Nikki B. Zite

Objectives Intrauterine contracepives (IUCs) are highly effective and safe for use in all women, including those who are nulliparous. However, many myths and barriers prevent more widespread utilisation. The objective of this article was to explore the health care provider (HCP), health system and user issues that prevent more widespread use of IUCs, particularly among nulliparous women, and to present the evidence that supports achieving greater utilisation of these devices. Methods MEDLINE, PubMed and Embase were used to identify studies reporting attitudes and beliefs around IUCs, and clinical studies providing evidence of their risks and benefits. Results HCP, health system and user factors limiting use of IUCs were identified. The most widely explored barriers in published studies are those at the HCP level. User barriers are less well documented and health system barriers are mostly assessed through indirect evidence. Many, but not all, of the barriers can be reduced through greater understanding of the evidence. Conclusions Efforts need to be made to disseminate the evidence, which shows that few contraindications exist to IUC use. Addressing HCP lack of knowledge, training and confidence with IUC insertions, particularly in nulliparous women, could make a substantial positive impact on IUC utilisation.

Female sterilisation is a safe and effective form of permanent birth control. In the United States (US), it is still the second most commonly used form of contraception overall and is the most frequently used method among married women and among women over 30 years of age. Although several European countries have noted a sharp decline in the number of women electing tubal sterilisation in recent years, such trends have not been as obvious in the US. While female sterilisation remains popular, there are considerable system-level barriers to getting the procedure for certain segments of the population as well as emerging concerns about appropriate utilisation of this contraceptive method in light of newer, reversible options and the knowledge that regret after permanent contraception is high. Given the complexity of this decision-making process, it is critical that providers ensure at the very least that women are aware of the potential disadvantages of tubal occlusion and are knowledgeable of other highly effective contraceptive methods that are available but vastly underutilised in the US, namely, vasectomy, intrauterine contraceptives, and implants.

To estimate whether the Medicaid-Title XIX Sterilization Consent Form (SCF) format--"standard" compared with "low-literacy"--is associated with women's understanding of tubal sterilization. This study was a randomized trial that took place in an obstetrics and gynecology residency clinic in the southeastern United States. Women, aged 21 to 45 years, were randomly allocated to receive a copy of either the standard or the low-literacy Medicaid-Title XIX SCF. A research assistant assessed women's sociodemographic characteristics, health-literacy skills, and understanding of sterilization using items from the Postpartum Tubal Sterilization Knowledge questionnaire. Women were also queried regarding their preferences for either version of the Medicaid-Title XIX SCF. We included 201 women in the study. Compared with women in the standard group (n=99), women in the low-literacy group (n=102) with no additional counseling better understood the length of time required between signing the form and undergoing sterilization (23.6% difference between groups, P<.01), the time interval until the form expired (33.7% difference between groups, P<.01), permanence of sterilization (15.7% difference between groups, P=.01), and that nonpermanent contraceptive options as effective as sterilization are available (8.2% difference between groups, P=.02). When given the choice to select either Medicaid-Title XIX SCF, 189 (94%) preferred the low-literacy version. Our results support replacing the standard Medicaid-Title XIX SCF with the low-literacy version to foster increased understanding of sterilization.

To evaluate readability and layout features of English-language instructions accompanying brandname urinary- and salivary-based over-the-counter (OTC) ovulation prediction devices (OPDs). We identified and purchased 6 urinary-based and 4 salivary-based OTC OPDs. McLaughlin's Simplified Measure of Gobbledygoop was used to calculate reading grade level, and prominent text point size was measured throughout the instructions. Total number and dimensions of illustrations were tallied. We also assessed layout features derived from the User-Friendliness Tool (UFT), including layout features, graphic characteristics, presence of a clear message and presentation of manageable information. Overall reading level of OTC OPD instructions ranged from 8th to 12th grade (mean +/- SD = 10.2 +/- 1.3). Mean page length was 29.0 +/- 12.8 cm, while average page width was 30.7 +/- 14.7 cm. Average text point size was 8.2 +/- 1.5 (range, 6-10). Illustrations were used throughout instructional materials (range, 5-10). None of the instructions scored high in all criteria on the UFT. Most OTC OPD instructions are written above the recommended sixth grade level and lower, printed in a font size smaller than suggested and illustrated inadequately to foster successful patient education.