Long-Acting Reversible Contraceptive Use Increasing

Janis C. Kelly

October 09, 2015

Use of long-acting reversible contraceptives (LARCs) increased from 8.5% of contraceptive users in 2009 to 11.6% in 2012, a period during which unintended pregnancy rates also dropped. The increase was similar among most racial and income subgroups, researchers report in an article published online October 5 in Obstetrics & Gynecology.

The study aloo reported data likely to allay fears that black women are being coerced into using long-acting birth control, as this was the only subgroup in which LARC use decreased. The data also suggested that many women are using LARC to delay and space, rather than limit, pregnancies.

LARC methods include intrauterine devices (IUDs) and subdermal hormonal implants, "some of the most effective contraceptive methods available," write Megan L. Kavanaugh, DrPh, and colleagues from the Guttmacher Institute in New York City.

The researchers analyzed data from the National Survey of Family growth, a nationally representative sample of females aged 15 to 44 years. Simple and multivariable logistic regression analyses of data for 6428 females in 2008 to 2010 were compared with data for 5601 females in 2011 to 2013. The primary outcome of the cross-sectional, descriptive study was current prevalence of LARC use.

The key findings were:

  • LARC use by Hispanic females increased from 8.5% to 15.1% (P < .01), the largest increase in any subgroup.

  • LARC use by women with private insurance increased from 7.1% to 11.1% (P < .01). (The authors note that the data collection predated the Affordable Care Act's contraceptive mandate.)

  • LARC use by women with fewer than two sexual partners in the previous year increased from 9.2% to 12.4% (P < .01).

  • LARC use by nulliparous women increased from 2.1% to 5.9% (P < .01).

  • LARC use by black women dropped from 9.2% to 8.6% (P = NS).

The latter finding addressed concerns "that promoting LARC methods to 'at-risk' women may disproportionately target minority, poor, and young women, further devalue their childbearing, or disregard the root causes of health inequalities that drive disparities in unintended pregnancies," the authors write.

That concern was further addressed in an accompanying editorial by Melissa L. Gilliam, MD, from the Department of Obstetrics and Gynecology, University of Chicago, Illinois, who writes, "[The authors] note that earlier increases in LARC use among African Americans have not continued throughout the past decade. In fact, in controlled analysis, African American women now appear to be less likely to use the IUD compared with women of other racial–ethnic groups. The authors suggest that this pattern makes coercion less likely and that underuse might be attributed to medical mistrust or poor access to these methods." Dr Gilliam noted.

"Yet, a counter suggestion is to insist on not being reassured. Being uncomfortable will compel us to do the hard work of addressing our biases, empowering our patients, and ensuring our systems are high-quality and equitable."

LARC use was not associated with poverty status. In addition, rates of LARC discontinuation resulting from dissatisfaction were similar between minority women and non-Hispanic white women.

Choice of LARC method might be affected by sociodemographic factors. The group that used implants rather than IUDs included more young, low-income, and black females. The researchers speculate that this difference might be driven either by user preference or by inequitable access and suggest continued monitoring of differences in IUD and implant use.

The authors write, "Some of the largest increases in LARC use documented between 2009 and 2012 were observed among nulliparous females and females intending a future or subsequent child, indicating that these methods are being used by some women to delay or space pregnancies rather than limit them."

Among the study limitations, the authors note that multiple hypothesis testing using the chosen significance threshold of P < .05 "may have resulted in some spuriously significant associations."

The authors have disclosed no relevant financial relationships. Dr Gilliam serves on the board of the Guttmacher Institute.

Obstet Gynecol. Published online October 5, 2015. Abstract, Editorial extract

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