Contraception as Preventive Medicine

Updates in Clinical Care provided by The Ryan Center at the University of Chicago

An Ounce of Prevention 
Given the current climate of change and controversy surrounding contraceptive access, we should once again examine the importance of contraception as a tool for preventive medicine.

Contraception is the key to prevention.
More than half of all US women will experience an unintended pregnancy at some point in their lives, and nearly one-third will have an abortion (1, 2). Unfortunately, the rate of unintended pregnancy in the United States has seen no improvement in recent years, and there was a slight increase from 2001 to 2006, from 50 to 52 per 1,000 reproductive-aged women. Poor and low-income women are at even higher risk of unintended pregnancy: the rate for women at or below the poverty limit is 66 per 1,000 women, compared to 10 per 1,000 women who are at >200% of the poverty limit (1).

Although incorrect and inconsistent use of contraception account for some unintended pregnancies, the majority (52%) occur among the small percentage of women (16%) who are not using any contraception (3).

On a note of positive change, we have seen teen pregnancy in the United States decline significantly since the mid-1990s. Although abstinence has played a role, several analyses have confirmed that contraception is responsible for the majority of the decline in teen pregnancies (4, 5). To review some of the latest research in the area of contraception, see recent studies highlighted on our Reproductive Health & Justice Research blog.

Increasing access to contraception, especially highly effective methods of contraception, is a vital public health issue.

1.  Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, 84(5):478–485.
2.  Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Gynecology, 2011, 117(6):1358–1366.
3.  Gold RB et al., Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
4.  Santelli J, et al. Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use, Am J Public Health, 2007, 97:150–156.
   5.  Teen Births at Record Low Thanks to Improvements in Contraceptive Use, New York: Guttmacher Institute, April 11, 2012, available at: http://www.guttmacher.org/media/inthenews/2012/04/11/index.html.

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The Ryan Center & Contraceptive Care
We are pleased to announce two new exciting programs offered by the Ryan Center.

Carol’s Contraceptive Access Project (CCAP)
Due to a generous donation, we are now able to provide contraception for patients at the Ryan Center, regardless of insurance or ability to pay. We have low-cost options and financial assistance for:

  • Immediate insertion of intrauterine devices and implantable contraception (e.g. Implanon®)
  • Same-day injections of Depo-Provera®
  • Combined hormonal contraceptives (the pill, patch, and ring)

Center for Contraceptive Management
We offer the full range of contraceptive options, including, but not limited to:

  • Intrauterine device (IUD) and Implanon®/Nexplanon® insertion
  • Depo-Provera injections
  • Surgical and “no-cut” Essure® tubal sterilization
  • Prescriptions for: oral contraceptive pills, the contraceptive vaginal ring (NuvaRing®), the contraceptive patch (Ortho Evra®), and emergency contraception

      *We specialize in contraception for medically complicated patients.

Contact us at 773-702-6118 to make an appointment.

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IUD Clinical Trial
Are you or your patient interested in receiving an investigational IUD for long-term birth control? Participants will be compensated up to $900 over the course of 5 years. Click here for more information. UPDATE: This study is now closed.

Minors Express Mainly Negative Opinions about Parental Notification Laws

In Abortion-Seeking Minors’ Views on the Illinois Parental Notification Law: A Qualitative Study, published in Perspectives on Sexual and Reproductive Health, author Erin K. Kavanagh and other researchers from the Section of Family Planning and Contraceptive research analyze abortion-seeking minors’ thoughts on mandatory parental involvement laws and the potential impact such a law might have on a minor’s decision and level of access to abortion services. 

In-depth interviews were conducted with 30 minors presenting for an abortion at one of three Chicago-area clinics in 2010. Interviewers described the Illinois parental notification law (which was passed in 1995 but is not in effect because of legal challenges) and a corresponding judicial bypass option to the minors and asked their opinions about them. Interviews were coded and analyzed using content analysis and grounded theory methods.

The participants believed this law would diminish minors’ reproductive autonomy and potentially expose them to unwanted pressure or interference in their abortion decision. At the same time, many felt that voluntarily seeking support from a trusted adult, but not necessarily a parent, could benefit minors. The authors suggest that policymakers might better understand the impact of parental notification laws on minors’ ability to make reproductive health decisions if teens’ voices were heard in the debates concerning these laws and question whether parental notification laws best serve the reproductive well-being of minors.

Obese Women Using Implanon May Have Lower Levels of Active Hormone

In Pharmacokinetics of the etonogestrel contraceptive implant in obese women, new research published in the American Journal of Obstetrics and Gynecology, author Sarah Momar and Section researchers examined serum levels of etonogestrel, the active hormone in Implanon, in a small cohort of obese women (BMI>30).

Researchers enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve.

All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women.

Although  this study finds that obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion, authors comment that more research is needed to determine if this translates to decreased contraceptive effectiveness.

New Study Examines Association between DMPA (Depo shot) and STI Risk among Adolescents

In the article Depot Medroxyprogesterone Acetate Use is Not Associated with Risk of Incident Sexually Transmitted Infections Among Adolescent Women, published in the Journal of Adolescent Health, author Amy Romer and other researchers from the Section of Family Planning and Contraceptive Research investigated whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of sexually transmitted infections (STIs) in a group of healthy adolescents. The authors found no evidence that DMPA use increased risk of STIs, and the only factor significantly associated with increased risk was a greater number of sexual partners (odds ratio, range = 1.91-2.62)

Adolescent women aged 14–17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed.

In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period.

The authors conclude that in this U.S.-based cohort of adolescent women, no evidence was found that DMPA use is associated with increased STI risk. Authors recommend that efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.

Reshaping Adolescent Sexual Health through Story Telling and Games

In the article From Intervention to Invitation: Reshaping Adolescent Sexual Health through Story Telling and Games, published in the African Journal of Reproductive Health, authors Melissa Gilliam, et al, from the Section of Family Planning and Contraceptive Research reviewed Game Changer Chicago. This project aims to reframe and retool adolescent sexual health education to focus on inviting rather than intervening with youth, which encourages self-empowerment that catalyzes increased awareness and self-efficacy. In addition to describing the Section’s ongoing work with sexuality education, technology and gaming, the article explores the project’s potential for successful implementation among youth in Africa.

Youth in both Chicago and Nigeria face disproportionately high rates of mortality and morbidity due to poor sexual and reproductive health. Game Changer Chicago is an initiative that incorporates digital storytelling, new media, and game design to conduct workshops with youth around issues of sexuality and emotional health. The intervention’s international, interdisciplinary team designed a series of workshops for teens to tell their stories in digital, “transmedia” formats.

Due to the positive feedback from youth participants, and the project’s promising potential to reach a wide audience online, the authors conclude that the program can continue to be successfully utilized and expanded by teens and adolescent reproductive health advocates in both domestic and international settings.

State-by-State Analysis of Laws that Help New Parents

In Expecting Better: A State-by-State Analysis of Laws That Help New Parents, a report published by the National Partnership for Women & Families, the authors documents workers’ rights under current state laws and the progress that states have made in promoting the economic security of new parents. An additional section discusses state policies that more broadly assist family caregivers — both parents and workers overall — in addressing the needs of their children and other family members.

The report notes that the U.S. (which does not offer paid leave protections for new parents) falls behind the 178 nations that guarantee paid leave for new mothers and the 54 nations that guarantee paid leave for new fathers. Just three national laws, addressing pregnancy discrimination, family and medical leave, and nursing mothers’ rights at work, help some new and expecting parents upon the birth of a child.

New parents must rely on the policies of their employers, but only 38% of workers have access to employer-provided short-term disability insurance and only one-tenth of the workforce has access to employer-offered paid leave to care for a new child. Significantly, workers in low-paying jobs — those with the greatest need for both job protection and wage replacement during leave from work — are far less likely to have access to either of these employer-provided benefits.

The report points out states that are doing better than others (e.g., CA and CT), but 18 states were graded with an “F” for “failing to provide a single benefit or program to help support families before and after the birth, adoption or foster placement of a child.”

Depo Not Associated with Risk of Incident STIs Among Teens

In Depot Medroxyprogesterone Acetate Use Is Not Associated with Risk of Incident Sexually Transmitted Infections Among Adolescent Women, published in the Journal of Adolescent Health, authors Amy Romer, et al, examines whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of acquisition of sexually transmitted infections (STIs) in a cohort of healthy adolescents, for whom prospective evidence is sparse.

Adolescent women aged 14–17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing and also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs.

The authors found that, in multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The number of total or unprotected sexual events during the diary period was not associated with the risk of STI. Older age was a protective factor for the development of Chlamydia trachomatis (odds ratio = .85; 95% confidence interval = .76–.96). The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period (odds ratio, range = 1.91–2.62).

In this cohort, the authors found no evidence that DMPA use was associated with increased STI risk and recommended that efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.

Experiences of LGBTQ Communities in the Healthcare System

In The Forgotten Minorities: Health Disparities of the Lesbian, Gay, Bisexual, and Transgendered Communities, published in Journal of Health Care for the Poor and Underserved, author Lea Mollon, a pharmacy student, describes her personal experiences as a lesbian woman within the health care system and discusses some of the broader health issues and experiences of the LGBTQ community.

Mollon describes an uncomfortable appointment with a primary care physician, reporting:

“At the time, I did not suspect that many of my future experiences with health care providers would involve repetitive and awkward explanations about my relationship status, my sexual identity, and why I didn’t need birth control.  Unfortunately, experiences like this are not rare for [LGBT] people seeking access to medical services.”

The author discusses health disparities experienced by the LGBTQ community and recent efforts through health care reform to improve research and knowledge in this area. She also suggests better training for providers so they can be more aware of LGBTQ patients’ needs and encourages providers to create a climate that is “sensitive and inclusive” by doing things such as “[u]sing gender neutral language when discussing personal relationships and having a standardized intake form with additional identifiers for sexual orientation, gender identity and expression, and alternative family units.”

What do Middle Schoolers Know about Sex Ed?

In What if You Already Know Everything About Sex? Content Analysis of Questions From Early Adolescents in a Middle School Sex Education Program, published in the Journal of Adolescent Health, authors Linda Charmaraman, et al, assessed sixth graders’ knowledge and curiosity about sex-related topics, which can guide the development of sexual health education and health care delivery.

This study aims to inform healthcare providers’ conversations with early adolescents about sexual matters and development of effective sexual health curricula by investigating the following: (1) What sex-related topics do early adolescents ask about anonymously? (2) Which issues related to sex are of most concern to early adolescents? (3) How does school context affect the types of questions raised?

Authors worked with roughly 800 students in eight ethnically diverse schools participating in an evaluation of a sex education curriculum.  Researchers submitted 859 anonymous questions that were content analyzed.  The author’s analysis examined whether the themes varied by coed/single-sex environments or by school-level sexual risk.

Results showed that sexual activity, female anatomy, reproduction, and puberty were the most frequently mentioned topics, whereas, questions on STIs, sexual violence, and drug/alcohol use were fewer.  Questions that avoided sexual topics came from lower sexual-risk schools; students at higher-risk schools asked about sexual initiation, contraception, vaginal and anal sex, general health, and pain during sex.  Single-sex classrooms elicited more direct and explicit questions about sex.

Policy Recommendations for Reducing Unplanned Pregnancy

In Policy Solutions for Preventing Unplanned Pregnancy, a research brief published by The Brookings Institution, author Adam Thomas of Georgetown University assessed various policy initiatives that have sought to address unintended pregnancy and the value of their continued implementation.

Thomas researched the impact of mass media campaigns discouraging unprotected sex, teen pregnancy prevention programs, and expansions in publicly funded family planning services and presents new research showing that expansions in these policies would likely lead to reductions in teen and unintended pregnancy, out-of-wedlock childbearing, and child poverty.

The author concludes that “evidence-based pregnancy prevention interventions are public policy trifectas: they generate taxpayer savings, they improve the lives of children and families, and they reduce the incidence of abortion.”