LARCs hold key to reducing unplanned pregnancy rate

Little has changed over the years with respect to the proportion of unplanned pregnancies in the United States, but the emergence – and increasing acceptance – of safe and reliable long-acting reversible contraceptives, or LARCs, offers hope for improved reproductive management and outcomes.

Currently, about half of the 6.7 million pregnancies that occur each year in the United States are unplanned, and while that is a startling figure, more startling is the fact that although the distribution has changed – with decreases in unplanned pregnancies among wealthier women, and increases among low-income women and minorities – the percentage hasn’t changed in decades, Dr. Eve Espey said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists in New Orleans.

Further, while only 11% of the women with unplanned pregnancies use no form of birth control, those women’s pregnancies make up only about 50% of the unplanned pregnancies overall; that means that half of all unplanned pregnancies occur in women who use at least one form of birth control, said Dr. Espey of the University of New Mexico, Albuquerque.

This is a problem that likely involves both contraceptive failures and user error.

"One of the things that I think we don’t appreciate is the extent to which women who do use contraceptives use them incorrectly or inconsistently, or use methods that have a high failure rate," she said.

These statistics, and the fact that unintended pregnancies are associated with an increased risk of numerous adverse outcomes, such as preterm birth and neonatal intensive care unit stays, underscore the importance of identifying and promoting contraceptive methods that will help women achieve better regulation of fertility, she said.

LARCs, according to burgeoning research – and a recent American College of Obstetricians and Gynecologists committee opinion – are the answer.

LARCs, including intrauterine devices and the contraceptive implant, should be first-line recommendations for all women and adolescents, according to an October 2012 opinion from the Committee on Adolescent Health Care LARC Working Group (Obstet. Gynecol. 2012;120:983-8). With both perfect and typical use, these contraceptive methods are associated with pregnancy rates of less than 1% per year – far better than reported rates among those using short-acting contraceptive methods such as condoms, oral contraceptives, the contraceptive patch, the vaginal ring, and depot medroxyprogesterone acetate injections, according to the committee opinion. Yet the use of short-acting methods, and particularly the use of oral contraceptives, dwarfs the use of LARC methods.

The use of IUDs is now about 7.5% – a substantial and encouraging increase over the 5.5% reported in recent years, but still far less than the 15%-20% of women who report oral contraceptive use, Dr. Espey said.

Findings from the Contraceptive CHOICE Project – a prospective cohort study designed to promote the use of LARCs among women and adolescents in the St. Louis area, and to reduce the rate of unintended pregnancies in the region, demonstrated that the unintended pregnancy rate was more than 20-fold greater with short-acting vs. LARC methods at 2- to 3-year follow-up. The rate was twice as high in adolescents as in adults (N. Engl. J. Med. 2012;366:1998-2007).

The CHOICE Project included 9,256 women who received a brief educational intervention and access to their contraceptive method of choice free of charge. The majority – 75% - chose LARC methods, suggesting that when cost and access barriers are removed, the typically low use of these highly effective methods (about 5.5% at the time of the study) increases substantially. The increased use of LARC methods was associated with an unplanned pregnancy rate of 35 per 1,000 women, compared with the national rate of 52 per 1,000 women, Dr. Jeffrey Peipert, the lead investigator for the project, said at the meeting.

Moreover, the continuation rate, which is strongly associated with outcomes, was 86% among LARC users at 12 months, compared with 55% for short-acting methods in a separate analysis of data from more than 4,100 project participants (Obstet. Gynecol. 2011;117:1105-13).

The abortion rate among CHOICE Project participants was 6 per 1,000 at follow-up, compared with the national rate of 20 per 1,000. The number needed to treat to prevent 1 abortion was 108.

"These are very reasonable numbers," said Dr. Peipert of Washington University in St. Louis, noting that the findings are all the more astounding given that the CHOICE population was much higher risk than the general population due to younger age, a high percentage of African Americans (about 50%), and lower socioeconomic status (about 40% had trouble affording basic necessities and 40% were uninsured).

If all women in the United States had access to LARC methods, more than 1 million unplanned pregnancies and nearly 900,000 abortions could be prevented each year, according to a CHOICE Project video he shared during his presentation.

"So if we truly want to reduce abortion in this country, what we need to do is increase contraceptive prevalence, and, in particular, talk about the advantages of LARCs," Dr. Espey said, referencing the CHOICE Project findings.

The currently available LARC methods include intrauterine devices and systems (the copper IUD and the hormonal intrauterine systems Mirena and Skyla) and the contraceptive implant (Nexplanon).

Skyla (Bayer HealthCare), approved in January, is the newest system on the market. Compared with Mirena (Bayer HealthCare) – a hormonal intrauterine system that has been available since 2000, the new system uses less levonorgestrel (14 mcg vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use, Dr. Espey said.

In her experience, some women prefer the 3- vs. 5-year product, even after they are told that the 5-year product can be removed early, she noted.

"It shouldn’t make a difference, but psychologically it does," she said.

As for the contraceptive implant, Nexplanon (Merck) is the latest-generation product, having replaced its predecessor, Implanon. The major difference between the two is that Nexplanon, which is approved for 3 years of use, can be seen on x-ray. Also, it only requires one hand for insertion, improving ease of use.

Overall, the implant, which works by preventing ovulation, is easy to learn, and is safe and highly effective, with very few contraindications, according to Dr. Tony Ogburn, who also spoke at the ACOG meeting.

Unpredictable bleeding can be an issue for some women, and is the most common reason for removal. Counseling and education, along with reassurance about Nexplanon’s safety, can promote continuation, he said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases. Physicians previously certified to insert Implanon can take an online training course to become certified for Nexplanon insertion; those not previously trained must attend a live course, said Dr. Ogburn of the University of New Mexico, Albuquerque.

Deciding which LARC method is appropriate in a given patient can be somewhat daunting, but an app available from the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use can help.

Dr. Espey, who swears by the app – even for "non-app people" like herself – said that it provides evidence-based reviews of every type of contraceptive method lined up against various patient characteristics and conditions, and coordinates recommendations.

For those averse to using an app, a chart is also available. Notably, the chart shows that most contraceptive use is safe.

There are a lot of misconceptions on the part of patients about the safety of one contraceptive method or another, and the fact is that contraception is "overmedicalized," Dr. Espey said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases, she added.

Of course, the low use of LARC methods is hardly the only hurdle when it comes to improving the unintended pregnancy rate in the United States. Compared with European Countries that have extremely low unintended pregnancy rates, the United States has a lack of comprehensive sex education that begins at a young age, and a greater cultural acceptance of teen motherhood. Progress in the United States also is hampered by patriarchal attitudes that may allow men control over reproductive health, and by a mismatch in cultural values that is apparent in the "wildly sexual" U.S. media and the puritanical views that limit conversations with children about sex and sexuality as a normal part of human behavior, Dr Espey said.

Additional hurdles include poverty, racism, and inadequate social and health care safety nets, she noted.

That’s not to say, however, that major inroads can’t be made by promoting LARC use. A flurry of research presented at the ACOG annual meeting that focused on various approaches to increasing use among patients highlights the increasing focus on, and commitment to, helping patients take control of their fertility. One study, for example, showed that the use of a short, simple counseling intervention – much like the one used for the CHOICE project, is feasible and effective for promoting LARC use when provided in the immediate postpartum period. Another suggested that while a postpartum educational script increased interest in LARC methods, certain barriers to access may limit uptake.

Dr. Espey said that it is important to focus first and foremost on LARC methods when counseling a patient about contraception.

"So often I think we approach contraceptive counseling as if we have to tell everybody about all the methods as if they were all equal, but in other kinds of medication we would naturally lean toward recommending methods that are most highly effective," she said.

For contraception, that’s intrauterine devices and implants, she added.

Dr. Peipert agreed, noting, "If we had a pill for hypertension that was 20-fold less effective, we wouldn’t offer it first line."

Not only are LARC methods the most effective contraceptive methods, but under the right circumstances they also have a high rate of acceptability, as demonstrated by the CHOICE Project, he said.

They also have the potential to dramatically reduce health care costs.

"We believe that family planning saves dollars. We spend over $11 billion each year on unintended pregnancy. No-cost contraception and wide access to contraception can prevent unintended pregnancy and save health care dollars," he said, adding that every dollar spent on family planning can save $3 or $4 down the road – and because of their effectiveness, the savings are even greater with LARC use.

"We really have an opportunity to impact public health. It’s been decades where we’ve been stuck at a rate of unintended pregnancy in the U.S. of close to 50%, and now, if we can shift our emphasis to LARC methods, I think we will finally see a reduction in unintended pregnancies," he said.

Dr. Espey and Dr. Ogburn reported having no disclosures. Dr. Peipert has received research funding from Bayer and Merck. The CHOICE Project was funded by an anonymous donation.

Little has changed over the years with respect to the proportion of unplanned pregnancies in the United States, but the emergence – and increasing acceptance – of safe and reliable long-acting reversible contraceptives, or LARCs, offers hope for improved reproductive management and outcomes.

Currently, about half of the 6.7 million pregnancies that occur each year in the United States are unplanned, and while that is a startling figure, more startling is the fact that although the distribution has changed – with decreases in unplanned pregnancies among wealthier women, and increases among low-income women and minorities – the percentage hasn’t changed in decades, Dr. Eve Espey said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists in New Orleans.

Further, while only 11% of the women with unplanned pregnancies use no form of birth control, those women’s pregnancies make up only about 50% of the unplanned pregnancies overall; that means that half of all unplanned pregnancies occur in women who use at least one form of birth control, said Dr. Espey of the University of New Mexico, Albuquerque.

This is a problem that likely involves both contraceptive failures and user error.

"One of the things that I think we don’t appreciate is the extent to which women who do use contraceptives use them incorrectly or inconsistently, or use methods that have a high failure rate," she said.

These statistics, and the fact that unintended pregnancies are associated with an increased risk of numerous adverse outcomes, such as preterm birth and neonatal intensive care unit stays, underscore the importance of identifying and promoting contraceptive methods that will help women achieve better regulation of fertility, she said.

LARCs, according to burgeoning research – and a recent American College of Obstetricians and Gynecologists committee opinion – are the answer.

LARCs, including intrauterine devices and the contraceptive implant, should be first-line recommendations for all women and adolescents, according to an October 2012 opinion from the Committee on Adolescent Health Care LARC Working Group (Obstet. Gynecol. 2012;120:983-8). With both perfect and typical use, these contraceptive methods are associated with pregnancy rates of less than 1% per year – far better than reported rates among those using short-acting contraceptive methods such as condoms, oral contraceptives, the contraceptive patch, the vaginal ring, and depot medroxyprogesterone acetate injections, according to the committee opinion. Yet the use of short-acting methods, and particularly the use of oral contraceptives, dwarfs the use of LARC methods.

The use of IUDs is now about 7.5% – a substantial and encouraging increase over the 5.5% reported in recent years, but still far less than the 15%-20% of women who report oral contraceptive use, Dr. Espey said.

Findings from the Contraceptive CHOICE Project – a prospective cohort study designed to promote the use of LARCs among women and adolescents in the St. Louis area, and to reduce the rate of unintended pregnancies in the region, demonstrated that the unintended pregnancy rate was more than 20-fold greater with short-acting vs. LARC methods at 2- to 3-year follow-up. The rate was twice as high in adolescents as in adults (N. Engl. J. Med. 2012;366:1998-2007).

The CHOICE Project included 9,256 women who received a brief educational intervention and access to their contraceptive method of choice free of charge. The majority – 75% - chose LARC methods, suggesting that when cost and access barriers are removed, the typically low use of these highly effective methods (about 5.5% at the time of the study) increases substantially. The increased use of LARC methods was associated with an unplanned pregnancy rate of 35 per 1,000 women, compared with the national rate of 52 per 1,000 women, Dr. Jeffrey Peipert, the lead investigator for the project, said at the meeting.

Moreover, the continuation rate, which is strongly associated with outcomes, was 86% among LARC users at 12 months, compared with 55% for short-acting methods in a separate analysis of data from more than 4,100 project participants (Obstet. Gynecol. 2011;117:1105-13).

The abortion rate among CHOICE Project participants was 6 per 1,000 at follow-up, compared with the national rate of 20 per 1,000. The number needed to treat to prevent 1 abortion was 108.

"These are very reasonable numbers," said Dr. Peipert of Washington University in St. Louis, noting that the findings are all the more astounding given that the CHOICE population was much higher risk than the general population due to younger age, a high percentage of African Americans (about 50%), and lower socioeconomic status (about 40% had trouble affording basic necessities and 40% were uninsured).

If all women in the United States had access to LARC methods, more than 1 million unplanned pregnancies and nearly 900,000 abortions could be prevented each year, according to a CHOICE Project video he shared during his presentation.

"So if we truly want to reduce abortion in this country, what we need to do is increase contraceptive prevalence, and, in particular, talk about the advantages of LARCs," Dr. Espey said, referencing the CHOICE Project findings.

The currently available LARC methods include intrauterine devices and systems (the copper IUD and the hormonal intrauterine systems Mirena and Skyla) and the contraceptive implant (Nexplanon).

Skyla (Bayer HealthCare), approved in January, is the newest system on the market. Compared with Mirena (Bayer HealthCare) – a hormonal intrauterine system that has been available since 2000, the new system uses less levonorgestrel (14 mcg vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use, Dr. Espey said.

In her experience, some women prefer the 3- vs. 5-year product, even after they are told that the 5-year product can be removed early, she noted.

"It shouldn’t make a difference, but psychologically it does," she said.

As for the contraceptive implant, Nexplanon (Merck) is the latest-generation product, having replaced its predecessor, Implanon. The major difference between the two is that Nexplanon, which is approved for 3 years of use, can be seen on x-ray. Also, it only requires one hand for insertion, improving ease of use.

Overall, the implant, which works by preventing ovulation, is easy to learn, and is safe and highly effective, with very few contraindications, according to Dr. Tony Ogburn, who also spoke at the ACOG meeting.

Unpredictable bleeding can be an issue for some women, and is the most common reason for removal. Counseling and education, along with reassurance about Nexplanon’s safety, can promote continuation, he said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases. Physicians previously certified to insert Implanon can take an online training course to become certified for Nexplanon insertion; those not previously trained must attend a live course, said Dr. Ogburn of the University of New Mexico, Albuquerque.

Deciding which LARC method is appropriate in a given patient can be somewhat daunting, but an app available from the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use can help.

Dr. Espey, who swears by the app – even for "non-app people" like herself – said that it provides evidence-based reviews of every type of contraceptive method lined up against various patient characteristics and conditions, and coordinates recommendations.

For those averse to using an app, a chart is also available. Notably, the chart shows that most contraceptive use is safe.

There are a lot of misconceptions on the part of patients about the safety of one contraceptive method or another, and the fact is that contraception is "overmedicalized," Dr. Espey said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases, she added.

Of course, the low use of LARC methods is hardly the only hurdle when it comes to improving the unintended pregnancy rate in the United States. Compared with European Countries that have extremely low unintended pregnancy rates, the United States has a lack of comprehensive sex education that begins at a young age, and a greater cultural acceptance of teen motherhood. Progress in the United States also is hampered by patriarchal attitudes that may allow men control over reproductive health, and by a mismatch in cultural values that is apparent in the "wildly sexual" U.S. media and the puritanical views that limit conversations with children about sex and sexuality as a normal part of human behavior, Dr Espey said.

Additional hurdles include poverty, racism, and inadequate social and health care safety nets, she noted.

That’s not to say, however, that major inroads can’t be made by promoting LARC use. A flurry of research presented at the ACOG annual meeting that focused on various approaches to increasing use among patients highlights the increasing focus on, and commitment to, helping patients take control of their fertility. One study, for example, showed that the use of a short, simple counseling intervention – much like the one used for the CHOICE project, is feasible and effective for promoting LARC use when provided in the immediate postpartum period. Another suggested that while a postpartum educational script increased interest in LARC methods, certain barriers to access may limit uptake.

Dr. Espey said that it is important to focus first and foremost on LARC methods when counseling a patient about contraception.

"So often I think we approach contraceptive counseling as if we have to tell everybody about all the methods as if they were all equal, but in other kinds of medication we would naturally lean toward recommending methods that are most highly effective," she said.

For contraception, that’s intrauterine devices and implants, she added.

Dr. Peipert agreed, noting, "If we had a pill for hypertension that was 20-fold less effective, we wouldn’t offer it first line."

Not only are LARC methods the most effective contraceptive methods, but under the right circumstances they also have a high rate of acceptability, as demonstrated by the CHOICE Project, he said.

They also have the potential to dramatically reduce health care costs.

"We believe that family planning saves dollars. We spend over $11 billion each year on unintended pregnancy. No-cost contraception and wide access to contraception can prevent unintended pregnancy and save health care dollars," he said, adding that every dollar spent on family planning can save $3 or $4 down the road – and because of their effectiveness, the savings are even greater with LARC use.

"We really have an opportunity to impact public health. It’s been decades where we’ve been stuck at a rate of unintended pregnancy in the U.S. of close to 50%, and now, if we can shift our emphasis to LARC methods, I think we will finally see a reduction in unintended pregnancies," he said.

Dr. Espey and Dr. Ogburn reported having no disclosures. Dr. Peipert has received research funding from Bayer and Merck. The CHOICE Project was funded by an anonymous donation.

Little has changed over the years with respect to the proportion of unplanned pregnancies in the United States, but the emergence – and increasing acceptance – of safe and reliable long-acting reversible contraceptives, or LARCs, offers hope for improved reproductive management and outcomes.

Currently, about half of the 6.7 million pregnancies that occur each year in the United States are unplanned, and while that is a startling figure, more startling is the fact that although the distribution has changed – with decreases in unplanned pregnancies among wealthier women, and increases among low-income women and minorities – the percentage hasn’t changed in decades, Dr. Eve Espey said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists in New Orleans.

Further, while only 11% of the women with unplanned pregnancies use no form of birth control, those women’s pregnancies make up only about 50% of the unplanned pregnancies overall; that means that half of all unplanned pregnancies occur in women who use at least one form of birth control, said Dr. Espey of the University of New Mexico, Albuquerque.

This is a problem that likely involves both contraceptive failures and user error.

"One of the things that I think we don’t appreciate is the extent to which women who do use contraceptives use them incorrectly or inconsistently, or use methods that have a high failure rate," she said.

These statistics, and the fact that unintended pregnancies are associated with an increased risk of numerous adverse outcomes, such as preterm birth and neonatal intensive care unit stays, underscore the importance of identifying and promoting contraceptive methods that will help women achieve better regulation of fertility, she said.

LARCs, according to burgeoning research – and a recent American College of Obstetricians and Gynecologists committee opinion – are the answer.

LARCs, including intrauterine devices and the contraceptive implant, should be first-line recommendations for all women and adolescents, according to an October 2012 opinion from the Committee on Adolescent Health Care LARC Working Group (Obstet. Gynecol. 2012;120:983-8). With both perfect and typical use, these contraceptive methods are associated with pregnancy rates of less than 1% per year – far better than reported rates among those using short-acting contraceptive methods such as condoms, oral contraceptives, the contraceptive patch, the vaginal ring, and depot medroxyprogesterone acetate injections, according to the committee opinion. Yet the use of short-acting methods, and particularly the use of oral contraceptives, dwarfs the use of LARC methods.

The use of IUDs is now about 7.5% – a substantial and encouraging increase over the 5.5% reported in recent years, but still far less than the 15%-20% of women who report oral contraceptive use, Dr. Espey said.

Findings from the Contraceptive CHOICE Project – a prospective cohort study designed to promote the use of LARCs among women and adolescents in the St. Louis area, and to reduce the rate of unintended pregnancies in the region, demonstrated that the unintended pregnancy rate was more than 20-fold greater with short-acting vs. LARC methods at 2- to 3-year follow-up. The rate was twice as high in adolescents as in adults (N. Engl. J. Med. 2012;366:1998-2007).

The CHOICE Project included 9,256 women who received a brief educational intervention and access to their contraceptive method of choice free of charge. The majority – 75% - chose LARC methods, suggesting that when cost and access barriers are removed, the typically low use of these highly effective methods (about 5.5% at the time of the study) increases substantially. The increased use of LARC methods was associated with an unplanned pregnancy rate of 35 per 1,000 women, compared with the national rate of 52 per 1,000 women, Dr. Jeffrey Peipert, the lead investigator for the project, said at the meeting.

Moreover, the continuation rate, which is strongly associated with outcomes, was 86% among LARC users at 12 months, compared with 55% for short-acting methods in a separate analysis of data from more than 4,100 project participants (Obstet. Gynecol. 2011;117:1105-13).

The abortion rate among CHOICE Project participants was 6 per 1,000 at follow-up, compared with the national rate of 20 per 1,000. The number needed to treat to prevent 1 abortion was 108.

"These are very reasonable numbers," said Dr. Peipert of Washington University in St. Louis, noting that the findings are all the more astounding given that the CHOICE population was much higher risk than the general population due to younger age, a high percentage of African Americans (about 50%), and lower socioeconomic status (about 40% had trouble affording basic necessities and 40% were uninsured).

If all women in the United States had access to LARC methods, more than 1 million unplanned pregnancies and nearly 900,000 abortions could be prevented each year, according to a CHOICE Project video he shared during his presentation.

"So if we truly want to reduce abortion in this country, what we need to do is increase contraceptive prevalence, and, in particular, talk about the advantages of LARCs," Dr. Espey said, referencing the CHOICE Project findings.

The currently available LARC methods include intrauterine devices and systems (the copper IUD and the hormonal intrauterine systems Mirena and Skyla) and the contraceptive implant (Nexplanon).

Skyla (Bayer HealthCare), approved in January, is the newest system on the market. Compared with Mirena (Bayer HealthCare) – a hormonal intrauterine system that has been available since 2000, the new system uses less levonorgestrel (14 mcg vs. 20 mcg), has a smaller frame and inserter tube that have been shown to be less painful on insertion in nulliparous women, is associated with more abnormal bleeding, and is approved for 3 years (vs. 5 years) of use, Dr. Espey said.

In her experience, some women prefer the 3- vs. 5-year product, even after they are told that the 5-year product can be removed early, she noted.

"It shouldn’t make a difference, but psychologically it does," she said.

As for the contraceptive implant, Nexplanon (Merck) is the latest-generation product, having replaced its predecessor, Implanon. The major difference between the two is that Nexplanon, which is approved for 3 years of use, can be seen on x-ray. Also, it only requires one hand for insertion, improving ease of use.

Overall, the implant, which works by preventing ovulation, is easy to learn, and is safe and highly effective, with very few contraindications, according to Dr. Tony Ogburn, who also spoke at the ACOG meeting.

Unpredictable bleeding can be an issue for some women, and is the most common reason for removal. Counseling and education, along with reassurance about Nexplanon’s safety, can promote continuation, he said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases. Physicians previously certified to insert Implanon can take an online training course to become certified for Nexplanon insertion; those not previously trained must attend a live course, said Dr. Ogburn of the University of New Mexico, Albuquerque.

Deciding which LARC method is appropriate in a given patient can be somewhat daunting, but an app available from the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria (US MEC) for Contraceptive Use can help.

Dr. Espey, who swears by the app – even for "non-app people" like herself – said that it provides evidence-based reviews of every type of contraceptive method lined up against various patient characteristics and conditions, and coordinates recommendations.

For those averse to using an app, a chart is also available. Notably, the chart shows that most contraceptive use is safe.

There are a lot of misconceptions on the part of patients about the safety of one contraceptive method or another, and the fact is that contraception is "overmedicalized," Dr. Espey said.

Contraceptives prevent pregnancy, which is inherently more dangerous than contraception in most cases, she added.

Of course, the low use of LARC methods is hardly the only hurdle when it comes to improving the unintended pregnancy rate in the United States. Compared with European Countries that have extremely low unintended pregnancy rates, the United States has a lack of comprehensive sex education that begins at a young age, and a greater cultural acceptance of teen motherhood. Progress in the United States also is hampered by patriarchal attitudes that may allow men control over reproductive health, and by a mismatch in cultural values that is apparent in the "wildly sexual" U.S. media and the puritanical views that limit conversations with children about sex and sexuality as a normal part of human behavior, Dr Espey said.

Additional hurdles include poverty, racism, and inadequate social and health care safety nets, she noted.

That’s not to say, however, that major inroads can’t be made by promoting LARC use. A flurry of research presented at the ACOG annual meeting that focused on various approaches to increasing use among patients highlights the increasing focus on, and commitment to, helping patients take control of their fertility. One study, for example, showed that the use of a short, simple counseling intervention – much like the one used for the CHOICE project, is feasible and effective for promoting LARC use when provided in the immediate postpartum period. Another suggested that while a postpartum educational script increased interest in LARC methods, certain barriers to access may limit uptake.

Dr. Espey said that it is important to focus first and foremost on LARC methods when counseling a patient about contraception.

"So often I think we approach contraceptive counseling as if we have to tell everybody about all the methods as if they were all equal, but in other kinds of medication we would naturally lean toward recommending methods that are most highly effective," she said.

For contraception, that’s intrauterine devices and implants, she added.

Dr. Peipert agreed, noting, "If we had a pill for hypertension that was 20-fold less effective, we wouldn’t offer it first line."

Not only are LARC methods the most effective contraceptive methods, but under the right circumstances they also have a high rate of acceptability, as demonstrated by the CHOICE Project, he said.

They also have the potential to dramatically reduce health care costs.

"We believe that family planning saves dollars. We spend over $11 billion each year on unintended pregnancy. No-cost contraception and wide access to contraception can prevent unintended pregnancy and save health care dollars," he said, adding that every dollar spent on family planning can save $3 or $4 down the road – and because of their effectiveness, the savings are even greater with LARC use.

"We really have an opportunity to impact public health. It’s been decades where we’ve been stuck at a rate of unintended pregnancy in the U.S. of close to 50%, and now, if we can shift our emphasis to LARC methods, I think we will finally see a reduction in unintended pregnancies," he said.

Dr. Espey and Dr. Ogburn reported having no disclosures. Dr. Peipert has received research funding from Bayer and Merck. The CHOICE Project was funded by an anonymous donation.