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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