What to Expect When You’re Not Expecting
IUDs are 20 times more effective at stopping unintended pregnancies than the pill. Why do so few American women use them?
The technology was not new, but it was still disruptive: a small, cheap piece of plastic, wrapped in copper wire, that could prevent pregnancy with a near-zero failure rate. Once in place, it would last for years.
The Dalkon Shield appeared in American drug stores in 1971; it wasn’t the first intrauterine device, but it was popular. The pill was now a decade old, and while still revolutionary, IUDs promised convenience that oral contraception couldn’t. The drug companies knew it. By the early ’70s, the Shield was one brand among dozens, and the head of family planning at Columbia was calling IUDs “the ideal” form of birth control. So simple you forgot they were there.
Two million women were using the Shield when, in 1974, the problems became too big to ignore. Stories were splashed across two columns in the New York Times: more than a dozen deaths and 200 infected abortions. Manufacturer A.H. Robbins pulled finally recalled the Shield in 1975. Fifteen years later, the company paid out a $2.5 billion settlement to thousands of women.
IUDs went from being the fastest growing form of birth control in the United States to being untouchable—a toxic product and an impossible sell.
Long overdue, then, is a study in this week’s New England Journal of Medicine confirming what physicians have argued since the Dalkon Shield scare: in addition to being safe, IUDs are radically more effective at preventing unintended pregnancies than pills, patches, or rings—particularly in young women.
Among developed nations, the United States has an unusually high level of unintended pregnancies: roughly half of the six million women who conceive each year do so by accident, often from improper or inconsistent contraceptive use. More than one million abortions result, incurring real costs (dollars), social costs (lost education, missed work), and, importantly, emotional ones.
Not surprisingly, the most commonly used form of birth control, the pill, is less effective “as used” than “as directed.” Owing to the varied hassles of having to pop a pill at the same time every day—what if you decide to stay at his place? What if that pastel case is contraband in your parents’ house?—according to the recent NEJM study’s authors, the real-world failure rate hovers at 10 percent. For teenage girls and high-risk populations, it’s worse.
IUDs have a failure rate of less than 1 percent, rivaling sterilization. So why does just one American woman in 20 use them? Abroad, IUDs are hardly so novel. A 2011 study from the World Health Organization reports that, in China, a full third of married Chinese women use so-called “long acting” devices. In Scandinavia, nearly 20 percent do. The highest users? Vietnamese and Egyptian women, at around 35 percent. Only in sub-Saharan Africa are IUDs less popular than in the Americas.
When American women were offered a choice of free contraception, though, as part of the recent NEJM study, 77 percent of them chose to have an IUD implanted—an indication that up-front cost may play a deciding role in how women manage their reproductive health.
Led by senior author Jeffrey Peipert of the Washington University School of Medicine in St. Louis, the researchers followed a diverse group of 7,500 Missouri women for four years. Participants, between the ages of 14 and 45, had to be sexually active and express a desire not to become pregnant in the next 12 months. The authors read aloud a standard script, stating that IUDs were proven to be the most effective type of birth control, but provided in-depth counseling on the risks and benefits on pills, patches, and rings as well. Women would be allowed to switch methods any time they desired, but those using only condoms or “natural planning” were excluded from the analysis. In the end, more than 5,700 women chose IUDs.
The results were striking: women using pills, patches, or rings “had a risk of contraceptive failure that was 20 times as high as the risk” among those using IUDs.” And, much as the authors had hypothesized, women younger than 21 who chose to use a pill, patch, or ring—rather than an IUD—were twice as likely to become accidentally pregnant than older women.
The authors also note that, by the third year of the study, nearly one in 10 women relying on pills, patches, or rings had had a “contraceptive failure.” And with each passing year, the rate climbed.
The study’s conclusion runs a single, unequivocal sentence: the effectiveness of IUDs is simply superior to other contraceptives.
“If there were a drug for cancer, heart disease, or diabetes that was 20 times more effective,” said Peipert, “we would recommend it first.”
How long it takes medical science to escape the dark shadow of the Dalkon Shield, however, one might only hypothesize.