Gaps in knowledge and training may prevent U.S. family physicians from offering IUDs to eligible patients.1 In a sample of 869 family physicians, only 24% had inserted an IUD in the previous year. Those who had were more knowledgeable about the method, more comfortable discussing it and more likely to believe their patients are receptive to discussing it than were their counterparts who had not recently inserted an IUD. The likelihood of providing the method rose with the number of IUDs physicians had inserted in their residency.
The data come from a self-administered survey conducted in 2008 among a random sample of 3,500 family physicians, drawn from the American Medical Association’s database of all U.S. physicians. Respondents were asked to provide demographic information; data on training and current provision of reproductive health services; and information on their knowledge, attitudes and experience regarding IUDs. Twenty-five percent of providers invited to participate returned valid surveys.
Respondents were primarily male (61%) and had completed their residency a mean of 14.8 years earlier. During their residency, 39% had inserted no IUDs, 38% had inserted 1–9 and 24% had inserted 10 or more. Physicians reported that 34% of their patients in an average week were of reproductive age; they provided Pap tests to 51% of those women and discussed contraception with 53%. Overall, 24% had inserted an IUD in the previous 12 months. In a bivariate analysis, those who had and had not provided the method differed significantly in some aspects of their practices: Compared with noninserters, inserters reported a higher proportion of their patients to be reproductive-age women (41% vs. 31%), and they performed Pap tests and discussed contraception with higher proportions of those women (68% vs. 45% and 68% vs. 48%, respectively).
Physicians who had inserted an IUD in the previous year displayed more positive beliefs about and accurate knowledge of IUDs than their peers who had not provided the method in that period. Higher proportions of inserters than of noninserters reported being comfortable discussing the method (96% vs. 79%), felt their patients were receptive to discussing it (89% vs. 55%) and felt the method was safe (97% vs. 86%). Compared with noninserters, inserters rated the method as more effective (mean, 1.1 vs. 1.3 on a four-point scale on which lower scores indicate greater effectiveness) and displayed greater knowledge about the IUD (3.3 vs. 2.8 on a four-point scale). They also scored higher on a five-point scale on which higher scores correspond to a greater likelihood of recommending the method in different scenarios, none of which precluded use (2.7 vs. 2.3).
In a multivariate analysis controlling for all variables that were significant in the bivariate analysis, having inserted an IUD in the previous 12 months was positively associated with being comfortable discussing the method (adjusted odds ratio, 2.4), believing patients to be receptive to discussing IUDs (3.0) and having greater knowledge about the method (1.9). The likelihood of recent insertion increased with the number of IUDs inserted in residency (1.4).
The researchers note that the IUD is a "user independent, highly reliable, safe, and cost-effective" method of contraception with great potential to decrease unintended pregnancy rates; yet, IUDs account for only 5% of contraceptive use in the United States. Despite limitations to this study that include a low response rate and possible sources of bias, the researchers believe the data indicate that underuse of the method can be remedied by modifying physicians’ approach to provision. Specifically, they recommend improving IUD-related education and insertion training among doctors in residency, as well as targeting such interventions to family physicians who already provide reproductive health services.—H. Ball