EDITORIAL
All Contraceptives Are Not Created Equal Nisha Fahey, BA
n the United States, about 3 million or 50% of all pregnancies annually are unplanned.1 Contraceptives are estimated to save $19 billion annually in direct medical costs through the prevention of unintended pregnancies.2 In an effort to increase contraception use and reduce the incidence of unplanned pregnancy, the Affordable Care Act (ACA) mandates that private insurance remove patient cost-sharing for contraception. To understand the potential impact of the ACA mandate, a recent study published in this journal demonstrated 64% higher odds of consistent contraception use among women in states that already have comprehensive insurance mandates to remove the cost to the patient.3 This is important because inconsistent and incorrect use of contraception are 2 factors that significantly contribute to the high rates of unplanned pregnancies.4 Increasing consistent use of contraception will contribute to a reduction in unplanned pregnancies, but correct use is still a relevant factor given that the most commonly used forms of contraception are user-dependent.5 To put it simply, “All contraceptives are not created equal.” The American College of Obstetricians and Gynecologists (ACOG) recommends long-acting reversible contraceptives (LARC) as first-line contraceptive choices.6 However, user-dependent, short-acting reversible contraceptives, such as hormone pill, patch, and vaginal ring, are used by 34.2% of women who practice contraception, whereas only 8.5% use LARC, which include intrauterine devices (IUDs) and implants.7,8 LARC removes user-dependency, leading to near identical “perfect use” and “typical use,” and therefore is significantly more effective than short-acting reversible contraceptives.9,10 Although the initiation cost of LARC is often higher than that of other contraceptives, cost-effectiveness analysis of all contraceptive methods available in the United States found the copper T-IUD to be the least costly ($647) and among the most effective over a 5-year period. The most popular form of contraception, oral contraceptive pills, had the third highest cost ($3381) and fared better than only the patch ($3458) and no-contraception use at all ($4739).2 In this issue of Medical Care, Pace and colleagues evaluated the hypothesis that the cost to patients associated with IUD is a barrier to utilization. The study analyzed contraception utilization data of 1,682,425 women obtaining oral contraceptive pills or IUDs through employee-sponsored insurance. The authors found that women enrolled in insurance programs with low cost-sharing for IUDs (average cost = $3.26) were 35% more likely to initiate IUDs than those in high cost-sharing programs (average cost = $161.56).11 Although these findings confirm that cost is a barrier, the low percentage of utilization—4.4% in high cost-sharing plans and 6.7% in low cost-sharing plans— indicates that other factors significantly contribute as well.11 Barriers that exist at the intersection of the clinician and the patient contribute significantly to drastically low use of the most cost-effective forms of contraception. Patient awareness and knowledge about contraception often comes from family, friends, and media.12 A lack of family and friends who use and advocate LARC might further perpetuate low utilization. In addition, the media markets IUDs to women with children and overemphasizes the risks.13 Furthermore, the history of IUDs in this country
I
From the College of Osteopathic Medicine, Des Moines University, Des Moines, IA. The author declares no conflict of interest. Reprints: Nisha Fahey, BA, College of Osteopathic Medicine, Des Moines University, 3200 Grand Avenue, Des Moines, Iowa 50312. E-mail: nisha.m. [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins ISSN: 0025-7079/13/5111-0957
Medical Care
Volume 51, Number 11, November 2013
www.lww-medicalcare.com |
957
Fahey
is tainted by one of the initial brands on the market in the 1960s that ultimately was removed due to safety concerns. The lasting effect of those cases prolongs the perception that IUDs are not safe, cannot be used by nulliparous women, and could lead to infertility.14 Since then, the safety of IUDs has improved drastically. Ample evidence shows no increased risk for pelvic inflammatory disease, infertility, or sexually transmitted infections.15 In addition to the historical background of IUDs, residency training also influences LARC provision. A survey of 430 US physicians found that 88% of obstetrics/gynecology and family medicine–trained physicians provided some form of LARC, in contrast to only 26% of internal medicine and pediatric physicians.16 Pace et al11 reported that women who had seen an OB/Gyn in the past year were more than twice as likely to have initiated IUD use. The financial stability of a health care practice plays a role as well. The high upfront cost to clinicians makes it challenging to adequately stock LARC in a cost-effective manner, especially if demand is low.9,17 Furthermore, health care providers often cite patient preference as the reason for not providing IUDs.18 Thus, patient and clinician perceptions and interactions result in a self-perpetuating cycle leading to underutilization of LARC. Adolescents are a particularly vulnerable population with 40% of all unintended pregnancies in the United States falling within this age group.1 Although short-acting contraceptives are twice as likely to fail when used by women under 20, only 4.5% use LARC.8,10 Despite explicit recommendations from ACOG that LARC is a first-line option for nulliparous and adolescent female patients, 16% of physicians view IUDs as unsafe for nulliparous women and 80% rarely or never give IUDs to this patient group.18,19 Unsurprisingly, most adolescents view IUDs as an inappropriate contraceptive method for their age group and have limited knowledge of LARC overall.13 In addition, the cost-sharing of LARC methods often makes these options prohibitive for adolescents. The Contraceptive CHOICE Project demonstrated the effectiveness of cost elimination coupled with patient education to increase LARC use. Specifically among adolescents, 69% chose LARC resulting in an 80% decrease in births.9,20 As a 24-year-old female medical student, my experience with reproductive health care ranges from the perspective of a patient to that of a health care provider. My first true exposure to high LARC use occurred while shadowing in a rural clinic in India as an undergraduate. At the time, I was surprised to see many women select an IUD as their form of contraception. A couple of years later in medical school was the first time I learned about all forms of contraception and the drastically higher efficacy of LARC compared with the more commonly used forms. I realized that in India I had observed providers counseling patients on first-line contraceptives in a setting where the government supported that same goal financially. Policy supporting the use of LARC through elimination of cost-sharing for contraception is an essential, yet incomplete, approach to preventing unplanned pregnancy.
958 | www.lww-medicalcare.com
Medical Care
Volume 51, Number 11, November 2013
As practitioners who strive to provide equal care to all patients, it is necessary to recognize that all contraceptives are not equal. The medical community must accomplish what policy alone cannot: educate patients and deliver first-line care so that women of all reproductive ages have access to contraception that meets their reproductive needs. REFERENCES 1. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities. Contraception. 2006;84:478–485. 2. Trussell J, Lalla AM, Doan QV, et al. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79:5–14. 3. Magnusson BM, Sabik L, Chapman DA, et al. Contraceptive insurance mandates and consistent contraceptive use among privately insured women. Med Care. 2012;50:562–568. 4. Gold RB, Sonfield A, Richards CL, et al. Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System. New York: Guttmacher Institute; 2009. 5. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat. 2010;29:1–44. 6. ACOG Practice Bulletin No. 121. Long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2011;118:184–196. 7. Jones J, Mosher WD, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics Reports. 2012;60. 8. Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril. 2012;98:893–897. 9. Secura GM, McNicholas C. Long-acting reversible contraceptive use among teens prevents unintended pregnancy: a look at the evidence. Obstet Gynecol. 2013;8:297–299. 10. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366:1998–2007. 11. Pace LE, Dusetzina SB, Fendrick AM, et al. The impact of out-ofpocket costs on use of intrauterine contraception among women with employer-sponsored insurance. Med Care. 2013;51:959–963. 12. Kaye K, Suellentrop K, Sloup C. The Fog Zone: How Misperceptions, Magical Thinking, and Ambivalence Put Young Adults at Risk for Unplanned Pregnancy. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy; 2009. 13. Teal SB, Romer SE. Awareness of long-acting reversible contraception among teens and young adults. J Adolesc Health. 2013;52(suppl. 4): S35–S39. 14. Sonfield A. Popularity Disparity: Attitudes About the IUD in Europe and the United States. Guttmacher Institute: Home Page. Available at: http://www.guttmacher.org/pubs/gpr/10/4/gpr100419.html. Accessed September 23, 2013). 15. Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). J Adolesc Health. 2013;52(suppl. 4): S14–S21. 16. Greenberg KB, Makino KK, Coles MS. Factors associated with provision of long-acting reversible contraception among adolescent health care providers. J Adolesc Health. 2013;52:372–374. 17. Kavanaugh ML, Jerman J, Ethier K, et al. Meeting the contraceptive needs of teens and young adults: youth-friendly and long-acting reversible contraceptive services in US family planning facilities. J Adolesc Health. 2013;52:284–292. 18. Tyler CP, Whiteman MK, Zapata LB, et al. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol. 2012;119:762–771. 19. American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. Obstet Gynecol. 2012;120:983–988. 20. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120:1291–1297.
r
2013 Lippincott Williams & Wilkins
All Contraceptives Are Not Created Equal Nisha Fahey, BA
n the United States, about 3 million or 50% of all pregnancies annually are unplanned.1 Contraceptives are estimated to save $19 billion annually in direct medical costs through the prevention of unintended pregnancies.2 In an effort to increase contraception use and reduce the incidence of unplanned pregnancy, the Affordable Care Act (ACA) mandates that private insurance remove patient cost-sharing for contraception. To understand the potential impact of the ACA mandate, a recent study published in this journal demonstrated 64% higher odds of consistent contraception use among women in states that already have comprehensive insurance mandates to remove the cost to the patient.3 This is important because inconsistent and incorrect use of contraception are 2 factors that significantly contribute to the high rates of unplanned pregnancies.4 Increasing consistent use of contraception will contribute to a reduction in unplanned pregnancies, but correct use is still a relevant factor given that the most commonly used forms of contraception are user-dependent.5 To put it simply, “All contraceptives are not created equal.” The American College of Obstetricians and Gynecologists (ACOG) recommends long-acting reversible contraceptives (LARC) as first-line contraceptive choices.6 However, user-dependent, short-acting reversible contraceptives, such as hormone pill, patch, and vaginal ring, are used by 34.2% of women who practice contraception, whereas only 8.5% use LARC, which include intrauterine devices (IUDs) and implants.7,8 LARC removes user-dependency, leading to near identical “perfect use” and “typical use,” and therefore is significantly more effective than short-acting reversible contraceptives.9,10 Although the initiation cost of LARC is often higher than that of other contraceptives, cost-effectiveness analysis of all contraceptive methods available in the United States found the copper T-IUD to be the least costly ($647) and among the most effective over a 5-year period. The most popular form of contraception, oral contraceptive pills, had the third highest cost ($3381) and fared better than only the patch ($3458) and no-contraception use at all ($4739).2 In this issue of Medical Care, Pace and colleagues evaluated the hypothesis that the cost to patients associated with IUD is a barrier to utilization. The study analyzed contraception utilization data of 1,682,425 women obtaining oral contraceptive pills or IUDs through employee-sponsored insurance. The authors found that women enrolled in insurance programs with low cost-sharing for IUDs (average cost = $3.26) were 35% more likely to initiate IUDs than those in high cost-sharing programs (average cost = $161.56).11 Although these findings confirm that cost is a barrier, the low percentage of utilization—4.4% in high cost-sharing plans and 6.7% in low cost-sharing plans— indicates that other factors significantly contribute as well.11 Barriers that exist at the intersection of the clinician and the patient contribute significantly to drastically low use of the most cost-effective forms of contraception. Patient awareness and knowledge about contraception often comes from family, friends, and media.12 A lack of family and friends who use and advocate LARC might further perpetuate low utilization. In addition, the media markets IUDs to women with children and overemphasizes the risks.13 Furthermore, the history of IUDs in this country
I
From the College of Osteopathic Medicine, Des Moines University, Des Moines, IA. The author declares no conflict of interest. Reprints: Nisha Fahey, BA, College of Osteopathic Medicine, Des Moines University, 3200 Grand Avenue, Des Moines, Iowa 50312. E-mail: nisha.m. [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins ISSN: 0025-7079/13/5111-0957
Medical Care
Volume 51, Number 11, November 2013
www.lww-medicalcare.com |
957
Fahey
is tainted by one of the initial brands on the market in the 1960s that ultimately was removed due to safety concerns. The lasting effect of those cases prolongs the perception that IUDs are not safe, cannot be used by nulliparous women, and could lead to infertility.14 Since then, the safety of IUDs has improved drastically. Ample evidence shows no increased risk for pelvic inflammatory disease, infertility, or sexually transmitted infections.15 In addition to the historical background of IUDs, residency training also influences LARC provision. A survey of 430 US physicians found that 88% of obstetrics/gynecology and family medicine–trained physicians provided some form of LARC, in contrast to only 26% of internal medicine and pediatric physicians.16 Pace et al11 reported that women who had seen an OB/Gyn in the past year were more than twice as likely to have initiated IUD use. The financial stability of a health care practice plays a role as well. The high upfront cost to clinicians makes it challenging to adequately stock LARC in a cost-effective manner, especially if demand is low.9,17 Furthermore, health care providers often cite patient preference as the reason for not providing IUDs.18 Thus, patient and clinician perceptions and interactions result in a self-perpetuating cycle leading to underutilization of LARC. Adolescents are a particularly vulnerable population with 40% of all unintended pregnancies in the United States falling within this age group.1 Although short-acting contraceptives are twice as likely to fail when used by women under 20, only 4.5% use LARC.8,10 Despite explicit recommendations from ACOG that LARC is a first-line option for nulliparous and adolescent female patients, 16% of physicians view IUDs as unsafe for nulliparous women and 80% rarely or never give IUDs to this patient group.18,19 Unsurprisingly, most adolescents view IUDs as an inappropriate contraceptive method for their age group and have limited knowledge of LARC overall.13 In addition, the cost-sharing of LARC methods often makes these options prohibitive for adolescents. The Contraceptive CHOICE Project demonstrated the effectiveness of cost elimination coupled with patient education to increase LARC use. Specifically among adolescents, 69% chose LARC resulting in an 80% decrease in births.9,20 As a 24-year-old female medical student, my experience with reproductive health care ranges from the perspective of a patient to that of a health care provider. My first true exposure to high LARC use occurred while shadowing in a rural clinic in India as an undergraduate. At the time, I was surprised to see many women select an IUD as their form of contraception. A couple of years later in medical school was the first time I learned about all forms of contraception and the drastically higher efficacy of LARC compared with the more commonly used forms. I realized that in India I had observed providers counseling patients on first-line contraceptives in a setting where the government supported that same goal financially. Policy supporting the use of LARC through elimination of cost-sharing for contraception is an essential, yet incomplete, approach to preventing unplanned pregnancy.
958 | www.lww-medicalcare.com
Medical Care
Volume 51, Number 11, November 2013
As practitioners who strive to provide equal care to all patients, it is necessary to recognize that all contraceptives are not equal. The medical community must accomplish what policy alone cannot: educate patients and deliver first-line care so that women of all reproductive ages have access to contraception that meets their reproductive needs. REFERENCES 1. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities. Contraception. 2006;84:478–485. 2. Trussell J, Lalla AM, Doan QV, et al. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79:5–14. 3. Magnusson BM, Sabik L, Chapman DA, et al. Contraceptive insurance mandates and consistent contraceptive use among privately insured women. Med Care. 2012;50:562–568. 4. Gold RB, Sonfield A, Richards CL, et al. Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System. New York: Guttmacher Institute; 2009. 5. Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat. 2010;29:1–44. 6. ACOG Practice Bulletin No. 121. Long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2011;118:184–196. 7. Jones J, Mosher WD, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics Reports. 2012;60. 8. Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril. 2012;98:893–897. 9. Secura GM, McNicholas C. Long-acting reversible contraceptive use among teens prevents unintended pregnancy: a look at the evidence. Obstet Gynecol. 2013;8:297–299. 10. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366:1998–2007. 11. Pace LE, Dusetzina SB, Fendrick AM, et al. The impact of out-ofpocket costs on use of intrauterine contraception among women with employer-sponsored insurance. Med Care. 2013;51:959–963. 12. Kaye K, Suellentrop K, Sloup C. The Fog Zone: How Misperceptions, Magical Thinking, and Ambivalence Put Young Adults at Risk for Unplanned Pregnancy. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy; 2009. 13. Teal SB, Romer SE. Awareness of long-acting reversible contraception among teens and young adults. J Adolesc Health. 2013;52(suppl. 4): S35–S39. 14. Sonfield A. Popularity Disparity: Attitudes About the IUD in Europe and the United States. Guttmacher Institute: Home Page. Available at: http://www.guttmacher.org/pubs/gpr/10/4/gpr100419.html. Accessed September 23, 2013). 15. Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). J Adolesc Health. 2013;52(suppl. 4): S14–S21. 16. Greenberg KB, Makino KK, Coles MS. Factors associated with provision of long-acting reversible contraception among adolescent health care providers. J Adolesc Health. 2013;52:372–374. 17. Kavanaugh ML, Jerman J, Ethier K, et al. Meeting the contraceptive needs of teens and young adults: youth-friendly and long-acting reversible contraceptive services in US family planning facilities. J Adolesc Health. 2013;52:284–292. 18. Tyler CP, Whiteman MK, Zapata LB, et al. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol. 2012;119:762–771. 19. American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. Obstet Gynecol. 2012;120:983–988. 20. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120:1291–1297.
r
2013 Lippincott Williams & Wilkins
