Abstract
Worldwide, there is an unintended pregnancy rate of 40%. That rate is higher in some areas, such as in the United States—where it is nearly 50%. These pregnancies have potentially negative outcomes for the mother and child that include health, economic, social, and psychological aspects. Long-acting reversible contraceptives (LARCs) are highly reliable methods for family planning. Identifying personal characteristics associated with choosing LARCs will better address the unintended pregnancy rates. The purpose of this research project was to evaluate characteristics of adolescents and women at high risk for unintended pregnancies by (a) describing the use of a LARC and selected personal characteristics for the years 2009 and 2014 and (b) exploring relationships among LARC choice and selected personal characteristics of clients seeking family planning services. A retrospective chart review was conducted on 268 randomly selected records, half of which were each from the years 2009 and 2014. One Midwestern U.S. family planning clinic was the site of the research. The characteristics used in the chart reviews were derived from the literature and Healthy People 2020 goals. Key differences between the years 2009 and 2014 included a significant increase in the number of LARCs prescribed to high-risk women. There was a significant relationship between the choice of a LARC and having used one in the past. Personal characteristics influencing LARC birth control choice included White, Hispanic females, those with a history of a teen pregnancy, those who experienced any previous pregnancy or live birth, and those below the poverty level. The findings indicate the importance of educating clients on LARC options. To foster initial use of a LARC, an application, based on the findings of this study, has been developed that provides individualized choices and education on contraceptive methods including LARCs.
Background
Birth control has been identified as one of the top 10 achievements in health care in the 20th century (Centers for Disease Control and Prevention, 1999). Despite the achievement and advancements in birth control choices in the last several decades, an estimated 40% of the 213 million pregnancies worldwide in 2012 were unintended (Sedgh, Singh, & Hussain, 2014). The rate is higher in some countries, such as the United States, where nearly one half of all pregnancies are unintended (Finer & Zolna, 2016). An unintended pregnancy is one that is mistimed (not wanted at the time of occurrence, but desired in the future) or unwanted (at any time) (Finer & Zolna, 2016). Following a long period of rise since 1982, the unintended pregnancy rate in the United States for women ages 15 to 44 decreased 18%, from 54 per 1,000 women in 2008 to 45 per 1,000 in 2011 (Finer & Zolna, 2016). One goal of the U.S. Department of Health and Human Services’ (DHHS, 2011) Healthy People 2020 campaign is to reduce unintended pregnancy even further, by a full 10% between 2010 and 2020.
To reduce the unintended pregnancy rate, family planning efforts should address access to effective contraceptives to those at greatest risk (Finer & Zolna, 2011). Risk factors for unintended pregnancy are highest for adolescent females (hereafter called adolescents) younger than age 18 years whose unintended rates reach 80% (Coles, Makino, & Stanwood, 2011). Other risk groups include young age (18–24 years) and low income (Finer & Zolna, 2011) females who have unintended pregnancies at 200% to 300% of the national rate. Rates are higher also for black females and those with lower educational attainment (Mosher, Jones, & Abma, 2012). Additionally, Hispanic females have higher rates than their White, non-Hispanic counterparts, and that rate has risen dramatically over the past two decades (Jones, Mosher, & Daniels, 2012).
The cost of unintended pregnancies places the adolescent or woman at risk (U.S. DHHS, 2014). The risks include delays in initiating prenatal care with an increased incidence of untoward maternal and fetal outcomes. This population is less likely to breastfeed, resulting in greater risks for childhood obesity, asthma, and problematic maternal–infant bonding, among others. The adolescents and women experiencing unintended pregnancies are more likely to develop depression and have an increased risk of physical abuse during pregnancy. Negative consequences are greater for adolescent mothers. Adolescent mothers are less likely to graduate high school, earn a General Education Development certificate by age 30, or earn a wage comparable with women who delay childbearing (U.S. DHHS, 2014). Adolescent mothers are also twice as likely to receive U.S. Federal benefits and continue them twice as long. Thus, the effects of unintended pregnancies have negative implications for the mother, child, and society at large.
Because 40% to 50% of all unintended pregnancies are due to inconsistent or inaccurate contraceptive use, there is a pronounced need for reliable contraceptive methods that are not subject to user error (Finer & Zolna, 2014). Long-acting reversible contraceptives (LARCs) are highly effective because they circumvent the gaps of contraceptive coverage and inadvertent discontinuation rates of short-acting methods (American Congress of Obstetrics and Gynecology [ACOG], 2011). Methods such as the intrauterine device and implant are effective for years, much longer than the most common reversible method of contraceptives, the birth control pill (Daniels, Daugherty, & Jones, 2014). Therefore, ACOG (2011) recommends LARCs to prevent unintended pregnancies as they require minimal client attention and are cost-effective. This recommendation was expanded in 2011 to encourage their use with adolescents.
The identification of personal characteristics associated with the choice of a reliable contraceptive method and its use in high-risk populations is postulated to better address the public health goals in the United States to reduce unintended pregnancy rates. The purpose of this research project was twofold. The research evaluated characteristics of adolescents and women at high risk for unintended pregnancies who are clients at one Midwestern U.S. county health department’s family planning clinic by (a) describing the use of LARCs and selected personal characteristics for the years 2009 and 2014 and (b) exploring relationships among LARC choice and selected personal characteristics of the clients.
For adolescents and women who are provided care at the family planning clinic, the questions to be answered by the research project are:
What self-described personal characteristics (age, income, race or ethnicity, primary language, health-risk behaviors, and medical history—including sexual and reproductive history) and birth control choice describe the clients of one Midwestern U.S. family planning clinic between the year 2009 and the year 2014? Have the self-described personal characteristics of women at high risk for unintended pregnancies changed between those 5 years? What are the relationships between LARC choice and selected self-described personal characteristics of clients seeking contraceptive care?
Review of Literature
With the advent of more choices in LARCs, it was anticipated by the Centers for Disease Control and Prevention (CDC; 2011) that the rate of unintended pregnancies across age groups would significantly diminish. In one recent large study, the use of LARCs was demonstrated to significantly reduce the pregnancy rates (Harper et al., 2015). A critical feature of the effectiveness of LARCs is their continuation rate. The continuation of non-LARC hormonal methods over 1 year is low across racial and ethnic groups (Wereth et al., 2015). Whereas the continuation rate at 12 months of LARCs is high. For example, the continuation rate of LARCs was 86% in one study when compared with a 55% continuation rate of oral contraceptives (Peipert et al., 2011).
The higher rate of LARC choice by female clients since their introduction is related to multiple factors. The literature has identified racial, and age differences exist amongst adolescents regarding contraceptives use and, if used, the type of contraceptives employed (Kann et al., 2015). Studies demonstrate that the choice of a LARC is due in part to availability of the services and education of the provider (Harper et al., 2015), client age (Dehlendorf et al., 2014), clients’ racial or ethnic background (Dehlendorf et al., 2014; Jacobs & Stanfors, 2013), appropriateness of the client education (Peipert et al., 2011; Sridhar, Chen, Forbes, & Glik, 2015), and advantages perceived by the client regarding continuation of the method (Berenson, Tan, & Hirth, 2015). In one study that included a program of client education regarding LARC options, a full 72% of adolescents chose them following a tailored educational program with free services (Secura et al., 2014). In another study, 54% of the sample chose a LARC in a study after using an application-based education program that provided information regarding the 10 most common, nonpermanent contraceptive methods while emphasized LARCs (Sridhar et al., 2015). In yet another study that included the provision of free care with LARC choice, there were 68% of clients who chose to use one of those methods (Peipert et al., 2011). Additionally, the health-care setting may have an influence as Title X clinics are associated with increased LARC choice (Park, Rodriguez, Hulett, Darney, & Thiel de Bocanegra, 2012).
This research is novel in that it included a more comprehensive exploration of personal characteristics than those found in the literature. It included age, income, race and ethnicity, primary language, health-risk behaviors, and medical history—including sexual and reproductive history. In addition, it explored trends of the characteristics over time.
Methods
The study was designed as a retrospective chart review to identify variables that have been associated with and may have influenced contraceptive choice and use. The personal characteristics included in the data collection tool for the chart reviews were derived from the literature and from the goals of Healthy People, 2020 (U.S. DHHS, n.d.). The variables selected included personal characteristics that may be associated with unplanned pregnancies. Variables selected for this study were restricted by the availability of such in the clinic’s records. Variables such as educational level, marital status, or cohabitation were not recorded. Language preference was based on clients’ choice of English or Spanish version of the personal medical history.
The study population was drawn from one Midwestern U.S. county health department’s family planning clinic, a Title X clinic, that provides services ensuring access to a broad range of family planning and related sexual health services for low income or uninsured males and females. The clinic provides all methods of contraceptives except surgical sterilization for which the clients are referred. During the year 2009, the clinic served 1,871 unduplicated clients (clients may have had more than one visit) and in 2014, the clinic served 1,197 unduplicated clients.
The county served by the family planning clinic has a higher adolescent birth rate, lower high-school educational attainment, lower female employment rates, and higher poverty rates—especially for Hispanic and Black populations—when compared with the State’s data (Center for Social Research, 2012). These rates are all associated with unintended pregnancy, and all have worsened over the past decade in this county. Underserved, low-income adolescents and women of one Midwestern U.S. county being served by the family planning clinic were the target population for this project.
A random sample of charts from the health department’s family planning clinic were reviewed for this study for the years 2009 and 2014 to evaluate the use of LARCs and self-reported personal characteristics that may influence the choice of LARCs. Inclusion criterion were that the charts were of family planning clients, 13 to 44 years of age, female, and reflected the care received for family planning services during the calendar years 2009 or 2014. Excluded were all client charts not meeting inclusion criteria. A random sample of 134 clients for each of the two calendar years were obtained, which equals 7.2% and 11.2% of the unduplicated clients for each year, respectively. Client charts were pulled collectively by year 2009 and then year 2014 prior to data collection, so it was not possible for charts to be duplicated within the 2 years. A total sample of 240 clients was sufficient to meet the criteria established by Nunnally and Bernstein (1994), who suggest that 20 subjects for each variable are needed for statistical analysis.
Following approval of the Institutional Review Board and Health Department ethical reviewers, as well as regional and State public health authorities, the research commenced. The research team, all of whom completed ethics training for research certification, received an orientation to ensure continuity and accuracy. Inter-rater reliability between all four data extractors was assured after 100% agreement on four chart audits following orientation. An additional nine chart data collection forms were audited during the data collection period for continuation of inter-rater reliability. All data extracted were confidential. The medical record management number was only used for sample selection by the clinic support staff and was not recorded by the researchers. All data collection forms were kept at the clinic under double-locks until moved to an Excel© file which was password protected.
Results
Findings for Research Questions #1 and #2
Comparison of Categorical Variables of 2009 and 2014.
LARC = long-acting reversible contraceptive; STI = sexually transmitted infection.
Not all variables sum to 134 due to missing data. *.05 level
Figure 1 displays the significant variables between the 2 years. The individual’s self-described health behavior risks of smoking, drinking alcohol, and using illegal drugs were not significantly different. Having a new sexual partner within the last 3 months was significantly higher in the more recent year, χ2 (1, N = 260) = 6.34, p = .03). The number of clients who had used a LARC previously increased over time, χ2 (1, N = 267) = 4.97, p = .03. Additionally, clients who were prescribed a LARC at the current clinic visit increased to a statistically significant level χ2 (1, N = 267) = 4.09, p = .04.
Significant Differences Between Years 2009 and 2014.
Comparison of Continuous Variables 2009 and 2014.
Not all variables sum to 134 due to missing data.
Types of Contraceptives Prescribed at Visit.
Not all variables sum to 134 due to missing data. *.05 level
Findings for Research Questions #3
Association of Personal Characteristics With LARC Use.
LARC = long-acting reversible contraceptive; STI = sexually transmitted infection.
Not all variables sum to 268 due to missing data.
Due to an n of 1 in a category, the value of this statistical analysis is limited. * .05 level
Significant Characteristics of LARC Users.
Discussion
Findings from the present study indicate that in the sample population from one Midwestern county health department’s family planning clinic differed between the years 2009 and 2014 by (a) an increase in being prescribed a LARC at the current visit, (b) an increase in having a new sex partner in the last 3 months, and (c) more frequently having used a LARC in the past. In addition, findings from the present study suggest that adolescents and women are more likely to choose a LARC as their contraceptive method if they (a) identified themselves as White, Hispanic and preferred the Spanish version of the medical history form; (b) had been pregnant or a live birth in the past; (c) used a LARC previously; or (d) had a history of a teen pregnancy. Findings of the present study are consistent with findings from previous studies that evaluated personal characteristics separately.
The overall LARC prescription rate of 19% across the 2 years of 2009 and 2014 (14.5% and 23.8%, respectively) is impressively higher than the 7.2% of the United States reported trend of LARC use from 2011 to 2013 (Romero et al., 2015). Very importantly, LARC use by teens in our study was 18%, which is much higher than the 7.1% reported for the LARC prescription rate for that population in Title X clinics (Region V: Adolescent Health Network, 2016) and the 4.3% among contracepting U.S. females, ages 15 to 19 (Kavanaugh, Jerman, & Finer, 2015). The positive trend in LARC use rate between the 5-year interval as noted in this study has been identified similarly in national data (Branum & Jones, 2015; Finer, Jerman, & Kavanaugh, 2012; Kavanaugh et al., 2015). However, the findings of this study indicate that our rate of LARC use (14.5%) in 2009 was impressively higher than the rate identified nationally (8.5%) at that time (Finer et al., 2012). The most recent available data from 2011 to 2013 indicate our rates continue to be higher than the national average (Berenson et al., 2015; Branum & Jones, 2015; Kavanaugh et al., 2015).
Having a new sexual partner within the last 3 months was significantly higher in 2014, when compared with 2009. The access to the Affordable Care Act (ACA)-sponsored medical insurance is postulated as the reason that allows some of the women who are concerned about their sexual health after initiation with a new sexual partner to seek birth control services. Other social reasons for the increase in reporting new sexual partners need to be investigated.
Clients who had used a LARC in the past increased over the two comparison years of our study. In addition, those who were prescribed a LARC with the current visit were significantly increased over the years. The trend of increased choice and use of LARCs is in keeping with the national data (Branum & Jones, 2015; Finer et al., 2012). The trend is also in keeping with recommendations to provide the safest, effective, and acceptable birth control to all women, with a concentration on high-risk women to use LARCs (ACOG, 2012; Daniels et al., 2014; U.S. DHHS, n.d.).
There was significant relationship between the ethnic characteristic of Hispanic heritage and LARC use. This is an important finding because this population has high rates of unintended pregnancies. It has been identified elsewhere that there is less awareness in Hispanic populations regarding LARCs, and it has been proposed that reaching these high-risk populations require effective educational approaches (Lopez, Stockton, Chen, Steiner, & Gallo, 2014). Once LARC use has begun, there is similar high satisfaction and continuation rates between Hispanic, Black and White, non-Hispanic females (Wereth et al., 2015). According to Branum and Jones (2015), LARC use increased from 2006–2010 to 2011–2013 among Hispanics by 129%, non-Hispanic, White women by 128%, and non-Hispanic, Black women by 30%. Although the use of LARCs by minorities in the present study is encouraging, more progress still needs to be made.
There was no significant difference between the 2 years regarding the poverty level of the clients. Poverty (income at or below the U.S. Federal poverty level) is associated with unplanned pregnancies and was 112 per 1,000 women aged 15 to 44 in 2011 (Finer & Zolna, 2016). The clinic serves a low-income population, so this finding was anticipated. However, the study also identified that a majority of the clients had no physician or regular health-care provider. This was unexpected as the ACA has been in effect since 2012. Therefore, those clients for whom the ACA applies who were in need of health-care insurance for health needs beyond family planning were able to apply for and be provided with a medical provider at the time of seeking contraception. It is uncertain why some of these clients were not availing themselves of this medical care provided by the ACA. Further, exploration is indicated.
Findings from this study indicate that 30% of the adolescents (age 15–19 years) experienced an adolescent pregnancy. The adolescent pregnancy rate was higher than the 18% of adolescents enrolled in the CHOICE birth control study (Secura et al., 2014) and the 13% in a study of adolescent risk behaviors (Cavazos-Rehg et al., 2010). The adolescent pregnancy rate found in this study is higher than the national average of 23.7% (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2015). In 2015, the CDC surveyed adolescents in grades 9 to 12, and over 48% of the females did not use condoms at the last time of sexual intercourse and over 66% did not use any other contraceptive method (Kann et al., 2015). The use of LARCs was only 4.5% among females in the same sample. The high percentage of adolescent pregnancies in this study emphasizes the need for contraceptives education, counseling, and access for this high-risk age-group.
Adolescents and women who have had a previous pregnancy or a live birth were more likely to use a LARC. According to the National Center of Health Statistics, parous women increased LARC use by nearly 70% from 2006–2010 to 2011–2013 to 10.6% (Branum & Jones, 2015). In the same report, the rate of LARC use was three times greater among parous (11.0%) than nulliparous women (2.8%) during 2011 to 2013. Increased use of LARCs may be affected positively by educational programs such as the “LARC Program” initiated by ACOG “to reduce unintended pregnancy in the US by providing information and resources on LARC methods and increasing access to the full range of contraceptive options” (ACOG, 2016).
Previous LARC users were shown to be more frequent current users of LARCs in this study. Once a client has used a LARC, she is more likely to use it again. The finding of this relationship is partly due to the continuation rate of 3 to 10 years for these methods, but also due to studies that demonstrate overall acceptability of these methods (Wereth et al., 2015). The choice of a LARC has been shown to be related to age, cultural, and educational considerations, as well as with the education offered (Berenson et al., 2015; Dehlendorf et al., 2014; Jacobs & Stanfors, 2013; Peipert et al., 2011; Sridhar et al., 2015). Early education of these methods that manages to successfully begin LARC use early in a females’ reproductive years is key to addressing the unintended pregnancy rates.
Clients in this study with a history of teen pregnancy between the 2 years of 2009 and 2014 were more likely (25%, 17%, respectively) than their peers to use LARCs. Limited research is available for comparison. In another study, 26% of adolescents chose a LARC within 8 weeks of childbirth (Berenson et al., 2015). The population of that study included postpartum teens for whom usual care would have included several discussions of and encouragement of reliable contraception as outlined by ACOG (Bromley & Garancher, 2014). The main emphasis for adolescent education is prevention of unwanted pregnancies through the use of LARCs. In addition to ACOG, the CDC has endorsed the use of LARCs for women less than 20 years of age (CDC, 2010). The American Academy of Pediatrics moved one step further with its recommendation of LARCs as the first line contraceptive option for teens (2014).
Limitations
Due to the nature of a retrospective chart audit, we were not able to obtain data on all risk factors for unintended pregnancy, such as educational attainment, coercion, and living arrangements. Also, the answers are based on self-report which may demonstrate some bias on sensitive questions such as alcohol use and number of sexual partners in the past 3 months.
Conclusion
Although the percentage of women prescribed LARCs in the current study was higher than the national average, the percentage needs to be increased to further prevent unintended pregnancies. Birth control pills are most commonly used contraceptives, but they have high failure and discontinuation rates. We can, and must, do better.
It was significant to find that those who have been a user of a LARC in the past would continue its use. It is also significant that clients were more likely to use LARCs if they had experienced a pregnancy or had a live birth in the past. These findings indicate the importance of educating clients on LARC options. A client’s satisfaction with a LARC method may lead to continued choice and use of one.
To foster initial use of a LARC, an application has been developed that provides tailored choices and education on contraceptive methods including LARCs (Carlson, Plonczynski, & Vitucci, 2016). This method of education augments usual care education by nurses, and the methodology has been shown to be favored by women seeking contraceptive services (Sridhar et al., 2015). To meet the need of the percentage of females speaking Spanish, further app development will include a Spanish version in order to provide accessible, confidential, and reliable information to this high-risk population.
The results of this study will advance the limited knowledge of personal characteristics influencing contraceptive choices. Findings from the study will be used at the family planning clinic to enhance client care by actively involving clients in identifying contraceptive methods that are tailored to the client’s preferences, risk factors, and needs. This tailored choice of contraceptives, including knowledge and access to LARC, is anticipated to reduce the unintended pregnancy rate.
Footnotes
Acknowledgments
The authors wish to thank Deb Hall, BSN, RN, Family Planning Program Coordinator, and the DeKalb County Health Department staff for their support and assistance in the conduction of this research. They recognize the detailed contribution of Isabel Contraras, RN and Lexie Williams, RN who worked on data collection as undergraduate research assistants.
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: We gratefully recognize the funders of this research: TriCounty Community Foundation grant; Sigma Theta Tau, Beta Omega Chapter; and College of Health and Human Sciences, Northern Illinois University (NIU). We are also most appreciative of the contributors toward research: DeKalb County Health Department; Isabel Contreras, Nursing Student, NIU; and Lydia Moore, Nursing Student, NIU.