LARCs hold key to reducing unplanned pregnancy rate

Little has changed over the years with respect to the proportion of unplanned pregnancies in the United States, but the emergence – and increasing acceptance – of safe and reliable long-acting reversible contraceptives, or LARCs, offers hope for improved reproductive management and outcomes.

Currently, about half of the 6.7 million pregnancies that occur each year in the United States are unplanned, and while that is a startling figure, more startling is the fact that although the distribution has changed – with decreases in unplanned pregnancies among wealthier women, and increases among low-income women and minorities – the percentage hasn’t changed in decades, Dr. Eve Espey said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists in New Orleans.

Dr. Eve Espey

Further, while only 11% of the women with unplanned pregnancies use no form of birth control, those women’s pregnancies make up only about 50% of the unplanned pregnancies overall; that means that half of all unplanned pregnancies occur in women who use at least one form of birth control, said Dr. Espey of the University of New Mexico, Albuquerque.

This is a problem that likely involves both contraceptive failures and user error.

"One of the things that I think we don’t appreciate is the extent to which women who do use contraceptives use them incorrectly or inconsistently, or use methods that have a high failure rate," she said.

These statistics, and the fact that unintended pregnancies are associated with an increased risk of numerous adverse outcomes, such as preterm birth and neonatal intensive care unit stays, underscore the importance of identifying and promoting contraceptive methods that will help women achieve better regulation of fertility, she said.

LARCs, according to burgeoning research – and a recent American College of Obstetricians and Gynecologists committee opinion – are the answer.

LARCs, including intrauterine devices and the contraceptive implant, should be first-line recommendations for all women and adolescents, according to an October 2012 opinion from the Committee on Adolescent Health Care LARC Working Group (Obstet. Gynecol. 2012;120:983-8). With both perfect and typical use, these contraceptive methods are associated with pregnancy rates of less than 1% per year – far better than reported rates among those using short-acting contraceptive methods such as condoms, oral contraceptives, the contraceptive patch, the vaginal ring, and depot medroxyprogesterone acetate injections, according to the committee opinion. Yet the use of short-acting methods, and particularly the use of oral contraceptives, dwarfs the use of LARC methods.

The use of IUDs is now about 7.5% – a substantial and encouraging increase over the 5.5% reported in recent years, but still far less than the 15%-20% of women who report oral contraceptive use, Dr. Espey said.

Findings from the Contraceptive CHOICE Project – a prospective cohort study designed to promote the use of LARCs among women and adolescents in the St. Louis area, and to reduce the rate of unintended pregnancies in the region, demonstrated that the unintended pregnancy rate was more than 20-fold greater with short-acting vs. LARC methods at 2- to 3-year follow-up. The rate was twice as high in adolescents as in adults (N. Engl. J. Med. 2012;366:1998-2007).

The CHOICE Project included 9,256 women who received a brief educational intervention and access to their contraceptive method of choice free of charge. The majority – 75% - chose LARC methods, suggesting that when cost and access barriers are removed, the typically low use of these highly effective methods (about 5.5% at the time of the study) increases substantially. The increased use of LARC methods was associated with an unplanned pregnancy rate of 35 per 1,000 women, compared with the national rate of 52 per 1,000 women, Dr. Jeffrey Peipert, the lead investigator for the project, said at the meeting.

Moreover, the continuation rate, which is strongly associated with outcomes, was 86% among LARC users at 12 months, compared with 55% for short-acting methods in a separate analysis of data from more than 4,100 project participants (Obstet. Gynecol. 2011;117:1105-13).

The abortion rate among CHOICE Project participants was 6 per 1,000 at follow-up, compared with the national rate of 20 per 1,000. The number needed to treat to prevent 1 abortion was 108.

"These are very reasonable numbers," said Dr. Peipert of Washington University in St. Louis, noting that the findings are all the more astounding given that the CHOICE population was much higher risk than the general population due to younger age, a high percentage of African Americans (about 50%), and lower socioeconomic status (about 40% had trouble affording basic necessities and 40% were uninsured).