Contraception

Romina L. Barral

Melanie A. Gold

Currently, adolescence and young adulthood can last for over 15 years. Since puberty occurs earlier in life and with an extended period until adult roles, there is a prolonged time period for contraceptive needs. Sexual activity, abortion, and birth rates among adolescents and young adults (AYAs) increased in the 1960s and 1970s, but those rates started to decline early in the 1990s, partially in response to the acquired immunodeficiency syndrome (AIDS) epidemic and also better contraceptive methods. Despite this progress, significant risk-taking behaviors remain and the need for higher usage of effective contraception continues.

EPIDEMIOLOGY

Pregnancy Rates

In 2009, the national pregnancy rate was approximately 102.1 pregnancies per 1,000 women aged 15 to 44 years, about 11.8% below the peak in 1990 (115.8).¹ The highest rate was among 25- to 29-year-old women (162 per 1,000) followed by women aged 20 to 24 years (158.3 per 1,000). The pregnancy rate for teenagers fell 43.6% during 1990 to 2009 (65.3 per 1,000 in 15- to 19-year-olds), to the lowest reported since 1976.

The pregnancy rate for 15- to 17-year-olds declined from 77.1 per 1,000 in 1990 to 36.4 per 1,000 in 2009.
The rate for older teenagers 18 to 19 years of age declined by over one-third during this time period, from 167.7 per 1,000 in 1990 to 106.3 per 1,000 in 2009.
Pregnancy rates for women in their early 20s declined by 22.5% from 1990 to 2009.
Declines in pregnancy rates for women aged 25 to 29 years were less marked from 1990 to 2009 falling 9.5% during the same time period (179 to 162).

Birth and Terminations of Pregnancy

Rates for all three age-groups (15 to 19, 20 to 24, and 25 to 29) fell for births, induced abortions (largest percent declines), and fetal losses. Patterns were generally similar across race and Hispanic ethnicity. Despite these declines,¹ the teen birth rates in the US are significantly higher than other industrialized nations with marked racial and ethnic disparities.²

The Centers for Disease Control and Prevention (CDC) analyzed data from the National Survey of Family Growth (NSFG) collected in 1995, 2002, and 2006 to 2010 and found that the decline in teen birth rates since 1995 were attributed to significant increases in the proportion of female adolescents who were abstinent, and, among sexually experienced female adolescents, increases in the proportion who were using effective contraception.

Sexual Activity and Contraceptive Usage

The percentage of teenagers who reported having had recent sex (defined and measured within the last month, 3 and 12 months), and the percentage using a method of contraception at first and last intercourse, remained unchanged from 2002 through 2006 to 2010. At the same time, males’ report of using condoms and of dual methods at first intercourse increased, as did males reporting that their female partners were using oral contraceptives and dual methods at last intercourse.³ Of note, although they reported an increase in these behaviors, the percentage of 15- to 19-year-olds reporting dual method use at last intercourse remained low at 13.1% in 2002 and 14.8% in 2006 to 2010.³ The 2006 to 2010 data showed that female adolescents are adopting newer contraceptive methods: a larger proportion reported using hormonal methods other than the pill at first intercourse, and a higher percentage had ever used emergency contraception (EC) (14%), the contraceptive patch (10%), and the contraceptive ring (5%). Reported oral and injectable contraceptive use did not change significantly since 2002 (20.7% in 2002 versus 20.3% in 2006 to 2010).³ Overall, initial declines in sexual activity and increases in contraceptive use explain the declines in teen pregnancy and birth rates (1998 to 2002). The lack of change in these risk behaviors between 2002 and 2006 to 2010 is reflected in trends in teen pregnancy and birth rates, that “with the exception of small fluctuation, have failed to continue to drop.”³

Despite increased availability of newer, more effective contraceptive methods, disparities in unintended pregnancies and birth rates across major sociodemographic groups persist due to variations in contraceptive use and access. More notably, there is a marked underutilization of the most effective methods across all ages and races.

CONTRACEPTIVE METHODS

The 2008 report on national pregnancy rates found that of the nearly 6.6 million pregnancies, 51% were unintended.⁴ Women aged 15 to 19 years reported greater unintended pregnancy rates (82%) compared to those who were 20 to 24 years old (64%). Most of these pregnancies are the result of contraceptive failure or nonuse. Both the effectiveness inherent to each method (perfect use) and how correctly and consistently each method is used (typical use) can affect overall effectiveness of each contraceptive method (Table 41.1). The gap between perfect use and typical use increases with methods that are more user-dependent. Adolescents represent a group with higher than usual failure rates for many user-dependent methods as well as higher discontinuation rates compared to adult women. The CHOICE study, conducted in St Louis, found that girls aged 14 to 19 years have higher rates of discontinuing reversible contraception compared to women aged 20 years and older, at the 24 months follow-up (adjusted hazard ratios for risk of discontinuation = 1.40, 95% CI 1.22, 1.60).⁵ Estimates of contraceptive failure from the 2002 NSFG showed that women younger than 30 years of age have higher probability of contraceptive failure (specifically pills, condom, and withdrawal) compared to the relevant reference groups (older than 30-year-old women) for the first 12 months of use.⁶ The most commonly used methods of contraception reported by sexually active teenagers are male condoms, followed by withdrawal and combination oral contraceptives (COCs). These methods have differing effectiveness: Typical-use failure rate is 15% for condoms, 27% for withdrawal, and 8% for COCs.⁷ More importantly, adolescents often use these methods inconsistently (nearly half “take breaks”) or discontinue them early (up to half discontinued COCs within the first 6 months of use).

Throughout this chapter we reference the United States Medical Eligibility Criteria for Contraceptive (US MEC),⁸ an excellent resource that provides guidance on contraceptive method safety for women with specific medical conditions. In addition, although this chapter provides an overview on most contraceptive methods, we refer the reader to Chapters 42,43 and 44 for information on specific contraceptive methods.

LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS

Long-acting reversible contraceptives (LARCs), also called highly effective reversible contraceptives (or HERCs), include intrauterine contraception (IUC) and subdermal implants. These are toptiered contraceptive methods based on effectiveness, with failure rates of less than 0.1% per year for both perfect and typical use (see Chapter 44). These methods have the highest rates of continuation and satisfaction of all reversible contraception.⁹ The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), the CDC, and the World Health Organization (WHO) all recognize the potential impact of LARCs to reduce unintended pregnancies.¹⁰ In fact, the ACOG recommends that LARCs be “first-line” choice for most women, emphasizing they are safe and appropriate for most women and adolescents and that, given the high risk of unintended pregnancy, adolescents may benefit from increased access to LARCs.⁹ This was supported by a policy statement released by the AAP (September 2014).¹¹

An analysis of data from the 2002 and 2006 to 2010 NSFG report confirms that the proportion of all LARC users across the US increased significantly between 2007 (3.7%) and 2009 (8.5%) among almost every subgroup of 15- to 44-year-old women; women of all ages, races/ethnicities, marital and educational statuses, income levels, and religions reported significant increases. The highest levels of use were reported among women aged 25 to 39 years, married and cohabiting women, women covered by Medicaid, women with a religious affiliation other than Catholic or Protestant, and those with no religious affiliation.¹² Another analysis of NSFG data compared use of LARCs from 2007 to 2009 and found that for adolescents aged 15 to 19 years, use of LARCs tripled from 1.5% to 4.5%, with most or all of this increase noted among women aged 18 to 19 years, and these percentages increased from 4% to 7% for women aged 20 to 24 years and 5% to 10% for those aged 25 to 29 years. “Discrepancies by race and ethnicity seen in 2002 continued through 2007 but were largely eliminated by 2009. The latest figures also show no real differences by income level. Women born in the US appear to be catching up to women born outside the US, who already had a higher level of use, likely due to a greater prevalence of these methods in Mexico”.¹²

Despite the increases reported, LARC use in the US lags behind use in other developed countries around the world. The United Nations 2011 Report on World Contraceptive Use reported LARC use among 15% of 15- to 49-year-old women who are married or in union in most other developed countries, including 11% of British women, 23% of French women, 27% of Norwegian women, and 41% of Chinese women. The large majority of LARC use is the intrauterine device (IUD).¹³

In the US, multiple reasons have been identified for lack of LARC use, including, but not limited to:

women’s lack of knowledge about and nonaccepting attitudes toward the methods, restrictive counseling and practice patterns among providers, myths and misconceptions among both users and providers
high initial up-front costs associated with initiating these methods (despite better cost-effectiveness over time)
pervasive misconceptions about risks and benefits of use.¹⁴

LARCs may have another advantage. One cause of unintended pregnancy among teenagers and young adult women is the rate of sexual assault, which is higher for youth than among any other group. Dating violence among the adolescent population is also an increasing risk affecting this age-group, and strong associations of intimate partner violence (IPV) with unintended pregnancy have been observed in prior studies. Male partners may be manipulating condom use and contraceptive methods in an attempt to get their partners pregnant, such as flushing COCs down the toilet, removing vaginal rings, and poking holes in condoms. LARCs are ideal for women in these violent or coercive settings to prevent unwanted pregnancies resulting from sexual assault or IPV. In fact, the copper IUD allows for discrete contraception because it is less likely to affect menstrual cycle regularity. Although the removal of an IUD may be more challenging, the strings can be cut high up in the cervical os if there is a need to hide the presence of the IUD or concern that the partner may feel or pull on the strings.

Intrauterine Devices

Current Use

Data from National Health Statistics Report¹⁵ found that ever use of an IUD among 15- to 44-year-old women in the US declined from 1982 (18%) through 2002 (5.8%), but increased between 2002 and 2006 to 2010 (7.7%). The type of IUD used (hormonal versus copper) was not assessed by the surveys used in this report. Adolescents continue to report using less effective contraceptive methods. Data that assessed IUD use per age-group, published in the NHSR in 2012, reported that in the period of 2006 to 2010, 2.7% of adolescents, aged 15 to 19 years, who used contraception reported using an IUD, compared to 5.6% in women aged 20 to 24 years, and an average of 5.9% of women aged 25 to 44 years. Although IUDs are extremely effective and safe methods with the lowest adverse side effect profiles, there are multiple myths and misconceptions about their use among both providers and users. The most frequent cited misconceptions among patients include fear of the IUD causing an abortion, previously overestimated risk of pelvic inflammatory disease (PID), secondary infertility after IUD removal, the IUD causing ectopic pregnancies, hair loss, as well as osteoporosis and cancer.
Patients are also concerned and confused about the amount of bleeding following IUD insertion, weight changes, and the amount of pain during insertion, as well as misperceiving that insertion must take place at a particular time during the menstrual cycle. In addition, providers have misconceptions regarding the need to obtain parental consent and safety for inserting IUDs in nulliparous women, the latter of which has been successful and preferable. The CHOICE study showed that teens prefer LARCs to other methods,⁵ and the ACOG states that nulliparity is not a contraindication to IUD use (see Chapter 44).⁹

TABLE 41.1
Percentage of Women Experiencing an Unintended Pregnancy During the First Year of Typical Use and Perfect Use of Contraception and the Percentage Continuing Use at the End of the First Year—the United States

	Women Experiencing an Unintended Pregnancy Within the First Year of Use
Method	Typical Use^a (%)	Perfect Use^b (%)	Women Continuing Use at 1 y^c (%)
No method^d	85	85
Spermicides^e	29	18	42
Withdrawal	27	4	43
Fertility awareness-based methods	25		51
Standard days method^f		5
TwoDay method^f		4
Ovulation method^f		3
Sponge
Parous women	32	20	46
Nulliparous women	16	9	57
Diaphragm^g	16	6	57
Condom^h
Female (Reality)	21	5	49
Male	15	2	53
Combined pill and POP	8	0.3	68
Evra patch	8	0.3	68
NuvaRing	8	0.3	68
Depo-Provera	3	0.3	56
IUD
ParaGard (Copper-T)	0.8	0.6	78
Mirena (LNG-IUS)	0.2	0.2	80
Implanon	0.05	0.05	84
Female sterilization	0.5	0.5	100
Male sterilization	0.15	0.10	100
Emergency contraceptive pillsⁱ	Not applicable	Not applicable	Not applicable
Lactational amenorrhea methods^j	Not applicable	Not applicable	Not applicable
^aAmong typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an unintended pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal, fertility awareness-based methods, the diaphragm, the male condom, the pill, and Depo-Provera are taken from the 1995 NSFG corrected for underreporting of abortion; see the text for the derivation of estimates for the other methods. ^bAmong couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an unintended pregnancy during the first year if they do not stop use for any other reason. See the text for the derivation of the estimate for each method. ^cAmong couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 year. ^dThe percentages becoming pregnant in the typical-use and perfect-use columns are based on data from populations where contraception is not used and from women who cease using contraception to become pregnant. Of these, approximately 89% become pregnant within 1 year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within 1 year among women now relying on reversible methods of contraception if they abandoned contraception altogether. ^eFoams, creams, gels, vaginal suppositories, and vaginal film. ^fThe TwoDay and Ovulation methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on cycle days 8-19. ^gWith spermicidal cream or jelly. ^hWithout spermicides. ⁱTreatment initiated within 72 hours after unprotected intercourse reduces the risk for pregnancy by at least 75%. The treatment schedule is 1 dose within 120 hours after unprotected intercourse and a second dose 12 hours after the first dose. Both doses of Plan B can be taken at the same time. Plan B (1 dose is 1 white pill) is the only dedicated product specifically marketed for emergency contraception. The Food and Drug Administration has in addition declared the following 22 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel or Ovral (1 dose is 2 white pills); Levlen or Nordette (1 dose is 4 light-orange pills); Cryselle, Levora, Low-Ogestrel, Lo/Ovral, or Quasence (1 dose is 4 white pills); Tri-Levlen or Triphasil (1 dose is 4 yellow pills); Jolessa, Portia, Seasonale, or Trivora (1 dose is 4 pink pills); Seasonique (1 dose is 4 light blue-green pills); Empresse (1 dose is 4 orange pills); Alesse, Lessina, or Levlite (1 dose is 5 pink pills); Aviane (1 dose is 5 orange pills); and Lutera (1 dose is 5 white pills). ^jLactational amenorrhea method is a highly effective temporary method of contraception. However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of breast-feeding is reduced, bottle feeds are introduced, or the baby reaches 6 months of age. Adapted from Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, et al., eds. Contraceptive technology. 19th revised ed. New York, NY: Ardent Media, 2007.