The Contraceptive CHOICE Project
/Background
Title: The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception
Publishing Info:
Done by a group at the department of Ob/Gyn at Washington St. Louis School of Medicine (first author was a PhD!)
Published in AJOG in 2010 (first 2500 patients)
Follow up was published in Clinical Ob/Gyn 2014 - 9256 women
Who funded this study
Funded by an anonymous foundation + also Midcareer Investigator Award in women’s Health Research, Clinical Translational Science Award, and NCRR
Why was this study done?
About half of the pregnancies that occur in the US are unintended
A lot of pregnancies results from incorrect or inconsistent use of birth control methods
At the time, LARC use was low, <3% of women in the US used a LARC
CHOICE was done to promote use of LARCs in the St. Louis region
Goal:
Objective: provide no-cost contraception to a large number of women in that region
Secondary: reduce unintended pregnancy at the population level
In order to accomplish, had to overcome two barriers:
Financial obstacles
Lack of patient awareness of LARC method safety and efficacy
Methods
Type of study
Prospective cohort study of 10,000 women in St. Louis region
Intervention
Provided each participant with the contraceptive of her choice at no cost for three years
Subject recruitment
Convenience sample - meaning no randomization, etc. Just chose women at specific clinic locations and via general awareness of CHOICE through medical providers
Clinics were university-affiliated clinics, two facilities providing abortion services, community clinics, etc.
Eligibility:
Age 14-45
Reside in or seek clinical services at recruitment sites in St. Louis region
Sexually active with male partner in last 6 months or anticipate sexual activity with male partner in next 6 months
No tubal or hysterectomy
Does not desire pregnancy in next year
Not currently using contraceptive method or interested in starting a new reversible contraceptive method
Recruitment and screening was done by person on site or by telephone
Person was trained with scripted intro to LARC methods if LNG-IUD, copper IUD, and subdermal implant
Enrollment occurs in 1.5-2 hr in person process
Rule out pregnancy
Due to staff constraints, not everyone got the same counseling - so at the community sites, patients received routine family planning counseling
Informed consent
LARC method
If they wanted a LARC method, then they had insertion by trained professional
Emergency contraception was provided if needed
Follow up: phone follow up at 3, 6, 12, 18, 24, 30, 36 months post enrollment
Given $10 for each completed survey
Also screened for gonorrhea and chlamydia at 12, 24, and 36 month contacts
Huge undertaking to follow people for 3 years!
Collected info on baseline demographics, OB and gyn history, etc.
Results
Findings for first 2500 women (2010 study)
Population
Between August 2007 - December 2008, screened 4107 women, 3522 met eligibility criteria, 2500 enrolled
74% (1845/2500) of enrollments occurred at university-based recruitment site
Average age: 25 (range 14-45), majority were 25 or younger (only 36.9% >25)
49% white, 44% black
42% no insurance, more than half reported difficulty paying for transportation food, housing, or medications
63.7% single or never married
41% nulliparous, 54% of parous women reported having 2 or more children
67.1% chose a LARC, and 32.9% chose other methods
Of those that chose LARCs: 46.8% LNG-IUD, 9.3% Copper IUD, 11.0% subdermal implant
LARC users more likely to be recruited at an abnortion clinic (RR 1.2, 95% CI 1.1-1.2), report greater parity, or history of abrotion
Those who reported black or other race, single or never married, one or no lifetime partners were less likely to choose LARC
Findings for all the patients
Demographics were overall pretty similar
At the end of the study:
LARC users were more likely than non-LARC users to continue at the 12 and 24 months with method (86% vs. 55% at 12 months, 77% vs 41% at 24 months)
At 12 months, the IUDs had highest continuation rates (88% for LNG-IUD, 84% for copper iUD), same at 24 months (79% for LNG-IUD and 77% copper)
Some people voiced concern that with increased LARC use, there may be increase in high risk sexual behavior — no evidence to suggest that there was increased sexual risk-taking
71% reported no change in their number of sexual partners at 6 and 12 months; only 16% report increase, and of those, 80% experienced a change from 0 to 1 partners
Percent of women reporting multiple partners at baseline was significantly reduced at 6 and 12 months (5.2%, 3.5%, 3.3% respectively)
Reduction of unintended pregnancies!
Failure rates for pill, patch, and ring = 4.8%, 7.8%, 9.4% at 1, 2, and 3 years
Failure rate for LARC users remained <1% throughout the 3 year follow up (cumulative was 0.3%, 0.6%, and 0.9% at each year respectively)
Non-LARC users were 22x as likely to experience an unintended pregnancy compared to LARC counterparts
Adolescent users of pill, patch, or ring were twice as likely as older women to experience unintended pregnancies
Very cool: super decreased rates of pregnancy, birth and abortion among teens!
National for each: 158/1000, 94/1000, 41/1000
CHOICE: 34/1000, 19.4/1000, 9.7/1000 - Greater than 75% reduction!
Contraception in the overweight and obese populations
BMI was not found to be significant factor associated with increased risk of method failure for pill, patch, or vaginal ring (there were a total of 334 unintended pregnancies, 128 were determined to be contraceptive failure)
Weight gain
Those who perceived weight gain were more likely to be implant or DMPA users
Objective weight gain on average was 10.3 lbs
Adjusted models only identified black race as having significant association with weight gain in 12 months
STIs: Prevalence of GC, CT, and trich were higher in the CHOICE cohort than the national average at baseline
7.9% had one or more
Conclusions
Huge # of women seeking reversible contraception
When barriers of cost, access, and knowledge are removed, women choose the most effective and least-user dependent methods more often
In general population, LARC use was 3%
In this population, 46% chose LNG IUD, 11.9% chose Copper IUD, and 16.9% chose implant
Continue to use them
Also found they were highly satisfied
Also decrease risk of unintended pregnancies, teen pregnancies
What do we do now?
Some pretty cool follow up:
Colorado Family Planning Initiative - provides access to long-acting reversible contraception
Teen birth rates cut in half, abortion rates cut in half
Average rate of first birth increased by 1.2 years among all women
Cost avoided: $66.1-69.6 million
Per CDC we have definitely increased LARC use now!
2015-2017: LARC use was up to 10.3%
LARC was highest among women 20-29 (13.1%)