Elsevier

Contraception

Volume 96, Issue 2, August 2017, Pages 106-110
Contraception

Original research article
“I wish they could hold on a little longer”: physicians' experiences with requests for early IUD removal,☆☆

https://doi.org/10.1016/j.contraception.2017.05.007Get rights and content

Abstract

Objective

This study describes the perceptions and experiences of family physicians when women request early intrauterine device (IUD) removal.

Study design

This qualitative study included semistructured individual interviews with 12 physicians who encountered patients seeking early IUD removal. We identified eligible participants via chart review. We analyzed interviews using deductive and inductive techniques to identify content and themes.

Results

Physicians consistently referred to IUDs as the “best” or their “favorite” method, and several joked that they tried to “sell” the IUD during contraceptive counseling. Most reported having mixed or negative feelings when patients opted to remove the IUD. Most encouraged their patients to continue the IUD, hoping to delay removal until symptoms resolved so that removal was not needed. Some physicians reported feeling guilty or as if they had “failed” when a patient wanted the IUD removed. Many providers reported a conflict between valuing patient autonomy and feeling that early removal was not in the patient's best interest.

Conclusions

Physicians have complex and contradictory feelings about early IUD removal. While most providers acknowledged the need for patient autonomy, they still reported encouraging IUD continuation based on their own opinion about the IUD.

Implications

While IUDs are highly effective and well-liked contraceptives, providers' responses to IUD removal requests have implications for both reproductive autonomy as well as the doctor–patient relationship. More work is needed to ensure that providers remove a patient's IUD when requested.

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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  • Cited by (0)

    Funding for research: Society of Family Planning, SFPRF13-3.

    ☆☆

    Disclosures: None.

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