LARCs hold key to reducing unplanned pregnancy rate

If all women in the United States had access to LARC methods, more than 1 million unplanned pregnancies and nearly 900,000 abortions could be prevented each year, according to a CHOICE Project video he shared during his presentation.

"So if we truly want to reduce abortion in this country, what we need to do is increase contraceptive prevalence, and, in particular, talk about the advantages of LARCs," Dr. Espey said, referencing the CHOICE Project findings.

The currently available LARC methods include intrauterine devices and systems (the copper IUD and the hormonal intrauterine systems Mirena and Skyla) and the contraceptive implant (Nexplanon).

Skyla (Bayer HealthCare), approved in January, is the newest system on the market. Compared with Mirena (Bayer HealthCare) – a hormonal intrauterine system that has been available since 2000, the new system uses less levonorgestrel (14 mcg vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use, Dr. Espey said.

In her experience, some women prefer the 3- vs. 5-year product, even after they are told that the 5-year product can be removed early, she noted.

"It shouldn’t make a difference, but psychologically it does," she said.

As for the contraceptive implant, Nexplanon (Merck) is the latest-generation product, having replaced its predecessor, Implanon. The major difference between the two is that Nexplanon, which is approved for 3 years of use, can be seen on x-ray. Also, it only requires one hand for insertion, improving ease of use.

Overall, the implant, which works by preventing ovulation, is easy to learn, and is safe and highly effective, with very few contraindications, according to Dr. Tony Ogburn, who also spoke at the ACOG meeting.

Unpredictable bleeding can be an issue for some women, and is the most common reason for removal. Counseling and education, along with reassurance about Nexplanon’s safety, can promote continuation, he said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases. Physicians previously certified to insert Implanon can take an online training course to become certified for Nexplanon insertion; those not previously trained must attend a live course, said Dr. Ogburn of the University of New Mexico, Albuquerque.

Deciding which LARC method is appropriate in a given patient can be somewhat daunting, but an app available from the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use can help.

Dr. Espey, who swears by the app – even for "non-app people" like herself – said that it provides evidence-based reviews of every type of contraceptive method lined up against various patient characteristics and conditions, and coordinates recommendations.

For those averse to using an app, a chart is also available. Notably, the chart shows that most contraceptive use is safe.

There are a lot of misconceptions on the part of patients about the safety of one contraceptive method or another, and the fact is that contraception is "overmedicalized," Dr. Espey said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases, she added.

Of course, the low use of LARC methods is hardly the only hurdle when it comes to improving the unintended pregnancy rate in the United States. Compared with European Countries that have extremely low unintended pregnancy rates, the United States has a lack of comprehensive sex education that begins at a young age, and a greater cultural acceptance of teen motherhood. Progress in the United States also is hampered by patriarchal attitudes that may allow men control over reproductive health, and by a mismatch in cultural values that is apparent in the "wildly sexual" U.S. media and the puritanical views that limit conversations with children about sex and sexuality as a normal part of human behavior, Dr Espey said.

Additional hurdles include poverty, racism, and inadequate social and health care safety nets, she noted.

That’s not to say, however, that major inroads can’t be made by promoting LARC use. A flurry of research presented at the ACOG annual meeting that focused on various approaches to increasing use among patients highlights the increasing focus on, and commitment to, helping patients take control of their fertility. One study, for example, showed that the use of a short, simple counseling intervention – much like the one used for the CHOICE project, is feasible and effective for promoting LARC use when provided in the immediate postpartum period. Another suggested that while a postpartum educational script increased interest in LARC methods, certain barriers to access may limit uptake.