Differences in Women Who Choose Subdermal Implants Versus Intrauterine Devices

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1 The Journal of Reproductive Medicine Differences in Women Who Choose Subdermal Implants Versus Intrauterine Devices Vien C. Lam, M.D., Emily E. Hadley, M.D., Abbey B. Berenson, M.D., Ph.D., Jacqueline M. Hirth, Ph.D., Kristofer Jennings, Ph.D., and Pooja R. Patel, M.D. ORIGINAL ARTICLES OBJECTIVE: To determine if there are any differences in the patient populations that choose subdermal implants versus intrauterine devices (IUDs) for contraceptive purposes. STUDY DESIGN: Retrospective chart review. Electronic medical records of women who presented to the University of Texas Medical Branch in Galveston s Regional Maternal Child Health Program Clinics in southeast Texas from March 2011 to March 2013 and received a subdermal implant or IUD were reviewed. Differences in characteristics of women who chose either form of contraception were determined. RESULTS: A total of 356 charts were reviewed. Of those, 188 (53%) women chose the subdermal implant and 168 (47%) chose an IUD. Patients who chose subdermal implants were more likely to have had a longacting reversible contraceptive (LARC) method previously (p<0.01), previous vaginal deliveries (p<0.001), and an interval from delivery to LARC placement of >1 year (p<0.001). LARC choice was race-specific in that, when compared to Caucasian women, African-American women were significantly more likely to choose an IUD, while Hispanic women were significantly more likely to choose subdermal implants (p=0.002). Facilities that offer LARC should offer both forms, as the lack of one type may discourage a patient from choosing LARC... CONCLUSION: Different populations choose subdermal implants versus IUDs for contraception. Further research is needed to determine etiologies for these differences. (J Reprod Med 2016;61: ) Keywords: birth control, contraception, contraceptive IUD, contraceptive methods, female contraception, intrauterine devices, long-acting reversible contraceptive (LARC), subdermal implant, unmedicated IUDs. The benefits of long-acting reversible contraception (LARC) are well known: it does not rely on user adherence for effectiveness, and discontinuation requires consultation with a medical provider, at which time provisions for another contraceptive can be made. 1 The American College of Obstetricians and Gynecologists (ACOG) has published several recommendations encouraging LARC use. 2-4 LARC devices are subdivided into 2 major categories: subdermal implants and intrauterine devices (IUDs). Recommendations are similar for both forms, as neither contains estrogen and therefore both can be used in patients with From the Departments of Obstetrics and Gynecology and of Biostatistics, and the Center for Interdisciplinary Research in Women s Health, the University of Texas Medical Branch, Galveston, Texas. Address correspondence to: Pooja R. Patel, M.D., Department of Obstetrics and Gynecology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX (popatel@utmb.edu). Financial Disclosure: The authors have no connection to any companies or products mentioned in this article /16/ /$18.00/0 Journal of Reproductive Medicine, Inc. The Journal of Reproductive Medicine 529

2 530 The Journal of Reproductive Medicine hypertension, diabetes, a greater risk of venous thromboembolism, or those older than 35 years of age who smoke. 5 Nevertheless, it is unknown whether there is a difference between the patient populations that use these forms of LARC. We performed this study to determine if there are any differences in the patients who choose subdermal implants versus those who choose IUDs. Materials and Methods After Institutional Review Board approval was obtained, a retrospective chart analysis was performed. Electronic medical records of patients who presented to the University of Texas Medical Branch in Galveston s Regional Maternal Child Health Program Clinics from March 2011 to March 2013 were reviewed. Women who received either a subdermal implant or an IUD were identified using ICD9 CPT codes J7302 (levonorgestrel IUD), J7300 (copper IUD), and J7307 (subdermal implants). Variables including age, BMI, number of previous cesarean or vaginal deliveries, level of the provider (physician versus non-physician such as nurse practitioners, certified nurse midwives, or physician assistants), interval from last delivery to LARC placement, and details regarding previous birth control use were abstracted from the records of these patients. All missing data were considered missing completely at random. A multivariable logistic regression was fit to predict the probability of IUD. p Values, odds ratios (ORs), and 95% confidence intervals (CIs) based on multivariable logistic regression are reported. Hypothesis testing was based on likelihood ratio tests; all CIs are based on the Wald construction. All calculations were done in R (R Foundation for Statistical Computing). Results A total of 356 women were identified who received an IUD or subdermal implant during this time period. Of these, 188 (53%) women received a subdermal implant and 168 (47%) women received an IUD (Table I). There was no significant difference in the distribution of age (p=0.33), BMI (0.22), provider level (p=0.21), whether the LARC was the first form of contraception used (p=12), or whether the LARC method was a repeat of the same method (p=0.99) (Table II). However, patients who chose IUDs were more likely to be African-American or Caucasian (p=0.002), to have had previous vaginal deliveries (p<0.001), to have an interval from de- livery to LARC placement of <1 year (p<0.02), and to be a previous LARC user (<0.001). Given that only 4 Asian women met inclusion criteria for the study, this data was removed from the logistic regression analysis with regards to race. Discussion We sought to determine if there are any differences in patients who choose the 2 forms of LARC. We were surprised to find that despite similar recommendations with regards to patient population, there was a significant difference in a variety of patient characteristics. Unfortunately, due to the nature of this study, we were unable to obtain qualitative data and were therefore unable to determine reasons for those differences. To the best of our knowledge, this is the first study that looks at the differences in patients who chose the subdermal implant versus the IUD. There have been multiple studies identifying characteristics of women who choose other forms of contraception. The contraceptive CHOICE study showed that there was a significant difference in women who chose LARC versus non-larc methods based on recruitment clinic, age, marital status, socioeconomic status, lifetime sexual partners, and reproductive history. 6 Multiple studies have shown that racial differences exist between contraceptive choices, Table I Comparison of Demographic Characteristics Subdermal IUD implant (n=168) (n=188) Characteristic No. (%) No. (%) Age <20 17 (10) 36 (19) (79) 143 (76) >35 19 (11) 9 (5) Race Black 19 (11) 11 (6) Asian 2 (1) 2 (1) Caucasian 62 (37) 30 (16) Hispanic 85 (51) 145 (78) BMI <30 88 (55) 120 (64) (45) 68 (36) Vaginal deliveries None 44 (26) 52 (28) Any 124 (74) 136 (72) Provider level Non-MD 31 (18) 19 (10) MD 137 (82) 169 (90) BMI = body mass index.

3 Volume 61, Number 11-12/November-December Table II Odds Ratios of Using IUD Versus Subdermal Implant Subdermal IUD implant (n=168) (n=188) Odds ratio Characteristic N (%) N (%) (95% CI) p Value a Age (median±sd) b 25±6 24± ( ) 0.33 Race c Caucasian 62 (37) 30 (16) REF Black 19 (11) 11 (6) 1.12 ( ) Hispanic 85 (51) 145 (78) 0.25 ( ) Asian 2 (1) 2 (1) BMI 0.22 <30 88 (55) 120 (64) REF (45) 68 (36) 1.64 ( ) Vaginal deliveries <0.001 None 44 (26) 52 (28) REF Any 124 (74) 136 (72) 4.69 ( ) Provider level 0.21 Non-MD 31 (18) 19 (10) REF MD 137 (82) 169 (90) 1.87 ( ) Interval from last delivery to LARC placement d 0.02 <1 year 53 (50) 32 (25) REF 1 year 52 (50) 94 (75) 0.36 ( ) Using contraception for the first time 0.12 No 105 (66) 123 (65) REF Yes 53 (34) 65 (35) 0.49 ( ) Missing 10 0 Previous LARC use <0.001 No 62 (63) 37 (41) REF Yes 37 (37) 53 (59) 0.16 ( ) Missing Replacement of same method 0.99 No 146 (87) 165 (88) REF Yes 22 (13) 23 (12) ( , ) a p Values obtained from multivariate logistic regression analysis. b Treated as a continuous variable. c Significance obtained after Asian category removed from analysis. d LARC = long-acting reversible contraception. Numbers do not add to total women for each form of LARC (i.e., 168 and 188) as women who were nulliparous were excluded from this analysis. Percentages are of total women who had previous children, not of total women who chose each form of LARC. likely due to contraceptive attitudes shared within an ethnic community We similarly observed that each race clusters towards one form of LARC over the other. This not only emphasizes the importance of ethnic attitudes as a driving force behind contraceptive choice, but also highlights a possible need to bring contraceptive counseling to community settings. By educating ethnic communities as a whole, the medical community can dispel any ethnic-based misconceptions and simultaneously reach a larger audience. We were surprised to find that women were significantly more likely to have an IUD as their first LARC device. Women were also more likely to have an IUD within 1 year of previous pregnancy than a subdermal implant. It is unknown if our findings are a regional phenomenon or represent the national population. Based on the literature supporting the strong influence of community beliefs on contraceptive choices, we can speculate that regional beliefs may motivate women to try IUDs first. This, however, contradicts the fact that a majority of the patients in the study were Hispanic, a population which is likely to choose subdermal contraceptive implants over IUDs. In addition, it is important to note that this data was missing for a substantial number of subjects in both categories. Our findings of an increased interval in starting the subdermal implant may be due to the misconception that the subdermal implant decreases the milk supply. Multiple studies have shown that the

4 532 The Journal of Reproductive Medicine subdermal implant does not change the volume and composition of breast milk, nor is it associated with adverse effects in infants who ingest the breast milk. 12,13 Nevertheless, this misconception pervades public knowledge and may explain our findings. We stratified BMI according to obese (BMI >30) or nonobese (BMI <30). Although we were unable to find other studies examining the relationship between LARC and BMI, it is well known that either form of LARC has no adverse effect on patient lipid profiles As both forms of LARC are equally effective in obese patients, it is promising that BMI has no role in deciding one LARC form over another. Finally, we found that women with vaginal deliveries are significantly more likely to choose IUDs than subdermal implants. Although we were unable to find any studies specifically addressing this topic, IUD insertion may be easier in women who have had previous vaginal deliveries, as vaginal deliveries can improve cervical stenosis 17 ; however, IUD insertion is not contraindicated in women without previous vaginal deliveries. In our search of the Internet we came across a few blogs in which the writer expressed a concern regarding her gynecologist inserting an IUD despite not having had a previous vaginal birth. 18 As women readily access the Internet to gain healthcare information, it is unclear whether this predisposition for IUD insertion is due to patient request. Further studies are needed to better elucidate the reasons for this difference. Only 10% of IUD users and 19% of implant users were teenagers. Research shows that LARC methods are accepted by teenagers but are the least common form of contraception used among them. 1 This may be due to several factors, including adolescent fear of pain and needles. 19 Nevertheless, as in the contraceptive CHOICE project, our study found that teenagers are more likely to choose subdermal implants than IUDs. 1 The reason for this discrepancy is unknown. The fact that a difference exists in the patient population that chooses subdermal implants versus IUDs despite similarities in recommendations suggests a need towards a standardized method of counseling. It is unclear whether the difference we saw was due to provider counseling or patientspecific reasons. We were unable to find any articles on reasons motivating women to choose one LARC method over another; however, research suggests that women prefer to make their contraceptive decisions with less physician influence than is desired when making general health decisions. 20 With regards to contraception counseling, there is no universally standardized counseling method. In fact, research shows that providers vary their contraceptive recommendations based on patient characteristics. 21,22 Perhaps providers should adopt a standardized counseling method that is only to inform, rather than persuade, women in choosing a form of contraception. Women can then take this information, discuss with peers if they so choose, and then make an educated decision. Providers can also educate communities as a whole so that peers and social circles are informed together, dispelling incorrect information regarding specific forms of contraception. There are a few limitations to our study. First, our sample resides in a single geographic region and may not represent the national U.S. population. Second, our survey was limited to low-income reproductive-age women and therefore may not be generalizable to other age groups or income levels. Finally, as this study is a retrospective chart review, our ability to establish causal relationships is limited, and not all variables were available for each patient. In conclusion, different patient populations choose different forms of LARC. This is important as facilities that offer LARC should therefore offer both forms, as the lack of one type may discourage a patient from choosing LARC in general. Further research is needed to determine reasons for these differences, as the target population for both patients is similar. References 1. Mestad R, Secura G, Allsworth JE, et al: Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project. Contraception 2011;84: American College of Obstetricians and Gynecologists: ACOG Committee Opinion No. 392, December Intrauterine device and adolescents. Obstet Gynecol 2007;110: American College of Obstetricians and Gynecologists Committee on Gynecologic Practice; Long-Acting Reversible Contraception Working Group: ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009;114: American College of Obstetricians and Gynecologists: ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011;118: ACOG Committee on Practic Bulletins-Gynecology: ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2006;107: Secura GM, Allsworth JE, Maddent T, et al: The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contra-

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