Better Contraception Teaching Reduces Unintended Pregnancies

Ricki Lewis, PhD

June 17, 2015

Educating young women about long-acting reversible contraceptives (LARCs) reduced unwanted pregnancy rates at 40 reproductive health clinics in the United States, according to results of a study published online June 17 in the Lancet.

Despite the recommendation dating from 2009 by the American College of Obstetricians and Gynecologists that LARCs, including intrauterine devices (IUDs) and implants, be used as first-line contraception, the methods are not used in the United States to the extent they are elsewhere. National surveys reveal that 25% of US physicians offer IUDs to women who have just had abortions, 38% offer them to adolescents, and 53% of them offer IUDs to women who do not have children.

Several factors underlie low use of LARCs in the United States: "Many providers aren't trained to provide them to women, women don't know about them, and they have high up-front costs, which now might be attenuated with more women with health insurance coverage through the [Affordable Care Act]," Cynthia C. Harper, PhD, a professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at the University of California, San Francisco Bixby Center for Global Reproductive Health, told Medscape Medical News. "It's very easy to provide pills and use condoms, whereas a physician or nurse needs training to be able to provide IUDs and the implant, she added.

About 51% of pregnancies in the United States are unintended. They disproportionately affect women who are minorities, those with low incomes, and/or those aged 18 to 24 years. The Centers for Disease Control and Prevention recommends LARCs for all women because the methods have a failure rate lower than 1%. The failure rate for oral contraceptives is 9% and for condoms, it is 18%.

Dr Harper and colleagues hypothesize that training providers to educate patients about LARCs could lower rates of unintended pregnancy. "Contraceptive choices are highly personal, but women should at least have access and information about all [US Food and Drug Administration]-approved contraceptives," Dr Harper said.

The researchers randomly assigned 20 of 40 geographically diverse Planned Parenthood health centers to receive an educational intervention for providers, and the other 20 (the controls) to continue counseling for contraception as they had been. Selection criteria for participating clinics were that they provide IUDs or implants to less than 20% of their patients, have no specific program to educate about or recommend LARCs, and do not share staff with other clinics in the study.

Participants were seeking visits for family planning or care after abortion. They were aged 18 to 25 years, were sexually active, and desired contraception.

The training covered counseling and technical skills. "A physician/counselor training team went to the clinic and held a half-day session for all clinic staff, including health educators. We used a multicomponent intervention to both increase their knowledge and also to change their attitudes about providing these methods," said Dr Harper. The training included placing and removing IUDs and implants, which advance practice nurses and physician assistants can be trained to do, she added.

After counseling, participants answered a questionnaire and providers documented sessions, including the chosen method of contraception.

Additional questionnaires administered at 3, 6, and 9 months probed use of and satisfaction with the chosen method. Participants took pregnancy tests at 6 and 12 months. They did not know whether or not their clinicians had had the educational intervention.

Primary outcome was selection of an IUD or implant, and secondary outcome was pregnancy within 12 months.

More of the participants whose providers received the intervention than participants at the control sites reported receiving counseling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693 patients; odds ratio, 3.8; 95% confidence interval [CI], 2.8 - 5.2), and more participants chose LARCs at the visit (224 [28%] vs 117 [17%]; odds ratio, 1.9; 95% CI, 1.3 - 2.8) if their providers had the training.

Pregnancy rate was lower among women whose providers had the intervention than among those whose providers did not have the intervention for family planning visits (7.9 vs 15.4 per 100 person-years), but not for postabortion visits (26.5 vs 22.3 per 100 person-years). The intervention effect on pregnancy rates among women visiting for family planning visits was significant (hazard ratio, 0.54; 95% CI, 0.34 - 0.85).

Of the 1500 participants, 211 became pregnant during the investigation (16.6 per 100 person-years): 15.0 per 100 person-years in the intervention group and 18.5 per 100 person-years among control patients (hazard ratio, 0.89; 95% CI, 0.64 - 1.24).

Participants in the intervention group and those in the control group reported autonomy in decision-making about contraception. For both groups, 78% of women reported choosing alone, 14% chose with the provider, 7% chose no method, and less than 1% said the provider alone chose the method of contraception.

The ability to obtain LARCs differed between the family planning vs postabortion patient groups. Women seeking family planning information were much more likely to obtain IUDs or implants than women postabortion (74 [73%] of 101 vs 51 [44%] of 115 patients). Nearly 25% of women postabortion became pregnant again within 12 months.

The primary reason for poor follow-up in obtaining LARCs is economics: "The cost of birth control methods such as IUDs and implants can be very high in the US because many states have restrictions on funding or providing low-cost contraceptives in the abortion care setting. Our federal Title X funding is to help low-income women to be able to access birth control, but it can't be used in the abortion care setting," Dr Harper said.

Nerys Benfield, MD, director, family planning, Department of Obstetrics and Gynecology, Women's Health, Montefiore Medical Center, Bronx, New York, agrees: "Studies like this show that it's not anything distinct about American women in being less likely to use LARCs, it's that we don't have equal access to the full range of contraceptive options. Cost is a big barrier."

A limitation of the study is that the findings may not be applicable to clinics that are not specialized for reproductive services.

"I hope that the study demonstrates that a small educational intervention aimed at the providers can have a dramatic impact on access to the full range of contraceptive options, which will lead women to choose more effectively in how they prevent pregnancy," Dr Benfield told Medscape Medical News.

One coauthor has consulted for Agile, Bayer, and Merck. The other coauthors and Dr have disclosed no relevant financial relationships.

Lancet. Published online June 17, 2015. Full text

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