CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 2, 392–408 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
State of Family Planning COURTNEY A. SCHREIBER, MD, MPH, and SARAH TRAXLER, MD Department of Obstetrics and Gynecology, Division of Family Planning, University of Pennsylvania, Philadelphia, Pennsylvania Abstract: Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Recent years have witnessed an unprecedented number of abortion restrictions, and research funding has decreased in related areas. Despite this, both the science and the implementation of improved family planning and abortion methods have progressed in the past decade. This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future. Key words: family planning, abortion, contraception
associated with a sustained decrease in the total fertility rate since the 1970s, the overall rate of unintended pregnancy has not changed over the past 20 years and persists as a significant public health problem in the United States. There are 6.6 million pregnancies in the United States each year and currently, about half (51%) are unintended.3,4 Public insurance programs pay for 48% of all births in the United States and pay for 64% of all births resulting from unintended pregnancies.4 These 1 million births from unintended pregnancies cost the federal and state governments about $11 billion annually.5 Recent years have witnessed an unprecedented number of abortion restrictions in the United States. Although the affordable care act promised to provide contraceptives as a component of primary health care for US women, this right is being currently diminished by legislators favoring corporations’ religious beliefs over women’s access to basic health care.6 Despite this, both the science and the implementation of improved family planning methods have progressed in the past decade. The use of the most effective contraceptives has increased among American women, and, although there has been a decreased investment by both
Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Since the enactment of the Economic Opportunity Act of 1964, family planning has been a major public health priority in the United States. Under Lyndon B. Johnson’s War on Poverty and then with Title X of the Public Health Service Act of 1970 under Richard Nixon, the United States began subsidizing contraception to decrease numbers of unwanted and ill-timed children and promote economic opportunities for women.1,2 Despite the fact that the family planning programs funded by these initiatives are Correspondence: Courtney A. Schreiber, MD, MPH, Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
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VOLUME 58
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NUMBER 2
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JUNE 2015
State of Family Planning the public and private sector in the development of novel contraceptives, a small number of methods are newly marketed and still more are under development. This year marked the tenth anniversary of the Society of Family Planning. This organization among others has been successful in supporting the scientific progress of reproductive health and family planning. Especially in the setting of restrictive state and federal policies, when it comes to women’s access to reproductive health care, scientific investigation and evidence-based clinical care offer hope to US women. The Institute of Medicine (IOM) has determined that women with unintended pregnancy are more likely to have shorter birth spacing, worse birth outcomes, delayed prenatal care, decreased breast feeding, decreased educational attainment, and increased economic hardship. Unintended pregnancy is often the inciting event that causes a woman to transition into poverty7 and has clear health, social, and economic consequences for women and their families.8–10 A recent analysis shows that access to birth control actually reduces the probability that a woman is living in poverty.11 This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future.
Contraception CONTRACEPTIVE UTILIZATION
Contraceptive use is almost universal for women of reproductive age and plays a fundamental role in determining healthy birth spacing and attainment of desired family size. According to data from the National Survey of Family Growth (NSFG) from 2006 to 2010,12 99.1% of women aged 15 to 44 living in the United States who have ever had vaginal intercourse use some form of contraception in their lifetime.13 And while women, on
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average, spend 5 years of their reproductive lives pregnant, attempting pregnancy, or postpartum, they spend the majority of their reproductive years attempting to avoid pregnancy.14 There are 43 million reproductive-aged women in the United States who are at risk for unintended pregnancy, and 89% are using a contraceptive method to avoid pregnancy. Thus, approximately 4.7 million women at risk of unintended pregnancy use no form of contraception. Pregnancies in these women account for half of all unintended pregnancies. Because pregnancy prevention depends on consistent and correct use of contraception, an additional 40% of unintended pregnancies occur in women who are incorrectly using contraception or have gaps in use. Only 5% of unintended pregnancies occur due to method failure in women who use contraception consistently and correctly.15 Data from the NSFG 2006-2010 show that 17.1% of women use oral contraceptive pills and 10.2% use condoms as their primary method of birth control.15 These methods have ‘‘typical use’’ failure rates of 9% and 18%, respectively.16 In survey data from the Guttmacher Institute that included 2000 reproductive-aged women at risk of unintended pregnancy, 15% experienced a gap in contraceptive insurance coverage17 while still at risk of unintended pregnancy. These gaps in coverage occurred more often in women using oral contraceptive pills and male condoms as their primary birth control method. Furthermore, 38% of women taking the oral contraceptive pill reported missing at least 1 pill in the month prior18 and 61% of women using condoms had inconsistent use. In contrast, women using long-acting reversible contraception (LARC) such as an intrauterine device (IUD) or contraceptive implant had much lower rates of gaps in use (4.2%).17 In December 2009, the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion www.clinicalobgyn.com
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recommending LARCs as first-line contraception to all women.19 The major advantage of LARCs compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the user for long-term effectiveness and demonstrate little difference between ‘‘perfect use’’ and ‘‘typical use’’ failure rates. Currently, only 3.5% of reproductive-aged women in the United States use an IUD as their primary method of birth control and 0.9% use a contraceptive implant. These methods have a failure rate of 0.2% to 0.8% and 0.05%, respectively,16 contribute to a clinically significant decrease in unintended pregnancy and abortion rate.20 CONTRACEPTIVE ACCESS AND UPTAKE
Cost Barriers and Facilitators Unintended pregnancy rates are highest among poor women, young women, and minority women, who are >5 times more likely to have an unintended pregnancy.21 In cross-sectional surveys of women with unintended pregnancy, many indicate that access and cost issues are reasons for not using contraception.17 Even with findings in a study showing LARC methods to be more cost-effective22 than other reversible methods or no method, upfront cost is still considered a significant barrier to LARC uptake. The Contraceptive CHOICE project removed all cost barriers to LARC provision and offered free contraception to a cohort of 10,000 reproductive-aged women living in the St Louis area. In this project, 75% of participants chose LARC as the primary method of birth control. At 12 months, LARC users had higher satisfaction rates (80%) compared with oral contraceptive pill users (54%)23; 24month continuation rates were much higher in LARC users compared with non-LARC users, 77% versus 41%.24 www.clinicalobgyn.com
Further findings from this study demonstrate a significant reduction in teen birth rate in CHOICE participants, 6.3 per 1000 compared with the national level of 34.3 per 1000.20 A reduction in abortion rate for the St Louis area was also seen relative to the rest of Missouri, and repeat abortions in the St Louis area compared with the surrounding region and the nation were significantly less.20 The CHOICE project’s medical contraindications to combined hormonal contraception (CHC) was very low in the select population, supporting provision of CHC without a prescription.25 ACOG also released an opinion that hormonal contraceptives should be available over the counter without a prescription. OTC availability would overcome major contraceptive access barriers. Provider Barriers and Facilitators Although the CHOICE project demonstrated a marked increase in LARC uptake when provided free of charge, California’s Family Planning Access Care and Treatment Program,26 a large Medicaid expansion in the state of California that eliminates the financial barrier to LARC by providing free contraception to men and women r200% of the federal poverty level, shows uptake of IUDs and implants similar to national averages. A survey conducted among medical directors of Family PACT provider sites help to explain these findings. Provider bias and misinformation can become a barrier between women and the most effective methods of contraception. Fifty-six percent of the provider respondents believed that IUDs can be inserted immediately postabortion, 76% believed that a followup visit is necessary after insertion, 41% agreed that IUD causes abortion, and 33% believed an IUD increases the risk of pelvic inflammatory disease (PID). These beliefs are seated in mythology, not evidence.19 Only 20% to 22% of respondents considered nulliparous
State of Family Planning women and teenagers as appropriate candidates for IUD insertion despite proof to the contrary.27 IUDs are appropriate for use in young nulliparous women, and are considered as the first-line contraceptive options by the American Congress of Obstetrics/Gynecologists and American Academy of Pediatrics. There is a great body of evidence that supports safety, efficacy, and satisfaction in this population.19–24 Provider barriers to contraceptive access are of national concern. In 2 separate cross-sectional surveys of health care providers conducted in 2002 and 2008, a majority of providers believe that nulliparous women and nonmonogamous women are not candidates for IUD placement.28,29 A more recent survey of family medicine physicians, obstetrician-gynecologists, and advanced practice clinicians from 2012 found that fewer respondents (16%) consider IUDs to be unsafe in nulliparous women, but 80% rarely or never provide IUDs to this population.30 The Centers for Disease Control and Prevention’s (CDC’s) US Medical Eligibility Criteria for Contraceptive Use (US MEC), released in 2010, provides guidance to clinicians on the safety of contraceptive methods in women with certain characteristics and medical conditions. In general, there is no age restriction for LARC use. The contraceptive implant is safe to use at any age, from menarche to menopause. With regard to IUD use, the benefits generally outweigh the risks for women of all ages. According to the guidelines, the only absolute contraindication to contraceptive implant use is current breast cancer. Contraindications to IUD use are few and include: (1) distortion of the uterine cavity; (2) current cancer (breast, cervical, endometrial, and gestational trophoblastic disease); (3) current pelvic infection (PID, immediate postseptic abortion, puerperal sepsis, purulent cervicitis, and
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tuberculosis); and (4) unexplained vaginal bleeding. The companion document to the US MEC, US Selected Practice Recommendations for Contraceptive Use 2013 (US SPR), includes guidelines for clinicians that help to remove provider-specific barriers to contraception initiation. These evidence-based guidelines empower clinicians to achieve timely provision of contraception to women. The guidelines also aid in providing contraception that is most appropriate, encouraging satisfaction and continuation to maximize effectiveness. Patient Beliefs and Misconceptions Patient-level misconceptions about contraception are also significant contributors to nonuse of contraception and subsequent unintended pregnancy. This is not surprising given the level of misconception among providers discussed above. Lack of knowledge regarding the most effective methods of contraception restricts the range of options available to women who desire to prevent pregnancy. According to data from the National Campaign to Prevent Teen and Unplanned Pregnancy, three fourths of young adults had heard of the IUD, whereas only 44% were aware of the contraceptive implant.31 This survey also showed that approximately one third of young adults report fear that long-term use of a hormonal contraceptive will lead to serious health problems, and 30% believe that the IUD will cause an infection. Many believe that it is healthy to periodically take a break from hormonal birth control. Half of women report that health concerns decrease their likelihood of ever using a specific method. TIMING OF CONTRACEPTIVE UPTAKE
Although contraceptive initiation would ideally occur before an unintended pregnancy, the postabortion and postpartum periods present key opportunities for www.clinicalobgyn.com
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education and immediate implementation of contraception to prevent repeat unintended pregnancy. There are many reasons to start immediate postabortion and postpartum contraception such as high motivation for contraception, convenience, reduce need for travel, and childcare. Postabortion Contraceptive Initiation Because more than half of women will resume intercourse within 2 weeks after an abortion,32 and women can ovulate as early as 8 days after abortion,33 initiation of contraception at the time of abortion reduces the risk of repeat pregnancy and abortion. The World Health Organization (WHO) supports initiation of any method of contraception immediately after surgical or medical abortion, reducing barriers to postabortion uptake and utilization of contraception.34 Immediate postinitiation of any type of contraception lowers the rates of repeat abortion incidence, but type of contraception started in the postabortion period has a significant impact on repeat unintended pregnancy and repeat abortion over time. In a study from Heikinheimo et al,35 users of the IUD and the contraceptive implant were much less likely to present for repeat abortion over the 3- to 5-year follow-up period compared with users of other methods. A retrospective chart review of 986 women presenting for termination of pregnancy by Cameron32 shows that women who initiate IUD or implant immediately postabortion are significantly less likely to present for a repeat termination of pregnancy in the subsequent 2 years (odds ratios of 0.05 and 0.06 for the IUD and implant, respectively). The postabortal period is an ideal time to initiate highly effective contraception. Women are likely motivated to prevent subsequent unintended pregnancies and there is enhanced ease of insertion.36 Furthermore, a study comparing immediate www.clinicalobgyn.com
versus delayed insertion of IUD postabortion showed that only 32% of women in the delayed insertion group returned for IUD insertion.37 Several studies evaluated in a Cochrane Review from 2002, however, demonstrate that IUD use in the immediate postabortion period is safe and associated with low risk of complications.38 Overall, the rates of perforation and PID were low. A systematic review completed in 2011 by Steenland et al,39 includes evaluation of 19 studies and reports that evidence suggests that postabortion IUD does not increase risk of pain, bleeding, or infection. Clinicians also may cite increased expulsion rates as a reason to delay IUD insertion beyond the immediate postabortion period. However, a randomized controlled trial (RCT) conducted by Bednarek et al,40 in which women were randomized to immediate insertion of IUD versus delayed insertion of IUD, demonstrates noninferior expulsion rates in the immediate insertion group (5% vs. 2.7%). The immediate insertion group also had higher rates of continuation at 6 months and a lower repeat pregnancy rate. Hohman et al41 also demonstrate in a RCT that women randomized to immediate postabortion IUD were significantly more likely to have an IUD placed compared with the delayed insertion group, and expulsion rates were similar between the 2 groups. The systematic review cited above suggests that, in general, expulsion rates are similar for the immediate postabortion interval compared with IUD insertion at other times.39 Postpartum To reduce adverse maternal and neonatal outcomes, the WHO recommends an interval of at least 24 months before attempting another pregnancy after a live birth.42 One third of all repeat pregnancies are conceived within 18 months of the previous birth. Short interpregnancy
State of Family Planning interval is associated with delayed prenatal care,43 premature birth,44 and low birth weight.45 In a cohort of >111,000 women from California, contraception use within 90 days postpartum was associated with avoidance of rapid repeat pregnancy (defined as repeat pregnancy 22% of teenage girls at risk for unintended pregnancy do not use contraception.52 In general, adolescents using contraception use methods with high ‘‘typical use’’ failure rates, including condoms and combined hormonal methods.53–58 Of US women aged 15 to 19 who are using a contraceptive method, only 4.5% use an IUD and 0.5% use a contraceptive implant to prevent unintended pregnancy.59 As LARC methods are the most effective at preventing unintended pregnancy, these methods should be first-line contraceptives offered to adolescents who are at high risk of unintended and rapid repeat pregnancy. In October 2012, ACOG released a committee opinion supporting the use of LARC in adolescents and encouraged providers to remove barriers to access.60 Although language in the package insert for the levonogestrel-releasing intrauterine system states that its use is recommended in women who have had at least 1 child,61 current evidence and practice show that this IUD is safe for use in adolescents. Moreover, the US Medical Eligibility Criteria (MEC) published by the CDC and the WHO do not place age restrictions on use of IUDs in adolescents and consider the overall benefits to outweigh the risks.62 In 2005, the manufacturers of the copper IUD T380A removed the language in the package insert www.clinicalobgyn.com
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recommending its use in women who have had at least 1 child.63 The contraceptive implant is approved for use in women of all ages. Although very little literature has been published so far regarding Skyla, the newest levonorgestrel intrauterine system that releases 13.5 mg levonorgestrel (LNG) at 14 mcg daily, this method is being marketed as a device that might be highly acceptable to young women. Attia et al64 found that the IUD has a pearl index of 0.18 per 1000 ‘‘women-years,’’ and the high potency of norgestrel means that endometrial concentrations of hormone in women using the LNG-IUS have been found to be 200 to 800 times those found after daily oral use, with plasma levels that are lower than other levonorgestrel contraception types. Side effects have mostly been correlated to the androgenic activity of the hormone, but have found to resolve within the first few months. Longterm side effects resemble those of other hormone-releasing IUDs, such as amenorrhea, hypomenorrhea, and oliomenorrhea. After 3 years, satisfaction rates for the LNG-IUS have been as high as 77% to 94%,65 with about 80% of women continuing to use the device each year. Future research is needed to directly compare the insertion experience, satisfaction, side effect profile, and efficacy of the 14mg LNG-IUS to the 53-mg LNG-IUS. Women With Chronic Disease Women with chronic medical conditions are a subset of the female population who are particularly at risk for adverse events during pregnancy.66 In the past, women with certain medical conditions frequently did not survive to reproductive age, but because of advances in technology and medical progress, women with chronic medical conditions are now more likely to reach reproductive age. Evidence shows that these women have fecundability rates similar to their healthy peers.67,68 www.clinicalobgyn.com
Although all women who undergo pregnancy are at risk for adverse events, pregnancy in women with chronic medical conditions could have significant consequences.69–72 These women have an increased risk of morbidity and mortality and often have exacerbation of disease status. Poor fetal outcomes, such as intrauterine fetal demise, preterm delivery, low birth weight, congenital anomalies, and teratogen exposure are also of concern. Despite these women’s regular interface with the health care system, women with chronic medical conditions often underutilize the most effective forms of contraception. According to some studies, as a result of provider unfamiliarity with LARC methods or uneasiness with any contraceptive method containing hormones, the majority of women with chronic medical conditions are using only minimal to moderately effective forms of contraception with high failure rates, such as combined oral contraceptive pills, barrier methods, natural family planning, or withdrawal.73–78 In June 2006, ACOG released a practice bulletin to discuss contraceptive choices for women with chronic medical conditions79 as unintended pregnancy rates in this population of women is equal to that of their healthy peers.80 The recommendation is that these women, in concert with their obstetrician and other care teams, optimize disease status before pregnancy, such that disease exacerbation is minimized and fetal and perinatal outcomes are improved. Thus, the most effective forms of contraception are imperative to help these patients obtain appropriate and desired timing of their families. These patients should not be excluded from hormonal contraception unless it is strictly contraindicated. Along with the ACOG bulletin, the US MEC can direct health care providers in prescribing the safest and most suitable contraceptive methods for women with a wide range of chronic medical conditions.
State of Family Planning In most cases, estrogen-containing contraceptives have the most frequent absolute contraindications for use, but can still be used in certain populations of women. Progestin-only contraceptives, such as progestin-only pills, the medroxyprogesterone injection, the etonogestrel contraceptive implant, and the levonogestrel IUD, can be used in most women with a chronic medical condition. The hormone-free copper IUD only has contraindications specific to IUD use. A summary of recommendations can be found at: http://www.cdc.gov/reproductive health/unintendedpregnancy/usmec.htm. Novel Contraceptive Technology Development Novel contraceptive technologies are in development for both men and women. The next generation of contraceptives may very well include nonhormonal targets, and hopefully a reversible but highly effective male-controlled contraceptive. Given the high acceptability of LARC methods, it is likely that we will see new long-acting methods introduced to the market.
Abortion UTILIZATION OF ABORTION SERVICES
Abortion is common in the United States, with approximately 1 million abortions performed annually.81 Of the 6.6 million unintended pregnancies in 2011, 40% ended in abortion, a decrease from 47% in 2008.4,82 There appear to be multifactorial reasons for this drop. Although the decrease in the proportion of pregnancies ending in abortion may have something to do with limited access to providers, a recent survey shows that increased contraception utilization coupled with a decrease in the unintended pregnancy rate, especially among adolescents, that
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had the most significant affect on the decline.83 Most women seek abortion early in pregnancy, and the vast majority of induced abortions occur early in gestation and can be performed in an outpatient setting. Ninety-two percent of abortions occur at 2000 OB/GYN residents have been trained in the provision of abortion.91 Residents who train in residencies with Ryan programs receive improved pregnancy options counseling and provision of contraception, training in medical abortion, uterine aspiration, and dilation and evacuation.91 For residents who opt out of abortion provision, the Ryan Residency program continues to provide training in uterine evacuation. Residents who partially participate in a residency family planning program but perform uterine evacuation for miscarriage or other indications have similar experience in uterine evacuation training.91 Residents involved in the Ryan Program during residency are more likely to provide abortion to patients in the future. Despite these improvements in abortion training through Accreditation Council for Graduate Medical Education mandates and Ryan Program support, abortion training in US OB/GYN residency programs and medical schools remains limited. In a recent survey of 425 fourth-year OB/GYN residents, 54% of respondents indicate that elective abortion training is routine. Most often, training sites were not within the training hospital.86 Evident from the survey is that more integrated training within the residency training curriculum correlated with increased exposure to and training in abortion provision. When abortion training is routinely integrated into OB/GYN residency programs, residents are more likely to report high satisfaction with the training, increased feelings of competency, and www.clinicalobgyn.com
intensions of future abortion provision. ACOG, as reported in Committee Opinion #424, supports availability of safe abortion services to all women and endorses incorporated family planning education and training for medical students and residents.89 There has been a significant amount of recent legislation aimed at restricting access to abortion services. Between 2011 and 2013, legislatures around the United States saw a total of 205 enactments of abortion restriction—more than that seen in the previous entire decade. Most measures were put forth in states already considered hostile to abortion rights. New restrictions passed include targeted regulation of abortion providers (TRAP laws), limits on the provision of medical abortion, bans on health insurance coverage (private, public, and through the new health care exchanges), bans on abortion after 20 weeks from fertilization, and ultrasound requirements. These regulations, especially TRAP laws, have forced some clinics unable to comply with the new laws to close. Laws requiring abortion providers to have hospital admitting privileges has increased burdens, and there has been a 4% decrease in the number of abortion providers nationwide since 2008.83 Currently, 87% of US counties are without an abortion provider. Restrictive abortion laws contribute to delays in obtaining abortion care. This results in abortions at later gestational ages and often compels women to travel to a state with less restrictive laws.92–97 Telemedicine using a health centerhealth center video conferencing system with a remote unlocking feature for the drug dispensation is used to help overcome regional variations and access to abortion care. A 2011 study of nearly 600 women seeking abortion at Planned Parenthood of the Heartland showed that telemedicine patients had comparable clinical outcomes as women who received face-to-face provision, with equivalent
State of Family Planning success rates and a low prevalence of adverse events. Ninety-four percent of these patients reported being ‘‘very satisfied’’ with the procedure.98 EARLY ABORTION
Vacuum aspiration is the most common technique used to complete an abortion and the WHO endorses this as the safest approach for surgical abortion.99 Manual vacuum aspiration (MVA) allows uterine evacuation to be performed in a variety of settings. This technique was introduced in the 1990s for use in low-resource settings, but currently is widely used in both highresource and low-resource settings.100,101 Approximately 50% of US abortion providers use MVA to complete abortion in the first trimester.102 According to guidelines released by the Society of Family Planning in 2013, evidence shows that MVA has high efficacy and safety for surgical abortion before 7 weeks. In a systematic review103 comparing MVA to electric vacuum aspiration, there were no significant differences observed between the 2 methods regarding incomplete abortion rate and patient satisfaction. There was less blood loss and less severe pain reported with MVA.104 Vacuum aspiration can be performed safely in the outpatient setting and 90% of abortions taking place in the United States occur in freestanding abortion clinics.101 Even though this model removes abortion care from mainstream medicine, the experience of freestanding clinics is a testament to the safety, efficacy, and costeffectiveness of office-based procedures. A recent study from Mexico City indicates that shifting from hospital-based dilation and curettage care to outpatient-based MVA care provided substantial cost savings.105 Extensive experience with pain management in office-based induced abortion care has now extended to management of spontaneous abortion—a procedure traditionally managed in the operating room
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under general anesthesia.106 In-office management of spontaneous abortion is safe and can be accomplished easily with MVA or medical management.107 Emergency room management of early pregnancy failure has also been shown to be feasible and may lead to expedited discharge for the emergency room.108 Medical Abortion Medical abortion safe and efficacious method of early abortion.109 Mifepristone, an antiprogestin, was approved in 2000 by the Food and Drug Administration (FDA) to induce abortion. The FDA-approved regimen for pregnancy termination includes 600 mg oral mifepristone followed by 400 mcg of buccal misoprostol 48 hours later. Efficacy of this method to induce abortion approaches 92% up to 49 days gestation.110 The FDA-approved regimen is costly and requires multiple visits to the clinic, both of which can present barriers to access. Several trials have been conducted to determine if other regimens may confer similar efficacy while reducing cost to individual women. A systematic review from 2013 that included 87 trials involving over 47,000 women showed that a 200 mg dose of mifepristone followed by misoprostol failed in only 4.8% of pregnancies.109 Using evidenced-based medication regimens of 200 mg mifepristone orally followed by 800 mcg of misoprostol buccally or vaginally reaches abortion completion rates of 98% up to 63 days gestation.111 A study from Gynuity Health involving 729 women undergoing termination of pregnancy showed efficacy of this regimen up to 70 days gestation.112 Recent guidelines jointly distributed by ACOG and the Society of Family Planning claim that evidence-based protocols are superior to the FDA-approved regimen.113 According to the guidelines, most women are candidates for medical abortion. Reasons for exclusion include anemia (hemoglobin www.clinicalobgyn.com
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State of Family Planning COURTNEY A. SCHREIBER, MD, MPH, and SARAH TRAXLER, MD Department of Obstetrics and Gynecology, Division of Family Planning, University of Pennsylvania, Philadelphia, Pennsylvania Abstract: Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Recent years have witnessed an unprecedented number of abortion restrictions, and research funding has decreased in related areas. Despite this, both the science and the implementation of improved family planning and abortion methods have progressed in the past decade. This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future. Key words: family planning, abortion, contraception
associated with a sustained decrease in the total fertility rate since the 1970s, the overall rate of unintended pregnancy has not changed over the past 20 years and persists as a significant public health problem in the United States. There are 6.6 million pregnancies in the United States each year and currently, about half (51%) are unintended.3,4 Public insurance programs pay for 48% of all births in the United States and pay for 64% of all births resulting from unintended pregnancies.4 These 1 million births from unintended pregnancies cost the federal and state governments about $11 billion annually.5 Recent years have witnessed an unprecedented number of abortion restrictions in the United States. Although the affordable care act promised to provide contraceptives as a component of primary health care for US women, this right is being currently diminished by legislators favoring corporations’ religious beliefs over women’s access to basic health care.6 Despite this, both the science and the implementation of improved family planning methods have progressed in the past decade. The use of the most effective contraceptives has increased among American women, and, although there has been a decreased investment by both
Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Since the enactment of the Economic Opportunity Act of 1964, family planning has been a major public health priority in the United States. Under Lyndon B. Johnson’s War on Poverty and then with Title X of the Public Health Service Act of 1970 under Richard Nixon, the United States began subsidizing contraception to decrease numbers of unwanted and ill-timed children and promote economic opportunities for women.1,2 Despite the fact that the family planning programs funded by these initiatives are Correspondence: Courtney A. Schreiber, MD, MPH, Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
392 | www.clinicalobgyn.com
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VOLUME 58
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NUMBER 2
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JUNE 2015
State of Family Planning the public and private sector in the development of novel contraceptives, a small number of methods are newly marketed and still more are under development. This year marked the tenth anniversary of the Society of Family Planning. This organization among others has been successful in supporting the scientific progress of reproductive health and family planning. Especially in the setting of restrictive state and federal policies, when it comes to women’s access to reproductive health care, scientific investigation and evidence-based clinical care offer hope to US women. The Institute of Medicine (IOM) has determined that women with unintended pregnancy are more likely to have shorter birth spacing, worse birth outcomes, delayed prenatal care, decreased breast feeding, decreased educational attainment, and increased economic hardship. Unintended pregnancy is often the inciting event that causes a woman to transition into poverty7 and has clear health, social, and economic consequences for women and their families.8–10 A recent analysis shows that access to birth control actually reduces the probability that a woman is living in poverty.11 This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future.
Contraception CONTRACEPTIVE UTILIZATION
Contraceptive use is almost universal for women of reproductive age and plays a fundamental role in determining healthy birth spacing and attainment of desired family size. According to data from the National Survey of Family Growth (NSFG) from 2006 to 2010,12 99.1% of women aged 15 to 44 living in the United States who have ever had vaginal intercourse use some form of contraception in their lifetime.13 And while women, on
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average, spend 5 years of their reproductive lives pregnant, attempting pregnancy, or postpartum, they spend the majority of their reproductive years attempting to avoid pregnancy.14 There are 43 million reproductive-aged women in the United States who are at risk for unintended pregnancy, and 89% are using a contraceptive method to avoid pregnancy. Thus, approximately 4.7 million women at risk of unintended pregnancy use no form of contraception. Pregnancies in these women account for half of all unintended pregnancies. Because pregnancy prevention depends on consistent and correct use of contraception, an additional 40% of unintended pregnancies occur in women who are incorrectly using contraception or have gaps in use. Only 5% of unintended pregnancies occur due to method failure in women who use contraception consistently and correctly.15 Data from the NSFG 2006-2010 show that 17.1% of women use oral contraceptive pills and 10.2% use condoms as their primary method of birth control.15 These methods have ‘‘typical use’’ failure rates of 9% and 18%, respectively.16 In survey data from the Guttmacher Institute that included 2000 reproductive-aged women at risk of unintended pregnancy, 15% experienced a gap in contraceptive insurance coverage17 while still at risk of unintended pregnancy. These gaps in coverage occurred more often in women using oral contraceptive pills and male condoms as their primary birth control method. Furthermore, 38% of women taking the oral contraceptive pill reported missing at least 1 pill in the month prior18 and 61% of women using condoms had inconsistent use. In contrast, women using long-acting reversible contraception (LARC) such as an intrauterine device (IUD) or contraceptive implant had much lower rates of gaps in use (4.2%).17 In December 2009, the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion www.clinicalobgyn.com
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recommending LARCs as first-line contraception to all women.19 The major advantage of LARCs compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the user for long-term effectiveness and demonstrate little difference between ‘‘perfect use’’ and ‘‘typical use’’ failure rates. Currently, only 3.5% of reproductive-aged women in the United States use an IUD as their primary method of birth control and 0.9% use a contraceptive implant. These methods have a failure rate of 0.2% to 0.8% and 0.05%, respectively,16 contribute to a clinically significant decrease in unintended pregnancy and abortion rate.20 CONTRACEPTIVE ACCESS AND UPTAKE
Cost Barriers and Facilitators Unintended pregnancy rates are highest among poor women, young women, and minority women, who are >5 times more likely to have an unintended pregnancy.21 In cross-sectional surveys of women with unintended pregnancy, many indicate that access and cost issues are reasons for not using contraception.17 Even with findings in a study showing LARC methods to be more cost-effective22 than other reversible methods or no method, upfront cost is still considered a significant barrier to LARC uptake. The Contraceptive CHOICE project removed all cost barriers to LARC provision and offered free contraception to a cohort of 10,000 reproductive-aged women living in the St Louis area. In this project, 75% of participants chose LARC as the primary method of birth control. At 12 months, LARC users had higher satisfaction rates (80%) compared with oral contraceptive pill users (54%)23; 24month continuation rates were much higher in LARC users compared with non-LARC users, 77% versus 41%.24 www.clinicalobgyn.com
Further findings from this study demonstrate a significant reduction in teen birth rate in CHOICE participants, 6.3 per 1000 compared with the national level of 34.3 per 1000.20 A reduction in abortion rate for the St Louis area was also seen relative to the rest of Missouri, and repeat abortions in the St Louis area compared with the surrounding region and the nation were significantly less.20 The CHOICE project’s medical contraindications to combined hormonal contraception (CHC) was very low in the select population, supporting provision of CHC without a prescription.25 ACOG also released an opinion that hormonal contraceptives should be available over the counter without a prescription. OTC availability would overcome major contraceptive access barriers. Provider Barriers and Facilitators Although the CHOICE project demonstrated a marked increase in LARC uptake when provided free of charge, California’s Family Planning Access Care and Treatment Program,26 a large Medicaid expansion in the state of California that eliminates the financial barrier to LARC by providing free contraception to men and women r200% of the federal poverty level, shows uptake of IUDs and implants similar to national averages. A survey conducted among medical directors of Family PACT provider sites help to explain these findings. Provider bias and misinformation can become a barrier between women and the most effective methods of contraception. Fifty-six percent of the provider respondents believed that IUDs can be inserted immediately postabortion, 76% believed that a followup visit is necessary after insertion, 41% agreed that IUD causes abortion, and 33% believed an IUD increases the risk of pelvic inflammatory disease (PID). These beliefs are seated in mythology, not evidence.19 Only 20% to 22% of respondents considered nulliparous
State of Family Planning women and teenagers as appropriate candidates for IUD insertion despite proof to the contrary.27 IUDs are appropriate for use in young nulliparous women, and are considered as the first-line contraceptive options by the American Congress of Obstetrics/Gynecologists and American Academy of Pediatrics. There is a great body of evidence that supports safety, efficacy, and satisfaction in this population.19–24 Provider barriers to contraceptive access are of national concern. In 2 separate cross-sectional surveys of health care providers conducted in 2002 and 2008, a majority of providers believe that nulliparous women and nonmonogamous women are not candidates for IUD placement.28,29 A more recent survey of family medicine physicians, obstetrician-gynecologists, and advanced practice clinicians from 2012 found that fewer respondents (16%) consider IUDs to be unsafe in nulliparous women, but 80% rarely or never provide IUDs to this population.30 The Centers for Disease Control and Prevention’s (CDC’s) US Medical Eligibility Criteria for Contraceptive Use (US MEC), released in 2010, provides guidance to clinicians on the safety of contraceptive methods in women with certain characteristics and medical conditions. In general, there is no age restriction for LARC use. The contraceptive implant is safe to use at any age, from menarche to menopause. With regard to IUD use, the benefits generally outweigh the risks for women of all ages. According to the guidelines, the only absolute contraindication to contraceptive implant use is current breast cancer. Contraindications to IUD use are few and include: (1) distortion of the uterine cavity; (2) current cancer (breast, cervical, endometrial, and gestational trophoblastic disease); (3) current pelvic infection (PID, immediate postseptic abortion, puerperal sepsis, purulent cervicitis, and
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tuberculosis); and (4) unexplained vaginal bleeding. The companion document to the US MEC, US Selected Practice Recommendations for Contraceptive Use 2013 (US SPR), includes guidelines for clinicians that help to remove provider-specific barriers to contraception initiation. These evidence-based guidelines empower clinicians to achieve timely provision of contraception to women. The guidelines also aid in providing contraception that is most appropriate, encouraging satisfaction and continuation to maximize effectiveness. Patient Beliefs and Misconceptions Patient-level misconceptions about contraception are also significant contributors to nonuse of contraception and subsequent unintended pregnancy. This is not surprising given the level of misconception among providers discussed above. Lack of knowledge regarding the most effective methods of contraception restricts the range of options available to women who desire to prevent pregnancy. According to data from the National Campaign to Prevent Teen and Unplanned Pregnancy, three fourths of young adults had heard of the IUD, whereas only 44% were aware of the contraceptive implant.31 This survey also showed that approximately one third of young adults report fear that long-term use of a hormonal contraceptive will lead to serious health problems, and 30% believe that the IUD will cause an infection. Many believe that it is healthy to periodically take a break from hormonal birth control. Half of women report that health concerns decrease their likelihood of ever using a specific method. TIMING OF CONTRACEPTIVE UPTAKE
Although contraceptive initiation would ideally occur before an unintended pregnancy, the postabortion and postpartum periods present key opportunities for www.clinicalobgyn.com
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education and immediate implementation of contraception to prevent repeat unintended pregnancy. There are many reasons to start immediate postabortion and postpartum contraception such as high motivation for contraception, convenience, reduce need for travel, and childcare. Postabortion Contraceptive Initiation Because more than half of women will resume intercourse within 2 weeks after an abortion,32 and women can ovulate as early as 8 days after abortion,33 initiation of contraception at the time of abortion reduces the risk of repeat pregnancy and abortion. The World Health Organization (WHO) supports initiation of any method of contraception immediately after surgical or medical abortion, reducing barriers to postabortion uptake and utilization of contraception.34 Immediate postinitiation of any type of contraception lowers the rates of repeat abortion incidence, but type of contraception started in the postabortion period has a significant impact on repeat unintended pregnancy and repeat abortion over time. In a study from Heikinheimo et al,35 users of the IUD and the contraceptive implant were much less likely to present for repeat abortion over the 3- to 5-year follow-up period compared with users of other methods. A retrospective chart review of 986 women presenting for termination of pregnancy by Cameron32 shows that women who initiate IUD or implant immediately postabortion are significantly less likely to present for a repeat termination of pregnancy in the subsequent 2 years (odds ratios of 0.05 and 0.06 for the IUD and implant, respectively). The postabortal period is an ideal time to initiate highly effective contraception. Women are likely motivated to prevent subsequent unintended pregnancies and there is enhanced ease of insertion.36 Furthermore, a study comparing immediate www.clinicalobgyn.com
versus delayed insertion of IUD postabortion showed that only 32% of women in the delayed insertion group returned for IUD insertion.37 Several studies evaluated in a Cochrane Review from 2002, however, demonstrate that IUD use in the immediate postabortion period is safe and associated with low risk of complications.38 Overall, the rates of perforation and PID were low. A systematic review completed in 2011 by Steenland et al,39 includes evaluation of 19 studies and reports that evidence suggests that postabortion IUD does not increase risk of pain, bleeding, or infection. Clinicians also may cite increased expulsion rates as a reason to delay IUD insertion beyond the immediate postabortion period. However, a randomized controlled trial (RCT) conducted by Bednarek et al,40 in which women were randomized to immediate insertion of IUD versus delayed insertion of IUD, demonstrates noninferior expulsion rates in the immediate insertion group (5% vs. 2.7%). The immediate insertion group also had higher rates of continuation at 6 months and a lower repeat pregnancy rate. Hohman et al41 also demonstrate in a RCT that women randomized to immediate postabortion IUD were significantly more likely to have an IUD placed compared with the delayed insertion group, and expulsion rates were similar between the 2 groups. The systematic review cited above suggests that, in general, expulsion rates are similar for the immediate postabortion interval compared with IUD insertion at other times.39 Postpartum To reduce adverse maternal and neonatal outcomes, the WHO recommends an interval of at least 24 months before attempting another pregnancy after a live birth.42 One third of all repeat pregnancies are conceived within 18 months of the previous birth. Short interpregnancy
State of Family Planning interval is associated with delayed prenatal care,43 premature birth,44 and low birth weight.45 In a cohort of >111,000 women from California, contraception use within 90 days postpartum was associated with avoidance of rapid repeat pregnancy (defined as repeat pregnancy 22% of teenage girls at risk for unintended pregnancy do not use contraception.52 In general, adolescents using contraception use methods with high ‘‘typical use’’ failure rates, including condoms and combined hormonal methods.53–58 Of US women aged 15 to 19 who are using a contraceptive method, only 4.5% use an IUD and 0.5% use a contraceptive implant to prevent unintended pregnancy.59 As LARC methods are the most effective at preventing unintended pregnancy, these methods should be first-line contraceptives offered to adolescents who are at high risk of unintended and rapid repeat pregnancy. In October 2012, ACOG released a committee opinion supporting the use of LARC in adolescents and encouraged providers to remove barriers to access.60 Although language in the package insert for the levonogestrel-releasing intrauterine system states that its use is recommended in women who have had at least 1 child,61 current evidence and practice show that this IUD is safe for use in adolescents. Moreover, the US Medical Eligibility Criteria (MEC) published by the CDC and the WHO do not place age restrictions on use of IUDs in adolescents and consider the overall benefits to outweigh the risks.62 In 2005, the manufacturers of the copper IUD T380A removed the language in the package insert www.clinicalobgyn.com
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recommending its use in women who have had at least 1 child.63 The contraceptive implant is approved for use in women of all ages. Although very little literature has been published so far regarding Skyla, the newest levonorgestrel intrauterine system that releases 13.5 mg levonorgestrel (LNG) at 14 mcg daily, this method is being marketed as a device that might be highly acceptable to young women. Attia et al64 found that the IUD has a pearl index of 0.18 per 1000 ‘‘women-years,’’ and the high potency of norgestrel means that endometrial concentrations of hormone in women using the LNG-IUS have been found to be 200 to 800 times those found after daily oral use, with plasma levels that are lower than other levonorgestrel contraception types. Side effects have mostly been correlated to the androgenic activity of the hormone, but have found to resolve within the first few months. Longterm side effects resemble those of other hormone-releasing IUDs, such as amenorrhea, hypomenorrhea, and oliomenorrhea. After 3 years, satisfaction rates for the LNG-IUS have been as high as 77% to 94%,65 with about 80% of women continuing to use the device each year. Future research is needed to directly compare the insertion experience, satisfaction, side effect profile, and efficacy of the 14mg LNG-IUS to the 53-mg LNG-IUS. Women With Chronic Disease Women with chronic medical conditions are a subset of the female population who are particularly at risk for adverse events during pregnancy.66 In the past, women with certain medical conditions frequently did not survive to reproductive age, but because of advances in technology and medical progress, women with chronic medical conditions are now more likely to reach reproductive age. Evidence shows that these women have fecundability rates similar to their healthy peers.67,68 www.clinicalobgyn.com
Although all women who undergo pregnancy are at risk for adverse events, pregnancy in women with chronic medical conditions could have significant consequences.69–72 These women have an increased risk of morbidity and mortality and often have exacerbation of disease status. Poor fetal outcomes, such as intrauterine fetal demise, preterm delivery, low birth weight, congenital anomalies, and teratogen exposure are also of concern. Despite these women’s regular interface with the health care system, women with chronic medical conditions often underutilize the most effective forms of contraception. According to some studies, as a result of provider unfamiliarity with LARC methods or uneasiness with any contraceptive method containing hormones, the majority of women with chronic medical conditions are using only minimal to moderately effective forms of contraception with high failure rates, such as combined oral contraceptive pills, barrier methods, natural family planning, or withdrawal.73–78 In June 2006, ACOG released a practice bulletin to discuss contraceptive choices for women with chronic medical conditions79 as unintended pregnancy rates in this population of women is equal to that of their healthy peers.80 The recommendation is that these women, in concert with their obstetrician and other care teams, optimize disease status before pregnancy, such that disease exacerbation is minimized and fetal and perinatal outcomes are improved. Thus, the most effective forms of contraception are imperative to help these patients obtain appropriate and desired timing of their families. These patients should not be excluded from hormonal contraception unless it is strictly contraindicated. Along with the ACOG bulletin, the US MEC can direct health care providers in prescribing the safest and most suitable contraceptive methods for women with a wide range of chronic medical conditions.
State of Family Planning In most cases, estrogen-containing contraceptives have the most frequent absolute contraindications for use, but can still be used in certain populations of women. Progestin-only contraceptives, such as progestin-only pills, the medroxyprogesterone injection, the etonogestrel contraceptive implant, and the levonogestrel IUD, can be used in most women with a chronic medical condition. The hormone-free copper IUD only has contraindications specific to IUD use. A summary of recommendations can be found at: http://www.cdc.gov/reproductive health/unintendedpregnancy/usmec.htm. Novel Contraceptive Technology Development Novel contraceptive technologies are in development for both men and women. The next generation of contraceptives may very well include nonhormonal targets, and hopefully a reversible but highly effective male-controlled contraceptive. Given the high acceptability of LARC methods, it is likely that we will see new long-acting methods introduced to the market.
Abortion UTILIZATION OF ABORTION SERVICES
Abortion is common in the United States, with approximately 1 million abortions performed annually.81 Of the 6.6 million unintended pregnancies in 2011, 40% ended in abortion, a decrease from 47% in 2008.4,82 There appear to be multifactorial reasons for this drop. Although the decrease in the proportion of pregnancies ending in abortion may have something to do with limited access to providers, a recent survey shows that increased contraception utilization coupled with a decrease in the unintended pregnancy rate, especially among adolescents, that
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had the most significant affect on the decline.83 Most women seek abortion early in pregnancy, and the vast majority of induced abortions occur early in gestation and can be performed in an outpatient setting. Ninety-two percent of abortions occur at 2000 OB/GYN residents have been trained in the provision of abortion.91 Residents who train in residencies with Ryan programs receive improved pregnancy options counseling and provision of contraception, training in medical abortion, uterine aspiration, and dilation and evacuation.91 For residents who opt out of abortion provision, the Ryan Residency program continues to provide training in uterine evacuation. Residents who partially participate in a residency family planning program but perform uterine evacuation for miscarriage or other indications have similar experience in uterine evacuation training.91 Residents involved in the Ryan Program during residency are more likely to provide abortion to patients in the future. Despite these improvements in abortion training through Accreditation Council for Graduate Medical Education mandates and Ryan Program support, abortion training in US OB/GYN residency programs and medical schools remains limited. In a recent survey of 425 fourth-year OB/GYN residents, 54% of respondents indicate that elective abortion training is routine. Most often, training sites were not within the training hospital.86 Evident from the survey is that more integrated training within the residency training curriculum correlated with increased exposure to and training in abortion provision. When abortion training is routinely integrated into OB/GYN residency programs, residents are more likely to report high satisfaction with the training, increased feelings of competency, and www.clinicalobgyn.com
intensions of future abortion provision. ACOG, as reported in Committee Opinion #424, supports availability of safe abortion services to all women and endorses incorporated family planning education and training for medical students and residents.89 There has been a significant amount of recent legislation aimed at restricting access to abortion services. Between 2011 and 2013, legislatures around the United States saw a total of 205 enactments of abortion restriction—more than that seen in the previous entire decade. Most measures were put forth in states already considered hostile to abortion rights. New restrictions passed include targeted regulation of abortion providers (TRAP laws), limits on the provision of medical abortion, bans on health insurance coverage (private, public, and through the new health care exchanges), bans on abortion after 20 weeks from fertilization, and ultrasound requirements. These regulations, especially TRAP laws, have forced some clinics unable to comply with the new laws to close. Laws requiring abortion providers to have hospital admitting privileges has increased burdens, and there has been a 4% decrease in the number of abortion providers nationwide since 2008.83 Currently, 87% of US counties are without an abortion provider. Restrictive abortion laws contribute to delays in obtaining abortion care. This results in abortions at later gestational ages and often compels women to travel to a state with less restrictive laws.92–97 Telemedicine using a health centerhealth center video conferencing system with a remote unlocking feature for the drug dispensation is used to help overcome regional variations and access to abortion care. A 2011 study of nearly 600 women seeking abortion at Planned Parenthood of the Heartland showed that telemedicine patients had comparable clinical outcomes as women who received face-to-face provision, with equivalent
State of Family Planning success rates and a low prevalence of adverse events. Ninety-four percent of these patients reported being ‘‘very satisfied’’ with the procedure.98 EARLY ABORTION
Vacuum aspiration is the most common technique used to complete an abortion and the WHO endorses this as the safest approach for surgical abortion.99 Manual vacuum aspiration (MVA) allows uterine evacuation to be performed in a variety of settings. This technique was introduced in the 1990s for use in low-resource settings, but currently is widely used in both highresource and low-resource settings.100,101 Approximately 50% of US abortion providers use MVA to complete abortion in the first trimester.102 According to guidelines released by the Society of Family Planning in 2013, evidence shows that MVA has high efficacy and safety for surgical abortion before 7 weeks. In a systematic review103 comparing MVA to electric vacuum aspiration, there were no significant differences observed between the 2 methods regarding incomplete abortion rate and patient satisfaction. There was less blood loss and less severe pain reported with MVA.104 Vacuum aspiration can be performed safely in the outpatient setting and 90% of abortions taking place in the United States occur in freestanding abortion clinics.101 Even though this model removes abortion care from mainstream medicine, the experience of freestanding clinics is a testament to the safety, efficacy, and costeffectiveness of office-based procedures. A recent study from Mexico City indicates that shifting from hospital-based dilation and curettage care to outpatient-based MVA care provided substantial cost savings.105 Extensive experience with pain management in office-based induced abortion care has now extended to management of spontaneous abortion—a procedure traditionally managed in the operating room
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under general anesthesia.106 In-office management of spontaneous abortion is safe and can be accomplished easily with MVA or medical management.107 Emergency room management of early pregnancy failure has also been shown to be feasible and may lead to expedited discharge for the emergency room.108 Medical Abortion Medical abortion safe and efficacious method of early abortion.109 Mifepristone, an antiprogestin, was approved in 2000 by the Food and Drug Administration (FDA) to induce abortion. The FDA-approved regimen for pregnancy termination includes 600 mg oral mifepristone followed by 400 mcg of buccal misoprostol 48 hours later. Efficacy of this method to induce abortion approaches 92% up to 49 days gestation.110 The FDA-approved regimen is costly and requires multiple visits to the clinic, both of which can present barriers to access. Several trials have been conducted to determine if other regimens may confer similar efficacy while reducing cost to individual women. A systematic review from 2013 that included 87 trials involving over 47,000 women showed that a 200 mg dose of mifepristone followed by misoprostol failed in only 4.8% of pregnancies.109 Using evidenced-based medication regimens of 200 mg mifepristone orally followed by 800 mcg of misoprostol buccally or vaginally reaches abortion completion rates of 98% up to 63 days gestation.111 A study from Gynuity Health involving 729 women undergoing termination of pregnancy showed efficacy of this regimen up to 70 days gestation.112 Recent guidelines jointly distributed by ACOG and the Society of Family Planning claim that evidence-based protocols are superior to the FDA-approved regimen.113 According to the guidelines, most women are candidates for medical abortion. Reasons for exclusion include anemia (hemoglobin www.clinicalobgyn.com
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