Copper T IUD: Safe, Effective, Reversible

Lack of accurate information and other barriers discourage IUD use.

Network: 2000, Vol. 20, No. 1

It is a good contraceptive with a bad reputation in some countries. The Copper T intrauterine device (IUD) is safe and reversible, requires little effort on the part of the user once inserted, and offers 10 years of prevention against pregnancy. However, in some countries family planning clients are reluctant to use IUDs, health workers are reluctant to provide them, or programs do not have the supplies or trained staff needed to offer them.

Fears about side effects, concerns about infection and infertility, lack of technical training for providers, and the time and costs involved in providing services combine to discourage use of IUDs in some countries. "The IUD is quite an effective method and has a lower rate of complications than hormonal methods," says Dr. Carlos Huezo, medical director of the International Planned Parenthood Federation (IPPF). "Therefore, it is regrettable that its use is low in many countries. We need to create an awareness of the safety of the IUD and how effective it is."

Worldwide, approximately 13 percent of all women of reproductive age use the IUD, making it the second most popular contraceptive (19 percent use female sterilization, the leading method). However, most IUD users are in a few countries, especially China, where a fifth of the world's population lives. While studies show the Copper T IUD is nearly as effective as male or female sterilization, the IUD is often ignored or overlooked. One reason is misinformation on the part of both clients and providers.

Myths and rumors

An international mail survey being conducted by IPPF and the World Health Organization (WHO) has found that inaccurate information about IUDs is a barrier to use worldwide. Dr. Huezo says preliminary data about clients' questions and concerns revealed that rumors are commonplace. The survey was sent to national institutions providing family planning services in 75 countries.

"The most common misconception was that IUDs work by causing an abortion," says Dr. Huezo. "We also heard that the IUD causes cancer. This was a quite common perception, but it came as a surprise to researchers. Another concern is that the IUD moves outside the uterus and can travel as far as the heart or brain."

IPPF and WHO are preparing a list of these misconceptions for providers and responses providers can give to address clients' concerns. For example, no scientific evidence indicates IUDs cause cancer. In fact, research suggests the devices reduce the risk of endometrial and cervical cancers. Although the IUD can be expelled through the vagina or very rarely can perforate the uterus during insertion, the IUD does not travel outside the uterus to other organs. IUDs prevent fertilization. Although the specific mechanisms are not fully understood, studies show the IUD effectively interrupts the reproductive process before implantation and pregnancy, suggesting that it does not act as an abortifacient.

"If we want to increase the acceptability of the IUD, or any other method, it is important to provide information and education to the community, the clients and potential clients," Dr. Huezo said. "It is also very important to update knowledge among the service providers -- not only those who directly provide (contraception) but those who provide other reproductive health services."

Up-to-date information is important. A study in Jamaica found that private physicians often denied family planning methods, basing their decisions on out-of-date information rather than current scientific evidence.¹ Twenty-nine percent of physicians required their patients take a rest after using an IUD -- before inserting another IUD or using another method -- and 11 percent required a blood test before IUDs were inserted. Neither is medically necessary.

Incorrect or out-of-date information extends to concerns about infection prevention. Some health workers are reluctant to recommend the IUD because they incorrectly believe it causes pelvic inflammatory disease (PID), a serious condition that can lead to infertility or death.

PID risks can be reduced by screening clients at high risk of sexually transmitted diseases. Women at risk of sexually transmitted diseases should consider another contraceptive option, such as condoms. "If an infection follows insertion, perhaps the woman had an infection, such as gonorrhea, that was present in the lower reproductive tract and was introduced into the upper tract," says Dr. Irina Yacobson of FHI, who has conducted IUD training in several countries. Leaving the IUD in place for its recommended life span can also help minimize infection risks. Providers should also use sterile insertion procedures, and encourage condom use if women have sex with potentially infected men.

Another barrier has been the requirement that women be menstruating before they receive an IUD, to be sure that they are not already pregnant. FHI has developed a simple checklist to help providers rule out pregnancy in nonmenstruating clients, and has trained providers in Kenya on how to use the checklist.

Side effects

For some clients, fear of IUD side effects is a deterrent to IUD use and a major reason for discontinuation. While IUD users generally report fewer side effects than users of hormonal or traditional methods, when side effects do occur, they can prompt client requests for IUD removal.²

Intermenstrual bleeding and cramping are the most common complaints during the first months of IUD use. An FHI study in Thailand found that during the first 12 months, intermenstrual bleeding and painful periods were the side effects most often cited by IUD users.³ In Bangladesh, 40 percent of the 3,678 users surveyed had their IUD removed, with about one-fifth of the removals due to menstrual problems.⁴ And in Nepal, women mistakenly thought increased bleeding and cramping during the first few months of IUD use were symptoms that the IUD was migrating outside the uterus and would eventually pierce the heart.⁵

A recent FHI study in Latin America, Asia and Africa found that factors contributing to discontinuation among 321 copper IUD users were expulsion (3.1 percent) and bleeding and pain (4.5 percent). Researchers also found that women younger than age 20 had higher expulsion rates than older women.⁶

Women should be counseled about side effects and what they mean before an IUD is inserted. If menstrual changes occur during the first few months of use, providers should reassure the woman that these side effects are normal and will usually diminish over time. It is not medically necessary to remove the IUD unless the woman also complains of fever, abdominal tenderness or unusual vaginal discharge -- signs of PID -- or severe pain -- a sign of uterine perforation or partial expulsion. Health workers can also help women cope with side effects by prescribing nonsteroidal anti-inflammatory drugs, such as ibuprofen. For example, doctors can recommend 400 milligrams of ibuprofen four times a day until bleeding stops for women with menstrual bleeding problems and pain.

However, if the woman cannot tolerate side effects and requests IUD removal, providers should comply and offer another method.

FHI research suggests that providers may be able to predict removals for bleeding or pain at the one-month follow-up visit. Scientists analyzed data from international studies and found that among 2,625 women, 89 had IUDs removed for bleeding or pain during the first year of use. Women who were not breastfeeding at the time of insertion were nearly three times as likely as breastfeeding women to request removal. Women living in West Asia or North Africa were nearly three times as likely to seek removals as their counterparts in other countries. Researchers concluded that several factors, which could be identified at the one-month visit, predicted IUD removal: reports of intermenstrual bleeding since last menses, excessive menstrual flow and not breastfeeding or stopping breastfeeding.⁷

Economic barriers

For clients and family planning programs, the cost of any method is always a concern. In addition to the cost of an IUD itself, clients must often travel long distances to clinics and pay for transportation, miss a day's work and find child care. Family planning clinics must consider the costs of staff time for counseling, insertion and follow-up visits.

Even the materials needed for IUD insertion can be expensive. For instance, in an FHI study in Kenya, some clients seeking an IUD were asked to bring gloves or cotton wool with them.⁸

While initial costs of IUD insertion may be high, the long-term use of the method makes it very cost-effective over time. An FHI study in Thailand compared contraceptive methods based on couple-years of protection (CYP) and found the IUD's cost, including follow-up visits, was about U.S. $0.86 per CYP after five years of use. The CYP costs of subdermal implants and injectables were U.S. $5.65 and $5, respectively.⁹ A study has shown similar cost-savings among U.S. women over five years.¹⁰

The cost of visits is important to consider. The number of recommended follow-up visits often varies from clinic to clinic, ranging from two to five during the 12 months following insertion. Some women return only because of scheduled visits, not because they are experiencing problems. Follow-up visits that are too frequent can lead to clinic overcrowding and divert staff and financial resources from women in need of medical care.

To learn whether follow-up visits could reduce program costs without compromising client health, FHI analyzed visits among IUD users in nine countries, looking specifically at visits for women who had no symptoms or mild symptoms but required some type of medical care. Of the more than 11,000 follow-up visits, less than 11 percent required care (treatment of side effects or IUD removal). Less than 1 percent required both treatment and removal.¹¹

Among the women with mild symptoms or no symptoms, nearly two-thirds said they likely would have returned to the clinic without a scheduled follow-up visit (most cited personal reasons or possible pregnancy as the reason). Women with severe or moderate symptoms said they would have returned to the clinic whether or not they were scheduled to. Researchers concluded that health workers spend time seeing healthy, satisfied IUD users, who really do not need medical services.

In Ecuador, FHI and the Population Council explored the impact of reducing the number of IUD follow-up visits on program costs and client quality of care. Researchers asked more than 3,300 new acceptors at the 20 clinics administered by the Centro Médico de Planificación Familiar (CEMOPLAF) why they made follow-up visits -- to report health problems or simply because they were told to return. CEMOPLAF required four visits within the first year of use.

In analyzing answers, they found that IUD follow-up visits accounted for 74 percent of all clinic visits and 64 percent of all clinic costs. While most clients made their first follow-up visit, the number who kept their second, third and fourth appointments declined rapidly. Of the women diagnosed with medical problems, including expulsion and PID, three-fourths said they would have returned without an appointment.¹²

As a result, CEMOPLAF adopted a new policy to require one IUD visit no sooner than 15 days after insertion. Also, women were encouraged to return any time they had a problem. Although the number of IUD insertions remained the same, the number of first-year follow-up visits declined by 36 percent. Reducing the number of follow-up visits allowed staff time to care for more urgent problems.

-- Barbara Barnett

References

1. McDonald OP, Hardee K, Bailey W, et al. Quality of care among Jamaican private physicians offering family planning services. Adv Contracept 1995;11(3):245-54.
2. Cleland J, Ali M. Quality of care and contraceptive continuation. In Ersheng G, Shah I, eds. Progress of Social Science Research on Reproductive Health: Anthology of Treatises of the International Symposium on Social Science Research on Reproductive Health, Shanghai, People's Republic of China, October 11-14, 1994. Beijing: China Population Publishing House, 1997.
3. Reinprayoon D, Gilmore C, Farr G, et al. Twelve-month comparable multicenter study of the TCu 380A and ML250 intrauterine devices in Bangkok, Thailand. Contraception 1998;58(4):201-6.
4. Akhter HH, Faisel AJ, Ahmen YH, et al. An IUD study to assess follow-up needed for removal or reinsertion. Summary Bibliography of BIRPERHT Studies. Dhaka: Bangladesh Institute of Research for Promotion of Essential & Reproductive Health and Technologies, 1994.
5. Nepal Ministry of Health and University Research Corporation. Developing Strategies to Increase IUD Use in Urban Areas, Population Council Operations Research Database Project Summaries. New York: Population Council, 1993.
6. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD. Contraception 1999;60(3):155-60.
7. Stanback J, Grimes D. Can intrauterine device removals for bleeding or pain be predicted at a one-month follow-up visit? Contraception 1998;58(6):357-60.
8. Stanback J, Omondi-Odhiambo, Omuodo D. Final Report, Why Has IUD Use Slowed in Kenya, Part A, Qualitative Assessment of IUD Service Delivery in Kenya. Research Triangle Park, NC: Family Health International, 1995.
9. Janowitz B, Kanchanasinith K, Auamkul N, et al. Introducing the contraceptive implant in Thailand: impact on method use and costs. Int Fam Plann Perspect 1994;20(4):132-36.
10. Trussell J, Leveque JA, Koenig JD, et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health 1995;85:494-503.
11. Janowitz B, Hubacher D, Petrick T, et al. Should the recommended number of IUD visits be reduced? Stud Fam Plann 1994;25(6):362-67.
12. Foreit J, Bratt J, Foreit K, et al. Cost control, access and quality of care: the impact of IUD revisit norms in Ecuador. J Health Popul Dev Countries 1998;1(2):11-18.

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