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INTRODUCTION
The intrauterine device (IUD) is an ideal postpartum
methodbecause it does not interfere with lactation, facilitates
adequatebirth spacing and does not require repeat health care
visits forcontraceptive refills. A recent committee opinion by
theAmerican College of Obstetricians and Gynecologists
(ACOG)recommends the IUD as a first-line choice for
adolescents.1Despite its potential benefits, the IUD remains
underused inthe United States by women of all age groups2and
research hasdemonstrated barriers for postpartum and
adolescentpopulations. A retrospective study found that only 60%
ofpostpartum women who requested an IUD obtained thedevice, waiting
an average of 60.5 days post-delivery forinsertion.3Providers may
limit IUD use among adolescents byciting concerns about infection,
expulsion, and infertility.4,5
The purpose of this research is to better understand barriers
toIUD uptake by postpartum adolescents. Through longitudinal
qualitative interviews, we identify factors that prevent, delay
orsupport uptake of the IUD among postpartum adolescentswho
expressed desire to obtain the IUD.
RESULTS
Twenty participants expressed desire for an IUD, almostalways in
the early postpartum period. Of these 20, twelve didnot receive an
IUD within the 12-month study period; three ofthese adolescents
experienced a repeat pregnancy.
Service level obstacles
For many, the health care system posed obstacles to IUDuptake.
Barriers included lack of insurance coverage, difficultyscheduling
appointments, limited clinic hours, referralrequirements, long wait
times, clinic closings, and lack ofprovider training. One
participant lacked Medicaid coverage at
her 6-week postpartum visit and used condoms instead;
sexperienced a repeat pregnancy. Several participants strugglwith
scheduling and attending appointments, often related juggling
multiple responsibilities as new parents. Despite beidissatisfied
with depot medroxyprogesterone acetate (DMPside effects, two
participants remained on the method becautheir providers were not
trained to insert IUDs.
Participants were informed of eligibility requirements
thprecluded them from obtaining an IUD. One was incorrectold by a
provider that she had to be 18 years old or haparental consent.
Another was denied an IUD because she ha sexually transmitted
infection (STI) at her 6-wepostpartum visit; she experienced a
repeat pregnancy aobtained an abortion. When she requested an IUD
poabortion she was told that she had to leave with the bir
control shot (DMPA).
Fears and Concerns
Participants
voiced multiple concerns about IUD-related sieffects, risks, and
procedures. Family members and frienwere very influential, with
older family members bei
Factors Influencing Uptake of Intrauterine Devices
among Postpartum Adolescents
Findings from the Postpartum
Adolescent Birth Control Study
November 2011
About Postpartum ABCs
The Postpartum Adolescent Birth Control Study
(Postpartum ABCs) is a longitudinal study of the lives
of first-time, African American adolescent mothers in
Chicago. Researchers interviewed mothers five times
during the first postpartum year to examine
contraceptive use, health status, social support, and
risk of repeat pregnancy. Transcribed interviews
were reviewed and coded with emergent themes
using Atlas.ti 5.0. For more information on the study,
visit familyplanning.uchicago.edu/ppabc.
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Our study notes that healthcare providers strongly influenceIUD
decision-making, sometimes preventing and at othertimes
facilitating device uptake. Other studies havedemonstrated provider
reluctance to use certain contraceptivemethods among urban
adolescents at risk of STIs.8A recentsurvey among adolescents and
young women with no historyof IUD use demonstrated that provider
counseling wasassociated with desire to use an IUD.9There is a
clear need for
additional training and education among clinicians as somemay
adhere to incorrect eligibility requirements (e.g. currentSTI
infection, age), lack experience with IUD insertion, and beunaware
of the benefits of IUDs for adolescents. Similarly,providers should
conduct more thorough counseling andeducation on the safety and
health benefits of the IUD withtheir adolescent patients.
Studies of pregnant adolescents show a lack of knowledge ofthe
safety and efficacy of the IUD compared to othermethods.10 The
significance of fears and misconceptionsshould not be
underestimated, as they prompted many of ourparticipants to choose
less effective methods. Our findings
suggest that discussing contraception with teens may not
beenough. Family members, peers, and even patient
educationmaterials can cause youth to focus on rare, serious side
effects.The role of male partners pregnancy desires was a new
findingthat undermined IUD uptake. Educational campaigns
andinterventions targeting postpartum adolescents network
ofinfluential people (e.g., family members, partners, and peers)may
be needed to shift general attitudes and knowledge ofIUDs. Future
research should identify the most effectivemessages and best
channels to deliver clear and balancedinformation about the
IUD.
Our study also revealed several facilitators to IUD use;
inparticular it shows how peers, partners and family memberscan
facilitate IUD adoption. In an older prospective study ofadolescent
Norplant users, almost half of the participantsreported that their
mothers significantly influenced theirdecision to initiate the
method.11While the literature oncondom negotiation among adolescent
dyads is robust, there isa scarcity of published data regarding
partner influence onhormonal birth control use, especially
long-acting reversiblecontraceptives. However, one recent survey
reveals perceivedpartner support to be an important predictor in
consistenthormonal method use among adolescent girls.12
Long-acting, reversible methods of contraception have shownto be
effective in preventing repeat pregnancy for adolescentmothers.
This qualitative research provides new insights as towhy
adolescents at high risk of rapid repeat pregnancy whodesire the
IUD may or may not initiate the method.
References
1. ACOG Committee Opinion No. 392, December 2007.
Intrauterine
device and adolescents. Obstet Gynecol. Dec 2007;110:1493-5.
2. Trussell J, Wynn LL. Reducing unintended pregnancy in the
United
States. Contraception. 2008;77:1-5.
3. Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine
device
insertion in postpartum women. Contraception. 2005;72:426-9.
4. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in
translating
evidence to practice: the provision of intrauterine
contraception. Obstet
Gynecol.2008;111:1359-69.5. Stanwood NL, Garrett JM, Konrad TR.
Obstetrician-gynecologists and
the intrauterine device: a survey of attitudes and practice.
Obstet Gynecol.
2002;99:275-80.
6. Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood
NL.
Immediate post-partum insertion of intrauterine devices.
Cochrane
Database Syst Rev. 2010:CD003036.
7. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK,
Creinin
MD. Postplacental or delayed insertion of the levonorgestrel
intrauterin
device after vaginal delivery: a randomized controlled trial.
Obstet Gynec
2010;116:1079-87.
8. Gilliam ML, Hernandez M. Providing contraceptive care to
low-income
African American teens: the experience of urban community
health
centers.J Community Health. 2007;32:231-44.9. Fleming KL,
Sokoloff A, Raine TR. Attitudes and beliefs about the
intrauterine device among teenagers and young women.
Contraception.
2010;82:178-82.
10. Stanwood NL, Bradley KA. Young pregnant women's knowledge
of
modern intrauterine devices. Obstet Gynecol. Dec
2006;108:1417-22.
11.Rickert VI, Hendon AE, Davis P, Kozlowski KJ. Maternal
influence on
the decision to adopt Norplant.J Adolesc Health.
1995;16:354-9.
12. Kenyon DB, Sieving RE, Jerstad SJ, Pettingell SL, Skay CL.
Individua
interpersonal, and relationship factors predicting hormonal and
condom
use consistency among adolescent girls.J Pediatr Health
Care.
2010;24:241-9.
This research brief was compiled by staff from the Section of
Family Planning and
Contraceptive Research at the University of Chicago. Funding was
provided by the
Eunice Kennedy Shriver National Institute of Child Health and
Human Developm
(grant no. 5K23-HD042614-02).
Suggested Citation: Factors Influencing the Uptake of
Intrauterine Devices amo
Postpartum Adolescents. Chicago: Section of Family Planning and
Contracep
Research, The University of Chicago (2011). Available at:
http://familyplanning.uchicago.edu/research/studies-by-topic/postpartum-
abcs/IUD.pdf.
This brief was adapted from the published article:
Weston MR, Martins SL, Neustadt AB, Gilliam ML. Factors
influencing the uptak
intrauterine devices among postpartum adolescents: a qualitative
study. Am J Ob
Gynecol. Jul 13 2011.
