Research finds reduced attendance following LARC
By Melinda Young
Adolescent and young adult patients who select long-acting reversible contraception (LARC) attend fewer well-woman visits and have reduced testing for sexually transmitted infections (STIs), new research shows.1
“Our interest in this question came because of two trends in reproductive health and contraceptive policy in the last two decades,” says Mieke Eeckhaut, PhD, associate professor in the department of sociology and criminal justice at the University of Delaware in Newark.
One trend is the increased interest in LARC to reduce unintended pregnancy rates and the focus on this method as part of reproductive health policy. The second trend is the increase in STI rates.
“STI rates have been going up steeply during those years, and they have continued to go up,” Eeckhaut says. “We know that LARCs do not prevent STIs, so a lot of policy has focused on increasing LARC use and pregnancy prevention and not as much on STI prevention.”
Testing is an important part of preventing and treating STIs.
“Our concern is that women using LARC are probably not as protected against STIs because we know that dual contraceptive use is low,” she adds.
When women receive a LARC method, they are routinely tested for STIs at that time. It is recommended that all sexually active women be tested once a year for STIs, and for those on hormonal birth control pills, this annual screening may occur when they see their OB/GYN for their annual visit, which is when doctors see if they want a renewed prescription to their contraceptives.
But for women with a LARC method, where pregnancy protection can last up to eight years for some intrauterine devices (IUDs) and three to five years for other LARCs, this annual visit may not be on patients’ radar.
With Delaware Medicaid encounter and claims data, including nearly 21,000 women from 2012 through 2019, investigators found there was a steep increase in LARC adoption due to the 2015-2020 Delaware Contraceptive Access Now (DelCAN) initiative, which offered provider training and assistance for LARC.1
The study found that when a young woman begins a new prescription method, such as birth control pills, her STI testing rates are higher than in years when she continued another contraceptive method. It also found that STI testing rates are lower in the years after LARC initiation than what would be expected if clinical recommendations were followed. This finding appears to be related to LARC users’ lower attendance to well visits.1
Women who skip well-woman visits are missing out on basic preventive healthcare, including STI testing.
“Because LARC methods are longer term, they don’t need a prescription each year, and maybe they’re not going to their well-woman visit and having basic preventive healthcare,” says Katie Fitzpatrick, MPP, PHD, associate professor in the department of consumer science at the University of Wisconsin – Madison.
“Women are not making that appointment or they’re not keeping that appointment — we don’t know,” Fitzpatrick says.
There are other contraceptive methods that could dampen adherence to annual well-woman visits, including permanent contraception methods and use of Opill, the first over-the-counter birth control pill approved to be marketed in the United States, Eeckhaut says.
“It’s a fact that needing a prescription for contraceptive use helps women to go to these yearly visits, and once that reason is no longer there, women have less incentive for wanting to go,” she explains. “Well-woman visits do more than STI testing.”
For instance, well-woman visits include health information and counseling at every visit, as well as Pap smears every few years, Fitzpatrick notes.
“Well-woman visits cover anything from social determinants of health, food insecurity to violence screening,” she says.
Family planning clinics and OB/GYN offices can improve patients’ scheduling of well-woman visits by having women schedule the next appointment as they leave. Then, if a patient has missed an appointment or has gone for more than a year without one, they can send automated text reminders or have someone call them to remind them of the importance of these visits, Fitzpatrick says.
Since some young women also have children, allowing women to bring their baby into the well-woman visit also can reduce their burden.
“Try to think about creative ways to help women who have children to still keep their visits,” Fitzpatrick says.
“Any burden physicians place on women can reduce their coming for a visit, so make it as easy as possible for women to make those visits,” she adds. “We know these visits are important, and they’re the first line of screening and preventing all sorts of [problems].”
The study’s authors focused on LARC vs. other methods but they found that — in general — a lot of young women are not being tested yearly.
“It’s not just reduced testing among those who use LARC, but testing rates are overall low,” Eeckhaut says. “Well-woman visits can be part of that solution, but STI testing overall needs to be a focus.”
Reproductive health clinicians need to focus less exclusively on pregnancy prevention and promote dual-method use to prevent STIs as well. Policy makers need to create programs that also promote overall sexual and reproductive health wellness and prevention.
“Have that be part of counseling and part of the conversation about contraception — a little more than it has been in recent decades when a lot of the focus has been on pregnancy. This is important,” Eeckhaut says.
What Eeckhaut hopes clinicians take away from the research is that the focus on LARC is a positive one because of its benefits, particularly in pregnancy prevention, and over-the-counter birth control pills also increase access to women who might not be able to get a prescription because of transportation and other issues. But more is needed to also preserve their health.
“While we make those changes in terms of improving access, we also need to think about unintended consequences and how we can mitigate those, and that’s what our paper is pointing to,” she says. “How can we make sure women are not skipping those visits because they don’t have a prescription and make sure they are not missing STI testing and other important services?”
Robert A. Hatcher, MD, MPH, Professor Emeritus of Gynecology and Obstetrics, Emory University School of Medicine in Atlanta, says, “Condoms should be part of the dialogue for all women receiving contraceptives for two reasons: Their use improves the contraceptive effectiveness of the method a woman has chosen, and they are the most effective means of preventing STIs.”
REFERENCE
- Eeckhaut MCW, Fitzpatrick K. Is use of long-acting reversible contraceptives (LARC) associated with reduced well-women visits and STI testing? Evidence from female Medicaid clients aged 15-24 in Delaware. Prev Med 2024;187:108089. [Online ahead of print].
