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Breaking the Contraceptive Barrier: Techniques for Effective Contraceptive Consultations

(Published September 2008)

Contraceptive Use and Knowledge

Contraceptive efficacy

Many women, and even some health care providers, have gaps in their knowledge about available contraceptive methods and how effectively each method prevents pregnancy. Figure 1 shows the percentage of women who experience an unintended pregnancy within the first year of use of various contraceptive methods. Note that the graph differentiates “typical use” (actual use of the method, including inconsistent and incorrect use) from “perfect use” (the effectiveness of the method if directions for use are followed at every act of intercourse). For some methods, there is a significant difference between effectiveness with perfect use and effectiveness with typical use.1

Intrauterine devices, the vaginal ring, injectable contraceptives, transdermal patches, implants, and combined oral contraceptive pills rank among the most effective reversible methods for preventing unintended pregnancy with perfect use. However, as shown in Figure 1, the methods that require more action from either the man or the woman (e.g., male condom, contraceptive pills) generally show a larger difference between effectiveness with perfect use and effectiveness with typical use.

In the United States, 76 percent of all couples who use a reversible form of contraception use either oral contraceptives or the male condom.2,3 Nearly two-fifths of women who rely on the pill use it inconsistently, reporting missing at least one pill during the previous three months. Three-fifths of women who rely on condoms report inconsistent use.4

Strategies for breaking barriers to contraceptive efficacy
  • Educate patients about the most effective contraceptive methods.
  • Dispel myths about contraceptive methods (e.g., that intrauterine device (IUD) use is limited to parous women).
  • Encourage use of highly effective contraceptive methods, such as long-acting and reversible methods (e.g., single-rod implant, IUDs).
  • Assist in overcoming barriers to use of highly effective contraceptive methods (e.g., not refilling a prescription unless the woman comes in for a Pap test).
  • Reduce gaps in use and inconsistent use of contraceptive methods by providing a prescription that lasts at least a year and can be filled three months at a time.

A recent study by the Guttmacher Institute reveals that each year only half of the women at risk for unintended pregnancy are adequately protected through consistent and correct use of contraceptives. Twenty-seven percent of women are at elevated risk for unintended pregnancy because they use their contraceptive method inconsistently or incorrectly. An additional 15 percent are at high risk because of gaps in contraceptive use caused by difficulty in using or accessing methods, infrequent sexual activity, or misperceptions of risk for pregnancy. Notably, these gaps often coincide with important life events, such as beginning or ending a relationship, changing a job, or a experiencing a personal crisis. Another 8 percent of women who are at risk for unintended pregnancy use no contraceptive method.4

Health care providers can help educate women about the most effective contraceptive methods. However, it is important to factor each patient’s personal and sexual situation into the effectiveness equation. The most effective methods do not protect against sexually transmitted infections. A discussion about using condoms in addition to other contraceptive methods may help a patient reduce her risk for acquiring a sexually transmitted infection (STI). In addition, the most effective methods may be the hardest to access, especially for teens. A discussion about having a back-up method for situations such as missed pills or delayed access may help a patient avoid an unplanned pregnancy.

Emergency contraception

Heather. Heather is 26 years old. She had an abortion two years ago. She tells you that she is not currently using any contraceptive method because she always asks her partner to use a condom.

Heather illustrates an important opportunity to discuss effective contraceptive methods, including emergency contraception (EC). In fact, a discussion about EC can serve as a bridge to a discussion of the range of contraceptive options. First, ask if her partner is using condoms correctly and consistently. Although condoms are not the most effective method for preventing unintended pregnancy, they are effective in preventing STIs, and any contraceptive method is more effective than no method. Suggest that she keep EC on hand and take it if a condom breaks during intercourse. Then ask if she is interested in hearing about contraceptive options she can use, reinforcing the message that two methods are better than one.

Only 1.3 percent of women who had an abortion in 2000 used emergency contraception to try to prevent pregnancy.5 In a large study in which women were given a supply of emergency contraception to keep at home, three out of four women who did not use EC said they did not realize they had put themselves at risk for pregnancy.6 This finding further highlights the issue of women not understanding the risk of pregnancy associated with both their menstrual cycle and contraceptive method.7 Women who are unsure whether they need EC often think they won’t become pregnant and decide to “wait it out.”8 Women, especially teens, don’t want to acknowledge the risk or are too embarrassed to get EC.9

Strategies for breaking barriers to emergency contraception
  • Help women understand when, during each cycle, they are most likely to get pregnant and most likely to benefit from taking EC.
  • Educate women about the effectiveness of various contraceptive methods and guide them toward using a highly effective method.
  • Overcome barriers to the use of EC including availability, cost, and misinformation about EC.
  • Make women aware of emergency contraception-related Web sites such as www.not-2-late.com.

Many other reasons keep women from using emergency contraception. Perhaps the most obvious is limited knowledge about EC among patients and many health care providers. Some patients, many members of the media, and even some health professionals believe that EC pills, sold under the brand name Plan B® (levonorgestrel) are “the abortion pill” (also known as mifepristone or MifeprexTM).10 Plan B does not cause abortions. It works to prevent pregnancy, not disrupt an established pregnancy. It contains progestin, which inhibits ovulation and helps prevent pregnancy through effects on sperm motility and thickening of a woman’s cervical mucus.10,13 There is also the misperception that the availability of EC reduces the use of regular contraceptives, despite studies of women of all ages demonstrating that the availability of EC does not change the use of regular contraceptives.11,12

Another major reason for not using EC is poor access. Currently EC is available from clinics or behind the pharmacy counter to men and women 18 years of age and older. Women under the age of 18 need a prescription, which makes access more difficult and may delay access to EC.13,14 In addition, some physicians and pharmacists refuse to prescribe or dispense EC, citing that its use runs contrary to their personal convictions.13,14

Cost, which ranges from $10 to $45 (plus the cost of an office visit for a patient under the age of 18), also may be a barrier for many patients.13,14 Some women are concerned about side effects, such as nausea, which were common with older EC methods but not with Plan B.

References:

  1. Trussell J. Reducing unintended pregnancy in the United States. Editorial. Contraception. 2008;77:1-5.
  2. Kost K, Singh S, Vaughan B, Trussell J, Bankole A. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception. 2008;77:10-21.
  3. Lepkowski JM, Mosher WD, Davis KE, Groves RM, van Hoewyk J, and Willem J. National Survey of Family Growth, Cycle 6: sample design, weighting, imputation, and variance estimation. National Center for Health Statistics. Vital Health Stat. 2006;2(142).
  4. Guttmacher Institute. Improving contraceptive use in the United States. In Brief. 2008 Series, No.1 April 2008.
  5. Jones RK, Darroch JE, Henshaw SK. Contraceptive use among US women having abortions in 2000-2001. Perspect Sex Reprod Health. 2002;34(6):294-303.
  6. Glasier A. Emergency contraception: is it worth all the fuss? Editorial. BMJ. 2006;333:560-1.
  7. Free C, Lee RM, Ogden J. Young women’s accounts of factors influencing their use and non¬use of emergency contraception: in-depth interview study. BMJ. 2002;325. Available from: http://www.bmj.com. Accessed January 23, 2008.
  8. Rocca CH, Schwarz EB, Stewart FH, Darney PD, Raine TR, Harper CC. Beyond access: acceptability, use, and nonuse of emergency contraception among young women. Am J Obstet Gynecol. 2007 Jan;196 (1):29.e1-e6.
  9. Lemay CA, Cashman SB, Elfenbein DS, Felice ME. Adolescent mothers’ attitudes toward contraceptive use before and after pregnancy. J Pediatr Adolesc Gynecol. 2007;20:233-40.
  10. Prine L. Emergency contraception, myths and facts. Obstet Gynecol Clin N Am. 2007;34:127-36.
  11. Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med. 1998;399(1):1-4.
  12. Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol. 2000 Jul;96(1):1-7.
  13. Planned Parenthood® Federation of America Emergency Contraception (Morning After Pill). Available from: http://www.plannedparenthood.org/ health-topics/emergency-contraception-morning-after-pill-4363.htm. Accessed February 28, 2008.
  14. Planned Parenthood Fact Sheet. Refusal clauses: a threat to reproductive rights. 2004.