Long-acting contraception as a public health priority

The copper IUD protects women for 10 years. It's 99% effective.
The copper IUD protects women for 10 years. It's 99% effective. (istock.com)

A call for doctors to more assertively discuss preventing unintended pregnancy.

Posted: March 23, 2014

Has your pediatrician ever asked you mothers out there when you plan to have your next baby? Or asked your teenage daughter when she wants to have a child?

It probably never happened, but don't be surprised if your doctors become more assertive. Those who care for children know that unintended pregnancies are a huge public health problem, and I predict more doctors will be empowering families to choose their reproductive futures.

A few weeks ago, I saw a 3-year-old with trouble breathing. His mother is a wonderful, conscientious caregiver who is a "high utilizer" in our office, having three children only 4 years apart, all with various chronic conditions.

Each time she comes in, she seems overwhelmed, anxious, emotionally drained. This scenario plays out in physicians' offices around the country.

Even in this divisive political time, everyone can embrace the goal of preventing unintended pregnancies. These are mistimed or unwanted, and rates over the last decade are rising.

About half of all pregnancies are unintended. That's 7 million a year, with 43 percent ending in abortion. We have one of the highest rates of unintended pregnancies of all developed nations.

An unplanned baby raises the risk of pregnancy-related complications for the mother and prematurity and other issues for baby.

An unintended arrival can also adversely affect a family's other children by draining limited financial and emotional resources. National estimates put the cost of such pregnancies at over $11 billion a year.

Optimal spacing between children has been shown to be 18 months to 59 months, the ideal being 21/2 years. Closer births raise potential risks.

The highest unintended pregnancy rate is among women 20 to 24, a time many are just starting their adult lives.

Unplanned pregnancies also afflict lower-income women at five times the rate of their upper-income counterparts, who also are less likely to choose to complete the pregnancy. Sexually active teens, not surprisingly, have some of the highest rates of all.

In 2009, the American College of Obstetricians and Gynecologists called unintended pregnancies one of the "major public health problems in the United States." The group said doctors should offer long-acting, reversible contraception (LARCs) for most women as a first-line method. The Institute of Medicine has declared that expanding access to LARCs should be a national priority.

What are LARCs? There are 3 types: the hormonal IUD, the copper IUD, and the contraceptive implant.

The copper IUD protects women against pregnancy for over 10 years and the hormonal IUD for 5. These are the most highly effective methods for sexually active women; they're more than 99 percent effective against unintended pregnancy. They are also very safe and cost-effective, with the implant costing less than half the expense of oral contraceptives. LARCs can be obtained at most gynecologists' offices, health centers, and, soon, in some pediatricians' offices.

LARCs also can eliminate user adherence and dependence issues because they require only a single act.

The most common contraceptive method in the U.S., the pill, is only 93 percent effective with typical use and has high failure rates.

"Would a physician recommend a vaccine that is 93 percent effective when another one is greater than 99 percent effective?" asks pediatric innovator Barry Zuckerman, founder of Medical-Legal Partnership, in a recent commentary. He agrees that "discussing LARCs should be among the highest priorities during clinical visits."

LARCs should be discussed in all settings where teens and young women are seen for clinical care: In emergency rooms, family practice offices, teen clinics, and in maternity wards soon after delivery.

There are more than 20,000 live births in Philadelphia almost every year. Each one deserves our best care, our best love, our best intentions.


Daniel Taylor is a pediatrician with St. Christopher's Hospital for Children. Daniel.Taylor@DrexelMed.edu.

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