IUDs and Implants Are the New Pill

Long-term devices are now the first-line recommendation for women of all ages.

As of this week, IUDs and implantable devices are almost unanimously the first-line recommendation for medical contraception in young women. According to an important new study that will appear in tomorrow's New England Journal of Medicine, more than 16 times more teenage women would choose these options over birth-control pills if given proper information and affordable access to all forms of medical contraception. That would dramatically lower rates of unplanned pregnancy and abortion, which cost the country billions of dollars every year.

Between 10 and 100 times more effective than birth-control pills, these two long-acting reversible contraceptive (LARC) methods are, by far, the most reliable and affordable options. They are more effective even than male or female sterilization (vasectomy or tubal ligation), which fail to prevent pregnancy 0.15 and 0.5 percent of the time, respectively. Of course, those procedures aren't on the table for young patients, but it's still interesting that a doctor could take a scalpel to a person's sex organs and render them still more likely to conceive than a person with a removable implant.

The United States has more teenage pregnancies than any other wealthy country, and the cost of that is around $11 billion every year─in the form of public assistance, care for infants more likely to suffer health problems, and income lost as a result of lower educational attainment and reduced earnings among children born to teenage mothers. So it's especially interesting that only about 4.5 percent of women 15 to 19-years-old currently use LARC. The reason for that became evident in the New England Journal of Medicine study.

Over the course of five years, researchers at Washington University in St. Louis provided free contraception (access and comprehensive education on all options) to thousands of local women as part of the CHOICE Contraceptive Project. Among 1,404 teenage women who had their pick of birth-control and thorough counseling on the plusses and minuses of each method, 74 percent chose IUDs or implants.

Teen Birth Rates (Per 1,000 Women)
U.S. teenagers are more likely to give birth than teenagers in any other industrialized country.
(CDC, UNECE Statistical Database, and UN Demographic Yearbook 2009-2010)

The St. Louis group showed that when women have access to all types of reversible birth-control at no cost, rates of teenage pregnancy and abortion plummet. The rate of unplanned pregnancy among the study population was just 3.4 percent, compared to a national average of 15.9 percent.

And less than 1 percent of the women had abortions, compared to a national average of 4.2 percent. That's consistent with known long-term trends.

Rates Among Women Ages 15 to 17 (Per 1,000 Women)
(CDC/NCHS, Guttmacher Institute)

The takeaway, according to Dr. Jeffrey Peipert, the principal investigator and a professor of obstetrics and gynecology, is that with a little more investment in getting people access to information about LARC, everyone wins. The key is educating not just patients, but doctors, many of whom are not comfortable implanting these devices and/or were not trained to recommend IUDs to young women. One long-standing reservation about IUDs in young women was a high risk of expulsion from the uterus, which was evident in the CHOICE project; but the IUDs were falling out at lower rates than people who opted to take the pill were forgetting to take it.

Peipert believes that because many pediatricians and gynecologists are only beginning to suggest long-acting reversible contraception to young patients, the tide is set to turn. It was not until 2012 that the American College of Obstetricians and Gynecologists recommended that doctors should encourage LARC among teenage patients, and it was not until this Monday that the American Academy of Pediatrics (AAP) announced new guidelines in the journal Pediatrics: Because of their effectiveness, safety, and ease of use, LARC methods should now be considered the contraceptives of choice for adolescents.

Birth-control pills fail 9 percent of the time (only 0.3 percent of the time when used “perfectly,” according to the AAP, which is uncommon), and male condoms fail 18 percent of the time when they are used alone (2 percent of the time when used consistently (“perfectly”)). IUDs have no such discrepancy in effectiveness; it requires a feat of creativity to misuse an IUD. So levonorgestrel IUDs fail 0.2 percent of the time, end of story. Contraceptive implants, which are placed under the skin of a woman’s upper arm and last several years, are even more reliable, with a failure rate of just 0.05.

For uninsured patients, IUDs and implantable devices cost several hundred dollars up front, but are still substantially cheaper than pills or patches in the long run, according to Peipert.

Teen Birth Rates, 2009 (Per 1,000 Women)
(National Center for Health Statistics, CDC/The Atlantic)

The St. Louis researchers describe the endeavor in the journal article as an effort to address the “stubborn” public health problem of unintended teenage pregnancy. Stubborn might seem like an odd appraisal in that rates have gone down significantly in recent years, or trivializing in that rates and costs are so exorbitant and insidious. But it is a stubborn problem in that it persists despite being, apparently, readily solvable. CDC has targeted the country’s teenage pregnancy rates as among a handful of what it calls “Winnable Battles.” Apart from the implication that some battles are un-winnable, it’s been a laudable initiative. The federal goal of reducing the rate of teenage pregnancy to 3 percent by 2015 is close to met. But that rate is still abnormally high, very expensive, and largely preventable.

Like any public-health solution, the primary challenge is culture. No less than the bastion of sexual liberation the U.S. Department of Health and Human Services recommends that countries with the most sex-positive sexual instruction have the best outcomes in preventing unintentional teenage pregnancy, and that the public-health issue is best addressed with "societal acceptance of adolescent sexual relationships." With the release of today's high-profile study Peipert and colleagues hope that doctors who are not recommending implants and IUDs to young women will change their practice; and that, if they don't, patients will prompt that discussion.