in Job Corps Sara Mackenzie MD MPH At the end of this session participants will be able to Identify individual factors contributing to high unintended pregnancy rates in US Identify most effective forms contraception ID: 705389
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Slide1
Use of Long Acting Reversible Contraceptives (LARC) in Job Corps
Sara Mackenzie, MD, MPHSlide2
At the end of this session, participants will be able to:
Identify individual factors contributing to high unintended pregnancy rates in U.S.
Identify most effective forms contraception
Take action to reduce barriers to contraception on centerSlide3
Contraception: A History
~2000 B.C. - Chinese drink cocktails of mercury and lead
~1850 B.C. - Egyptians use crocodile dung and honey
~630 B.C. - Greek use the silphium plant for contraception & abortion
1864 - Edward Bliss Foote promotes the “Womb Veil” a rubber diaphragm
1960 - FDA approves hormonal birth control pill for contraceptive useSlide4
Question
What proportion of
all
US pregnancies are unintended?
51%
77%
12%
34%Slide5
Question
What proportion of
all
US pregnancies are unintended?
51%
77%
12%
34%Slide6
Question
What proportion of
pregnancies in 15-25 year olds are
unintended?
51%
77%
12%
34%Slide7
Question
What proportion of
pregnancies in 15-25 year olds are
unintended?
51%
77%
12%
34%Slide8
Disparities in unintended pregnancy:Highest rates in:
Younger age groups
Low income women
Minority women
Women without high school degreeSlide9
Finer, L.B. (2010) Unintended Pregnancy Among U.S. Adolescents: Accounting for Sexual Activity. Journal of Adolescent Health. 47(3):
312-314Slide10
Outcomes unintended pregnancy:
40% end in abortion; 60% live birth*
Births associated with unintended pregnancy are associated with adverse maternal and child outcomes (i.e., prematurity, higher rates negative physical and mental health issues child)*
Within Job Corps – MSWR for birth or pregnancy complications, delayed completion of program or failure to return
*Unintended Pregnancy in the United States. Fact Sheet. 2015.
G
utmacher
I
nstitute
http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html#10Slide11
What can we do?Slide12
Adolescent Brain Development
Impulsivity
Risk Taking
Sensation Seeking
Impatience (preference for immediate reward over delayed gratification
)
Makes delayed benefits vs
immediate
reward decision-making hardSlide13
Reducing Rates of Unintended Pregnancy
Increased time between onset sexual activity and desired pregnancy
Conflicting influences of biology (hormones, impulsive behavior, risk-taking behavior) and development of executive decision making
in the
frontal lobe
Cultural conflicting messages – sexuality in media but difficulty discussingSlide14
Birth control works when used consistently
www.gutmacher.orgSlide15Slide16Slide17
An overwhelming array of choices!
Women in Job Corps have the right to informed choice
How we present options or create/reduce barriers to options influences decision-making
Current standard of care: recommended tiered approach to contraceptive counseling
starting with most effective methods
first*!
*
Ott
, M.A. et al. (2014) Contraception for Adolescents,
Pediatrics
134 (4)Slide18
Long-Acting Reversible Contraception
Intrauterine Device (IUD)
Hormonal IUDs - Mirena, Skyla & Liletta
Nonhormonal Copper IUD - Paragard
Contraceptive Implant
NexplanonSlide19
Nonhormonal Copper IUD (ParaGard T380A)
What is it?
A T-shaped device with a copper wire wound round it
Inserted into uterus by a health professional
Can be used as emergency contraception
Effective for up to 10 years
How does it work?
Causes changes in uterine lining
Prevents the sperm from fertilizing egg
Decreases sperm’s ability to penetrate cervical mucus
How well do they work?Typical Use: <1 per 100 women become pregnant in a yearPerfect Use: <1 per 100 women become pregnant in a yearSlide20
Nonhormonal Copper IUD (ParaGard T380A)
What is it?
A T-shaped device with a copper wire wound round it
Inserted into uterus by a health professional
Can be used as emergency contraception
Effective for up to 10 years
How does it work?
Causes changes in uterine lining
Prevents the sperm from fertilizing egg
Decreases sperm’s ability to penetrate cervical mucus
How well do they work?Typical Use: <1 per 100 women become pregnant in a yearPerfect Use: <1 per 100 women become pregnant in a yearSlide21
Emergency Contraception: Copper IUDMore effective than either emergency contraceptive pill – if unprotected sex during fertile period:
8 in 100 women will become pregnant
Only 1 in 100 if use progestin only ECP
Only 2 in 100 if use estrogen – progestin ECP
Only 1 in 1000 if use copper IUD
Emergency Contraception Fact Sheet, WomensHealth.gov available at: http://www.womenshealth.gov/publications/our-publications/fact-sheet/emergency-contraception.pdfSlide22
Hormonal IUD (Mirena)What is it?
A T-shaped intrauterine device that releases progesterone
Inserted into uterus by a health professional
Effective for up to 5 years
How does it work?
Thickens cervical mucus
Thins uterine lining
Prevents sperm from reaching or fertilizing egg
How well do they work?
Typical Use: <1 per 100 women become pregnant in a year
Perfect Use: <1 per 100 women become pregnant in a yearSlide23Slide24
Hormonal Implant (Nexplanon)What is it?
A single rod containing
etonogestrol
& barium sulfate (radio opaque)
Inserted inside of the
nondominant upper arm, 6 to 8 cm above the elbow
Effective for up to 3 years
Placement takes 1 minute; removal 5 minutes
How does it work?
Thickens cervical mucus
Thins uterine liningHow well do they work?Typical Use: <1 per 100 women become pregnant in a yearPerfect Use: <1 per 100 women become pregnant in a yearSlide25
Method
Pros
Cons
Non-Hormonal IUD
Regular menses
continues
May increase menstrual bleeding
and cramps
Risk of perforation: 1/1000
Risk of expulsion: 2-10/100
Not use if allergy copper or Wilson’s Hormonal IUDReduces heavy menstrual bleeding (on average by 90%) menses may cease; decrease crampsNo weight gainMay decrease endometriosisCan be used if can’t take estrogenIrregular bleedingRisk of perforation: 1/1000Risk of expulsion: 2-10/100Rare: breast tenderness, acne, headachesCannot be used if hx breast cancer or severe liver diseaseImplant
Reduces heavy menstrual bleeding; menses may cease (1 in 3 women); decrease cramps
Can be used if can’t take estrogen
Cannot be used if history breast cancer or severe liver disease
Irregular bleeding
Rare: infection at site, headaches, nausea, breast tenderness
https://
www.plannedparenthood.org/learn/birth-control
Slide26
Whoops-Proof Birth Control: how to reach women and increase their positive regard for the most effective methods of contraception
The National Campaign to Prevent Teen and Unplanned Pregnancy & Smart Design
2015
http://thenationalcampaign.org/sites/default/files/resource-primary-download/whoops_proof_insights.pdfSlide27Slide28
How to ensure access:Center provider
Treasure Island – provider has training to place
Develop a relationship with community provider
Hubert Humphry – St Paul DOH sends provider to center each week
San Jose – Planned Parenthood within walking distance
Work to reduce barriers associated with transportation and time and maintenance of confidentiality.Slide29
CostBalance financial short term vs long term
MSWR, student not returning
Assistance programs:
ARCH Patient Assistance Program:
http://www.archpatientassistance.com/eligibility/
(Skyla and
Mirena
)
Paragard
http://paragard.com/What-it-costs.aspx
Patient directSlide30
Questions?