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Various models of Intra-Uterine Devices IUDs, circa 1960 to 1994. Inserted into the uterus, they provide long-lasting and effective birth control, but they are not without controversy. Image Credit: The New York Times

Educate mom, reduce unintended pregnancies

Educating young women about intrauterine devices and contraceptive implants — which are more effective than condoms or the pill — dramatically cut the number of unintended pregnancies among women seeking family planning.

In a University of California San Francisco (UCSF) study done with researchers from Planned Parenthood Federation of America, and published in The Lancet, involved 40 Planned Parenthood centers around the country. It is the first clinic-based intervention in a randomized trial to reduce unintended pregnancies, which remain stubbornly high in the United States, at about 50 percent.

Since 2009, the American College of Obstetricians and Gynecologists has recommended that IUDs and implants - known as LARC, for long-acting reversible contraceptives - be used as first-line contraceptive methods for most women. Though LARC methods are safe and highly effective for women of all ages, healthcare providers are less familiar with these methods and do not routinely include them in contraceptive counseling.

National surveys show that just 38 percent of U.S. physicians who provide contraceptives offer IUDs to adolescents, 53 percent offer them to women without children and 25 percent offer them immediately after abortion, although it is safe to do so.

"There has been heavy reliance in the United States on the pill and condoms for young people. It's easy for people to forget to use these methods, which can lead to accidental pregnancies," said Cynthia Harper, PhD, a professor of Obstetrics, Gynecology & Reproductive Sciences at the UCSF Bixby Center for Global Reproductive Health. "It's important that women also learn about methods that give a higher level of protection against pregnancy when they seek contraceptive care. Women consider healthcare providers a highly-trusted source of information on birth control, so it's especially important that providers tell women about all of the methods they can use."

Researchers tested the training at Planned Parenthood health centers across the country, some of which provided abortion and others only family planning services. They assigned half of the health centers at random to receive the contraceptive training and the other half to continue delivering the care they were already giving.

To be eligible for the study, women had to be between the ages of 18 and 25 and receiving contraceptive counseling because they did not want a pregnancy in the coming year. Ultimately, 1,500 women enrolled.

A key part of the intervention was teaching all health care workers to inform women that different birth control methods have very different levels of effectiveness. For example, less than 1 percent of women using an implant or IUD will get pregnant in the course of a year, while on average 9 percent of women on the pill and 18 percent women whose male partners use condoms will get pregnant in that same time.

While 71 percent of the providers who received the training discussed IUDs and implants with their patients, just 39 percent of providers in the control group did. As a result, 28 percent of women in the intervention group chose IUDs or implants, compared with 17 percent in the control group. Women reported a high level of autonomy in choosing their birth control methods, saying they either made the choice on their own or did it together with their providers.

The training resulted in a striking reduction in the number of unintended pregnancies — from 15 to 8 per 100 women over a year — but only among the women who had come to Planned Parenthood seeking family planning services. For reasons that are not entirely clear, there was no effect among the women who sought birth control after an abortion. Fewer women wanting to use IUDs or implants post-abortion were actually able to get them, and nearly a quarter were pregnant again within a year.

Researchers said restrictions on using public funding for contraception in places that provide abortions may have discouraged many women. IUDs and implants are expensive, costing up to $1,000, and nearly 38 percent of the women in the study had no medical insurance. Over time, however, these methods are cheaper than the pill, since they do not require re-supply.

Copper IUDs have been available in the U.S. since the late 1980s, hormonal IUDs since 2000 and the contraceptive implant since 2006, but American women are still far behind their European counterparts in adopting them. While nearly a quarter of French women use these methods, just 9 percent of U.S. women do, and the Centers for Disease Control and Prevention (CDC) recommends increasing access to them.

"This study shows how important it is that women's health care providers have full information about available birth control methods and are trained to provide all of these methods to patients at the same visit," said Carolyn Westhoff, MD, senior medical advisor at Planned Parenthood Federation of America. "It's one very important part of making sure that women can have the birth control of their choosing — without any barriers."

Abstract
Background
Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates.

Methods
We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011–13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18–25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates.

Findings
Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8–5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3–2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34–0·85).

Interpretation
The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits.

Other authors of the study include Corinne Rocca, PhD, Kirsten Thompson, MPH, Suzan Goodman, MD, Philip Darney, MD, and Joseph Speidel, MD, of UCSF's Bixby Center; Johanna Morfesis, NP, of Planned Parenthood Federation of America. It was funded by the William and Flora Hewlett Foundation.

About UCSF: UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children's Hospital San Francisco. Please visit http://www.ucsf.edu.

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