New research shakes up the premise that implants and other long-acting contraception methods are far and away the most effective choice.
The HER Salt Lake Contraceptive Initiative first provided participants with contraceptive counseling that focused on their needs and values. Then, the initiative got them started on their chosen method right away and provided refills and other support. In centering their preferences and making their birth control choice accessible, participants experienced similarly low failure rates no matter the method, researchers report June 16 in JAMA Network Open.
“This shows that patients actually don’t have to choose between something that they like and something that they need — very often, one method can be both,” says Katharine White, chief of obstetrics and gynecology at Boston Medical Center, who was not involved in the study. “This is not trying to put down any method. It’s about opening the scope and expanding our view” of options that meet people’s values, she says.
The HER Salt Lake study, conducted by a research team from the University of Utah, included four Salt Lake City family planning clinics. The study was open to people who could become pregnant ages 16 to 45 and whose incomes were below the federal poverty threshold. Included participants planned to avoid pregnancy for at least a year and were either a new patient wanting contraception or an established patient seeking a new method.
There was a choice of seven reversible birth control methods: the copper intrauterine device, or IUD, hormonal IUD, contraceptive implant, contraceptive injection, pill, vaginal ring or male condoms. The first three methods are placed by a medical provider, the injection occurs at a medical office and the remaining options are user-controlled.
“Patients received their preferred method, had timely access, felt respected and could stop and switch methods at any time,” says Jessica Sanders, a reproductive health researcher at University of Utah Health.
The analysis included more than 4,000 participants, 82 percent of whom completed the full three years of follow-up. The research team kept track of how long people continued with their original method. The team also calculated the contraceptive failure rate, defined as a pregnancy despite using the original method in the four weeks prior. That came to 96 pregnancies.
Over three years, there was around 1 pregnancy per 100 participants per year among users of all methods except male condoms. The variation was narrow overall, ranging from 0.7 per 100 per year for hormonal IUD users to 1.6 per 100 per year for pill users. The estimated rate for condom users, 2.6 per 100, is limited by a small sample size.
“People should feel really valid in whatever decision they make,” Sanders says. “These are all effective methods at preventing pregnancy.”
The greater parity among the effectiveness of different methods stands in contrast to a memorable statistic from a 2012 study. The Contraceptive CHOICE Project’s stated goal was to promote the use of long-acting reversible contraceptives, according to the project team at Washington University School of Medicine in St. Louis. The study reported that participants using the contraceptive patch, the pill or the ring had a failure rate of 4.6 per 100 people per year, about 20 times higher than that of implants or IUDs.
“What HER Salt Lake adds is incredible evidence that having the ideal access and support to use [preferred] methods actually increases the effectiveness of shorter-term methods for preventing pregnancy,” says Anu Manchikanti Gómez, a sexual and reproductive health equity researcher at the University of California, Berkeley, who was not involved in the study.
That support and access can prevent lapses in consistent use. And it’s not only about forgetting to take a pill. It can be hard for some to take time off from work to see a doctor. Others don’t have transportation to get to the pharmacy. “A missed refill, a delayed appointment, out-of-pocket costs or an unavailable method creates that gap — it’s not necessarily on the person,” Sanders says. “The small disruptions matter.”
The study also adds to the evidence behind respecting patient preferences in choosing a birth control method. Person-centered contraceptive counseling focuses on the values and priorities of the patient. Those could include effectiveness, avoiding side effects or being able to start and stop a method at home rather than depend on a medical visit. Often, health care providers have thought primarily in terms of effectiveness, recommending long-acting methods instead of prioritizing patients’ preferences.
White starts conversations about contraception by asking, “What is important to you about your birth control?” and leaves it open-ended to let the patient be the guide. “When people feel heard,” she says, “they are more likely to have trust in the care they are getting [and] to reach back out if they have any problems.”
Read the full article here
