By Rebecca Bowers

EXECUTIVE SUMMARY

Family planning providers should develop ways to provide contraceptives to patients in one visit (known as Quick Start) for all methods, according to the Family Planning National Training Center’s Contraceptive Access Change Package. New research indicates that while most public-sector and private providers consider Quick Start for combined hormonal contraceptives and depot medroxyprogesterone acetate (DMPA) safe for use among adolescents, fewer private providers utilize the technique.

  • There is no medical reason for providers to require multiple visits routinely to start any contraceptive method if the U.S. Selected Practice Recommendations for Contraceptive Use criteria for excluding pregnancy are met.
  • While the use of DMPA is associated with loss of bone mineral density, the loss appears to be significantly or completely reversible, evidence suggests. In most situations, the benefits of DMPA use will outweigh the theoretical fracture risks.

Family planning providers should develop ways to provide contraceptives to patients in one visit (known as Quick Start) for all methods, according to the Family Planning National Training Center’s Contraceptive Access Change Package.1 However, new research indicates that while most public-sector and private providers consider Quick Start for combined hormonal contraceptives and depot medroxyprogesterone acetate (DMPA) safe for use among adolescents, fewer private providers utilize the technique for this population.2

To perform the analysis, researchers at the Centers for Disease Control and Prevention mailed surveys to a random sample of 4,000 public health centers that provide family planning services and 2,000 office-based physicians. The 33-item questionnaire was designed to evaluate attitudes and practices among clinicians regarding providing contraception and applying federal guidance and recommendations about contraception.

The analysis indicates that 87.5% of public-sector providers and 80.2% of office-based clinicians consider Quick Start initiation of combined hormonal contraceptives to be safe for teens, with similar numbers indicating they thought it was safe for DMPA (80.9% and 78.8%, respectively). However, providers, especially office-based ones, indicated a lower use of Quick Start initiation of contraception methods. A total of 45.2% said they used the technique with combined hormonal methods, and 46.9% said they employed the tactic for DMPA starts.

Quick Start use fared better with public-sector providers: 74.2% indicated they used it with combined hormonal methods, while 71.4% did so with DMPA.

Providers generally perceive combined hormonal contraceptives and DMPA as acceptable contraceptive methods for adolescents, notes researcher Isabel Morgan, MSPH, who is now enrolled in the maternal and child health doctoral program at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health. The current study allowed the study team to identify provider concerns about same-day initiation of these methods to adolescents, she said in a press statement.

Guidance Backs Use

According to the Family Planning National Training Center’s Contraceptive Access Change Package, providers of family planning services should develop systems to provide contraception in one visit for all contraception methods. This practice allows providers to help all patients, including women choosing long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants, to leave the office visit with their chosen contraception method.2

Women should be offered the opportunity to begin a birth control method at the time of the office visit instead of waiting for their next menses or coming back for a follow-up appointment.3 There is not a medical reason for providers to routinely require multiple visits to start a contraceptive method, provided the U.S. Selected Practice Recommendations for Contraceptive Use criteria for excluding pregnancy are met.4

What are those criteria? Providers can be reasonably certain that a woman is not pregnant if she does not have any pregnancy symptoms or signs and if she meets any of the following criteria:

  • she has not had intercourse since her last normal period; OR
  • she has been using a reliable contraceptive method correctly and consistently; OR
  • it is within seven days after her normal menses; OR
  • the patient is within four weeks postpartum and is not lactating; OR
  • it is within the first seven days after an abortion or miscarriage for the patient; OR
  • the patient is completely or nearly completely breastfeeding, amenorrheic, and it is less than six months after childbirth.4

What About DMPA and Teens?

According to a 2014 American College of Obstetricians and Gynecologists Committee Opinion, DMPA’s convenient dose schedule of four times per year makes it attractive to many women, especially adolescents. Although DMPA use is associated with loss of bone mineral density (BMD), the losses appear to be substantially or fully reversible, according to evidence, the guidance states.5 However, the drug still carries a black box warning mandated by the Food and Drug Administration stating that prolonged DMPA use may result in significant BMD loss, the BMD loss is greater with longer use of the drug, and it may not be possible to completely reverse the BMD loss after discontinuing the drug.5 This concern is not reflected in the U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.6

The latest edition of Contraceptive Technology advises that providers counsel both adult and adolescent patients about the advantages and risks, including the black box warning, of DMPA use.7 In most situations, the benefits of DMPA use will outweigh the theoretical fracture risks, it states.

REFERENCES

  1. Family Planning National Training Center. Contraceptive Access Change Package. April 2017. Available at: https://bit.ly/2ANQ7yR. Accessed Jan. 17, 2019.
  2. Morgan IA, Ermias Y, Zapata LB, et al. Health care provider attitudes and practices related to ‘Quick Start’ provision of combined hormonal contraception and depot medroxyprogesterone acetate to adolescents. J Adolesc Health 2018; doi:10.1016/j.jadohealth.2018.08.012.
  3. Gavin L, Moskosky S, Carter M, et al; Centers for Disease Control and Prevention (CDC). Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(RR-04):1-54.
  4. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-66.
  5. [No authors listed]. Committee Opinion No. 602: Depot medroxyprogesterone acetate and bone effects. Obstet Gynecol 2014;123:1398-1402.
  6. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.
  7. Wu W-J, Bartz D. Injectable contraceptives. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 21st revised edition. New York: Ayer Company Publishers, 2018.