Evidence-Based Best Practices for Contraceptive Provision

Beatrice A. Chen, MD, MPHAssociate Professor of Ob/Gyn

University of PittsburghReproductive Bridges Coalition Day of Learning

Pittsburgh, PAMarch 24, 2018

Objectives

• To understand how to quick-start a contraceptive method

• To identify barriers to LARC insertion and how to overcome them

• To describe recommended follow-up after contraceptive initiation

Contraceptive Use By Effectiveness, 2011-2013

38.3%

16.0% 15.5%

9.4%6.4% 5.1%

3.0% 2.8% 1.6% 0.8%

% of US women 15-44 years

Really really wellPretty wellNot as well

Daniels K et al. NCHS Data Brief. 2014;173:1-8.

Trends in contraceptive use between 2008, 2012, and 2014

26.6%

10.0%

5.6%

0.5%

27.5%

16.3%

5.2%

21.8%

6.5%

11.8%

2.6%

25.3%

14.6%

8.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Femalesterilization

Malesterilization

IUD Implant Pill Condom Withdrawal

2008 2012 2014

*

** *

*

* Statistically significant change between tested years

Kavanaugh M and Jerman J. Contraception 2018; 97:14-21.

% of US women 15-44 years currently using contraception

What is the best method of contraception for women?

Available for iOS and Android

https://itunes.apple.com/us/app/contraception/id595752188?mt=8

CDC MEC 2016

When and how to initiate a birth control method?

• For contraceptive methods other than IUDs, the benefits of starting a contraceptive method likely exceed any risk, even in situations in which the health care provider is uncertain whether the woman is pregnant

CDC SPR 2016

“Quick-starting” a contraceptive method

• Historically, women were instructed to wait until their next menses to start OCPs

• However: Inadvertent exposure to hormones in early

pregnancy does not increase risk of adverse outcomes or cause teratogenic effects

Women may become pregnant while waiting to start OCPs

Women may not start OCPs at correct time, or may never start them

Westhoff C et al. Contraception. 66:141-145, 2002.

• “Quick-starting” OCPs on day of visit can improve initial continuation rates

• Has been studied with OCPs, vaginal ring, patch, DMPA, and contraceptive implant and in adolescents

• Standard of care by CDC and ACOG “Benefits of starting the implant, DMPA,

combined hormonal contraceptives, and progestin-only pills likely exceed any risk”

“Quick-starting” a contraceptive method

CDC SPR 2016; Westhoff C et al. Contraception. 66:141-5, 2002; Schafer et al. Contraception 73:488-92, 2006; Murthy et al. Contraception 72:333-6, 2005; Nelson and Katz. Contraception 75:84-7; Richards et al. Contraception 95:364-70.

• Initiation of hormonal contraception as soon as possible, regardless of menstrual cycle day

• High-sensitivity UCG on day of visit• Women receive LNG-EC if needed• Follow-up pregnancy test in 2-4 weeks• Abstain or use additional contraceptive protection

until the method is effective

“Quick-starting” a contraceptive method

CDC SPR 2016

How long does it take before a hormonal contraceptive is

effective?Method # of daysCombined hormonal contraceptives 7 daysProgestin-only pills 2 daysDepot medroxyprogesteroneacetate

7 days

Etonogestrel contraceptive implant 7 days

CDC SPR 2016

Quick-starting after emergency contraception (EC)

• Options for EC Levonorgestrel (LNG) 1.5 mg PO x 1 Ulipristal acetate (UPA) 30 mg PO x 1 Cu-IUD

• Both LNG and UPA ECP can be taken within 5 days of unprotected intercourse (UPI) UPA is more effective than LNG at 3-5 days after

UPICDC SPR 2016

Quick-starting after emergency contraception

• If taking UPA as EC Delay initiation of HC until ≥ 5 days after use of

UPA since HC may ↓ effectiveness of UPA Can start nonhormonal contraception

immediately after UPA Abstain or use barrier contraception for 7 days Check UCG in 3 weeks But need to weigh possible decreased

effectiveness of UPA vs. risk of not starting a contraceptive method

CDC SPR 2016

Quick-starting after emergency contraception

• If taking LNG as EC Can start any contraceptive method

immediately Abstain or use barrier contraception for 7 days Check UCG in 3 weeks

CDC SPR 2016

Effects of BMI on ECP efficacy

• Obese women (BMI >30) have 3x risk of pregnancy after taking ECP compared to women with normal BMI Higher risk of pregnancy with LNG > UPA

• Overweight women have 1.5x risk of pregnancy after ECP

• Most effective method of EC regardless of weight?

Glasier et al. 2011. Contraception 84:363-7.

Cu-IUD as EC• Can insert Cu-IUD within 5 days of first act of

unprotected intercourse as EC (off-label)• Can be continued as regular contraception 6 month IUD continuation rates 80%

CDC SPR 2016Envall et al. 2016. Acta Obstet Gynecol Scand 95:887-93.

Barriers to LARC initiation

IUDs in adolescents

• ACOG: LARC methods “should be offered routinely as safe and effective contraceptive options for nulliparous women and adolescents”

• American Academy of Pediatrics also endorses LARC use for adolescents

• Contraceptive CHOICE project: High LARC satisfaction and continuation rates in

adolescents (82-86% continuation at 1 year)

ACOG Practice Bulletin No. 186, 2017.

Local barriers to adolescent LARC access

• QI project assessing adolescent LARC access in 56 UPMC gynecologic practices across 11 counties in western PA

• Investigators posing as nulliparous adolescents followed a pre-set script with questions about how to get an IUD

• What do you think were their responses?Lim and Krajewski. J Pediatric Adolesc Gynecol 2017;30:321.

Responses

• Out of 56 practices, 6 did not insert IUDs• 78% would not schedule an appointment for

a same-day LARC insertion• 50% did not offer after-school appointments• 56% stated that a parent was required for

the visit• Some practices (10%) demonstrated LARC-

positive language but 56% demonstrated LARC-negative language

Lim and Krajewski. J Pediatric Adolesc Gynecol 2017;30:321.

LARC-Negative Language“Would I want the IUD for my daughter? No.”

“You don't want the pill then? 16 is very

young to get the IUD.”

“No, uh-uh. I'm sorry but we

won't do that. Not here.”

“It [the IUD] is going to cost

you thousands of dollars.”

Slide courtesy of Lim and Krajewski 2017

Identified barriersIDEOLOGICAL

INFORMATIONALLOGISTICAL

LARCS not offered as first line

LARC-negative languageRequire parental presence

Will not insert for nulliparous women

Unreliable resources offered

No insurance information offered

Require insertion over two visits because:

1. Device not stocked2. No insurance authorization

3. Staff citing outdated guidelines in referencing

patient safety

Slide courtesy of Lim and Krajewski 2017

PA law for birth control in minors• Minors can receive contraception on their

own consent; includes EC Facilities receiving Title X funding explicitly

prohibited under federal law from requiring a minor to get parental consent before providing contraception

• Minors are entitled to confidentiality• Minors may consent to STD/HIV testing and

treatment• Minors may consent to confidential

pregnancy testing and treatment (except abortion)

https://www.aclupa.org/our-work/duvall-reproductive-freedom-project/minorsaccesstoconfidential/minors-health-care-and-the-law/

Same-day LARC access

• Survey of 636 California Family PACT providers found: 58% required 2 or more visits to place an IUD 47% required 2 visits to place an implant Main reasons for delay included:

Reasons more than 1 visit needed IUD* Implant*Screening tests or wait for results 68% (62-74) 24% (17-34)Clinic flow, scheduling issues, few clinicians

50% (44-57) 64% (61-80)

Need to order the method 29% (23-34) 29% (21-39)

Biggs et al. Obstet Gynecol. 126: 338-45, 2015.* [% (95% CI)]

Study of STD screening strategies

• Retrospective cohort study of all IUD insertions at Kaiser Permanente Northern CA from Jan 2005 to Aug 2009

• Of 57,728 IUD insertions, 47% were unscreened within 1 year of insertion Of screened women, 19% screened on same day Nonscreening had equivalent risk of PID as any

screening Same-day screening equivalent to prescreening

• Separate visit for STI screening is unnecessary and costly

Sufrin et al. Obstet Gynecol 2012;120:1314-21.

STI screening at time of IUD insertion

• Overall rate of PID among women with IUDs inserted is low 0-5% among women with STIs at time of insertion 0-2% among women without STIs

• Screening for STIs not required unless risk factors exist, e.g. age <25 or multiple partners

• Asymptomatic woman with risk factors should be tested and IUD can be placed same-day

Tepper et al. Contraception 2013;87:645-9.Mohllajee et al. Contraception 2006;73:145-53.Sufrin et al. Obstet Gynecol 2012;120:1314-21.

Same-day IUD insertion

ACOG Committee Opinion No. 615: Access to Contraception Should try to initiate and place LARC in a

single visit as long as pregnancy may reasonably be excluded Two-visit IUD insertion protocols are a

barrier to contraceptive access STI testing can occur on same day as

LARC placement

ACOG Committee Opinion No. 615, 2017.

Post-pregnancy LARC

• LARC insertion immediately after an induced or spontaneous abortion is safe and effective Since ovulation can occur as early as 10 days

after abortion, immediate IUD insertion may reduce repeat unintended pregnancy

• Post-abortion LARC placement result in higher rates of use and lower rates of repeat abortion

• ACOG also supports immediate postpartum LARC as a best practice

ACOG Practice Bulletin No. 186, 2017.

Pelvic exams: to do, or not to do

• For healthy women, no baseline exams or tests are necessary before initiation of: Progestin only pills (POPs) Depot medroxyprogesterone acetate (DMPA) Contraceptive implant

• Blood pressure should be checked before: Combined hormonal contraceptives (CHCs)

• Baseline weight/BMI may be useful for all methods

CDC SPR 2016

What about STI testing?

STI testing without a pelvic exam

• Self-collected vaginal swabs for NAAT Equivalent in sensitivity and specificity to

clinician-collected swabs Highly acceptable

• First-catch urine specimen for nucleic acid amplification testing (NAAT) Slightly less sensitive than vaginal/cervical

specimens

CDC STD Treatment Guidelines, 2015.CDC MMWR 2014;63:1-19.

Number of packs to prescribe

Providing a year’s supply of contraception:• Improves adherence• Improves continuation rates• Reduces unintended pregnancy rates• Is cost-effective

However, insurance company barriers may prevent women from receiving multiple packs at one time

ACOG Committee Opinion No. 615, 2015.Foster DG et al. Obstet Gynecol 2011;117:566-72.Foster DG et al. Obstet Gynecol 2006;108:1107-14.

State policies

• Oregon passed a law in 2015 requiring insurers to pay for 3 mo supply of contraceptives initially, followed by 12 mo supply

• State laws requiring coverage of a year’s worth of contraceptives have been enacted in: California, Colorado, DC, Hawaii, Illinois,

Maine, Nevada, New Mexico, New York, Vermont, Virginia, and Washington

https://www.kff.org/womens-health-policy/fact-sheet/oral-contraceptive-pills/, accessed 3/20/18

Follow-up after initiation of hormonal contraception

• No routine follow-up visit needed for implant, DMPA, POPs, CHCs, IUDs

• At routine visits, assess satisfaction, whether she has any concerns, changes in health status that may affect continued eligibility

• IUD: at routine visits, consider checking for strings

• CHCs: at routine visits, assess BP

CDC SPR 2016

Follow-up after initiation of hormonal contraception

• Offer options for follow up at any time for side effects/problems, to change the method, or for removal/replacement

• Consider assessing weight changes and counseling as needed

• Specific populations may need more frequent follow-up (adolescents, medical conditions)

CDC SPR 2016

Conclusions

• Quick-start contraception when possible Caution with HC after UPA

• LARCs are safe and acceptable in adolescents

• Same-day access to LARC improves uptake Think about the barriers that your office may

have, and ways to overcome those barriers• STI testing can occur on same day as LARC

placement

Conclusions

• Pelvic exams not needed for most contraceptive methods

• Routine follow-up visits not needed for all methods However, should check BP at follow-up visits for

CHCs Can check IUD strings at follow-up visits for IUDs

• Encourage follow-up as needed for any problems

Questions?