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Enter Name on Title Master

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Neena Qasba, M.D.,

John Stutsman, M.D., Greta Weaver, Katherine Weber, Joanne Daggy, PhD., Velvet Miller, Ph.D.,

R.N.,

04/18/23 1

Rapid Repeat Pregnancy and Birth Spacing in Adolescents

Authors• Neena Qasba, M.D. PGY-4 OBGYN Resident at Indiana

University– No disclosures

• John Stutsman, M.D. Faculty OBGYN and Medical director of Planned Parenthood Indiana and Kentucky– Merck – speakers’ bureau for Nexplanon– Afaxys – Medical Advisory Board – Actavis – Medical Advisory Board

• Greta Weaver and Katherine Weber- medical students at Indiana University– No disclosures

• Joanna Daggy, Ph.D. Biostatistics Indiana University– No disclosures

04/18/23 2

Content

• Background

• Research Project Objective

• Methods

• Results

• Conclusion

• Question & Answer

04/18/23 3

04/18/23 4

Background- Adolescent Pregnancy in Indiana

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Background- Adolescent Pregnancy in Indiana

Age Indiana U.S.

Under 15 93 3,974

15-17 2,132 95,538

18-19 5,785 234,234

15-19 7,917 329,772Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

04/18/23 6

Background- Adolescent Pregnancy in Indiana

Teen Birth Rate (births per 1,000 females aged 15-19)

Indiana

U.S.

Age 15-19 34.8 31.3

Age 15-17 16.0 15.4

Age 18-19 61.2 54.1

Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

04/18/23 7

Background- Adolescent Pregnancy in Indiana

Race/Ethnicity Indiana U.S.

White (non-Hispanic)

5,566 (69%) 130,198 (39%)

Black (non-Hispanic)

1,531 (19%) 79,936 (24%)

Asian 42 (1%) 5,773 (2%)Hispanic 832 (10%) 111,236 (33%)

Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

04/18/23 8

Background- Adolescent Pregnancy in Indiana

% Repeat Births* Indiana

U.S.

Females under 20 years of age

16% 18%

White (non-Hispanic)

15% 14%

Black (non-Hispanic) 19% 20%Hispanic 23% 20%Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

• High school drop-out rates– Only 50% of teen mothers receive a high

school diploma by age 22

• Children of teenage mothers are more likely to have:– lower school attainment themselves– more health problems– increased rates of juvenile incarceration– Give birth as a teenager– unemployment

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Background- Repeat Pregnancy and Socioeconomic Consequences

http://www.cdc.gov/teenpregnancy/aboutteenpreg.htm

04/18/23 10

Background- Repeat Pregnancy and Fetal-Maternal Outcomes• A short interpregnancy interval (IPI) is an indicator

defined by Healthy People 2020 as 18 months between a previous delivery and subsequent last menstrual period

• The resulting RRPs are associated with adverse maternal and neonatal outcomes

References 1-7

Background- Long-Acting Reversible Contraception• Intrauterine device (IUD)

– Levonorgestrel (LNG) IUD •Mirena ® or Skyla ®•Lasts 5 years or 3 years respectively

– Copper IUD•Paraguard ®•Lasts 10 years

• Subdermal implant– Etonogestrel subdermal implant

•Nexplanon ®•Lasts for 3 years

04/18/23 11

Background- LARC and Birth Spacing

• Women who used LARC had almost 4 times the odds [95% CI, 3.55-4.26] of achieving an optimal birth interval compared with women who used less contraceptive effective methods

• One study estimated that the subdermal implant was associated with longer interpregnancy interval in adolescents compared with less effective methods (18.7 mo vs. 11.9 mo.)

04/18/23 12

Thiel de Bocanegra H, Chang R, Howell M, et al. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2014;210:311.e1-8.

Baldwin M, Edelman A. The effect of long-acting reversible contraception in rapid repeat pregnancy in adolescents: A review. J Adolesc Health. 2013;52:S47-S53.

Background- Adolescent LARC in St. Louis Missouri (CHOICE)

• Contraceptive CHOICE Project– Longitudinal, observational study of women’s

choice, use, and continuation of available contraceptive methods

– All methods were offered to study participants at NO cost

• Among adolescents aged 14-20, 62% choose LARC method (658/1054)

• Young women aged 14-17 years preferred implant over IUD

04/18/23 13

Mestad R, Secura G, Allsworth J, Madden T, Zhao Q, Peipert J. Acceptance of long-acting reversible contraceptive methods by adolescents participants in the Contraceptive CHOICE project. Contraception 2011; 493498: 84.

Effectiveness of LARC Methods (CHOICE)

04/18/23 14

Winner B, Peipert JF, Zhao Q, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J Med. 2012;366:1998-2007

Background- CHOICE project

• Longitudinal study from 2008-2013 that followed 1,404 teenagers aged 15 to 19 years old for 2-3 years after choosing their contraceptive method.– 72% chose an IUD or implantSecura, G, Madden, T, McNicholas C, Mullersman, J, Buckel, C, Zhao Q, Peipert, J. Provision of No-Cost, LARC and Teen Pregnancy. NEJM. Oct 2014. 371(14): 1316-23.

04/18/23 15

Mean annual rate per 1000 teens

CHOICE participants

Typical U.S Teen

pregnancy rate 34.0 158.5

birth rate 19.4 94.0

abortion rate 9.7 41.5

Background- Case for Adolescent LARC in Colorado• How Colorado’s teen birthrate dropped 40% in four years

– “Since 2009, the state has provided 30,000 contraceptive implants or intrauterine devices (IUDs) at low or no cost.”

– “teen abortion rate fell by 35 percent between 2009 and 2012”

– “the state saved $42.5 million in health-care expenditures associated with teen births.”

• Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? – Prospective longitudinal trial– the relative risk of repeat pregnancy at 12 months after delivery

was 5.0 times greater (95% confidence interval [CI], 1.9–12.7) for the control group compared to those who received an immediate postpartum implant

04/18/23 16

Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012;206:481.e1-7. http://www.washingtonpost.com/news/morning-mix/wp/2014/08/12/how-colorados-teen-birthrate-dropped-40-in-four-years/

Cost Effectiveness of LARC

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Han. Cost-effectiveness of immediate postpartum Etonogestrel implants. Am J Obstet Gynecol 2014.

04/18/23 18

04/18/23 19

Study Design and

Methods

Study ObjectiveThe Impact of Immediate Postpartum

Contraceptionon the Rate of Rapid Repeat Pregnancy in

Adolescents in downtown Indianapolis hospital systems

• The objective of this study is to determine and to compare the rapid repeat pregnancy rates and subsequent abortion rates in our urban Indianapolis hospital system between postpartum adolescents who received immediate postpartum contraception and those who did not.

04/18/23 20

Study Design

• Retrospective Cohort Study

• Postpartum adolescents: ages 10-18 at time of delivery.

• Delivery between July 1, 2010 to July 1, 2012.

• Received prenatal and postpartum care at Health Net, Coleman Center, or Wishard, and delivered at Methodist, University, or Wishard hospital.

• Records available in the electronic record system including INPC and Planned Parenthood.

• Of the 330 charts that were reviewed, 277 of them had complete prenatal and postpartum information throughout the study period.

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Variables

04/18/23 22

• age at time of delivery• Gestational age• race/ethnicity• insurance status• zip code of residence• clinic where prenatal care was received• hospital of delivery• Mode of delivery• Pregnancy complications• If immediate postpartum contraception was given (ETN implant

or DMPA)• Attendance at postpartum visit and if contraception given or

changed• Date of removal of ETN or IUD• Subsequent repeat pregnancy with documented by UPT, LMP,

ultrasound, or pregnancy termination procedure

04/18/23 23

Results

Demographics

04/18/23 24

RRP N= 79N (%)

No RRPN=198N (%)

P-value

Race Hispanic Black White Other

60/277 (21.6%)114/277 (41.1%)80.277 (28.9%)23/277 (8.4%)

17 (21.5%)28 (35.4%)27 (34.2%)7 (8.9%)

43 (21.77)86 (43.3%)53 (26.8%)16 (8.1%)

0.558

Insurance Status Public Private Unknown

217/277 (78.3%)21/277 (7.6%)39/277 (14.0%)

61 (77.2%)5 (6.3%)13 (16.5%)

156 (78.8%)16 (8.1%)26 (13.1%)

0.716

Previous pregnancy Yes No

58/277 (20.9%)219/277 (79.1%)

27 (34.2%)52 (65.8%)

31 (15.7%)167 (84.3%)

0.001

Method Type

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Method

Immediate postpartum contraception

28.9% 80/277

Immediate postpartum ETN implant

9.8% 27/277

Immediate postpartum DMPA

19.1% 53/277

RRP by Method

04/18/23 26

Method RRP RRP (%)(p-value 0.001)

Immediate postpartum ETN implant

1/27* 3.7%

Immediate postpartum DMPA

12/53 22.6%

No immediate postpartum contraception

66/197 33.5%*the one pregnancy that occurred in this group resulted after removal of the ETN implant

Odds of RRP- Logic Regression Model

04/18/23 27

Variable Odds Ratio

95% CI* p-value

Immediate postpartum DMPA (No vs. Yes)

2.33 [1.11, 5.18] .031

Immediate postpartum ETN implant (No vs. Yes)

16.0 [3.11, 293.2] .008

Attendance Post-partum visit (No/not documented. vs. Yes)

1.45 [0.77, 2.75] .250

Postpartum DMPA (No vs. Yes) 3.37 [1.54, 7.93] .004

Postpartum ETN implant (No vs. Yes) 5.55 [2.20, 16.13] .0006

Age at delivery (years) 1.51 [1.12, 2.08] .009

Previous pregnancies (Yes vs. No) 2.08 [1.05, 4.12] .035

04/18/23 28

• On average, patients need to receive an implant during the immediate postpartum period to prevent one additional rapid repeat pregnancy. *

*3.6 (95% CI, 3-5)

As this is not an RCT, the NNE has been adjusted for covariates (depo in inpatient, implant at postpartum, depot at postpartum, attendance at PP, age at first delivery, and gravida).

Ralf Bender and Volker Vervölgyi, Estimating adjusted NNTs in randomised controlled trials with binary outcomes: A simulation study.Contemporary Clinical Trials. 2010. 31(5): 498 – 505.Ralf Bender and Maria Blettner, Calculating the “number needed to be exposed” with adjustment for confounding variables inepidemiological studies. Journal of Clinical Epidemiology. 2002. 55: 525 – 530.

04/18/23 29

Summary

Conclusions

04/18/23 30

• Use of LARC is low among adolescents in our hospital systems

• Immediate postpartum ETN implant placement is very effective in preventing RRP

• Immediate postpartum DMPA is not as effective in preventing RRP

• Given low attendance at postpartum visit, the immediate postpartum period is an ideal opportunity to offer effective contraception to adolescents

Future Steps

04/18/23 31

• Share ideas and information with lactation consultants to standardize postpartum patient counseling

• Work with CMS for postpartum LARC reimbursement– Develop tool kit for providers and health

systems to educate on LARC and proper coding

04/18/23 32

Contact us at: Neena Qasba, MD nqasba@iupui.eduJohn W. Stutsman, MD jostutsm@iupui.edu

References

04/18/23 33

• U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 . Retrieved on May 15, 2014.

• Shachar BZ , Lyell DJ. Interpregnancy Interval and Obstetrical Complications. Obstet Gynecol Surv. 2012;67:584-96.• Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta

analysis. JAMA 2006;295:1809–23.• Conde-Agudelo A, Rosas-Bermudez A, Castaño F, Norton MH. Effects of birth spacing on maternal, perinatal, infant, and child

health: a systematic review of causal mechanisms. Stud Fam Plan 2012;43:93–114.• Howard EJ, Harville E, Kissinger P et al. The Association Between Short Interpreganacy Interval and Preterm Birth in

Louisiana: A Comparison of Methods. Matern Child Health J. 2013;17:933-9.• Hussaini KS, Ritenour D, Coonrod DV. Interpregnancy Intervals and the Risk for Infant Mortality: A Case Control Study of

Arizona Infants 2003-2007. Matern Child Health J. 2013;17:646-53• Khoshnood B, Lee KS, Wall S, Hsieh HL, Mittendorf R. Short interpregnancy intervals and the risk of adverse birth outcomes

among five racial/ethnic groups in the United States. Am J Epidemiol. 1998;148:798–805.• Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to Prevent Unintended Pregnancy: Increasing Use of Long-

Acting Reversible Contraception. Hum Reprod Update. 2011;17:121-137.• Short Interpregnancy Intervals and Risk of Adverse Birth Outcomes in Indiana: Statistics from the Live Birth Data 1990 –

2005, Indiana State Department of Health, Maternal and Child Special Health Care Services, 2008.• Gemmill A, Duberstein Lindberg L. Short Interpregnancy Intervals in the United States. Obstet Gynecol. 2013;122: 64-71 •  Winner B, Peipert JF, Zhao Q, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J Med. 2012;366:1998-

2007• Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants

make a difference? Am J Obstet Gynecol 2012;206:481.e1-7. • Lewis, L, Doherty, D, Hickey M, Skinner R. Implanon as a contraceptive choice for teenage mothers: a comparison of

contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 421:426. 81• Baldwin M, Edelman A. The effect of long-acting reversible contraception in rapid repeat pregnancy in adolescents: A review.

J Adolesc Health. 2013;52:S47-S53.• Mestad R, Secura G, Allsworth J, Madden T, Zhao Q, Peipert J. Acceptance of long-acting reversible contraceptive methods by

adolescents participants in the Contraceptive CHOICE project. Contraception 2011; 493498: 84. • Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception.

2005;72:426e9• Wilson EK, Fowler CI, Koo HP. Postpartum contraceptive use among adolescent mothers in seven states. J Adolesc Health.

2013;52(3):278-83.

04/18/23 34

Questions?

04/18/23 35

• Cost of the outcomes of unintended pregnancy was estimated at $4.6 Billion dollars

• If 10% of women aged 20-29 switched from short acting forms of contraception to LARC, there would be an estimated cost savings of $436 million dollars.

Trussell J, Henry N, Hassan F, Prezioso A, Law A, Filonenko A. Burden of unintended pregnancy in the US: potential savings with increased use of LARC. Contraception 2013;87:154-61.

04/18/23 36

Background- Cost Effectiveness of LARC

04/18/23 37

Background- Contraceptive Use in Adolescents in Indiana

Contraceptive Use Indiana U.S.Used DMPA, vaginal ring, ETN implant, or IUD

11% 7%

Used OCPs 28% 23%No method 13% 15%

Centers for Disease Control and Prevention (CDC). 1991-2013 High School Youth Risk Behavior Survey Data. Available at http://nccd.cdc.gov/youthonline/. Accessed on [9/22/2014].