Contraception safety message is not received

EXECUTIVE SUMMARY

A new survey of women presenting for pregnancy counseling at a university family planning clinic showed about half of pregnant women incorrectly believe that hormonal contraception is more dangerous than pregnancy.

• Worldwide, 342,900 women die each year from pregnancy and pregnancy-related causes. In comparison, for nonsmoking women ages 15-34 in the United States, the risk of dying with use of oral contraceptives (OCs) is about one in 1.67 million, which is similar to the risk of being struck by lightning.

• Use evidence-based resources to address safety concerns, such as the U.S. Medical Eligibility Criteria for Contraceptive Use.

Clinicians might want to spend more time emphasizing the safety of hormonal contraception. Why? A new survey of women presenting for pregnancy counseling at a university family planning clinic showed about half of pregnant women incorrectly believe that hormonal contraception is more dangerous than pregnancy.1

Worldwide, 342,900 women die each year from pregnancy and pregnancy-related causes.2 In comparison, for nonsmoking women ages 15-34 in the United States, the risk of dying with use of oral contraceptives (OCs) is about one in 1.67 million, which is similar to the risk of being struck by lightning.3 (See box on p. 95 on putting voluntary risks in perspective.)

Researchers at the University of Rochester (NY) offered an anonymous survey to women receiving pregnancy counseling at the university’s family planning clinic in an effort to evaluate patients’ knowledge of medical risks from hormonal contraception compared with risks from pregnancy.

Only 16% the women surveyed were actively using contraception. Most said they thought that hormonal contraception (84%) and pregnancy (88%) were safe. However, when asked which was safer, 46% chose pregnancy over contraception.

When asked about specific risks, 57% of the women felt there were no concerns with pregnancy versus no concerns with contraception (31%). Significantly more women expressed more concerns with contraception use than pregnancy: pulmonary embolism (40% with contraception versus 7% with pregnancy), cancer risk (24% with contraception versus 2% with pregnancy) and infertility (29% with contraception versus 7% with pregnancy).1

In a 2011 study performed to assess women’s knowledge of the health risks of pregnancy, more than 75% of respondents rated birth control pills as more hazardous to a woman’s health than pregnancy.4 The greater the women’s education, the more likely she was to believe that oral contraceptives were riskier than pregnancy, research indicated.4

Women do not know the medical risks of pregnancy, observes Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. Education is needed is to help women understand pregnancy’s health risks, says Nelson, who co-authored the 2011 study.

The study was presented at the recent American College of Obstetricians and Gynecologists annual clinical meeting. In a press statement accompanying the presentation, Brandy Becker, MD, co-author, said, "The risks of pregnancy, deemed such a natural and healthy process by society, get overshadowed by the highly publicized reports of contraceptive-related complications. If women continue to receive more influence on their contraceptive choices from media than their healthcare providers, we will never make progress at lowering unplanned pregnancy rates.

Use the U.S. MEC

How can clinicians best address some of the common misperceptions when it comes to hormonal contraceptive safety?

Use evidence-based resources, says Sarah Betstadt, MD, MPH, assistant professor in the Department of Obstetrics and Gynecology in the Division of General Obstetrics and Gynecology at the University of Rochester (NY). For contraception, the gold standard resource is the Centers for Disease Control’s (CDC’s) U.S. Medical Eligibility Criteria for Contraceptive Use.5

The guidance from the CDC is a resource that summarizes all of the available literature on contraceptive use as it relates to different medical conditions, states Betstadt, who is a co-author of the current paper. From this literature review, the CDC has made recommendations on the safety of each contraceptive method in the context of individual medical conditions, she notes.

The CDC has provided an excellent summary chart that can be easily downloaded from its website that all clinicians can use in the office, notes Betstadt. (Go to http://1.usa.gov/chY2AV. Links to download the summary charts in English and Spanish are available at the bottom of the page.) For example, a contraceptive method that can be used safely, without risk is given a recommendation of "1, while a method that should not be used, because risk outweighs benefit, is a "4, explains Betstadt. A good example of a "4 recommendation would be using a combined hormonal contraceptive pill in the setting of an acute deep venous thrombosis, she notes.

"This is an excellent resource that clinicians can use to allow [patients] to see that most contraceptive methods are safe for women, even with medical conditions such as hypertension and diabetes, explains Betstadt. "It is much riskier for these women to have an unplanned pregnancy.

Patient Risk Put into Perspective

Mortality risk in the United States per year

While skydiving

1 in 1,000

From an accident

1 in 2,900

From an automobile accident

1 in 5,000

In an airplane crash

1 in 250,000

From being struck by lightning

1 in two million

Risk per year for women preventing pregnancy using combined oral contraceptives

Nonsmoker, ages 15-34

1 in 1.67 million

Nonsmoker, ages 35-44

1 in 33,000

Smoker, ages 15-34

1 in 57,800

Smoker, ages 35-44

1 in 5,200

Undergoing tubal sterilization

1 in 66,700

Risk from pregnancy

1 in 6,900

Source: Trussell J, Guthrie KA. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.

REFERENCES

1. Becker BJ, Betstadt SJ. Patient perception of safety of hormonal contraception compared to pregnancy. Presented at the 61st annual clinical meeting of the American College of Obstetricians and Gynecologists. New Orleans, May 2013.

2. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375:1,609-1,623.

3. Trussell J, Jordan B. Reproductive health risks in perspective. Contraception 2006; 73:437-439.

4. Nelson AL, Rezvan A. A pilot study of women’s knowledge of pregnancy health risks: implications for contraception. Contraception 2012; 85(1):78-82.

5. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.