July 1, 2010 — Summary of "The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception," Secura et al., American Journal of Obstetrics and Gynecology, June 2010.
Of the roughly three million women who experience unintended pregnancies in the U.S. every year, about half report using contraception in the month when conception occurred. Most of these pregnancies occur after incorrect or inconsistent contraception use, rather than method failure, because most women use a contraceptive method with adherence requirements.
Long-acting reversible contraception (LARC) methods -- implants and intrauterine devices -- are used by fewer than 3% of U.S. women, despite having higher levels of safety, efficacy and cost-effectiveness than shorter-acting methods. The low rates of LARC use result from several factors, including high up-front costs, women's knowledge of and attitudes toward LARC, and practice patterns among providers.
Gina Secura of Washington University in St. Louis' Department of Obstetrics and Gynecology and colleagues analyzed the contraceptive choices and baseline characteristics of the first 2,500 women enrolled in the St. Louis-based Contraceptive CHOICE Project. The project aims to reduce unintended pregnancies by removing two known barriers to LARC use -- financial obstacles and lack of patient awareness of safety and efficacy.
Women were eligible if they were ages 14 through 45, had been sexually active with a male partner in the past six months or expected to be sexually active in the next six months; did not want to become pregnant in the next year; had not had a tubal ligation or hysterectomy; and were not using contraception or wanted to change methods. Participants were recruited at university-affiliated clinics, community health centers and two local abortion clinics. All participants received pregnancy and sexually transmitted infection testing and any related counseling and treatment.
Trained staff offered potential participants scripted information about LARC and a chance to enroll in the CHOICE project, which would provide them with no-cost contraception for three years. Women could choose a LARC method -- including levonorgestrel intrauterine contraception (LNG-IUC), copper intrauterine contraception (copper IUC) or subdermal implant -- or another type of reversible method -- including oral contraceptives, vaginal rings, transdermal patch, depo-medroxyprogesterone acetate injections or condoms. Researchers conducted follow-up interviews by phone after three months and again every six months until 36 months.
More than two-thirds of the participants chose LARC, with 47% selecting the levonorgestrel IUC, 9% choosing the copper IUC and 11% opting for the implant. Among the other LARC options, 6% of participants chose the DMPA injection, while 27% chose combined hormonal methods, including oral contraceptives (12%), transdermal patches (3%) and vaginal rings (12%).
LARC users were more likely to be recruited at an abortion clinic than other sites, and they were more likely a history of abortion compared with non-LARC users. Women were less likely to choose LARC if they described their race as black or other, were not married, or had had no more than one sexual partner.
About 63% of participants were ages 25 and younger. Forty-two percent of participants reported no insurance, and more than half were receiving public assistance or had difficulty paying for necessities. Forty-four percent of the participants were black, and 49% were white.
The large percentage of women who chose LARC "is evidence of a greater than expected interest in the use of the most effective, reversible methods of contraception to prevent pregnancy," the researchers write, adding that CHOICE "demonstrates the potential for much greater use of LARC methods that are 'forgettable' and therefore effectiveness is not dependent on patient adherence." The researchers attributed the high acceptance rate of LARC to the brief standardized script that explained LARC to all women, the absence of financial obstacles, and the fact that the devices were available to all eligible women, including young women, women who have not had children and women who have had an STI.
The findings "suggest that there is not a particular type of woman who selects LARC; rather, LARC methods are acceptable and wanted by a diverse group of women who are considering a new method of contraception." By removing the financial barriers and "addressing misperceptions" associated with LARC, the methods can be introduced "as a first-line contraceptive option," the study states, adding, "Widespread use of LARC may dramatically reduce unintended pregnancy while reducing long-term costs associated with contraception."