Method Discontinuation & Pregnancy Among Young Women Who Initiate Hormonal Contraceptives Tina...

Method Discontinuation & Pregnancy Among Young Women Who Initiate

Hormonal Contraceptives

Tina Raine-Bennett MD, MPHProfessor

Obstetrics Gynecology and Reproductive SciencesSan Francisco General Hospital

Bixby Center for Global Reproductive Health University of California, San Francisco

October 2010

Department of Obstetrics, Gynecology & Reproductive

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Disclosures

• Speaker Bureau - Merck (Schering Plough) Implanon trainer

• Consultant and Research Grant support on Emergency contraception - Teva (Duramed – Barr)


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Acknowledgements• Beth Brown MA, MPA• Phil Darney MD, MSc• Anne Foster-Rosales MD, MPH• Cynthia Harper PhD• Abby Sokoloff MPH• Ushma Upadhyay PhD, MPH• RAs: Laura Mendoza, Claudia Paredes, Gloria Roman,

This study was supported by National Institute of Child Health and Human Development Grant R01 HD045480


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Background• The rate of unintended pregnancy

remains unacceptably high.• Unintended pregnancies have

significant consequences.• They are becoming increasingly

concentrated among minority and socioeconomically disadvantaged women.

Finer et al. Disparities in rates of unintended pregnancy in the U.S., 1994 and 2001 Perspectives , 2006 38:90-96

Unintended Pregnancy Occurs More Frequently in Young, Poor, and Minority Women

0 20 40 60 80 100 120

Race/ethnicity

% of Poverty

Education

Unintended Pegnancies per 1,000 women aged 15-44

< HS DiplomaHS Diploma/GED

Some CollegeCollege Graduate

<100%

100-199%>200%

BlackHispanic

White


Women at risk of pregnancy

11%

89%

Not using contraceptivesUsing contraceptives

Contraceptive Use Month of Conception

52%48%

Not using contraceptivesUsing contraceptives

Contraceptive Use PredictsUnintended Pregnancy


Method Choice is Key

Improved Delivery systems:• Convenience• Compliance• Efficacy

Vaginal Ring & Contraceptive Patch


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• By Race– African American less likely to use the pill – African American and Hispanic women more likely to use

injectable– African American women more likely to use condoms

• By Income– Women with Medicaid less likely to use the pill than

women with private insurance

• By education– Less educated women less likely to use the pill and more

likely to use injectable

Contraceptive Method Choice Differences

Frost et al. Factors associated with contraceptive choice and Inconsistent Method Use, United States 2004 Perspectives 2008 40:94-104


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Significance

• Little is known about use of relatively newer methods

• Our understanding of disparities in contraceptive use by race and socioeconomic status is limited

• Information is needed to help providers understand more about diverse women who present to clinics for birth control


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Longitudinal Cohort Study


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Study Objectives• Assess long-term (12 month) use of hormonal

contraception among a diverse cohort of young women

• Assess unintended pregnancy rates and correlation with use patterns

• Compare discontinuation rates of relatively newer methods - the Patch and the Ring to the Pill

• Compare discontinuation rates of Depo-Provera to the Pill

• Assess factors associated with discontinuation


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Study Setting• Four Planned Parenthood Clinics in Northern CA

•Oakland Eastmont Mall•Hayward•Richmond – Hilltop Mall•Vallejo

• Sub-urban communities• Primarily uninsured; eligible for CA state family

planning assistance program (FamilyPACT)


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Eligibility Criteria• Age 15-24

• English or Spanish speaking

• Non-married

• Not pregnant or desiring pregnancy in the next year

• Selected to initiate the pill, patch, ring, or DMPA*

• Previous hormonal method use okay but not the method they were currently selecting (also eligible if switching to a new method)

* Enrollment started September 2005; DMPA added to the protocol in October 2005


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Study Methods• Longitudinal Cohort Study – September 2005 to July 2008• Patient seen by clinic staff using standard clinic protocols

BC method selected• Enrolled in study by research staff - baseline questionnaire

completed• Follow-up questionnaires:

– 3 months– 6 months– 12 months

• Pregnancy tests done at 6- and 12- month follow-ups; chart review at the end of study

• Participants received $30 at baseline, $20 at 3 months and 6 months, and $30 at 12 months

(in-person or by phone)


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Study Methods

• Outcomes of interest:– Discontinuation of method selected– Subsequent use of hormonal

methods•Switching•Breaks

– Pregnancy


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Data Analysis

• Kaplan-Meier survival analysis estimates of the probability of continuation

– (women censored if lost to F/U or became pregnant)

• Predictors of discontinuation of selected method – Cox proportional hazards regression model

• Choice of model variables guided by the theory of reasoned action

Understanding and Modifying Contraceptive Behavior

Belief of Consequences &

Value of Consequences

General Attitude Toward

Behavior

Perception of Wishes of

Partners Parents & Peers

Social Expectations

Intent to Engage

in Behavior

Performance of Behavior

Theory of Reasoned Action

Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. 1980.

Moore PJ, Adler NE, Kegeles SM. Adolescents and the contraceptive pill: the impact of beliefs on intentions and use. Obstet Gynecol. 1996;88:48S-56S.


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RESULTS

Study Enrollment and Follow-up

Screened 1,501

Women Enrolled: -Pill -Patch -Ring -DMPA

1,387 432 401 259 295

Completed F/U#1 1,238 (89%)



Completed at least one F/U 1,316 (95%)

Baseline Demographics(Comparisons to Pill Initiators)

Pill Patch Ring DMPA Total

Column Percents (N=1,387)

Mean Age 18.6 19.2* 20.4* 18.9 19.2

Race White Latina Black Asian/PI Multi/Other

1224301420

7*28

41*10

14*

1226351214

1428

38*6*

14*

1126361116

Low Neighborhood Income 41 51* 47 40 45

Working or In School 85 82 82 80 82

Defined as living in a zip code where the percentage of families living below the federal poverty level is greater than the national average*P< 0.05 compared to Pill

BaselineContraceptive & Reproductive Characteristics

(Comparisons to Pill Initiators)Pill Patch Ring DMPA Total


Ever Pregnant 33 52* 60* 59* 49

Ever had a Birth 13 21* 24* 24* 20

Ever had an Abortion 27 44* 50* 50* 41

Ever Used Hormonal BC 29 43* 79* 53* 48

Has Current Main Partner 86 81 85 82 83

*P< 0.05 compared to Pill

BaselineContraceptive Beliefs & Attitudes

(Comparisons to Pill Initiators)



Endorsed Negative Attributes of CHC

44 55* 51 65* 53

Peers Very Much Against Use of BC 12 14 18* 10 13

Main Partner Very Much Against Use of BC 15 13 16 10 14

Strongly Agree- Parents Upset if Knew Used BC 25 22 14* 16* 20


Negative Attributes Scale – Level of Agreement with 13 Statements like “It is dirty to put the ring in the vagina” and “it is hard to take a pill every day” and “the patch is messy on the skin”

CHC – Combined Hormonal Contraceptive BC - Hormonal Birth Control

BaselinePregnancy and Contraceptive Use Intentions

(Comparisons to Pill Initiators)



Would be very upset if pregnant in next 3 months

45 40 45 45 44

Does not want child in next 2 years or ever

72 72 70 68 71

Very sure will continue BC method selected for 1 year

48 37* 34* 48 42



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Main Outcomes

Kaplan- Meier Survival Analysis of Continuation of the Method Selected

N= 1,316 (women with at least one F/U visit)

0.00

0.25

0.50

1.00

0 1 2 3 4 5 6 7 8 9 10 11 12

Pill

Duration of use (months)Patch

0.75

Ring DMPA

Prob

abili

ty o

f Co

ntinu

ation

Baseline Factors Associated with DiscontinuationCharacteristic N=1,267 Adjusted Hazard Ratio 95% CI

Method selected Pill Patch Ring DMPA

ref 1.90***

1.18 1.24*

--(1.59 - 2.27)(0.94 - 1.46) (1.03 - 1.51)

Older Age, years 0.96*** (0.93 - 0.99)

Race White Latina Black Asian/PI Multi-racial/Other

ref 1.10 1.22 1.10 1.22

--(0.86 - 1.41)(0.95 - 1.55)(0.82 - 1.47)(0.93 - 1.58)

In school or working 0.82* (0.83 - 0.98)

Ever Pregnant 1.10* (0.95 - 1.28)

Does not want pregnancy in next 2 years or ever 0.94 (0.82 - 1.09)

Very sure will use BC for 1 year 0.73*** (0.64 - 0.83)

Endorsed negative BC attributes 1.18 (1.00 - 1.39)

Main Partner very much against use of any hormonal BC 1.20 (0.99 - 1.47)

Peers very much against use of any hormonal BC 0.90 (0.73 - 1.10)

*P< 0.05 **p<0.01 ***p<0.001 Excludes 49 women who had missing information on independent variables

Main Reason for Discontinuation N=991

Pill (%)

Patch (%)

Ring (%)

DMPA (%)

Total (%)

Side effects 33 35 26 46 36Access/supply/cost barriers 9 8 10 17 11Not sexually active/No need 15 8 11 11 11Difficulties with use 20 9 14 1 11Pregnancy related 5 9 8 3 6Medical/health concerns 4 6 6 3 4Wanted to become pregnant

2 1 2 2 2

Other reasons* 14 25 25 20 21

Excludes 278 women who did not discontinue the baseline method.Pearson Chi-square (18) = 97.9 P ≤ 0.001

Pregnancies (per 100 person years)By Method Selected and Contraceptive Use Pattern

Contraceptive Use Pattern

Continuation of Method Selected**

n=325 (25%)

Discontinuation of Method Selected

With Switch toAnother Effective Method

n=738 (56%)

Discontinuation ofMethod Selected

Without Subsequent Use of Another Effective Method

n=253 (19%)

Pill 4.4 19.2 34.5 16.5

Patch 19.6 28.8 39.1 30.1

Ring 12.4 34.3 52.7 30.5

DMPA 5.7 17.1 20.4 16.1

Total 9.1 23.9 37.2 22.9

**46% of women in this category (n=144) reported taking breaks


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Summary• Contraceptive Method independently

associated with discontinuation• Contraceptive Continuation at 12 months low

for all method initiators; lowest for Patch and DMPA initiators however.

Pill 32.7

Patch 12.1

Ring 29.4

DMPA 10.9

Women per 100 Person Years


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Summary• Other factors independently associated with

continuation:– Being very sure/intent on using the

method selected– Older age– Being in school or employed


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Summary• Pregnancy rate associated with:

– Method Selected– Switching– Breaks– Discontinuation

• DMPA initiators had higher discontinuation rate but pregnancy rate comparable to pill initiators


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Limitations

• Generalizability– Study conducted in Northern California

(suburban, uninsured women) - may not be generalizable to other populations

• Study Design– Observational study – women selected BC

methods; difficult to measure “selection bias” (i.e. bad or good contraceptors selected or given certain methods)

• Social Desirability Bias– Self-report data and biological markers used


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Conclusions - Implications

• Access isn’t enough

– 12-month contraceptive continuation was low for this cohort of women with minimal access barriers

• New delivery systems not fulfilling the promise

– While they provide women with more options, the patch and the ring may not be better options than the pill or DMPA for high-risk women


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Conclusions - Implications

• Intent matters – Providers may be able ask patients very simple

questions to identify women at risk for contraceptive discontinuation

• Improved understanding of contraceptive intent is needed

• Context matters– Age, employment, school important

• Unclear if these factors can be addressed with clinic interventions

• Improved understanding of what providers do is needed

Many Thanks to the staff of the Golden Gate and Shasta Diablo Planned Parenthood Affiliates

for their assistance in conducting this study

Questions – Contact Dr. Tina [email protected]

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Method Discontinuation & Pregnancy Among Young Women Who Initiate Hormonal Contraceptives Tina...

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