By Rebecca Bowers

EXECUTIVE SUMMARY

In 2002, just 2.4% of U.S. women using birth control were using long-acting reversible contraceptive (LARC) methods, such as the intrauterine device or the contraceptive implant. By 2014, about 14% of women using birth control reported LARC use.

  • The increase in LARC method use has come in part as a result of the research demonstrating its positive effect on unintended pregnancy and abortion.
  • In presenting information about LARC methods and other contraceptive options, clinicians should strive to offer comprehensive, scientifically accurate information in a medically ethical and culturally competent manner to support patients in identifying the method that best meets their needs.

In 2002, just 2.4% of U.S. women using birth control were using long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) or the contraceptive implant. By 2014, about 14% of women using birth control reported LARC use.1

The increase in LARC method use has come in part as a result of research demonstrating its positive effect on unintended pregnancy and abortion. In the Contraceptive CHOICE project, 9,256 women 14-45 years of age received their choice of contraceptive method free of charge. About 75% of women chose long-acting methods, with significant results. The project researchers noted a significant decrease in unintended pregnancy and abortion rates among participants in the study compared to a similar population from the same region.2

In the Zika Contraception Access Network (Z-CAN), a program designed to prevent unintended pregnancies and decrease birth defects during the height of the 2016-17 Zika virus outbreak in Puerto Rico, 67.5% of 21,124 women chose a LARC method and received it during their initial visit.3

In the Colorado Family Planning Initiative, clients of Title X-funded clinics in 37 counties received no-cost access to LARC methods. Data indicate that the use of LARC methods increased from 5% to 19% among low-income young women and teens. Along with the increased use of LARC methods, investigators observed decreases in birth rates and abortion rates in both age brackets.4

Since the 2008 inception of the American College of Obstetricians and Gynecologists (ACOG) LARC Program, the program has worked to increase access to the full spectrum of contraceptive methods by connecting providers, patients, and the public with the most up-to-date information and resources on LARC, says Eve Espey, MD, MPH, professor in and chair of the Department of Obstetrics and Gynecology at the University of New Mexico in Albuquerque. Espey serves as chair of the ACOG LARC Work Group.

Updated guidance concerning LARC use also has increased use of the method. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 classifies IUD use in women who have not had a baby and in adolescents (20 years of age or younger) as Category 2, indicating the advantages outweigh the risks. Implants are classified as Category 1 indicating no restrictions.

The insertion of the copper IUD or levonorgestrel IUD immediately after an induced or spontaneous first-trimester abortion is classified as Category 1. Insertion in the second trimester after abortion is classified as Category 2. Contraceptive implant insertion immediately after an induced or spontaneous first-trimester abortion or second-trimester abortion (using medication, uterine aspiration, or dilation and evacuation) is given a Category 1 classification.5 Both the American Academy of Pediatrics and ACOG endorse the use of LARC for adolescents.6

Check ACOG Resources

The ACOG LARC Program’s Postpartum Contraceptive Access Initiative offers an online resource hub, technical assistance, and comprehensive, individualized trainings, all free of charge. The initiative is designed to promote the success and sustainable implementation of immediate postpartum LARC services.

The immediate postpartum period can be a good time to provide long-acting reversible contraceptive methods. The prenatal care period is an ideal time for healthcare provider discussions with patients about long-term birth control in the immediate postpartum period. These counseling discussions should provide information on the advantages of LARC methods, IUD expulsion risks, contraindications, and alternative options to ensure informed decision making.7

LARC use is safe in the postpartum period. According to the US Medical Eligibility Criteria for Contraceptive Use, initiating IUDs and implants immediately postpartum has a Category 1 (no restriction for use) or Category 2 (the advantages generally outweigh the theoretical or proven risks) classification.5

Another free ACOG clinical resource is the ACOG LARC Program Help Desk, an online platform that offers individualized, expert technical assistance for clinicians on any LARC-related questions, including payment and reimbursement issues, coding, and clinical concerns. The Help Desk also includes information resources available for free access and download.

Clinicians also should check out ACOG’s LARC video series. The series includes 25 short videos that provide overviews of various LARC-related topics and that were developed in collaboration with Innovating Education in Reproductive Health. The on-demand videos serve as content refreshers for experienced clinicians and educational tools for learners.

Focus on Shared Decision Making

Recently, many thought leaders have expressed concerns about potential contraceptive coercion and have proposed a lengthier patient-centered counseling model when providing LARC methods, notes Anita Nelson, MD, professor in and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.

To reinforce the tenets of reproductive justice, the SisterSong: Women of Color Reproductive Justice Collective and the National Women’s Health Network have developed the LARC Statement of Principles. National organizations, including the Society for Adolescent Health and Medicine, Advocates for Youth, and Physicians for Reproductive Health, endorse the principles that “commit to ensuring that people are provided comprehensive, scientifically accurate information about the full range of contraceptive options in a medically ethical and culturally competent manner to ensure that each person is supported in identifying the method that best meets their needs.”8

In talking with young women about contraception, clinicians may want to use conversation openers such as, “I want you to know that I recommend these methods to all of my patients, regardless of their race, social class, or number of children; however, these methods might not be right for everyone, and I want to make sure we find the one that works best for you.”9

It also is critical for healthcare professionals to self-evaluate how their personal biases may affect their contraceptive counseling methods with young people.10

Consider using questions such as “What matters most to you in a contraceptive method?” and “What are your preferences?” to support patients while reinforcing shared decision making.10 (Read more about reproductive justice tenets in Contraceptive Technology Update’s June 2018 “Teen Topics” column, “Beyond Efficacy: Applying a Reproductive Justice Framework to Contraceptive Counseling for Young People,” at https://bit.ly/2AP8iUB.)

REFERENCES

  1. Kavanaugh ML, Jerman J. Contraceptive method use in the United States: Trends and characteristics between 2008, 2012 and 2014. Contraception 2018;97:14-21.
  2. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291-1297.
  3. Lathrop E, Romero L, Hurst S, et al. The Zika Contraception Access Network: A feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreak. Lancet Public Health 2018;3:e91-e99.
  4. Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014;46:125-132.
  5. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.
  6. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2017;130:e251-e269.
  7. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:e32-e37.
  8. Shah B, Akers A. Collaboration or coercion: Challenges in prioritizing youths’ agency and autonomy in contraceptive counseling and provision. Presented at the Society for Adolescent Health and Medicine Annual Meeting. Seattle; March 2018.
  9. National Women’s Health Network and SisterSong: Women of Color Reproductive Justice Collective. Long-Acting Reversible Contraception Statement of Principles. Available at: https://bit.ly/2VXopsj. Accessed Jan. 17, 2019.
  10. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: Perceptions of young adult women. Am J Public Health 2016;106:1932-1937.