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Thanks to Early View, many of you have already seen the first article in our special September 2014 issue on long-acting reversible contraceptive (LARC) methods, "Game Change in Colorado: Widespread Use of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women" (click here for the news release), by Sue Ricketts, of the Colorado Department of Public Health and Environment, et al.
HERE'S WHAT ELSE IS IN THIS ISSUE OF PERSPECTIVES:
- Counseling About IUDs: A Mixed-Methods Analysis
- Women's Social Communication About IUDs: A Qualitative Analysis
- Who Is Using Long-Acting Reversible Contraceptive Methods? Findings from Nine Low-Fertility Countries
- The Relationship Between Contraceptive Features Preferred by Young Women and Interest in IUDs: An Exploratory Analysis
- COMMENT: Applying Principles from Behavioral Economics to Promote Long-Acting Reversible Contraceptive (LARC) Methods
- VIEWPOINT: Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods
- Digests (summaries of other important research in the field)
The Likelihood of Discussion About IUDs During Family Planning Visits May Vary with Provider and Patient Characteristics
IUDs were mentioned in 75% of clinic visits in a study of women receiving contraceptive counseling, and providers mainly initiated those mentions, according to "Counseling About IUDs: A Mixed-Methods Analysis," by Christine Dehlendorf, of the University of California, San Francisco, et al. A provider-initiated discussion about IUDs was much less likely to occur in visits with providers older than 55 than in those with providers younger than 46. Additionally, a patient-initiated discussion about the method was more likely to occur in visits by patients aged 25–29, or 35 and older, than in those by patients younger than 20.
The study took two approaches to gathering information. It analyzed audio recordings and survey data from 342 clinic visits by women who wanted to discuss changing or beginning a contraceptive method at six facilities in the San Francisco Bay Area between 2009 and 2012.
In general, providers more frequently discussed the potential adverse effects of IUD use than the potential benefits. The counseling provided was often not interactive, required patients to return to the clinic or obtain a referral elsewhere in order to have the IUD inserted, and did not highlight connections between patients' contraceptive preferences and the characteristics of the IUD.
The researchers note that women's selection of a new contraceptive method is influenced by provider counseling and that the study's findings thus suggest opportunities for interventions. They recommend increased efforts to offer continuing education for older providers, as well as proactive education efforts, through physicians and nonclinical approaches like social media, to inform younger women about the IUD. They also suggest increased provision of same-day insertions, as well as providers' proactive mention of IUD benefits and exploration of patients' preferences during contraceptive counseling.
Women Consider Social Networks a Key Source of Contraceptive Information
Participants in a 2013 qualitative study reported that communication with family and friends was a valued means of obtaining information about contraceptives, according to "Women's Social Communication About IUDs: A Qualitative Analysis," by Nora Anderson, of the University of California, San Francisco, et al. However, women also reported that negative information was often more prevalent and more memorable than positive information in these encounters.
The authors conducted 24 in-depth interviews and three focus groups with a sample of San Francisco women aged 15–45 to explore how contraceptive information travels through social networks, and the influence of that information on women's attitudes toward and use of contraceptives. In 83% of interviews and two of the three focus groups, women said they preferred to learn about a contraceptive method from a woman who had used it herself. Many women who said they would like to hear from a friend also said they would seek additional information from a health care provider. One participant noted that birth control was "a normal thing to talk about" with her friends.
However, the authors suggest that there are potential disconnects between the information that IUD users convey to their friends and the information that women who have never used the method are interested in learning. Current and past IUD users focused on method characteristics such as its high efficacy rates and long-lasting protection. Yet the two most common questions among never-users were "How does it feel?" and "Is the insertion painful?" The authors argue that both clinical and social communications about IUDs may be failing to address women's most common questions and concerns, and that this failure may be contributing to low levels of use of this highly effective method.
U.S. Women Are Less Likely Than Women in Other Low-Fertility Countries to Rely on Long-Acting Reversible Contraceptive Methods
Women in the United States use long-acting reversible contraceptive (LARC) methods less frequently than women in other low-fertility countries, according to "Who Is Using Long-Acting Reversible Contraceptive Methods? Findings from Nine Low-Fertility Countries" by Mieke C. W. Eeckhaut et. al., of the University of California, Los Angeles. Among married or cohabiting U.S. women aged 18–44 who used contraceptives in 2008–2010, only 10% used LARC methods. Significantly higher rates of LARC use were reported at around the same time in Russia (32%), France (27%), Austria (23%), Georgia (23%) and Bulgaria (18%).
The authors' analyses of data from the 2008–2010 National Survey of Family Growth found higher levels of LARC use among 18–24-year-old U.S. women than among other age-groups. They also revealed higher levels among women who have had at least one child than among those who have not given birth. U.S. women aged 35–44 and those who have had three or more children were more likely than the youngest women and childless women, respectively, to rely on sterilization rather than on LARC methods. The authors also analyzed Generations and Gender Programme surveys conducted from 2004 to 2010 in eight countries whose low-fertility levels are comparable to that of the United States. These data showed that the vast majority of LARC use was attributable to IUDs in every country except Australia, where reliance on implants accounted for more than half of LARC use.
LARC methods are considered highly effective contraceptives because they do not rely on user intervention. The authors note that increasing their usage in the United States could be an effective way to decrease the nation's high number of unintended pregnancies, 43% of which are attributed to inconsistent or incorrect use of contraceptives. In addition, the authors suggest, promoting LARC methods as an alternative to sterilization could reduce the number of women who experience regret after sterilization.
According to the authors, several factors may be contributing to the low levels of LARC usage in the United States, including the high up-front cost of IUDs and public perception of safety concerns. The study results suggest that certain demographic groups may particularly benefit from increased access to LARC methods, including women who have not had children, teen mothers and women found to have high levels of sterilization regret. The authors recommend further investigation of barriers to LARC use among these subgroups of U.S. women. They note that future efforts should address not only access and cost issues, but also women's perceptions of and demand for LARC methods.
Young Women's Interest in Using an IUD Is Linked to the Features They Value in a Contraceptive Method
About half (48%) of women participating in an online survey reported that they were unsure whether they would ever use an IUD, while 20% thought they might and 32% indicated that they would not, according to "The Relationship Between Contraceptive Features Preferred by Young Women and Interest in IUDs: An Exploratory Analysis" by Anu Manchikanti Gomez of the University of California, Berkeley, and Jennifer B. Clark of Palo Alto University. The authors shed some light on the complexities of contraceptive decision-making by exploring correlations between contraceptive features that women prefer and their self-reported interest in using an IUD.
Gomez and Clark analyzed results from an Internet survey of 382 heterosexual U.S. women aged 18–29. They found that the contraceptive features preferred by the largest proportions of women were that a method not interfere with sexual pleasure (87%), and that it reduce menstrual bleeding (81%) and alleviate menstrual cramps (80%). Women who preferred a method that would not interfere with sexual pleasure were more likely than those who did not have this preference to report interest in using an IUD. Other features associated with an increased likelihood of interest in using an IUD were methods that are highly effective without the user's having to do anything and methods that have a long lifespan without user intervention. Women who preferred methods that can be seen by the user or that allow fertility to resume immediately after discontinuation were less likely than others to be interested in IUD use.
The authors suggest that future research should examine the relationship between contraceptive preferences and decision-making within more diverse groups of women. They recommend further study of factors that may influence contraceptive preferences, including women's personal experiences with various methods, their friends' and family members' experiences, their childbearing desires and their perceptions of their ability to become pregnant. Gomez and Clark hope that the results of this study and future research will be incorporated into contraceptive counseling to help ensure that every woman is able to access the method most suited to her needs.
Commentary Proposes Approaches for Promoting Highly Effective Contraceptives
A new commentary explores the use of behavioral economics as an approach for helping women in their contraceptive decision making, and particularly their decisions regarding use of highly effective long-acting reversible contraceptive (LARC) methods. According to "Applying Principles from Behavioral Economics to Promote Long-Acting Reversible Contraceptive (LARC) Methods," by Jack Stevens and Elise D. Berlan of The Ohio State University, the use of select principles of behavioral economics may help identify ways for providers to better present contraceptive options to their patients, which would allow women to more effectively choose the methods that best meet their needs.
The first principle the authors explore addresses the need to present an optimal number of contraceptive method choices. They suggest that both having too many options and having too few options may impede women's choice of LARC methods. They propose that providers offer LARC methods as the preferred or first option to clients who are deemed medically eligible and appropriate, rather than presenting a diverse menu of choices. Similarly, they suggest that clients might become overwhelmed when given too many options, and might benefit from being presented with a small pool of method choices that are appropriate to their specific preferences. The authors acknowledge that attempting to influence contraceptive decision making can be controversial, but they note that women generally want providers to play a role in the decision, and providers can tailor the list of methods they suggest on the basis of what features are important to individual clients.
The second principle the authors explore addresses how information about contraceptive methods is presented. They suggest that clients may be more enthusiastic about LARC methods if these methods are presented in a positive way, with a focus on their benefits, rather than in a way that emphasizes their disadvantages or potential side effects.
Lastly, they suggest that LARC methods run counter to the idea that consumers want to enjoy benefits as soon as possible and defer costs in the long run, given that these methods have high up-front costs. Finding ways to reduce the up-front costs or illustrating the cost savings over time may help expand use of these methods.
Viewpoint: Long-Acting Reversible Contraceptive Use Must Be Driven by Women's Preferences
Prioritizing the effectiveness of long-acting reversible contraceptive (LARC) methods over their other features might deny some women reproductive control, according to "Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods," by Anu Manchikanti Gomez of the University of California, Berkeley, et al. This new Viewpoint appears in the September 2014 special LARC-themed issue of Perspectives on Sexual and Reproductive Health. It explains that enthusiasm about LARC methods has increased among U.S. reproductive health professionals in recent years because of their potential to help decrease the national rate of unintended pregnancy. Failure to temper this enthusiasm could lead to programs and contraceptive counseling that promote their use among those identified as "high-risk" populations—young, black, Latino and poor women—in ways that restrict the contraceptive options for these women.
The authors stress that the use of LARC methods should be driven by women's desires and not by programmatic efforts to reduce population-level unintended pregnancy. They recommend that programs designed to promote LARC use prioritize the needs and preferences of individual women, noting that several features beyond effectiveness—such as the ease of a partner's or parent's detecting a contraceptive method— influence women's method selection. Even while it is important to continue to remove structural and clinical barriers to LARC use so women can have a comprehensive range of contraceptive options, the authors note that "as long as a woman's choice is based on accurate information and a good understanding of her own priorities, that decision should be supported as a positive outcome."
Digests
The Digests section of this issue contains summaries by Perspectives editors of recent research on a range of topics: disparities in knowledge about contraception by age and by race or ethnicity; the potential of social media to supplement contraceptive counseling; antiretroviral therapy's role in preventing HIV transmission and more. Click here to access these valuable resources.