Image: PD/IUD

Key study points:

1. When offered no-cost contraception, most women chose highly effective long-acting reversible contraceptives (LARCs), such as intra-uterine devices (IUDs) and the implant.

2. Women and adolescents offered no-cost contraception had lower rates of teenage pregnancy, abortion and repeat abortion than comparable populations.

3. Combining no-cost contraception with clinician recommendation of LARCs as first-line for all women (including nulliparous and/or teenagers) promises reductions in unintended pregnancies and thus, abortions.

Primer: The US has an unintended pregnancy rate of 49% for women of all ages, and 80% for pregnancies in women 19 and younger. Unintended pregnancies present a considerable economic burden on society and are associated with an increased risk of health problems for both mother and child for reasons including inappropriate prenatal care and inadvertent in-utero exposures. One of the most effective ways to decrease unintended pregnancies is to increase access to and decrease cost of effective contraception. In fact, public funding of family planning programs has proven prudent—for every $1 spent, taxpayers are saved an estimated $4.74 in pregnancy-related costs.

Currently, there are a number of contraceptive methods available: surgical sterilization, LARCs, oral contraceptive pills (OCPs), transdermal patch the vaginal ring, male condoms and diaphragms, among others. Long-acting reversible contraception (LARCs) are as effective as sterilization yet entirely reversible. Moreover, they require little maintenance—the IUD is a small device implanted in the uterus that lasts for 5-10 years (copper-eluting IUD lasts for 10 years, progesterone-eluting IUD lasts for 5 years) and the implant is placed in the arm and lasts for 3 years. Despite their effectiveness, LARCs have been historically underutilized in the US. Given their efficacy, convenience, and cost-effectiveness, the American College of Obstetrics and Gynecology recommends LARCs as first-line options for women of reproductive years.

The present work is part of a larger project out of Washington University called the “Contraceptive CHOICE Project” and evaluates the effects of provision of no-cost contraception to women at risk for unintended pregnancy.

Background reading:

This [prospective cohort] study: recruited 9,256 females aged 14-45 from two major abortion clinics in St. Louis, counseled them on contraception with emphasis on LARCs and provided them contraception of their choice at no cost. Proxies for the rate of unintended pregnancy (rates of abortion, repeat abortion and teenage births) were compared to published rates in Kansas City and a nonmetropolitan region of Missouri.

Women offered no-cost contraception experienced lower rates of repeat abortions compared to controls (p<.001), lower abortion rates (less than half of regional and national rates) and a teenage birth rate well below the national average of 0.63%. After counseling on the superior efficacy of LARCs, the majority (75%) of study participants chose LARCs, compared with utilization rates of 3% LARCs in the general population.

Study author, Jeffrey F. Peipert, M.D., Ph.D., talks to 2 Minute Medicine: Department of Obstetrics & Gynecology, Division of Clinical Research, at the Washington University in St. Louis School of Medicine, St. Louis, MO

“Our hope is that this article and our previous one in the NEJM (Effectiveness of LARC) will change how clinicians counsel women about contraception and increase support for no-cost contraception in healthcare reform. The findings are important for women’s health, prevention, public health, and healthcare costs (and cost savings). Family planning saves healthcare dollars. We finally may be able to reduce unintended pregnancies in the U.S., which has one of the highest rates of teen births and unintended pregnancies among developed countries.”

In sum: Combining no-cost contraception with counseling about LARCs greatly reduced unintended pregnancies in at risk women and adolescents. A limitation of this study is that the study population was high risk, and thus the observed reduction in risk is likely greater than it would be in the general population. However, given the magnitude of reduction in risk, it is likely that the studied intervention, education and access to no-cost LARCs, were expanded, unintended pregnancy rates would decrease nationwide.

Click to read the study in the current issue of Obstetrics & Gynecology

By Maren Shapiro and Leah Hawkins, MD

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