Oct08-final
Assessment and Patient Satisfaction following…
Aarti Umranikar and Sameer Umranikar
Assessment and Patient Satisfaction
following the Use of Intrauterine
Contraceptive Devices
AARTI UMRANIKAR AND SAMEER UMRANIKAR
Ob jec tive: The aim of the study was to de
ter
mine the in
crease in use of the
intrauterine con tra cep tive de vice (IUD/IUS) used by women from Southampton, U.K.;
to as sess views of pa tients re gard ing the con tra cep tive ser vices of fered; and as sess
pa tient sat is fac tion.
Study De
sign: The tar
get group for this study were the pa
tients at
tend
ing the
Con
tra
cep
tive Sex
ual Health (CASH) clinic and the Pri
mary Care Set
ting in
Southampton. In for ma tion was ob tained about the types of con tra cep tives used by the
1,524 women who formed part of the study group from where data was col lected. A
ques tion naire was then sent to 50 women of this group, re gard ing their ex pe ri ence
while re ceiv ing the intrauterine con tra cep tive de vice and the sat is fac tion de rived.
Each item was graded on a scale of 5 to 1, that is, ‘ex
tremely happy’ to ‘very
dis sat is fied’ us ing the Likert Scale of pa tient sat is fac tion.
Re sults: Out of the 1,524 pa
tients, 7.02% women pre
ferred to use IUD/IUS while
30.19% used a com
bined pill, 9.84% used in
jec
tion Depo-Provera, 6.30% used
im plants and 46.72% used other meth ods like con doms. 94.4% of the women were
very sat is fied with the over all ser vices of fered (grades 5 and 4 on Likert scale).
It was ob served that there is a di rect cor re la tion be tween women’s as sess ment of
ser vices and their ex pe ri ence of coil in ser tion. If the ex pe ri ence of the woman at coil
in
ser
tion was very good, it cor
re
lated well with the level of sat
is
fac
tion that she
ex pressed about ser vices of fered and this was sta tis ti cally sig nif i cant.
Con clu sion: In crease in us age of IUD/IUS was re corded at 7.02% for those women
from Southampton U.K. who availed NHS fa cil ity, com pared to the na tional av er age of
4%; and these pa tients were very sat is fied with the ser vices pro vided.
Dr. Aarti Umranikar is Specialist Registrar in Obstetrics and Gynaecology, St. Mary’s
Hospital, Portsmouth, U.K; and Dr. Sameer Umranikar is Specialist Registrar in
Obstetrics and Gynaecology, North Hampshire NHS Trust, U.K.

INTRODUCTION
Planning the size of the family and contraception are important issues
worldwide. In offering optimum contraceptive services, factors like the
safety and efficacy of the method, its convenience, cost, reversibility,
acceptability, availability of services and the trained service providers
play a vital role. A successful programme is often the result of patients
receiving adequate information on the various contraceptive methods
available and also on the provision of good quality services.

608 Assessment and Patient Satisfaction following…
There are a number of methods of contraception available worldwide
and practised as well in various countries. One such method of
contraception is the intrauterine contraceptive device (IUD). While the
World Health Organization (WHO) estimates 156 million IUD/IUS
users worldwide, 60% (92 million) are from China alone, while in the
U.K., the current usage is around 4%.
Modern IUD/IUS are safe, reliable and highly cost effective methods
of contraception. Clinical effectiveness of IUD/IUS is excellent with a
recognised failure rate being quoted as 0.2–2/100 woman years for the
IUD and 0.16/100 woman years being quoted for the hormone releasing
intrauterine system (Mirena IUS). This compares well with a failure
rate of 0.5/100 woman years for female sterilization.
The safety, effectiveness and acceptability of the currently available
IUD/IUS depends not only on the device itself but also on the quality of
services provided which include expertise in counselling, good fitting
techniques and an easily accessible follow-up care.
The recent NICE guidelines on Long Acting Reversible
Contraceptives (LARC) have demonstrated excellent cost effectiveness
of these methods, which is greater than the combined oral
contraceptive pill even at one year of use. In fact, the IUD/IUS were the
most cost effective of all the LARC methods looked at in the guidelines.
Despite all this, surveys indicate that in England and Wales, IUD/IUS
are underused as compared to other methods of contraception.
Available literature suggests that a number of factors may be
associated with a reluctance to use the IUD/IUS, which include pain,
menstrual disturbances, infection, pregnancy, infertility and doubts
about its effectiveness.
There are few studies which explore women’s view or perceptions
about contraception and even fewer that examine the way they
perceive the IUD/IUS.
Against this background, work was undertaken to find out that the
usage of IUD/IUS as a method of contraception; to identify any
deficiencies in the services provided to the user; to assess views of
patients regarding IUD/IUS as a contraceptive method; and their
overall satisfaction regarding the services.
METHODOLOGY
The present study was undertaken in 2006 in Southampton, U.K., in
Contraception and Sexual Health (CASH) clinics and in primary care
settings.
The study-design was circulated to all doctors working in the
contraception and sexual health clinics and to all practice managers
from GP surgeries in Southampton, where IUD insertions were being
regularly undertaken. Data was collected from CASH clinics and also
from four GP surgeries which participated in the study. Study-design
was approved by the local Ethics Committee.

Aarti Umranikar and Sameer Umranikar 609
From this, information was obtained regarding the type of
contraceptive method used by women. This enabled us to find out the
use of IUD/IUS as a contraceptive method chosen by women in
comparison to other contraceptive methods offered.
Relevant findings were entered from these records with special
reference to counselling, information provided by the doctor about
failure rate of IUD/IUS, effect on menstruation, risk of expulsion, risk
of perforation, infection, etc.
A total number of 50 such women were given a set of two
questionnaires (Appendices 1 and 2) regarding their experience while
using the contraceptive services; and 39 women agreed to participate
and replied by filling the proforma of several questions. Analysis of the
data was undertaken regarding quality of services provided and
patient satisfaction. The questionnaire involved details about patient
satisfaction ranging from extremely happy to very dissatisfied, graded
from 5 to 1, respectively. All the results on satisfaction were assessed
using ‘Likert Scale of Patient Satisfaction’.
RESULTS
A total number of 1,524 patients attended the clinics during the study
period
TABLE 1: Method of Contraception Used by Women
Method of Contraception
No. of Women
Percentage
Combined Oral Contraceptive Pill
459
30.19
(COCP) + Progesterone Only Pill (POP)
Injection Depo Provera
150
9.84
IUD/IUS
107
7.02
Implants
96
6.30
Others (Condoms, etc.)
712
46.72
Total
1,524
100
The findings show that a majority of women used either barrier
contraception or the combined oral contraceptive pill. The usage of
IUD/IUS was found to be 7.02%.
The following is the analysis of data from 50 patients who had
undergone an IUD insertion:
TABLE 2: Age Distribution of the 50 Patients Who Used IUD/IUS
Age Group
No. of Women
Percentage
Below 20 years
1
2
20–40 years
41
82
Above 40 years
8
16
Total
50
100


610 Assessment and Patient Satisfaction following…
TABLE 3: Type of IUD Used by the 50 Patients
Type of IUD
No. of Women
Percentage
T-Safe Cu 380 A
23
46
Mirena IUS
24
48
Nova T
3
6
Frameless


Inert


Total
50

100

Using Fisher’s Exact Test, it was seen that there exists a statistically
significant correlation between the women’s perceptions regarding
‘overall services’ with their ‘experience at the time of coil insertion’ (P <
0.001). This shows that those women who had a good experience at the
time of coil insertion expressed a satisfactory response regarding the
services provided.
When overall services were compared with other parameters like
counselling, ability to ask questions, provision of information leaflets
and advice on pain relief, it was seen that there exists a correlation but
was not found to be statistically significant. (p>0.01)
DISCUSSION
Nearly 40 years ago, the United Nations conference on population
recognised family planning as a basic human right and stated that all
couples and individuals have the basic human right to plan their
families freely and responsibly and to have the information, education
and means to do so. As a result, over the past several decades, family
planning and contraception have emerged as the most important basic
social right of a human being and more so of a woman.
Large scale research conducted all over the world has led to the
development of various methods of contraception to be presented to the
woman or her partner. An ideal contraceptive should be 100%
convenient, coital independent, 100% reversible, 100% safe, cheap,
easy to distribute, independent of medical profession (no monitoring or
follow-up required), acceptable to be used by the woman and obviously
visible to the woman. All the available methods of contraception fall
short by one or more criteria, yet their efficacy far outweigh their risks
and, hence, are in use today. The various methods could be surgical like
sterilization (tubal ligation and vasectomy) and non-surgical like the
oral contraceptive pill (mini-pill, combined pill), male condom, female
condom, injection, implant, intrauterine device, intrauterine
systems-hormone releasing (IUD/IUS), caps, diaphragms, foams, gels,
etc. Different countries, all over the world, show varying percentages of
contraceptive methods used. In the U.K., 28% of the women use the pill,
21% use male condoms, 4% use the IUD/IUS (3% IUD + 1% IUS ) 3%
use injection/implant, 1% caps or diaphragms, 22% use surgical

Aarti Umranikar and Sameer Umranikar 611
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612 Assessment and Patient Satisfaction following…
methods (sterilization male, female), 2% use safe period method, and
1% use emergency contraception as per the Omnibus Survey, 2002
(Office for National Statistics).
Meanwhile, statistics from the developing world shows that in India,
1.9% use IUD/IUS, 1.2% use the pill, 31% women undergo sterilization
and 40.7% use other methods. In Sri Lanka 2% of the women use IUD,
5% use pills, 7.7% undergo sterilization, 3% use injectable and 62% use
any other method. In the U.S., the use of IUD as a method of
contraception fell from 10% in the mid-1970s to only 1% in 2003–04. It
is interesting to note that a survey on contraceptive use by female
members of the American College of Obstetricians and Gynaecologists
showed than 17% of them used IUD to postpone a pregnancy and 27%
used an IUD when no future pregnancy was desired.
USE OF IUD
In the present study, 7.02% of women used IUD/IUS as a method of
contraception, which is above the national standard of 4%.
The Omnibus Survey, conducted by the office for National Statistics,
reveals results conducted in the UK where the use of IUD was 4% in
1997–98; and 2001–02 the usage of IUD was 3% and IUS was 1% (total
2
usage 4%).
However, our present study with 7% usage of IUD/ IUS could be a
reflection of the high standard of counselling, provision of information
and good quality of services provided in this region.
As seen from the Table 4, patient feedback was obtained through
two questionnaires. Patients psychometric expressions like ‘strongly
disagree, very happy, disagree, happy, unhappy’ were converted into a
score using Likert Scale 5 points. (5=strongly agree or very happy,
4=agree or happy, 3=neither agree nor disagree or satisfied,
2=disagree or unhappy, 1=strongly disagree or very unhappy).
Patient’s responses to 13 questions that were asked have been graded
using the Likert Scale of Satisfaction. This is a widely used scale since
1932 and grades patient responses related to their satisfaction.
It has the advantage of better gradation but sometimes respondents
may not be able to perceive smaller differences. The scale still is a
representation of an ordinal level of measurement and is in common use.
A summative score of all the parameters of satisfaction gives the
following results:
Score of 5 has been the highest category, that is, very happy.
When calculated for all women under all 12 parameters, it gave a
value of 788.6 points out of 1080;
Score of 4 is the second category, that is, happy and a value of
338.9 points was obtained;
Score of 3 is the third category which meant neither satisfied nor
dissatisfied, a value of 27.8 was obtained;

Aarti Umranikar and Sameer Umranikar 613
Similarly, for second category, that is, unhappy, a value of 15.6
was obtained; and
For category one which means very unhappy a score of 11.2 was
obtained.
Non-responders score was 28. All these point out that the highest
score was obtained by category one which testified highest level
satisfaction.
All women expressed maximum satisfaction regarding counselling
provided by doctors. It is known that a well-undertaken consultation
with good counselling helps to increase women’s understanding of the
IUD/IUS which in turn reduces unfounded fears or exaggerated
concerns.
This finding was confirmed, stating that 100% compliance was noted
as regards discussing the efficacy, benefits, risks, etc., with patients
thus stressing the importance of counselling resulting in better usage
of this method.
It was observed that 44.44% of the patients felt that they could ask
the service providers (doctor/nurse) questions they wanted to, while
55.6% could ask most of the questions. This shows that the doctor’s
ability to communicate, availability, approachability, ability to allay
anxiety and fear was very good. This is probably one important area
that helps women opt to use the IUD/IUS. Good training to service
providers and their motivation has probably resulted in good
counselling and women therefore rightly felt that their questions were
answered and difficulties solved.
94.4% of the women were provided with pre- and post-insertion
information leaflets and 94.4% of women understood it. 72.2% of patients
read all the information provided, 16.6% read most of it, 5.6% read some
of it and 5.6% gave no response, that is, they could not remember.
All these observations document that the most important and
effective way of counselling and communication was direct face-to-face
discussion by the doctor supported by provision of written information
leaflets.
Experience of Women with Regard to Coil Insertion
38.9% of women said that they were very happy with the procedure of
coil insertion, 27.8% were happy while 22.2% were just satisfied. 5.6%
were unhappy and 5.6% were very unhappy. The major reason for
dissatisfaction was the pain factor, despite the fact that all women
received pain relief advice. Two women had written an added comment
that the pain was too severe.
Experience Regarding Overall Service
94.4% of women were happy with the services provided. No woman was
unhappy with the service. Analysis of Table 4 showed that there is some

614 Assessment and Patient Satisfaction following…
correlation between women’s assessment of services. If the experience
of coil insertion has been good for the woman, there is a good chance
that she would be satisfied with overall services provided. This
correlation is statistically significant (p<0.001). There is also direct
correlation between counselling and overall services. All the women
agreed that they would recommend the services to a friend thereby
indicating 100% user satisfaction.
Work done by R. Tewari and V.J. Kay on assessment of user
satisfaction and duration of use of IUD observed that overall
satisfaction with family planning services in Fife, Scotland, among 254
women was high with similar side effects in different types of IUDs
except for higher mood disorders with LNG-IUS. A study by C. Asker, et
al.
, in Birmingham identified the perceptions of non-users of IUD,
which were found to be mainly related to lack of information, reported
side effects, anxiety about process of fitting, risk of infection, lack of
personal control, rarely messy and embarrassing while fitting, hidden
nature of the device and unreliability. Many such studies have quoted
the efficacy and safety of IUDs. However, a comprehensive study
auditing compliance by practitioners and assessing patient satisfaction
is not undertaken by investigators, as is done in our present study.
CONCLUSIONS
An overall 7.02% uptake of IUD was recorded as a method of
contraception used by women, which is in line with the target to be
achieved as per NICE guidelines. This is above the U.K. national
standard of 4%.
Patient’s feedback reported a very satisfactory overall response
(94.4% of women) regarding services offered.
There was a direct correlation between experiences at coil insertion
and overall services offered thereby meaning that good fitting
techniques along with appropriate counselling and information
provision are of paramount importance. This was statistically
significant.
REFERENCES
Asker C., Stokes L.H., : What is it about Intrauterine De vices that Women Find
Beaven J. and
Un
ac
cept
able? Fac
tors that make Women Non-users: A
Wil son S.
Qual i ta tive Study. London: Jour nal of Fam ily Planning
2006
and Re pro duc tive Health Care, 32(2), 89–94.
Guillebaud
: Con tra cep tion — Your Ques tions An swered, London:
J.2004
Churchill Livingstone, 16–17.

Aarti Umranikar and Sameer Umranikar 615
Tewari R. and
: Com pli ance and User Sat is fac tion with the Intra-uterine
Kay V.J.
Con tra cep tive De vice in Fam ily Planning Ser vice: The
2004
Re sults of a Sur vey in Fife, Scot land, Au gust 2004, London:
The Eu ro pean Jour nal of Con tra cep tion and Re pro duc tive
Health Care,
58(2), 195–211.
UNFPA
: Information and Knowledge for Optimal Health (Info),
2006 – 2007
Baltimore: Population Reports (Info), 3–7.
2003
: State of World Pop u la tion, Information and Knowledge for
Optimal Health (Info), New York: Population Reports
(Info), 3–7..
White, B.
: Pa tient
Sat is fac tion
Sur veys
Mea sur ing
Pa tient
1999
Sat is fac tion: How to do it and why to bother, Amer i can
Acad emy of Fam ily Phy si cians,
1–5.
APPENDIX 1: Pre-IUD Insertion Questionnaire
1.
I Consider myself to be in the following age-group
<20yrs
20-40yrs
>40yrs
2.
Are you a first time user of the coil (IUCD /IUS)?
Yes/No
If Yes, proceed to 3, 4; If No, proceed to 5
3.
State the contraceptive method you are currently using
Pill/Injection/implant/Condoms/None/Other (please specify)
4.
Is the coil being fitted as
Planned contraceptive / Emergency contraceptive
5.
Are you here for a coil replacement/coil check
Yes/No
If Yes, proceed to 6, 7, 8 and 9; If No, proceed to 10
6.
Your coil has been fitted as part of
Emergency contraceptive / Planned contraceptive
7.
How long are / have you been using the coil?
Months/Years
8.
Have you ever become pregnant with the coil?
Yes/No
9.
Has the coil ever fallen out / been expelled?
Yes/No
10. Are you here for a coil removal?
Yes/No
If Yes, proceed to 11, 12
11. Possible reasons for coil removal
Ongoing pain/Bleeding problems/Risk of infection/Worried about risk of
ectopic pregnancy/Partner feels the coil threads/Foreign body effect/Worried
about becoming pregnant with the coil/any other (please state)
12. Your coil was fitted as part of
Emergency contraceptive/Planned contraceptive

616 Assessment and Patient Satisfaction following…
APPENDIX 2: Post-IUD Insertion Questionnaire
1.
I had all the appropriate counselling regarding the chosen
contraceptive method
Strongly agree/Agree/Disagree/Strongly disagree
2.
I was unable to ask the doctor/nurse questions I wanted to
Strongly agree/Agree/Disagree/Strongly disagree
I was provided with the patient information leaflet
Agree/Disagree/Cannot remember
3.
I did not understand the information provided
Agree/Disagree
4.
How much of the information leaflet were you able to read?
I did not read it/I read some of it/I read most of it/I read all of it
5.
I was advised regarding timing of insertion of coil (with respect to
menstrual cycle)
Agree/Disagree
6.
I received adequate advice regarding pain relief
Agree/Disagree
7.
What was your expertise regarding coil insertion?
Very Happy/Happy/Satisfied/Unhappy/Very Unhappy
8.
Did you have enough time to recover
Adequate/Inadequate
9.
Did you receive the after-fitting advice leaflet and emergency
contact numbers
Yes/No/Cannot remember
10. Would you recommend this method to a friend?
Strongly Agree/Agree/Disagree/Strongly Disagree
11. Your opinion regarding the overall service
Very happy/happy/Unhappy
THE INDIAN JOURNAL OF SOCIAL WORK, Vol ume 69, Issue 4, October 2008