LARC use sees substantial increase — How to boost use in women at risk

Include counseling on IUD use for emergency contraception

Good news: More women are choosing long-acting reversible contraceptives (LARC methods) such as the intrauterine device (IUD) and the contraceptive implant. The proportion of U.S. women using these highly effective methods increased significantly between 2002 and 2009, growing from 2.4% to 8.5%, according to results of a new analysis of data from the 2006-2010 National Survey of Family Growth.1 The increase occurred among women in almost every age, race, education, and income group, researchers state.

Data indicate the highest use of LARC methods was among women ages 25-39 and among those who already had at least one child. Just 2% of women with no children had used long-acting methods, compared with 15% of women with one or two children.1 Could provider misperceptions be playing a role in the lower use of LARCs in women most at risk for unintended pregnancy?

Previous research points to "yes," according to Lawrence Finer, PhD, director of domestic research at the Guttmacher Institute in New York City and lead author of the current study. A 2008 survey among physicians, nurse practitioners, and physician assistants indicates that many providers are less likely to offer IUDs to young women and those without children, two groups at high risk of unintended pregnancy, he notes.2

The challenge is to bring providers' knowledge and attitudes in line with the latest evidence-based practice guidelines from the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists (ACOG), and other professional groups, states Finer. (To help clinicians obtain needed information on LARC methods, ACOG now offers a dedicated web space to LARC methods, http://bit.ly/MpQ63R. Click on "LARC Clinical Resources" to download copies of ACOG practice bulletins, committee opinions, and other guidance on LARC use.)

In the remarkable St. Louis Contraceptive CHOICE Project, 69% of adolescents ages 14-17 chose to use an IUD or an implant, notes Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. Of these young teen-agers using LARC methods, 63% chose the implant.3

Since contraception is covered as a preventive service under the Affordable Care Act, there are more opportunities for women to access LARC methods, says Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of Washington, DC-based iWomansHealth, which focuses on information on women's health issues for clinicians and consumers. It is more important than ever for clinicians to be trained to place intrauterine contraceptives and implants, she says. "Any clinician who knows how to do an accurate pelvic exam has the basic skills for placement" of the IUD, Wysocki states. "Now that cost isn't the issue, the time is right for clinicians to get up to speed." (Clinicians can take advantage of insertion training of the Nexplanon implant at a preconference session of the November 2012 Contraceptive Technology Quest for Excellence conference in Atlanta. The training session is limited to 50 participants. Go to the Contemporary Forums web site, www.contemporaryforums.com. Under "Upcoming Conferences," select "View Complete Calendar," then "November" to access information on the Quest for Excellence conference and preconference sessions.)

Look at the IUD for EC

Clinicians also need to consider intrauterine devices for emergency contraception. Results of a new meta-analysis by international researchers indicate that IUDs inserted shortly after unprotected intercourse have a failure rate of less than one per 1,000 and are more effective than emergency contraceptive pills (ECPs) in protecting women from unwanted pregnancies.4

To conduct the research, investigators looked at 42 studies conducted in six countries between 1979 and 2011.The studies involved eight types of IUDs and 7,034 women. Analysis yielded a pregnancy rate of 0.09% among women using IUDs inserted from two to 10 or more days after unprotected intercourse (74% of devices inserted within five days).

In an Asian study, not one of 1,963 women who received a copper T IUD for emergency contraception became pregnant.5

One of the unintended but foreseen consequences of ECPs going over the counter is that women get them without seeing a provider, thus the opportunity for emergency IUD insertion is lost, observes James Trussell, PhD, professor of economics and public affairs and director of the Office of Population Research at Princeton (NJ) University and a co-author of the meta-analysis. Providers could be proactive by discussing IUDs for EC in advance of need, he notes.

What's your stance?

When it comes to IUDs for EC, a 2012 study indicates many clinicians are slow to embrace its use. A study of California contraceptive providers reveals 85% of clinicians never recommended the IUD for emergency contraception, and 93% require at least two visits for an IUD insertion.6

If patients demand the service, providers will deliver it, says David Turok, MD, MPH, assistant clinical professor in the Department of Obstetrics and Gynecology at the University of Utah School of Medicine in Salt Lake City. Hopefully, more women will find out about the IUD EC option and request it, thus encouraging providers to offer it, Turok states. He will present data this month at the 2012 North American Forum on Family Planning in Denver on the effectiveness of the copper T IUD when used for EC. (Look to Contraceptive Technology Update to report on the findings in an upcoming issue.)

Look for accumulating data on Quick Start methods to include the copper IUD, the LNG IUD, and the contraceptive implant, says Turok. Providers are getting the message that it is safe to begin contraceptive injections and combined oral contraceptives on the day that people present requesting contraception, he says. More progress might be made by encouraging providers to screen for contraceptive use/risk of unplanned pregnancy AND offer patients the method they want, Turok states.

"When women have had unprotected intercourse in the last five days, these instances could be perceived as emergency contraception," says Turok. "My opinion is that it will seem more sensible to providers to screen for contraceptive need/risk of unplanned pregnancy and deliver any method, than to screen for EC."

It might be time to try a new approach, Turok suggests. Providers should be encouraged to screen for contraceptive need and give patients the available data to provide the methods, as well as counsel on oral EC and offer the copper IUD when appropriate, he notes. Based on existing data, providers should encourage use of the copper IUD within five days of unprotected intercourse, says Turok.

"I think it is reasonable if a patient understands the risk of pregnancy with the use of EC to insert a levonorgestrel [LNG] IUD or contraceptive implant at that time, with the understanding that if they have a pregnancy, the LNG IUD would need to be removed, and if they choose to continue a pregnancy, they would need to have the implant removed," Turok suggests.

All of these approaches are aimed toward overall increased use and access to highly effective reversible methods, says Turok.

"I think we can make significant advances on the provider side by packaging the message," he states. "The IUD for EC is just a part of that."

References

  1. Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007-2009. Fertil Steril 2012. Doi: 10.1016/j.fertnstert.2012.06.027.
  2. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008; 111(6):1,359-1,369.
  3. Mestad R, Secura G, Allsworth JE, et al. Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception 2011; 84(5):493-498.
  4. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012. Doi: 10.1093/humrep/des140.
  5. Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG 2010; 117(10):1,205-1,210.
  6. Harper CC, Speidel JJ, Drey EA, et al. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstet Gynecol 2012; 119:220-226.