(Published July 2008)
Rationale for Implantable Contraception
Decades of research have shown that women want the ability to choose whether and when to bear children. Advances in effective, convenient, and safe contraception have resulted in a decline in birth rate. The use of effective contraception by women not yet wanting to start a family has contributed to the better health of infants, children, and women.
Even after a lengthy history of contraception development, decades of worldwide use, and an ever expanding variety of choices, the selection of contraception is still a focus of much debate. With so many alternatives to choose from, why should we consider yet another option? Reflecting on the statistics below will help to answer this question.
Unintended Pregnancy Statistics
Women in the United States have high rates of unintended pregnancy. While unintended pregnancy rates are high worldwide (four in 10) they are highest in the United States where they reach five in 10.1 There are over six million pregnancies each year in the United States, and nearly half are unintended. Low income and cohabitating women are particularly vulnerable to unintended pregnancy.2 Approximately seven percent of women who don’t use contraception are responsible for about half of all unintended pregnancies. The remainder of unintended pregnancies occurs in women using some form of contraception within the past year.1 Half of unintended pregnancies—one in four pregnancies overall—end in elective abortion, making the abortion rate in the US highest of all Western developed countries and Japan. In 2004 the abortion rate was about 238 per 1,000 pregnancies.3,4 These statistics demonstrate that unintended pregnancy continues to be a major public health issue in the United States.
Risk is Growing
The number of women at risk for unintended pregnancy is growing. The percentage of women estimated to be at risk for unintended pregnancy was 5.2 percent in 1995; increasing to 7.4 percent in 2002.5 These data reflect the percentage of women aged 15 to 44 in the US who do not desire pregnancy, are not using contraception, and have had intercourse within the previous three months. This group of women accounts for approximately 50 percent of the unintended pregnancies occurring each year.
The consequences of unintended pregnancies are highly significant both socially and economically.6 Unintended pregnancies result in considerable costs whether or not the woman chooses to bear the child, place the child up for adoption, or terminate the pregnancy. A recent literature review estimated the total economic health care burden of unintended pregnancies in the United States; direct medical costs of unintended pregnancies were $5 billion, while direct medical cost savings due to contraceptive use were estimated at $19 billion.7
Current Contraceptive Use
Contraceptive methods are underutilized by women in the United States. There are over 42 million fertile, sexually active women in the US who do not want to become pregnant, yet only 89 percent are practicing contraception.8 Reasons women cite for not using contraception include limited access, high cost, an uncooperative partner, belief of sterility, lack of preparation for coitus, belief that they are at low risk for pregnancy, guilt, fear of doctor, inadequate information, and concern about side effects of a method.
“Unintended pregnancy continues to be a major public health issue in the United States according to The National Survey of Family Growth, which is a series of nationally representative surveys, which collect detailed reproductive information from women of reproductive age.”9
About one quarter of the couples using contraception selected a non-reversible method (Figure 1) and about one fifth of women used oral contraceptives (OCs).8 Oral contraceptives require daily effort and significant motivation by the woman in order to achieve maximum effectiveness. Oral contraceptives have a high rate of imperfect use, as do the contraceptive patch and depot medroxyprogesterone acetate (DMPA) injections. An estimated one-quarter of women are using a contraceptive method with a low rate of effectiveness, such as the condom, withdrawal, or other non-hormonal method. Very few women (1.2 percent) take advantage of other hormonal contraceptive methods that are rapidly reversible yet are highly effective in preventing undesired pregnancy.8
Oral contraceptives and condoms are the methods used by most women in the United States (Figure 1) as opposed to more effective contraceptive options such as intrauterine contraception or contraceptive implants. A high number of unintended pregnancies are due to not using a contraceptive method (49 percent), inconsistent method use (49 percent condom, 76 percent pill), or method failure (42 percent condom).10
An estimated 3.7 million women begin using oral contraceptives each year.11 Many women unfortunately fail to use OCs consistently or correctly to achieve the 99 percent efficacy reported with perfect use. Rather, 92 percent to 97 percent contraceptive efficacy is the typical use effectiveness, most likely reflecting imperfect use.12 The typical oral contraceptive user misses three or more pills each cycle by the third month of use.13
Women’s Satisfaction with Chosen Method
“The statistics are high; 1 in 20 American women has an unintended pregnancy every year.”2
According to a 2004 survey of 1,049 women aged 18 to 49 commissioned by ARHP and conducted by Harris International, many women are not satisfied with their choice of contraception.14
A subset of 602 women were asked to state their primary method of birth control and rate how satisfied they were with their current form of birth control. Significantly, 27 percent were dissatisfied with their current form of contraception.14
Even among women who reported being satisfied with their current method, 37 percent were interested in discussing alternative contraceptive methods.14
There is also a high rate of oral contraceptive discontinuation. About 50 percent to 75 percent of women not wanting to become pregnant discontinue oral contraceptives within one year.13 Rosenberg, et al. conducted a nationwide prospective study of 1,657 women initiating oral contraceptives or switching to a new oral contraceptive.15
Of the 293 women who discontinued oral contraceptives:
- 46 percent cited side effects as the reason
- 23 percent had no continuing need for contraception
- 14 percent reported method-related problems
- 17 percent had other unspecified reasons
More than four-fifths of women who discontinued OCs (but remained at risk for unintended pregnancy) either failed to adopt another method of contraception or adopted a less effective contraceptive method.15 Failure to immediately substitute a new contraceptive method after stopping one form of contraception is a common occurrence.15 Clinicians are the focal point for improving oral contraceptive compliance. By providing anticipatory counseling about side effects, clinicians can help patients expect these minor conditions and understand their transitory nature.
"Choice of contraception is essential to meet diverse user needs and preferences that may change with the user’s stage of life. Only by offering choice of method will the maximum number of women be protected and the greatest savings to health service be realized”6
These data are not presented to highlight the inadequacies of oral contraceptives, but to suggest that many women who use methods that require daily motivation for effectiveness are at risk for unintended pregnancy. Oral contraceptives requiring daily use have a large discrepancy between typical and perfect use efficacy rates.
The Association of Reproductive Health Professionals (ARHP) is an advocate for the availability of as many safe, effective options in contraception as possible. Since sterilization is permanent, it is not the best choice for most women. Many women, especially those who are younger, desire reversible methods of contraception. Also, many women who have selected sterilization regret their decision; 20 percent of women who select sterilization at age 30 years or younger later express regret because they either want more children (33 percent) or have a change in marital status (24 percent).16 Many young women choose sterilization because they are unaware of equally effective reversible options. Women older than 30 were less likely (six percent) to express sterilization regret 14 years after the procedure.16
Consumer choice of contraceptives is limited by poor awareness of existing contraception options according to The Contraceptive Knowledge and Awareness Study, conducted by Organon in 2005.17 This study was carried out with 7,000 women 16 to 40 years of age representing 14 countries. The authors concluded that contraceptive knowledge rarely extends beyond the pill. Many women are insufficiently informed to even consider new contraceptive methods among their options. Yet, women who were using the lesser-known methods of contraception, such as the vaginal ring, the single-rod implant, or the contraceptive transdermal patch, reported higher levels of satisfaction than women using the pill.
- Highly effective
- Extended duration of protection
- No daily effort
- Stable hormone levels
- Contains no estrogen
- Can be used during lactation
- Discreet, virtually invisible
- Rapidly reversible
A contraceptive method that is highly effective, safe, requires no daily effort, and is rapidly reversible is desirable. These criteria also include, for some women, a contraceptive method that does not contain estrogen, which may increase health risks associated with classical migraines or thrombophilias. While other contraceptive methods, such as intrauterine devices or DMPA, may help some patients meet these needs, progestin-only contraceptive implants create another reasonable option for women.
Progestin-only contraceptive implants provide numerous benefits, most notably their high level of effectiveness (Table 1). In addition, implants have a long duration of action and they are not subject to patient error or imperfect use. Implants provide continuous steroid release supplying in steady steroid levels in peripheral sera. Implants are not subject to ‘first-pass’ effect or metabolism that is associated with the hepatic portal system as is found with oral contraceptives. Implants have higher bioavailability, allowing similar efficacy with lower doses of hormone and parallel decreases in adverse effects. Contraceptive implants may be especially attractive to postpartum women because contraceptive implants do not contain estrogen and they can be used during lactation as early as four weeks postpartum.18,19 They are highly effective contraceptives that do not require daily adherence. Implants are virtually invisible, easy to insert and remove, and have a rapid return of fertility for women desiring to conceive.
"According to the World Health Organization, the evidence accumulated over the 30 to 40 years that contraceptive implants have been in existence indicates that they constitute one of the safest and most effective forms of contraception that exist.”20
Irregular vaginal bleeding may present a challenge to some patients with the contraceptive implant. Also, insertion and removal require a clinician visit. Implants, like other non-barrier forms of contraception, do not protect from sexually transmitted diseases and infections including HIV.
- Guttmacher Institute. Abortion in Context: United States and Worldwide. 1999. Accessed August 23, 2007.
- Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health. 2006;38(2):90–96.
- Strauss LT, Gamble SB, Parker WY, Cook DA, Zane SB, Hamdan S; Centers for Disease Control and prevention. Abortion Surveillance—United States, 2004. MMWR Surveill Summ. 2007 Nov 23;56(9):1-33.
- Henshaw S. Unintended pregnancy in the United States. Fam Plan Perspect. 1998;30:24--29,46.
- Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: 1982-2002. Advance Data. 2004 Dec 10;(350):17-52.
- Varney SJ, Guest JF. Relative cost effectiveness of Depo-Provera, Implanon, and Mirena in reversible long-term hormonal contraception in the UK. Pharmacoeconomics. 2004;22(17):1141-51.
- Trussell J. The cost of unintended pregnancy in the United States. Contraception. 2007;75:168-170.
- Guttmacher Institute. Facts in Brief. Contraceptive use. March 2005. www.guttmacher.org/pubs/fb_contr_use.html. Accessed October 22, 2007.
- Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat. 23(25). 2005. Available at www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf. Accessed April 10, 2007.
- Jones RK. Contraceptive use among U.S. women having abortions in 2000-2001. Perspect Sex Reprod Health. 2002;34(6):294-303.
- Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. J Reprod Med. 1995a;40:355-60.
- Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception. 1995; 51:283-88.
- Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation. Fam Plan Perspect. 1998;30(2):89-92.
- Association of Reproductive Health Professionals. Revisiting Your Regular Women’s Health Care Visit/ Harris Interactive for the Association of Reproductive Health Professionals. Conducted June 30-July 14, 2004. August 5, 2004. (slide presentation)
- Rosenberg MJ, Waugh MS. Oral contraceptive discontinuation: a prospective evaluation of frequency and reasons. Am J Obstet Gynecol. 1998;179: 577-82.
- Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93(6):889.
- Organon. Knowledge gap restricts women’s contraceptive choice.
- Reinprayoon D, Taneepanichskul S, Bunyavejchevin S, et al. Effects of the etonogestrel-releasing contraceptive implant (Implanon) on parameters of breast feeding compared to those of an intrauterine device. Contraception. 2000;62(5):239-46.
- Diaz S. Contraceptive implants and lactation. Contraception. 2002;65:39-46.
- World Health Organization. Contraceptive implants come of age. 2003. www.who.int/reproductive-health/hrp/progress/61/news61/html. Accessed August 2, 2007.