|July 2012 · Vol. 24, No. 7
EXAMINING THE EVIDENCE
Does long-acting reversibleYes. In this prospective cohort study of 7,486 women, 156 unintended pregnancies were attributed to contraception failure. Failure rates at years 1, 2, and 3 in oral contraceptive (OC), patch, or ring users were 4.8%, 7.8%, and 9.4%, respectively, compared with 0.3%, 0.6%, and 0.9% in intrauterine device (IUD) or implant users (P<.001). For OC, patch, or ring users, those younger than age 21 had almost twice the risk of a pregnancy as older study participants (hazard ratio, 1.9; 95% confidence interval, 1.2–2.8). No significant difference was found in the pregnancy rate according to age in women using IUDs or implants.
unintended pregnancy better
than OCs, transdermal patch,
and vaginal ring— regardless
of a patient’s age?
Professor and Associate Chairman, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville. He serves on the OBG Management Board of Editors.
Because half of US pregnancies continue to be unintended, rates of induced abortion in our patients remain high. In addition, unintended pregnancies lead to negative health and social consequences for women and infants. This recent report from the Contraceptive Choice Project, spearheaded by Dr. Jeffrey Peipert from the Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, and published in New England Journal of Medicine underscores the high efficacy of long-acting reversible contraceptives, a term referring to IUDs and the contraceptive implant, in preventing unintended pregnancy in a US population.
Details of the study
Eligibility in the Project included age 14 to 45 years, residence in the St. Louis, Missouri, area, and the need for contraception. The woman’s contraceptive of choice was made available at no charge, with most women choosing a long-acting method. The published study includes outcomes for 7,486 women who used OCs, the patch, the ring, an IUD, implant, or depot medroxyprogesterone acetate (DMPA) injections.
Among women using OCs, the patch, or the ring, the pregnancy rate was 4.55 per 100 participant-years. This rate was nearly 22-fold higher than that observed in women using IUDs or the implant (hazard ratio, 21.8; 95% confidence interval, 13.7–34.9): that rate was 0.27 per 100 participant-years. A similar low rate of pregnancy was noted among women who chose DMPA and returned every 3 months for follow-up injections.
Among women younger than 21 years who used OCs, the patch, or the ring, the rate of unintended pregnancy was twice as high as in older women using these same methods. By contrast, regardless of age, pregnancy rates were uniformly low among women using long-acting methods.
The authors point out that their study design was not randomized—participants were at high risk for unintended pregnancy and willing to begin using a new contraceptive method, which could have resulted in higher adherence rates and lower failure rates.
Access is ongoing barrier to use
These important data from the Contraceptive Choice Project clarify that long-acting reversible contraceptives represent powerful tools to help women minimize unintended pregnancy and induced abortion, and that women will choose these methods if they are accessible.
The findings in this report also make it clear that rates of unintended pregnancy are particularly high among adolescents using shorter-acting hormonal contraceptives (OCs, patch, or ring) and that longer-acting contraceptives are particularly useful in our younger patients. Other recent reports have provided clear evidence that immediately providing long-acting contraceptives after childbirth or induced abortion reduces unintended pregnancy in these settings.1,2
In the United States, inadequate access to long-acting reversible contraceptives continues to constrain use. Accordingly, insurance policies that fully cover longer-acting contraceptives could go a long way toward reducing the rate of unintended pregnancies and induced abortions in our patients.
If long-acting reversible contraceptives become more available in the United States, I look forward to a time when the great majority of our patients’ pregnancies are planned and when far fewer women will face the troubling prospect of an induced abortion.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Given the limitations of shorter-acting methods, it is time to change our paradigm with regard to counseling women seeking contraception. Longer-acting contraceptives, including IUDs, the implant and injections, should be regarded as first-line options. Shorter-acting methods, including OCs, the patch, and the ring, should be considered second-line options and provided to women who choose not to use longer-acting methods or those who financially do not have access to them.
ANDREW M. KAUNITZ, MD
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1. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol. 2012;206(6):481. e1–e7.
2. Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT. Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 20119;364(23):2208–2217.
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