Abstract
Keywords
Introduction
Unintended pregnancy disproportionately affects minority populations, but the effect of age, race, and ethnicity on use of long-acting reversible contraception (LARC) has not been well studied. Half of unintended pregnancies occur in women using contraception; therefore, a highly effective contraceptive method such as LARC has potential to have a large impact on unintended pregnancy rates. 1 There are racial and ethnic differences in contraceptive selection.2-5 LARC, which includes intrauterine contraceptive devices (IUDs) and implants, is highly effective and safe for preventing unintended pregnancy. However, its use remains low in women of all reproductive ages, particularly in adolescents, who are at disproportionately higher risk for unintended pregnancy. 6
The decline in the US teen pregnancy rate across all racial and ethnic groups 7 is in large part attributable to increases in the proportion of female adolescents using highly effective contraception.8,9 IUDs or hormonal methods are used by 60% of sexually experienced adolescents, most often by non-Hispanic white adolescents (66%), followed by Hispanic adolescents (54%) and non-Hispanic black adolescents (46%). 9 Issues of cost and access affect adolescent LARC use, and when these barriers are eliminated, 69% of adolescents 14 to 17 years old and 61% of those 18 to 20 years old choose LARC.8,9
This study examined the initiation and continuation of LARC utilization in an urban Boston Title X–supported community health center with a large black and Hispanic population over a 5-year period among older and younger women to understand the effect of age, race, and ethnicity on LARC use in order to reduce the unintended pregnancy rate.
Materials and Methods
We conducted a retrospective cohort study of all women who received a LARC method (IUD or etonogestrel implant) from 2006 through May, 2010 at the Dimock Center, a Title X–supported community health center in the Roxbury neighborhood of Boston, Massachusetts. We reviewed the charts of all women who, based on International Classification of Diseases, Ninth Revision and Current Procedural Terminology coding, had an IUD or implant inserted during the study period. There were no exclusion criteria. The institutional review board at our institution approved this study.
We collected demographic data and information regarding the reason for selecting LARC, number of prior contraceptive methods, reason for discontinuing, duration of use, and whether the device was in place at the time of chart review. When multiple reasons for placement or discontinuation were documented, all were included in the analysis. Participants were stratified into the following groups based on age at the time of IUD or implant placement: (a) younger women, defined as those <23 years of age and (b) older women, defined as those ≥23 years of age. We chose these groups because the younger group was more likely to be seen by a pediatrician while the older group was more likely to be seen by an obstetrician-gynecologist. Data are presented as median (interquartile range) or proportion and was compared with the Wilcoxon rank sum, χ2, or Fisher’s exact test, as appropriate.
Results
There were 276 women who had an IUD or implant inserted from 2006 through 2010. The majority (60.1%) of women were black, 18.5% were Hispanic, and 9.1% were white. At the time of contraceptive placement, 26.1% of women were younger than 23 years, and 73.9% were age 23 or older. Approximately half (48.2%) of the women were privately insured, and 46.4% had Medicaid. Younger and older women differed with regard to race/ethnicity, parity, and type of insurance coverage (all P ≤ .005). A larger proportion of younger women were Hispanic, and fewer were white or black. Younger women were more likely to be insured by Medicaid, while older women were more likely to have private insurance. The IUD was the most common LARC method used in both age groups, with the vast majority using the levonorgestrel intrauterine system. While the number of LARC placements increased after 2007 and remained relatively stable during the subsequent 3 years, the lower proportion in 2010 reflects the fact that we only included women who received LARC during the first 5 months of that year. Patient characteristics are summarized in Table 1.
Patient Characteristics. a
Values are shown as n (%), unless otherwise specified.
Comparisons are between the younger and older groups.
Age at time of first recorded intrauterine device or implant placement.
There were no differences in LARC utilization or duration of use of IUDs or implants by age, race or ethnicity. Younger women and older women were similarly likely to continue their IUD or implant, with 76.4% of younger women and 69.6% of older women using LARC at the time of chart review (P = .28). Of those who had their contraceptive method removed during the time studied, the mean duration of use was 7.1 months (range = 1.4-13.7 months) for younger women compared with 11.2 months (range = 4.6-21.0 months) for older women, which was not significant (P = .22). These relationships held true when comparing black women with Hispanic women within each of the age strata. The reasons for LARC removal did not differ between younger and older women, with the most frequently cited reason being irregular bleeding, followed by pain or cramping (Table 2).
Reasons for Long-Acting Reversible Contraceptive Placement and Removal.
Only reasons that were mentioned by at least 5 women are included in the table. Reasons for placement that are not shown include the following: contraindication to other methods and first form of birth control. Reasons for removal that are not shown include the following: time to replace method, desired replacement of method, pelvic inflammatory disease, amenorrhea, partner feels intrauterine device, and strings cut during procedure.
Comparisons are between the younger and older groups.
Long-range reversible contraception was the first method of birth control for 5.6% of women in the younger group and 3.4% in the older group (P = .12; Table 1). Younger women were more likely than older women to have tried 2 or more methods before LARC (32.8% vs 40.3%, P = .12). The most common reason for choosing LARC in the older age group was that it was their method of choice (51.0%) and in younger women because they were postpartum (54.2%; Table 2).
Discussion
This pilot study population was composed of a high proportion of black and Hispanic women, groups that have disproportionately higher risks of unintended pregnancy, using a Title X–funded community health center. We found opportunities to reduce unintended pregnancy rates through increased LARC use given LARC was not a first-line method in the vast majority (96.0%) of women, regardless of age, race, or ethnicity. Yet nearly 40% of younger women and half of older women identified LARC as their method of choice. Educating providers and patients about the suitability of LARC as first-line contraception, particularly for younger women, may improve contraception continuation and further reduce unintended pregnancy in this population.
The most common reasons for discontinuation in all age groups were irregular bleeding, pain, or cramping. Women who are counseled well on the potential side effects may be more likely to continue LARC, emphasizing the need for education of providers and patients. 10 Numerous studies have demonstrated false beliefs around prescribing practices and misconceptions about risk of LARC.10-12
Low patient awareness appears to be a barrier to LARC in this population. Studies have shown that 60% to 80% of adolescents have never heard of IUDs,13,14 and a brief educational intervention targeting females 14 to 24 years old significantly improved attitudes toward IUDs. 13 Standardized scripts outlining the effectiveness of LARC methods improved initiation rates among participants 14 to 20 years old. 7 In the contraceptive CHOICE project, with standardized counseling and no financial barriers, 70% of participants chose LARC, with 63% of young women 14 to 17 years old choosing the implant, and 71% of young women 18 to 20 years old choosing an IUD, and >90% of women continuing LARC at 6 months, suggesting it be considered first-line contraception for women of any age.15,16
In a Title X–supported center, where many adolescents from low-income families receive family planning services, patient-borne cost is not generally a barrier to care. However, availability of the IUD was sometimes limited in our center. The Centers for Disease Control and Prevention assessed the provision of LARC by US family planning providers at Title X–supported centers. Only half had IUDs on site, only One-third had implants available, and patients served at Title X–supported clinics were more likely than those who received office-based care to be referred elsewhere for LARC. 17 Despite more regular availability of implants and equal training of providers in our center, IUDs were overwhelmingly chosen over implants in our population. We speculate that the lower uptake of implants was therefore because of provider counseling and/or patient preference.
The adolescent birth rate in Boston for black women (17.7) and Hispanic women (30.4) is significantly higher than for white women (11.3). In the Roxbury neighborhood, where the health center in this study is located, the adolescent birth rate declined by 40.2% from 26.1 in 2005 to 15.6 in 2010. 18 Some speculate this decline may in part be explained by increased LARC utilization, but this has not yet been studied. We conclude that there is an opportunity to improve the rate of LARC use as first-line contraception to further reduce unintended pregnancy in our population, and while a significant number of younger women used LARC, it often was not until they were postpartum.
The next steps are to reduce barriers to using LARC as a first-line contraceptive through provider and patient education, to work toward health care systems that allow regular availability of LARC in community health centers, and to implement evidence-based best practices for increasing LARC uptake as a first-line method.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award 1UL1 TR001102-01) and financial contributions from Harvard University and its affiliated academic health care centers.