Research
ajog.org
GYNECOLOGY
Contraceptive continuation in Hispanic women S. Rose Werth, BA; Gina M. Secura, PhD, MPH; Hilary O. Broughton, MSW; Maria E. Jones, BA; Viani Dickey, BA; Jeffrey F. Peipert, MD, PhD OBJECTIVE: The purpose of this study was to examine the effect of
Hispanic ethnicity on the continuation and satisfaction of reversible contraceptive methods. STUDY DESIGN: We analyzed 12 months of data that were collected from 7913 participants in the Contraceptive CHOICE Project. Kaplan-Meier survival curves were used to estimate continuation, and Cox proportional hazard models were used to estimate the risk of discontinuation. RESULTS: Hispanic women were more likely to choose a long-acting
reversible contraceptive (LARC) method compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75%, respectively; P < .05). The 12-month continuation rates were higher for
LARC methods than combined hormonal methods for all race/ethnicity (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%). There was no statistical difference in discontinuation of LARC methods at 12 months. Eighty percent of LARC users reported high satisfaction levels at 12 months, regardless of race/ethnicity. CONCLUSION: Hispanic women in the Contraceptive CHOICE Project
experienced high continuation and satisfaction for LARC methods, similar to women of other ethnicities. Key words: continuation, ethnicity, long-acting reversible contraception, race
Cite this article as: Werth SR, Secura GM, Broughton HO, et al. Contraceptive continuation in Hispanic women. Am J Obstet Gynecol 2014;211:.
H
ispanics are the largest minority group in the United States and have the highest fertility and birth rates.1,2 More than one-half of the pregnancies (54%) among Hispanic women are unintended, second only to non-Hispanic black women (67%).3 Even with recent declines in teenage births, the 2012 birth rate for Latina teens 15-19 years old was 46.3 per 1000 teens, which is higher than both nonHispanic white women (20.5 per 1000 teens) and non-Hispanic black women (43.9 per 1000 teens).4 Hispanic women report lower current use of contraception and are less likely to have used contraception at first intercourse, compared with nonHispanic women.5 Among those currently using contraception, Latina women most commonly choose female sterilization followed by the oral
contraceptive pill (OCP) and male condoms, which have typical use failure rates of 9% and 18%, respectively.5,6 When compared with other races/ ethnicities, fewer Latina women use the pill compared with non-Hispanic white women; in 2008 a higher percentage of Latina women reported use of the intrauterine device (IUD) compared with non-Hispanic white and non-Hispanic black women (4.8%, 3.3%, and 2.2%, respectively).5 Previous research suggested that the high rate of unintended pregnancy among Hispanic and non-Hispanic black women has led to greater use of sterilization within these groups.7 Long-acting reversible contraception (LARC), which includes IUDs and the subdermal implant, offer an alternative to sterilization. LARC has been shown to be highly effective, safe, and cost-effective
From the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO. Received May 30, 2014; revised Aug. 3, 2014; accepted Sept. 3, 2014. Supported in part by an anonymous foundation. J.F.P. has served on advisory boards for TEVA Pharmaceuticals, Activis, Bayer Healthcare, and MicroChips and is a Nexplanon trainer for Merck. The remaining authors report no conflict of interest. Corresponding author: Jeffrey F. Peipert, MD, PhD. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.09.003
and is now recommended as first-line contraception for most women.8-13 Nationally, we have observed a significant increase in LARC use between 2007 and 2009 across all races and ethnicities: non-Hispanic black women (2.3-9.2%), non-Hispanic white women (3.48.3%), and Hispanic women (5.58.5%).14 Studies have demonstrated high levels of continuation and satisfaction with LARC methods among women, including teens and postpartum adolescents.10,15,16 However, no studies to date have reported the effect of Hispanic ethnicity on method continuation and satisfaction. In this analysis, we compared 12-month method continuation rates and satisfaction levels by race and ethnicity among women enrolled in the Contraceptive CHOICE Project (CHOICE). We hypothesize that Hispanic women will report similar or higher rates of LARC continuation and satisfaction compared with nonHispanic white and non-Hispanic black women.
M ATERIALS
AND
M ETHODS
CHOICE is a prospective cohort study of 9526 St. Louisearea women. Through convenience sampling, we recruited women 14-45 years old in university
MONTH 2014 American Journal of Obstetrics & Gynecology
1.e1
Research
ajog.org
Gynecology
and community clinics that provided contraceptive care and 2 facilities that provided abortion services. CHOICE promoted the use of LARC methods by removing the cost, education, and access barriers that often are experienced in contraceptive services. A detailed explanation of the methods of CHOICE has been published previously.17 All participants provided written informed consent, and the study was approved by the Washington University School of Medicine Human Subjects Protection Office before participant recruitment. To be eligible to participate in CHOICE, women had to meet the following inclusion criteria: 14-45 years old, sexually active with a male partner (or intent to be within the next 6 months), willing to try a new contraceptive method or not currently using contraception, not desiring pregnancy in the next 12 months, residing in or seeking clinical services at recruitment sites in the St. Louis area, and consenting in English or Spanish. To recruit a diverse participant sample that included Hispanic women, we created recruitment and study materials in English and Spanish. Research assistants who were fluent in Spanish recruited Spanish-speaking study participants and conducted follow-up surveys. At enrollment, study participants underwent standardized contraceptive counseling that presented evidence-based and accurate information about each contraceptive method in the order of method effectiveness.18 Participants chose and were provided their method at no cost for 2-3 years. Staff members administered a baseline survey to collect demographic information and a reproductive history. Participants were followed with telephone surveys at 3 months, 6 months, and every 6 months thereafter for the duration of follow-up period. Participants were paid $10 for each completed survey. Information regarding method use and satisfaction was collected at each follow-up survey. To be included in this analysis, a participant had to receive and start her baseline chosen method of
contraception within 3 months of enrollment. We defined method continuation as reporting method use at 3, 6, and 12 months without a period of nonuse of >1 month. Women were coded as having discontinued their method if they reported discontinuation or removal of their contraceptive method at 10%. We described satisfaction rates using frequencies and percentages.
To account for participants who were lost to follow up, we censored participants at their last completed survey
MONTH 2014 American Journal of Obstetrics & Gynecology
1.e3
Research
ajog.org
Gynecology
TABLE 1
Baseline characteristics by race and ethnicity (continued) Race and ethnicity Hispanic women (n [ 419)
Characteristic
Non-Hispanic black women (n [ 4129)
Non-Hispanic white women (n [ 3365)
P value < .0001
Feelings if pregnant in the next 3 months, n (%) Very upset
237 (57)
2712 (66)
2067 (62)
95 (23)
906 (22)
906 (27)
Somewhat upset Would not care
38 (9)
271 (7)
224 (7)
Somewhat pleased
28 (7)
158 (4)
119 (4)
Very pleased
18 (4)
50 (1)
32 (1)
99 (24)
1771 (43)
910 (27)
< .0001
102 (24)
2160 (52)
934 (28)
< .0001
Current sexually transmitted infection, n (%)
11 (3)
468 (12)
72 (2)
< .0001
Never used contraceptives, n (%)
22 (5)
110 (3)
60 (2)
< .0001
168 (40)
1781 (43)
1600 (48)
63 (15)
352 (9)
506 (15)
102 (24)
875 (21)
413 (12)
38 (9)
354 (9)
363 (11)
Ring
26 (6)
227 (6)
311 (9)
Depot medroxyprogesterone
18 (4)
448 (11)
119 (4)
4 (1)
92 (2)
53 (2)
History of abortion, n (%) History of sexually transmitted infection, n (%)
< .0001
Baseline chosen method, n (%) Levonorgestrel intrauterine system Copper intrauterine device Implant Oral contraceptive pills
Patch
< .0001
Long-acting reversible contraceptive vs combined hormonal methods, n (%) Long-acting reversible contraceptive methods (levonorgestrel intrauterine system, copper intrauterine device, implant)
333 (83)
3008 (82)
2519 (78)
Combined hormonal methods (pill, patch, ring)
68 (17)
673 (18)
727 (22)
Percentages may not add up to 100% because of rounding. a Data are given as mean standard deviation. Werth. Contraceptive continuation in Hispanic women. Am J Obstet Gynecol 2014.
date and used contribution time and method use data up to the last contact. Participants who discontinued because of a pregnancy or a desire to conceive were censored at the point of discontinuation. All analyses were completed using STATA software (version 11; StataCorp, College Station, TX). The a-level for all analyses was set at .05.
R ESULTS Among the 9256 women enrolled in CHOICE, 7913 women (85%) met the inclusion criteria for this analysis
(Figure 1). Hispanic women represented 5% of the total cohort, which is similar to the percentage of Hispanic persons in the St. Louis area.19 Forty-five percent of Hispanic participants were born in another country, of which 73% were born in Mexico. The baseline characteristics of the analysis sample are presented by race and ethnicity in Table 1. Hispanic women in CHOICE were more likely to be receiving public assistance, to have a high school education or less, and to desire 3 children. They were less likely to have insurance
1.e4 American Journal of Obstetrics & Gynecology MONTH 2014
and to report a history of abortion. Hispanic women were more likely to choose a LARC method, compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75% respectively; P < .05). Because we detected a significant interaction between contraceptive method and race/ethnicity, Table 2 presents continuation rates that were stratified by contraceptive method. We found no confounders in this analysis. The 12month continuation rates were higher for LARC methods than combined
ajog.org hormonal methods (OCPs, patch, ring) for all race/ethnicities (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%, respectively). We found no statistically significant difference in LARC discontinuation at 12 months by race/ethnicity (Figure 2; P ¼ .27). Hispanic and non-Hispanic white women were equally likely to continue LARC methods (hazard ratio, 0.96; 95% confidence interval, 0.69e1.34). Hispanic women who used the OCP, patch, or ring were more likely to discontinue combined hormonal methods by 12 months, compared with non-Hispanic white and non-Hispanic black women (Figure 3; P
ajog.org
GYNECOLOGY
Contraceptive continuation in Hispanic women S. Rose Werth, BA; Gina M. Secura, PhD, MPH; Hilary O. Broughton, MSW; Maria E. Jones, BA; Viani Dickey, BA; Jeffrey F. Peipert, MD, PhD OBJECTIVE: The purpose of this study was to examine the effect of
Hispanic ethnicity on the continuation and satisfaction of reversible contraceptive methods. STUDY DESIGN: We analyzed 12 months of data that were collected from 7913 participants in the Contraceptive CHOICE Project. Kaplan-Meier survival curves were used to estimate continuation, and Cox proportional hazard models were used to estimate the risk of discontinuation. RESULTS: Hispanic women were more likely to choose a long-acting
reversible contraceptive (LARC) method compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75%, respectively; P < .05). The 12-month continuation rates were higher for
LARC methods than combined hormonal methods for all race/ethnicity (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%). There was no statistical difference in discontinuation of LARC methods at 12 months. Eighty percent of LARC users reported high satisfaction levels at 12 months, regardless of race/ethnicity. CONCLUSION: Hispanic women in the Contraceptive CHOICE Project
experienced high continuation and satisfaction for LARC methods, similar to women of other ethnicities. Key words: continuation, ethnicity, long-acting reversible contraception, race
Cite this article as: Werth SR, Secura GM, Broughton HO, et al. Contraceptive continuation in Hispanic women. Am J Obstet Gynecol 2014;211:.
H
ispanics are the largest minority group in the United States and have the highest fertility and birth rates.1,2 More than one-half of the pregnancies (54%) among Hispanic women are unintended, second only to non-Hispanic black women (67%).3 Even with recent declines in teenage births, the 2012 birth rate for Latina teens 15-19 years old was 46.3 per 1000 teens, which is higher than both nonHispanic white women (20.5 per 1000 teens) and non-Hispanic black women (43.9 per 1000 teens).4 Hispanic women report lower current use of contraception and are less likely to have used contraception at first intercourse, compared with nonHispanic women.5 Among those currently using contraception, Latina women most commonly choose female sterilization followed by the oral
contraceptive pill (OCP) and male condoms, which have typical use failure rates of 9% and 18%, respectively.5,6 When compared with other races/ ethnicities, fewer Latina women use the pill compared with non-Hispanic white women; in 2008 a higher percentage of Latina women reported use of the intrauterine device (IUD) compared with non-Hispanic white and non-Hispanic black women (4.8%, 3.3%, and 2.2%, respectively).5 Previous research suggested that the high rate of unintended pregnancy among Hispanic and non-Hispanic black women has led to greater use of sterilization within these groups.7 Long-acting reversible contraception (LARC), which includes IUDs and the subdermal implant, offer an alternative to sterilization. LARC has been shown to be highly effective, safe, and cost-effective
From the Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO. Received May 30, 2014; revised Aug. 3, 2014; accepted Sept. 3, 2014. Supported in part by an anonymous foundation. J.F.P. has served on advisory boards for TEVA Pharmaceuticals, Activis, Bayer Healthcare, and MicroChips and is a Nexplanon trainer for Merck. The remaining authors report no conflict of interest. Corresponding author: Jeffrey F. Peipert, MD, PhD. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.09.003
and is now recommended as first-line contraception for most women.8-13 Nationally, we have observed a significant increase in LARC use between 2007 and 2009 across all races and ethnicities: non-Hispanic black women (2.3-9.2%), non-Hispanic white women (3.48.3%), and Hispanic women (5.58.5%).14 Studies have demonstrated high levels of continuation and satisfaction with LARC methods among women, including teens and postpartum adolescents.10,15,16 However, no studies to date have reported the effect of Hispanic ethnicity on method continuation and satisfaction. In this analysis, we compared 12-month method continuation rates and satisfaction levels by race and ethnicity among women enrolled in the Contraceptive CHOICE Project (CHOICE). We hypothesize that Hispanic women will report similar or higher rates of LARC continuation and satisfaction compared with nonHispanic white and non-Hispanic black women.
M ATERIALS
AND
M ETHODS
CHOICE is a prospective cohort study of 9526 St. Louisearea women. Through convenience sampling, we recruited women 14-45 years old in university
MONTH 2014 American Journal of Obstetrics & Gynecology
1.e1
Research
ajog.org
Gynecology
and community clinics that provided contraceptive care and 2 facilities that provided abortion services. CHOICE promoted the use of LARC methods by removing the cost, education, and access barriers that often are experienced in contraceptive services. A detailed explanation of the methods of CHOICE has been published previously.17 All participants provided written informed consent, and the study was approved by the Washington University School of Medicine Human Subjects Protection Office before participant recruitment. To be eligible to participate in CHOICE, women had to meet the following inclusion criteria: 14-45 years old, sexually active with a male partner (or intent to be within the next 6 months), willing to try a new contraceptive method or not currently using contraception, not desiring pregnancy in the next 12 months, residing in or seeking clinical services at recruitment sites in the St. Louis area, and consenting in English or Spanish. To recruit a diverse participant sample that included Hispanic women, we created recruitment and study materials in English and Spanish. Research assistants who were fluent in Spanish recruited Spanish-speaking study participants and conducted follow-up surveys. At enrollment, study participants underwent standardized contraceptive counseling that presented evidence-based and accurate information about each contraceptive method in the order of method effectiveness.18 Participants chose and were provided their method at no cost for 2-3 years. Staff members administered a baseline survey to collect demographic information and a reproductive history. Participants were followed with telephone surveys at 3 months, 6 months, and every 6 months thereafter for the duration of follow-up period. Participants were paid $10 for each completed survey. Information regarding method use and satisfaction was collected at each follow-up survey. To be included in this analysis, a participant had to receive and start her baseline chosen method of
contraception within 3 months of enrollment. We defined method continuation as reporting method use at 3, 6, and 12 months without a period of nonuse of >1 month. Women were coded as having discontinued their method if they reported discontinuation or removal of their contraceptive method at 10%. We described satisfaction rates using frequencies and percentages.
To account for participants who were lost to follow up, we censored participants at their last completed survey
MONTH 2014 American Journal of Obstetrics & Gynecology
1.e3
Research
ajog.org
Gynecology
TABLE 1
Baseline characteristics by race and ethnicity (continued) Race and ethnicity Hispanic women (n [ 419)
Characteristic
Non-Hispanic black women (n [ 4129)
Non-Hispanic white women (n [ 3365)
P value < .0001
Feelings if pregnant in the next 3 months, n (%) Very upset
237 (57)
2712 (66)
2067 (62)
95 (23)
906 (22)
906 (27)
Somewhat upset Would not care
38 (9)
271 (7)
224 (7)
Somewhat pleased
28 (7)
158 (4)
119 (4)
Very pleased
18 (4)
50 (1)
32 (1)
99 (24)
1771 (43)
910 (27)
< .0001
102 (24)
2160 (52)
934 (28)
< .0001
Current sexually transmitted infection, n (%)
11 (3)
468 (12)
72 (2)
< .0001
Never used contraceptives, n (%)
22 (5)
110 (3)
60 (2)
< .0001
168 (40)
1781 (43)
1600 (48)
63 (15)
352 (9)
506 (15)
102 (24)
875 (21)
413 (12)
38 (9)
354 (9)
363 (11)
Ring
26 (6)
227 (6)
311 (9)
Depot medroxyprogesterone
18 (4)
448 (11)
119 (4)
4 (1)
92 (2)
53 (2)
History of abortion, n (%) History of sexually transmitted infection, n (%)
< .0001
Baseline chosen method, n (%) Levonorgestrel intrauterine system Copper intrauterine device Implant Oral contraceptive pills
Patch
< .0001
Long-acting reversible contraceptive vs combined hormonal methods, n (%) Long-acting reversible contraceptive methods (levonorgestrel intrauterine system, copper intrauterine device, implant)
333 (83)
3008 (82)
2519 (78)
Combined hormonal methods (pill, patch, ring)
68 (17)
673 (18)
727 (22)
Percentages may not add up to 100% because of rounding. a Data are given as mean standard deviation. Werth. Contraceptive continuation in Hispanic women. Am J Obstet Gynecol 2014.
date and used contribution time and method use data up to the last contact. Participants who discontinued because of a pregnancy or a desire to conceive were censored at the point of discontinuation. All analyses were completed using STATA software (version 11; StataCorp, College Station, TX). The a-level for all analyses was set at .05.
R ESULTS Among the 9256 women enrolled in CHOICE, 7913 women (85%) met the inclusion criteria for this analysis
(Figure 1). Hispanic women represented 5% of the total cohort, which is similar to the percentage of Hispanic persons in the St. Louis area.19 Forty-five percent of Hispanic participants were born in another country, of which 73% were born in Mexico. The baseline characteristics of the analysis sample are presented by race and ethnicity in Table 1. Hispanic women in CHOICE were more likely to be receiving public assistance, to have a high school education or less, and to desire 3 children. They were less likely to have insurance
1.e4 American Journal of Obstetrics & Gynecology MONTH 2014
and to report a history of abortion. Hispanic women were more likely to choose a LARC method, compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75% respectively; P < .05). Because we detected a significant interaction between contraceptive method and race/ethnicity, Table 2 presents continuation rates that were stratified by contraceptive method. We found no confounders in this analysis. The 12month continuation rates were higher for LARC methods than combined
ajog.org hormonal methods (OCPs, patch, ring) for all race/ethnicities (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%, respectively). We found no statistically significant difference in LARC discontinuation at 12 months by race/ethnicity (Figure 2; P ¼ .27). Hispanic and non-Hispanic white women were equally likely to continue LARC methods (hazard ratio, 0.96; 95% confidence interval, 0.69e1.34). Hispanic women who used the OCP, patch, or ring were more likely to discontinue combined hormonal methods by 12 months, compared with non-Hispanic white and non-Hispanic black women (Figure 3; P
