P re v e n t i o n o f U n i n t e n d e d P re g n a n c y A Focus on Long-Acting Reversible Contraception Sarah Pickle, MDa,*, Justine Wu, Edith Burbank-Schmitt, BAb
a MD, MPH ,
KEYWORDS Unintended pregnancy Unplanned pregnancy Contraception Long-acting reversible contraception Family planning Electronic health record KEY POINTS Half of all pregnancies in the United States are unintended. Unintended pregnancies (UIPs) are more prevalent among minority and disadvantaged women and are associated with a higher risk for poor maternal and child health outcomes. With the recent passage of the Patient Protection and Affordable Care Act and its accompanying mandated contraceptive provision, there is an urgent need for more primary care providers to provide contraceptive services. Long-acting reversible contraceptives (LARC), specifically the intrauterine device and the subdermal progestin implant, are highly effective and safe for use in most women, yet remain underused in the United States. Providing LARC without patient cost sharing can decrease the rate of UIP and abortion. Clinicians should incorporate the use of Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use in their routine practice to provide evidencebased contraceptive services that are individually tailored to the user’s characteristics or medical conditions. Clinicians should advise LARC as first-option contraceptive for most women, if they desire and can access these methods.
INTRODUCTION
Of the approximately 6 million pregnancies that occur annually in the United States, half are unintended.1 Unintended pregnancy (UIP) is defined as a pregnancy that
Conflict of Interest: Dr J. Wu is a trainer for Nexplanon (Merck & Co, Inc, Whitehouse Station, NJ). a Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 262, New Brunswick, NJ 08901, USA; b Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 262, New Brunswick, NJ 08901, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 239–260 http://dx.doi.org/10.1016/j.pop.2014.02.004 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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was mistimed (29% of all pregnancies) or unwanted (19% of all pregnancies).2 Of those pregnancies that are unintended, half end in elective abortion.1 Collectively, women who experience UIP are at increased risk of delaying prenatal care, experiencing maternal depression, and suffering physical violence during pregnancy.3–7 Birth outcomes are less favorable as well, including low birth weight and increased risk of birth defects.8 Children born as a result of UIP are more likely to live in poverty, experience adverse physical and psychological outcomes during childhood, and achieve lower educational attainment.5,9,10 Although the overall US rate of UIP for all women has essentially been unchanged since 1994, teen pregnancy rate has declined, largely because of increased contraceptive use among adolescents, with a small contribution because of abstinence.11 The rate of UIP is declining at a slower rate among minority women and lower-income women of all ages.1,12 In 2006, the total cost of UIP in the United States was estimated to be $11.1 billion.13 The cornerstone to preventing UIP is widespread provision of contraception to women of childbearing age who do not currently desire pregnancy. Public funding for contraceptive services prevents 2.2 million unplanned pregnancies per year.14 Family planning is among the core strategic areas in the Healthy People 2020 initiative, a 10-year agenda for improving the health and lives of Americans. Among the family planning goals for Healthy People 2020 are to increase the proportion of intended pregnancy from 51% (2002 data) to 56% and to reduce the number of women who become pregnant despite using a reversible form of contraception from 12.4% (2002 data) to 9.9%.15 To achieve these outcomes, the Healthy People 2020 agenda calls for increased capacity in family planning services, particularly among publicly funded entities, to reach underserved and minority women at highest risk for UIP.15 Whether in the public or private sector, primary care providers (PCPs) have an important role to play in preventing UIP. In 2010, patients made 11.5 million visits to primary care offices for contraception and family planning counseling.16 This number is expected to increase significantly with the implementation of the Affordable Care Act (ACA), which includes a provision that requires coverage for contraceptive counseling and services without patient cost sharing.17 This discussion is focused on reversible contraceptive methods, because women using reversible methods represent most women at risk for UIP. Although male partners can play an important role in prevention of UIP, this discussion is directed to contraceptive use in women. Currently available reversible contraceptive methods and emergency contraception (EC) are presented, accompanied by a discussion of their effectiveness and use patterns among US women. Although a detailed summary of all contraceptive methods is beyond the scope of this article, clinical tools to assist in patient-centered contraceptive selection are presented in the context of the patient-centered medical home (PCMH). CURRENTLY AVAILABLE CONTRACEPTIVE METHODS IN THE UNITED STATES
Reversible forms of contraception can be divided into short-acting methods (userdependent methods that must be used with each coital act, daily, weekly, monthly, or every 3 months) versus long-acting reversible devices (ie, user-independent methods that maintain efficacy without patient intervention) (Table 1). EC is postcoital contraception (Table 2), defined as any method that is used to prevent pregnancy after intercourse.18,19 EC does not disrupt an implanted pregnancy18 and is therefore not an abortifacient, as defined by the US Food and Drug Administration (FDA)20 and the American Congress of Obstetricians and Gynecologists.21 EC decreases the risk of pregnancy from 52% to 99%, depending on the method used for each coital
Prevention of Unintended Pregnancy
Table 1 Short-acting methods and long-acting reversible contraceptive methods Long-Acting Reversible Contraceptive Methods
Short-Acting Methods
Copper T380A intrauterine device
Barrier methods (cervical cap, male/female condoms, diaphragm)
Levonogestrel intrauterine device
Oral contraceptive pills (combined estrogen and progestin, progestin only)
Subdermal progestin implant
Transdermal patch Vaginal ring Progestin injection
act.18,19,22–33 There has been no proven population impact from EC use (no decrease in the rate of UIP), likely attributable to underuse of the method among women at the highest risk for UIP.34–36 CONTRACEPTIVE METHOD EFFECTIVENESS
The risk of pregnancy during 1 year of method use is summarized in Table 3.40 The most effective methods (eg, implant, intrauterine device [IUD], sterilization) are associated with extremely low failure rates (
a MD, MPH ,
KEYWORDS Unintended pregnancy Unplanned pregnancy Contraception Long-acting reversible contraception Family planning Electronic health record KEY POINTS Half of all pregnancies in the United States are unintended. Unintended pregnancies (UIPs) are more prevalent among minority and disadvantaged women and are associated with a higher risk for poor maternal and child health outcomes. With the recent passage of the Patient Protection and Affordable Care Act and its accompanying mandated contraceptive provision, there is an urgent need for more primary care providers to provide contraceptive services. Long-acting reversible contraceptives (LARC), specifically the intrauterine device and the subdermal progestin implant, are highly effective and safe for use in most women, yet remain underused in the United States. Providing LARC without patient cost sharing can decrease the rate of UIP and abortion. Clinicians should incorporate the use of Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use in their routine practice to provide evidencebased contraceptive services that are individually tailored to the user’s characteristics or medical conditions. Clinicians should advise LARC as first-option contraceptive for most women, if they desire and can access these methods.
INTRODUCTION
Of the approximately 6 million pregnancies that occur annually in the United States, half are unintended.1 Unintended pregnancy (UIP) is defined as a pregnancy that
Conflict of Interest: Dr J. Wu is a trainer for Nexplanon (Merck & Co, Inc, Whitehouse Station, NJ). a Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 262, New Brunswick, NJ 08901, USA; b Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 262, New Brunswick, NJ 08901, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 239–260 http://dx.doi.org/10.1016/j.pop.2014.02.004 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
240
Pickle et al
was mistimed (29% of all pregnancies) or unwanted (19% of all pregnancies).2 Of those pregnancies that are unintended, half end in elective abortion.1 Collectively, women who experience UIP are at increased risk of delaying prenatal care, experiencing maternal depression, and suffering physical violence during pregnancy.3–7 Birth outcomes are less favorable as well, including low birth weight and increased risk of birth defects.8 Children born as a result of UIP are more likely to live in poverty, experience adverse physical and psychological outcomes during childhood, and achieve lower educational attainment.5,9,10 Although the overall US rate of UIP for all women has essentially been unchanged since 1994, teen pregnancy rate has declined, largely because of increased contraceptive use among adolescents, with a small contribution because of abstinence.11 The rate of UIP is declining at a slower rate among minority women and lower-income women of all ages.1,12 In 2006, the total cost of UIP in the United States was estimated to be $11.1 billion.13 The cornerstone to preventing UIP is widespread provision of contraception to women of childbearing age who do not currently desire pregnancy. Public funding for contraceptive services prevents 2.2 million unplanned pregnancies per year.14 Family planning is among the core strategic areas in the Healthy People 2020 initiative, a 10-year agenda for improving the health and lives of Americans. Among the family planning goals for Healthy People 2020 are to increase the proportion of intended pregnancy from 51% (2002 data) to 56% and to reduce the number of women who become pregnant despite using a reversible form of contraception from 12.4% (2002 data) to 9.9%.15 To achieve these outcomes, the Healthy People 2020 agenda calls for increased capacity in family planning services, particularly among publicly funded entities, to reach underserved and minority women at highest risk for UIP.15 Whether in the public or private sector, primary care providers (PCPs) have an important role to play in preventing UIP. In 2010, patients made 11.5 million visits to primary care offices for contraception and family planning counseling.16 This number is expected to increase significantly with the implementation of the Affordable Care Act (ACA), which includes a provision that requires coverage for contraceptive counseling and services without patient cost sharing.17 This discussion is focused on reversible contraceptive methods, because women using reversible methods represent most women at risk for UIP. Although male partners can play an important role in prevention of UIP, this discussion is directed to contraceptive use in women. Currently available reversible contraceptive methods and emergency contraception (EC) are presented, accompanied by a discussion of their effectiveness and use patterns among US women. Although a detailed summary of all contraceptive methods is beyond the scope of this article, clinical tools to assist in patient-centered contraceptive selection are presented in the context of the patient-centered medical home (PCMH). CURRENTLY AVAILABLE CONTRACEPTIVE METHODS IN THE UNITED STATES
Reversible forms of contraception can be divided into short-acting methods (userdependent methods that must be used with each coital act, daily, weekly, monthly, or every 3 months) versus long-acting reversible devices (ie, user-independent methods that maintain efficacy without patient intervention) (Table 1). EC is postcoital contraception (Table 2), defined as any method that is used to prevent pregnancy after intercourse.18,19 EC does not disrupt an implanted pregnancy18 and is therefore not an abortifacient, as defined by the US Food and Drug Administration (FDA)20 and the American Congress of Obstetricians and Gynecologists.21 EC decreases the risk of pregnancy from 52% to 99%, depending on the method used for each coital
Prevention of Unintended Pregnancy
Table 1 Short-acting methods and long-acting reversible contraceptive methods Long-Acting Reversible Contraceptive Methods
Short-Acting Methods
Copper T380A intrauterine device
Barrier methods (cervical cap, male/female condoms, diaphragm)
Levonogestrel intrauterine device
Oral contraceptive pills (combined estrogen and progestin, progestin only)
Subdermal progestin implant
Transdermal patch Vaginal ring Progestin injection
act.18,19,22–33 There has been no proven population impact from EC use (no decrease in the rate of UIP), likely attributable to underuse of the method among women at the highest risk for UIP.34–36 CONTRACEPTIVE METHOD EFFECTIVENESS
The risk of pregnancy during 1 year of method use is summarized in Table 3.40 The most effective methods (eg, implant, intrauterine device [IUD], sterilization) are associated with extremely low failure rates (
