Contraception and at risk populations

Major health disparities occur in at risk groups of women who do not have access to reliable and affordable contraception. In this World Contraception Day blog, Dr. Alicia Christy and Dr. Carolyn Sufrin highlight these at risk groups and discuss the barriers that need to be eliminated in order to reduce unintended pregnancies and improve health.

Unintended pregnancy is a major global issue. Women with unintended pregnancies have a higher likelihood of problems such as late entry to care, higher use of alcohol and drugs during pregnancy, and preterm birth. The frequency of unintended pregnancy is often higher among lower income women, making the financial impact of an unplanned conception even more significant. This burden is even greater among single mothers.

Many at risk women, particularly poor women, incarcerated women, women of color, adolescents and women with chronic medical conditions, do not have adequate access to reliable and affordable contraception, resulting in major health disparities among this group.

Reducing unintended pregnancies in different groups

Any efforts to decrease unintended pregnancy will need to include elimination of barriers to at-risk women. Patients’ access to highly-effective contraception will increase when obstacles such as a lack of insurance, inadequate coverage that requires large out of pocket expenses, and extremely high premiums are removed.

In addition to decreasing economic barriers, education of both patients and providers is of critical importance. In order to maximize opportunities to educate patients, physicians should consider every contact with their patients as a teachable moment. Healthcare providers should also educate themselves about the safety and efficacy of contraception, as well as the use of emergency contraception.

Nearly half of adolescent pregnancies are unintended.

Nearly half of adolescent pregnancies are unintended. Difficulties with access to contraception, and poor compliance make this at risk group more likely to have an unplanned conception.  Although long-acting reversible contraceptives (LARCs) are an excellent choice for adolescents, many providers believe that teens are not appropriate candidates for some contraceptive methods, like intrauterine devices (IUDs).

Education is a critical aspect of any intervention in adolescents, as evidenced by a review of 53 randomized controlled trials that enrolled over 100,000 adolescents.

Data from the Centers for Diseases Control (USA) has shown that LARCs are an excellent choice of contraception for women with chronic medical conditions, particularly those that cannot use hormonal contraception. Women who have pre-existing conditions, such as diabetes and hypertension, are at much greater risk for complications related to hormonal contraception as well as obstetrical complications.

Homeless women are an at-risk group who are not only economically disadvantaged, but also have unstable living conditions and are more likely to have chronic medical conditions and mental illness. These women are also good candidates for LARCs.

Providers who are unable to provide LARCs such as IUDs and implants should refer patients to physicians who can offer these methods. In particular, physicians should help correct misconceptions about LARCs’ mechanisms of action, and the mistaken belief that some forms of contraception – particularly emergency contraceptives—cause abortion. These erroneous perceptions create unnecessary barriers to patients seeking safe and effective contraception options.

Women who are incarcerated are a particularly vulnerable population. They are at high risk for unintended pregnancy upon release, with only 28% using contraception prior to incarceration, 85% intending to be sexually active upon release, and, few with a positive pregnancy attitude.

Most jails and prisons do not have contraception, including for women who were already using it pre-incarceration.

Offering contraception pre-release is an excellent time for some women to initiate contraception, as it avoids access barriers many face in the community. However, most jails and prisons do not have contraception, including for women who were already using it pre-incarceration.

While it is important to advocate for expanded access to contraception for incarcerated women, this must be done with attentiveness to the potential for coercion in the incarcerated environment, and measures must be taken to ensure that these vulnerable women do not experience undue pressure to choose contraception in general or any method in particular, especially provider-controlled LARC methods and permanent sterilization.

Emergency contraception is an often underutilized form of contraception. Both levonorgestrel (Plan B) and ulipristal acetate (Ella) are safe and effective, and do not cause abortion. If used within 24 hours of unprotected intercourse, the chance of preventing an unintended pregnancy is very high.

The American College of Obstetricians recommends that all reproductive age women who are at risk for unintended pregnancy receive an advance prescription for emergency contraception so that it is readily available if needed.

Unintended pregnancy has recently gained greater public attention. The United Nations has highlighted the importance of improving maternal health through decreasing unintended pregnancies. In the United States, the U.S. Department of Health and Human Services has targeted this issue through the Healthy People 2020 family planning objectives. This goal of this initiative is to increase the USA’s rate of intended pregnancies in the U.S. to 56%.

It is the goal of Contraception and Reproductive Medicine to publish information that will inform and guide healthcare providers about the options and importance of effective contraception. The journal also welcomes new research on contraception use and reproductive care of at-risk populations.

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