litigious culture of the United States. It seeks to quash the rumors of the danger of infertility by refuting evidence from several studies, including an assessment of the actual risks of using an IUD. This journal article is available in Journal of Student Nursing Research: http://repository.upenn.edu/josnr/vol1/iss2/5 Vol 1, Iss 2, 2008 Journal of Nursing Student Research 24 Intrauterine Device Use in America: Cultural Barriers Propagated by Fear and Misinformation Abstract Grace R. WilsonGrace R. Wilson The intrauterine device (IUD) is the most popular form of reversible contraception in the world. The United States, however, has extremely low usage rates due to negative beliefs about the safety of its use. This article explores the reason for these false beliefs and why they are only found within the litigious culture of the United States. It seeks to quash the rumors of the danger of infertility by refuting evidence from several studies, including an assessment of the actual risks of using an IUD. with the large amounts of media attention given to class action lawsuits against pharmaceutical companies discouraged the populace from using a proven effective medical device. For many women, the IUD represents a form of contraception that is private, easy to use, extremely effective and completely reversible. In the United States, however, it has been recommended that IUDs not be used by nulliparous women and women who might want to conceive in the future because of the supposed risk of infertility. This limits their options to monthly or daily contraceptives. For some women, the use of shorter term contraceptives is unacceptable or impossible due to forgetfulness or the lack of local pharmacies. Also, certain IUDs provide women who cannot take hormonal contraceptives with a much more effective method compared to barriers, such condoms and diaphragms, and spermicide. Misinformation The IUD has been subject to misleading interpretations of study results, stemming from the preconceived notion that its use can cause infertility. Grimes (2001) reexamined various IUD studies and found that a bias existed due to differences in participants and misreading of the results. The study he analyzed showed a significant delay of childbirth after discontinuing birth control for nulliparous IUD users contrasted against oral contraceptive and barrier method users. From these results, it was determined that nulliparous women should not use an IUD due to the risk of infertility, also speculating that PIDrelated infertility was the cause of delay of childbirth. T IUD is a highly effective form of contraception that has been in use for over half a century. It has been shown to be extremely effective and it has a user satisfaction rate of 95% (Hatcher et al, 2002). Across the globe, the IUD is the most popular form of reversible contraceptive, used by over 160 million women (Peterson & Curtis, 2005). North America has a significantly lower usage rate at 1.5% compared to other geographic regions of similar socioeconomic and health status such as Australia and New Zealand (5.2%), Europe and the former USSR (7.2%) and Scandinavia (18.2%) (Johnson & Morgan, 2005) A major cause of this disparity was the Dalkon Shield litigation in the 1970’s leading to a popular belief that all types of IUDs cause an increase in the rate of pelvic inflammatory disease (PID) which can cause infertility. The primary users of the Dalkon Shield were nulliparas who became infertile due to PID. Since that time, the risk of infertility has been falsely tied with the use of other IUD brands and types. Because the Dalkon Shield was only marketed in the United States, the fear of infertility is centered in there. In 1970, when the Dalkon Shield was introduced, nearly 10% of US contraception users had an IUD. After reports of infections began to arise and investigations tied to lawsuits ensued, a panic spread through the population causing a drop in IUD usage in the US to today’s level. The United States, as one large cultural group, tends to react to medical scandals with intense media coverage leading to a lasting stain on the product’s reputation accompanied by widespread panic of users of the product. The litigious nature of Americans coupled 1 Wilson: Intrauterine Device Use in America: Cultural Barriers Propagated Published by ScholarlyCommons 2008 Vol 1, Iss 2, 2008 Journal of Nursing Student Research 25 Wilson, G. Grimes argued that the study was flawed because of a selection bias. He states, “Women who chose to use IUDs differed in important respects from those who chose oral contraceptives; on enrollment, nearly twice as many reported not wanting children... Those who opted for an IUD also were older, heavier, and more likely to be cigarette smokers” (p. 6). These factors present valid reasons for a delay of child birth that were not cited by the study as possible causes. Grimes also researched the prevalence of PID in IUD users. The theory that IUDs cause tubal infertility relies on a woman becoming infected with the sexually transmitted infections (STI) such as chlamydia or gonorrhea which can lead to PID, in turn causing tubal infertility. He reported that there is no significant statistical correlation between the use of an IUD, including long term use, and tubal infertility. Outdated regulations lead to reduction in use The shadow cast over the American populace by the Dalkon Shield incident highlighted the lack of regulation for contraceptive devices. The Food and Drug Administration (FDA) responded by enacting excessively limiting guidelines for contraindications for the IUD, including nulliparity. The American Journal of Public Health recently published a study on the barriers to contraceptive use due to regulations such as these (Grossman et al, 2006). Their primary focus on IUD use was in regard to recent practice guideline changes, such as the World Health Organization (WHO) announcing that the benefits of IUDs outweigh any theoretical or proven risks for nulliparas. The journal’s study suggested that many doctors in the United States are still reluctant to insert an IUD for a nulliparas because of the historical cases of infertility caused by the Dalkon Shield. Despite the claims of respected entities, such as the WHO, doctors are still unwilling to risk causing infertility to a woman who has not already had a child, even if that woman eventually desires never to conceive. As a result, many women are denied the opportunity to have an IUD inserted, and many are misled into believing that they cannot use an