Ob/Gyns Should Offer Long Acting Reversible Contraception First to Lower Unintended Pregnancy Rates

The Contraceptive CHOICE Project, a research study at Washington University in St. Louis, found that offering long-acting, reversible contraception (LARC) to women first, citing its low-failure rates, and providing contraception at no cost reduced rates of unintended pregnancy and abortion and increased continuation rates.

“I think we need a complete shift in how we offer contraception to patients,” said Jeffrey Peipert, MD, PhD, of the University of Washington in St. Louis. Peipert presented The CHOICE Project research at the 61st American Congress of Obstetricians and Gynecologists annual meeting. “We need to start with the most effective methods, long-acting reversible options, and then if women are not interested in those methods, move to [offering] other forms of contraception.”

Between August of 2007 and September of 2011, the CHOICE Project enrolled 9,256 participants from the St. Louis area diverse in age, education and race. The study offered hormonal and non-hormonal IUDs, a sub-dermal implant, the pill, patch, or ring to qualifying women for free. Clinicians introduced IUDs and the sub-dermal implant first, informing patients that LARC methods are reversible and the lowest failure rates of the options.

“Our goal was to increase the acceptance and use of long-acting methods and to measure acceptability, satisfaction, side effects and rates of continuation across all contraceptive methods and to compare them to LARC,” Peipert said.

The rate of unintended pregnancy among study participants was 35 per 1000 women, compared to the national rate of 52 per 1000 women. The pill, patch and ring users were 20 times more likely to have an unintended pregnancy in the first year compared to LARC users; LARC users continued to have the lowest rate of unintended pregnancy in their two and three year follow-ups. The study also resulted in a 17% decline in teen births.

Peipert said that clinicians tend to deemphasize LARC methods when counseling patients, even though hormonal IUDs, non-hormonal IUDs and sub-dermal implants have failure rates that rival sterilization.

Hesitation toward LARC use may originate from myths and misinformation resulting from negative outcomes in early IUD use in the 1970s, but these beliefs are untrue for today’s IUDs, Peipert said.  For example, pelvic inflammatory disease (PID) incidence is similar with IUD use as that of the general population; IUDs preserve fertility at similar rates to other forms of contraception and IUDs can actually help prevent ectopic pregnancy, rather than cause it.

Peipert not only encourages clinicians to present LARC options first along with information on failure rates, but also urges them to offer IUDs to teens and nulliparous women together with STD and condom use counseling. He also encourages clinicians to insert IUDs immediatly post-abortion and post-partum. There are low incidences of complication and high patient motivation at this time. IUDs have the lowest rates of expulsion when inserted within ten minutes of placental delivery, and do not increase risks for post-partum bleeding or infection.

Seventy-five percent of the women in the Contraceptive CHOICE Project chose a LARC method. Of these, 86% were still using that method at one year. Of women who chose a non-LARC method, 55% were still using this method at 1 year.

Study results point to significant policy implications, and an opportunity to drastically reduce healthcare costs, Peipert said. “No-cost contraception and easy access to LARC can reduce unintended pregnancy. One dollar of family planning investment saves three to four dollars down the road, and that savings is greater with LARC methods,” he said.

“We’ve been stuck for decades at a rate of unintended pregnancy in the US of close to 50%. Now, if we can shift our recommendations to LARC methods, I think we can finally see a reduction in unintended pregnancy.”