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Study says two-thirds were using contraception
"How did this happen?" asks the woman sitting in your office as you share the news from the pregnancy test. "I was using birth control."
Research from a new French survey on contraception underscores this familiar scene. Investigators found that one-third of the pregnancies among women in their study were unplanned and that two-thirds of these pregnancies occurred in contraception users.1 Improved education by family planning providers remains a major goal to ensure that women use a contraceptive method that will work for them, the researchers conclude.
"The key points for clinicians to keep in mind when counseling on proper contraceptive use is that there exists a difference between theoretical and practical efficiency of contraceptive method, and that they should invite women to take into account their social, affective (emotional) and sexual lifestyle when choosing a contraceptive method," says lead author Nathalie Bajos, PhD, research scientist in public health with the Paris-based National Institute for Health and Medical Research.
The cross-sectional population-based survey looked at the characteristics of current contraceptive use, the different types of contraceptive failure, and the reasons reported for not using contraception. A representative sample of 14,704 French households randomly was selected from the telephone directory; all women (n = 1,034) who in the last five years had an abortion or whose last pregnancy was unintended were selected. A total of 1,829 women selected on a random basis.
One-fifth of the unplanned pregnancies happened among women using the Pill; another tenth were among women with intrauterine devices, researchers report. One in eight of the unwanted pregnancies were among women choosing condoms, while one-fifth occurred among those using such methods as withdrawal or avoiding intercourse on fertile days in the menstrual cycle. About one-third of the unwanted pregnancies were among women using no contraception. Half of the unplanned pregnancies ended in abortion, researchers report.
The main reasons given for contraceptive failures were the misuse of the methods or the failure of the partner to withdraw, say researchers. With pill users, 60% said they had forgotten one or more pills, while more than 18% said it was due to illness or taking other medication. One-fifth had no or offered no explanation. More than 57% of the women whose IUD had failed said they did not know what had gone wrong or had no explanation, while more than 30% said the IUD was in the wrong position or fell out, and more than a tenth blamed illness or medication.
The new research should remind clinicians that it is how contraceptives are used that determines how well they function, says Michael Rosenberg, MD, MPH, clinical professor of obstetrics and gynecology and adjunct professor of epidemiology at the University of North Carolina at Chapel Hill and president of Health Decisions, a private research firm specializing in reproductive health. Rosenberg has looked at contraceptive use and compliance issues.2,3
"One of the more interesting findings was the fact that of all contraceptive users, a relatively high proportion [21% of OC users, 58% of IUD users, and 19% condom users] did not know how their failure occurred," states Rosenberg. "This fact underscores both the importance of adequate initial as well as the need for follow-up counseling."
When discussing contraceptive choices with your patients, remember that "the best method is the one that is medically appropriate and is used every time by someone happy with the method," a position often stated by the authors of A Pocket Guide to Managing Contraception.4
Keep the following ideas in mind when helping women make informed contraception choices:
• Be aware of your own biases.
• Each contraceptive method has advantages and disadvantages.
• Effectiveness and safety are important.
• Convenience and ability to use method may determine effectiveness.
• Protection against sexually transmitted infections and HIV needs to be considered for women and men at risk.
• Effects of method on menses may be very important to the woman.
• Ability to negotiate with partner may help determine method and selection.
• Other influences (religion, privacy, past experience, friend’s advice, frequency of intercourse) may impact patient’s preferences.
• Discuss all methods with patient, even those you may not use in your own practice.
• Consider discussing methods with the couple, particularly if there appear to be issues. Such questions as "Is your partner opposed to this method?" and "Will using this method embarrass your partner?" may help to understand the support available for use of the chosen method.4
"Important but underutilized resources include distribution of written materials and access to follow-up after initial counseling/prescribing," adds Rosenberg.
1. Bajos N, Leridon H, Goulard H, et al. Contraception: From accessibility to efficiency. Hum Reprod 2003; 18:994-999.
2. Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling, and satisfaction with oral contraceptives: A prospective evaluation. Fam Plann Perspect 1998; 30:89-92, 104.
3. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: Risk indicators for poor pill taking and discontinuation. Contraception 1995; 51:283-288.
4. Hatcher RA, Nelson AL, Zieman M, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation, 2002-2003. Accessed at www.managingcontraception.com.
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