The most effective reversible means of pregnancy prevention has been proven to be long-acting reversible contraceptives, otherwise known as LARCs. It seems strange, then, that usage statistics of LARCs are not generally higher around the world. We can find some answers to this question by looking closely at European trends, as well as comparisons to the situation in the United States.
Health care providers (HCPs) in Europe use simulation as an educational and training tool to encourage increased adoption of IUDs. Much in the same way, initiatives in the United States are increasingly turning to simulation training in order to address impediments preventing the uptake of LARCs and thus increase patient usage rates. This article examines European statistics and protocols which pertain to IUDs, and analyzes the obstacles which seem to impede a more widespread uptake of this birth control.
IUD Insertion and Simulation Training
The Journal of European Continuing Medical Education (CME) published a study entitled ‘Assessment of a high-fidelity mobile simulator for intrauterine contraception training in ambulatory reproductive health centers’. This study explored the“benefits from using a high-fidelity mobile simulator to teach IUD insertion to clinicians in geographically dispersed ambulatory health care settings. The participants, many of whom had prior experience with IUD provision, reported increased competency and comfort with IUD insertion after training on the [VirtaMed] PelvicSim.”
The study’s participants found the training so useful, to the point that it was reported:“All participants would recommend the PelvicSim for IUD training, and nearly all (97.2%) reported that the PelvicSim was a better method to teach IUD insertion than the simple plastic models supplied by IUD manufacturers.”
Image credit: VirtaMed
IUDs are immensely popular outside of the United States, as noted by the Guttmacher’s Institute’s ‘Popular Disparity: Attitudes About the IUD in Europe and the United States’. Indeed, the study comments that this“is the case not only in the developing world, but in European countries that in many ways are similar to the United States.”
In contrast to this, however, the 2018 World Contraceptive Report by the United Nations places IUD usage in the United States in 2015 at just 10% in comparison to Statista’s 2016 data for European IUD usage, at 11%. Demonstrably, the margin is not so wide after all.
Variability in IUD- Uptake Across Europe
IUD usage varies widely within Europe, as set out by the United Nations’ 2018 World Contraceptive Report. This variation has happened over approximately the past fifty years, with disparities existing both from country to country as well as within countries. Many European countries show a decline in IUD usage over the past twenty years, which is in contrast to the United States’ increasing IUD adoption.
Though in 1994 Estonia displayed a rate of 36% IUD usage, by 2004 the number was down to 22%. Germany’s rate of usage doubled between 1992 and 2008, and today stands at a similar adoption rate to the United States, its contemporary rate of 9% is still vastly behind the mid-eighties IUD prevalence of 15% usage. The United Kingdom and Belgium also align most closely with the United States’ rate of approximately 10% IUD use.
The IUD usage rate of other countries is far lower. For instance, since 2002 Albania’s IUD usage has remained below 1%, and whilst Poland climbed to 8% back in 1991, by 2011 usage rates had fallen below 1%.
There are myriad and varied factors which influence how likely a patient is to choose an IUD in addition to how likely a healthcare provider is to recommend them as a course of action , which includes cost . Many countries’ HCPs are united by a range of anxieties which stem from fears around both insertion and side-effects of IUDs.
A paper co-authored by KJ Buhling for the European Journal of Obstetrics and Gynecology, entitled ‘Understanding the barriers and myths limiting the use of intrauterine contraception in nulliparous women’, discovered that HCPs in Sweden reported concerns about IUCs  both affecting normal menstruation and causing pain during insertion. Similar concerns of insertion pain arose in The Netherlands, Turkey, Ireland and the UK.
There were also concerns widely held in the Netherlands, the UK and Ireland, and Russia, that women who have not yet given birth – or nulliparous women - are not good IUC candidates. This, along with cost, represented a barrier for German HCPs. French, Turkish and Russian HCPs also held concerns that IUCs increase the likelihood of women contracting pelvic inflammatory disease (PID).
Other reasons cited included the elevated risk for ectopic pregnancy and the higher risk of fertility, in addition to other specific difficulties for nulliparous women. Risks like these include the increased risk of uterine perforation and expulsion of the IUD. Much of these risks, however, remain unsubstantiated and many of these have been subsequently disproved or negated, particularly those pertaining to the increased risk of PID and the ineligibility of nulliparous women.
Combating Barriers to Boost IUD Uptake
It naturally follows that if European health care providers themselves hold strong reservations about IUDs, many patients may be subject to persistent myths and misunderstandings around this form of contraception.
Potentially, simulation training could help to dispel misconceptions and anxieties surrounding LARCs, which would help to increase global HCP’s comfort in performing IUD insertion, with low uptake statistics. The following is an extract from a paper entitled ‘Assessment of a high-fidelity mobile simulator for intrauterine contraception training in ambulatory reproductive health centers’:
“Despite the high level of perceived competency before training, the self-reported comfort level after training increased for all tasks, with more than half of respondents feeling slightly or much more comfortable with uterine sounding, understanding the steps of IUD placement, IUD insertion on a live patient, [and] minimizing pain on a live patient.”
Despite the variety in obstacles standing in the way of increased IUD uptake, simulation training holds great potential as a way of modifying both practitioner and patient concerns over difficulty, complications or pain from IUD insertion. In addition, it may mitigate persistent misconceptions regarding patient eligibility for this highly effective and reversible form of contraception.
 The term LARC, for clarity’s sake, refers to injections, intrauterine devices (IUDs), and implants. IUD and IUC are often used synonymously (intrauterine contraception); IUS (intrauterine system) typically refers to Levonorgestrel Intrauterine Systems (LNG IUS).
 The data indicates that countries which had communist regimes in the 90s and high IUD utilization have subsequently rapidly decreased their use of IUDs, whereas those with relatively low usage in the 90s have roughly doubled in the 2000s.
 Over time, France’s rate of IUD usage has appeared to hold steady. Nonetheless, the report ‘IUD use in France: women's and physician's perspectives’ suggests that,“the considerable age discrepancy in IUD use in France, with very few young women most at risk of an unintended pregnancy using the method, reflects a knowledge gap shared by users and providers. These findings suggest there are significant opportunities to improve contraceptive care in France.”
 The report ‘Worldwide use of intrauterine contraception: A review’ for Contraception by Buhling et al. notes that which practitioners (including general practitioner, gynecologists, family physicians) can perform IUD insertion has a significant effect on patient usage statistics. In Germany, it is only obstetrician-gynecologists (OB-GYNs) who can provide IUC services to patients. In the Netherlands, however, patients can visit a general practitioner or family physician for their IUC needs.
 In the Contraception study, it cites, “Differences in the range of IUC options may affect access for numerous reasons. However, the most obvious factor that influences access is cost.” In the UK, the National Health Service fully subsidizes all T-framed, U-framed, and frameless copper devices, in addition to Levonorgestrel Intrauterine Systems (LNG IUS). Cost, in the USA, is dependent upon insurance plan can fall anywhere in the range of free for the patient to over $800, payable upfront. By contrast, women in Sweden women can have a copper IUD fitted free of charge but must pay for the LNG IUS.
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