One way to reduce the occurrence of unintended pregnancy and consequent health effects is through effective contraceptive use. There are a number of contraceptive methods. Each method is associated with varying benefits, drawbacks, and efficacy. Barrier methods such as condoms or diaphragms, although widely used, have high failure rates and require action at the time of the sex act. Furthermore, hormonal methods, like the pill, require users to remember to use or change them at a specified time. One-time intervention methods, which are also the most effective, include intrauterine device (IUD), implant, and sterilization. Each of these methods has less than 1 pregnancy per 100 women per year. IUDs and implants are the most effective form of reversible contraception, as sterilization is permanent.
Intrauterine devices are important to examine both because of their effectiveness and rise in popularity over the past 10 years in the United States. Broadly, IUDs are small t-shaped plastic devices that are inserted by a healthcare provider and left in the uterus for 5-10 years. General side effects include bleeding pattern changes and pain with insertion. But there are many benefits to IUD, such as the user having little to think about once it is in place, the device’s discreteness, that it does not directly interfere with sex activities, and that it can be inserted at any time during the reproductive lifespan.
There are a number of factors that lead women to disproportionately select highly effective contraceptive methods like the IUD. First, the fractured nature of the U.S. political system makes it hard for women to understand their rights and options regarding contraception. Factors such as the political climate and federal funding, which are out of a woman’s control, affect their ability to obtain contraception. Furthermore, an estimated 50% of women need public assistance to pay for reproductive health services including contraception. Low-income women frequently see the upfront cost of IUD to be a barrier, even if it is cost-effective long-term.
Within the healthcare setting, there is wide variation in provider knowledge of contraceptive options. Contraceptive counseling of women differs by clinician perceptions of the patient. For example, in one study, 524 providers were shown standardized videos depicting patients of low or high socioeconomic status and varying races. The study sought to determine whether IUD recommendations differ amongst African American, Latina, and white patients. The results show that providers may have a bias towards recommending IUDs toward low-income or minority populations. The provider recommendations were somewhat contradictory, with the highest odds of recommendation occurring amongst low-income women of color or high-income white women. This may be an effect of provider knowledge that low-income and minority women have higher rates of unintended pregnancy and lower rates of contraceptive use. It may also be a remnant of the historical narrative that encouraged Latina and African American women to limit their family size.
Despite the many barriers that are contributing to disparities in contraceptive selection, several interventions have demonstrated ways to combat this problem. The Contraceptive CHOICE project, out of Washington University St. Louis, aimed to reduce financial barriers to contraception, promote long-acting methods of contraception, and reduce rates of unintended pregnancy in St. Louis, Missouri. Approximately 10,000 women of reproductive age were provided contraceptive counseling and their method of choice at no cost for up to 3 years. When participants were counseled and cost was removed as a barrier, approximately 75% initially chose IUD or implant. At 1-year follow-up, women who had selected IUD or implant had the highest rates of continuation and satisfaction compared to participants who had selected other methods. The CHOICE project indicates that removing cost as a barrier and providing comprehensive contraceptive counseling to women may lead to higher rates of selection of efficacious contraceptive methods.[11,12]
Moving forward, it is important to recognize the multiple attributes that affect an individual’s contraceptive decision-making. Furthermore, acknowledging the influence of contraceptive knowledge and support at the clinical level is important, as the majority of women obtain contraception in this setting. In order to reduce disparities in unintended pregnancy within the United States, it will be critical to affect change in the selection of highly effective methods of contraception through interventions on multiple levels.
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2. Guttmacher Institute, the. (2015). Unintended pregnancy in the United States fact sheet.
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4. American College of Obstetrics and Gynecology. (2014). Long-acting reversible contraception (LARC): IUD and implant FAQ 184. Online 17 March 2016. Retrieved from: http://www.acog.org/Patients/FAQs/Long-Acting-Reversible-Contraception-LARC-IUD-and-Implant
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9. Dhelendorf, C., Ruskin, R., Grumbach, K., Vittinghoff, E., Bibbins-Domingo, K., Schillinger, D., Steinauer, J. (2010). Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status. American Journal of Obstetrics and Gynecology. 203(319): e1-8.
10. Harris, L. (2010). Interdisciplinary perspectives on race, ethnicity, and class in recommendations for intrauterine conception. American Journal of Obstetrics and Gynecology. 203: 293-295.
11. Diedrich, J.T., Zhao, Q., Madden, T., Secura, G.M., Peipert, J.F. (2015). Three-year continuation of reversible contraception. American Journal of Obstetrics and Gynecology. 662(213): e1-8.
12. Secura, G.M., Allworth, J.E., Madden, T., et. al. (2010). The contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. American Journal of Obstetrics and Gynecology. 2013(115): e1-e7.