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Contraception
Corner
A Planned Production
Anita L. Nelson, MD; Miriam Zieman, MD
This is a tremendously exciting time to launch "Contraception
Corner," a new column in THE FEMALE PATIENT®. The
recent or anticipated introduction of at least four highly effective,
reversible methods of hormonal contraception is coinciding with
increasing acknowledgment of the importance of family planning.
The Centers for Disease Control and Prevention cited family planning
as one of the 10 most important advances in public health of the
20th century.1
The key role that pre-conception care plays in optimizing maternal-fetal
outcomes is slowly being recognized by the professional community,
although implementation is only in the most rudimentary stage. Planned
and "prepared-for" pregnancies are the ultimate goal; however, they
are such relatively rare events that statistics on US pregnancies
do not even estimate the proportion that qualify to be so categorized.
At best, experts can estimate the proportion of pregnancies that
are "intended." However, intended pregnancies include not only the
planned, prepared-for pregnancies (the goal), but also the planned,
"unprepared-for" pregnancies (resulting from unprotected intercourse,
but with no pre-conception health evaluation or folic acid supplements)
and the unplanned ("but it's ok, I guess") and unprepared-for ("oops!")
pregnancies that are not terminated.
Pre-conception preparation is critical. Diabetic women with reasonably
good nonpregnant glycemic control (fasting blood glucose [FBG] <120
mg/dL; 2-hour postprandial [PP] BG <200 mg/dL) face a 9% risk
of conceiving a fetus with a major congenital anomaly.2
Early prenatal care that achieves an FBG <105 mg/dL and a 2-hour
PPBG <120 mg/dL in the first trimester lowers that risk to 6%
to 7%. However, tight pre-conception glycemic control drops this
rate to 1% to 2.1%, which is similar to that in the general population.2,3
Nevertheless, about 40% of diabetic women conceive without consulting
a clinician and with inadequate glycemic control.4 Many
women who avoid pre-conception contact fear that they will be advised
against pregnancy or lectured about the dangers.
Women with pre-existing medical problems are not the only ones
who eschew the benefits of pre-conception care. Interviews conducted
by Moos et al showed that no gravidas in the second half of pregnancy
were even familiar with pre-conception care. These women thought
that pregnancy planning focused on delivery, not conception.5
The most effective intervention to prevent unwanted postcoital
pregnancy is the progestin-only emergency contraceptive pill (ECP).
Not only are these ECPs more effective than the traditional Yuzpe
method, but they also have far fewer side effects and no contraindications.
The American Medical Association with other medical organizations
and advocacy groups, including the Association of Reproductive Health
Professionals, endorsed a motion to make ECPs available over the
counter. Trussell et al estimated that the abortion rate would be
halved if ECPs were widely available.6 In the United
States, 1.3 million abortions are performed each year, and 43% of
women have had an elective abortion by age 45.7 By contrast,
only 1% of US women have ever used ECPs.8
Timely access to ECPs is key. A World Health Organization study
showed that the pregnancy rate in women using levonorgestrel-containing
ECPs was only 0.5% if these pills were started in the first 12 hours
after accidental exposure to sperm.9 This rate rose progressively
with time; by the last 12 hours of the traditional 72-hour window,
the pregnancy rate was 4.1%. Recognizing the importance of timely
access, some states have passed legislation enabling pharmacists
to provide ECPs without a prescription by working under protocols
developed with physicians. One such program in Washington state
has been very successful, and has revealed other key issues, such
as the fact that peak demand for ECPs occurs on Saturdays and Sundays,
when potential users would have the most difficulty in contacting
their physicians.
An even better approach is to provide ECPs by advance prescription.
Tom Purdon, MD, president of the American College of Obstetricians
and Gynecologists (ACOG), undertook as his presidential initiative
a program to increase ECP availability and utilization. He has called
upon all ACOG fellows to routinely offer these pills to patients
at each annual visit, and he has urged US women to ask for ECPs
if their physicians do not offer them. Surveys of physicians show
that although they recognize that ECPs are safe and effective, they
tend to wait for patients to ask for them. Unfortunately, surveys
of reproductive-aged women show that only a few are aware that anything
can be done after coitus to prevent pregnancy.8
Advance prescription of ECPs enables women immediate access at
the time of need, eliminating delays in contacting physicians or
in finding a pharmacy carrying these products. Advance prescription
increases ECP utilization but does not diminish a woman's use of
her primary method of birth control.10 Accidents happen;
prudence dictates preparation in all aspects of life. ECPs belong
in the medicine cabinet next to the bandages. The US Food and Drug
Administration has approved a long list of norgestrel- and levonorgestrel-containing
pills as emergency contraception, as well as two dedicated products
(PREVEN and Plan B) for such use.
With modern methods of contraception, pregnancy planning and preparation
can become a reality, but only if physicians educate women about
how effective and safe contraception is in preventing accidental
and unprepared-for pregnancy. They must also guide women to the
realization that pregnancy planning is not only feasible but also
their responsibility. An easy question can be posed to them to facilitate
achievement of this goal: "When do you plan to have your next pregnancy?"
It's a start.
REFERENCES
- Centers for Disease Control and Prevention. Ten great public
health achievements-United States, 1900-1999. JAMA. 1999;281:1481.
- Fuhrman K, Reiher H, Semmler K, Glockner E. The effect of intensified
conventional insulin therapy before and during pregnancy on the
malformation rate in offspring of diabetic mothers. Exp Clin
Endocrinol. 1984; 83:173-177.
- Ray JG, O'Brien TE, Chan WS. Preconception care and the risk
of congenital anomalies in the offspring of women with diabetes
mellitus: a meta-analysis. QJM. 2001;94:435-444.
- Holing EV. Preconception care of women with diabetes: the unrevealed
obstacles. J Matern Fetal Med. 2000; 9:10-13.
- Moos MK, Petersen R, Meadows K, et al. Pregnant women's perspectives
on intendedness of pregnancy. Womens Health Issues. 1997;7:385-392.
- Trussell J, Ellertson C, Stewart F. The effectiveness of the
Yuzpe regimen of emergency contraception. Fam Plann Perspect.
1996;28:58-64, 87.
- Henshaw SK. Unintended pregnancy in the United States. Fam
Plann Perspect. 1998;30:24-29, 46.
- Delbanco SF, Mauldon J, Smith MD. Little knowledge and limited
practice: emergency contraceptive pills, the public, and the obstetrician-gynecologist.
Obstet Gynecol. 1997;89: 1006-1011.
- Task Force on Postovulatory Methods of Fertility Regulation.
Randomized controlled trial of levonorgestrel versus Yuzpe regime
of combined oral contraceptives for emergency contraception. Lancet.
1998;352:428-433.
- Glasier A, Baird D. The effects of self-administering emergency
contraception. N Engl J Med. 1998;339:1-4.
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