Growing Number of Contraceptive Options Available to Women

Tara Haelle

May 10, 2018

AUSTIN, Texas — Healthcare providers need to use "a reproductive justice framework for contraceptive counseling," according to an expert who spoke here at the American College of Obstetricians and Gynecologists 2018 Annual Meeting.

"Provide nonjudgmental, nondirective counseling that empowers women to make the best choice for them," said Eve Espey, MD, from the University of New Mexico Health Sciences Center in Albuquerque.

The goal of contraception should be not only to reduce unintended pregnancies, but also to empower women to make decisions that feel most appropriate for them, she explained.

Espey cited a study of 30 black and Latina women on Medicaid who described their experience with contraceptive counseling as impersonal, not mindful of their preferences, containing undertones of coercion if they wanted a different method than their provider recommended, and imbued with racial discrimination (J Health Care Poor Underserved. 2011;22:1387-1400).

In fact, a request for a contraceptive appointment should be considered "high priority, since unintended pregnancy is a public health emergency," Espey told Medscape Medical News.

It is vital for all healthcare providers to bring up contraception in every conversation they have with women in their care who are of child-bearing age, a member of the audience said after the presentation.

"As obstetricians–gynecologists, we don't see the patient until she's already pregnant," she said. But previous visits to the emergency department, a family doctor, a surgical referral, and other encounters are opportunities to find out if a woman is using reliable contraception, "so we're not the only providers having the conversation."

Each year in the United States, 23% of pregnancies are unintended but carried to term, 21% are unintended and aborted, and 5% are unintended and end in miscarriage.

From 2008 to 2011, there was a steady decline in the number of unintended pregnancies, which contributed to the lowest abortion rate since 1973, when Roe v. Wade was decided.

Teen births are at an all-time low, driven largely by a 50% drop in unintended pregnancies among black and Latina adolescents. More consistent use of contraception, the use of long-acting reversible contraception, and increased abstinence have all contributed to the decline, Espey reported.

However, unintended pregnancy rates remain high among women of color, partially because of inadequate insurance coverage, inadequate sex education, and a mismatch in cultural values — the emphasis on sexuality in the media clashes with a focus on traditional morals.

In public discourse, "contraception is the new abortion," Espey told the audience.

Long-Acting Reversible Contraception

Effective methods of contraception are more available than ever, including long-acting reversible contraception. These include the subdermal implant, which can last for 4 years, levonorgestrel intrauterine devices (IUDs), such as Kyleena, Liletta, Mirena, and Skyla, and the nonhormonal copper IUD ParaGard — all of which can last 6 years.

Long-acting reversible contraception tends to be what women choose first, said Espey.

The Contraceptive CHOICE Project showed that when 10,000 women 14 to 45 years of age were offered contraception at no cost, 75% chose an implant or an IUD (Am J Obstet Gynecol. 2010;203:115.e1-115.e7). Other research from that project showed that women who chose a long-acting method were more likely than women who chose a different method to still be using their preferred choice at 12 months (86% vs 55%) (Clin Obstet Gynecol. 2014;57:635-643).

But misconceptions exist. "Good evidence contradicts a persistent misconception that IUDs are not appropriate for adolescents and nulliparous women," Espey told Medscape Medical News.

She recommends the US Medical Eligibility Criteria (US MEC) app, which helps providers determine whether patients can safely use certain contraceptive methods.

The most recent version of the app has added postpartum women, women with cystic fibrosis or multiple sclerosis, women taking selective serotonin reuptake inhibitors or St. John's wort, and includes ulipristal acetate (ella, Watson Laboratories) as an option for emergency contraception.

"Immediate postpartum LARC is an exciting innovation, although reimbursement barriers currently limit its use," said Espey. Postpartum IUD placement requires training, but it could reduce rapid repeat pregnancy and has a low expulsion risk, of 10% to 30%.

And "ulipristal acetate is a well-kept secret," she added. "Many obstetrician–gynecologists are not familiar with this emergency contraceptive and are unaware that it is more effective than levonorgestrel (Plan B and generics)."

If a patient is in need of emergency contraception, it is better to prescribe ulipristal acetate, which delays ovulation and prevents pregnancy up to 5 days after unprotected sex, than levonorgestrel, she explained.

And women should be given emergency contraception regardless of their weight, despite concerns about reduced effectiveness in heavier women, she pointed out, adding that the copper IUD is the most effective for this purpose, followed by ulipristal acetate.

Evidence suggesting that other hormonal contraception is less effective in overweight and obese women is limited, especially because compliance is more important than weight, Espey said.

She wrapped up her presentation with a discussion of the most recent developments with Essure (Conceptus Inc), a permanent contraceptive.

"The FDA has placed additional requirements for use of Essure, including a mandated checklist, to ensure patients make an informed decision," Espey told Medscape Medical News.

Overall, the presentation "was very informative in terms of what's new and up and coming, what we need to look out for, and tweaking our counseling for contraception," said Leia Medlock, MD, an obstetrician–gynecologist in private practice at Simmonds, Martin, & Helmbrecht Chartered in Germantown, Maryland.

"Birth control for women is best chosen by them — not us — so we have be supportive of their desires," Medlock told Medscape Medical News. That way, they are "more likely to use it longer."

"It was the best session I had," said Julia Rivera-Figueroa, MD, an obstetrician–gynecologist at Jackson County Memorial Hospital in Altus, Oklahoma.

"Espey was very open and very good, and she was very unbiased," Rivera-Figueroa said.

Espey, Medlock, and Rivera-Figueroa have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting. Presented April 29, 2018.

Follow Medscape OBGYN on Twitter @MedscapeObGyn and Tara Haelle @TaraHaelle

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