The 'Get It and Forget It' methods are here: Remove obstacles to use
St. Louis project promotes use of long-acting reversible contraception
Where do long-acting reversible contraceptives (LARC) fit in at your facility? How are you encouraging women to use the "Get It and Forget It" methods? If you are seeing low numbers of women choosing intrauterine devices (IUDs) or the contraceptive implant, you might want to change your counseling strategy.
Take a tip from the Contraceptive CHOICE Project in St. Louis. This project is a prospective cohort study of women ages 14-45 who want to avoid pregnancy for at least one year and are initiating a new form of reversible contraception.
Women screened for this study are read a script regarding long-acting reversible methods of contraception to increase awareness of these options. Participants choose their contraceptive method that is provided at no cost. From the beginning, the emphasis is placed on the effectiveness of the LARC methods compared to pills, the contraceptive patch, and the contraceptive vaginal ring.
The project enrolled 9,256 women. The first woman enrolled in August 2007, with the last woman entered in September 2011. Of those women enrolled in the program, 75% have chosen an IUD or an implant. Among women who chose these methods, 86% are still using them at one year. Just 55% of women who chose other methods, such as the Pill, ring, and contraceptive patch, maintained method use at the same point.
Women using the LARC methods and the contraceptive injection had the lowest unintended pregnancy rates at one, two, and three years of follow-up. Pill, ring, and patch users had much higher unintended pregnancy rates, more than 16 times higher than LARC users in Year One. (Visit the project's website, www.choiceproject.wustl.edu, and click on "Study Findings" to obtain more statistics from the project.)
Of the first 5,086 women ages 14-45 enrolled in the CHOICE Project, 69% of women ages 14-17 and 61% of women ages 18-20 chose a LARC method. About 65% of women ages 14-17 chose the implant, while 71% of those ages 18-20 picked the IUD.1
Despite a 2007 committee opinion from the American Congress of Obstetricians and Gynecologists recommending the T380A and levonorgestrel IUDs for adolescents, many clinicians remain reluctant to provide IUDs to young women.2 Findings from a study of California providers indicated only 39% considered a teen to be an appropriate IUD candidate.3 In a survey of St. Louis providers, just 31% of providers considered an IUD appropriate for teens, 50% would insert one for a 17-year-old with one child, and only 19% would insert one for a 17-year-old without any pregnancies.4
What are the most popular forms of contraception used by adolescents? According to the latest findings from the National Survey of Family growth, they are condoms and withdrawal, followed by birth control pills.5 Just 3.6% of women ages 15-19 used the IUD, and the implant was not included as a separate method.6 This use of less-reliable methods likely contributes to the 80% unintended pregnancy rate of adolescent women.7
The U.S. adolescent pregnancy rate rose for the first time in 2006, after a steady decline in the past 15 years. The rate increased by 3% over the 2005 rate in women ages 15-19.8
"This finding certainly suggests that all providers of contraceptives in the United States need to learn from and adopt approaches used by the St. Louis Contraceptive CHOICE Project to increase use of LARC methods," says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta.
What drives LARC choice?
Why have so many women chosen LARC methods in the CHOICE Project?
For the answer, we look to Jeffrey Peipert, MD, MPH, MHA, Robert J. Perry professor of obstetrics and gynecology and vice chair for clinical research at Washington University School of Medicine in St. Louis, who is directing The Contraceptive CHOICE study. Peipert notes five factors:
- Women desire effective methods of contraception, and these methods are the most effective.
- All providers involved in the project believe in LARC methods and are willing to use them in almost all women.
- Access and affordability barriers are removed. All methods are provided free of charge and can be obtained easily at the project's health center.
- Providers dispel the myths and misconceptions about these methods.
- Providers offer education and counseling regarding side effects and management of side effects.
For Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville, the Contraceptive CHOICE Project is reminiscent of the 1989 movie, "Field of Dreams." In that movie, Kevin Costner heard a voice that indicated "if you build it, he [Shoeless Joe Jackson] will come." Peipert and his group have convincingly demonstrated that if providers make long-acting reversible contraceptives available, women will make them their first-choice birth control option, says Kaunitz.
"Findings from the Contraceptive CHOICE Project represent the type of authoritative data that should result in changing our contraceptive paradigm," notes Kaunitz. "Given their high continuation and low failure rates, LARC methods should be first-line contraceptives for our patients; if, and only if, such methods are not suitable or accessible, then shorter-acting methods — pills, patches, rings — represent appropriate choices."
Check the order
When you talk with women regarding their birth control options, when do LARC methods enter the conversation?
During contraceptive counseling at the CHOICE Project, methods are presented in order of effectiveness, explains Gina Secura, PhD, adjunct assistant professor of epidemiology and senior scientist/epidemiologist in the Department of Obstetrics and Gynecology in the Division of Clinical Research at Washington University. According to Secura, the counselor presents the information about effectiveness, side effects, advantages, and disadvantages for each method in order of effectiveness. Counselors also advocate the dual use of condoms for prevention of sexually transmitted infections. Free condoms are available to all participants.
What is the order of presentation of methods at the CHOICE Project? The "top tier" reversible methods (intrauterine and implant contraceptives) lead the way:
- levonorgestrel intrauterine system (LNG-IUS, Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ);
- copper T380A IUD (ParaGard, Teva Women's Health, North Wales, PA);
- contraceptive implant (Implanon, Merck & Co., Whitehouse Station, NJ);
- contraceptive injection (depot medroxyprogesterone acetate, DMPA; Depo-Provera, Pfizer, New York City; Teva Pharmaceuticals USA, North Wales, PA);
- oral contraceptives;
- contraceptive vaginal ring (NuvaRing, Merck & Co.);
- contraceptive patch (Evra, Ortho Women's Health & Urology, Raritan, NJ). [The chart also may be viewed online at Planned Parenthood's website. Go to www.plannedparenthood.org. Under "The Facts On," select "Birth Control," then select "Compare Effectiveness of Birth Control Options."]
How long to use IUDs?
The approved duration of use of the levonorgestrel IUD is five years, although studies have shown contraceptive efficacy to seven years.9
According to A Clinical Guide For Contraception, "the LNG IUD can be used for at least seven years, and probably 10 years."10 The contraceptive implant is marketed with a duration of action for three years; however, pharmacokinetic data from Implanon users show stable serum concentrations of etonogestrel out to 36 months, suggesting that the method is effective for longer than that.11 Three studies in which a total of 275 used Implanon for longer than three years found no pregnancies during the fourth year of use.11
Researchers at Washington University in St. Louis are conducting the Evaluation of Prolonged Use of IUD/Implanon for Contraception (EPIC) Study to confirm whether the levonorgestrel IUD and the subdermal implant are effective for longer than their current Food and Drug Administration-approved durations, reports Peipert. If these methods can be left in place for a longer period of time, they will be even more cost-effective, he notes.
"Imagine a 400-pound woman who comes in for IUD removal after five years of [Mirena] use; it may be very difficult to remove the Mirena and to reinsert," notes Peipert. "We can avoid the potential risks of this procedure if the device is actually effective for seven, 10, or 12 years."
References
- 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; 84:493-498.
- ACOG Committee opinion number 392. Obstet Gynecol 2007; 110:1,493-1,495.
- Harper C, Blum M, Thiel de Bocanegra H, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008; 111:1,359-1,369.
- Madden T, Allsworth JE, Hladky KJ, et al. Intrauterine contraception in St. Louis: a survey of obstetrician and gynecologists' knowledge and attitudes. Contraception 2010; 81:112-116.
- Abma JC, Martinez GM, Copen CE. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008. National Center for Health Statistics. Vital Health Stat 2010; 23.
- Mosher WD, Jones J. Use of contraception in the United States: 1982–2008. National Center for Health Statistics. Vital Health Stat 2010; 23.
- Henshaw SK. Unintended pregnancy in the United States. Fam Plan Perspect 1998; 30:24-29.
- Guttmacher Institute. U.S. teenage pregnancies, births, and abortions: national and state trends and trends by race and ethnicity. Accessed at http://www.guttmacher.org/pubs/USTPtrends.pdf.
- Dean G, Schwarz EB. Intrauterine contraceptives (IUCs). In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011; 149.
- Speroff L, Darney PD. A Clinical Guide for Contraception. Fifth ed. Philadelphia: Lippincott Williams & Wilkins; 2011.
- Raymond E. Contraceptive implants. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011; 195.
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