BIRTH SPACING and USE of LARC Stephanie Teal, MD, MPH Professor of Obstetrics and Gynecology and Pediatrics University of Colorado School of Medicine

1/18/2018

BIRTH SPACING AND USE OF LARC Stephanie Teal, MD, MPH Professor of Obstetrics and Gynecology and Pediatrics University of Colorado School of Medicine

THIS ACTIVITY IS JOINTLY-PROVIDED BY SYNAPTIV AND THE COLORADO HOSPITAL ASSOCIATION

Safe Deliveries Project Partnership

■ Colorado Hospital Association ■ Anthem Blue Cross and Blue Shield Foundation ■ March of Dimes Colorado/Wyoming Chapter ■ Colorado Perinatal Care Quality Collaborative

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Why is a Professor of Family Planning speaking at this conference?

Outline of Presentation

■ What is the relationship between birth spacing and birth outcomes? ■ Is there unmet need for improved birth spacing? ■ Does improved access to highly effective contraceptives – Increase interpregnancy intervals? – Time to first pregnancy? – Reduce unintended pregnancy? ■ Does improved access to highly effective contraceptives improve birth outcomes?

Unintended Pregnancy, Birth Spacing and Birth Outcomes ■ Regardless of birth interval, unintended pregnancies have greater risk of adverse outcomes – Preterm birth (PTB) and delivery of LBW infants ■ The link between unintended pregnancy and poor birth outcomes is likely multifaceted, – Maternal socioeconomic risk factors, – Inadequate prenatal care, and – Preconceptual and prenatal maternal behavioral risk factors

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Short Interpregnancy Interval and Perinatal Outcomes

■ Multiple studies show association of short IPI and: – Delayed PNC, preterm birth, neonatal morbidity, low birthweight ■ Retrospective study of primiparous women with singleton gestation delivering in US – N=1,964,000 – Short IDI associated with PTD, SGA, low Apgar, NICU admission

DeFranco EA, et al. Influence of interpregnancy interval on neonatal morbidity. Am J Obstet Gynecol. 2015 Mar;212(3):386.e1-9. Orr ST et al., Unintended pregnancy and preterm birth. Pediatric Perinatal Epidemiology. 2000; 14:309–313. Yee LM, et al. The association between interdelivery interval and adverse perinatal outcomes in a diverse US population. J Perinatol. 2016 Mar 31.

Is there an unmet need for improved birth spacing?

■ 33% of US pregnancies have interpregnancy interval of <18 months ■ 9% have interdelivery interval of <18 months ■ Half of postpartum women resume intercourse within 6 weeks of delivery ■ 117,000 postpartum Medicaid recipients in CA: – 60% did not have a contraceptive claim within 3 months postpartum ■ 13% received contraception at first postpartum visit: significantly more likely to have an adequate IPI ■ Infant <9 months is a risk factor for abortion in next pregnancy

Does improved access to LARC increase IPI?

■ 2006-2010 NSFG data ■ Contraceptive use at – 0, 3, 6, 12, 18 months

■ Pregnancy within 18 months – Hormonal method users=12.6% – LARC users=0.5% ■ At least 70% of pregnancies within 12 months were unintended

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Contraception for Young Mothers

■ 12 to 49% of adolescent mothers are pregnant again within one year (RRP) ■ A second child in adolescence predicts a high risk of negative outcomes ■ Teens have the highest rate of PTB by age group ■ Many different interventions with limited success ■ Norplant associated with prevention of RRP in adolescents

Meade, C.S. Soc Sci Med, 2005. 60(4): p. 661-78. Stevens-Simon C. Am J Prev Med, 2001. 21(1): p. 60-5.

Immediate post-partum implants

■ All adolescents in CAMP delivered 6/1/08-11/30/09 ■ Prenatally, offered immediate PP implant ■ Immediate PP IUDs not available ■ Records reviewed; phone interviews for missing data ■ Variables: demographic, reproductive, contraceptive use, discontinuation/re-initiation of contraceptives, pregnancy ■ Consistent Contraception ■ Using one or more contraceptive method(s) for 80% of the year of observation

Participation

N=396

83% Mean ± SD 72% N = 396 Primiparous IPI or % Controls Primiparous Age (years) 18.6 ± 1.7 n=171 n=225 14.7 Race/ethnicity43.1% 56.8% LARC Black 35.6% Hispanic 40.2% White 18.7% n=161 n=213 42.7% Primigravid 64.6% 94.2% 94.6% LARC Primiparous 76.5% BMI (kg/m2) 24.3 Under weight 10.1% Average weightn=153 52.9% n=204 48.6% Overweight 89.5%/ obese 37.0% 90.7% LARC

Tocce KM, Sheeder JL, Teal SB. Am J Obstet Gynecol. 2012 Jun;206(6):481.e1-7.

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Implant Continuation

100% 90% 86.3% 80% 67.0% Reasons for 70% discontinuation n=46 60% Irregular bleeding 19 50% (41.6%) 40% Headache 5 (10.9%) 30% Moodiness 4 (8.7%) 20% Weight gain 4 (8.7%) 10% 0% 12 months 24 months

Tocce K. Am J Obstet Gynecol. 2012.

Repeat Pregnancy

50% IPI control 45% 41.2% 40% 35% 30% p≤0.001 25% 20% 18.6% p≤0.001 15% 10% 8.2% 5% 2.6% 0% 12 months 24 months

Tocce K. Am J Obstet Gynecol. 2012.

Cost-effectiveness

■ Costs estimated using Colorado Medicaid payments – Implant device, insertion, removal, ectopic, SAB, NSVD, C/S ■ Outcomes estimated using results of CAMP IPI project

Han L, Teal SB, Sheeder J, Tocce K. Am J Obstet and Gynecol. 2014 Jul;211(1):24.e1-7.

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Annual costs/1000 women

Han L, et al. Am J Obstet and Gynecol. 2014 Jul;211(1):24.e1-7.

Cost- effectiveness

For every dollar spent $0.79, $3.54, and $6.50 would be saved at 12, 24,and 36 months.

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LARC uptake: BC4U

Patch None 1% 1%

Ring 5% OCPs 14% LNG-IUS 31% DMPA 6%

Implant 34% Cu-T 73% IUD 8%

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Colorado Birth Rate 110 99.7 100

88.8 90 86.3

78.7 80 76.3 72.1 71.9

60 15-19 yo 20-24 yo 50

per 1,000 females 1,000 per 42.5 38.5 40 33.4 28.9 30 25.6 23.4 20.3 20

10 2008 2009 2010 2011 2012 2013 2014 Year

Abortion Rate 25

21.4

19.3 20 18.4 18.1 17.6 17.6

10.3 15-19 yo 20-24 yo 10 9.1 per 1,000 females 1,000per 7.5 6.8 6.0 5.4

0 2009 2010 2011 2012 2013 2014 Year

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Unintended Pregnancy Rate 90

78 80 75 70 70 65 64 61 60 60

38 15-19 yo 40 35 34 20-24 yo

per 1,000 females 1,000per 29 30 26 23 21 20

0 2008 2009 2010 2011 2012 2013 2014 Year

Average age at first birth, Colorado, 1990-2014

28.0

The Colorado Family Planning 27.1 Initiative started in 2009 26.9 27.0 26.7 26.5

26.2 25.9 25.8 25.8 26.0 25.7 25.4 25.3 25.2 24.9 25.0 25.0

24.0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

2nd order Births 1400 1258 1183 1200

1000 947

777 800 653

Number 600 551 551 15-19 yo

400 56%

200

0 2008 2009 2010 2011 2012 2013 2014 Year

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Does LARC really reduce unintended pregnancy in teens?

Pregnancy Rates among Sexually Experienced U.S. Adolescents, as Compared with CHOICE Participants

Secura GM et al. N Engl J Med 2014;371:1316-1323.

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Why was I invited to this conference?

■ I don’t even deliver babies any more

In the realm of PTB prevention, these numbers are more impactful than all of the previous efforts with tocolytics and progesterone…(nationwide the) downstream impact would be prevention of more than $1 billion in health care expenditures… A. Caughey, Obstet Gynecol Survey

Effect on low birthweight & preterm birth

Adjusted for: maternal age, race/ethnicity, BMI, education, income, marital status, prenatal care, smoking status, history of gonorrhea, history of chlamydia, history of congenital anomaly, and interpregnancy interval.

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Direct link between LARC use and reduced PTB

■ N=112,000 Medicaid births in California, second order or higher (2011) – How long ago was the prior birth? – Was the birth preterm? – Contraceptive method after the prior birth? ■ 9.75% of births preterm ■ For each additional month of contraceptive use, odds of PTB ↓ 1.1% ■ Mean contraceptive coverage duration was greatest with IUD and implants

Missed opportunities

Patients with Providers too little info perceive to request disinterest LARC

Missed opportunity to Providers increase LARC uncertain of awareness suitability of and LARC knowledge Teal S, Romer SE. J Adolesc Health. 2013 Apr;52(4 ):S35-9.

■ LARC initiation and use is very high in Colorado Colorado ■ This results in reductions in: results – Teen births – Abortions – Unintended pregnancies – Rapid 2nd births – Preterm births – Low birth weight – Costs ■ Same-day initiation is important and reasonable ■ Patients know what they want, are confident in their choices, and continue use

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Your questions!