EXECUTIVE SUMMARY
About 46% of participants in the 2015 Contraceptive Technology Update Contraception Survey say they have seen “dramatically more” women choosing long-acting reversible contraceptive (LARC) methods such as the intrauterine device and contraceptive implant in the last year.
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The American College of Obstetricians and Gynecologists recently strengthened its recommendation regarding use of LARC methods as the most effective and safe forms of reversible contraception.
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Educating providers about LARC and encouraging them to offer these methods to their patients might increase uptake. Research indicates that women who have heard of the IUD from their providers are more likely to be interested in it than women who have not.
About 46% of participants in the 2015 Contraceptive Technology Update Contraception Survey say they have seen “dramatically more” women choosing long-acting reversible contraceptive (LARC) methods such as the intrauterine device (IUD) and contraceptive implant in the last year.
“We have been offering IUDs to women for many years, and, yes, we have definitely seen an increase in requests and insertions of these methods,” says Corinne Rovetti, APRN-BC, nurse practitioner at the Knoxville (TN) Center for Reproductive Health. “I believe the most significant reason being the Affordable Care Act coverage. Also, there has been huge increased marketing of these methods.”
According to a recently published study that looked at data from the National Survey of Family Growth from 2009 to 2012, women’s use of LARC methods has been steadily increasing for about a decade.1 (See infographic at http://bit.ly/1PjKFoO.) During 2009-2012, use of LARC methods, particularly IUDs, increased almost uniformly across the national population of users, with significant increases documented among some of the groups of females who are typically at highest risk for unintended pregnancy, such as young adults and disadvantaged females. (Contraceptive Technology Update reported on the research. See “More women reported to be moving to long acting reversible contraceptives,” January 2016.)
The American College of Obstetricians and Gynecologists (ACOG) recently strengthened its recommendation regarding use of LARC methods as the most effective and safe forms of reversible contraception.2
The recommendation, released by ACOG’s Committee on Gynecologic Practice and its Long-Acting Reversible Contraception Working Group, urges providers to encourage patient consideration of implants and intrauterine devices, to educate patients on LARC options, and to advocate for insurance coverage and appropriate payment and reimbursement for every type of contraceptive method.
The Committee Opinion guides clinicians to increase access to LARC methods by encouraging best practices in provision of LARC methods, including removing barriers to LARC insertion, says Eve Espey, MD, MPH, chair of the College’s LARC Working Group. A few best practices include the following:
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Create same-day protocols for IUD and implant insertion. If pregnancy can reasonably be ruled out, insert the IUD or implant on the same day the woman comes in for contraception.
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Strike requirements for an additional visit prior to IUD insertion for sexually transmitted infection (STI) screening. If screening test results are positive, infections may be treated with the IUD in place.
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Offer LARC methods at the time of delivery, abortion, or dilation and curettage for miscarriage.
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Offer the copper IUD for emergency contraception.
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On the advocacy side, work to allow Medicaid and private insurance to reimburse for immediate postpartum IUDs and implants.2
EDUCATE AND INFORM
Providers should encourage consideration of implants and IUDs for all appropriate candidates, including nulliparous women and adolescents, states the new committee opinion.2 Educating providers about LARC and encouraging them to offer these methods to their patients might increase uptake. Research indicates that women who have heard of the IUD from their providers are more likely to be interested in it than women who have not.3
The Association of Reproductive Health Professionals offers a free webinar, Comparative Contraception: Reversible and Permanent Options, to help providers discuss LARC and permanent birth control methods. (Access the webinar at http://bit.ly/1O9NvK0.) After viewing the webinar, providers should be able to do the following:
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describe the benefits, risks, and side effects of long-acting reversible and permanent contraceptive methods;
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identify potential candidates for long-acting reversible and permanent contraception;
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discuss myths and other potential barriers to the use of long-acting reversible and permanent contraception;
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describe shared decision-making that helps women choose a contraceptive method;
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identify sources of evidence-based information for patients on long-term and permanent contraception.
PENCIL IN AWARENESS WEEK
Want to promote awareness about LARC methods? Consider participating in the 2016 LARC Awareness Week, Nov. 13-19.
The annual event, coordinated by the California Family Health Council with other women’s health advocacy groups, seeks to increase awareness about LARCs as a safe, effective, low-maintenance, and long-acting birth control method. The event website, www.love-my-larc.org, offers resources, such as a Why LARCs information sheet and a media kit for promoting the event.
The California Family Health Council also has developed the website www.safeandeffective.org to help patients and providers understand the benefits and disadvantages of LARC methods. At the website, providers can obtain information on training staff to counsel on LARC methods. There also are training videos and a facilitator’s guide that will help provide a 30-minute in-service training for staff of reproductive health and family planning clinics who provide contraceptive counseling to adolescents and young women. The material is appropriate for physicians, nurse practitioners, nurses, health educators, and others. Also available on the website is patient information on LARC methods and resources to help providers develop a LARC clinic at their facilities.
WHAT'S THE NEXT STEP?
What can providers expect when it comes to increasing access to LARC methods?
“I think the next great step forward will come when postpartum women can routinely count on getting their implants and IUDs before they are discharged home from delivery,” says Anita Nelson, MD, professor emeritus in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
Postpartum women are in need of effective contraception. Results from a recent national study indicate that at three months postpartum, 72% of women were using some type of contraceptive; 6% used LARCs, and 0.5% of these women became pregnant within 18 months of delivery. In comparison, 28% of women relied on hormonal methods, and 25% used less-effective forms of contraception. Data indicate 13-18% of these women became pregnant within 18 months, as did 23% of women using no contraception.4 At least 70% of pregnancies among U.S. women in the first year after delivery of a child were unintended, data indicate.4 (Read more on the research. See “Long-acting reversible contraceptives used by few women after delivery,” Contraceptive Technology Update, September 2015.)
The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) classifies immediate postpartum copper IUD insertion as Category 1 and immediate postpartum levonorgestrel intrauterine system insertion in nonbreastfeeding and breastfeeding women as Category 2. Insertion of the implant is safe at any time in nonbreastfeeding women after childbirth (Category 1 rating). The US MEC classifies the placement of an implant in breastfeeding women less than four weeks after childbirth as Category 2 because of theoretic concerns regarding milk production and infant growth and development. Implants may be offered to women who are breastfeeding and more than four weeks after childbirth because the US MEC classifies delayed insertion as Category 1.5
Insurance-related barriers might prevent many women from obtaining LARCs before being discharged from the hospital. In many states, intrauterine devices or the contraceptive implant are not included in the “global” obstetric fee, which means hospitals will incur a financial loss if a postpartum patient receives a LARC method prior to discharge. Advocacy is needed to help remove such financial barriers to effective contraception.6
REFERENCES
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Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009-2012. Obstet Gynecol 2015; 126(5):917-927.
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Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2015; 126(4):e44-48.
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Fleming KL, Sokoloff A, Raine TR. Attitudes and beliefs about the intrauterine device among teenagers and young women. Contraception 2010; 82:178-182.
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White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol 2015; 125(6):1471-1477.
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Centers for Disease Control and Prevention (CDC). Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. Morb Mortal Wkly Rep 2011; 60(26):878-883.
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Rodriguez MI, Evans M, Espey E. Advocating for immediate postpartum LARC: increasing access, improving outcomes, and decreasing cost. Contraception 2014; 90(5):468-471.
