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Thorough look at underuse of long-term reversible contraceptives

IUDs and Hormonal Implants Remain Underused Contraceptives

Our Review Summary

Hormonal and copper IUDs.

Hormonal and copper IUDs.

Changes in the behavior of doctors could make a big difference in how many women opt for using long-acting reversible contraceptives (LARCs). This Jane Brody column reports on a committee’s strong argument urging obstetricians and gynecologists to increase their prescribing of long-acting alternatives. The committee states that only about half of all doctors offer these devices in their practice, even though research shows these alternatives are more effective and relatively safe.

The story does a great job of examining the way that up-front higher cost may be confusing some patients about the true long-term savings these devices can provide. It would have been nice to hear from someone — a clinician perhaps — who does not routinely prescribe LARCs and why that’s the case. What are their concerns and what are the obstacles to making this more widely available?

 

Why This Matters

Preventing unwanted pregnancies could work much better if the doctors who see women recommended better options known as long-acting reversible contraceptives or LARCs more often. Some of the resistance to LARCs is likely among older docs who remember the scary history of pelvic inflammatory disease (and infertility) from IUDs.  And the rest may be from those with concerns about high upfront costs. In addition, insertion of IUDs and Implanon are specialized skills that not all practitioners have (gynecologists and family practitioners are usually the ones to offer these methods, not internists), whereas as most practitioners are comfortable prescribing the pill.

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

We applaud the way this story examines what may be the “under use” of devices and clearly explains some of the nuance about up-front costs versus the long-term cost of contraception. Bravo for pointing out that the Affordable Care Act now covers these devices, which at one time may have seemed “too expensive” for some patients.

We think it would have been even better if the story had a few actual figures in it – to demonstrate this. For example, one website from Planned Parenthood explains the cost for the copper IUD this way:

“The cost for the medical exam, the IUD, the insertion of the IUD and follow-up visits to your health care provider can range from $500 to $900. That cost pays for protection that can last more than a decade.”

As the story points out – that cost will not fall to an individual patient who is covered under the ACA. But the old prejudices about cost may be part of the reason for the gap in popularity.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

The story gives figures on the effectiveness of a variety of contraception methods.

Here is an excerpt:

In a 2012 study of 7,486 women aged 14 to 45, long-acting reversible contraceptives, or LARCs, were shown to be 20 times as effective in preventing pregnancy than the pill, contraceptive patch or vaginal ring. The risk of an unwanted pregnancy with these other methods was especially high among women under 21, whose rate of unintended pregnancy was nearly double that among older women.

Absolute risks are also cited in the report on one-year pregnancy rate with real-world use, which is another strength of the story.

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

The story lists some of the potential side effects of long-acting implants or IUDs. These include “irregular bleeding and cramping” as short-term impacts. We’ll give the benefit of the doubt, but we would have liked an additional comment by someone not connected to the committee report on whether there are any long-term studies underway about downstream potential impacts for women 5 or 10 years after using these. In addition, rare but potentially serious complications of copper IUDs, such as perforation (when the IUD pushes through the wall of the uterus), could have been mentioned.

Does the story seem to grasp the quality of the evidence?

Not Satisfactory

The Committee report from the American College of Obstetrics and Gynecology relied on reviews of many high-quality peer-reviewed studies related to long-term contraception alternatives. However, the story doesn’t establish what kinds of evidence the committee based its recommendations on. Had the story taken greater pains to discuss this aspect of the report, readers could be more confident that the recommendations are solid and worth following.

Does the story commit disease-mongering?

Satisfactory

There was no disease mongering in this story.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story quotes one expert, Megan Kavanaugh, who is one of the authors of one of the studies referenced in the article. Kavanaugh works for the Guttmacher Institute, and has declared no conflicts in other publications on contraception. It would have been nice to hear from someone who is totally independent of the studies and report covered in the column, but we think Dr. Kavanaugh qualifies as sufficient for a Satisfactory rating here.

Does the story compare the new approach with existing alternatives?

Satisfactory

This story did a great job of outlining many different alternative methods of contraception and their effectiveness.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

You could say this story was about availability itself, and especially about why things that are widely available are not prescribed by doctors more often. All of these long-term contraceptives are available.

Does the story establish the true novelty of the approach?

Satisfactory

LARCs are not novel and the story establishes this.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story does not appear to rely on a news release.

Total Score: 9 of 10 Satisfactory

Comments (2)

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Linda Prine MD

November 2, 2015 at 7:14 am

The health insurance companies are a big part of the problem. They require prior authorizations or don’t cover them at all. Medicaid payments typically are a negotiated rate with each clinic so there is no mechanism for billing a big added expense like this, so many Medicaid clinics do not provide them. And then you have Title X family planning clinics that are under attack by Congress, struggling financially, and going out of business.

Reply

Laurence Alter

November 2, 2015 at 7:45 am

To Gary & Staff,
I can’t see a link to this story, so I can only go on your summarized points (years and years of computer/on-line use have not helped me use/find links), I assume the news article did not quote an authority from the field of endocrinology – an obvious source (ex.: Endocrine Society). This is doubly important as this is go-to sub-specialty when the primary physician (internist) is inconclusive in his/her diagnosis.
Respectfully,
Laurence

Reply