Unintended Pregnancy in U.S. The Importance of LARC: What have We Learned? Long-acting Reversible Contraception (LARC)

Transcription

1 Unintended Pregnancy in U.S. The Importance of LARC: What have We Learned? Colleen McNicholas, DO, MSCI Department of Obstetrics & Gynecology Washington University in St. Louis School of Medicine Over 3 million unintended pregnancies 59% mistimed 39% unwanted 1.2 million abortions 367,752 births to teens years Contraception 52% non-use 43% incorrect use Aug 2014 Finer Contraception 2011; Hamilton NCHS 2012; Frost Guttmacher Inst 2008 Long-acting Reversible Contraception (LARC) Dr. McNicholas has no financial disclosures LNG-IUS 99% effective 20 mcg levonorgestrel/day Up to 5 years Copper T IUD 99% effective Copper ions Up to 10 years Subdermal Implant 99% effective 60 mcg etonogestrel/day Up to 3 years Objectives Review the methods of The CHOICE Project Describe the counseling model Review of important findings Translating evidence into practice LARCfirst.com IUD Use in the US: Users (millions) Users (in millions) 7 Percentage of all contraceptors Percentage of all contraceptors 1

2 Recent LARC Use By Age The CHOICE Project: Inclusion Criteria Study participants years Residents of Saint Louis City or Country Sexually active with male partner or plans to become sexually active Does not desire pregnancy during next 12 months Desires reversible contraception Willing to start a new contraceptive method Finer, Fertility and Sterility 2012 Contraceptive CHOICE Project: Study Details ELIGIBLE The Contraceptive CHOICE Project Tiered Contraceptive Counseling 94% 87% 81% 11 LNG-IUS Cu-IUD Implant DMPA Pills Patch Ring Other Secura G, Am J Obstet & Gynecol 2010 Madden T, Contraception 2012 The CHOICE Project: Objectives Increase uptake of LARC Measure choice, satisfaction, side-effects, and continuation across all reversible contraceptive methods Provide enough no-cost contraception to make population impact on unintended pregnancies Teen pregnancy Repeat abortion Contraceptive Counseling Standardized script read to all participants regardless of age Included commonly used reversible methods All women heard about all the methods Tiered counseling = start with most effective methods first Evidence-based using CDC medical eligibility criteria Provided by trained non-clinicians Additional teaching aids used Madden Contraception

3 Baseline Characteristics Baseline Chosen Method % LNG-IUS 46.0 Copper IUD 11.9 Implant 16.9 DMPA 6.9 Pills 9.4 Ring 7.0 Patch 1.8 Other <1.0 75% Peipert Obstet & Gynecol 2012 Baseline Characteristics Baseline Chosen Method Teens % LNG-IUS 32.0 Copper IUD 5.0 Implant 34.0 DMPA 9.0 Pills 13.0 Ring 2.0 Other % Baseline Characteristics Parity or more 10.8 Prior unintended pregnancy % or more 36.2 History of abortion % Yes 41.8 Choice of LARC Methods by Teens Updated data from Mestad Contraception 2011, unpublished data 3

4 12- & 24-Month Continuation: Overall Cohort Method 12-Month (%) 24-Month (%) LNG-IUS Copper IUD Implant Any LARC DMPA OCPs Ring Patch Non-LARC Peipert Obstet Gynecol 2011; O Neil Obstet Gynecol In Press 12-Month Satisfaction*: Overall Cohort & By Age Method Overall (%) (%) (%) LNG- IUS % 84% Copper IUD % 81% Implant % 78% Any LARC % 82% DMPA % 52% Pills % 50% Ring % 52% Patch % 38% Non-LARC % 50% *Very or somewhat satisfied combined Rosenstock Obstet Gynecol & 24-Month Continuation: By Age Unintended Pregnancy by Contraceptive Method 12-Month 24-Month Participants with Contraceptive Failure (%) 12% 10% 8% 6% 4% 2% 0% LARC DMPA PPR Year HR adj = % CI 14.0, 35.4 Rosenstock Obstet Gynecol 2012; O Neil Obstet Gynecol In Press Winner NEJM Month Satisfaction*: Overall Cohort & By Age Method Overall (%) (%) (%) LNG- IUS 83.1 Copper IUD 80.2 Implant 77.0 Any LARC 81.2 DMPA 50.1 Pills 49.3 Ring 49.7 Patch 37.2 Non-LARC 48.8 *Very or somewhat satisfied combined Rosenstock Obstet Gynecol 2012 Method Failure by Age Winner NEJM

5 Pregnancy Outcomes: CHOICE Compared to U.S. CHOICE Annual Rate U.S. Rate Reduction Pregnancy * 63% Unintended pregnancy * 43% Abortion ^ 47% All rates per 1,000 women years * 2006 data ^ 2008 data Teen Outcomes: CHOICE Compared to U.S. Pregnancy among sexually active teens CHOICE Annual Rate * 2008 U.S. Rate* CI 25.7, 44.1 Abortion , 15.8 Birth , 27.4 CHOICE Data: Unpublished; U.S. Data: Finer 2011, Jones 2011 *All rates per 1,000 teens years In Press, NEJM 2014; U.S. Data: Kost 2012 Repeat Abortion in St. Louis Region What We Know Data obtained from MO DHHS Represents women who reside in Missouri at time of abortion Repeat abortion measured as ever had a previous abortion Compared to Kansas City & non-metro MO KC: One abortion clinic KC: Similar demographic characteristics to STL LARC methods are highly effective at preventing pregnancy regardless of age Women & teens overwhelming choose LARC Women & teens much more likely to still be using LARC at 1 & 2 years compared to more commonly used non-larc methods Now What? 29 Repeat Abortion Percent of repeat abortions 55% 50% 45% St. Louis City/County 40% Kansas City Non-Metro Missouri 35% 30% 25% Test of Trend : STL, p=.002; KC, p=.003; Non-metro MO, p=.18 The Secret: 3 Key Ingredients Education regarding all methods, especially LARC Reframe the conversation to start with the most effective methods Access to providers who will offer & provide LARC Dispel myths and increase the practice of evidencebased medicine Affordable contraception Institute of Medicine recommendation, Affordable Care Act, Medicaid Expansion, local funders 5

6 Dissemination Strategies Provide technical assistance to end users >100 national & international requests LARC First Resource Center Develop short videos Open the Dialogue Pathway to CHOICE What Method is Right for You? Create online Resource Center to disseminate CHOICE materials LARC First 31 Contraceptive Menu of Options LARC First Resource Center Make it Better! LARC First Resource Center Courtesy of Mary Alexander, Healthy Start Indianapolis 6

7 To Learn More Visit