Intrauterine Contraception: Study to Evaluate Clinical Practice and to Increase Utilization

For the past decade, preventing unintended pregnancies has been an important issue for women's health. Against this background, the intrauterine device (IUD) has been established either as the most cost-effective method of contraception (in study models that span two or more years1,2) or the second most cost-effective reversible method (in studies that span two years or less3). … despite the proven safety and cost-effectiveness of today's IUDs, women who have unintended pregnancies are relying on less effective methods of contraception … Nonetheless, despite the proven safety and cost-effectiveness of today's IUDs, women who have unintended pregnancies are relying on less effective methods of contraception,4 many obstetrics/gynecology professionals in the United States remain reluctant to recommend use of the IUD, and fewer than 1% of women in the United States report using an IUD.5 This statistic contrasts sharply with the nearly 12% mean rate of IUD use worldwide—a rate which has been measured as high as 33% in China and 18% in Scandinavia.6 In the United States, at least 37% of couples rely on permanent sterilization for contraception,7 although permanent sterilization is not as cost-effective as the IUD1,2 and is associated with higher morbidity rates8 and lower patient satisfaction rates.9 Are we encouraging use of the most effective and cost-effective methods for patients who want a reversible contraceptive method? If cost is removed as a barrier to contraception, are members who do not want to become pregnant moved toward more cost-effective contraceptive methods? By providing evidence-based medical information about today's IUDs to professionals and patients, can we increase use of this most cost-effective method of contraception? In 2002, the Kaiser Foundation Health Plan in California made a benefits change to cover the cost of the most cost-effective contraceptive methods, including IUDs, injectables, implantables (when available), and emergency contraception. This change was the result of years of advocacy work by committed physician-leaders in obstetrics/gynecol-ogy and adolescent health departments across both the Northern and the Southern California Kaiser Permanente (KP) Regions. Understanding the potential of IUDs for reducing the number of unintended pregnancies and understanding perceived nationwide attitudes about IUDs, a team of investigators designed a study hypothesizing that a clinician-focused intervention offering evidence-based medical information to physicians, nurse practitioners, staff, and patients would result in greater utilization of IUDs than would removing the cost of the IUD as a barrier to its use. A secondary goal of the study was to decrease the rate of tubal sterilizations, the most common form of contraception in the United States. Funding was sought and obtained through the assistance of the Women's Health Research Institute (WHRI), and the study was approved by the Kaiser Permanente Northern California Institutional Review Board.