Should Healthcare Professionals Be Advocating Long-Acting Reversible Contraception?

“Worldwide, approximately 20 million pregnancies are terminated by abortion every year…”

Unintended pregnancy is common. Almost one in five pregnancies ends in induced abortion [101] and in some developed countries as many as one in three children are born following pregnancies that are unplanned or mistimed [1]. Worldwide, approximately 20 million pregnancies are terminated by abortion every year – more than one million of them in the USA and over 200,000 of them in the UK [101]. Almost all of them are preventable. The majority of people have access to at least some modern methods of contraception and most of the methods, if used consistently and correctly, will prevent over 95% of pregnancies [2]. Very few unintended pregnancies occur as the result of a true failure of contraception. In the developing world most result from the failure to use any method of contraception; however, in many industrialized countries the majority result from the failure of the couple to use their chosen method correctly or consistently [101].

“Condoms and contraceptive pills rely on consistent and correct use for their effectiveness.”

The vast majority of women who have an abortion had no wish to get pregnant [1] and many undoubtedly had good intentions about using contraception. The sad truth is that many people are simply not very good at it. In a national survey of 10,683 US women having an abortion in 2000–2001, 54% claimed to be using contraception in the month of conception [3] and in a Scottish study of over 300 interviews with women having induced abortion, over 80% claimed to have done so [4]. In the US study, 28% of women said they were using condoms and 14% said they were using the pill; in Scotland, 55% claimed to have been using condoms and 20% claimed to have been using oral contraceptives when they got pregnant. Condoms and contraceptive pills rely on consistent and correct use for their effectiveness. However, poor compliance with oral contraception is common. In one US study, 47% of women reported missing one or more pills each cycle and 22% reported missing two or more [5]. In another, which used electronic diaries to record compliance, 63% of women in the first cycle of use and 74% in the second cycle missed one or more pills [6].

“…it is very easy to stop using the pill or condoms. Indeed, for many people, doing so appears to be more a matter of inertia… ”

Poor compliance and discontinuation of oral contraceptives together account for an estimated 700,000 unintended pregnancies in the USA each year [7]. Inconsistent and incorrect use is even higher with methods of contraception that rely on use with every act of intercourse, such as condoms. To make matters worse, discontinuation rates of all methods of contraception are disappointingly high, but for methods that are easy to discontinue approximately half the women who start using a method have stopped within 1 year [2]. And it is very easy to stop using the pill or condoms. Indeed, for many people, doing so appears to be more a matter of inertia than a clear decision to stop; they do not get round to getting more supplies, they forget to take their pills with them when going away on holiday, they simply don't use a condom even though they have one. By contrast, long-acting reversible methods of contraception (LARC; intrauterine devices [IUD] and systems [IUS], implants and injectables) are highly effective, depend much less – if at all – on compliance for their effectiveness and tend to be associated with lower discontinuation rates [8,102]. Based on data from US women, while typical failure rates of oral contraceptives and condoms are approximately 15% and 8%, respectively, those for the IUS are 0.1% and for contraceptive implants, 0.05% [2]. Moreover, while at the end of 1 year 47% of first time users have stopped using condoms and 32% have stopped using the pill, only 19% have had their IUS removed and only 16% their implant [2]. Very few women using LARC have an unintended pregnancy. In the two US and Scottish studies cited above [3,4], less than 1% of women having an abortion were using LARC.

“Very few women using LARC have an unintended pregnancy.”

The potential of LARC has not gone unrecognized. In a national evidence-based guideline the National Institute for Health and Clinical Excellence (NICE) in the UK concluded that “increasing the use of long-acting reversible contraception will reduce the number of unintended pregnancies” [102]. There is some evidence for this. A number of researchers in the USA have drawn attention to the influence of increased use of Depo Provera® (Pfizer Inc., NY, USA) in the drop in teenage pregnancy rates observed in the USA in recent years [9–11]. In a Californian study designed to investigate condom use, Darney and coworkers demonstrated a much lower pregnancy rate among teenage mothers using long-acting contraception to prevent another unintended pregnancy [12]. While no teenager using Norplant® (Leiras Oy, Helsinki, Finland) conceived, 33% of condom users and 30% of oral contraceptive users became pregnant while using their method during the 2 years of the study.

So yes, since unintended pregnancy is so common; since many people find it so hard to use contraception consistently and correctly; since long-acting methods take the responsibility for using contraception effectively out of their hands; and since most people who don't want to have a baby would presumably prefer to prevent pregnancy rather than have an abortion, health professionals should be advocating LARC.

Do health professionals need to advocate it? Yes, clearly they do. The use of long-acting contraception is low in most countries. In the industrialized world 16% of women aged 15–49 years who are married or in consensual union use oral contraceptives, 15% rely on male or female sterilization and 13% on condoms – only 9% use LARC [103]. In the developing world some 18% use LARC, but very high use of single methods in a few countries (the IUD in China, implants in Indonesia and injectables in South Africa) accounts for much of this, while in other countries with high rates of unintended pregnancy and of maternal mortality and morbidity use is almost nil [103]. In the UK, only 2% of women use implants and 2% the IUS [13], while in the USA in 2002 less than 1% of women used an intrauterine contraceptive [104]. However, we need to advocate LARC not only to potential users but also to potential providers. Family doctors and their practice nurses in the UK have reservations regarding the provision of LARC and it is likely that this is true of other providers in other countries [14,15]. UK health professionals are concerned about the effects of Depo Provera on bone mineral density, they lack the skills to insert intrauterine methods and they think that most women stop using Implanon® (Organon Middle East Ltd, Nicosia, Cyprus) after only a few months [14,15]. Their view of continuation rates is false, however, most providers remember the implants they have taken out rather then the ones that have stayed in.

“…since many people find it so hard to use contraception consistently and correctly; since long-acting methods take the responsibility for using contraception effectively out of their hands … health professionals should be advocating LARC.”

In a clinic-based study in Scotland, UK, continuation rates of Implanon were 89% at 6 months; 75% at 1 year; 59% at 2 years and 47% at 2 years and 9 months – much, much better than continuation rates of the contraceptive pill [16]. Recognizing the potential of LARC to prevent unintended pregnancy, the governments of both Scotland and England are actively planning campaigns (directed at both users and providers) to promote its use [105,106].

Is there any reason not to advocate LARC? There are three issues that need to be considered; cost, coercion and sexually transmitted infections (STIs). First, cost: some providers and program managers find long-acting methods expensive. In the UK, an IUD costs the National Health Service approximately £10 (US$15); an IUS £83 (US$125); Implanon £81 (US$122) and Depo Provera £24 (US$36) for 1 year, and this does not include the cost of the consultation and insertion procedure. In other countries the cost is considerably more. Nevertheless when the low failure rate of LARC and the cost of a pregnancy are taken into consideration, NICE concludes that LARC are more cost effective than either the pill or male condom, even if the method is discontinued after only 1 year [102].

Second, coercion: excessive enthusiasm for any method of contraception may risk potential users being pressured or coerced into using it [17]. Since LARC methods are long-acting, since their provision involves an ‘invasive procedure’ and, for all but Depo Provera, since they cannot be discontinued without the help of a healthcare professional, coercion really could be an issue. It probably happens sometimes, but in the UK, where healthcare is free of charge, it feels almost impossible to persuade women to accept methods of contraception about which they have reservations (and equally difficult to persuade them not to use a method about which the provider may have reservations!). This is probably not a bad thing since women who are persuaded to use a method they do not like may be much more likely to stop using it.

Third, STIs: some argue that increasing the use of LARC will decrease the use of condoms and so will put more people at risk of STIs. Of course, only couples who use condoms are also protected against STIs and, while dual protection is widely encouraged among women using the pill it is rarely used – except, one suspects, by couples who are so careful about their sexual behavior that they are highly unlikely to be at risk of STI. In the Californian study [12], teenagers using contraceptive implants were less likely than oral contraceptive or condom users to report condom use. However, the proportion of implant users self-reporting new STIs at 2-year follow-up was not significantly greater than that of oral contraceptive or condom users. The authors comment that teenagers who choose oral contraceptives and condoms do not use them consistently enough to avoid either pregnancies or STIs – and that may also be true of many adults. They also highlight that the lower rate of STIs (and perhaps pregnancy too), despite less condom use, probably reflected differences in sexual behavior among teenagers who chose to use implants. If we succeed in encouraging more people to use LARC, and if those people would otherwise have relied on condoms as their sole method of contraception, it is possible that we may see an increased rate of STIs. Personally, I doubt it, but there is certainly a need for more research on the association between use of LARC, sexual risk taking and STI acquisition.

In conclusion then, yes, health professionals should be encouraging the use of LARC. It may not be all that easy to undo some of the reservations many women appear to have regarding LARC [18], but it should certainly be worth the effort.