ACOG 2013

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.

NEW ORLEANS – The proportion of American College of Obstetricians and Gynecologists fellows practicing in private settings has declined steadily over the past 2 decades, survey data show.

Between 1992 and 2012, the percentage of fellows in solo practice decreased from 32% to 19%, while the percentage employed by hospitals increased steadily from 5% to 15%, and those employed as academic faculty increased from 9% to 12%, Jeffrey C. Klagholz reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). Three percent were employed by HMOs, and 2% by the government; these remained basically static over time.

The percentage of fellows in private practice groups ranged from 44% to 52% (median of 48%) across the seven ACOG surveys on professional liability administered during the study period, according to Mr. Klagholz of ACOG in Washington, who noted that the findings were confirmed, and expanded upon, by data from a recent Socioeconomic Survey of ACOG Fellows.

During a session on workforce issues affecting ACOG fellows at the annual meeting, poster coauthor William Rayburn expanded on this report, and outlined a number of other recent and predicted changes in workforce trends and demand for obstetric and gynecologic care.

Of note, the proportion of resident graduates has not kept pace with increases in the population, and the proportion moving on to an accredited fellowship program – such as female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, or reproductive endocrinology – more than doubled, increasing from 7% to 17% between 2000 and 2009. The percentage increases to 27% when minimally invasive surgery, pediatric and adolescent gynecology, and family planning and reproductive health fellowship programs are included, said Dr. Rayburn, chair of obstetrics and gynecology at the University of New Mexico, Albuquerque.

"We’re getting the message here that ... our graduates are moving more in the direction of subspecializing, and that concerns me with regard to the number of general obstetricians and gynecologists for our growing population, with there not being an increase in the number of residents," he said.

Adding to the shortage problem is the fact that a greater number of ACOG fellows are physicians aged 60 years or older, who are reaching "very senior status," compared with those who are aged 39 years or younger (about 5,500 vs. about 4,000 in 2012), he said.

Traditionally, the drop off in the number of ob.gyns. actually practicing obstetrics begins at about age 55 years. In fact, only one in three ACOG fellows and junior fellows in practice is aged 55 years or older.

"I daresay, anyone who is that age or older, at some time, is thinking of what they will do down the road and when they will eventually retire," he said, adding, "I think this is an important concept, because we have what’s called a static pipeline. That is, the number of resident graduates, which is not increasing, is actually lower than the number who are entering retirement age," Dr. Rayburn said.

If those residents are subspecializing more, the value that general ob.gyns. bring to the health care of women is tremendous, he added.

As for where women’s health care is most needed, it appears that while there is a shortage of ob.gyns., the bigger problem is "maldistribution," Dr. Rayburn said, explaining that the vast majority of ob.gyns. practice in metropolitan areas.

Generally speaking, one full-time ob.gyn. equivalent is needed per 10,000 population, but 49% of the more than 3,300 counties in the United States have no ob.gyn.

This affects about 10 million women who will be eligible for health care coverage under the Affordable Care Act, if they aren’t covered already, Dr. Rayburn said.

Reaching these patients will require "getting creative" about finding ways to deliver care. Outreach clinics, greater use of physician extenders, and collaborative efforts with primary care physicians are among the approaches he mentioned.

A related concept – demand for care – is an important one, especially considering the aging of the population, but it can be difficult to predict. Although 80% of ob.gyn. care is provided to reproductive-age women, and little is provided to those over age 65 years, ob.gyns. are "still a significant player in taking care of women who are aged 40-64 years," he said.

Given shortages in the primary care fields, it is likely that ob.gyns. will play an increasing role in taking care of these women.

Data from a recent study, which Dr. Rayburn hopes to publish soon, suggest that demand for women’s health care services will grow by about 6% by 2020.

"In other words, you’re going to be working 6% harder than you are right now in terms of meeting the demand of your patients," he said, noting that the estimate is a conservative one and that demand will vary greatly by geographic region.

For example, areas such as Montana, North Dakota, and West Virginia will likely see decreasing demand, which may be a good thing since these areas have general ob.gyn. shortages, he said.

Texas and Florida, as well as areas in the Intermountain West are expected to experience booming demand, with increases of more than 10%.

"So we’ve got to think of alternative modes of treating patients, with probably more of a collaborative, team-based effort in which you and I as physicians are team leaders," he said.

Dr. Rayburn and Mr. Klagholz reported having no disclosures.

NEW ORLEANS – The proportion of American College of Obstetricians and Gynecologists fellows practicing in private settings has declined steadily over the past 2 decades, survey data show.

Between 1992 and 2012, the percentage of fellows in solo practice decreased from 32% to 19%, while the percentage employed by hospitals increased steadily from 5% to 15%, and those employed as academic faculty increased from 9% to 12%, Jeffrey C. Klagholz reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). Three percent were employed by HMOs, and 2% by the government; these remained basically static over time.

The percentage of fellows in private practice groups ranged from 44% to 52% (median of 48%) across the seven ACOG surveys on professional liability administered during the study period, according to Mr. Klagholz of ACOG in Washington, who noted that the findings were confirmed, and expanded upon, by data from a recent Socioeconomic Survey of ACOG Fellows.

During a session on workforce issues affecting ACOG fellows at the annual meeting, poster coauthor William Rayburn expanded on this report, and outlined a number of other recent and predicted changes in workforce trends and demand for obstetric and gynecologic care.

Of note, the proportion of resident graduates has not kept pace with increases in the population, and the proportion moving on to an accredited fellowship program – such as female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, or reproductive endocrinology – more than doubled, increasing from 7% to 17% between 2000 and 2009. The percentage increases to 27% when minimally invasive surgery, pediatric and adolescent gynecology, and family planning and reproductive health fellowship programs are included, said Dr. Rayburn, chair of obstetrics and gynecology at the University of New Mexico, Albuquerque.

"We’re getting the message here that ... our graduates are moving more in the direction of subspecializing, and that concerns me with regard to the number of general obstetricians and gynecologists for our growing population, with there not being an increase in the number of residents," he said.

Adding to the shortage problem is the fact that a greater number of ACOG fellows are physicians aged 60 years or older, who are reaching "very senior status," compared with those who are aged 39 years or younger (about 5,500 vs. about 4,000 in 2012), he said.

Traditionally, the drop off in the number of ob.gyns. actually practicing obstetrics begins at about age 55 years. In fact, only one in three ACOG fellows and junior fellows in practice is aged 55 years or older.

"I daresay, anyone who is that age or older, at some time, is thinking of what they will do down the road and when they will eventually retire," he said, adding, "I think this is an important concept, because we have what’s called a static pipeline. That is, the number of resident graduates, which is not increasing, is actually lower than the number who are entering retirement age," Dr. Rayburn said.

If those residents are subspecializing more, the value that general ob.gyns. bring to the health care of women is tremendous, he added.

As for where women’s health care is most needed, it appears that while there is a shortage of ob.gyns., the bigger problem is "maldistribution," Dr. Rayburn said, explaining that the vast majority of ob.gyns. practice in metropolitan areas.

Generally speaking, one full-time ob.gyn. equivalent is needed per 10,000 population, but 49% of the more than 3,300 counties in the United States have no ob.gyn.

This affects about 10 million women who will be eligible for health care coverage under the Affordable Care Act, if they aren’t covered already, Dr. Rayburn said.

Reaching these patients will require "getting creative" about finding ways to deliver care. Outreach clinics, greater use of physician extenders, and collaborative efforts with primary care physicians are among the approaches he mentioned.

A related concept – demand for care – is an important one, especially considering the aging of the population, but it can be difficult to predict. Although 80% of ob.gyn. care is provided to reproductive-age women, and little is provided to those over age 65 years, ob.gyns. are "still a significant player in taking care of women who are aged 40-64 years," he said.

Given shortages in the primary care fields, it is likely that ob.gyns. will play an increasing role in taking care of these women.

Data from a recent study, which Dr. Rayburn hopes to publish soon, suggest that demand for women’s health care services will grow by about 6% by 2020.

"In other words, you’re going to be working 6% harder than you are right now in terms of meeting the demand of your patients," he said, noting that the estimate is a conservative one and that demand will vary greatly by geographic region.

For example, areas such as Montana, North Dakota, and West Virginia will likely see decreasing demand, which may be a good thing since these areas have general ob.gyn. shortages, he said.

Texas and Florida, as well as areas in the Intermountain West are expected to experience booming demand, with increases of more than 10%.

"So we’ve got to think of alternative modes of treating patients, with probably more of a collaborative, team-based effort in which you and I as physicians are team leaders," he said.

Dr. Rayburn and Mr. Klagholz reported having no disclosures.

NEW ORLEANS – The proportion of American College of Obstetricians and Gynecologists fellows practicing in private settings has declined steadily over the past 2 decades, survey data show.

Between 1992 and 2012, the percentage of fellows in solo practice decreased from 32% to 19%, while the percentage employed by hospitals increased steadily from 5% to 15%, and those employed as academic faculty increased from 9% to 12%, Jeffrey C. Klagholz reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). Three percent were employed by HMOs, and 2% by the government; these remained basically static over time.

The percentage of fellows in private practice groups ranged from 44% to 52% (median of 48%) across the seven ACOG surveys on professional liability administered during the study period, according to Mr. Klagholz of ACOG in Washington, who noted that the findings were confirmed, and expanded upon, by data from a recent Socioeconomic Survey of ACOG Fellows.

During a session on workforce issues affecting ACOG fellows at the annual meeting, poster coauthor William Rayburn expanded on this report, and outlined a number of other recent and predicted changes in workforce trends and demand for obstetric and gynecologic care.

Of note, the proportion of resident graduates has not kept pace with increases in the population, and the proportion moving on to an accredited fellowship program – such as female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, or reproductive endocrinology – more than doubled, increasing from 7% to 17% between 2000 and 2009. The percentage increases to 27% when minimally invasive surgery, pediatric and adolescent gynecology, and family planning and reproductive health fellowship programs are included, said Dr. Rayburn, chair of obstetrics and gynecology at the University of New Mexico, Albuquerque.

"We’re getting the message here that ... our graduates are moving more in the direction of subspecializing, and that concerns me with regard to the number of general obstetricians and gynecologists for our growing population, with there not being an increase in the number of residents," he said.

Adding to the shortage problem is the fact that a greater number of ACOG fellows are physicians aged 60 years or older, who are reaching "very senior status," compared with those who are aged 39 years or younger (about 5,500 vs. about 4,000 in 2012), he said.

Traditionally, the drop off in the number of ob.gyns. actually practicing obstetrics begins at about age 55 years. In fact, only one in three ACOG fellows and junior fellows in practice is aged 55 years or older.

"I daresay, anyone who is that age or older, at some time, is thinking of what they will do down the road and when they will eventually retire," he said, adding, "I think this is an important concept, because we have what’s called a static pipeline. That is, the number of resident graduates, which is not increasing, is actually lower than the number who are entering retirement age," Dr. Rayburn said.

If those residents are subspecializing more, the value that general ob.gyns. bring to the health care of women is tremendous, he added.

As for where women’s health care is most needed, it appears that while there is a shortage of ob.gyns., the bigger problem is "maldistribution," Dr. Rayburn said, explaining that the vast majority of ob.gyns. practice in metropolitan areas.

Generally speaking, one full-time ob.gyn. equivalent is needed per 10,000 population, but 49% of the more than 3,300 counties in the United States have no ob.gyn.

This affects about 10 million women who will be eligible for health care coverage under the Affordable Care Act, if they aren’t covered already, Dr. Rayburn said.

Reaching these patients will require "getting creative" about finding ways to deliver care. Outreach clinics, greater use of physician extenders, and collaborative efforts with primary care physicians are among the approaches he mentioned.

A related concept – demand for care – is an important one, especially considering the aging of the population, but it can be difficult to predict. Although 80% of ob.gyn. care is provided to reproductive-age women, and little is provided to those over age 65 years, ob.gyns. are "still a significant player in taking care of women who are aged 40-64 years," he said.

Given shortages in the primary care fields, it is likely that ob.gyns. will play an increasing role in taking care of these women.

Data from a recent study, which Dr. Rayburn hopes to publish soon, suggest that demand for women’s health care services will grow by about 6% by 2020.

"In other words, you’re going to be working 6% harder than you are right now in terms of meeting the demand of your patients," he said, noting that the estimate is a conservative one and that demand will vary greatly by geographic region.

For example, areas such as Montana, North Dakota, and West Virginia will likely see decreasing demand, which may be a good thing since these areas have general ob.gyn. shortages, he said.

Texas and Florida, as well as areas in the Intermountain West are expected to experience booming demand, with increases of more than 10%.

"So we’ve got to think of alternative modes of treating patients, with probably more of a collaborative, team-based effort in which you and I as physicians are team leaders," he said.

Dr. Rayburn and Mr. Klagholz reported having no disclosures.

NEW ORLEANS – Use of an investigational vaginal misoprostol insert significantly reduced the time to vaginal delivery, compared with a vaginal dinoprostone insert, and also reduced the need for maternal and neonatal antibiotics in both nulliparous and parous women undergoing labor induction, according to findings from a randomized, double-blind, phase III study.

Time to vaginal delivery was a mean of 29.2 hours in 441 nulliparous women who were treated with the 200-mcg controlled-release misoprostol vaginal insert (MVI) for labor induction, compared with 43.1 hours in 451 nulliparous women treated with a 10-mg controlled-release dinoprostone vaginal insert (DVI). Time to vaginal delivery was a mean of 13.4 hours in 237 parous women treated with MVI, compared with 20.1 hours in 229 parous women treated with DVI, Dr. R. Lamar Parker reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

The rate of cesarean delivery did not differ between the treatment groups (34.5% vs. 37.3% for nulliparous women treated with MVI and DVI, respectively, and 10.1% and 7.0% for parous women treated with MVI and DVI, respectively), said Dr. Parker, a gynecologist in group practice in Winston-Salem, N.C.

The groups also did not differ with respect to the rates of intrapartum, postpartum, or neonatal adverse events, most of which were mild or moderate, but the MVI group did experience more uterine activity–related adverse events, including tachysystole requiring intervention (13.3% vs. 4% in the MVI vs. DVI groups).

In another analysis of the study data, Dr. Deborah A. Wing and her colleagues found that MVI also significantly shortened the time to any delivery mode, compared with DVI (18.3 vs. 27.3 hours), and significantly shortened the duration of both the latent and active phases of labor (12.1 vs. 18.6 hours, and 4.8 vs. 6.9 hours, for the latent and active phases, respectively).

Significant reductions in the duration of latent and active labor with MVI vs. DVI treatment occurred in both nulliparous and parous women.

Shorter duration of these labor phases, regardless of the treatment used for labor induction, was associated with a significant reduction in the need for intrapartum, postpartum, and neonatal antibiotics, Dr. Wing, professor of clinical obstetrics and gynecology at the University of California, Irvine, and Long Beach Memorial Medical Center in Long Beach, Calif., reported in a separate poster.

Significantly fewer women who received MVI, compared with those who received DVI, required antibiotics during the intrapartum period (relative risk, 0.65) and postpartum period (RR, 0.55).

Also, antibiotics were required less often during the intrapartum, postpartum, and neonatal periods for both women and neonates when active or latent labor was shorter than the median duration, and when the total time to delivery and the duration of labor from rupture of membranes to delivery was shorter than the median duration, Dr. Wing noted.

Women included in this multicenter study were aged 18 years or older (mean of 26 years), had reached 36 weeks’ or more gestation, had parity of 3 or less, and had body mass index of 50 kg/m² or less at study entry. All had a baseline modified Bishop score of 4 or less (mean of 2.4 and 2.3 in the MVI and DVI groups, respectively) and required labor induction.

Those with pregnancy-related or fetal complications were excluded.

The findings are of note, because in the United States nearly a quarter of deliveries involve labor induction.

"While many methods are used, the American College of Obstetricians and Gynecologists and the World Health Organization recommend low-dose prostaglandins for cervical ripening prior to induction of labor," the authors wrote.

Currently, DVI (PEG₂), which is available as a vaginal insert or a vaginal gel, is the only Food and Drug Administration–approved prostaglandin for this purpose. Oral misoprostol, a prostaglandin E, is approved for prevention of gastric ulcers in patients using NSAIDS, but misoprostol tablets are often used off-label either orally or vaginally to induce labor, they said.

The tablet splitting and repeat administration required for vaginal use of oral misoprostol increases the likelihood of inaccurate dosing, they explained.

MVI (PEG₁), however, is a controlled-release vaginal insert that can remain in place for 24 hours. It can also be removed – thereby terminating drug administration - at the onset of active labor or in the event of adverse effects, they said.

A new drug approval application for MVI was accepted for review by the FDA in October 2012.

This study was sponsored by Ferring Pharmaceuticals. Dr. Parker and Dr. Wing reported serving as consultants to Ferring Pharmaceuticals and formerly receiving research support from Cytokine PharmaSciences, which is a wholly owned subsidiary of Ferring Pharmaceuticals.

NEW ORLEANS – Use of an investigational vaginal misoprostol insert significantly reduced the time to vaginal delivery, compared with a vaginal dinoprostone insert, and also reduced the need for maternal and neonatal antibiotics in both nulliparous and parous women undergoing labor induction, according to findings from a randomized, double-blind, phase III study.

Time to vaginal delivery was a mean of 29.2 hours in 441 nulliparous women who were treated with the 200-mcg controlled-release misoprostol vaginal insert (MVI) for labor induction, compared with 43.1 hours in 451 nulliparous women treated with a 10-mg controlled-release dinoprostone vaginal insert (DVI). Time to vaginal delivery was a mean of 13.4 hours in 237 parous women treated with MVI, compared with 20.1 hours in 229 parous women treated with DVI, Dr. R. Lamar Parker reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

The rate of cesarean delivery did not differ between the treatment groups (34.5% vs. 37.3% for nulliparous women treated with MVI and DVI, respectively, and 10.1% and 7.0% for parous women treated with MVI and DVI, respectively), said Dr. Parker, a gynecologist in group practice in Winston-Salem, N.C.

The groups also did not differ with respect to the rates of intrapartum, postpartum, or neonatal adverse events, most of which were mild or moderate, but the MVI group did experience more uterine activity–related adverse events, including tachysystole requiring intervention (13.3% vs. 4% in the MVI vs. DVI groups).

In another analysis of the study data, Dr. Deborah A. Wing and her colleagues found that MVI also significantly shortened the time to any delivery mode, compared with DVI (18.3 vs. 27.3 hours), and significantly shortened the duration of both the latent and active phases of labor (12.1 vs. 18.6 hours, and 4.8 vs. 6.9 hours, for the latent and active phases, respectively).

Significant reductions in the duration of latent and active labor with MVI vs. DVI treatment occurred in both nulliparous and parous women.

Shorter duration of these labor phases, regardless of the treatment used for labor induction, was associated with a significant reduction in the need for intrapartum, postpartum, and neonatal antibiotics, Dr. Wing, professor of clinical obstetrics and gynecology at the University of California, Irvine, and Long Beach Memorial Medical Center in Long Beach, Calif., reported in a separate poster.

Significantly fewer women who received MVI, compared with those who received DVI, required antibiotics during the intrapartum period (relative risk, 0.65) and postpartum period (RR, 0.55).

Also, antibiotics were required less often during the intrapartum, postpartum, and neonatal periods for both women and neonates when active or latent labor was shorter than the median duration, and when the total time to delivery and the duration of labor from rupture of membranes to delivery was shorter than the median duration, Dr. Wing noted.

Women included in this multicenter study were aged 18 years or older (mean of 26 years), had reached 36 weeks’ or more gestation, had parity of 3 or less, and had body mass index of 50 kg/m² or less at study entry. All had a baseline modified Bishop score of 4 or less (mean of 2.4 and 2.3 in the MVI and DVI groups, respectively) and required labor induction.

Those with pregnancy-related or fetal complications were excluded.

The findings are of note, because in the United States nearly a quarter of deliveries involve labor induction.

"While many methods are used, the American College of Obstetricians and Gynecologists and the World Health Organization recommend low-dose prostaglandins for cervical ripening prior to induction of labor," the authors wrote.

Currently, DVI (PEG₂), which is available as a vaginal insert or a vaginal gel, is the only Food and Drug Administration–approved prostaglandin for this purpose. Oral misoprostol, a prostaglandin E, is approved for prevention of gastric ulcers in patients using NSAIDS, but misoprostol tablets are often used off-label either orally or vaginally to induce labor, they said.

The tablet splitting and repeat administration required for vaginal use of oral misoprostol increases the likelihood of inaccurate dosing, they explained.

MVI (PEG₁), however, is a controlled-release vaginal insert that can remain in place for 24 hours. It can also be removed – thereby terminating drug administration - at the onset of active labor or in the event of adverse effects, they said.

A new drug approval application for MVI was accepted for review by the FDA in October 2012.

This study was sponsored by Ferring Pharmaceuticals. Dr. Parker and Dr. Wing reported serving as consultants to Ferring Pharmaceuticals and formerly receiving research support from Cytokine PharmaSciences, which is a wholly owned subsidiary of Ferring Pharmaceuticals.

NEW ORLEANS – Use of an investigational vaginal misoprostol insert significantly reduced the time to vaginal delivery, compared with a vaginal dinoprostone insert, and also reduced the need for maternal and neonatal antibiotics in both nulliparous and parous women undergoing labor induction, according to findings from a randomized, double-blind, phase III study.

Time to vaginal delivery was a mean of 29.2 hours in 441 nulliparous women who were treated with the 200-mcg controlled-release misoprostol vaginal insert (MVI) for labor induction, compared with 43.1 hours in 451 nulliparous women treated with a 10-mg controlled-release dinoprostone vaginal insert (DVI). Time to vaginal delivery was a mean of 13.4 hours in 237 parous women treated with MVI, compared with 20.1 hours in 229 parous women treated with DVI, Dr. R. Lamar Parker reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

The rate of cesarean delivery did not differ between the treatment groups (34.5% vs. 37.3% for nulliparous women treated with MVI and DVI, respectively, and 10.1% and 7.0% for parous women treated with MVI and DVI, respectively), said Dr. Parker, a gynecologist in group practice in Winston-Salem, N.C.

The groups also did not differ with respect to the rates of intrapartum, postpartum, or neonatal adverse events, most of which were mild or moderate, but the MVI group did experience more uterine activity–related adverse events, including tachysystole requiring intervention (13.3% vs. 4% in the MVI vs. DVI groups).

In another analysis of the study data, Dr. Deborah A. Wing and her colleagues found that MVI also significantly shortened the time to any delivery mode, compared with DVI (18.3 vs. 27.3 hours), and significantly shortened the duration of both the latent and active phases of labor (12.1 vs. 18.6 hours, and 4.8 vs. 6.9 hours, for the latent and active phases, respectively).

Significant reductions in the duration of latent and active labor with MVI vs. DVI treatment occurred in both nulliparous and parous women.

Shorter duration of these labor phases, regardless of the treatment used for labor induction, was associated with a significant reduction in the need for intrapartum, postpartum, and neonatal antibiotics, Dr. Wing, professor of clinical obstetrics and gynecology at the University of California, Irvine, and Long Beach Memorial Medical Center in Long Beach, Calif., reported in a separate poster.

Significantly fewer women who received MVI, compared with those who received DVI, required antibiotics during the intrapartum period (relative risk, 0.65) and postpartum period (RR, 0.55).

Also, antibiotics were required less often during the intrapartum, postpartum, and neonatal periods for both women and neonates when active or latent labor was shorter than the median duration, and when the total time to delivery and the duration of labor from rupture of membranes to delivery was shorter than the median duration, Dr. Wing noted.

Women included in this multicenter study were aged 18 years or older (mean of 26 years), had reached 36 weeks’ or more gestation, had parity of 3 or less, and had body mass index of 50 kg/m² or less at study entry. All had a baseline modified Bishop score of 4 or less (mean of 2.4 and 2.3 in the MVI and DVI groups, respectively) and required labor induction.

Those with pregnancy-related or fetal complications were excluded.

The findings are of note, because in the United States nearly a quarter of deliveries involve labor induction.

"While many methods are used, the American College of Obstetricians and Gynecologists and the World Health Organization recommend low-dose prostaglandins for cervical ripening prior to induction of labor," the authors wrote.

Currently, DVI (PEG₂), which is available as a vaginal insert or a vaginal gel, is the only Food and Drug Administration–approved prostaglandin for this purpose. Oral misoprostol, a prostaglandin E, is approved for prevention of gastric ulcers in patients using NSAIDS, but misoprostol tablets are often used off-label either orally or vaginally to induce labor, they said.

The tablet splitting and repeat administration required for vaginal use of oral misoprostol increases the likelihood of inaccurate dosing, they explained.

MVI (PEG₁), however, is a controlled-release vaginal insert that can remain in place for 24 hours. It can also be removed – thereby terminating drug administration - at the onset of active labor or in the event of adverse effects, they said.

A new drug approval application for MVI was accepted for review by the FDA in October 2012.

This study was sponsored by Ferring Pharmaceuticals. Dr. Parker and Dr. Wing reported serving as consultants to Ferring Pharmaceuticals and formerly receiving research support from Cytokine PharmaSciences, which is a wholly owned subsidiary of Ferring Pharmaceuticals.

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Weight gain between pregnancies decreases the likelihood of a successful vaginal birth after cesarean section, according to findings from a large population-based retrospective cohort study.

The more weight a woman gains between pregnancies, the lower her chances are of a successful vaginal birth after cesarean section (VBAC); conversely, overweight and obese women who lose weight between pregnancies may improve their chances of a successful VBAC, Dr. Lisa S. Callegari reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The overall VBAC success rate among 8,861 women included in the study was 66%, but differences were seen with VBAC success based on prepregnancy body mass index category: The success rate was 70% for normal-weight women, 62% for overweight women, and 56% for obese women, said Dr. Callegari of the University of Washington, Seattle.

After adjustment for a number of factors, including demographics, smoking status, interpregnancy interval, birth year of second pregnancy (to account for temporal changes in VBAC practices), and prenatal care adequacy, weight loss among normal-weight women was not found to be associated with VBAC success, but weight gain of between one and two BMI units (about 6-12 pounds) among normal-weight women was associated with a 7% decrease in the VBAC success rate, compared with weight maintenance.

High weight gain, defined as an increase of more than two BMI units (about 12 pounds) between pregnancies, was associated with a 13% decrease in the VBAC success rate, compared with weight maintenance.

For overweight and obese women, moderate and high weight gain did not affect VBAC success, but weight loss in overweight women was associated with a 12% increase in VBAC success, and weight loss equivalent to 1 or more BMI units in obese women was associated with a 24% increase in VBAC success, Dr. Callegari said.

The findings are based on an analysis of longitudinal birth certificate data linked with hospitalization records between 1992 and 2009. Women who were included underwent primary cesarean delivery for their first birth, and attempted a trial of labor for their second birth.

Although limited by the use of birth certificate data, and also by a large number of cases with missing BMI information, the findings are bolstered by the use of population-based data, an observed dose-response effect, and the biologic plausibility for the findings, Dr. Callegari said.

The findings are important because increasing the rates of VBAC has been proposed as a strategy for decreasing cesarean section rates. However, VBAC rates have been declining in recent years, falling from 23% in 1996 to less than 10% currently. The causes are multifactorial, but these findings suggest that the modifiable risk factors of overweight and obesity are among them, Dr. Callegari said.

"In terms of clinical implications, normal-weight women should return to within one BMI unit of their prepregnancy weight, and overweight and obese women should lose greater than or equal to one BMI unit between pregnancies in order to optimize their chances of VBAC success," she concluded.

Dr. Callegari reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

NEW ORLEANS – Acceptance is growing for routine bilateral salpingectomy at the time of hysterectomy to reduce the risk of ovarian serous carcinoma, based on findings from a retrospective cohort study.

The bilateral salpingectomy rates at a single institution increased from 3% in 2010 to 73% in the first 6 months of 2012 – a year after the center began offering the procedure to all women undergoing hysterectomy with ovarian preservation, Dr. Susan K. Park reported at the annual meeting of the American College of Obstetricians and Gynecologists.

"Across the board, patient acceptance of undergoing salpingectomy was very high," she said. Patients were counseled at a preoperative appointment that salpingectomy may reduce the risk of posthysterectomy pelvic adnexal masses and serous carcinomas.

Only two women who were offered the procedure declined, said Dr. Park of Olive View–UCLA Medical Center, Los Angeles.

Moreover, there was no difference in operating time or surgical morbidity in a case-control study involving 133 women who underwent hysterectomy with ovarian preservation and salpingectomy and in 433 controls who did not undergo salpingectomy.

Study subjects were women undergoing abdominal, laparoscopic, or vaginal hysterectomy with ovarian preservation. The salpingectomy rate was lowest for vaginal hysterectomy, as visualization of the fallopian tubes is often difficult with that approach. In fact, two of six women who were unable to undergo salpingectomy despite giving consent were unable to have the procedure because of poor visualization of the tubes, Dr. Park said.

The findings are important given that emerging research points to the fallopian tubes as the site of serous carcinogenesis, Dr. Park said.

Though limited by the retrospective, single-center design, this study is the largest known study to date to look at the feasibility and safety of performing salpingectomy at the time of hysterectomy with ovarian preservation, she said.

Long-term follow-up to evaluate the effects of routine bilateral salpingectomy in these subjects is underway, she noted.

Dr. Park reported having no disclosures.

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

[email protected]

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

[email protected]

NEW ORLEANS – A postpartum educational script about long-acting reversible contraceptive methods appears to increase interest in those methods, but access may be limited for some women, findings from a randomized controlled trial suggest.

Long-acting reversible contraceptive (LARC) use after the 6-week postpartum visit in 400 women who received the "LARC Script" intervention and 400 controls who did not receive the intervention did not differ significantly (17.6% vs. 13.3%, respectively), but interest in LARC use among those not using a LARC method at follow-up did differ significantly between the groups (31.2% vs. 25.8%), Dr. Jennifer H. Tang reported at the annual meeting of the American College of Obstetricians and Gynecologists.

These findings suggest that the LARC Script is effective, but that barriers – such as financial and provider barriers – may be limiting uptake of LARC use, said Dr. Tang of the University of North Carolina at Chapel Hill.

Study subjects were 800 women aged 14-45 years who were recruited post partum between May 2011 and January 2012 and randomized to the intervention and control groups prior to discharge. A 20-item baseline survey lasting about 10 minutes was administered to all participants; the 1-minute intervention consisting of information about LARC was administered to intervention group subjects, with follow-up surveys conducted at 1-2 weeks (to confirm the 6-week visit) and at 6 weeks to assess outcomes.

About 40% of the subjects were Hispanic, median parity was two, and about a third had no insurance. Only a third of subjects were trying to conceive when they became pregnant, and 20% reported using some form of contraceptive to prevent pregnancy when they became pregnant. Most (80%) were not interested in becoming pregnant again, Dr. Tang said.

Approximately 40% of pregnancy intervals in the United States are less than 18 months, and intervals of 18 months or less are associated with poorer pregnancy outcomes. Thus, the findings of this study suggest a need for additional study to identify barriers to LARC access, she said.

"We need to look into reasons why women who want to receive LARC aren’t actually getting it," she said.

This study was funded by the Fellowship in Family Planning. Dr. Tang reported having no disclosures.

[email protected]

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

NEW ORLEANS – Use of a novel guided educational pamphlet during the immediate postpartum period is feasible and effective for promoting the use of long-acting reversible contraceptive methods, according to findings from a prospective cohort study.

Of 134 study subjects aged 18 years or older, 78% reported a preference regarding contraceptive method at baseline, and the most popular choices were non–long-acting reversible contraceptive (LARC) methods followed by intrauterine devices (IUDs), implants, and injections. Nearly a quarter (23%) of these women changed their minds after the intervention, with 94% of those ultimately choosing a LARC method, Dr. Ariel Cohen reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Of the 22% of women who had not decided on a contraceptive method at baseline, more than half selected a method after the intervention, and 82% of those selected a LARC method, with IUD being the most popular choice followed by implant and injection methods, said Dr. Cohen of Baystate Medical Center, Springfield, Mass.

The intervention involved a brief interaction between the subject and a research assistant within 4 days of delivery. The research assistant guided the subject through an eight-page educational pamphlet, which included three sections: an interactive section including six questions about contraceptive preferences, a comparative effectiveness section including a World Health Organization contraceptive comparative effectiveness chart, and an information section that provided more details about each contraceptive method.

Subjects were asked about their predelivery method of choice, and were called at 3 months and 6 months post partum for a follow-up evaluation.

The initial intervention took a mean of 8 minutes, and the research assistant had little difficulty obtaining the necessary time and privacy with the subjects, Dr. Cohen noted.

Mean age of the women was 24 years. Most identified as white or Hispanic, most (58%) had at least one other child (median parity, 2), and 84% had a 12th grade education or less.

The findings are important because although ACOG recommends that contraceptive counseling be provided during the intrapartum period, many physicians delay contraception discussion until the postpartum visit, Dr. Cohen said.

"However, research has shown that patients who are at the highest risk for unintended pregnancy have up to a 50% no-show rate at the postpartum visit," she said.

The immediate postpartum period provides a unique opportunity for contraceptive counseling, she added.

"Not only is the patient a captive audience ... she’s also highly motivated to avoid a rapid repeat pregnancy," she said.

Based on these findings, it appears this educational tool would be useful prior to discharge, if administered by either a physician or trained nurse or medical assistant, she said, noting that plans are underway to validate the tool by developing a pre- and posttest and conducting a randomized study, she said.

Dr. Cohen reported having no disclosures.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.

NEW ORLEANS – A telephone call made at 4 weeks postpartum to reinforce counseling about contraception did not increase the use of highly effective contraception at 6 months, according to findings from a randomized controlled study involving 258 women.

However, the rates of highly effective contraceptive use at 6 months were fairly high, at 71% and 67% in the intervention and control groups, respectively, and the study identified three factors associated with contraceptive use, Dr. Michelle M. Isley reported at the annual meeting of the American College of Obstetricians and Gynecologists.

On multivariate analysis, an intention to use a highly effective contraceptive method at 1-2 days postpartum was positively associated with use of such a contraceptive method at 6 months. A plan to breast-feed for a longer period of time, and a history of miscarriage were each negatively associated with the use of a highly effective contraceptive method at 6 months, said Dr. Isley of Ohio State University, Columbus.

The finding that an intention to use contraception was associated with actual use at 6 months has possible implications for patient counseling, she said. "This suggests that counseling in the prenatal period is valuable."

Dr. Isley noted, however, that 60% of study participants said their provider had talked to them about contraception prior to delivery. "I think we could do better here."

The finding of a negative association between plans to breast-feed for a longer period and use of contraception at 6 months suggests there may be a perception that birth control is not safe to use during breast-feeding. A simple educational intervention about birth control methods that are safe and effective during breast-feeding could be useful in these cases, Dr. Isley said.

Women planning to breast-feed may also be counting on reduced fertility during lactation.

"If women are relying on lactational amenorrhea for their birth control, then I think we ought to provide better, more thorough information about this method so that women can use it more effectively," she said.

As for the findings of a negative association between prior miscarriage and contraceptive use at 6 months postpartum, it is possible that these women believe their fertility is decreased, but more research is needed to clarify this association, she noted.

Study subjects had a mean age of 29 years and were enrolled and randomized at 1-2 days postpartum. Each woman completed a baseline questionnaire on demographic information and contraceptive use intentions. Those randomized to the intervention group received a phone call at 4 weeks postpartum from a study staff member, who readdressed the importance of postpartum contraception, answered basic questions about contraception, and encouraged the woman to attend her postpartum visit.

Contraceptive methods considered to be highly effective in this study were reversible methods including pills, patch, injection, implants, and intrauterine devices. The intervention and control groups did not differ significantly with respect to baseline characteristics.

The results underscore the importance of finding new and inventive ways of providing postpartum contraception, Dr. Isley said.

"As we all are aware, unintended pregnancy is a prevalent public health problem," she said, noting that improving the postpartum use of highly effective contraceptive methods can decrease unintended pregnancy and provide women with a method for controlling the timing of pregnancy.

"More efforts need to be made to figure out how to talk to women about birth control and how to promote these highly effective methods so that ultimately we can decrease mistimed and unintended pregnancies," she said.

Dr. Isley reported having no disclosures.