Use of Long-acting Reversible Contraception Is Increasing: Have You Changed Your Recommendations?

Abstract & Commentary

By Jeffrey T. Jensen, MD, MPH , Leon Sperof Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, is Editor for OB/GYN Clinical Alert.

Synopsis: Although the pill and female sterilization remain the most popular methods of contraception, fewer women report using condoms as a primary method and more are using intrauterine devices. Still, 11% of women at risk for unintended pregnancy report using no method.

Source: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Jones J, et al. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics Reports; No 60. Hyattsville, MD: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf. Accessed Oct. 29, 2012.

The National Survey of Family Growth (NSFG) is a national representative survey designed to provide data that supplement and complement the National Vital Statistics by collecting information on the factors that affect birth rates — including sexual activity, marriage, divorce, cohabitation, contraceptive use, and infertility. The NSFG originally was conducted as a periodic survey designed to interview a large number of women within a short period of time. Beginning in 2006, the design was changed to continuously interview smaller numbers of men and women for a longer period. The current report compares data using both of these methodologies involving the largest samples of women in the NSFG's history — 10,847 interviewed in 1995, and 12,279 interviewed between June 2006 and June 2010. These large numbers permit detailed comparisons that were not possible in previous reports. The key results from the 2006-10 cycle are that 62% of reproductive age (defined as 15-44) women report current use of a contraceptive method. Among women using a contraceptive method in the month of the interview, the most common methods used are the pill (28%, or 10.6 million women) and female sterilization (27%, or 10.2 million women). Big changes in use patterns occurred with certain methods, principally use of intrauterine devices (IUDs; increased from 0.8% in 1995 to 5.6% in 2006–2010) and condoms (decreased from 20.4% in 1995 to 16.4% in 2006-10). On a discouraging note, 11% of women at risk for pregnancy report not currently using any method of contraception.

Commentary

This report provides important information on family planning trends in the United States. Established in 1973 by the National Center for Health Statistics, the NSFG contributes important representative data of factors affecting the formation, growth, and dissolution of families, including contraception, sterilization, and sexual activity. The NSFG was conducted five times (1973, 1976, 1982, 1988, 1995) with a national representative sample of women only. A sixth periodic survey, conducted in 2002, included both men and women. Beginning in 2006, the NSFG shifted to a continuous survey design that interviewed both men and women, and the current cycle for analysis concluded in June 2010. The present analysis permits a detailed comparison of trends in family planning over the last 15 years.

First the positives: Results from the 2006-10 survey show that use of more effective contraceptive methods is up. Particularly encouraging is the use of the most effective long-acting methods like IUDs. Compared to 1995, where fewer than 1% of women reported current use of an IUD, this has increased to almost 6% in 2010. The increase in IUD use is associated with a roughly equivalent decrease in the number of women reporting use of male condoms as a primary method of contraception (from 20.4% in 1995 to 16.4% in 2006-10). Since typical use failure of condoms (17%) is substantially higher than that of an IUD (< 1%), this is an excellent trade that should be driving down rates of unintended pregnancy and abortion.

Now the bad news: Current users of a contraceptive method at the time of the 2006-10 survey represented 62.2% of the sample, a drop of 2.0% since 1995. This translates to an estimated 1,235,100 fewer contraceptive users (2% of 61,755,000 women aged 15-44). Since an increase in the number of women desiring pregnancy might explain this decrease, it is important to point out that the decline is absorbed instead by a 2.4% boost in the proportion of women most at risk (e.g., those who report being sexually active within the last 3 months before the interview, not using a method, and not intending pregnancy) from 5.2% to 7.7%. This 2.5% increase in women not using contraception translates into an additional 1.5 million women at risk of unintended pregnancy. This is a continuation of a disturbing trend; the uptick in nonuse was 7.4% in the 2002 survey.1

The public health implications of this increase are noteworthy; it has been estimated that the 5.2% of non-users in the 1995 sample contributed 54% of all unintended pregnancies (the rest occurred as a consequence of contraceptive failure).2 Although national vital statistics data have not yet been correlated with the 2006-10 figures, conservatively running the numbers would support that the increase in women not using contraception may have resulted in more than 500,000 unintended pregnancies and 270,000 abortions in 2010. Although the overall numbers of unintended pregnancies and abortions are dropping, this is due to the increased use of more effective methods like the IUD. In other words, an even more impressive reduction in unintended pregnancies and abortions may have occurred if the number of nonusers had not increased between 1995 and 2010.

So why the increase in nonuse? Access and affordability issues must be considered among the potential explanations for the increase in nonuse of contraception. Since providing family planning services saves public money, it makes good sense to support universal access to family planning services.3 This is an important part of health care reform that we should all discuss in our communities. At the same time, in our office practices, we should be spreading the word about long-acting reversible contraception, and moving nonusers of contraceptives to use of any method.

References

  1. Mosher WD, et al. Use of contraception and use of family planning services in the United States, 1982–2002. Advance data from vital and health statistics; no 350. Hyattsville, MD: National Center for Health Statistics. 2004.
  2. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-29, 46.
  3. Trussell J, et al. Cost effectiveness of contraceptives in the United States. Contraception 2009;79:5-14.