Promoting Long Acting Reversible Contraceptives

CONTRACEPTIVES 3

Promoting Long Acting Reversible Contraceptives

Jessie McCarty

Concordia University

Introduction

Unintended pregnancies are a problem throughout the world. Although there are many birth control options available, many women still get pregnant when they have no desire to become pregnant, including those who are using contraceptives. Secura (2013) stated “Unintended pregnancy remains a significant global public health problem; 41% of all pregnancies worldwide in 2008 were unintended…Among US women, nearly half of unintended pregnancies are due to incorrect or inconsistent use of a contraceptive method” (p.271). In addition to these facts, The American Congress of Obstetricians and Gynecologists ([ACOG], 2009) stated “Unintended pregnancy persists as a major public health problem in the United States. Over the past 20 years, overall rates in the United States have not changed and remain unacceptably high at approximately 50% of all pregnancies… Unwanted births to women aged 15–24 years nearly doubled between 1995 and 2002”. These high percentages suggest there is a public health crisis occurring both globally and nationally regarding unintended pregnancies. The ACOG (2009) explained “High unintended pregnancy rates in the United States may in part be the result of relatively low use of long-acting reversible contraceptive (LARC)”. Therefore, increasing the use of LARC could be effective in reducing unintended pregnancy rates, especially in adolescents and young adult women.

General Description

Promoting LARC throughout the United States could lead to a decrease in unintended pregnancy rates. Typically, the most common types of contraceptives promoted to adolescents and young adult women include condoms and oral contraceptives. However, the ACOG (2009) stated “Combined oral contraceptives and condoms, the predominant reversible contraceptive methods used in the United States, are user dependent, have relatively low continuation rates, and have relatively high failure rates with typical use patterns”. Therefore, promoting LARC over short term methods could be an effective way to reduce unintended pregnancies.

Background Information

There are many contraceptive options available to women in the United States. For the purpose of this paper, the focus will be on reversible options both in the terms of short term contraceptives and long acting contraceptives LARC includes Levonorgestrel-releasing intrauterine devices (IUD) such as Mirena and Skyla and the copper containing IUD, ParaGard. The birth control implant, implanted into the upper arm, is another LARC available in the United States. Other contraceptive options, which are not LARC, include condoms, oral contraceptives, diaphragms, spermicides, natural family planning, and hormonal options in the form of an injection, a patch, or vaginally inserted ring (Centers for Disease Control and Prevention [CDC], 2013). Understanding the statistics behind the failure rates of these different options can help highlight why LARC have been shown to decrease unintended pregnancies.

Biostatistics

According to the CDC (2013) LARC have a smaller failure rate than other contraceptive methods. The failure rate for LARC is 0.8% for the copper IUD, 0.2% for Levonorgestrel IUD, 0.05% for the implant (CDC, 2013). On the other hand, more common contraceptive methods, such as condoms and oral contraceptives, have higher failure rates. The failure rate is 9% for oral contraceptives, 18% for male condom, 9% for the hormonal vaginal ring, 12% for the diaphragm, 28% for spermicides, and 24% for natural family planning (CDC, 2013). However, despite the large difference in failure rates, LARC are not as common as other options for young adult women and adolescents.

The popularity of LARC differs throughout the world. “Injectable and implantable methods are used by an estimated 3.4% and intrauterine methods by 15.5% of women worldwide (Blumenthall, Voedisch, & Gemzell-Danielsson, 2010, p.121). The United States, in comparison to many European countries, use LARC less often. However, ACOG (2012) stated “Long acting reversible contraception (LARC) methods are increasing in popularity with use increasing from 2.4% of all U.S. women using contraception in 2002 to 8.5% in 2009. Approximately 4.5% of women aged 15–19 years who are currently using a method of contraception use LARC, with most using an IUD”.

Epidemiology and Program Need

Getting an IUD use was initially promoted to those in monogamous relationships who had already given vaginal birth. However, IUD insertion no longer has these strict requirements. The ACOG (2012) now approves of IUD insertion in adolescents with no previous history of pregnancy. Secura (2013) stated LARC is “extremely safe and over 99% effective at preventing pregnancy. LARC are only infrequently contraindicated, even among younger and nulliparous women” (p.271). Therefore, the IUD is safe to use in most adolescents and young adult women as a contraceptive method. Also, it is important to note “complications of IUDs and the contraceptive implant are rare and differ little between adolescents and older women” (ACOG, 2012). However, it is important to still educate these groups about sexually transmitted infections (STI) and the need for condom use to prevent STI transmission.

Increasing LARC use in the United States is very important to decrease pregnancy rates, especially adolescent and young adult pregnancy rates. According to ACOG (2012) “Adolescents most commonly use contraceptive methods with relatively high typical use failure rates such as condoms, withdrawal, or oral contraceptive pills. Nonuse, inconsistent use, and use of methods with high typical use failure rates are reflected in the high rate of unintended adolescent pregnancies in the United States”. Secura (2013) added “In real-world tests LARC methods were over 20 times more effective at preventing unintended pregnancy compared to the contraceptive pill, patch, or ring” (p.271). Therefore, there is evidence proving LARC is more effective. Since there is a nationwide need to decrease teenage pregnancy and unintended pregnancies with young adult women, programs must be initiated to promote LARC.

Specific Population

As aforementioned, despite the slight increased use of LARC, unintended pregnancies are a problem for women of all childbearing ages. However, adolescents and young adult women are more likely to have higher failure rates with common contraceptives, such as oral contraceptives and condoms, and are more likely to be inconsistent with the use of contraceptives (ACOG, 2012). Therefore, this specific population should be encouraged to use LARC. ACOG (2013) stated forms of LARC “are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women...Health care providers should consider LARC methods for adolescents and help make these methods accessible to them”.

Encouraging LARC can decrease unintended pregnancy rates for adolescents and young adult women. Not educating this population about LARC will only lead to further unintended pregnancy rates to this population and this population will continue to use less reliable birth control options. Teenage pregnancy is correlated with socioeconomic problems such as poverty and decreased chances of the mother getting a higher education. Therefore, providing LARC in turn could lead to less poverty, a higher educated population, and less mothers relying on government financial support.

Health Belief Model

In order to initiate a program promoting the use of LARC, one must use a theory to best understand how to make this behavior change. The Health Belief Model (HBM) is a very applicable model to use to promote LARC. According to DiClemente, Salazar, & Crosby (2013), the HBM is based on the construct “that behavior change will occur only when sufficient benefits remain after subtracting the costs incurred by performing the behavior” (p.87). In other words, the behavior change must be worth the process of making the change. If people can see a threat, and understand they can gain something from the change, then the behavior change will more likely occur.

In terms of using the HBM in terms of promoting the use of LARC, adolescent girls and young adult women must understand they are susceptible to getting pregnant if they are sexually active and must be educated on the severity of the results of unintended pregnancies. Both perceived severity and perceived susceptibly increase the level of threat the specific population will have. Therefore, educating this target group about the benefits of LARC, the risks of being sexually active using less reliable methods, and the realistic susceptibly of getting pregnant, together can increase the threat the population feels and increase the chances they will switch to LARC.

Once a perceived level of threat has been established, researchers must prove there is a net gain to taking action (DiClemente, Salazar, & Crosby, 2013). This net gain can depend on “modifying factors such as gender, race, age, knowledge” (DiClemente, Salazar, & Crosby, 2013, p.87). Therefore, information about the gain must be geared towards the specific population showing how this population can benefit from using LARC. Benefits for young adult women and adolescents using LARC include not having to deal with unintended pregnancy, not having to possibly get an abolition, and not ending up raising a child when the women is not ready to have children.

According to the HBM, once the target audience is educated about the perceived threat, and they understand the benefits of making the behavior change, they will make the behavior change if the gain is worth the risks of making the behavior change. In terms of unintended pregnancy, if the target audience is educated about the risks of unintended pregnancy, and the benefits of using LARC, they will more likely use LARC than traditional, and less reliable, contraceptive methods.

Current Literature

Throughout the United States, there have been many program initiated to address unintended pregnancies. These programs have ranged from abstinence only education programs to programs providing funding for abortions. Many programs provide education about birth control options, but very few programs have been started focusing on LARC and the growing research supporting increased LARC use to drastically decrease unintended pregnancy rates. Secura (2013) stated “If we are serious about reducing unintended pregnancy, we need to be serious about increasing the use of methods that we know work. Greater LARC use and continuation has been proven to effectively reduce unintended pregnancy, including abortion and teen pregnancy” (p. 271). Thus, although there are few programs promoting LARC to tackle the unintended pregnancy crisis, understanding these active programs and the results can help to promote further programs to be implemented.

Contraceptive Choice Project

The Contraceptive Choice Project (CHOICE project, n.d.) was started “to remove the financial barriers to contraception, promote the most effective methods of birth control, and reduce unintended pregnancy in the St. Louis area”. The CHOICE project enrolled 9, 256 women over four years and educated the women about birth control options. Approximately 75% of the women chose LARC (CHOICE project, n.d.). According to the CHOICE project (n.d.) “Among women who chose a LARC method, 86% were still using the method at 1 year. For women who chose a non-long-acting method, only 55% were still using their method at 1 year”. Furthermore, those using LARC reported more satisfaction with their contraceptive method and “Women using either LARC or the shot had the lowest unintended pregnancy rates during year 1, year 2, and year 3 of their follow-up. Pill, patch and ring users had much higher unintended pregnancy rates; they were 20 times more likely to have an unintended pregnancy compared to LARC users in Year 1” (CHOICE project, n.d.). The large difference in unintended pregnancy rates between the groups shows a large beneficial impact of educating women about LARC and encouraging LARC use. Once could say the HBM was used in this situation since the women were educated about the risks of unintended pregnancy and the benefits of LARC. The women were educated on the level of threat of using traditional methods, and made the behavior change to switch to LARC, deciding it was worth the behavior change to get the expected net gain of not having an unintended pregnancy.

The Iowa Initiative to Reduce Unintended Pregnancies

The Iowa Initiative was started with the similar plan of the CHOICE project. Women were educated about the contraceptive choices, including LARC. As with the CHOICE project, once women were educated about LARC, they were more likely to use LARC. Once this program was started the use of IUDs and implants increased from 2,200 in 2007 to over 9,700 in 2011, unintentional pregnancies decreased by 4%, and abortions declined by 3% ( Iowa Initiative, 2013). Once again, the HBM could have been the model used in this program since women were educated about the perceived level of threat and the net gain from using LARC and, in the end, decided to make the behavior change.

Health Promotion Program

The Wisconsin Wise Choices Program would be a program to provide sexually active adolescents and young adult women with education about LARC and the option to use LARC. This program will make the women in the target group understand why they are susceptible to unintended pregnancies and educate these women about the effectiveness of their current methods, or the most common contraceptive methods such as condoms and oral contraceptives, versus the effectiveness of LARC. The target group should also understand the severity of the results of getting pregnant as a teenager or as a young adult, the ability to lessen the chance of getting pregnant by using long term birth control, and understand the net gain to using LARC would be to not get pregnant.

The goals of this program would be to increase the use of LARC and, in return, see a decrease in unintended pregnancies and abortions. The program would be based on acknowledging the importance of educating women and making women feel empowered to make their own choices regarding contraceptive choices. Women should be educated about the risks and benefits of all contraceptive choices and about sexually transmitted infections. There should be financial support offered to help with contraceptive choices and a phone number for women to contact regarding questions and counseling. Also, local health centers and health care professionals should be updated on the benefits of LARC and encouraged to promote these options. Activities can also be used to address unintended pregnancies and the benefits of LARC, such as having sex education sessions at schools, education sessions with parents after school, and providing lectures for healthcare professionals to encourage them to provide long term birth control. Television and radio advertisements can be used to briefly provide awareness about the benefits of LARC and the option of using LARC for young adults and adolescents.