Significant public health disparities exist surrounding teen and unplanned pregnancy in the United States. Women of color and those with lower education and socioeconomic status are at much greater risk of unplanned pregnancy and the resulting adverse outcomes. Unplanned pregnancies reduce educational and career opportunities and may contribute to socioeconomic deprivation and widening income disparities. Long-acting reversible contraception (LARC), including intrauterine devices and implants, offer the opportunity to change the default from drifting into parenthood to planned conception. LARC methods are forgettable; once placed, they offer highly effective, long-term pregnancy prevention. Increasing evidence in the medical literature demonstrates the population benefits of use of these methods. However, barriers to more widespread use of LARC methods persist and include educational, access, and cost barriers. With increasing insurance coverage under the Affordable Care Act and more widespread, no-cost coverage of methods, more and more women are choosing intrauterine devices and the contraceptive implant. Increasing the use of highly effective contraceptive methods may provide one solution to the persistent problem of the health disparities of unplanned and teen pregnancies in the United States and improve women’s and children’s health.
Unintended pregnancy and teen pregnancy continue to be significant public health challenges in the United States, and are listed among the priorities of Healthy People 2020. Approximately half of all pregnancies in the United States are unintended, and approximately half of those end in abortion, resulting in 1.2 million abortions per year. The risk of experiencing a pregnancy before age 20 years has fallen from 4 in 10 in the 1990s to the current rate of 3 in 10, but continues to be high relative to other developed countries.
There is significant disparity in the rates of teen and unintended pregnancy by race/ethnicity, education, and income level. Figure 1 displays changes in teen birth rates over the past 2 decades, stratified by race/ethnicity. Black and Latina teenagers are more than twice as likely as white teenagers to experience a pregnancy, with half of black and Latina teens becoming pregnant before age 20. Half of teen mothers do not receive a high school diploma by age 22, perpetuating a cycle of lower educational attainment and poverty. The unintended pregnancy rate is 5 times higher in poor women compared with their wealthier counterparts and almost 5 times higher in women with less than a high school degree compared with college graduates.
Unintended, teen, and rapid repeat pregnancies have substantial negative health and socioeconomic impacts on women and their families. These outcomes include higher rates of maternal depression, intimate partner violence, and low-birthweight infants and lower rates of breast-feeding. Long-term developmental outcomes include poorer behavioral, mental, and physical health for the children. In addition, lower educational attainment for the mothers, fathers, and their children lead to higher rates of poverty and the need for federal aid. There is evidence that unintended pregnancies and births are increasing in poorer and less educated women, a very concerning trend, given the societal costs associated with these births.
The public health cost of births resulting from unintended pregnancies in 2006 was estimated to be $11 billion in maternity and infant care alone, not accounting for the costs of abortion care, additional care required due to poorer perinatal outcomes, lost productivity, and government benefits. Contraception has been shown to be a highly cost-effective public health measure, with every $1 in public funding for family planning saving taxpayers $3.74 in pregnancy-related costs alone.
Additionally, the most effective methods of contraception, intrauterine devices (IUDs) and subdermal contraceptive implants (long-acting reversible contraceptive [LARC] methods: see Table 1 ), are among the most cost-effective methods; in one analysis, LARC methods were more cost effective than the use of short-acting methods or no method, with savings of more than $7 for each $1 spent. This benefit is seen because LARC methods are able to overcome the estimated 53% of annual costs of unintended pregnancy that are due to imperfect contraceptive adherence.
| Currently available LARC methods | Clinical points |
|---|---|
| 52 mg levonorgestrel-releasing intrauterine system | |
| 13.5 mg levonorgestrel-releasing intrauterine system | |
| Copper T380A intrauterine device | |
| Single-rod, 68 mg etonogestrel implant |
a Trussell, J. Contraceptive failure in the United States. Contraception 2011;83:397-404
c Jensen JT. Noncontraceptive applications of the levonorgestrel intrauterine system. Curr Womens Health Rep 2002;2:417-22
f Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicenter, cohort clinical trial. BJOG 2010;117:1205-20
h Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120:1298-305.
Unintended pregnancy most often occurs due to nonuse, including gaps in use, or inconsistent or incorrect use of contraception. The most commonly used reversible contraceptive methods are the oral contraceptive pill and the male condom, which have typical-use annual failure rates of 9% and 18%, respectively. Failures with pills are 2-fold greater in women younger than 21 years of age compared with older women, significantly contributing to the risk of teen pregnancy.
Significant disparities by race, income, and education also exist for the consistent use of reversible methods. Black, low-income women, women with less than a college education, and Medicaid-insured women are more likely to experience both gaps in their contraceptive use and method failures. The reasons behind these disparities are multifactorial, but point to the need for increased access to contraceptive methods that decrease or eliminate gaps and method failures.
By removing user dependency, IUDs and implants are associated with annual failure rates of 0.2–0.8% (IUDs) and 0.05% (implants). They also have high continuation rates that are unaffected by race or socioeconomic factors. The use of LARC methods is increasing across all contraceptive users, from 8.5% in 2009 to 11.6% in 2012, indicating improving acceptability. This trend is important, given that more widespread use of the most effective methods of contraception is one potential solution to reduce the rates of unintended and teen pregnancy in the United States.
Long-acting reversible contraception
IUDs and implants utilize one-time placement with long periods of efficacy; these methods are highly effective because they are not user dependent (see Table 1 ). They are forgettable and their continuous use eliminates gaps in contraceptive coverage, which are common with methods requiring frequent dosing. LARC methods are ideal for women at high risk of unintended pregnancy, such as adolescents, and all women who desire highly effective methods. In addition, they do not contain estrogen and therefore have few contraindications, making them ideal for use in women with medical conditions.
Intrauterine devices (IUDs)
There are currently several hormonal IUDs and one nonhormonal IUD available in the United States, and multiple other types are available internationally. The most commonly used hormonal IUD is the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS), which is Food and Drug Administration (FDA) approved for up to 5 years of use. A newer 52 mg LNG-IUS was recently FDA approved for up to 3 years of use and is a lower-cost alternative for organizations that qualify for 340B pricing and for uninsured women. A lower dose (13.5 mg) levonorgestrel-releasing IUD with a smaller frame is FDA approved and effective for up to 3 years. This smaller hormonal IUD was originally marketed for nulliparous women; however, the 52 mg LNG-IUS has also been shown to be safe and acceptable in this population, with high continuation rates. The Copper T380A IUD, the nonhormonal IUD, contains copper and has been shown to be effective for up to 10 years, possibly longer.
The primary mechanism of action of all IUDs is the prevention of fertilization. Levonorgestrel-containing IUDs achieve this by thickening of the cervical mucus and inhibition of sperm motility and function. The copper ions released from the copper IUD, along with products released in the inflammatory reaction it induces, are toxic to both sperm and oocytes, preventing the formation of viable embryos. All IUDs are greater than 99% effective, with 0.8% of women using the copper IUD and 0.2% of women using the LNG-IUS experiencing a pregnancy in the first year of use.
Previous concern about the risk of pelvic infection and ectopic pregnancy with IUDs has prevented more widespread use of these methods. However, multiple studies have shown that these risks are minimal. The IUD does not increase the risk of pelvic inflammatory disease (PID) beyond a small increase in risk in the first 20 days after insertion. Women with current infection with Neisseria gonorrhoeae or Chlamydia trachomatis are at slightly higher risk for pelvic infection, but routine antibiotic prophylaxis at insertion is unnecessary.
Evidence shows that risk-based screening for N gonorrhoeae and C trachomatis at the time of insertion and treatment of women found to have infection, while leaving the IUD in place, is safe and effective. Additionally, IUD use significantly lowers the risk of the ectopic pregnancy because it lowers the risk of any pregnancy. However, if a woman with an IUD does become pregnant, there is a higher chance of an ectopic location than if she were not using an IUD. Most importantly, there is evidence that use of IUDs does not increase the risk of subsequent infertility.
The main complication associated with IUD insertion is the risk of perforation. The European Active Surveillance Study on Intrauterine Devices evaluated more than 60,000 women at 1230 centers and found perforation rates of 1.4 and 1.1 per 1000 insertions for the LNG-IUS and copper IUD, respectively. Most of these were complete perforations and were removed by laparoscopy with no serious complications. The strongest risk factors for perforation were breastfeeding at the time of insertion and being less than 9 months postpartum, but even in women with both risk factors, perforation was rare.
Subdermal contraceptive implants
Various types of progestin-based subdermal contraceptive implants have been available for almost 50 years. There are several types available globally, but currently only the single-rod, etonogestrel-releasing implant is available in the United States. It is inserted in a subdermal location in the inside of the upper arm and is effective for up to 3 years. The current version of this implant includes a simpler insertion device to prevent deep insertion and barium to allow for radiographic visualization. The prevention of pregnancy occurs by thickening of the cervical mucus and suppression of ovulation. It is more than 99% effective, with 0.05% of women experiencing a pregnancy within the first year of use. The insertion and removal process requires a company-sponsored training program. The average insertion and removal times are less than 1 and 4 minutes, respectively, and complications associated with insertion and removal have been shown to be 1% and 1.7%, respectively, and are expected to be lower with the redesigned inserter.
The main side effect related to all LARC methods is the complaint of bleeding abnormalities. In 1 analysis of 12-month contraceptive continuation and satisfaction, 14% of copper IUD users and 5% of LNG-IUS users discontinued use because of bleeding and/or cramping. Similarly, 10% of implant users discontinued the method because of unpredictable bleeding. However, overall continuation rates for LARC methods were still much higher than for non-LARC methods. There is also some evidence that women who are counseled about possible side effects, including irregular bleeding and amenorrhea, are more satisfied with and more likely to continue their method.
Barriers to LARC use
The American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have specifically recommended that the use of LARC methods be expanded. The reason for the low uptake of the more effective LARC methods is complex and includes patient-, provider-, and systems-level barriers. There are data to suggest that women have a low knowledge of IUDs, and there is a persistent stigma related to the history of IUDs, including the increased risk of infection associated with the Dalkon Shield. Many providers do not offer LARC methods to all women or offer them only under highly restrictive conditions to a small subset of eligible women, contrary to the evidence-based recommendations by the Centers for Disease Control and Prevention and many other national and international organizations.
There is a common misconception that IUDs are unsafe or contraindicated in adolescents, nulliparous women, women who are not married or who have multiple sexual partners, and women who have had a sexually transmitted infection (STI) or ectopic pregnancy. There is also some evidence that providers are less likely to recommend IUDs to women of lower socioeconomic status. The reasons behind this are unclear but may include a perceived increased risk of STI in women of low socioeconomic status.
These myths have limited the use of IUDs in those women at high risk for unintended pregnancy. In fact, there are very few contraindications to the use of IUDs and subdermal implants, and they are the safest options for women in whom estrogen-based contraception is contraindicated because of medical conditions that increase the risk of venous thromboembolism or stroke. In addition, there is evidence that the discontinuation of these methods is not higher in young or nulliparous women. See Table 2 for a review of the evidence related to many of the patient and provider misconceptions about IUDs.
| Patient and provider misconceptions | Evidence |
|---|---|
| IUDs cause STIs/PID | The increased risk of PID is within the first 20 days after insertion. Infection with Neisseria gonorrhoeae or Chlamydia trachomatis infection at the time of IUD placement increases the risk. After the periinsertional period, there is no increased risk of infection compared with women without an IUD. |
| IUDs cause infertility | IUD users do not appear to have an increased risk of tubal infertility. The risk of tubal-factor infertility is instead caused by upper genital tract infection. |
| IUDs are abortifacients | The primary mechanism of action of all IUDs is the prevention of fertilization. This is achieved with the LNG-IUS by thickening of the cervical mucus and inhibition of sperm motility and function. The copper IUD causes damage to sperm and oocytes, thereby preventing the formation of viable embryos. |
| IUDs increase the risk for ectopic pregnancy | IUD use significantly lowers the risk of the ectopic pregnancy because it lowers the risk of pregnancy. However, if a woman with an IUD does become pregnant, there is a higher chance of an ectopic location than if she were not using an IUD, but the absolute risk is still very low. |
| IUDs are not recommended for nulliparous women | No studies have shown increased risks associated with IUD insertion in nulliparous women. Some studies have found decreased rates of expulsion. |
| IUDs are not recommended for young women | Women younger than 20 years old have similar IUD satisfaction and continuation rates (> 80% at 12 mo) as older women. |
| IUD insertion is difficult | Available evidence from primary care settings and with advanced practice clinicians shows that successful insertion occurs in over 95% of first attempts, including in adolescents and nulliparous women. |
| IUD expulsion is common | Expulsion rates are between 2% and 10%. Risk factors for expulsion are obesity, heavy periods, and immediate postpartum or postabortion insertion. |
| Many women request early removal of IUDs because of side effects | IUD users have the highest satisfaction and continuation rates compared with users of other methods. At 12 months, more than 80% of IUD users are still using the method, compared with 57% of DMPA users and 49–55% of pill, patch, or ring users. |
| IUD insertion is painful | The largest study available used a scale of 0 (no pain) to 10 (severe pain) and showed that 48% of women rated IUD insertion as less than 1, 15% rated it 1–2, 11% rated it ≥ 5, and 4% rated it ≥ 7. Older age, nulliparity, non–breast-feeding status, and > 3 months since last delivery were related to greater pain rating. Some lidocaine formulations, naproxen, and tramadol have been found to be moderately effective in preventing pain. |
| You need to have testing done before getting an IUD | The only requirements prior to placing an IUD is to have a normal gynecological examination and that the provider be reasonably sure a woman is not currently pregnant. The copper IUD can also be used for emergency contraception. |
| Your partner will feel the IUD | When IUD strings are cut long enough, they become soft and curl up. If they are cut too short, they may stick out of the cervix and be felt as sharp by a woman’s partner. |
Despite the fact that postpartum women using injectables, pills, the patch, or the ring have been shown to have a 20-30 times higher risk of a rapid repeat pregnancy compared with women using LARC, only 6% of women use a LARC method at 3 months postpartum. Immediate postpartum and postabortal IUD insertion has been shown to be safe and effective, with acceptable expulsion rates and good continuation rates, and the postpartum time period is often ideal for initiation of LARC methods. Similarly, immediate postpartum implants have been shown to be safe and acceptable and to decrease the risk of rapid repeat pregnancy in adolescents, a population at particularly high risk for rapid repeat pregnancy.
Another barrier at the provider and clinic level can be the requirement of a second visit for insertion. Same-day insertion protocols have been shown to lessen patient burden and cost, improve the uptake of the LARC, and prevent unintended pregnancies. Clinics and providers should optimize their practices to make same-day insertion possible for most women, including stocking the devices in-office and using checklists to be reasonably sure a patient is not pregnant (see Table 3 ). The criteria in this checklist has been found to have a 99-100% negative predictive value for ruling out a pregnancy. By using this checklist, providers can initiate same-day contraception without routine pregnancy testing or requiring a second visit.
