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Original research article

Intrauterine contraception: attitudes, practice, and knowledge among Swedish health care providers☆,☆☆ Matilda Ekelund 1 , Marielle Melander 1 , Kristina Gemzell-Danielsson⁎ Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden Received 24 September 2013; revised 10 December 2013; accepted 23 December 2013

Abstract Objectives: Intrauterine contraception (IUC) is safe and highly effective, but its use remains low. Previous studies have shown that knowledge of IUC among health care providers (HCPs) is poor and that IUC is recommended to a very limited group of women. This study sought to investigate attitudes, practices and knowledge regarding IUC among Swedish HCPs. Study design: A pretested, national Web survey was emailed to 1157 HCPs who provide contraceptive counseling in Sweden. The collected data were transferred to IBM SPSS Statistics 20 and analyzed using χ 2 test, Fisher’s Exact Test, Student’s t test, and Kendall's tau-b, as appropriate. Results: A total of 692 individuals (471 midwives and 221 gynecologists) answered the survey, resulting in a response rate of 60%. Younger HCPs and HCPs who performed a large number of IUC insertions considered the method applicable for a broad spectrum of women. Fewer than 30% considered IUC an option for younger women, women with a previous ectopic pregnancy or women with pelvic inflammatory disease. During insertion, 24% of the gynecologists and 15% of the midwives used analgesia in the form of paracetamol or nonsteroidal antiinflammatory drug, transcutaneous electrical nerve stimulation, hot water bottles or misoprostol for cervical ripening. HCPs at workplaces with guidelines for the insertion procedure were more likely to use analgesia and misoprostol. HCPs who performed a large number of insertions per month reported a greater use of analgesia and misoprostol (pb.01). Conclusion: Swedish gynecologists and midwives do not always adhere to scientific evidence and follow existing guidelines with regard to IUC. Efforts are needed to increase the number of HCPs offering IUC, especially to young and nulliparous women. Implications: Greater educational efforts are needed to counter reluctance among HCPs toward using IUC, especially in young and nulliparous women. © 2014 Elsevier Inc. All rights reserved. Keywords: Insertion; Facilitating interventions; Analgesia; Nulliparous

1. Introduction Intrauterine contraception (IUC) is safe and highly effective, but its use in Sweden is relatively low, especially among young, nulliparous women [1]. Still, the relatively high number of unwanted pregnancies and induced abortion rate [2,3] indicates an unmet need for effective contracep☆ Funding: supported by grants from the Stockholm County Council (ALF project) and Karolinska Institutet, Stockholm, Sweden. ☆☆ None of the authors have any conflicts of interest. ⁎ Corresponding author. Kristina Gemzell-Danielsson WHO-centre, C1:05 Karolinska University Hospital SE-171 76 Stockholm Sweden. Tel.: +46 8 517 72128 (or − 79539). E-mail address: [email protected] (K. Gemzell-Danielsson). 1 Equal contribution.

0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2013.12.014

tion. Previous international studies have shown that health care providers (HCPs) have recommended IUC to a very limited population of women [4–8] and have often exaggerated the side effects of the method [4,5,7]. The prevalence of IUC use in Europe is approximately 12% [9]. The typical woman who uses IUC is 38 years old, married or living with a partner, and has 1.38 children [10]. Despite international guidelines encouraging that national records be kept of contraceptive use [2], no such recordkeeping exists in Sweden. The most recent countrywide investigation was carried out in 1996 and showed the use of IUC to be 3% among women 19 to 24 years old compared to 23% among women ages 35 to 39 [11]. The fact that older women tend to be the ones who use IUC may also be seen in the 2010 sales figures for the levonorgestrel-releasing

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intrauterine system (LNG-IUS): 9 prescriptions per 1000 were written for women 20 to 25 years old compared to 38 per 1000 for women 35 to 39 years old [12]. A Swedish study showed that not only is the use of IUC low among young women, but that nulliparous women used them less frequently than parous women [13]. According to the World Health Organization’s medical eligibility criteria for contraceptive use, IUC may be recommended to women regardless of age. Neither prior pelvic inflammatory disease (PID) nor previous ectopic pregnancy precludes the use of IUC [14]. Nevertheless, consistent research findings indicate that only a minority of contraception prescribers considered nulliparous women [4,5], teenagers [5,8] and women with a known history of PID [4,7,8] or ectopic pregnancy [5] to be suitable candidates for IUC. The anticipation of pain and the technical difficulties during IUC insertion are suspected to be contributing factors for prescribers’ reluctance to recommend IUC [15]. Analgesia, such as paracetamol and nonsteroidal anti-inflammatory drug (NSAID), transcutaneous electrical nerve stimulation (TENS), paracervical block (PCB) and lidocaine gel/spray are frequently used, despite the lack of scientific evidence for their clinical efficacy [16]. In Sweden, contraceptive counseling and prescribing of contraceptives are mainly performed by two professional groups: gynecologists and midwives. The latter are nurses with an additional 1.5 years of training in sexual and reproductive health. They are responsible for three quarters of all contraceptive prescriptions [17]. Family physicians in Sweden generally do not prescribe contraceptives or insert intrauterine devices (IUDs). The purpose of our study was to investigate the attitudes and knowledge Swedish gynecologists and midwives have regarding IUC and explore their use of prophylactic analgesia and facilitating interventions at IUC insertion.

2. Materials and methods An online questionnaire was sent to 1157 HCPs in Sweden. Inclusion criteria for study participation were an occupation as a gynecologist or midwife actively involved with contraceptive counseling and provision. Participants were recruited through contact with county councils, youth clinics, midwifery clinics, operations managers for women’s clinics, coordinating midwives, the Swedish Midwifery Association, the Swedish Society for Obstetrics and Gynecology and the Association of Swedish Youth Clinics. The study was approved by the local ethics review board at Karolinska Institutet. Prior to the study’s inception, the survey instrument was tested twice: first on a group of midwives at the Sexual and Reproductive Health Clinic, Karolinska University Hospital, Stockholm, and then on medical students at Karolinska Institutet. An email containing the questionnaire and a description of the study was distributed to 1325 midwives and

gynecologists in October 2011. The survey period extended over 3 weeks. Two reminders were sent out at weekly intervals to those who had not responded by the end of the first week. The questionnaire comprised 27 questions and had an estimated total response time of 10 min. Except for the last question, which was an open comment field, the survey contained single-option and multi-item questions. Each HCP was asked to estimate the frequency of side effects caused by IUC on a three-point scale representing low, moderate or high. The first part of the questionnaire sought to identify the participant’s demographic characteristics. The next part explored prescribing habits, i.e., which contraceptive methods were most often recommended for different groups of women and to whom the HCP was willing to recommend IUC. Respondents were also asked about the use of analgesia such as paracetamol, NSAIDs, application of local lidocaine gel or PCB, pain relief with TENS and hot water bottles, or cervical ripening with misoprostol. The collected data were transferred to IBM SPSS Statistics 20 and analyzed by that program. The χ 2 test was used for analysis of nominal variables and comparison between groups. In cases where the sample group was too small, the difference between groups was calculated using Fisher’s Exact Test. For numerical tests, such as age and number of insertions per month, Student’s t test and Kendall’s tau-b were used as appropriate. A p value b .05 was considered statistically significant. 3. Results Of the 1325 emails sent out, 137 were returned as undeliverable, and 41 responding HCPs were excluded because they reported that they were not currently prescribing contraceptives. Of the 1157 HCPs who were included in the study, 692 completed the survey, for a response rate of 60%. A majority of the participants were midwives between 51 and 60 years old (Table 1). The gynecologists were mostly less than 40 years old. The HCPs said that 92% of them performed IUC insertions; 96% of the gynecologists reported performing them; and 90% of the midwives also reported that they did so, which represented p=.01. Of the HCPs, 96% believed that their patients using IUC were satisfied with the method. Our data showed that women usually volunteered their preferred contraceptive method, except for IUDs, which were more often suggested by an HCP. 3.1. Recommended contraceptives in general and for specific patient scenarios HCPs were presented with nine redundant patient scenarios and asked whether they considered IUC appropriate in each case. Only a minority of the participants said that women below age 17, those women with prior PID or women who had had an ectopic pregnancy were appropriate

M. Ekelund et al. / Contraception xx (2014) xxx–xxx Table 1 Demographic data for health care providers participating in study (N=692) Profession Midwife Gynecologist Sex Female Male Age, years ≤ 40 41–50 51–60 N 60 Number of years in practice b5 5–15 16–30 N 30 Practice a Midwifery clinic Women’s clinic Youth clinic Outpatient care/health clinic Other Inserts IUD Yes No Number of insertions per month b b1 1–5 6–10 N 10 a b

n (%) 471 (68) 221 (32) 468 (99) 3 (1) 80 (17) 136 (29) 196 (42) 59 (12) 50 (10) 111 (24) 192 (41) 118 (25) 354 (75) 65 (14) 101 (21) 27 (6) 20 (4) 633 (92) 59 (8) 97 (14) 339 (49) 150 (22) 43 (6)

Multiple options possible. Among those inserting IUD.

candidates for IUC (Table 2). The most commonly recommended method of birth control for all scenarios was oral contraception (OC), except for women not in a

Table 2 Percentage of health care providers considering IUC appropriate for various populations Population

n (%) considering IUC appropriate

Percentage recommending IUC as first choice

Most commonly recommended contraceptive (%)

Women ≤17 years Women 18–23 years Women 24–29 years Women ≥30 years Women with previous PID Women planning pregnancy within 2–3 years Women with previous ectopic pregnancy Women, nulliparous Women without a monogamous relationship

173 (25) 421 (61) 590 (85) 652 (94) 186 (27) 550 (80)

0 b1 12 54

OC (69) OC (79) OC (67) IUC (54)

218 (32) 440 (64) 360 (52)

2 2

Double Dutch: condom+other contraceptive.

OC (78) Double Dutch (44)

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monogamous relationship, for whom the “double Dutch” (OC and condom) was most commonly recommended, and for women over 30 years of age, the only group for whom an IUD was suggested as the option of choice (Table 2). 3.2. IUC insertion; pain, analgesics and cervical ripening Most HCPs considered the risk for pain during IUC insertion as moderate for LNG-IUS (n= 448, 65%) and the copper intrauterine device (Cu-IUD) (n= 419, 61%). Of the HCPs, 10% (n= 70) considered the risk for pain high for LNG-IUS, and 9% (n= 60) thought the same for the Cu-IUD. The HCPs who estimated the risk for pain as high during IUC insertion more commonly used prophylactic analgesia compared to those who estimated pain as moderate or low. Gynecologists recommended pretreatment less often than midwives (pb.01). A minority of the HCPs reported the use of some kind of analgesia, such as paracetamol, NSAIDs, the application of local lidocaine gel or PCB, TENS, hot water bottles or misoprostol, during IUC insertion (Table 3). Of those HCPs who estimated the pain at IUC insertion as high, 36% stated that they did not consider the use of analgesia TENS, hot water bottles or misoprostol necessary. However, 31% reported using locally applied lidocaine. Gynecologists reported a significantly higher use of medical interventions (lidocaine, misoprostol, PCB) than midwives (24% to 15%, respectively) (p b. 01). Only 2% of the midwives and 1% of gynecologists believed that no effective pain-relieving method for IUC insertion existed. HCPs working at clinics where guidelines for IUC insertion procedures were available used analgesia and cervical ripening with misoprostol to a larger extent than HCPs working in clinics having no such guidelines (p=.01). The exceptions were PCB, which was commonly used where no guidelines existed, and a heating pad or hot water bottle, although no difference was reported when the latter was used. 3.3. Risk perception of complications Most participants considered the risk for PID to be low among IUC users. This was especially true of to the LNGIUS (n= 563, 81%) compared to the Cu-IUD (n= 451, 65%). A majority also believed the risk for ectopic pregnancy to be low for LNG-IUS (n= 649, 94%) and Cu-IUD (n= 547, 79%). 3.4. Provider characteristics Some characteristics were associated with HCPs who had a more liberal view of IUC provision. In general, younger HCPs who had fewer years of practice but who commonly performed more IUC insertions per month considered all of the women they saw in their practice as candidates for IUC. No significant difference was seen in comparing female and male HCPs. Gynecologists recommended IUD as their first choice more often than midwives (pb.05). Significantly more often than midwives, gynecologists also considered IUDs suitable for women older than 30 years (p=.03), those with a previous PID (pb.01) or ectopic pregnancy (pb.01), and

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Table 3 Use of analgesia and misoprostol by health care provider for cervical ripening during IUD insertion

Prophylactic analgesia

Analgesia and cervical ripening during insertion

Paracetamol NSAID+paracetamol Other Does not recommend prophylaxis Xylocaine gel/spray PCB Misoprostol TENS Warm pad, hot water bottle Does not use any of these methods

women who were not in a monogamous relationship (p=.03). Among HCPs who performed a large number of insertions per month, a greater use of analgesia and cervical ripening with misoprostol was reported (pb.01). 4. Discussion 4.1. IUC candidates for general and specific scenarios In our survey, only a small percentage of Swedish HCPs actively involved in contraceptive counseling and prescribing regarded younger women, nulliparous women and women with previous ectopic pregnancy or PID as appropriate candidates for IUC. This is in spite of WHO´s evidence-based eligibility criteria and local guidelines stating the opposite [14,17]. HCPs were more likely to recommend an IUC as a woman's age increased, suggesting their discomfort in considering younger women equally suitable for IUC as older women. Our findings in this regard agree with previous studies in other settings [5,6,8]. By contrast to the practice of the majority of HCPs surveyed, recent studies have shown that IUC is a good choice for young women [18] and that women b 20 years of age are not more likely to discontinue IUC than older women [19]. The supposedly increased risk for sexually transmitted infections among younger women has been shown to be one reason why young women are not as likely to be recommended IUC as older women [5]. By way of confirmation, 40% of the HCPs in our study would not recommend IUC to a woman unless she was in a monogamous relationship. Additionally, our study shows that, in contrast to other contraceptives, when IUC is chosen, it is more often the woman who suggests this method rather than the HCP. Young women in Sweden receive information about contraception from peers who are most likely to be taking OC [20,21] and who have been shown to have a poor knowledge of IUC [22,23]. This new generation of young women are, therefore, less likely to ask for IUC when consulting with midwives or gynecologists. Adolescents prefer long-acting, reversible contraceptives. Since they rely on HCPs to provide them with complete and accurate

Midwives (%) 314 (67)

Gynecologists (%) 129 (58)

182 (39) 78 (17) 38 (8) 32 (7) 106 (23) 4 (b1) 53 (11) 64 (14) 38 (8) 223 (47)

50 (23) 32 (14) 9 (4) 74 (33) 19 (9) 45 (20) 62 (28) 2 (b 1) 9 (4) 112 (51)

232 (34) 110 (16) 47 (7) 106 (15) 125 (18) 49 (7) 115 (17) 66 (10) 47 (7) 335 (48)

information [24], prescribers should openly discuss IUC with such women, especially young women, in order to increase the use of IUC and reduce the rate of unintended pregnancies which is highest in this age group. Another reason given for the restrictive prescription of IUC has been the fear of subsequent infertility [5,25]. However, a majority of the participants in our study continue to recommend IUC to women who wish to become pregnant within a few years; fear of infertility after IUC use does not seem to be an issue for Swedish HCPs. It also indicates that prescribers do not consider it wasteful if an IUC with a possible effective lifespan of 5 years is used for a shorter time. This is in agreement with health economic calculations demonstrating that IUC is cost effective even if used for a limited period [26]. 4.2. IUC insertion: pain, analgesics and cervical ripening One identified obstacle to IUC use is the insertion procedure, which has been shown to be difficult in certain cases and to some extent painful for most women [27,28]. A majority of the participants in our study stated that the pain accompanying IUC insertion was moderate, highlighting the need for effective pain relief. The most common recommendation for prophylactic pain relief was NSAID, followed by paracetamol, although both methods lack evidence to support their short-term analgesic effect during IUC insertion [29,30]. Similarly, there is no scientific recommendation regarding use of analgesia and cervical ripening during IUC insertion [16]. These factors might explain the lack of guidelines for IUC insertion in most health care facilities. Perhaps, gynecologists used lidocaine gel, misoprostol and PCB to a greater extent than midwives because midwives need a physicians prescription to gain access to such injectables as misoprostol or lidocaine. 4.3. Risk perception of complications The risk for PID is slightly elevated during the first 20 days after IUC insertion, but there is no greater long-term risk than if IUC had not been used at all [31]. In our study, the majority of those surveyed stated that the risk for PID after IUC insertion was low, but only 27% considered IUC

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appropriate for women with a history of PID. Although most participants also estimated the risk for ectopic pregnancy as low during IUC use, less than one third of the participants considered IUC a suitable option for a woman with a previous ectopic pregnancy, despite the fact that the absolute risk for ectopic pregnancy is lower during IUC use [14]. 4.4. Characteristics of HCPs and their use of IUC Our study established a correlation between the age and number of years IUC-prescribing HCPs had been in practice and their tendency to view only certain women as suitable candidates for IUC. This agrees with the results of previous studies [4,5,7,32]. HCPs who perform IUC insertions have been shown to possess greater knowledge of IUC, be more comfortable in discussing IUC with patients, consider patients more open to discussions about IUC and more frequently recommend IUC [33]. The finding that gynecologists tended to recommend IUC to a greater extent than midwives may be because HCPs in the group surveyed were younger and performed IUC insertions slightly more often. It may also be that gynecologists have more accurate knowledge of IUC as a result of their longer education. Gynecologists are often referred cases after other methods of contraception have failed. In such instances, IUC might be more readily recommended. Therefore, the gynecologists may accumulate greater experience using IUC and therefore have more confidence in recommending it. HCPs who insert a large number of IUCs per month reported more extensive use of analgesia and misoprostol for cervical ripening, indicating their comfort level with the procedure. It might be that the mechanically challenging insertion process discourages HCPs from recommending IUC. Or perhaps, HCPs who insert a greater number of IUCs have increased empirical experience, resulting in more extensive use of misoprostol for pain relief, thus making the procedure suitable for more women. It has previously been shown that HCPs who frequently do IUC insertions report experiencing significantly fewer insertion problems than those who performed insertions less often [27]. 4.5. Limitations and strengths Since not all Swedish HCPs who prescribe contraceptives were included in this study and because the response rate was not 100%, selection bias is possible. The study design also did not enable any conclusions regarding causality. Most questions did not separate the two types of IUCs (LNG-IUS and Cu- IUD), which could have affected the answers. On the other hand, the study was nationwide, surveying a large population and achieving a higher response rate than might otherwise have been expected for this type of inquiry [34]. Its quantitative aspects and large number of participants enable generalization. Finally, the Web survey method facilitated the completion of the questionnaire and minimized the risk of human error.

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5. Conclusion This large survey of Swedish HCPs actively engaged in contraceptive counseling and prescription shows that such providers do not entirely operate according to scientific evidence and national or international guidelines. Renewed efforts are needed to increase the understanding of IUC among HCPs so that they may offer it as an option to a broad range of sexually active women, including those who are young and nulliparous. Acknowledgments The authors are grateful for the assistance of Sara Norrestam in the construction of the survey and the help of Mesfin Tessma with the statistical analyses. References [1] Larsson G, Blohm F, Sundell G, Andersch B, Milsom I. A longitudinal study of birth control and pregnancy outcome among women in a Swedish population. Contraception 1997;56(1):9–6. [2] Silva M. The Reproductive Health Report: the state of sexual and reproductive health within the European Union. Eur J Contracept Reprod Health Care 2011;16(1):1–0. [3] Socialstyrelsen. Aborter 2010. Stockholm: Socialstyrelsen 2011 Jun. Report No.:1400–351. [4] Stubbs E, Schamp A. The evidence is in. Why are IUDs still out? Family physicians' perceptions of risk and indications. Can Fam Physician 2008;54(4):560–6. [5] Harper CC, Blum M, de Bocanegra HT, Darney PD, Speidel JJ, Policar M, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111(6):1359–69. [6] Wellings K, Zhihong Z, Krentel A, Barrett G, Glasier A. Attitudes towards long-acting reversible methods of contraception in general practice in the UK. Contracept 2007;76(3):208–14. [7] Stanwood NL, Garrett JM, Konrad TR. Obstetrician–gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99(2):275–80. [8] Madden T, Allsworth JE, Hladky KJ, Secura GM, Peipert JF. Intrauterine contraception in Saint Louis: a survey of obstetrician and gynecologists' knowledge and attitudes. Contracept 2010;81(2): 112–6. [9] UN.org. [Internet]. New York United Nations. Available from: http:// www.un.org/esa/population/publications/contraceptive2011/ wallchart_graphs.pdf. 2011. [10] Romer T, Linsberger D. User satisfaction with a levonorgestrelreleasing intrauterine system (LNG-IUS): data from an international survey. Eur J Contracept Reprod Health Care 2009;14(6):391–8. [11] Lalos A. Reproduktion, prevention och sexualitet. Sex i Sverige - om sexuallivet i Sverige 1996. Stockholm: Folkhälsoinstitutet; 1998, pp. 183–98. [12] Socialstyrelsens statistikdatabas [database on the Internet]. Stockholm: Socialstyrelsen; 1996 [cited 2011 Nov 2]. Available from: http://192. 137.163.49/sdb/lak/val.aspx. [13] Lindh I, Ellstrom AA, Blohm F, Milsom I. A longitudinal study of contraception and pregnancies in the same women followed for a quarter of a century. Hum Reprod England 2010:1415–22. [14] Department of Reproductive Health, World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: World Health Organization; 2010. Report no.: 978 92 4 156388. [15] Middleton AJ, Naish J, Singer N. General practitioners' views on the use of the levonorgestrel-releasing intrauterine system in young,

6

[16]

[17] [18] [19]

[20]

[21]

[22]

[23]

[24]

[25]

M. Ekelund et al. / Contraception xx (2014) xxx–xxx nulligravid women, in London, UK. Eur J Contracept Reprod Health Care 2011;16(4):311–8. Gemzell-Danielsson K, Mansour D, Fiala C, Kaunitz AM, Bahamondes L. Management of pain associated with the insertion of intrauterine contraceptives. Hum Reprod Update 2013;19(4):419–27. Antikonception. Information från Läkemedelsverket. 2005;16(7):7–88. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contracept 2009;79(6):418–23. Behringer T, Reeves MF, Rossiter B, Chen BA, Schwarz EB. Duration of use of a levonorgestrel IUS amongst nulliparous and adolescent women. Contracept 2011;84(5):e5–10. Gemzell-Danielsson K, Thunell L, Lindeberg M, Tyden T, Marintcheva-Petrova M, Oddens BJ. Comprehensive counseling about combined hormonal contraceptives changes the choice of contraceptive methods: results of the CHOICE program in Sweden. Acta Obstet Gynecol Scand 2011;90(8):869–77. Aneblom G, Larsson M, Odlind V, Tyden T. Knowledge, use and attitudes towards emergency contraceptive pills among Swedish women presenting for induced abortion. BJOG 2002;109(2):155–60. Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device. Contracept 2008;78(3):211–7. Barrett M, Soon R, Whitaker AK, Takekawa S, Kaneshiro B. Awareness and knowledge of the intrauterine device in adolescents. J Pediatr Adolesc Gynecol 2012 Feb;25(1):39–42. Mestad R, Secura G, Allsworth JE, Madden T, Zhao Q, Peipert JF. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception. United States: 2011 Elsevier Inc; 2011, pp. 493–8. Black KI, Lotke P, Lira J, Peers T, Zite NB. Global survey of healthcare practitioners' beliefs and practices around intrauterine

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

contraceptive method use in nulliparous women. Contraception 2013 Nov;88(5):650–6. Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: increasing use of long-acting reversible contraception. Hum Reprod Update 2011;17(1):121–37. Black K, Lotke P, Buhling KJ, Zite NB. A review of barriers and myths preventing the more widespread use of intrauterine contraception in nulliparous women. Eur J Contracept Reprod Health Care 2012 Oct;17(5):340–50. Marions L, Lovkvist L, Taube A, Johansson M, Dalvik H, Overlie I. Use of the levonorgestrel releasing-intrauterine system in nulliparous women — a non-interventional study in Sweden. Eur J Contracept Reprod Health Care 2011 Apr;16(2):126–34. Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009(3). Hubacher D, Reyes V, Lillo S, Zepeda A, Chen P-L, Croxatto H. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol 2006 Nov;195(5):1272–7. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339(8796):785–8. Black KI, Sakhaei T, Garland SM. A study investigating obstetricians' and gynaecologists' management of women requesting an intrauterine device. Aust N Z J Obstet Gynaecol Australia 2010:184–8. Rubin SE, Fletcher J, Stein T, Segall-Gutierrez P, Gold M. Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice. Contracept 2011;83(5):472–8. Cook C, Heath F, Thompson RL. A metaanalysis of response rates in Web or Internet-based surveys. Educ Psychol Meas 2000;60(6):821–36.