Contraceptive care best practices
These 5 practice-changing initiatives can help reduce the number of unwanted pregnancies and allow women to take more control of their reproductive health.
5. Routinely counsel about, and advance-prescribe, emergency contraception pills
Physicians should counsel and advance-prescribe emergency contraception pills (ECPs) to women, including adolescents, using less reliable contraception, as recommended by ACOG, AAP, and the CDC.14,37,38 It’s also important to provide information on the copper IUD as the most effective method of emergency contraception, with nearly 100% efficacy if placed within 5 days.39 An easy-to-read patient hand-out in English and Spanish on EC options can be found at https://beyondthepill.ucsf.edu/tools-materials.
Only 3% of respondents participating in the 2006-2010 National Survey of Family Growth received counseling about emergency contraception in the past year.40 ECPs are most effective when used within 24 hours but have some efficacy up to 5 days.37 Due to the Affordable Care Act, most insurance plans will cover ECPs if purchased with a prescription, but coverage varies by state.41 Ulipristal acetate (UPA) ECP is only available with a prescription. Advance prescriptions can alleviate financial burdens on women when they need to access ECPs quickly.
Women should wait at least 5 days before resuming or starting hormonal contraception after taking UPA-based ECP, as it may reduce the ovulation-delaying effect of the ECP.14 For IUDs, implants, and depo, which require a visit to a health care provider, physicians evaluating earlier provision should consider the risks of reduced efficacy against the many barriers to access.
UPA-based ECPs (such as ella) may be more effective for overweight and obese women than levonorgestrel-based ECPs (such as Plan B and Next Choice).14 Consider advance-prescribing UPA ECPs to women with a body mass index (BMI) >25 kg/m2.42 Such considerations are important as the prevalence of obesity in women between 2013 and 2014 was 40.4%.43
In May 2016, the FDA noted that while current data are insufficient regarding whether the effectiveness of levonorgestrel ECPs is reduced in overweight or obese women, there are no safety concerns regarding their use in this population.44 Therefore, a woman with a BMI >25 kg/m2 should use UPA ECPs if available; but if not, she can still use levonorgestrel ECPs. One study, however, has found that UPA ECPs are only as effective as a placebo when BMI is ≥35 kg/m2, at which point a copper IUD may be the only effective form of emergency contraception.45
Transitioning from customary practices to best practices
Following these practical steps, FPs can improve contraceptive care for women. However, to make a significant impact, clinicians must be willing to change customary practices that are based on tradition, routines, or outdated protocols in favor of those based on current evidence.
One good place to start the transition to best practices is to familiarize yourself with the 2016 US Medical Eligibility Criteria for Contraceptive Use26 and Selected Practice Recommendations for Contraceptive Use.14 TABLES 214,26,46,47 and 3 offer additional resources that can enhance contraceptive counseling and further promote access to contraceptive care.
The contraceptive coverage guarantee under the Affordable Care Act has allowed many women to make contraceptive choices based on personal needs and preferences rather than cost. The new contraceptive coverage exemptions issued under the Trump administration will bring cost back as the driving decision factor for women whose employers choose not to provide contraceptive coverage. Providers should be aware of the typical costs associated with the various contraceptive options offered in their practice and community.
CORRESPONDENCE
Jessica Dalby, MD, Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, 1102 South Park St, Suite 100, Madison, WI 53715; Jessica.Dalby@fammed.wisc.edu.
