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Wednesday, February 5, 2014

We Are Due For an Update
Elizabeth Schmidt, MD
Elizabeth Schmidt, MD
Family Planning Fellow
Washington University
St. Louis, MO

As a medical student I attended a lecture in which the speaker asked, “What was the greatest development of the 20th century?” I eagerly raised my hand and responded, “Birth control!” The lecturer gave me an odd look and said, “I would disagree and say that it was oral rehydration therapy.” As a lowly medical student I had to swallow my retort, but as a practicing ob-gyn I can enthusiastically confirm that contraception, if not the greatest development of the 20th century, is certainly one of the best. What other invention has allowed women to determine their futures and also helped create healthier families? With the epidemic of unintended pregnancy in the United States, two contraceptive methods have emerged as a potential solution. The intrauterine device and the subdermal implant, referred to as long-acting reversible contraception (LARC), have revolutionized the world of family planning.

As we have seen with the contraceptive CHOICE Project in St. Louis, women overwhelmingly choose, are satisfied with, and continue LARC, and doing so decreases rates of both unintended pregnancy and abortion.1,2,3 So, why are only 8.5% of contracepting reproductive-aged women in the United States using these fantastic methods?4 A significant barrier that we as physicians can immediately address today is ourselves! Physicians play a crucial gatekeeping role in educating and providing women with contraceptive options. Just as we install the proper software updates to our computers and smartphones, we need to incorporate the proper clinical updates into our daily clinical practice.
We have the opportunity to be on the front lines in the battle against unintended pregnancy and provide excellent health care for our patients. However, as shown in the article by Biggs et al5 in the March issue of Obstetrics & Gynecology, we are missing this chance. In their study, medical directors from 1,000 sites participating in California’s Medicaid family planning program were surveyed to assess their beliefs and practices regarding LARC. The goal of the study was to evaluate the effect of enhanced training efforts and recently updated guidelines regarding LARC provision and services. A very concerning half of all respondents didn’t discuss the contraceptive implant with their patients, and 25% didn’t mention IUDs. Additionally, a quarter of clinicians incorrectly considered women with a history of pelvic inflammatory disease to be unsuitable candidates for either type of IUD. Of note, these respondents already had education and training about LARC and were providing family planning services.
One possible solution to this problem is use of performance indicators. In a 2012 study from UCSF, health care providers at California Title X clinics were given performance reports comparing them to their peers.6 This confidential performance feedback, without disciplinary action or audit, was found to provide motivation for change and improved quality among care providers in family planning services.
On an individual level we must continue to educate ourselves, our fellow physicians, mid-level providers, residents, and medical students about LARC. To help, the CHOICE Project has made all of their educational materials available on their website, and ACOG has a LARC Program resource web site as well, Lastly, we need to counsel and encourage our patients to choose the contraceptive method that is best for them. By endorsing and providing LARC we are empowering women and providing them with the best, most up-to date care possible.
  1. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291–7.
  2. Rosenstock JR, Peipert JF, Madden T, Zhao Q, Secura  GM. continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012;120:1298-1305.
  3. O-Neil-Callahan M, Peipert JF, Zhao Q, Madden T, Secura G. Twenty-four-month continuation of reversible contraception. Obstet Gynecol 2013;122:1083-91.
  4. Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009, Fertil Steril 2012;98:893-7.
  5. Biggs AM, Harper CC, Malvin J, Brindis CD. Factors influencing the provision of long-acting reversible contraception in California. Obstet Gynecol 2014 Mar. [Epub ahead of print]
  6. Watts LA, deBocanegra HT, Darney PD, Hulett D, Howell M, Mikanda J, et al. In a California program, quality and utilization reports on reproductive health services spurred providers to change. Health Aff (Millwood) 2012; 31:852-62.