Women in many countries are far from taking full advantage of modern intrauterine
devices (IUDs), which are among the safest and most effective contraceptives available.
Many women, for whom the IUD could be the ideal method, are using alternatives that are
less convenient and may not be as safe.
A negative opinion toward IUDs among potential users and providers alike, based upon
misconceptions or lack of current scientific information, is a major obstacle to IUD use.
To be sure, many countries also have limitations within their health systems that make
them poorly prepared to offer sufficient IUD services. Another serious obstacle in some
countries is a lack of trained providers to handle IUD insertion and management. Adverse
public opinion and the consequent weak social acceptance of this excellent method,
however, are fundamental obstacles worldwide.
Uninformed opinions about IUDs can result in negative messages to potential users, thus
reducing demand, and may discourage providers from offering the method. Negative messages
also affect policy-makers, who will not provide the political support required for
adequate supply of the method. As scientists, health-care providers and policy-makers, we
have a solemn responsibility to help create the climate for a better-informed public
opinion.
Scientists must play a vital role in correcting these misconceptions. It is obvious that
researchers should report their findings without hiding any relevant information. The
problem is that the public often does not comprehend the nuances of scientific data and is
slow to understand that what seemed true yesterday may not be so today.
One example of this can be seen in the incorrect perceptions about safety, especially
regarding the risks of pelvic inflammatory disease (PID) and ectopic pregnancy. Early
reports of high PID risk, largely influenced by the Dalkon shield, remain in the public's
mind. The Dalkon shield was discontinued more than 20 years ago, in 1975. In reality,
research has shown there is no increased risk of PID among women in monogamous
relationships using today's IUDs, but this finding has not been widely disseminated.
We have not been able to correct the wrong message and let the public know that the risk
of PID depends more on the sexual behavior of the user or her partner than on the IUD, and
that appropriate counseling, client selection, and IUD insertion technique should prevent
complications. The result of our failure is that many women still believe that any IUD is
a dangerous method to use, independent of their sexual behavior and of the quality of the
services provided by the clinic.
Similarly, epidemiological analysis clearly shows that users of modern IUDs are at low
risk of ectopic pregnancy, yet clinicians and the general public alike are often poorly
informed about this risk.
Statements on efficacy can be misleading. It may be hard for the public to understand the
meaning of published IUD pregnancy rates of 1 to 6 percent a year. Many people may not
realize that rates as high as 6 percent correspond to old inert IUD models and to specific
subsamples of younger women. In addition, those figures do not reflect the pregnancy rates
of the newer copper IUDs, which have consistently been below 1 percent per year, even
among women under age 30.
The lack of updated information on IUD effectiveness explains the commonly held, but
incorrect, opinion that pills are more effective than IUDs in everyday practice. This is
far from the reality in developing countries. Consequently, women for whom avoiding
pregnancy is a very important issue are often discouraged from using the IUD, since they
wrongly view it as a less effective method.
Another example of how misconceptions discourage use involves the IUD's mechanism of
action. Decades ago, it was found that an intrauterine foreign body did not prevent
fertilization in several species of rodents, and there were clear indications that
implantation of the fertilized egg was prevented. From that information, it was
incorrectly concluded that the mechanism of action of IUDs in women was the same. The lack
of evidence that fertilization occurred during IUD use in humans and other primates did
not change that concept. More recent studies have demonstrated mechanisms of action in
women that clearly precede and prevent fertilization.
In countries where there is a strong religious or political rejection of abortion, this
kind of misconception has a dramatic impact, since preventing implantation of a fertilized
egg has been defined by some as interruption of pregnancy. Our current understanding of
the mechanism of action for copper IUDs indicates that the primary mechanism is the
prevention of fertilization.
Women deserve accurate information about all methods to make well-informed choices about
their contraceptive use. Our current knowledge shows clearly that IUDs are safe, highly
effective, affordable and convenient to use, provided they are offered by high-quality
service delivery units. In many countries, however, use of this method is being
discouraged by incorrect perceptions about its safety, effectiveness and mechanism of
action.
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