Patient-centered Contraception

Nearly half of pregnancies in the United States are unintended.

Approximately 6.4 million pregnancies per year

Unintended, occur after

desired family size reached -

20%

Intended - 51%

Unintended, occur earlier

than desired - 29%

Outcomes of Unintended Pregnancies

Approximately 3.0 Million Annually

Most unintended pregnancies occur when women fail to use contraceptives or

use their method inconsistently.

Half of women at risk are not fully protected from unintended pregnancy.

28 million U.S. women at risk for unintended pregnancy

Consistent, long-acting

method use - 50%

At-risk gap use - 15%

Inconsistent use - 27%

Nonuse all year - 8%

Unintended pregnancy rate by race/ethnicity/income

0

20

40

60

80

100

120

140

160

180

Below poverty level Above poverty level

all

white

latina

black

Unintended pregnancies per 1,000 women

Why do women experience unintended pregnancies?

Efficacy: Numbers & Categories Table“Less Effective Methods”

85%85%No methodNo Method

3%14%Male latex condoms

5%21%Female condoms

9%-26%20%-40%Cervical cap

620%Diaphragm

Perfect-Use Rate of Pregnancy

Typical-Use Rate of Pregnancy

Family Planning Method

Effectiveness Group

1%-9%20%Fertility Awareness

4%19%Withdrawal

6%26%Spermicide

Less effective

Yolanda

17 year-old high school senior Requests pregnancy test, birth control pill

Had unprotected sex 4 days ago

Urine pregnancy test is negative.

What do you do next?

Emergency Contraception:

Levonorgestrel (Plan B)

Take at once, up to 5 days after unprotected sex.Lowers risk of pregnancy by 58-89%

Levonorgestrel EC:Mechanism of Action

Inhibits ovulation

Does NOT cause abortion

Ulipristal acetate: a new emergency contraceptive option

Decreases risk of unintended pregnancy by about 90%

Maintains nearly full efficacy up to 5 days after unprotected intercourse

Hormonal Contraceptives What is needed before prescribing?

Medical historyREQUIRED

Blood pressureRECOMMENDED

Pap smear

Pelvic/breast exam

STI testing

Hemoglobin

NOT REQUIRED

Hormonal ContraceptivesWhich women/teens can’t use estrogen?

Estrogen contraindications: • Migraine with aura• Uncontrolled hypertension• Postpartum < 6 weeks• History of DVT

Smoking: NOT a contraindication in women/teens under age 35

Yolanda is eligible for the pill.

When should she start?

.

Should Yolanda get a prescription for EC, too?

Advance EC prescrbing

Jessyka21 year old waitress

Had a medication abortion 1 week ago in your office

Has severe PMS symptoms

OCs helped just a bit

Extended Cycle Regimens

Liz 21-year-old healthy college student

Takes oral contraceptive, but forgets pills often

Has trouble getting refills while at college, and now the pills are too expensive

Adherence with OCs:What Women Do!

Potter L et al. 1996.

Percent of Women (%)

Number of pills missed

What are the common reasons for missing pills?

Back to Liz…

She would like to try something easier to remember.

What information do you need?

Efficacy: Numbers & Categories Table

“Effective Methods”

Perfect-Use Rate of Pregnancy

Typical-Use Rate of Pregnancy

Family Planning Method

Effectiveness Group

0.1%-0.5%Unknown (8%)Vaginal ring

0.3%-0.8%Unknown (8%)Transdermal patch

0.1%-0.5%8%Birth control pills

Effective

Estrogen/progestin vaginal ring

• Active for at least 3 weeks

• Lowest estrogen dose: 15 mcg / day

• Same efficacy and contraindications as OCs

• May remove for up to 3 hours

• QuickStart same as with OCs

Estrogen / Progestin Patch

• 1 patch weekly for 3 weeks, then one week off• Same efficacy & contraindications as OCs• OK to shower, swim, exercise with patch on• Failures in trials were in women over 198

pounds, but still rare• Higher risk of clots? Conflicting studies…

Gallo MF, et al. Cochrane Reviews. 2003, Issue 1. Art. No. CD003552.Jick S, et al. Contraception 73 (2006)

How many refills should we give Liz?

Resa16 years old

Doesn’t want to get pregnant until she finishes school

Wants contraception that she can hide from her mom

What are her choices?

Highly Effective Methods

NOT USER DEPENDENT

0.3%0.3%Hormone shot

Perfect-Use Rate of Pregnancy

Typical-Use Rate of Pregnancy

Family Planning Method

Effectiveness Group

0.6%-1.5%0.8%-2%Intrauterine

devices

0.1%0.1%Implants

0.1%-0.5%0.2%-0.5%Male and female

sterilization

Highly Effective(for all users)

Progestin-Only Injection

Hatcher, R et al. A Pocket Guide to Managing Contraception, 2007-2008

Depo Provera & Bone Density

Weighing risks and benefits:

No need to restrict Depo Provera use

Amy

21-year-old G4P2

New boyfriend wants her to get pregnant, but she doesn’t want a child now.

Intrauterine Devices

IUD Myths DebunkedIUDs can be used safely by nulligravid women and teens!

IUDs DO NOT raise risk of PID.

IUDs DO NOT raise risk of infertility.

IUDs DO NOT raise risk of ectopic pregnancy.

IUD Myths DebunkedIUDs DO NOT cause abortion.

OK to insert IUD at any point in the menstrual cycle.

OK to insert immediately post-partum or following surgical abortion

OK to test for STIs at time of insertion (& treat infections with IUD in place)

Blanca

36-year-old G6P4Has fibroids and anemia

Progestin IUD (MIRENA)

Progestin Implant

• Highly effective and rapidly reversible• Discreet• Not user-dependent• Contain no estrogen• Can be used during lactation• Active hormone:

etonogestrel (68 mg)

Reinprayoon. Contraception 2000Diaz. Contraception 2000

Features of Progestin Implants

Causes spotting

Requires certified clinician visits for insertion and removal

Counseling to Enhance Adherence

• LISTEN to her ideas about the best method.

• EXPLORE lifestyle issues that may impact adherence.

• ENCOURAGE her to call you with problems/concerns.

Impact of Choice

Pariani. Stud Fam Plann, 1991 1991

% of Women Continuing Contraceptive Use at 1 Year

Inconsistent pill use is linked to:low level of satisfaction with provider & low continuity of care.

Percent of pill users who missed one or more pills during the past three months

34

47

36

51

0

10

20

30

40

50

60

Very satisfied w/provider

Not very satisfied w/provider

Usually see sameclinician

Do not usually seesame clinician

Office barriers to adherence

Feeling unable to call a provider with questions is linked to contraceptive non-use.

% of at-risk women experiencing contraceptive non-use in the past year

Electronic Health Records

Take-home message:Be pro-active with contraception!

DE-LINK pap smears from birth control prescriptions.

ROUTINELY prescribe 1-year supply with 3 packs at a time.

Use Quickstart.

Ask about contraceptive needs at all types of visits.

Emphasize high-efficacy methods, but honor women’s choice whenever possible.

References and Resources

• Hatcher et al, Contraceptive Technology 2007• Managing Contraception – book online @

www.managingcontraception.org• Medical Eligibility Criteria for Contraceptive Use 2010 by WHO

www.who.int/reproductive-health • Association of Reproductive Health Professionals www.arhp.org • Alan Guttmacher Institute www.agi-usa.org• Planned Parenthood www.plannedparenthood.org• The Cochrane Collaboration www.cochrane.org• www.Not-2-Late.com• Reproductive Health Access Project www.reproductiveaccess.org