Clinical Review

Battle of the Contraceptives

Which are the best at pregnancy prevention? Here is the data on the number of unintended pregnancies in women ages 14 to 45 taking short- and long-term contraceptives.

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Because half of US pregnancies continue to be unintended, rates of induced abortion in our patients remain high. In addition, unintended pregnancies lead to negative health and social consequences for women and infants. A report from the Contraceptive Choice Project, spearheaded by Dr. Jeffrey Peipert from the Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, and published in New England Journal of Medicine, underscores the high efficacy of long-acting reversible contraceptives, a term referring to intrauterine devices (IUDs) and the contraceptive implant, in preventing unintended pregnancy in a US population.

Details of the study
Eligibility criteria for the Project included age 14 to 45, residence in the St. Louis, Missouri, area, and the need for contraception. The woman’s contraceptive of choice was made available at no charge, with most women choosing a long-acting method. The published study includes outcomes for 
7,486 women who used oral contraceptives (OCs), the patch, the ring, an IUD, an implant, or depot medroxyprogesterone acetate (DMPA) injections.

Among women using OCs, the patch, or the ring, the pregnancy rate was 4.55 per 100 participant-years. This rate was nearly 22-fold higher than that observed in women using IUDs or the implant (hazard ratio, 21.8): that rate was 0.27 per 100 participant-years. A similar low rate of pregnancy was noted among women who chose DMPA and returned every three months for follow-up injections.

Among women younger than 21 who used OCs, the patch, or the ring, the rate of unintended pregnancy was twice as high as in older women using these same methods. By contrast, regardless of age, pregnancy rates were uniformly low among women using long-acting methods.

Study limitations
The authors point out that their study design was not randomized—participants were at high risk for unintended pregnancy and willing to begin using a new contraceptive method, which could have resulted in higher adherence rates and lower failure rates.

Access is ongoing 
barrier to use
These important data from the Contraceptive Choice Project clarify that long-acting reversible contraceptives represent powerful tools to help women minimize unintended pregnancy and induced abortion, and that women will choose these methods if they are accessible.

The findings in this report also make it clear that rates of unintended pregnancy are particularly high among adolescents using shorter-acting hor monal contraceptives (OCs, patch, or ring) and that longer-acting contraceptives are particularly useful in our younger patients. Other recent reports have provided clear evidence that immediately providing long-acting contraceptives after childbirth or induced abortion reduces unintended pregnancy in these settings.1,2

In the US, inadequate access to long-acting reversible contraceptives continues to constrain use. Accordingly, insurance pol icies that fully cover longer-acting contraceptives could go a long way toward reducing the rate of unintended pregnancies and induced abortions in our patients.

If long-acting reversible contraceptives become more widely available in the US, I look forward to a time when the great majority of our patients’ pregnancies are planned and when far fewer women will face the troubling prospect of an induced abortion.

1. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol. 2012;206(6):481.e1–e7.

2. Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen JT; Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med. 2011;364(23):2208–2217.

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