key: cord-0874122-5hy4uxpf
authors: Nelson, Anita L.
title: Pulling back the curtain on trends in contraceptive use in recent years: What can we predict for the future?
date: 2020-07-25
journal: F S Rep
DOI: 10.1016/j.xfre.2020.07.005
sha: c189611e6dc6ef85d0d3aef9dbd22f19fc159ced
doc_id: 874122
cord_uid: 5hy4uxpf

nan

(1) They report increases in the utilization 3 of both contraceptive implants (particularly by adolescent women) and intrauterine devices, 4 and decreases in the use of oral contraceptives and permanent contraception. They also report 5 that the percent of sexually active women who use no method remained stubbornly unchanged 6 at 12%. The overall 4% increase in use of IUDs and implants seen in this study between 2013-2017 9 extends the 3.1% increase seen between 2009-2012. It would be reasonable to ask if these 10 trends predict future increases in women's use of these highly effective and safe methods. 11 However, analyzing the forces that were responsible for this observed growth, one wonders if 12 these rates might actually represent a high-water mark. Enthusiasm for IUDs and implants clearly grew in the wake of the CHOICE study, which 1 demonstrated high rates of acceptance of IUDs and implants, their superior pregnancy 2 protection and their high continuation rates. Three quarters of subjects chose IUDs or implants. 3 It was suggested that if their efficacy-based structured counselling approach were adopted 4 elsewhere, uptake of these methods would significantly expand. About that same time, the 5 Affordable Care Act progressively removed many of the financial barriers to long-acting 6 methods, which measurably increased IUD use by privately insured women. implants placed immediately following delivery before discharge home were highly successful. 8 Women provided those devices in hospital were far more likely to still be using them 6 months 9 postpartum compared to women who delayed their initiation until the 6-week postpartum visit. 10 In relatively short order, the MediCaid programs in dozens of states started reimbursing 11 hospitals and providers for postpartum provision. Enthusiasm for implants and IUDs was palpable. Every study that resulted in increased 1 utilization of these methods was hailed a success. At one point, family planning programs were 2 debating what usage percentages should be adopted as targets. The thought was that 3 "appropriate counselling" could be documented if a greater percentage of patients in a clinic 4 chose these "top tier" methods. At a more fundamental level though, many thought leaders have progressively moved away 1 from structured counselling that stressed efficacy as the most important variable in method 2 selection. They saw that it did not promote patient autonomy and had begun to rekindle 3 distrust with the medical system. What has emerged to replace that model is the person-4 centered framework for high-quality, equitable contraception care.(4) This approach does not 5 merely focus on reducing unintended pregnancies, but adds prioritizing the individual's 6 wellbeing and promoting positive experiences with care. From a utilitarian viewpoint, the idea 7 is that women, who, based on their own preferences and priorities, choose the methods they 8 want to use, will be more successful users. 9 10 Echoes from the history of some family planning experiences seem to be heard today around 11 IUDs and implants. Studies have shown that these more effective methods may not meet the 12 preferences of many people of color. The mistrust of the medical system becomes even more 13 important when women must rely on clinicians not only to place the device but also to remove 14 it on demand. Enthusiasm clinicians express for the IUDs and implant may be interpreted as 15 pressure, which violates a woman's autonomy. And when women's requests for removal are 1 resisted or ignored, clinician-patient relationships are jeopardized and the appeal of the 2 method is undermined.(5) Whether it is related to these concerns or not, calls for women-3 controlled methods are increasing. Some new methods such as the 13-cycle EE/segestrel 4 vaginal ring and vaginal pH regulators for contraception still require clinicians to prescribe 5 them, but their use is controlled by the woman. Newer apps and biometric devices that can be 6 used for fertility awareness methods may be appealing precisely because they require no 7 interaction with the medical system. Covid-19 pandemic has also accelerated the introduction of non-traditional avenues to 10 contraception. Telemedicine has enjoyed a huge jump start that enables women access to 11 contraception without needing an office visit. In many states, pharmacists can both prescribe 12 and dispense pills, patches, vaginal rings and injections. By increasing easier access to these 13 methods, we may be biasing the choices women make. Similarly, increasing the number of 14 cycles of pills, patches and rings dispensed at once further enhances the convenience (and 15 8 effectiveness) of those methods but may well inhibit the use of methods that require office 1 visits (and procedures) with a clinician. Over-the-counter access to hormonal methods has been 2 endorsed by ACOG and other groups to diminish access barriers, which may further diminish 3 relative attractiveness of IUDs or implants. While women may be able to remove their own 4 IUDs, they cannot place them themselves. Finally, the critical ongoing problem that Kavanaugh and Pliskin remind us of in their article is 7 the persistently high proportion (12%) of sexually active women who use no method of birth 8 control even though they do not desire to become pregnant. Studies show that this 12% 9 contributes disproportionately to the unintended pregnancies, abortions and unintended 10 births. We still do not seem to understand what motivates these women. It is apparently not a 11 problem with the survey tool; NSFG specifically asks about traditional methods of 12 contraception, such as fertility awareness and coitus interruptus, which other surveys often 13 neglect. It is quite conceivable that some of these women rely on abortion as their method of 14 family planning where the procedure is safe, legal and available. But there are clearly other 15 9 forces at work. Indifference and ambivalence about both pregnancy and contraception are 1 common. It may not be socially acceptable for a woman to admit that she wants to become 2 pregnant when she does not have the social and financial resources to support a child. 3 Traditional women's roles may call for them to view the pregnancy as a gift or at least as 4 something to accepted. Perhaps these women should be given ongoing preconception care to 5 insure they are ready for pregnancy when they conceive. Some may need education; surveys

Use of contraception among reproductive-aged women in the United States

Early Impact of the Affordable Care Act on Uptake of

Providing quality family planning services: 6 Recommendations of CDC and the U.S. Office of Population Affairs

Beyond same-day long-acting 9 reversible contraceptive access: a person-centered framework for advancing high-quality, 10 equitable contraceptive care

She just told me to leave it": Women's 12 experiences discussing early elective IUD removal