EXECUTIVE SUMMARY

One in three women of reproductive age has been diagnosed with at least one chronic condition that could lead to adverse health and pregnancy outcomes — yet few are using the most effective forms of birth control to prevent unplanned pregnancies, according to research from the University of Utah.

Women who have a history of heart disease, breast cancer, epilepsy, high blood pressure, and diabetes are at risk for complications during pregnancy.

However, women with such pre-existing conditions may not be receiving adequate counseling about the safest and most effective birth control options for them, researchers say.


The 34-year-old patient was diagnosed with diabetes in early adolescence. She is not using any form of contraception. What are the best options for her?

One in three women of reproductive age has been diagnosed with at least one chronic condition that could lead to adverse health and pregnancy outcomes — yet few are using the most effective forms of birth control to prevent unplanned pregnancies, according to research from the University of Utah.1

Women who have a history of heart disease, breast cancer, epilepsy, high blood pressure, and diabetes are at risk for complications during pregnancy. However, women with such pre-existing conditions may not be receiving adequate counseling about the safest and most effective birth control options for them, researchers say.

While many health providers may consider reproductive-age women fairly healthy, chronic health conditions exist in this age population. An analysis of a nationwide healthcare claims database of reproductive-age women from 2004-2011 indicates that despite the potential for serious maternal and fetal pregnancy-associated risks, contraceptive use was not optimal among women with medical conditions.2

“Unfortunately, many of these women aren’t seeing an OB/GYN until they are pregnant,” said lead author Lori Gawron, MD, MPH, assistant professor of in the University of Utah Department of Obstetrics and Gynecology, in a press statement.3 “That suggests to me that there are a lot of missed opportunities in the healthcare system to make sure these women understand the risks of pregnancy, particularly if their disease isn’t under control.”

More Than 700,000 Women Assessed

Researchers used the Utah Population Database to identify 742,000 reproductive-age women who sought treatment at either University of Utah Health or Intermountain Healthcare between January 2010 and December 2014. They used administrative codes to identify highly effective contraception and flag chronic health conditions listed in the US Medical Eligibility Criteria for Contraceptive Use (US MEC) known to increase risk of adverse pregnancy outcomes. Multinomial logistic regression was used to relate demographic and disease status to contraceptive use.

The results show that of the 741,612 women assessed, 32.4% had at least one chronic health condition, and 7.3% had two or more chronic conditions. Researchers report that 7.6% of women with a chronic health condition used highly effective contraception, compared to 5.1% of women without a chronic condition. The proportion of women using long-acting reversible contraception did not increase with the number of chronic conditions (5.8% with one condition vs. 3.2% with more than one).1

Researchers point to the low percentage of women with comorbid conditions who indicated use of the most highly effective forms of birth control. Previous research suggests that women with chronic conditions experience a greater risk of unplanned pregnancy, along with an increased risk of adverse maternal and neonatal outcomes.4

The reasons for unintended pregnancy vary between patients, noted co-author Jessica Sanders, PhD, MSPH, family planning research director at University of Utah Health. Women with comorbid conditions may have competing priorities, making the balance between healthcare concerns, medication use, and contraception “overwhelming.”

“However, this also presents healthcare providers with a tremendous opportunity to increase awareness of and access to forms of contraception that are acceptable to these women so they can optimize their health prior to pregnancy and achieve their reproductive goals without medical complications,” Sanders said.3

Put US MEC to Use

The American College of Obstetricians and Gynecologists released a Practice Bulletin in 2019 to help providers guide patients with comorbid conditions in choosing the most effective contraception method.5 The publication is aimed at helping clinicians to use the US MEC rating system.6 It recommends combinations of medical conditions and contraceptive methods which are rated on a safety scale of 1 to 4. Category 1 indicates there are no restrictions for use of the method, while Category 4 indicates the method could present an unacceptable health risk for the patient.

In the case of the mid-30s patient with diabetes, use of combined hormonal contraceptives is contraindicated (US MEC Category 3 or 4, depending on the severity of the condition). Since the contraceptive injectable DMPA increases lipoprotein profiles favorable to atherosclerosis, the shot is given a US MEC Category 3 rating for women with diabetes of more than 20 years’ duration, or evidence of microvascular disease. What choices may be offered such patients? The progestin-only pill, levonorgestrel intrauterine devices, and the subdermal implant are suitable alternatives.5

It is up to the woman and her family to determine if she wants to become pregnant, Gawron said. However, the woman should be counseled on what the risks are ahead of time, she stated.

“If she isn’t willing to take those risks, then she should be using the safest and most effective birth control method that works for her,” said Gawron.

REFERENCES

  1. Gawron LM, Sanders JN, Sward K, et al. Multi-morbidity and highly effective contraception in reproductive-age women in the US intermountain west: A retrospective cohort study. J Gen Intern Med 2019 Nov 7. doi: 10.1007/s11606-019-05425-5. [Epub ahead of print].
  2. Champaloux SW, Tepper NK, Curtis KM, et al. Contraceptive use among women with medical conditions in a nationwide privately insured population. Obstet Gynecol 2015;126:1151-1159.
  3. University of Utah Health. One-third of reproductive age women have health conditions that may complicate pregnancy. Nov. 7, 2019. Available at: https://bit.ly/379Ja9F.
  4. Chor J, Rankin K, Harwood B, et al. Unintended pregnancy and postpartum contraceptive use in women with and without chronic medical disease who experienced a live birth. Contraception 2011;84:57-63.
  5. ACOG Practice Bulletin No. 206: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2019;133:e128-e150.
  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.