Taking the provider "out of the loop:" patients' and physicians' perspectives about IUD self-removal

Taking matters into our own hands? Hierarchies of power and knowledge in online framings of IUD self-removal

This article examines how intrauterine device (IUD) self-removal is framed in online sources containing the views of contraceptive providers. While research has explored power and knowledge hierarchies in clinical interactions between contraceptive users and providers, and has highlighted the safety of IUD self-removal, little is known about how self-removal is represented by providers in accessible online sources that may be relied upon by contraceptive users for information. A discourse analysis of 42 provider-generated online sources found that provider authority over contraception is reinforced through biomedical constructions of risk and safety in framings of self-removal. The data reveal how the sharing of self-removal experiences between IUD users via online platforms was perceived to threaten contraceptive provider expertise, resulting in the dismissal of users' experiential knowledge. While some sources were supportive, the framings of self-removal discussed in this paper typically mirror the unequal power relations of in-person contraceptive user/provider interactions. The sources analysed therefore demonstrate how power and knowledge hierarchies are reproduced and extend beyond clinical interactions to the digital context, reflecting broader socio-structural controls over bodies, knowledge, and reproductive decision-making.

Social Determinants of Health and Patient-Reported Difficult Discontinuation of Long-Acting Reversible Contraception

Background: Some individuals who receive long-acting reversible contraception (LARC) face barriers to discontinuation. The inability to discontinue a contraceptive method when desired negatively impacts a person's reproductive autonomy. Persons impacted by social determinants of health (SDH) may be disproportionately affected. The objective of this study is to evaluate the association of SDH with patient-reported difficult LARC discontinuation. Methods: A retrospective cross-sectional analysis of data from the 2017-2019 cycle of the National Survey of Family Growth was conducted. The main outcome was patient-reported difficulty discontinuing a LARC method (intrauterine device or implant) in the last 10 years. Descriptive statistics were used to identify demographic characteristics and SDH domains. Multivariable logistic regression models were used to estimate associations across SDH domains with difficult LARC removal. Results: A total of 754 respondents reported wanting to have their LARC removed, and 105 (11%) reported difficulty discontinuing LARC methods. One-third of respondents experienced one or more SDH, notably food insecurity (26%) or transportation barriers (30%). After adjusting for age, race, education, geographic location, parity, and body mass index (BMI), persons with one or more SDH had an increased adjusted odds ratio (aOR) for difficultly discontinuing LARCs compared with respondents without any SDH (2.11; 95% confidence interval [CI]: 1.21, 3.69). Transportation barriers demonstrated the largest aOR of 2.90 (95% CI: 1.07, 7.87). Conclusions: SDH are associated with challenges to LARC discontinuation. SDH are unique risk factors that can impact one's entire contraceptive experience. A nuanced discussion of SDH at the time of contraceptive counseling may be a critical step in addressing the intersectionality of method selection and reproductive agency.

IUD self-removal: A randomized controlled trial of a self-removal guide in clinical and nonclinical settings

OBJECTIVES

Intrauterine device (IUD) users often encounter barriers to desired removal. Self-removal, while previously found to be successful only 19% of the time, may mitigate these obstacles. Our primary objective was to evaluate the effectiveness of our previously developed IUD self-removal guide. Our secondary objectives were to evaluate the acceptability of the guide and characterize the self-removal process. STUDY DESIGN: This was a randomized controlled trial comparing IUD self-removal success rates with and without a guide. Participants selected a clinical or nonclinical setting for self-removal. The primary outcome was the rate of successful IUD self-removal. Covariates of interest included demographic characteristics, parity, body mass index, and attempted removal setting.

RESULTS

Of the 116 participants, 35 (30%) successfully removed their IUDs, 20 (32%) randomized to the guide, and 15 (28%) randomized to no guide (p = 0.7). While our guide was not associated with increased successful self-removal, the majority (97%) of those randomized to it reported it to be helpful. Those who selected a nonclinical setting (80%) were more successful at self-removal (35% vs 9%, p = 0.01). Most participants would recommend IUD self-removal to a friend (68%) and attempt again with a future IUD (80%).

CONCLUSIONS

The proportion of participants who successfully removed their IUDs was higher than previously shown, with or without the use of our guide. Our inclusion of a nonclinical setting was novel, in which the proportion of successful self-removal was significantly higher. Providers should consider discussion of IUD self-removal, with a reasonable expectation about the likelihood of success, as a means of increasing reproductive autonomy.

IMPLICATIONS

IUD self-removal was feasible and acceptable.

Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics

OBJECTIVES

To explore the prevalence of intrauterine device self-removal practices before and during the COVID-19 pandemic among family planning clinics.

STUDY DESIGN

This is a secondary analysis of data from a descriptive, longitudinal study using a clinic-based convenience sample from the Abortion Clinical Research Network assessing baseline and pandemic-adaptive family planning practices.

RESULTS

Of the 63 sites that provided contraception, 5 (7.9%) reported providing guidance on intrauterine device self-removal at baseline. Sixteen sites (25.4%) provided guidance on self-removal by the end of the study period. Self-removal counseling was associated with being an academic center and reporting a median lower number of monthly contraceptive encounters.

CONCLUSIONS

Endorsement of IUD self-removal increased to one-quarter of sites by the final timepoint.

IMPLICATIONS

Twenty-five percent of family planning clinics reported provision of intrauterine device self-removal guidance by eight months into the COVID-19 pandemic, a three-fold increase from baseline; these findings suggest clinician support for patient autonomy in contraceptive self-management and limited concern for safety issues with self-removal during a public health emergency.

Recap of the sixth international symposium on intrauterine devices and systems for women's health

Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.

Uterine Artery Rupture Caused by IUD Extraction: A Case Report

It’s been 100 years since the first intrauterine device (IUD) was invented in Germany in 1920. IUDS are widely favored by women of childbearing age for their efficiency, convenience, cheapness, and variety of materials. According to incomplete statistics, about 26 million people worldwide will need to have their IUDS removed from 2015 to 2025 alone. With such a large case base, we have to pay attention to the safety of IUD removal. There are few international guidelines on IUD placement and removal. Therefore, this paper will report a case of uterine artery rupture caused by ring removal, and discuss the important steps of ring removal surgery, so as to enhance the attention of physicians to the standard and safety of ring removal and improve the quality of medical treatment.

Developing an intrauterine device self-removal guide: a mixed methods qualitative and small pilot study

Background

The intrauterine device (IUD) is a highly effective form of long-acting reversible contraception (LARC) with few contraindications. Users, however, often encounter barriers to desired removal. IUD self-removal may mitigate these obstacles. We sought to develop a guide for IUD self-removal with the aim of increasing user control over the method.

Methods

This was a two-phase mixed-methods qualitative and small pilot study with the aim of developing an IUD self-removal guide. We conducted an online content analysis of advice for IUD self-removal as well as interviews with expert key informants to develop an IUD self-removal guide. We next recruited IUD-users who had previously attempted self-removal to participate in focus group discussion and individual interviews to further refine the guide. In the second phase of the study, we piloted the guide among eight IUD-users seeking removal interested in attempting self-removal.

Results

Expert key informants agreed that IUD self-removal was safe and low risk. The primary components of successful IUD self-removal elicited were ability to feel and grasp the strings, a crouched down position, and multiple attempts. A preference for presenting IUD self-removal as safe was emphasized. In the second phase, participants in the clinical pilot suggested more information for non-palpable strings, but liked the style and information provided. One participant successfully removed their IUD.

Conclusions

IUD-users reported satisfaction with our guide. In our small pilot, the majority were unable to remove their own IUD. A larger study is needed to assess acceptability, feasibility, and efficacy in increasing successful self-removal.

Comparing perceptions of long-acting reversible contraception among women during periods of incarceration and women attending a local clinic; an exploratory study

OBJECTIVES

The objective of this study was to understand perceptions of long-acting reversible contraception (LARC) among incarcerated women. We compared survey responses specific to IUDs and implants between a convenience sample of incarcerated women to a sample of women attending a local ob/gyn clinic.

STUDY DESIGN

We conducted a cross-sectional survey among two groups: (1) incarcerated women receiving medical care at the state correctional facility, and (2) women receiving care at an ob/gyn clinic in the same community. The anonymous survey included questions about demographic variables, current and past contraceptive use, and perception of IUDs and implants.

RESULTS

Almost half of the total sample stated that they might consider an IUD or implant for contraception. Incarcerated women tended to be less likely to give an affirmative answer to current or future use of an IUD or implant (29% vs 39%, p=0.19). Concerns about pain and side effects were similar between the groups, but more incarcerated women cited concerns about device removal (72% vs 57%, p=0.02) and the level of training of the provider inserting the device (68% vs 53%, p=0.02). Incarcerated women interested in using the IUD or implant were more comfortable with device placement in the community than in the correctional setting (42% to 30%, p<0.001).

CONCLUSIONS

Incarcerated women have concerns about LARC that may be specific to their experience of incarceration. Providers working with incarcerated women should consider these when counseling patients on contraceptive choices. Options for post-release follow-up care and device removal should be included in this discussion.

The limitations of patient-centered care: The case of early long-acting reversible contraception (LARC) removal

Patient-centered care (PCC) is frequently recommended to improve healthcare outcomes in the United States. Despite its purported benefits, little research explores how and to what extent providers implement this model in their care. We examine such processes through the case of contraception, specifically, "early" removals of long-acting reversible contraception (LARC). In-depth interviews with 51 healthcare providers reveal that while providers describe embracing patient-centeredness when considering patients' early LARC removal requests, their implementation ironically sidelines patient preferences and needs. Rather than be responsive to patients' requests, all providers in the study resist early LARC removal by: withholding information about self-removal of intrauterine devices (IUDs); negotiating with patients to keep their device longer; setting subjective timelines to prolong LARC use; and/or engaging in delay tactics to wear down patients' resolve for removal. Furthermore, beyond simply resisting LARC removal requests using these strategies, providers purposively employ tenets of PCC to sway patients away from removal. In other words, providers utilize PCC as a means to undermine it. Understanding how providers implement patient-centered care reveals the challenges to doing so, even in cases like early LARC removal where providers indicate patient-centeredness is a priority. It also elucidates the need for enhanced training, specificity, and institutionalization around patient-centered models of care; informs interventions that promote LARC use among patients; as well as offers opportunities for improving patient-provider exchanges generally.

Exploring the experience of IUD self-removal in the United States through posts on internet forums

OBJECTIVE

Some intrauterine devices (IUD) users self-remove their IUDs, and these experiences are not well understood. This study examines what IUD users post in internet forums about their experience, as well as advice and questions shared among IUD users about self-removal.

METHODS

This study uses qualitative analysis of internet health and parenting forum postings about IUD self-removal identified from an internet search engine. We analyzed the data using inductive and deductive content analyses.

RESULTS

Twenty-eight sites, containing 1742 posts by 1197 unique users, satisfied our eligibility criteria. Users reported successful IUD self-removal attempts as "quick," "easy," and "painless"; it was rare to encounter IUD users describing complications of their self-removal attempts. Users described unsuccessful attempts as failure to find or grasp strings. Many IUD users described their successful removal techniques and gave advice to other users who were struggling with self-removal. Users frequently utilized the forum to ask questions about IUD self-removal methods and timing, pain, when to seek medical intervention, and the effects on future fertility.

CONCLUSIONS

Posts describing successful IUD self-removal report positive experiences. IUD users who have difficulty with self-removal may utilize internet forums to learn from others' experiences.

IMPLICATIONS

Exploring IUD users' experiences with and questions about self-removal may inform strategies to develop better resources for those who desire self-removal.

Long-Acting Reversible Contraception: Placement, Continuation, and Removal Rates at an Inner-City Academic Medical Center Clinic

Long-Acting Reversible Contraception (LARCs) has the potential to decrease unintended pregnancies but only if women can easily access a requested method. Retrospective electronic chart review identified women desiring LARC placement over a one-year period ending 31 December 2016. Most of the 311 insertions were for family planning, with 220 new insertions and 60 replacements. Delays occurred in 38% (n = 118) of patients, averaged 5 ± 5 weeks, and 47% received interval contraception. Reasons included absence of qualified provider (n = 44, 37%), pending cultures (n = 31, 26%), and Mirena availability. Teenage LARC use favored Nexplanon whereas older women preferred Mirena (p < 0.01). Of the 11% choosing early LARC removal, a significant number were African Americans (p = 0.040) or teenagers (p = 0.048). Retention time varied by device type; most patients switched to other contraceptives. No patients experienced IUD expulsion. Understanding barriers, attempting to remedy them, and addressing the side effects associated with LARC use is of importance in this inner-city patient population in the United States.