Why are Women not Using Long-Acting Contraceptives?
Why are Women not Using Long-Acting Contraceptives?
abstract & commentary
Tanfer and colleagues from the battelle centers for Public Health Research and Evaluation in Seattle, Wash., examined data from the 1993 and 1995 National Surveys of Women to examine the reasons why women do not use implant and injectable contraceptives. Implant use was relatively more prevalent among women who were young, who did not have a college degree, who had been married, who were Catholic, who were Hispanic, and who had two or more children and did not want any more children. Injectable use was similar except more prevalent among black women and among women who had attended college, and interestingly, among women who lived in the West. In 1993, the main reasons given for not using the implant were that more than one-fourth of the women in the survey had not heard of the implant, about one-fourth were satisfied with their current method, and 12% feared the method. By 1995, the proportion reporting lack of knowledge had declined to 9%; satisfaction with the current method had increased to 28.1%; and fear of the method had increased to 22%. Only 2.3% in 1995 cited excessive cost as a reason. In 1995, 9.1% of the women had not heard of the injectable method and 27% reported not knowing enough about it. Similarly to the implant method, 20.6% reported satisfaction with their current method and 17% feared the injectable method. Side effects were relatively common, a major reason for discontinuing implants (about 50% of those with side effects), but not a major reason for discontinuing the use of the injectable method (about 5% of those with side effects). Tanfer et al concluded that the use of these methods could be increased by targeting education about the methods to potential users. (Tanfer K, et al. Fam Plann Perspect 2000;32:176-183, 191.)
COMMENT BY LEON SPEROFF, MD
Norplant and Depo-Provera were marketed in the United States in 1991 against a background of many years of success, safety, and acceptance throughout the rest of the world. Neither of these methods achieved a high level of use. In 1995, 0.9% of women of childbearing age were using the implant and 1.9% injectables. This failure to use new methods occurred despite the fact that half of pregnancies in the United States continued to be unintended. A general principle of family planning, supported by appropriate evidence, is that the more contraceptive methods available, the lower the rate of unintended fertility will be. So, what happened?
There were three probable reasons for the loss of appeal with the implant method. More awareness of the method may have increased concern for cost and side effects. The nearly doubling of the proportion of women fearing the implant method from 1993 to 1995 undoubtedly reflected the negative publicity surrounding litigation and suggestions of coercive use that occurred at that time. And it is likely that the marketing of Depo-Provera affected the implant’s potential market.
The injectable method, according to this report, appeals to distinct groups of women (single women, women who have children, women with less than a college education, and women who want a future pregnancy). Interestingly, age and race were not factors.
After nearly a decade since the introduction of Norplant and Depo-Provera to the U.S. market, it is apparent that neither method will achieve the popularity of the oral contraceptive, sterilization, and barrier methods. Is the cup half empty or half full? The pessimistic response is that the implant and injectable methods have proved to be disappointing. The optimistic response is that other methods are very good, and that there is a niche for long-acting methods. Furthermore, this report indicates that the long-acting niche can be expanded with an educational effort directed to appropriately targeted groups of women.
This study identified the characteristics of the women who reported lack of knowledge or fear about the methods. Lack of knowledge was more likely encountered in younger women, married women, and women with no college education, while fear of side effects was more common in single women, women with one or more children, and women using a barrier method. Satisfaction with medically prescribed methods was an important reason for not using long-acting methods of contraception, especially among college-educated women.
Fear of side effects is an understandable motivation to avoid a method of contraception. But what really impresses me is the large proportion of women who had either not heard of the methods or did not know enough about the methods to make a choice. It seems to me that a significant number of those who feared the side effects could be accounted for by a lack of knowledge. Therefore, lack of knowledge emerges as the major operating force.
Contraceptive implants are a good choice for women of reproductive age who are sexually active and desire long-term, continuous contraception. Implants should be considered for women who:
• want to delay the next pregnancy for at least 2-3 years;
• desire a highly effective, long-term method of contraception;
• experience serious or minor estrogen-related side effects with oral contraception;
• have difficulty remembering to take pills every day, have contraindications or difficulty using IUDs, or desire a noncoitus-related method of contraception;
• have completed their childbearing but are not yet ready to undergo permanent sterilization;
• have a history of anemia with heavy menstrual bleeding;
• intend to breastfeed for a year or two;
• women with chronic illnesses, whose health will be threatened by pregnancy.
For women who are spacing their pregnancies, the difference between implants and Depo-Provera in the timing of the return to fertility can be critical. Implants allow precise timing of pregnancy because the return of ovulation after removal is prompt. Depo-Provera, on the other hand, can cause up to 18 months’ delay in return to fertility. By that time, 90% of users of either method will have ovulated, but in the first several months, the difference is dramatic. By three months after removal, half of implant users will have ovulated, but 10 months must elapse before half of Depo-Provera users are ovulatory.
A large, five-year follow-up study in developing countries confirmed the low pregnancy rates associated with Norplant, 0.23 per 100 woman-years for intrauterine pregnancy and 0.03 per 100 woman-years for ectopic pregnancy.1 When the women using Norplant were compared to women using nonhormonal methods of contraception and to the expected population rates, there was no excess of cancers, connective tissue diseases, or cardiovascular events. Importantly, the complaints of headache and mood disturbances (including anxiety and depression) were similar to those reported by women using oral contraceptives, although higher than women using IUDs.
In the United States, the primary motivations for implant use have been problems with previous contraceptive methods and ease of implant use. Although fear of pain during implant insertion is a prominent source of anxiety for many women, the actual pain experienced does not match the expectations. The level of satisfaction has been high in self-motivated and well-informed users.2 Teenagers provide an example of well-documented success. Their one-year pregnancy rates are much lower, and their continuation rates are much higher than that with oral contraceptives.3-7 However, teenage discontinuation of the method due to side effects (especially irregular bleeding and weight gain) is more common with Norplant.8
The introduction of new implant methods hopefully will be a boost to the use of this long-acting method of contraception. The new methods include the two rod levonorgestrel implants (Norplant-2 or Jadelle), Implanon, a single implant that contains 3-keto desogestrel (etonorgestrel), and Uniplant, a single implant contraceptive containing nomegestrol acetate. A single silastic implant containing nestorone is also being studied.
Depo-Provera should be considered for women who have any of the following characteristics:
• At least one year of birth spacing desired
• Highly effective long-acting contraception not linked to coitus
• Estrogen-free contraception needed
• Private, coitally independent method desired
• Breastfeeding
• Sickle cell disease
• Seizure disorder
In Western societies, depression, fatigue, decreased libido, and hypertension are frequently encountered. Whether medroxyprogesterone acetate causes these side effects is difficult to know since they are very common complaints in nonusers as well.9 When studied closely, no increase in depressive symptoms can be observed— even in women with significant complaints of depression prior to treatment.10
Even attempts to document a greater weight gain specifically associated with Depo-Provera are unable to do so.11-13 As with oral contraception, the weight gain may not be hormone-induced but does reflect lifestyle and aging. Remember if symptoms are truly due to the progestin, Depo-Provera, unlike pills and implants, takes 6-8 months after the last injection to leave the body. Clearance is slower in heavier women.
It seems to me that a greater effort to educate women about these methods is needed. The responsibility for this effort must be shared by the pharmaceutical industry and clinicians. A favorable attitude based upon an awareness and knowledge of the vast amount of data derived from many studies and widespread use of these methods is a good starting point for all clinicians who care for women.
References
1. Fraser IS, et al. Contraception 1998;57:1-9.
2. Sivin I, et al. Obstet Gynecol 1998;92:337-344.
3. Cromer BA, et al. Pediatrics 1994;94:687-694.
4. Cullins VE, et al. Obstet Gynecol 1994;83:1026-1032.
5. Polaneczky M, et al N Engl J Med 1994;331:1201-1206.
6. Berenson AB, et al. Am J Obstet Gynecol 1995;172:1128-1137.
7. Darney PD, et al. Am J Obstet Gynecol 1999;180:929-937.
8. Berenson AB, et al. Am J Obstet Gynecol 1997;176:586-592.
9. Westhoff C, et al. Contraception 1995;51:351-354.
10. Westhoff C, et al. Contraception 1998;57:237-240.
11. Moore LL, et al. Contraception 1995;52:215-219.
12. Mainwaring R, et al. Contraception 1995;51:149-153.
13. Taneepanichskul S, et al. Contraception 1998;58:149-151.
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