Removing barriers might offer substantial public health impact
Teenagers who received free contraception and were educated about the benefits and disadvantages of various birth control methods in the Contraceptive CHOICE Project conducted in St. Louis were dramatically less likely to get pregnant, give birth, or obtain an abortion compared with other sexually active teens, data suggests in a recently released study.1
The Contraceptive CHOICE Project, a large prospective cohort study conducted by researchers at the Washington University School of Medicine in St. Louis, was designed to promote the use of long-acting, reversible contraceptive (LARC) methods to reduce unintended pregnancy in the St. Louis region. Participants were educated about reversible contraception, with an emphasis on the benefits of LARC methods, provided their choice of reversible contraception at no cost, and were followed for two to three years.
To perform the currently published analysis, researchers looked at pregnancy, birth, and induced-abortion rates among females ages 15 to 19 years in this cohort and compared them with those observed nationally among U.S. teens in the same age group.
Of the 1,404 participants enrolled in CHOICE, 72% chose an intrauterine device (IUDs) or implant (LARC methods); 28% selected another method. This statistic compares with an estimated 5% U.S. teens who choose long-acting birth control.2 Almost 500 of the teens in the study were of minor age (ages 14-17) upon enrollment; half of these minors reported having had a prior unintended pregnancy, and 18% had had at least one abortion. Participants ages 14-17 years provided written assent, and a parent or guardian provided written consent. Minors could enroll under a waiver of parental consent if they did not know the whereabouts of their parents or guardians or if they did not want their parents or guardians to know that they were seeking contraception; just four out of the 484 teens ages 14-17 (under 1%) were enrolled under waiver.1
During the 2008-2013 study period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1,000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1,000, respectively.1 "When we removed barriers to contraception for teens such as lack of knowledge, limited access, and cost in a group of teens, we were able to lower pregnancy, birth, and abortion rates," said Gina Secura, PhD, the study’s first author and director of the CHOICE Project in a statement. "This study demonstrates there is a lot more we can do to reduce the teen pregnancy rate."
Teen pregnancy has been designated by the Centers for Disease Control and Prevention as one of six Winnable Battles because of the magnitude of the problem and the belief that it can be addressed by known, effective strategies. The agency’s Winnable Battle target is to reduce the teen birth rate by 20%, from 37.9 per 1,000 teens in 2009 to 30.3 per 1,000 teens by 2015.3
Two-thirds of teens in the CHOICE study still were using IUDs and implants at 24 months after beginning use, compared with one-third of teens still using shorter-acting methods, such as birth control pills. What are some of the reasons these LARC adopters continued to use their chosen methods?
LARC methods are easy and forgettable, according to Jeffrey Peipert, MD, MPH, MHA, Robert J. Perry Professor of Obstetrics and Gynecology and vice chair for clinical research at Washington University School of Medicine in St. Louis. These advantages are the key ingredient of LARC methods, which makes intrauterine and implant contraceptives "get-it-and-forget-it" methods, says Peipert.
The CHOICE Project provided a place where young women could call, come in, have questions answered and concerns addressed, which helped young women with method continuation. The regular check-in phone calls, made at three months, six months, and every six months for the duration of the project, allowed participants to communicate about method usage, notes Peipert.
Women in the CHOICE Project who selected LARC methods were able to receive non-contraceptive benefits from their chosen contraception, such as reduced bleeding and painful periods in levonorgestrel intrauterine device users, and reduced painful periods in implant users, as well as highly effective birth control, says Peipert. "With a continued need for contraception, why NOT continue?" Peipert states. (To read more about the Project, see the Contraceptive Technology Update article, "Short-term bleeding and cramping with LARC method satisfaction eyed," November 2014, p. 121.)
Three steps to success
Lack of information about effective contraception, limited access, and cost remain barriers to the use of LARC methods for many teens.4-6
What are some steps providers can take to make "LARC First" in their own practices? In a September 2014 webinar sponsored by the American College of Obstetricians and Gynecologists, David Eisenberg, MD, MPH, FACOG, assistant professor division of clinical research in the Department of Obstetrics & Gynecology at Washington University School of Medicine, outlined three steps:
Provide education regarding all methods, especially LARC.
Reframe the conversation to start with the most effective methods, Eisenberg suggests.
Promote access to providers who will offer and provide LARC methods.
Clinicians can dispel myths and increase the practice of evidence-based medicine when it comes to LARC methods, says Eisenberg. Providers who perform intrauterine contraceptive and implant insertions should sign up in the national My Provider registry. That registry is operated by the Association of Reproductive Health Professionals and the Bedsider online resource. Visit LARC.arhp.org for more information.
Make LARC methods affordable contraception.7
The Affordable Care Act (ACA) added contraceptive counseling and supplies, including LARC methods, to its list of preventive services for women, based on recommendations from the Institute of Medicine.8 Health coverage offered through the expansion of the Medicaid program must comply with the ACA contraceptive coverage requirement.
To determine whether an insurance plan is complying with the ACA requirement, refer your patients to a guide, Getting the Coverage You Deserve, created by the National Women’s Law Center. (Access the guide at http://bit.ly/1fVBQAX.) The guide is designed to provide women with information on the coverage of preventive services in the healthcare law and tools they can use if they encounter problems with their coverage.
For financial assistance with obtaining the levonorgestrel intrauterine system, eligibility requirements and applications are available online through the Arch Foundation (http://bit.ly/1tmygqS). Information on obtaining assistance with the copper-T intrauterine device is available online at http://bit.ly/1p4cz7M.
- Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med 2014; 371(14):1,316-1,323.
- Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007-2009. Fertil Steril 2012; 98:893-897.
- Centers for Disease Control and Prevention. Winnable battles. Fact sheet. Accessed at http://1.usa.gov/1CaBSLd.
- Kavanaugh ML, Frohwirth L, Jerman J, et al. Long-acting reversible contraception for adolescents and young adults: patient and provider perspectives. J Pediatr Adolesc Gynecol 2013; 26:86-95.
- Kavanaugh ML, Jerman J, Ethier K, et al. Meeting the contraceptive needs of teens and young adults: youth friendly and long-acting reversible contraceptive services in U.S. family planning facilities. J Adolesc Health 2013; 52:284-292.
- Secura G, McNicholas C. Long-acting reversible contraceptive use among teens prevents unintended pregnancy: a look at the evidence. Expert Rev Obstet Gynecol 2013; 8:297-299.
- Eisenberg DL. Best practices in long-acting reversible contraception: recommendations from ACOG and the CDC. Accessed at http://bit.ly/1z251Mw.
- Institute of Medicine. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: National Academies Press; 2011.