The United States has long been in need of a magic bullet to prevent unintended pregnancy. Half of all pregnancies in the United States are unintended, a statistic that has remained unchanged for 3 decades.[1, 2] In fact, recent US data indicate a discouraging increase in unintended pregnancies between 2001 and 2008. Disparities in unintended pregnancy persist with high rates among women who are poor, have less education, or are black.
Yet unlike many health care conditions that defy prevention, unintended pregnancy can be averted via a plethora of contraceptive methods. And what is increasingly evident is that there are clearly superior methods when it comes to effectiveness: intrauterine devices (IUDs) and implants, which are collectively known as long-acting reversible contraception (LARC). There are 3 types of LARC available in the United States: the levonorgestrel-releasing intrauterine system (Mirena, Skyla), the copper IUD (ParaGard), and the etonogestrel implant (Implanon, Nexplanon). These methods are highly effective, used separately from sex, do not require ongoing user effort, and have high rates of continuation and satisfaction. LARC may not be a magic bullet, but it is as close to one as currently exists.
One of the most exciting contraceptive studies to date is the Contraceptive CHOICE Project, which was designed to promote LARC. Women in this study were offered the reversible contraceptive method of their choice at no cost. Women received counseling about all of the reversible contraceptive methods and could choose any one that they wanted; however, counseling specified that IUDs and the implant were the most effective methods available. In an analysis of contraceptive failure among 7486 participants in the Contraceptive CHOICE Project, the risk of unintended pregnancy among women using oral contraceptives, the contraceptive patch, or the contraceptive vaginal ring was nearly 22 times that of women using an IUD or implant (adjusted hazard ratio 21.8; 95% confidence interval, 13.7–34.9). That is quite a compelling statistic to use when talking with women about their contraceptive options. If we had an antihypertensive medication or cancer treatment that was 22 times more effective than another drug or treatment, would we even consider using the less effective one?
Despite the superior effectiveness of LARC, a minority of US women is using these methods. In a national survey of 1200 women aged 18 to 45 years conducted in 2013 by the American College of Nurse-Midwives (ACNM), only 6.4% of women reported using IUDs and 1.8% used implants. Women most commonly reported using oral contraceptives (27.2%), condoms (20.3%), or withdrawal (12.8%), all of which are far less effective than LARC. However, in the Contraceptive CHOICE Project, two-thirds (67%) of the first 2500 women who enrolled in the study chose to use an IUD or implant. This suggests that contraceptive affordability and counseling can increase LARC use. Contraceptive affordability should be less of an issue with the implementation of the Affordable Care Act and its provisions for contraceptive coverage. Contraceptive counseling is crucial in light of the fact that many women do not understand the effectiveness of contraceptive methods. In the ACNM survey, women incorrectly ranked both oral contraceptives and condoms as more effective than IUDs and implants.
What can clinicians do to increase the number of women who are using highly effective LARC? First, clinicians must make certain their knowledge of LARC methods is accurate and current. Numerous clinician and consumer myths and misconceptions surround the LARC methods. Misinformation must be countered with evidence. A variety of resources for clinicians that address education, training, practice, and coding and billing can be found on the American College of Obstetrician and Gynecologists’ LARC Web site (https://www.acog.org/About_ACOG/ACOG_Departments/Long_Acting_Reversible_Contraception).
Second, clinicians and staff members they work with should discuss LARC with all women requesting contraception who are appropriate candidates for LARC. Studies have shown that nurse practitioners, physicians, and health educators are not consistently counseling about LARC methods as an option and use overly restrictive patient selection criteria that are not evidence based.[9-11] The vast majority of women, including adolescents and nulliparous women, are eligible for IUDs and implants.[4, 12, 13] The US Medical Eligibility Criteria for Contraceptive Use are the evidence-based resource that should be used to assess which contraceptive methods are medically appropriate for a woman. These criteria can be accessed online (http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm) and are available in an iPhone/iPad app. When counseling women about LARC, use patient-friendly terminology that conveys the benefits of these methods (see Box 1 for suggestions). Remind patients that while LARC methods can be used for up to 3 (Implanon, Nexplanon, Skyla), 5 (Mirena), or 10 (ParaGard) years, they can be removed at any time and are immediately reversible.
Third, provide LARC methods as quickly and easily as possible for women who choose them. Have these methods available in your practice at all times. Adopt protocols for same-day insertion and avoid unnecessary delays, such as waiting to insert until menses or results from sexually transmitted infection or cervical cancer screening tests are available.
Few decisions impact a woman's life as much as choosing whether and when to have children. One of the most important roles of midwives and other women's health clinicians is to ensure women have the knowledge and methods they need to have intended pregnancies. As this New Year begins, resolve to ensure that the women you care for are well informed about LARC and offer LARC as first-line methods to adolescents and women seeking contraception.
Box 1. Alternative Terms for Long-Acting Reversible Contraception
Highly effective and reversible
The best methods we have
The methods health care providers use
Safest and most effective
The most effective methods
The best we've got
The Cadillac, Mercedes, and BMW of contraception
Reprinted with permission from Patty Cason, MS, FNP-BC.