Lower unintended pregnancy rates: Use IUD for emergency contraception
Copper-T IUD most effective form of EC, but use remains low
Women seeking emergency contraception (EC) are at high risk of unintended pregnancy. To counter this possibility, family planning providers often issue advance supply of emergency contraceptive pills (ECPs). But is this practice effective in addressing the problem?
EXECUTIVE SUMMARY
Women seeking emergency contraception (EC) are at high risk of unintended pregnancy. Family planning providers often issue advance supply of emergency contraceptive pills (ECPs).
- Analysis of all available data to date indicates that efficacy of advance provision compared with standard provision of ECPs in reducing unintended pregnancy rates at the population level has not been demonstrated.
- The copper-T intrauterine device (ParaGard IUD) is the most effective method of EC with a failure rate of less than 0.1%, yet few family planning providers offer EC IUD insertions. Results of a survey among 1,246 California state family planning program clinicians indicate 85% never recommended the copper IUD for EC and 93% required two or more visits for an IUD insertion.
Analysis of all available data to date indicates that efficacy of advance provision compared with standard provision of ECPs in reducing unintended pregnancy rates at the population level has not been demonstrated.1 Data show that while any use of ECPs was two to seven times greater among women who received an advanced supply of pills, there was no significant reduction in unintended pregnancy (relative risk 0.90, 95% confidence interval 0.69-1.18) over 12 months when advance provision was compared with standard provision of ECPs.
The copper-T intrauterine device (ParaGard IUD, Teva Women’s Health, North Wales, PA) is the most effective method of EC with a failure rate of less than 0.1%, yet few family planning providers offer EC IUD insertions. Results of a survey of 1,246 clinicians in a California state family planning program, where contraceptives approved by the Food and Drug Administration are available at no cost to low-income women, show most clinicians (85%) never recommended the copper IUD for emergency contraception, and most (93%) required two or more visits for an IUD insertion.2
Why are providers hesitant when it comes to inserting IUDs for EC? David Turok, MD, associate professor in the University of Utah Department of Obstetrics and Gynecology in Salt Lake City, hears several explanations when he speaks to family planning groups. Providers say their clinics don’t have the financial resources to stock devices, don’t have the time to obtain preapprovals for insertions, or don’t have the flexibility in scheduling time for EC insertions, he says. Such practices need to change, he says.
"We need to have the ability to view these things as true contraceptive emergencies, just like cardiologists and emergency room physicians view chest pain as a cardiac emergency," explains Eleanor Bimla Schwarz, MD, MS, director of the Women’s Health Services Research Unit and associate professor of medicine, epidemiology, and obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh. "In those cases, we’re not telling people come back tomorrow or some other day.’ We see them on the spot, and that’s the shift that we need to make in order to make it happen."
Schwarz and Turok led a session at the recent Reproductive Health 2013 national conference in Denver to optimize chances for women seeking EC to initiate a highly effective method of contraception before leaving the clinic.3 Participants were asked to reflect on challenges that might arise in their own clinical settings when trying to offer emergency IUD placement and to brainstorm potential solutions. The session also focused on helping women who opt for ECPs to transition to other highly effective methods of contraception, such as the contraceptive implant (Nexplanon, Merck & Co., Whitehouse Station, NJ) or the levonorgestrel IUD (Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ), before leaving the clinic.
What did Pittsburgh do?
Researchers at the University of Pittsburgh have developed a program to ensure that all women who seek EC or walk in pregnancy (WIP) testing are equipped with the knowledge and services they need to avoid unintended pregnancy.
The researchers explored how often women seeking clinic-based pregnancy testing who don’t desire pregnancy might benefit from EC, as well as examined variables associated with patients asking for EC when use is indicated. They invited women seeking pregnancy testing or EC from a Pittsburgh inner-city Title-X-funded family planning clinic to complete surveys. Twenty-seven percent of women were seeking EC, and 73% were seeking pregnancy testing. Of those seeking pregnancy testing, 39% might have benefited from same-day use of EC pills.
Researchers found that women who had never used EC and who had more than one episode of unprotected sex within the past month were less likely to request EC when use was indicated, while single women were more likely to request EC. Counseling regarding EC options is important for women seeking same-day pregnancy testing who don’t desire pregnancy, researchers conclude.4
The Pittsburgh researchers then looked at what it would take for a Title X clinic to routinely offer women seeking EC or WIP same-day placement of highly effective reversible contraception. They also looked at the impact of brief structured counseling about long-acting reversible contraception (LARC), combined with the offer of same-day placement, on women’s knowledge of IUDs and implants and contraceptive use. (See the brief scripted counseling message on this page.)
Of women who came into the Pittsburgh clinic for EC, 29% received an IUD within five days, and 34% had an IUD within three months. These women represent an additional 5% of women who received an IUD more than five days after their EC visit. About 19% of women reported the counseling prompted their switch to an IUD.3
During the baseline period, no women received an IUD on the day of their clinic visit, Schwarz noted. After researchers implemented the brief counseling script, 10.5% of women had an EC IUD inserted.
A total of 95 women came to the clinic for EC and left with levonorgestrel ECPs; seven of those women were pregnant by three months. Ten women who presented for EC left with ulipristal acetate pills; three of them were pregnant by three months. In contrast, none of the women who requested EC and had a copper-T IUD inserted same-day (25 women) were pregnant at three months.3
Look at opportunities
When can a copper-T IUD be placed for EC? According to the recently released U.S. Selected Practice Recommendations for Contraceptive Use, it can be inserted within five days of unprotected intercourse, but can be inserted six or more days after unprotected sex if the day of ovulation can be estimated and not more than five days have passed since ovulation, says Schwarz.5
What can be gained from the results of the Pittsburgh project? Schwarz says it is possible for a Title X clinic to routinely inform women about the option of EC IUD. As only 10-20% of women might opt for same-day intrauterine contraception, this practice will not flood most clinic schedules, she notes. Clinics must have IUDs in their stock cabinet prior to establishing same-day EC IUD insertion services, Schwarz says.(To read about Utah clinics’ experience with IUD EC insertions, see the story on p. 136.)
Same-day placement uses counseling script
Looking for a quick way to counsel on long-acting reversible contraception (LARC) for same-day placement? Here is a brief counseling script, used by researchers at the University of Pittsburgh:
• "The birth control methods that work best to prevent pregnancy are the implant and the IUD. These methods are more effective than condoms, pills, or the Depo shot. The implant and IUD are as effective as having your tubes tied, but they can be reversed at any time if you decide to become pregnant or want to switch to a different method.
• The birth control implant is called Nexplanon. It is a small flexible rod that is placed under the skin of the upper arm and can be used for three years.
• An IUD is a small, flexible, T-shaped device that is slid into the uterus and can be used for at least five years. There are two types that you might have heard of: the Mirena IUD and the copper IUD, sometimes called ParaGard.
• If you have had sex without a condom or other type of birth control in the last seven days and don’t want to become pregnant, the copper IUD might be your best option today because it is more effective than emergency contraceptive pills.
• Do you have any questions about implants, IUDs, or any other types of birth control?"
REFERENCES
- Rodriguez MI, Curtis KM, Gaffield ML, et al. Advance supply of emergency contraception: a systematic review. Contraception 2013; 87(5):590-601.
- Harper CC, Speidel JJ, Drey EA, et al. Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstet Gynecol 2012; 119(2 Pt 1):220-226.
- Schwarz EB, Turok D. She needs EC... does your emergency response team offer an IUD? Presented at the Reproductive Health 2013 annual meeting. Denver; September 2013.
- Lee JK, Parisi SM, Baldauf E, et al. Asking for what she needs? Pregnancy testing or EC? Contraception 2013; 87(6):859-863.
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, second edition. MMWR Recomm Rep 2013; 62(RR-05):1-60.
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