Troubling Gap in Women's Contraceptive Use

Nicola M. Parry, DVM

November 12, 2015

Despite the potential for adverse maternal and fetal outcomes, contraceptive use in women with certain medical conditions is suboptimal, according to a new study.

Steven W. Champaloux, PhD, MPH, a scientist in the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC), and colleagues published the results of their study online November 5 and in the December issue of Obstetrics & Gynecology.

"[O]ur analysis demonstrated that their contraceptive method use is not optimal, because the prevalence of female sterilization and reversible prescription methods was low among both younger and older women with medical conditions. In addition, similar to the proportion among all women, the most frequently used methods among women with medical conditions were shorter acting prescription methods, which are not as effective as [long-acting reversible contraceptive methods (LARCs)] or female sterilization," the authors write.

Pregnancy in older women is becoming more common in the United States. However, older women have an increased risk for pregnancy-related complications and are also more likely to have preexisting conditions such as hypertension or diabetes mellitus. In addition, because unintended pregnancy is a significant public health problem, its prevention remains an important area of need for the United States.

Therefore, the researchers compared contraceptive use among women with and without selected medical conditions. They used a nationwide database to identify women of childbearing age (15 - 44 years; n = 368,448) who were privately insured continuously from January 2004 to September 2011. The researchers evaluated the use of current permanent or reversible prescription contraceptive use among those women during the study's index period from October 2010 to September 2011. They excluded women who had undergone a hysterectomy during this 7-year period.

Using International Classification of Diseases, Ninth Revision, diagnosis codes, the investigators selected medical conditions within the study population that are considered to be associated with increased health risks from an unintended pregnancy according to the CDC's US Medical Eligibility Criteria for Contraceptive Use guidelines.

"Large Unmet Need"

Twelve percent of the women in the study had any of the selected medical conditions, and hypertension (8%) and diabetes (3%) were the most prevalent. Among the women with medical conditions, only 40% of those aged 15 to 34 years, and 32% of those aged 35 to 44 years, were using sterilization or reversible prescription methods during the index period. These proportions were low among women across all of the conditions examined.

The odds of sterilization were higher among women with any medical condition compared with no condition for those aged 15 to 34 years (odds ratio [OR], 4.88; 95% confidence interval [CI], 4.46 - 5.33) and 35 to 44 years (OR, 1.16; 95% CI, 1.11 - 1.21).

Among the younger group, the odds of sterilization were increased in particular in women with hypertension (OR, 7.29; 95% CI, 6.55 - 8.10), diabetes (OR, 4.09; 95% CI, 3.43 - 4.87), stroke (OR, 4.57; 95% CI, 3.17 - 6.60), and thrombophilia (OR, 8.75; 95% CI, 5.97 - 12.82).

The results of the study demonstrate a large unmet need for contraceptive use among women with medical conditions. The findings were "consistent with another study that found women with diabetes were more likely to undergo sterilization compared with women without any medical conditions and also found that women with diabetes received less contraceptive counseling than women without any medical conditions," the authors write.

Similarly, among women using reversible prescription methods, the odds of using LARCs were increased among those women with any condition compared with women with no condition for those aged 15 to 34 years (OR, 2.24; 95% CI, 2.06 - 2.45) and 35 to 44 years (OR, 1.14; 95% CI, 1.08 - 1.21).

Among the younger group, more women with medical conditions (45%) used sterilization or reversible prescription methods compared with women with no medical condition (39%). The highest proportion of sterilization or reversible prescription contraceptives was among those who had recently undergone bariatric surgery (53%), and the lowest was among women with epilepsy (37%).

Among the older group, similar proportions of women with any or no medical condition (30% vs 32%) used sterilization or reversible prescription methods. The highest rate of sterilization or reversible prescription contraceptive use was also seen among those who had undergone bariatric surgery (33%), whereas the lowest rate was seen among women with breast cancer (20%).

Sterilization and LARCs were more likely to be used by younger women with medical conditions (7% each) than those without (2% and 3%, respectively), whereas the rates in older women with medical conditions (9% and 5%, respectively) were similar to those in women without medical conditions (8% and 6%, respectively).

Women aged 15 to 34 years with any medical condition used shorter-acting reversible prescription contraceptives (32.1%) more frequently than sterilization (6.5%) or LARCs (6.7%). For women aged 35 to 44 years with any medical condition, those percentages were 15.6%, 9.4%, and 5.4%, respectively.

"Although there was an overall low prevalence of sterilization, our study demonstrated increased odds of sterilization for women with medical conditions compared with women without medical conditions; this association was strongest among younger women with hypertension, diabetes, stroke, and thrombophilia," the authors write. "The magnitude of the associations suggests that health care providers may be more aware of the need for highly effective contraception among women with these conditions," they conclude.

LARC Use on the Rise

Data from the 2011 to 2013 National Survey of Family Growth, collected by the CDC's National Center for Health Statistics, have also been recently published. The survey investigated current contraceptive use among 5601 women aged 15 to 44 years and demonstrated that, from 2011 to 2013, 61.7% of respondents were currently using contraception.

Similar to the results of the study by Dr Champaloux and colleagues, the 2011 to 2013 National Survey of Family Growth showed that overall, women used shorter-acting methods including the pill (25.9%), contraceptive ring or patch (2.6%), or injectable forms (4.5%) more frequently than sterilization (25.1%) or LARCs (11.6%). However, the data also highlighted that LARCs are becoming more popular among women: their rate of use has doubled since the 2006 to 2010 National Survey of Family Growth report, when the rate of LARC use was only 6.0%.

In an editorial accompanying the study published by Dr Champaloux and colleagues, Mary E. D'Alton, MD, a professor of obstetrics and gynecology at the Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York City, emphasizes the troubling nature of the rate and pattern of contraceptive management among women in this study and congratulates the study's authors "for reporting this gap in contraceptive care for some of this country's most vulnerable women."

She also notes that the vulnerability of women with complex medical disorders and the risk for complications associated with unintended pregnancy cannot be underestimated and should play a central role in future strategies for improving contraceptive care. "Special attention needs to be paid to those with chronic medical conditions receiving particularly low rates of contraception services, such as women with epilepsy," writes Dr D'Alton.

She also stressed the need for a concentrated effort by the obstetric community and follow-through by clinicians in other specialties to improve contraceptive care in women. "The reward for such a strategy could be the prevention of many cases of severe maternal morbidity, and potentially mortality, in the United States each year," she concludes.

The authors received no external funding for this study. The authors and editorialist have disclosed no relevant financial relationships.

Obstet Gynecol. 2015;126:1151-1159. Abstract


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