Preventing Unintended Pregnancy

Abstract & Commentary

By Rebecca H. Allen, MD, MPH, Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, is Associate Editor for OB/GYN Clinical Alert.

Dr. Allen reports no financial relationships relevant to this field of study.

Synopsis: In this large prospective cohort study, women who received free contraception had lower rates of abortion, repeat abortion, and teenage births compared to their regional and national peers.

Source: Peipert JF, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291-1297.

The authors performed a prospective cohort study, the Contraceptive CHOICE Project, in which women at risk of unintended pregnancy in the St. Louis, Missouri, region received a reversible contraceptive method of their choice for up to 3 years at no cost. The purpose of the study was to promote the use of long-acting reversible contraception (LARC), and the participants were read a standardized counseling script which stated that intrauterine devices (IUDs) and the subdermal implant were the most effective methods of contraception. The women then chose their desired method and were followed prospectively. The authors compared repeat abortions in the St. Louis region with those in Kansas City, Missouri, and nonmetropolitan Missouri. In addition, abortion rates among participants aged 15-44 years and births among participants aged 15-19 years were compared with regional and national rates after standardization for age and race.

The CHOICE Project enrolled 9256 women between August 2007 and September 2011, of whom 46% chose the levonorgestrel IUD, 12% chose the copper IUD, 17% chose the subdermal implant, 9% chose oral contraceptive pills (OCPs), 7% chose the contraceptive vaginal ring, 7% chose the depot medroxyprogesterone acetate (DMPA) injection, and 2% chose the contraceptive patch. The teenage birth rate among participants was 6.3 per 1000 compared to a national rate of 34.3 per 1000. For CHOICE participants, the abortion rates from 2008-2010 ranged from 4.4-7.5 per 1000 after adjusting for age and race. These rates were lower than other women in St. Louis city and county as well as the national rate of 19.6 per 1000. The authors estimated that one abortion could be prevented for every 79-137 women who were given no-cost contraception per the study protocol. The proportion of abortions that were repeat abortions overall in St. Louis city and county decreased significantly compared to Kansas City, Missouri.

Commentary

The study investigators finally have proven what we all know intuitively to be true: If access to contraception is increased for women, abortion rates will decrease. This should be a public health intervention on which we can all agree. In the United States, the unintended pregnancy rate currently stands at 49% and is a major public health problem.1 The most common reversible methods of contraception used in the United States are oral contraception and male condoms.2 Condoms and oral contraceptives are dependent on user adherence and therefore have higher failure rates among typical users. In contrast, LARC, due to its high efficacy and continuation rates, is considered in the top tier of contraceptive efficacy. This study was successful in promoting the use of LARC among its participants and uptake was even higher than the study investigators anticipated. The Contraceptive CHOICE Project investigators have previously reported continuation rates at 12 months of 88% for the levonorgestrel IUD, 84% for the copper IUD, and 83% for the subdermal implant.3 Similar rates were found among teenagers and young women in the study compared to older women.4 Satisfaction rates were also higher for LARC methods in the study compared to other methods of contraception such as OCPs and DMPA. Furthermore, the investigators have shown that CHOICE participants using the pill, patch, or ring were 22 times more likely to experience a contraceptive failure than those using the IUD, subdermal implant, and DMPA injection.5

Unfortunately, in the United States, only 5.5% of women practicing contraception used IUDs as of 2008 and implant users were even fewer.2 For many women, the high up-front cost of IUDs and the contraceptive implant is a barrier to accessing the most effective methods of contraception. For other women, lack of provider knowledge and training or pre-insertion testing requirements are preventing increased LARC use.6 It is notable that in the same issue of Obstetrics and Gynecology, a study reported that the risk of pelvic inflammatory disease in women receiving IUDs was very low and testing on the same day of IUD insertion, if indicated, was acceptable practice.7 The Institute of Medicine has recommended that contraception be covered without cost to patients under the Patient Protection and Affordable Care Act of 2010. The Contraceptive CHOICE Project has shown in St. Louis, Missouri, how this policy will likely ameliorate the high unintended pregnancy and abortion rates in the United States. Many women in the CHOICE Project obtained their method immediately after abortion, a population at high risk for repeat abortion. Previous studies have shown that provision of LARC at the time of abortion decreases the chance of repeat abortion.8 Currently, many providers are offering women immediate IUD or implant insertion after abortion, but this practice needs to be expanded.9 Billing and insurance coverage issues such as device reimbursement and insertion on the same day as another procedure hopefully will be resolved by the Affordable Care Act.

References

  1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;38:90-96.
  2. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Statistics 2010;23:1-44.
  3. Peipert JF, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011;117: 1105-1113.
  4. Rosenstock JR, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120:1298-1305.
  5. Winner B, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012;366:1998-2007.
  6. ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114:1434-1438.
  7. Sufrin CB, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012;120:1314-1321.
  8. Cameron ST, et al. Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy. BJOG 2012;119:1074-1080.
  9. Allen RH, et al. Expanding access to intrauterine contraception. Am J Obstet Gynecol 2009;201:456.e1-5.