Despite advancements in contraceptive technology and the millions of dollars that is spent each year on contraception research and development, unplanned pregnancy rates in the U.S. have remained essentially unchanged for decades. The cost of these unplanned pregnancies is enormous, both in terms of public health and personal financial and emotional costs, and while they occur in all socioeconomic groups, unplanned pregnancies tend to happen more frequently in the underserved – women who are already financially and socially challenged. Approximately 50 percent of all pregnancies in the United States are unplanned, and of these, 43 percent will end in abortion.
“Approximately 50 percent of all pregnancies in the United States are unplanned, and of these, 43 percent will end in abortion.”
Over three million women in the U.S. each year experience an unplanned pregnancy, but this is not, however, usually due to failure to attempt contraception. About 90 percent of sexually active women use some form of contraception. The 10 percent of women who do not use contraception account for approximately half of unplanned pregnancies, but the other half occur in women who were attempting to use some form of birth control.
How do these failures occur? The efficacy of each form of contraception is measure both in “perfect use” and “actual use.”
The efficacy for perfect use reflects how effective the actual method is if it is used perfectly every time. The failure rate with perfect use reflects the fact that each device or medication has limits as to how effective it can be. Even if the pills are taken correctly at the right time every day, there is still a chance that the medication will not be able to prevent a pregnancy. For example, perfect use efficacy for condoms is 98 percent. Even if a condom is used correctly every time, there is still a 2 percent chance of failure.
“The 10 percent of women who do not use contraception account for approximately half of unplanned pregnancies, but the other half occur in women who were attempting to use some form of birth control.”
Actual use efficacy is lower than perfect and takes into account not only the innate failure rate of the method chosen but also the fact that there is an element of human error in contraception use. Condoms do break, or are not used correctly, or are not used every time. In actual use, condoms have an 18 percent failure rate. The actual use failure rate for birth control pills is about 9 percent, even though the perfect use rate is less than 1 percent. Human error accounts for a large proportion of contraceptive failure, but while education and reminder methods may help to improve compliance to some extent, the contraceptive methods that rely heavily on a person having to perform a function correctly – at the right time, every time, will inevitably result in substantially less than perfect success. Couple this with lack of access or financial barriers to purchasing contraception on a regular basis, and the success rates fall even more. This is particularly relevant in the underserved population.
The answer to these dilemmas may lie in a family of contraceptives known as long-acting reversible contraception, or LARCs. LARCs include both subdermal implants and intrauterine devices. The advantage to these forms of contraception is that once the device has been placed, a woman does not need to do anything to make it work, essentially removing the element of human error. Couple this will the very high efficacy of these methods – actually more effective at preventing pregnancy than a tubal ligation – and one can achieve actual failure rates of less than one percent. Once placed, the devices remain in place and active for between 3-10 years depending on the type of device. As a result, continuation rates for these methods tend to be much higher than for methods that involve having to remember to refill a prescription, get to the pharmacy, or obtain the money to pay for it. While the upfront costs to these methods are higher, they are covered by most insurance plans, and there are private grants which help to pay for these devices for the uninsured. With new health care policy changes, access and affordability should improve further still.
If such highly effective contraception exists, why have the unplanned pregnancy rates failed to decrease? Unfortunately LARCs have not gained the popularity of oral contraceptives or other forms of birth control. For some, the cost may be prohibitive, and for others, access may be limited. Many patients, as well as a fair number of providers, still remember the days of the Dalkon shield, an IUD available in the 1970s that increased the risk of pelvic organ infections and resulted in infertility. For these reasons, IUDs were only used in women who had already had their children and were long-term monogamous relationships. However, the new generation of IUDs is not associated with an increased the risk of pelvic infections outside of the small risk associated with placement of the device. The American College of Obstetrics and Gynecology actually recommends LARCs as the first-line choice for birth control for all women, including adolescents – a group that may lack both financial and physical access to contraception as well as the maturity to use contraception accurately at all times. The results of unplanned pregnancy in this population are particularly devastating.
Access to LARCs may also be a deterrent. While most Ob/Gyns are capable of placing these devices, many women receive their birth control from their primary care providers or pediatricians. These providers are often not familiar with these forms of birth control, nor have they been trained to place them. In these cases, patients are often prescribed a shorter-acting form of birth control despite the unfortunately high rate of failure associated with these methods. In one large study, women were given education about various forms of birth control, including LARCs, and were then offered their choice at no cost. Seventy-five percent women, when educated and when financial and access barriers had been removed, chose to have a LARC placed, and 86 percent of them continued with this method, as opposed to only about half of those who chose a shorter-acting method.
Continuance rates for short-acting forms of contraception, such as birth control pills, tend to be relatively low. One reason for this may be due to the side effects that some women experience when starting hormonal contraception. Estrogen containing compounds are contraindicated in women at high risks for developing blood clots and in women over the age of 35 who smoke. Some women may also experience headaches, bloating, breast tenderness or mood changes when starting some form of combined hormonal contraception (a group which includes birth control pills, rings and patches). Women who experience these side effects often choose to stop the method but may fail to contact their provider to arrange for another form of contraception. These women are at a particularly high risk of experiencing an unplanned pregnancy as a result. Rather than avoiding the issue and risking an unplanned pregnancy, women with these concerns should consult their provider and ask about non-hormonal options, such as the copper IUD, or progestin-containing IUDs in which there is minimal release of hormones to the rest of the body.
Despite the high theoretical efficacy for many of the most commonly used forms of birth control, failures, resulting in unplanned pregnancies, continue to occur at an unacceptably high rate. One can hope that with the acceptance of newer forms of birth control, which are far less prone to failure, we may finally start to see a decrease in this troubling statistic.
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