(Published September 2008)
Health Care System Barriers
Health care professionals often underestimate the profound effect they can have on a woman’s use of contraception. Unfortunately, the health care system itself can create barriers for women who are seeking contraception. Barriers include delayed initiation of contraception, inappropriate contraindications, misinformation, and the availability and cost of insurance or contraceptive methods.1 Clinician limitations present another barrier and include lack of comfort with or knowledge about various contraceptive methods, lack of experience with certain methods, and lack of time to discuss methods with patients.
Delayed initiation of contraception
Faith. Faith is a 20-year-old college student. She has been sexually active for three years, and you saw her nine months ago for a full examination, including her first pelvic exam and Pap test. Today she phones and explains that she has been using condoms as her contraceptive method, but she is now in a more serious relationship and wants a prescription for the pill because she has heard that it is more effective than condoms.
This case study presents a young woman who is seeking a more effective contraceptive method than she is currently using. Perhaps you are concerned because you do not know the date of her last period or whether she is pregnant. Perhaps you are concerned that you have not recently performed a pelvic exam, Pap test, sexually transmitted infection (STI) screening, and blood pressure check. However, it is probably not in her best interest to ask her to make an appointment to see you and delay her starting oral contraceptives.
The World Health Organization (WHO), Planned Parenthood® Federation of America (PPFA), and American College of Obstetricians and Gynecologists (ACOG) support unbundling services and not linking the provision of contraception with a pelvic exam, Pap test, or STI screening.1 In fact, pelvic exams are not a requirement for initiating hormonal contraception.2 In addition, ACOG recommends delaying the initial Pap test until three years after the initiation of sexual activity or age 21.3 Although WHO guidelines state that taking blood pressure measurements is desirable before the start of oral contraceptives (OCs), they also state that OCs should not be denied if blood pressure cannot be measured.4
In Faith’s case, pelvic exam, Pap test, and blood pressure results are available from her examination nine months ago. The use of oral contraceptives is not linked to cervical cancer or infection; therefore, it is not necessary to screen for STIs or perform a Pap test before a patient starts using OCs. Oral contraceptives are not teratogenic and will not produce adverse fetal effects if the patient is already pregnant.1 Finally, with the Quick Start method, patients no longer need to wait until the Sunday after the next menses to initiate OCs (see Quick Start method box).
Asking women to delay starting hormonal contraceptives such as OCs, the patch, or vaginal ring is a barrier erected by many health care providers. This delay can cause some women never to start the contraceptive method and some women to conceive during the time they are waiting to start.1
Quick Start Can Help Overcome Barriers in the Health Care System
The health care system raises barriers to initiating contraception by having women wait until the Sunday after menses before they start OCs or wait for a follow-up visit before intrauterine device (IUD) insertion.1 The Quick Start method provides an alternative that can help women start contraception and prevent unintended pregnancy. The Quick Start method can be used with OCs, IUDs, the patch, vaginal ring, injection, or implant. It significantly improves the rate of women continuing to use OCs.5 In addition, it has been shown that adolescents who use the Quick Start method have better compliance at three months.6
Inappropriate contraindications and misinformation
Misinformation may hamper a health care provider’s ability to counsel a patient effectively on contraception, as shown in the case study of Mikayla.
Mikayla. Mikayla is 19 years old and new to your practice. She successfully used Depo-Provera® (depot medroxyprogesterone acetate [DMPA]) for two years until her physician told her she had to stop. She tells you that the doctor said something about it “destroying her bones.”Mikayla’s physician switched her to birth control pills; however, she had trouble remembering to take her pill each day and to refill the prescription each month. She tells you that she is currently not using any contraceptive method.
This case highlights the need to consider whether the benefits of continuing DMPA outweigh the risks for each woman. Recognize that stopping or changing contraceptive methods may lead to an increased risk of unintended pregnancy. Mikayla went from an effective method to a method she did not use effectively to no method. It is important to present women with contraceptive options they can embrace and use effectively.
Although DMPA has a “black box” warning that prolonged use may result in the loss of bone density, the Food and Drug Administration (FDA) approved this warning despite a lack of evidence that prolonged use of DMPA causes an increase in fracture or has an effect on postmenopausal bone health.1 Studies have shown the loss of bone mineral density associated with DMPA is substantially reversed after discontinuation in premenopausal women who have had DMPA treatment for up to five years.7 Experts in family planning have called for the FDA to rescind the black box warning, and both ACOG and WHO support long-term use of DMPA for contraception in women 18 to 45 years of age.1,4,8 Environmental factors, such as nutrition and exercise, have a more substantial impact on bone mass,9 and health care providers should encourage women to promote bone health through weight-bearing exercise, intake of calcium and vitamin D, avoidance of tobacco, and limits on alcohol.10 It is also important to remember that the risks of DMPA must be balanced against the risks of pregnancy.10
Some patients and health care providers also have concerns about the risk of venous thromboembolism (VTE) associated with use of the contraceptive transdermal patch (norelgestromin/ ethinyl estradiol, brand name OrthoEvra®) or oral contraceptives. The FDA created a warning for the patch stating that the total estrogen dose is higher with the patch than with oral contraceptives, although the peak level is lower.1 In January 2008, results from a new epidemiological study were added to the patch labeling showing twice the VTE risk with the patch compared with oral contraceptives.11 However, the risk of thromboembolism is significantly higher in pregnancy compared with using the patch.1,12 In addition, a recent study estimated VTE incidence in the general population of women of reproductive age is likely to be in the range of 5 to 10 per 10,000 women-years. Studies with hormonal contraceptives have often used a much lower value of 0.5 to 1 VTE per 10,000 women-years as the basis for comparison in the general population of reproductive-age women.13 Comparing VTE risk that can be attributed to OCs and the transdermal patch to this higher VTE risk in the general population of reproductive-age women would decrease the estimates of additional risk attributed to OCs and the patch.13 The bottom line: the risk of VTE from pregnancy is greater than the risk from either OCs or the patch.
|Pelvic inflammatory disease (PID)
Copper and levonorgestrel intrauterine system (LNG IUS) IUDs do not appear to differ in PID risk, with LNG IUS potentially offering protection from PID.14
|Infertility due to tubal infection or inflammation
Research consistently demonstrates no difference in fertility rates in multiparous women who discontinued IUDs.15,16
Research consistently demonstrates no difference in fertility rates in multiparous women who discontinued IUDs.15,16
|Need for monogamous relationship
No longer a barrier.14
|Use in teens
Recent research shows that an IUD is a good option for many teens.17
|Use in nulliparous women
No basis in evidence for limiting IUDs to parous women.18,19
|Postpartum or postabortion use
It is safe to insert either type of IUD immediately postabortion, and there may be practical advantages to doing so. Patients may be highly motivated to begin contraception and are likely to experience less discomfort with insertion at this time.14 It is recommended to wait at least four weeks postpartum before inserting an IUD.20
|Use in patient with history of STIs
||According to WHO guidelines, IUDs should not be inserted in women who have current purulent cervicitis or chlamydial infection or gonorrhea. Women with these infections who already have an IUD in place can usually be treated without removal of the IUD. The advantages of IUDs generally outweigh the risks in women who have vaginitis or other STIs.20|
Many patients and health care providers also have concerns about intrauterine devices, many of which are the result of misinformation. Pelvic inflammatory disease, infertility, and restrictions on their use in nulliparous women are among the concerns that often inappropriately limit the use of this highly effective method of contraception. Table 2 presents information to help address these and other concerns about IUDs.
Daphne’s case study helps to illustrate additional benefits of IUDs for some women.
Daphne. Daphne is a recently divorced 34-year-old mother of one. She experiences extremely heavy bleeding during menstruation. Her pelvic examination is normal. She asks about a tubal ligation or maybe even getting a hysterectomy to eliminate the heavy bleeding, which she finds problematic.
At 34 and recently divorced, Daphne is not an ideal candidate for tubal ligation. Many women regret sterilization. There is no medical justification for a hysterectomy. Discuss the levonorgestrel-releasing IUD with Daphne and its potential benefits for menorrhagia. Daphne also may be a good candidate for the etonogestrel contraceptive implant (Implanon®).
Johanna’s case study presents patient characteristics that require an understanding of the current recommendations for hormonal contraceptives in patients with coexisting medical conditions.
Johanna. Johanna is new to your practice. She is 35 years old, smokes about a half a pack of cigarettes a day, and uses combination oral contraceptives as birth control. She tells you that she has used the pill for years, is very good about remembering to take it, and thinks it helps her with migraines around the time of her period. She is recently divorced and is currently dating two men, one seriously and one casually.
Refer to the section below, Hormonal Contraceptives and Coexisting Medical Conditions, for information about use of oral contraceptives and coexisting medical conditions, such as Johanna’s migraines and smoking.
Hormonal Contraceptives and Coexisting Medical Conditions
Hypertension: According to WHO guidelines, combined oral contraceptives (COCs) should not be used in women with hypertension whose blood pressure is >160 (systolic) or >100 (diastolic). COCs are not usually recommended unless other methods are not available or acceptable for women who have hypertension above those levels.20
Migraine: COCs should not be used in women of any age who have migraine with aura. Auras are sensory disturbances such as bright or shimmering light or shapes at the edge of the field of vision or dark holes or blind spots that occur before the migraine. However, the advantages of COCs generally outweigh the risks in women who have migraine without aura who are younger than 35. For older women who have migraine without aura, COCs usually are not recommended unless other methods are not available or acceptable.20
Diabetes: COCs can be used without restriction in women with a history of gestational diabetes only. Advantages of COCs generally outweigh risks in women who have diabetes without vascular disease. COCs usually are not recommended unless other methods are not available or acceptable for women who have end-organ damage or diabetes of more than 20 years duration.20
Obesity: Obesity (body mass index of at least 30 kg/m2) may impair the effectiveness of combination oral and transdermal contraceptives. However, the incrementally higher failure rates in these women should not exclude the use of these contraceptives in favor of less effective methods.8,22
Smoking: COCs are not recommended in women older than 35 who smoke more than 15 cigarettes per day.20
Insurance and financial barriers
"A delay in obtaining a needed contraceptive refill may result in significant reduction of contraceptive efficacy and is a very common reason for contraceptive failure."23
- James Trussell, PhD
Approximately 46 million Americans have no insurance, and millions more are underinsured.24 Many insurance plans do not cover pharmaceuticals. A recent study found that more than half of private providers believe that a sizeable minority of patients have payment problems.25 In addition, an estimated 50 percent of all reproductive-age women who are sexually active rely on publicly funded family planning services.26,27 More than one in five public providers report that the majority of their patients seeking contraception have difficulty paying for visits.27 These statistics reveal important barriers to effective contraception for many women who may not be able to afford an office visit or a prescription.
Current policies for coverage of contraceptives may be another barrier and a major factor in poor contraceptive success.26 Many patients pay high out-of-pocket costs in the form of copays and deductibles. Even women who have private insurance paid approximately 60 percent of the total cost of the pill, although the typical out-of-pocket cost for non-contraceptive drugs is only 33 percent.26 Bolstering this barrier are limitations insurance companies place on dispensing OCs. Although many providers write prescriptions for three months of pills at one time, insurance plans often limit coverage to one pack at a time.26 Even though dispensing a year’s supply of OCs is more cost effective and improves continuation of the method,28 73 percent of women receive only one pack of oral contraceptives per pharmacy visit.29
Insurance barriers play a role in inconsistent and transient use of contraceptives. Statistics show that 57 percent of women discontinue OCs within six months. Although many women cite side effects as their reason for discontinuing OCs, one study demonstrated that the most important factor was not side effects but difficulty obtaining more pills and using pills correctly. Many of the women who discontinue OCs do so without finding another effective birth control method, resulting in an unintended pregnancy.30
- Leeman L. Medical barriers to effective contraception. Obstet Gynecol Clin N Am. 2007;34:19-29.
- Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, et al. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs evidence. JAMA. 2001;285:2232-9.
- ACOG practice bulletin. No. 45: Cervical cytology screening. Int J Gynaecol Obstet. 2003;83:237-47.
- World Health Organization. WHO statement on hormonal contraception and bone health. Available from: http://www.who.int/reproductive-health/family_planning/bone_health.html. Accessed November 30, 2006.
- Westoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraceptive initiation method. Contraception. 2002;66:141-5.
- Lara-Torre E, Schroeder B. Adolescent compliance and side effects with quick start initiation of oral contraceptive pills. Contraception. 2002;66:81-5.
- Kaunitz AM, Arias R, McClung M. Bone density recovery after depot medroxyprogesterone acetate injectable contraception use. Contraception. 2008;77:67-76.
- ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107:1453-72.
- Cromer BA, Lazebnik R, Rome E, Stager M, Bonny A, Ziegler J, et al. Double-blind randomized controlled trial of estrogen supplementation in adolescent girls who receive depo medroxyprogesterone acetate for contraception. Am J Obstet Gynecol. 2005;192:42-7.
- DiVasta AD, Gordon CM. Bone health in adolescents. Adolesc Med. 2006;17:639-52.
- Drugtopics.modernmedicine.com. Available from: http://drugtopics.modernmedicine.com/drugtopics/Drug+Topics+Daily+News/New-esti...d-to-Ortho-Evra-PI/ArticleStandard/Article/detail/486039?cont. Accessed February 28, 2008.
- Toglia MR, Nolan TE. Venous thromboembolism during pregnancy: a current review of diagnosis and management. Obstet Gynecol Surv. 1999;54:29-14.
- Heinemann LAJ, Dinger JC. Range of published estimates of venous thromboembolism incidence in young women. Contraception. 2007;75:328-36.
- MacIsaac L, Espey E. Intrauterine contraception: the pendulum swings back. Obstet Gynecol Clin N Am. 2007;34:91-111.
- Vessey MP, Lawless M, McPherson K, Yeates D. Fertility after stopping use of intrauterine contraceptive device. Br Med J (Clin Res Ed). 1983;286:106.
- Andersson K, Batar I, Rybo G. Return to fertility after removal of a levonorgestrel releasing intrauterine device and Nova-T. Contraception. 1992;46:575.
- Toma A, Jamieson MA. Revisiting the intrauterine contraceptive device in adolescents. J Pediatr Adolesc Gynecol. 2006;19:291-6.
- Otero-Flores JB, Guerrero-Carreno FJ, Vazquez-Estrada LA. A comparative randomized study of three different IUDs in nulliparous Mexican women. Contraception. 2003;67(4):273-6.
- Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69(5):407-12.
- World Health Organization. Medical eligibility criteria for contraceptive use. 3rd ed. Geneva: World Health Organization; 2004.
- Grimes DA, Mishell DR. Intrauterine contraception as an alternative to interval tubal sterilization. Contraception. 2008;77:6-9.
- Armstrong C. ACOG releases guidelines on hormonal contraceptives in women with coexisting medical conditions. Am Fam Physician. 2007;75(8):1251.
- Trussell J. Reducing unintended pregnancy in the United States. Editorial. Contraception. 2008;77:1-5.
- US Census Press Releases, 2006. Income climbs, poverty stabilizes, uninsured rate increases.
- Guttmacher Institute. Improving contraceptive use in the United States. In Brief. 2008 Series, No.1 April 2008.
- Espey E. Cosgrove E, Ogburn T. Family planning American style: why it’s so hard to control birth in the US. Obstet Gynecol Clin N Am. 2007;34:1-17.
- Guttmacher Institute, News Release 2005. Gap widening between U.S. women’s birth control needs and government response. Available from: http://www.guttmacher.org/media/nr/2005/02/22/index.html. Accessed January 14, 2007.
- Foster DG. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol. 2006;108(5):1107-14.
- Phillips KA. Out-of-pocket expenditures for oral contraceptives and number of packs per purchase. J Am Med Womens Assoc. 2004;59(1):36-42.
- Westhoff CL, Heartwell S, Edwards S, Zieman M, Stuart G, Cwiak C, et al. Oral contraceptive discontinuation: do side effects matter? Am J Obstet Gynecol. 2007;196:412.e1-e7.