Contraception Editorial September 2008
By: J. Joseph Speidel, Cynthia C. Harper, and Wayne C. Shields
The 80 million unintended pregnancies that occur worldwide each year (38% of all pregnancies) can justifiably be deemed an “epidemic.” These pregnancies result in 42 million induced abortions and 34 million unintended births — births that contribute substantially to the annual world population growth of 78 million.1,2
Among developed countries, the US record of family planning is uniquely deficient. Of 6.1 million pregnancies in 2001, half were unintended (as were more than 80% of the 800,000 annual teen pregnancies), resulting in 1.3 million abortions, 4 million births (of which one-third were unintended) and 800,000 miscarriages.3
As Frost et al.4 noted in a recent study published by the Guttmacher Institute: “Unintended pregnancy can force women and their families to confront difficult abortion decisions or the potentially negative consequences associated with unplanned childbearing—including child health and development issues, relationship instability, and compromises in education and employment that may exacerbate ongoing poverty.” This same study attributes 52% of unintended pregnancies in the USA to nonuse of contraception, 43% to inconsistent or incorrect use, and only 5% to method failure.4
Leading causes of unintended pregnancy are closely related to contraceptive method choice. In 2002, more than half of contraceptive users relied on methods with high failure rates under typical use: 31% used the pill, 18% the male condom and 5% the 3-month injectable.5 While with perfect use these methods are highly effective, 9% of pill users, 17% of condom users and 5% of injectable users will become pregnant during the first year of typical use.5,6 To make matters worse, about half of condom and injectable contraception users — and almost one-third of pill users — will discontinue within a year.6
The potential of long-acting reversible contraception methods
Long-acting reversible contraception (LARC) methods, including intrauterine contraceptives and implants, have a proven record of very high effectiveness, many years of effectiveness, convenience, cost effectiveness, suitability for a wide variety of women and, in general, high user satisfaction.7,8,9,10,11,12,13,14 With typical use, the first year failure rate of the copper T 380A (ParaGard®) is 1%, the LNG-IUS (Mirena®) is 0.1% and the implant available in the USA (Implanon®) is 0.1%5. One-year continuation rates are also markedly superior to short-acting reversible contraceptives being 78% for the copper T 380A, 80% for the LNG IUS and 84% for Implanon®.6
Yet, LARC methods make up a very small share of world contraceptive use. For example, implants and IUCs account for only about 2% of contraceptive use in the USA.5
Figures can be deceiving: while the IUC is used worldwide by 14% of women who are married or in some type of committed relationship, this number is skewed as more than half of the 150 million women in the world using an IUC are in China. A more accurate picture emerges when focusing on regional data: the percentage of women using IUC who are married or in union is 7% in Latin America, 6% in Asia (excluding China) and just 1% in Africa.7 Use in developing countries is only 6% when China is excluded. There are notable exceptions to this global pattern. IUC has been used extensively in a small number of countries, including Uzbekistan (50%), China (40%), Egypt (37%), Vietnam (36%), Cuba (35%), Tunisia (28%), Jordan (24%), Turkey (20%), France (17%) and Mexico (14%)7. Recent events also bode well for increased utilization of LARC worldwide, such as the liberalization of World Health Organization (WHO) medical eligibility criteria for IUC use8,9 and the introduction of Implanon® in the USA.
Unfortunately, outdated perceptions about appropriate patient candidates for LARC among health care providers continue to negatively impact their use. An emerging body of research has disproved a number of contraindications to IUC use. Specifically, women of any age or parity and those who are postpartum or post first or second trimester abortion are eligible for IUC. The benefits of IUC also outweigh the risks of a wide variety of medical conditions that might contraindicate the use of combined hormonal contraceptives.8,9,11,12,14,15,16,17,18
The issue of increased risk or greater severity of infection among IUC users has been a prominent concern. However, the rate of pelvic inflammatory disease (PID) in IUC users is low, with cases concentrated in the first 20 days after insertion.19,20
Shelton21 has developed a mathematical model that estimates the risk of PID attributable to IUC. For example, in a client population with a 10% prevalence of STI and no STI screening before insertion, the risk of PID attributable to the IUC would be 0.3% and about half that if clients were screened using a risk-assessment protocol. WHO guidelines allow for use of IUC by those with HIV; however, women with AIDS should be monitored for pelvic infection.8,9
Barriers to increased use of LARC
Use of LARC in both the USA and worldwide will not reach its full potential until a number of barriers are addressed:
- Providers both lack information and are misinformed. Providers continue to be concerned about IUC use due to unsubstantiated risk related to STIs, ectopic pregnancy, infertility, use postpartum, use postabortion, use by nulliparous women, use by teens, patient acceptability and legal matters. A study of 816 contraceptive providers serving low-income clients through California’s publicly funded Family PACT Program showed that almost 95% consider the IUC to be safe, but fewer than 65% generally discuss the option with patients seeking contraception. Providers also were misinformed about side effects; for example, about one-quarter described hormonal side effects of ParaGard®, a nonhormonal method.22
- Providers lack adequate training in IUC and implant insertion. In the same Family PACT survey, 69% of providers reported that they were trained in IUC insertions, and 61% had IUC available at their practice, but only 60% felt “very comfortable” inserting ParaGard®, and just 40% felt “very comfortable” inserting Mirena®. Although IUCs are reimbursable for Family PACT providers, more than 40% have never dispensed IUC, and just 1.3% of female clients were given IUC in 200522.
- Patients’ fears, misinformation and lack of knowledge have resulted in low demand. A 1996 survey of reproductive-age US women revealed that 32% had little or no knowledge about IUC; only 21% felt that the term “safe” closely described it; and only 16% had a favorable opinion of it23. Negativity towards IUC stems largely from the misconception that it is an abortifacient, and the Dalkon Shield controversy. A more recent 2007 study among adolescent and young women found that most (60%) had never heard of IUC24. Manufacturers have invested relatively little to improve perceptions of IUC, particularly compared to the advertising budgets for oral contraceptives25.
- LARC is expensive and provider reimbursement low, especially in the USA. Manufacturers have kept product pricing high in the USA and up-front costs can make these methods unaffordable for many women. While companies have a strong incentive to market pills that might bring in more than $1000 profit over a 10-year period, the one-time sale of a copper IUC yields only about $200 profit for the same time period.25,26 In the USA, the current public sector price for ParaGard® is $200 (more than 100 times the cost of manufacture), Mirena® is $330 (with the exception of a small number available through the ARCH Foundation) and Implanon® is $436. Private sector pricing is substantially greater. Although IUC is inexpensive when the cost is prorated over 5 years,26 the high copayments of many health insurance plans result in a prohibitive initial cost for women — and women who lack health insurance are least likely to be able to afford IUC.
Recommendations for action
Past experience with the successful introduction of new contraceptives, or reintroduction in the case of the IUC, provides guidance to improve provision and use. Recommended activities include the following:
- Undertake research to determine why provider practices are not evidence based, to elucidate health system barriers and to inform the design of interventions to encourage provision.
- Develop information and training materials to address knowledge gaps and misinformation, as well as evidence-based screening tools and training curricula that incorporate the latest adult learning principles.
- Provide training and technical assistance. Training and medical education at the preservice level must include the full health care team of professionals involved in contraceptive counseling and provision. In addition to Ob/Gyn and family practice physicians, advance practice clinicians, nurses, social workers and other counselors need to be knowledgeable about LARC. Provider training must include supervised hands-on experience with LARC methods and mentoring as needed. Ongoing technical assistance must address the health system issues such as intake, counseling, clinic protocols, consent forms, malpractice insurance, record keeping, insurance claims and management of side effects and complications.
- Address the high cost of LARC methods through better insurance coverage, lower prices for public sector use and price competition with generic or alternative IUCs and implants.
- Increase patient awareness with audience-appropriate educational materials and direct-to-consumer marketing.
- Fully fund family planning programs for low-income clients. An annual expenditure of about $3.5 billion is needed to serve the 17 million US women in need of publicly funded contraceptive services.27,28 This can be compared to public outlays of $1.85 billion in FY2006 — about half of the total needed29. Fifteen billion dollars a year is needed for family planning programs in developing countries, yet only 10% of the funds needed from foreign aid donors are now being committed.30,31,32
There are many examples of successful introduction of LARC around the world. With adoption of better family planning policies, effective health professional training programs and commitment of the needed resources, these success stories can be replicated on a large scale in an increasing number of countries.
J. Joseph Speidel
Department of Obstetrics, Gynecology and Reproductive Sciences
Bixby Center for Global Reproductive Health
University of California, San Francisco
San Francisco, CA
Cynthia C. Harper
Department of Obstetrics, Gynecology and Reproductive Sciences
Bixby Center for Global Reproductive Health
University of California, San Francisco
San Francisco, CA
Wayne C. Shields
Association of Reproductive Health Professionals
- The Alan Guttmacher Institute . Sharing responsibility: women, society and abortion worldwide. New York (NY): Alan Guttmacher Institute; 1999;Available at:http://www.guttmacher.org/pubs/sharing.pdf(Accessed May 23, 2008).
- Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat . World population prospects: the 2006 revision. Available at http://www.un.org/esa/population/publications/wpp2006/wpp2006.htm (Accessed March 20, 2007).
- Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38:90–96.
- Frost JJ, Darroch JE, Remez L. Improving contraceptive use in the United States. In: Brief. New York: Guttmacher Institute; 2008;No. 1. Available at: http://www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf (Accessed June 25, 2008).
- Guttmacher Institute . Facts on contraceptive use. Facts in brief. New York: Guttmacher Institute; 2008; Available at: http://www.guttmacher.org/pubs/fb_contr_use.html (Accessed May 20, 2008).
- Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D editor. Contraceptive technology 19th revised edition. New York: Ardent Media; 2007; Available at: http://www.contraceptivetechnology.com/table.html (Accessed June 25, 2008).
- Clifton D, Kaneda T, Ashford L. Family planning worldwide 2008 data sheet. Washington, DC: Population Reference Bureau; 2008.
- World Health Organization web site . Medical eligibility criteria for contraceptive use.. 3rd ed.. Geneva: Department of Reproductive Health and Research, WHO; 2004; Available from http://www.who.int/reproductive-health/publications/mec/ [Accessed May 12, 2008].
- World Health Organization Web site . Selected practice recommendations for contraceptive use. 2nd ed.. Geneva: Department of Reproductive Health and Research, WHO; 2004; Available from http://www.who.int/reproductive-health/publications/spr/index.htm [Accessed May 12, 2008].
- International Collaborative Post-marketing Surveillance of Norplant. Post-marketing surveillance of Norplant contraceptive implants: I. Contraceptive efficacy and reproductive health. Contraception. 2001;63:167–186.
- Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv. 2002;57:120–128.
- Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception. 2004;69:437–446.
- Chiou CF, Trussell J, Reyes E, et al.Economic analysis of contraceptives for women. Contraception. 2003;68:3–10.
- Darney PD. Time to pardon the IUD? N Engl J Med. 2001;345:608–610.
- Grimes D, Schulz K, van Vliet H, Stanwood N. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev. 2003;(1):CD003036.
- Prager S, Darney P. The levonorgestrel intrauterine system in nulliparous women. Contraception. 2007;75:S12–S15.
- United Nations Development Programme , United Nations Population Fund, World Health Organization , Bank W. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception. 1997;56:341–352.
- Grimes D, Lopez L, Schulz K, Stanwood N. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev. 2004;CD001777.
- Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339:785–788.
- Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet. 2000;356:1013–1019.
- Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet. 2001;357:443.
- Harper CC, Blum M, de Bocanegra HT, Darney PD, Speidel JJ, Policar M, et al.Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol. 2008;111:1359–1369.
- Forrest JD. U.S. women’s perceptions of and attitudes about the IUD. Obstet Gynecol Surv. 1996;51(12 Suppl.):S30–S34.
- Johnson L, Whitaker A, Harwood B, Creinin M, Chiappetta L, Gold M. Adolescent and young women’s knowledge and attitudes toward using intrauterine contraceptive devices (IUDs). J Pediatr Adolesc Gynecol. 2007;20(2):S115–S116.
- Hubacher D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health. 2002;34:98–103.
- Trussel J, Leveque JA, Koenig JD, et al.The economic value of contraception: a comparison of 15 methods. Am J Public Health. 1995;85:494–503.
- Speidel JJ, Weiss DC, Ethelston SA, Gilbert SM. Family planning and reproductive health: the link to environmental preservation. San Francisco (Calif): Bixby Center for Reproductive Health Research & Policy, University of California, San Francisco; 2007; (An abridged version of this paper appeared in Population and Environment (2007) 28:247-258.) Available at:http://bixbycenter.ucsf.edu/publications/files/Speidel_FamilyPlanning_2007.pdf.
- Sonfield A. Preventing unintended pregnancy: the need and the means. New York: Guttmacher Institute; 2003.
- Sonfield A, Alrich C, Gold RB. Public funding for family planning, sterilization and abortion services, FY 1980–2006. Occasional Report. New York: Guttmacher Institute; 2008;No. 38.
- Summary of the ICPD Programme of Action . UNFPA. United Nations Department of Public Information. Available at: http://www.unfpa.org/icpd.summary.htm (Accessed June 25, 2008).
- Speidel JJ. Population donor landscape analysis for review of Packard Foundation International Grantmaking in Population, Sexual and Reproductive Health and Rights. The David and Lucile Packard Foundation. Available at:http://www.packard.org/assets/files/population/program%20review/pop_rev_speidel_030606.pdf2005; (Accessed July 13, 2006).
- In: Flow of Financial Resources for Assisting in the Implementation of the Programme of Action of the International Conference on Population and Development, Report of the Secretary-General to the 41st Session of the Commission on Population and Development. New York: United Nations; 2008.