Tuesday, May 16, 2006

Contraceptive Use and Discontinuation

A study in the May 2006 issue of the American Journal of Obstetrics and Gynecology surveyed women on their contraceptive use. Conducted in Atlanta,
"Women between the ages of 18 and 45 years who were using any method of birth control were approached while waiting for their appointment (n = 413), and those who agreed to participate signed an informed consent form and filled out a short, baseline questionnaire (n = 369 by September 2004). OC users were invited to participate in a longitudinal study, in which the women were requested to fill out five 1-week diaries, in which they recorded daily information on whether they took their pill, the exact time they took their pill, and if they engaged in sexual intercourse. Women who agreed to participate received a coupon for a free movie rental for each diary they completed and mailed back to the study personnel."
Despite the incentive, only 98 women returned at least 1 diary. According to the methods section, "Nonrespondents and women who declined to participate were less educated (25.0% attended graduate school vs 40.8% of respondents) and more likely to be of black race/ethnicity as compared with respondents (36.7% vs 19.4%). Respondents and nonrespondents did not differ by age (65.3% vs 65.0% <30 years), weight (44.9% vs 42.3% <150 lbs), or marital status (54.1% vs 56.7% single)."

Some of the findings:
  • "Of the 369 women who were initially recruited into the CHIC Study, the majority were 26 to 35 years old (mean: 29.3), single, and highly educated (Table I). Most participants were of race/ethnicity white or black (48.8% and 40.9%, respectively) and nearly half had BMIs in the overweight or obese range (mean BMI = 27.2). The most popular method of contraception was OCs (39.6%), followed by male condoms (21.4%), and tubal ligation (7.6%). The majority of women were not dual method users (75.6%); however, among those women who did use an additional method, male condoms were the most popular method."
  • "Ninety-one women had never used another form of birth control before beginning their current method. Many of these women chose effective methods to protect themselves from unintended pregnancy: 52.8% OCs; 24.2% male condoms; 4.4% injectables, transdermal patch, or vaginal ring; 2.2% intrauterine device (IUD); 2.2% withdrawal; and 14.2% diaphragm or other unspecified methods."
  • "Among women who reported using condoms before starting their current method of contraception (n = 76), women discontinued the use of this method for the following reasons: 22.4% not having sex, 6.6% trying to get pregnant, and 71.1% for other reasons... The vast majority of these women indicated that they were now using a more effective method of birth control (71.1% OCs, 6.6% injectables or transdermal patch)."
  • "Among the 128 who reported using OCs just before switching to their current method, 22.7% discontinued the use of OCs because they were not having sex, 14.1% were trying to get pregnant, and the remaining 63.3% discontinued OCs for other reasons."
  • "Many of these women changed to another reliable form of birth control after discontinuing OCs (32.8% a hormonal method, 11.7% sterilization). However, 10.2% started to use the withdrawal method as their primary method of birth control."
  • "On average, women had sexual intercourse 1.5 times a week. Of note, 26.4% of women had sexual intercourse on days they missed pills just before or after their placebo week. Women who miss pills immediately before or after the placebo week resume some normal follicular development, and may be at risk of pregnancy"

    The authors' commentary:
  • "it is alarming that the vast majority of women who discontinue the use of OCs switch to a less effective method of contraception."
  • "Perhaps clinicians need to engage their patients in more discussion on why they are discontinuing the use of an effective method of contraception, such as OCs."

    Based on this study, it seems that clinicians may need to have more explicit conversations with women to help them choose contraceptives based on their needs, the effectiveness of different methods, lack of effectiveness of withdrawal, and appropriate and consistent use. Have you ever read the insert for oral contraceptives? I have a masters degree, and I still find portions of it confusing. The women in this study were largely educated as well. The rate of unintended pregnancy is very high in this country, and some simple outreach by clinicians and/or pharmacists may help reduce confusion and better empower women to take control of their reproductive years.
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