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Barriers to the Best Birth Control What Stands in Women’s Way?

Barriers to the Best Birth Control What Stands in Women’s Way?. Rachael Phelps MD Medical Director Planned Parenthood of the Rochester/Syracuse Region. Unintended Pregnancy in the U.S. 49%. 6.7 million pregnancies. 51%. 22%. 7%. Intended Pregnancy. Unintended Pregnancy.

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Barriers to the Best Birth Control What Stands in Women’s Way?

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  1. Barriers to the Best Birth ControlWhat Stands in Women’s Way? Rachael Phelps MD Medical Director Planned Parenthood of the Rochester/Syracuse Region

  2. Unintended Pregnancy in the U.S. 49% 6.7 million pregnancies 51% 22% 7% Intended Pregnancy Unintended Pregnancy Finer LB, Zolna, MR. Contraception. 2011.

  3. UNFPA State of World Populations 2011

  4. Poverty: Growing Disparities Overall unintended pregnancy rates have plateaued, yet disparities have increased Women > 200% poverty line Among poor women Unintended pregnancy rates now 5 TIMES HIGHER FOR POOR WOMEN Finer, LB, Contraception 2011

  5. So the question is WHY??? Women & Teens are not using the most effective methods of contraception

  6. Effectiveness of Birth Control Used by Contracepting Women(U.S. women 15-44 yrs-CDC NSFG 2006-2008) Extremely effective: >99% Very effective: ~92% Moderately Effective: ~85%

  7. Women Frequently Miss Pills Potter, L. et all. Family Planning Perspectives, 28:154-158, 1996

  8. WE LARC Long Acting Reversible Contraception(LARC) = IUDs & Implants • Most effective methods: >99% • Safest • No estrogen • Contraindications rare • Highest patient satisfaction • (80% LARC vs 50% short acting) • Highest continuation rates • (86% LARC vs. 55% short acting) • Long-term protection last 3-12 years • Rapid return of fertility • Most cost effective • Least likely to be used (5%) Secura GM. The Contraceptive Choice Project. Am J Obstet Gyn. 2011.

  9. Women & Teens are not using the most effective methods of contraception. So the question is WHY???

  10. Why Are IUDs Underused? Lack of awareness of method among women Myths & misconceptions among women Myths & misconceptions among providers Lack of physician training Expensive upfront cost Lack of insurance coverage Weir E. CMAJ. 2003.; Stanwood NL, et al. Obstet Gynecol. 2002. Steinauer JE, et al. Fam Plann Perspect. 1997.

  11. Women lack basic knowledge about contraception

  12. $100 Million/Yr. for Abstinence Education “the term ‘abstinence education’ means an educational or motivational program which:” • “teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity;” • “teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical side effects;” U.S. Section 510(b) of Title V of the Social Security Act

  13. Teens Denied Accurate Information Waxman, H. U.S. House of Representatives Report 2004

  14. Condom Misinformation • “In heterosexual sex, condoms fail to prevent HIV approximately 31% of the time.” • “The popular claim that ‘condoms help prevent the spread of STDs,’ is not supported by the data.” • “Pregnancy occurs 1/7 times that a couple uses a condom.” Waxman, H. U.S. House of Representatives Report 2004

  15. Gender Bias “Just as a woman needs to feel a man’s devotion to her, a man has a primary need to feel a woman’s admiration. To admire a man is to regard him with wonder, delight and approval. A man feels admired when his unique characteristics and talents happily amaze her.” Waxman, H. U.S. House of Representatives Report 2004

  16. “5 major needs of women: financial support, family commitment, affection, conversation, honesty and openness.” “5 major needs of men: sexual fulfillment, physical attractiveness, domestic support…” Waxman, H. U.S. House of Representatives Report 2004

  17. Lack of Sex Education • 1 out of 5 unmarried young adults say they never had sex education in school • Of those who had it more than 1 out of 4 had it before age 15 only. Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  18. Unmarried 18-29 year olds… • 30% say they know little or nothing about condoms • 63% say they know little or nothing about birth control pills • 56% say they have not heard of the birth control Implant • 90% believe they have all the knowledge they need to avoid an unplanned pregnancy Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  19. Among 18-29 y/o Condom Users…. More than 1 out of 4 did not know how to use a condom correctly! • More than 1/3 believed it is ok to use vaseline or petroleum jelly with condoms • 1/4 believed wearing 2 condoms provides extra protection • Almost half think condoms are as or more effective than the pill (condom users twice as likely to get pregnant as pill users) Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  20. Seriously??? • Almost 1 in 5 young adults believe douching after sex can prevent pregnancy • Almost 1 in 5 young men believe sex standing up reduces the risk of pregnancy Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  21. Young Pregnant Women Lack Knowledge about IUDs How safe/effective are IUDs compared to pills, injections, or tubal sterilization? Unsure of safety Unsure of efficacy 71% 58% Stanwood NL, et al. Obstet Gynecol. 2006.

  22. Birth Control Myths

  23. Women’s Misconceptions about the Risk of Contraception Pose a Significant Barrier to Use • Unmarried young women (18-29) • Half believed that using hormonal contraception for a long period of time was likely to cause serious health problems like cancer and this concern reduces their likelihood of using pills or other hormonal methods. • Among women who used OCP- almost half incorrectly believed they should take a break from the pills every few years Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  24. The Pill: Misinformation • 36% believed the pill is likely to cause weight gain and this concern reduces their likelihood of using the pill. • 40% believed the pill is likely to cause severe mood swings and this concern reduces their likelihood of using the pill. • 40% believed their chance of getting pregnant within a year of using the pill is 50% or greater (actually 8% with typical use/ <1% perfect use) Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  25. Common Myths About OCPs Yale University Health Services’ study, 1991 Belief About OCs % of Yale College Students OCs are associated with substantial risk OCs increase risk of breast cancer OCs increase risk of cervical cancer OCs increase blood pressure OCs cause heart disease or heart attack 49% 47% 29% 19% 9% Peipert, Gutmann. Obstet Gynecol. 1993;82:112.

  26. What Don’t Patients Know About Health Benefits of OCPs % of patients who did not know that ... Yale University 19911 Brown University 19952 OCs protect against ovarian cancer OCs protect against endometrial cancer OCs protect against ectopic pregnancy OCs protect against PID OCs protect against benign breast disease OCs decrease dysmenorrhea 80% 80% 88% 89% 95% 75% 77% 81% 91% 90% 95% 34% 1. Peipert, Gutmann. Obstet Gynecol. 1993;82:112; 2. Tessler, Peipert. Women’s Health Issues. 1997;7:400.

  27. Use Tools: Risk Comparisons Annual risk of death (per 100,000) *Nonsmoker, age 15–34 Bennett P. In: Risk Communication and Public Health. 1999; Chang J, et al. MMWR. 2003. Harvard Center for Risk Analysis. 2006’ Schwingl PJ, et al. Am J Obstet Gynecol. 1999. Trussell J, Jordan B. Contraception. 2006.

  28. IUD Misinformation • More than 1/2 believed IUDs are likely to cause an infection and this will make them less likely to use method • Almost 1/2 believed IUDs can move around in a woman’s body • 40% believed women must undergo surgery for an IUD • 1/4 young adults believed that an IUD can’t be stopped early Kaye, Kelleen et al.The Fog Zone. The National Campaign to Prevent Teen and Unplanned Pregnancy 2009

  29. Myths and Misconceptions Lead to Discontinuation of BC OR ELSE ……

  30. Lack of EC Use… • Education • Misinformation • Access • Cost • Perceptions of pregnancy risk • Stigma of EC use, particularly multiple use

  31. EmergencyContraception Without a Prescription Sweden Denmark Belgium U.K. U.S. (>18) U.S. (>17) Portugal Norway Latvia Estonia Switzerland Netherlands Canada France Finland 1999 2000 2001 2002 2003 2004 2005 2006 2009

  32. What Can We Do To Increase EC Use? • Destigmatize Repeat or Frequent Use and… • Advance Provision! • Advance Provision! • Advance Provision! 5

  33. Lack of Contraceptive Access for Teens in School Clinics National Assembly on School-Based Health Care (NASBHC) 2000

  34. Lack of Physician Training

  35. Quick Start MethodImproving Contraceptive Initiation • Start method today (OCP, Ring, Patch, DMPA) • If unprotected IC in past 5 days: Also offer EC • Back-up for 7 days QUICK START: • Patients are more likely to start method • Improves continuation rates • Offers earlier protection from pregnancy • No significant difference in the bleeding patterns compared with menses start Westoff C, Kerns J, Morroni C, et al. Contraception. 2002;66:141-5.

  36. Initiation of Hormonal Contraceptives Pregnancy test Pelvic exam Pap smear STI screening Leeman L. Obstet Gynecol Clin N Am. 2007

  37. Reproductive Coercion Pregnancy Coercion • Forced or pressured to get pregnant • Told not to use BC • Threatened he would leave if she does not get pregnant • Said would have baby with someone else • Physical abuse because she didn’t want to become pregnant Birth Control Sabotage • Takes condom off during sex • Puts holes in condom • Breaks condom on purpose • Takes away her birth control • Keeps her from going to clinic to get birth control • Made her have sex without condom

  38. Reproductive Coercion in Family Planning Clinics • 1 in 5 reported pregnancy coercion • Almost 1 in 6 reported BC sabotage • > 1 in 3 reporting IPV report reproductive coercion • Unintended pregnancy rates were 42% higher in women experiencing reproductive coercion Miller, E et al. Contraception April 2010

  39. Lack of Insurance Coverage and High Costs

  40. Patient Protection & Affordable Care Act HHS ASPE Issue Brief The cost of Covering Contraceptives through Health Insurance 2012

  41. Extremely effective Very effective What Birth Control Are Women Using? U.S. women 15-44 yrs-CDC NSFG 2006-2008

  42. Extremely effective Very effective What Birth Control Would Women Choose? Contraceptive Choice Project: Madden,T et al. Contraception 84 (2011)

  43. Extremely effective Very effective What Birth Control Are Teens Using? U.S. teens 15-19 yrs-CDC NSFG 2006-2008

  44. Extremely effective Very effective What Birth Control Would Teens Choose? Contraceptive Choice Project: Mestad, R et al. Contraception 84:2011.

  45. Extremely effective (>99%) Very effective (91% typical use) Satisfaction with BC Method Piepert JF et al. Obstet Gynecol May 2011

  46. Extremely effective (>99%) Very effective (91% typical use) Continuation Rates at 1 Year Piepert JF et al. Obstet Gynecol May 2011

  47. Thank You! Questions?

  48. Fabulous Reproductive Health Resources www.arhp.org - Free webinars, great provider and patient resources www.core.arhp.org - Evidence based downloadable slide sets www.prch.org/arshepdownloads - 13 downloadable power point modules on adolescent reproductive health topics www.managingcontraception.com - Managing Contraception pocket handbook www.plannedparenthood.org - Provider and patient resources www.cdc.gov/reproductivehealth/UnintendedPregnancy/ index.htm - Medical Eligibility Criteria for Contraception www.advocatesforyouth.org – Advocates for Youth www.guttmacher.org – Guttmacher Institute www.siecus.org - The Sexuality Information and Education Council of the United States

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