Method Discontinuation & Pregnancy Among Young Women Who Initiate Hormonal Contraceptives

1. Method Discontinuation & Pregnancy Among Young Women Who Initiate Hormonal Contraceptives Tina Raine-Bennett MD, MPH Professor Obstetrics Gynecology and Reproductive Sciences San Francisco General Hospital Bixby Center for Global Reproductive Health University of California, San Francisco October 2010

2. Disclosures Speaker Bureau - Merck (Schering Plough) Implanon trainer Consultant and Research Grant support on Emergency contraception - Teva (Duramed – Barr)

3. 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

4. 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

5. Unintended Pregnancy Occurs More Frequently in Young, Poor, and Minority Women < HS Diploma HS Diploma/GED Some College College Graduate >200% 100-199% <100% Hispanic Black White Finer et al. Disparities in rates of unintended pregnancy in the U.S., 1994 and 2001 Perspectives , 2006 38:90-96

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

7. Method Choice is Key

8. Vaginal Ring & Contraceptive Patch Improved Delivery systems: • Convenience • Compliance • Efficacy

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

10. 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

11. Longitudinal Cohort Study

12. 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

13. 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)

14. 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

15. 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)

16. Study Methods • Outcomes of interest: • Discontinuation of method selected • Subsequent use of hormonal methods • Switching • Breaks • Pregnancy

17. 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

18. Understanding and Modifying Contraceptive Behavior Theory of Reasoned Action Belief of Consequences & Value of Consequences General Attitude Toward Behavior Intent to Engage in Behavior Performance of Behavior Perception of Wishes of Partners Parents & Peers Social Expectations 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.

19. RESULTS

20. Study Enrollment and Follow-up

21. Baseline Demographics(Comparisons to Pill Initiators) 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

22. BaselineContraceptive & Reproductive Characteristics(Comparisons to Pill Initiators) *P< 0.05 compared to Pill

23. BaselineContraceptive Beliefs & Attitudes(Comparisons to Pill Initiators) *P< 0.05 compared to Pill 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

24. BaselinePregnancy and Contraceptive Use Intentions(Comparisons to Pill Initiators) *P< 0.05 compared to Pill

25. Main Outcomes

26. Kaplan- Meier Survival Analysis of Continuation of the Method Selected N= 1,316 (women with at least one F/U visit) 1.00 Probability of Continuation 0.75 0.50 0.25 0.00 0 1 2 3 4 5 6 7 8 9 10 11 12 Duration of use (months) Patch Pill Ring DMPA

27. Baseline Factors Associated with Discontinuation *P< 0.05 **p<0.01 ***p<0.001 Excludes 49 women who had missing information on independent variables

28. Main Reason for Discontinuation N=991 Pearson Chi-square (18) = 97.9 P ≤ 0.001 Excludes 278 women who did not discontinue the baseline method.

29. Pregnancies (per 100 person years)By Method Selected and Contraceptive Use Pattern **46% of women in this category (n=144) reported taking breaks

30. 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

31. Summary • Other factors independently associated with continuation: • Being very sure/intent on using the method selected • Older age • Being in school or employed

32. Summary • Pregnancy rate associated with: • Method Selected • Switching • Breaks • Discontinuation • DMPA initiators had higher discontinuation rate but pregnancy rate comparable to pill initiators

33. 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

34. 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

35. 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

36. 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 Raine-Bennett rainet@obgyn.ucsf.edu