Use of intrauterine contraception worldwide

1. Series 1
Diversity of practice: provision and
uptake of intrauterine contraception
(IUC) worldwide

2. INTRA group: Intrauterine coNtraception:
Translating Research into Action
 A panel of independent physicians with expert interest in
intrauterine contraception
– Formation of the INTRA group and its ongoing work is supported
by Bayer Pharma
 Purpose:
– To encourage more widespread use of IUC methods in a broad
range of women through medical education

3. Core Slide Kit: Terms of use
 If any adjustments are made to the originals, neither Bayer Pharma nor the
INTRA Group can accept responsibility whatsoever for their content.
– If you make changes you should not use the INTRA slide template.
 When using any of these slides, even if you modify them in some way, please
acknowledge to your audience that the original slides were provided by the
INTRA Group:
– “The global INTRA group is a panel of independent physicians with expert interest
in intrauterine contraception. Formation of the INTRA group and its ongoing work is
supported by Bayer Pharma”.
 You may select any combination of slides to present on to others; however,
the context of the slides should be maintained wherever possible.
 Please be aware that recommendations and regulations around
communications on contraception as well as product labels vary globally, and
ensure that the content and recommendations included in the slides are
aligned to the local regulations and product labels of the country where you
are presenting.

4. In this series:
 Variation in prevalence of IUC use
 Practitioner variation
 Variation in the numbers of providers with the appropriate
skill set
 Local variation in practices

5. VARIATION IN PREVALENCE OF
IUC USE

6. Wide global variation in prevalence of IUC use
14.3
9.2
15.1
17.9
12.4
7
4.8 4.4
1.1
22.8
12.7
24.7
27
17.1
9.6
6.1
15.4
1.8
0
10
20
30 Women using IUC (%)
Contraceptors using IUC (%)
Women(%)
1. United Nations, 2011
2. Bühling et al 2014
Prevalence of IUC use among women aged 15–49 years, married or in
union*: variation between continents1,2
Contraceptors: women using any form of contraception
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women,
but this group of users is not captured in available data.

7. Variation in prevalence of IUC use* within Africa1
Area of Africa Women aged 15–49 years, married or in union (%)
Using any
method of
contraception
Using any
modern method
of contraception
Using IUC
Sub-Saharan 21.8 15.7 0.5
Northern (excl. Sudan) 60.5 54.0 22.3
Eastern 28.4 22.9 0.5
Middle 18.6 6.6 0.2
Northern 50.4 44.8 18.1
Southern 58.4 58.1 1.1
Western 14.4 8.7 0.7
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.
1. Bühling et al 2014

8. Prevalence of IUC use* within Asia
 Extremely wide regional variation in prevalence of
IUC use:
– Lowest prevalence in Southern Asia (2.0%)1
– Highest prevalence in Central Asia (41.5%)1
 With regard to individual Asian countries2:
– Highest prevalence: China (40.6%), Democratic People’s
Republic of Korea (42.8%) and Vietnam (43.7%)
– Lowest prevalence: Nepal (0.7%), the Maldives (0.8%),
Bangladesh (0.9%), Afghanistan (1.0%), Myanmar (1.8%) and
Cambodia (1.8%)
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but
this group of users is not captured in available data.
1. Bühling et al 2014
2. United Nations, 2011

9. Variation in prevalence of IUC use* within
Europe1,2
Area of Europe Women aged 15–49 years, married or in union (%)
Using any
method of
contraception
Using any
modern method
of contraception
Using IUC
Eastern 74.9 54.3 16.3
Northern 80.1 77.2 11.9
Southern 63.8 46.3 5.7
Western 71.9 68.6 11.4
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but
this group of users is not captured in available data.
1. Bühling et al 2014
2. United Nations, 2011

10. Prevalence of IUC use* within Europe1
France
22.7%
Northern Europe
Germany
5.3%
Estonia
35.9%
Latvia
28.0%
Finland
25.8%Norway
23.3%
Sweden
16.2%
Ireland
8.4%
Belarus
25.7%
Moldova
25.2%
Romania
6.7%
Slovenia
22.9%
Macedonia
0.4%
Eastern Europe
Southern Europe
Western Europe
Netherlands
8.0%
Switzerland
6.0%
Portugal
7.3%
Spain
6.4%
Italy
5.8% Greece
3.6%
UK
10.0%
Poland
8.4%
Czech
Republic
13.9%
• Highest prevalence: Eastern Europe (16.3%)
• Lowest prevalence: Southern Europe (5.7%)
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.
1. United Nations, 2011

11. Prevalence of IUC use* within North America
 Prevalence of IUC use has increased over recent years1
– 5.3% in the US
– 1.0% in Canada
 Rates of IUC use in the US are influenced by ethnicity
– Hispanic women are more likely to use IUC than Caucasians2
1. United Nations, 2011;
2. Mosher, 2010
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.

12. Variation in prevalence of IUC use* within Latin
America and Caribbean
Area of Latin
America and
Caribbean
Women aged 15–49 years, married or in union (%)
Using any
method of
contraception
Using any
modern method
of contraception
Using IUC
Caribbean 61.6 57.0 11.3
Central America 68.2 63.0 9.6
South America 76.1 69.6 5.5
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.
1. Bühling et al 2014

13. Variation in prevalence of IUC use* within
Latin America
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.
Argentina
9.5%
Bolivia
8.4%
Brazil
1.9%
Chile
18.9%
Colombia
11.2%
Ecuador
10.1%
Guyana
7.3%
Paraguay
12.3%
Uruguay
12.3%
Peru
3.8%
Suriname
1.5%
Venezuela
9.5%
Mexico
11.6%
1. United Nations, 2011

14. Prevalence of IUC use* within Latin America
 Higher prevalence in Central America (9.6%) versus
South America (5.5%)
 Central America
– Highest prevalence: Mexico (11.6%), Costa Rica (6.9%),
Honduras (6.6%) and Panama (6.0%)
– Lowest prevalence: El Salvador (0.8%), Guatemala (1.9%) and
Nicaragua (3.4%)
 South America
– Highest prevalence: Chile (18.9%), Paraguay (12.3%) and
Uruguay (12.3%)
– Lowest prevalence: Suriname (1.5%), Brazil (1.9%) and
Peru (3.8%)
*Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single
women, but this group of users is not captured in available data.
1. United Nations, 2011

15. Worldwide distribution of IUC users is not uniform1
 83% of the world’s users
of IUC are in Asia1,2
 Almost two-thirds (64%)
of the world’s IUC users
are in China alone1
– The majority of women
in Asia use non-
hormonal methods
(stainless steel and
copper IUDs)3
Asia
83%
Europe
8%
Africa
4%
Latin America
& Caribbean
4%
North
America
1%
Oceania
0.03%
Europe
8%
Africa
4%
Oceania
0.03%
North
America
1%
Asia
83%
Latin America &
Caribbean
4%
1. Bühling et al 2014
2. United Nations, 2011
3. Cheung, 2010

16. Reasons for geographical variation in IUC use1
Positive or
negative
influence on IUC
uptake
Types of providers
authorised and the
locations at which
women can access IUC
Funding models
and variation in
cost (to women)
Medico-legal
environment
Differences in
clinical practices
Availability of HCPs with
the appropriate skill set
(availability of practical
training for HCPs)
The types of
devices that are
available in
different countries
1. Bühling et al 2014

17. PRACTITIONER VARIATION

18. Providers of IUC services, by country1
Provider
Country OB/GYN
FP physician
or GP
Nurse, midwife
or other provider
Europe
Germany 
UK  
France   
Sweden  
The Netherlands  
North America
USA   
Canada  
1. Bühling et al 2014

19. Providers of IUC services, by country1
Provider
Country OB/GYN
FP physician
or GP
Nurse, midwife
or other provider
Latin America
Mexico  
Costa Rica   
Colombia   
Argentina  
Brazil   
Asia/Asia-Pacific
China 
India  
Australia  
1. Bühling et al 2014

20. Locations for IUC services, by country1
Location
Country
Provider’s
office
Sexual health,
contraception or
youth clinic
Abortion
clinic
Hospital-
based
community
clinic
Europe
Germany 
UK   
France    
Sweden    
The Netherlands   
North America
USA    
Canada    
1. Bühling et al 2014

21. Locations for IUC services, by country1
Location
Country
Provider’s
office
Sexual health,
contraception or
youth clinic
Abortion
clinic
Hospital-
based
community
clinic
Latin America
Mexico    
Costa Rica  
Colombia    
Argentina   
Brazil  
Asia/Asia-Pacific
China   
India    
Australia    
1. Bühling et al 2014

22. Providers and locations of IUC services
influence uptake
Germany France
Providers: OB/GYN only1
Locations: Providers office only1
Providers: OB/GYN, FP physicians,
GPs, nurses, midwives1
Locations: Providers office, sexual
health, contraception or youth clinic,
abortion clinic, hospital-based
community clinic1
IUC utilisation: 5.3%2 IUC utilisation: 22.7%2
Expanding the types of HCPs and range of
locations increases utilisation
1. Bühling et al 2014
2. United Nations, 2011

23. Case study 1: impact of authorising midwives on
IUC uptake in Turkey1
Initial attempts to extend access to IUC to rural areas via mobile clinics failed
owing to difficulties in providing adequate post-placement follow-up care
Turkish government conducted a study to assess whether local midwives
could safely place and remove IUC devices
Based on the results of this study, local midwives were authorised to offer
IUC services
A steady and sustained increase in IUC uptake was achieved over the
following decade
1. d’Arcangues, 2007

24. Case study 2: impact of authorising GPs on IUC
uptake in Egypt1
 IUC services used to be provided only by OB/GYNs
 Since the mid-1980s, a steady increase in IUC use has
been achieved
 This was in part due to the following:
– Authorising GPs to perform placements and removals
– Careful attention to the training and certification of the
new providers
1. d’Arcangues, 2007

25. VARIATION IN THE NUMBERS OF
PROVIDERS WITH THE APPROPRIATE
SKILL SET

26. A paucity of adequately trained providers limits
IUC uptake1
Not enough expert providers offer placement training
(long waiting lists for training places in some countries)
Insufficient providers with the necessary skill set to offer an IUC
placement service
Women may face long waiting lists for IUC placements
Women who would otherwise have chosen IUC opt for other more
immediately available methods
1. Black et al. 2012

27. Factors limiting the number of trained providers
Both scenarios lead to shortages of providers with the necessary
skills to perform IUC placements
Scenario 1: paucity of
trainers: experienced
providers may be reluctant to
offer training to others for fear
that they may lose an
important source of income1
Scenario 2: some healthcare
systems indirectly discourage
HCPs from developing IUC
placement skills: referral
systems may make it
advantageous for providers to
refer rather than provide a
placement service themselves1
1. Black et al. 2012

28. VARIATION IN THE DEVICES
AVAILABLE AND THE COST
TO WOMEN

29. Types of devices available globally
Country LNG-IUS
Copper IUDs
(number of devices) Stainless
steel IUD
1 2–10 10+
Argentina  
Australia  
Brazil  
Canada  
China   
Colombia  
France  
Germany  
Mexico 
The Netherlands  
New Zealand  
Sweden  
UK  
USA  
1. Bühling et al 2014

30. Reimbursement for IUC varies globally (1)
 Reimbursement for IUC either by government or private insurance varies
between countries
– In some countries, for example the UK, both copper IUDs and Mirena are fully
reimbursed and are free to women
– In some countries, only copper IUDs are free to women
 In Colombia and Mexico, copper IUDs are free of charge in public clinics1
 In New Zealand, copper IUDs are free to women but Mirena is not1,2
– In some countries, Mirena is reimbursed and is free to women
 In Australia, Mirena is partially subsidised by the government1,2
– In some countries, certain subsets of women receive reimbursement for IUC
 In France, for women <18 years of age, IUD cost and the placement procedure can be
free in family planning clinics2
 In Germany, IUC is reimbursed by public and private insurances for women with HMB
and those with certain illnesses that contraindicate use of COCs and POPs2
 In Sweden, Mirena can be subsidised for young women and in two counties all
contraceptive methods are free for women under the age of 23 or 25 years2
1. Black et al 2012;
2. Bühling et al 2014

31. Reimbursement for IUC varies globally (2)
 Reimbursement for the IUC placement procedure either
by government or private insurance varies between
countries
– In some countries, women do not have to pay for the IUC
placement procedure
 In France, IUC placement is reimbursed up to 65% by public
insurance and 35% by private insurance (approximately 90% of the
French population receive complementary private insurance)
1. Bühling et al 2014

32. Other intrauterine devices available in Asia1
Frameless copper device
GyneFix
Combined stainless steel
and copper devices
Uterine-shaped IUDGamma Cu 380 IUD
Framed copper devices
Flexi T CuAiMu Mcu
Stainless steel rings
Single ring Double ring
1. Cheung 2010

33. LOCAL VARIATION IN
CLINICAL PRACTICES

34. Product labelling in certain countries is more
restrictive than international Medical Eligibility
Criteria1–4
The Mirena package insert is more restrictive than
supported by evidence
German product labelling
is as a ‘second choice for
nulliparae’
Recommended patient
profile: a parous woman in
a stable, long-term
relationship
Extensive list of
contraindications
HCPs infrequently recommend IUC to women, particularly those who are
nulliparous or adolescent
1. WHO MEC, 2010;
2. US MEC, 2010;
3. UK MEC, 2009
4. Lyus, 2009;

35. Guidelines: variation in pre-insertion screening
requirements may influence IUC uptake accordingly
STI screeningCervical cancer screening
UK
Pre-placement
Pap smears
are not
mandated1
US
Can screen for
STIs and place
IUC on the
same day and
treat any
positive result
in situ4
UK
High-risk women
should be tested
for STIs prior to
placement, but if
not possible,
antibiotic
prophylaxis should
be given1
Australia
Screening
recommended
in higher risk
groups e.g
sexually active
women younger
than 25 years
old3
Germany
Pap smear
within
6 months of
placement is
mandatory2
1. NICE 2005
2. German guidelines 1985
3. Family Planning NSW 2011
4. ACOG 2011

36. Conclusion
 There is a wide variation in continental, regional and
global IUC use
– Global distribution of use is uneven with highest use in Asia (83%)
 EU (8%), Africa (4%), Oceania (0.03%), North America (1%),
Latin America and Carribean (4%)
– Factors influencing this wide variation includes:
 The types of devices available
 Access to treatment
 Differences in funding methods
 Differences in clinical practice and lack of skillset
 Medico-legal environment
– Subsequently, there is a local variation in product labelling and
pre-insertion screening recommendations which might influence
IUC uptake accordingly