Understanding barriers and myths to IUC use - Outcomes of a global HCP survey Series 3

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

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. Speaker notes: This slide summarises the agreed terms of use of the Educational Slide Kit contents.

Rationale & Methodology

Rationale for the survey To understand, for the first time at a global level, the extent to which various barriers and misperceptions regarding IUC persist among providers of contraception To identify areas where further education is needed To establish a benchmark for follow-up research in the future

15 participating countries globally Target numbers of respondents per country Sweden Russia UK Canada Ireland The Netherlands US France Germany Turkey Mexico Colombia Brazil Australia Argentina Target n=1,750

Survey conduct Conducted online between February and March 2012 Respondents who had previously given their consent to be contacted about research, were recruited by email invitation Potential respondents were screened to ensure that they: Saw at least 20 women per month for contraception Were either an OB/GYN, GP or FP clinician* Quotas were set for individual countries to ensure recruitment of representative samples e.g. for Sweden, 70% midwives and 30% OB/GYN Respondents meeting the screening criteria proceeded to a structured questionnaire Comprising 13 questions taking approximately 12−14 minutes to complete *Included physicians working in family planning, midwives and nurses with a specific women’s health qualification, depending on the relevant providers in individual countries

Survey scope Barriers to use of IUC in women in general Perceptions of the efficacy and risks of IUC Perceptions of the ease of IUC insertion and discomfort associated with IUC insertion Attitudes towards proactive inclusion of IUC in contraceptive counselling Knowledge of WHO MEC for IUC Opinions on what would increase their knowledge/confidence in IUC for nulliparous women

Results

Survey flow Screening N=3,094 Canada/Europe N=1,103 USA N=156 Latin America N=402 Australia N=126 Screening failures N=1,307 Main Questionnaire N=1,787

Sample sizes and composition Quotas were applied to ensure representative samples of providers were recruited in each country GPs FP clinicians* Gynecologists Total Canada 75 25 100 Germany 150 France 125 UK 110 40 Russia Sweden 70 30 The Netherlands Turkey Ireland 80 23 103 US 31 156 Mexico Argentina 101 Brazil Colombia Australia 51 50 126 TOTAL 447 210 1,130 1,787 *Country-specific specialties: FRA: Doctor working in family planning; UK: Family planning nurse; SWE: Midwife; US: Women’s health nurse practitioner; AUS: GP with special interest in women’s health, family planning nurse practitioner, physician working in family planning centre/clinic

Global results

Barriers to use of IUC in general: global dataset In response to the multiple-choice question, ‘What are the three main barriers for you as a physician when considering IUC?’, the five barriers most frequently cited among 1,787 respondents were: 1 1 2 References: 1. Black K et al. A global online survey exploring healthcare providers’ knowledge, attitudes and beliefs regarding the use of intrauterine contraception in nulliparous women: Poster P102 presented at: European Society for Contraception meeting, Athens, June 21-24 2012 2. Data on file 2 2 Respondents (%) Black K et al Poster ESC 2012 Data on file

Barriers to use of IUC in nulliparous women: global dataset In response to the multiple-choice question, ‘What are the three main barriers for you when considering IUC as an option for nulliparous women?’, the most frequently cited barriers among 1,787 respondents were: 1 1 2 References: 1. Black K et al. A global online survey exploring healthcare providers’ knowledge, attitudes and beliefs regarding the use of intrauterine contraception in nulliparous women: Poster P102 presented at: European Society for Contraception meeting, Athens, June 21-24 2012 2. Data on file 2 2 2 Respondents (%) Black K et al Poster ESC 2012 Data on file

Perceptions of IUC insertion in nulliparous women: global dataset 77% believed that insertions are more difficult in nulliparous than parous women1* 82% believed that insertions are more painful for nulliparous than parous women1 20 40 60 80 100 20 40 60 80 100 Respondents (%) Respondents (%) References: 1. Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 2. Data on file 2 2 *Subset of 1,594 respondents, excluding those who do not insert IUC themselves Black K et al 2013 Data on file

Barriers to use of IUC in nulliparous women: subgroup analyses1 Respondents citing a concern as one of their three main barriers (%) PID Painful insertion Difficult insertion Medical specialty OB/GYN (n=1,130) 55 38 51 GP (n=447) 43 40 66 FP clinician (n=210) 31 49 63 Years of experience 1–10 (n=580) 42 41 11–20 (n=611) 50 57 >20 (n=596) 39 56 References: 1. Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 Black K et al. 2013 

Barriers to use of IUC in nulliparous women by medical specialty and years of experience1 OB/GYNs were more frequently concerned about PID and less frequently concerned about difficult insertions compared with GPs and FP clinicians More recently qualified respondents (1–10 years’ experience) were less frequently concerned about PID than more experienced colleagues Particularly those who have practised for >20 years References: 1. Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 Black K et al;.2013 

Knowledge of the WHO MEC for IUC Globally, among a total of 1,787 respondents3: Only 50% correctly identified nulliparity as category 2 (benefits outweigh the risks1) 13% believed that nulliparity was category 3 (risks outweigh benefits1) or 4 (contraindicated1) Almost 1 in 4 admitted that they ‘did not know’ how nulliparity is categorised (and did not guess) Percentage of respondents who correctly identified the WHO MEC category for nulliparity2 Respondents (%) Country or region Total (n=1,787) Europe/Canada (n=1,103) USA (n=156) Latin America (n=402) References: 1. World Health Organization. Medical eligibility for contraceptive use, 5th edition 2015. Available online at: http://www.who.int/reproductive-health/publications/med.pdf 2. Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 3. Black K et al. A global online survey exploring healthcare providers’ knowledge, attitudes and beliefs regarding the use of intrauterine contraception in nulliparous women: Poster102 presented at: European Society for Contraception meeting, Athens, June 21-24 2012 WHO MEC, 2010 Black K et al; 2013  Black K et al; Poster ESC 2012

Attitudes towards the proactive inclusion of IUC in contraceptive counselling according to a woman’s age and parity status Global dataset Percentage of respondents reporting that they proactively include IUC in counselling Respondents (%) Woman’s age (years) 30–39 ≥40 18–29 References: 1. Black K et al. A global online survey exploring healthcare providers’ knowledge, attitudes and beliefs regarding the use of intrauterine contraception in nulliparous women: Poster P102 presented at: European Society for Contraception meeting, Athens, June 21-24 2012 Black K et al; Poster ESC 2012

What would increase HCP knowledge and confidence in IUC for nulliparous women? In response to the multiple-choice question, ‘What would best increase your knowledge and confidence in using intrauterine contraception in nulliparous women?’, the five most frequently cited answers among 1,787 respondents were1: References: 1. Data on file Respondents (%) Data on file

European/Canadian results

Five most frequently reported barriers to use of IUC in general European/Canadian subset1 Canada (n=100) Germany (n=150) France UK Russia Netherlands Turkey Ireland (n=103) Sweden Barrier The woman has not had a baby yet Concerns about PID Concerns about insertion pain Concerns about difficult insertion Disruption of normal menstruation Financial cost is too high Women do not like it Concerns about expulsion Concerns about ectopic pregnancy The woman may not be monogamous The age of the woman References: 1. Bühling KJ et al. Understanding the barriers and myths limiting the use of intrauterine contraception in nulliparous women: results of a survey of European/ Canadian healthcare providers. European Journal of Obstetrics & Gynecology and Reproductive Biology 2014 (183), 146–154 Bühling KJ et al. 2014

Five most frequently reported barriers to use of IUC in nulliparous women European/Canadian subset1 Canada (n=100) Germany (n=150) France UK Russia Netherlands Turkey Ireland (n=103) Sweden Barrier Concerns about PID Concerns about insertion pain Concerns about difficult insertion Disruption of normal menstruation Financial cost is too high Women do not like it Concerns about expulsion Concerns about ectopic pregnancy The woman may not be monogamous The age of the woman Concerns about infertility References: 1. Bühling KJ et al. Understanding the barriers and myths limiting the use of intrauterine contraception in nulliparous women: results of a survey of European/ Canadian healthcare providers. European Journal of Obstetrics & Gynecology and Reproductive Biology 2014 (183), 146–154 Bühling KJ et al. 2014

Perceptions of IUC risks for nulliparous women: PID, perforation, expulsion: European/Canadian subset1 20 40 60 80 100 Respondents (%) References: 1. Data on file Data on file

Attitudes towards the proactive inclusion of IUC in contraceptive counselling according to a woman’s age and parity status European/Canadian subset1 Percentage of respondents reporting that they proactively include IUC in counselling Respondents (%) References: 1. Data on file 18–29 30–39 ≥40 Woman’s age (years) Data on file

Initiatives to increase knowledge and confidence Summary of global results

More presentations at local meetings Initiatives for increasing knowledge and confidence in IUC for nulliparous women1 In response to the question, ‘What would best increase your knowledge and confidence in using IUC in nulliparous women?’ the most frequent responses in Europe and Canada were: 58% 44% 52% 41% 40% More presentations at local meetings (36%) and easily accessible scientific data (36%) More presentations at local meetings Articles in professional magazines/newspapers References: 1. Bühling KJ et al. Understanding the barriers and myths limiting the use of intrauterine contraception in nulliparous women: results of a survey of European/ Canadian healthcare providers. European Journal of Obstetrics & Gynecology and Reproductive Biology 2014 (183), 146–154 More presentations at local meetings (49%) and specific practical training on insertion (47%) More presentations at international (38%) and national (37%) conferences More social acceptance of IUC (30%), more presentations at national conferences (29%) and articles in professional magazines/newspapers (29%) Bühling KJ et al. 2014

Initiatives for increasing knowledge and confidence in IUC for nulliparous women1 In response to the question, ‘What would best increase your knowledge and confidence in using IUC in nulliparous women?’ the most frequent responses by country were: Articles in professional magazines/newspapers (45%) and easily accessible scientific data (45%) More presentations at local meetings (48%) Articles in professional magazines/newspapers (40%) References: 1. Data on file More social acceptance of IUC (38%) and more requests for IUC from nulliparous women (37%) More social acceptance of IUC (39%) More presentations at national conferences (31%) Data on file

Conclusions (1) The two main barriers to providers considering IUC for women requesting contraception are: Nulliparity Concerns about PID Globally, the three most frequently reported barriers to considering IUC as an option for a nulliparous woman were concerns about1: Difficult insertion PID Insertion-related pain Despite evidence to the contrary,2,3 a substantial proportion of providers believe that: Nulliparous women using IUC are at higher risk of PID/infertility than women not using IUC Nulliparous women are at higher risk of uterine perforation and expulsion than their parous counterparts References: Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 Black K et al. A review of barriers and myths preventing the more widespread use of intrauterine contraception in nulliparous women. The European Journal of Contraception and Reproductive Health Care. 2012 Lyus R et al. on behalf of the Board of the Society of Family Planning. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Contraception 2010;81:367–71 Black K et al. 2013 Black K et al. 2012 Lyus et al. 2010

Conclusions (2) Providers’ knowledge of the WHO MEC is poor1 Only 50% correctly identified that nulliparity is category 2 (benefits outweigh the risks) Providers are less likely to proactively include IUC in contraceptive counselling for a nulliparous woman than a parous woman1 This is regardless of the woman’s age Women <18 years of age are discriminated against, regardless of parity The challenge is to ensure that providers of contraception understand the evidence and do not disregard IUC as a potential option for nulliparous women2 Further education is needed, particularly on risk of PID and infertility Initiatives are needed to increase awareness and understanding of the WHO MEC Practical hands-on training needs to be more widely available to increase the provider’s confidence in performing IUC insertions in nulliparous women References: Black K et al. Global survey of healthcare practitioners‘ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013 Nov;88(5):650-6 Lyus R et al. on behalf of the Board of the Society of Family Planning. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Contraception 2010;81:367–71 Black K et al. 2013 Lyus et al. 2010