Original research article“I wish they could hold on a little longer”: physicians' experiences with requests for early IUD removal☆,☆☆
Introduction
Long-acting reversible contraception (LARC) includes the intrauterine device (IUD) and the contraceptive implant, the most effective reversible contraceptives [1]. Changes in eligibility criteria [2] have increased the number of patients who can use LARC, and LARC has received attention from public health organizations for its potential to decrease undesired pregnancy, abortion, health care costs and teen birth [3], [4], [5], [6]. National and local policy changes have increased accessibility and affordability of LARC as well as increased provision within primary care settings [7], [8], [9], [10], [11], [12], [13].
While provider enthusiasm for the IUD may lead to greater access to this method, it may also present a barrier to IUD removal. A small proportion of LARC users (10%–20%) discontinue use in the first year [14], [15], and unlike with other contraceptives, these patients usually need a visit with their provider to discontinue the method. In a previous study, we interviewed patients about their experiences discussing early1 IUD removal with their physicians. Patients reported that their physicians often preferred them to continue the IUD even when the patients preferred removing the device [16]. Since most patients cannot, or prefer not to, remove an IUD themselves [17], physician attitudes and reluctance to remove the device have potential implications for reproductive autonomy. Several authors and researchers have raised concerns about the relationship between LARC and reproductive autonomy [18], [19], [20], [21], and difficulty accessing removal is another way in which LARC users could face unintentional reproductive coercion. Other previous studies have also documented patients' experiences with provider reluctance to provide LARC removal [22], [23], but no previous study has investigated providers' perspectives about LARC removal. This study examines family physicians' perspectives on early IUD removal.
Section snippets
Sample and recruitment
We recruited Family Medicine attending and resident physicians from two primary care clinics in the Bronx, NY. We excluded the nurse practitioners and obstetrician-gynecologists who also provide IUD care in these health centers in order to recruit a more homogenous sample. We identified providers by chart review, and providers were eligible if they had a patient aged 15–44 years who had a visit to discuss IUD removal within 9 months of insertion during the period of chart review. We excluded
Results
Of 807 charts that we reviewed, we identified 61 eligible visits with 35 providers. Of these providers, we excluded 5 who were not family physicians and 7 who were either part of the research team or had been involved with the prior patient study. We informed all 23 remaining providers about the study; one provider declined, and we contacted the rest individually to schedule interviews, which we conducted until thematic saturation, which occurred after 12 interviews. Demographic characteristics
Discussion
This study follows a previous study that investigated patients' experiences discussing IUD removal with their providers, including times when providers resisted IUD removal [16]. The results from this provider study confirm much of what was found in the patient study: that providers preferred IUD continuation and often encouraged patients to continue with the IUD if they thought it was in the patient's best interest. This study also demonstrated that physicians bring some biases to the IUD
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