Contraceptive Choice & Reducing Unplanned Pregnancy. Dr Paula Briggs Consultant in Sexual & Reproductive Health, UK

Contraceptive Choice & Reducing Unplanned Pregnancy Dr Paula Briggs Consultant in Sexual & Reproductive Health, UK

Demographics

Liverpool, UK

Conflicts Dr Paula Briggs has received funding from: MSD Bayer Astellas GSK Pfizer

UK teenage pregnancy rates are the highest in Europe Country Teenage birth rate (per 1,000 women aged 15-19) Country Teenage birth rate (per 1,000 women aged 15-19) Korea 2.9 Germany 13.1 Japan 4.6 Austria 14.0 Switzerland 5.5 Czech Republic 16.4 The Netherlands 6.2 Australia 18.4 Sweden 6.5 Ireland 18.7 Italy 6.6 Poland 18.7 Spain 7.9 Canada 20.2 Denmark 8.1 Portugal 21.2 Finland 9.2 Iceland 24.7 France 9.3 Hungary 26.5 Luxembourg 9.7 Slovak Republic 26.9 Belgium 9.9 New Zealand 29.8 Greece 11.8 United Kingdom 30.8 Norway 12.4 USA 52.1 23/04/2014 5

Change in teenage pregnancy over time 46.6 Under 18 Conception Rate* 44.8 43.6 42.5 42.8 42.1 41.6 41.4 40.6 41.4 39.7 37.1 Adjusted R 2 = 0.81 P-value < 0.0001 34.2 30.7 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 A steady and statistically significant decrease in teenage pregnancy has been observed in England since 1998 A steeper decrease has been observed since 2007 * per 1,000 Women aged 15-17

Number of cycles sold* LARC usage in England over time 25,000 20,000 15,000 10,000 5,000-1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Depo Provera Mirena Implanon / Nexplanon Noristerat IUD Total Overall increase in LARC usage over time. IUD usage has decreased steadily since 1998 whereas Mirena and especially Implanon/Nexplanon usage have increased substantially over the same period Usage of Depo Provera remained stable * In thousand cycles sold

UK Policy Initiatives to reduce teenage abortion rate

National data for LARCs over last 8 years IMS LARC Units (MAT, 000's) 350 300 250 200 150 100 50 0 LARC Usage 2005-2011 2005 2006 2007 2008 2009 2010 2011 IMS, March 2012

Number of abortions Number of abortions is highest in the 20-24 age group 60,000 55,481 50,000 40,000 34,551 40,800 30,000 27,978 27,046 20,000 10,000 3,718 0 under 16 16-19 20-24 25-29 30-34 35+ Age 1. Office for National Statistics & Department of Health. Statistical bulletin, Abortion Statistics: England and Wales 2010; published May 2011.

Expenditure on contraception for women of reproductive age versus abortion rate per 1000 women of similar age in 2009/10 NHS information centre, 2010 and ONS 2011

Accidental pregnancy in first year of use typical use 20 15 Perfect use Typical use percent 10 5 0 diaphragm withdrawal condom POP COC Injectable IUD IUS Implant sterilisa on Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J et al. Contraceptive Technology, revised edition 19. NY: Ardent Media, 2007

CHOICE Study 9,256 women aged 14-45 recruited from St. Louis region, US All participants received reversible contraceptive method of their choice at no cost Abortion rates in CHOICE cohort less than half regional and national rates (P<0.001) Fell by 21% during study Teenage birth within CHOICE cohort 6.3 per 1,000 compared with 34.3 per 1,000 US rate Expanding study nationally could save 41-71% of abortions in US Peipert et al. Obstet Gynecol 2012; Oct 3 (eprint)

Are women satisfied with their method? Women using LARC methods had the highest satisfaction at 1 year follow up Peipert JF et al. Obstet Gynecol 2011; 117(5): 1105-1113

Contraceptive awareness needs to be improved YouGov 2010 survey of 503 women aged 16 to 24 77% wanted a contraceptive method that they didn t have to think about every day plan for during sex Only 1% were aware of all 4 LARCs (IUD, IUS, contraceptive implant, and injection) Just 7% were using an IUD, IUS, contraceptive implant, or injection http://www.mariestopes.org.uk/pressreleases/uk/conception_at_christmas_%e2%80%93_low_ awareness_of_reliable_contraception_increases_the_risk_of_unplanned_pregnancies.aspx

Providing contraceptive choice demonstrates that the majority of women will choose LARCs Contraceptive method choices after counselling (N=2,500) 1 Long-acting Shorter-acting 33% 67% LARC=long-acting reversible contraceptive. 1. Secura GM et al. Am J Obstet Gynecol. 2010;203:115.e1 115.e7 2. Mestad et al. Contraception 2011;84:495-8. 69% of 14-17 year-olds chose a LARC with 63% of these choosing an implant 2

Cumulative percentage of participants who have had an unintended pregnancy at years 1,2 3 Pill Patch Ring Winner et al. N Eng J Med 2012

Probability of not having an unintended pregnancy according to age and method Winner et al. N Eng J Med 2012

Etonogestrel implant effectiveness in post marketing use 1 Overall Analysis Pregnancy rate 0.049/100 implants sold Pearl Index 0.031/100 woman-years of exposure Contraceptive Method Failure Only Pregnancy rate 0.010/100 implants sold Pearl Index 0.006/100 woman-years of exposure 1. Graesslin O et al. Eur J Contracept Reprod Health Care. 2008;13(suppl 1):4 12.

Acceptance of implants Cautious counselling versus try it and see follow up over 1 year Continuation rates 92% for cautious approach 80% for just-try-it approach Try it and see group 20% first learnt about method during same consultation as implant inserted all kept it for 12 months Cautious group Only 4% learnt about implant at insertion visit Rubenstein et al. Eur J Contracept Reprod Health Care 2011

Nexplanon Audit Leeds Student Medical Practice A prospective study of 400 women who had an etonogestrel contraceptive implant (Nexplanon ) was initiated in September 2010 A questionnaire was completed at fitting with telephone follow up arranged at 3, 6 and 12 months

Reasons for requesting an implant were:- 54% active choice 34% current contraceptive problems 9% implant due for replacement 3% medical contraindications to other methods

Contraceptive use prior to implant fitting was:- 46% COC 16% POP 13% condoms 11% subdermal implant 4% no regular method

At 6 months -197 patients: 95% still had the implant 5% implant removed Of the women who still had the device 16% were using medication to control side effects: 72% COC 4% contraceptive patch 8% progestogen 8% acne treatments 4% mefenamic acid 4% paracetamol Main reason for removal: Unacceptable bleeding (n=8) mood swings (n=1)

Continuation rates 86.2% 54.7% DMPA=depomedroxyprogesterone acetate; OCP=oral contraceptive pill. Peipert JF, et al. Obstet Gynecol. 2011;117:1105 13. ~4-fold higher discontinuation rate with non-larc

LARC does prevent further unplanned pregnancies post-abortion Case-note review, Scotland Over two year period 12.3% repeat abortion Teenagers 10 times more likely to have repeat abortion Social deprivation had no effect Using COC as a reference (age controlled) IUS/IUD and implant associated with lowest chance of repeat abortion IUS/IUD users 20 times less likely Implant users 16 times less likely Injectable users similar to COC/no method users Cameron et al. BJOG 2012:119;1074-80

Intrauterine contraception and nulliparous women Use patient choice complex medical problems e.g. cardiovascular disease, HIV, taking liver enzyme inducers Safety in nullips no evidence of increased risk of expulsion, pelvic infection or infertility well-accepted (80% for IUS versus 73% in COC group at 12 months) easily fitted Pakarinen, Contraception, 2003; Prager et al. Contraception 2007

For many women, a daily contraceptive regimen may not be a suitable option Up to 32% of women on a new oral contraceptive discontinue use within 6 months 1 The Pill is user dependent and requires regular visits to HCPs NICE states that: Increased use of Long-Acting Reversible Contraception (LARC) methods will reduce the number of unintended pregnancies 2 1. Rosenburg MJ and Waugh MS, Am J Obstet Gynecol. 1998; 179: 577-582. 2. NICE. Clinical Guideline No. 30, Long-acting Reversible Contraception; October 2005

LARCs offer the highest levels of efficacy Incidence of unintended pregnancy within 1 st year of typical use 1 1. Trussell J. Contraception 2011;83(5):397-404

Use of LARC in General Practice 30

LARC usage by age varies considerably % Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% LARC Method by Age Primary Care Patients in UK 0% Age <18 Age 18-20 Age 21-23 Age 24-29 Age 30-35 Age 36-41 Age 42 + Over Mirena Nexplanon Depo Provera Total IUD Data Source: CSD Patient Data Report 1, CSD UK Ltd, December 2013 Source; CSD, GP data only

NICE & LARC Women should be provided with sufficient information to make an informed choice Health Care Professionals (HCPs) who do not provide LARC should have a referral mechanism in place HCPs should receive training to develop and maintain skills to provide LARC NICE. Clinical Guideline No. 30, Long-acting Reversible Contraception; October 2005

NICE & LARC LARC methods are cost effective options* LARC methods are more cost-effective than the combined oral contraceptive even at 1 year of use IUD, IUS & implants are more cost-effective than injections NICE. Clinical Guideline No. 30, Long-acting Reversible Contraception; October 2005 * Cost effectiveness relates to the comparative analysis of alternative courses of action in terms of their costs and consequences e.g. Cost: ingredient cost, visits, disposables, removal and method failure. Consequence: unintended pregnancy avoided.