Abstract
Every woman should possess the power to decide whether or not she chooses to become pregnant at any given point in her life. Unplanned pregnancy may have a huge impact on a woman’s health, economic, and social well-being, and yet an estimated 41% of pregnancies worldwide are unintentional. There are a multitude of reversible contraceptive options available and many factors that contribute to a woman’s decision regarding which method is right for her. Efficacy, effort and side effect profile are important considerations and vary widely between methods. Surprisingly, condoms and the oral contraceptive pill, which have relatively high typical use failure rates at 21% and 9% respectively and require frequent user action, are the most popular reversible contraceptive options in Canada. In contrast, intrauterine contraceptive devices, with failure rates of <0.8% and almost no user action, have extremely poor uptake. Recognizing that the variation of side effect profiles will also impact use, this disconnect between efficacy, effort and use suggests that forces beyond the intrinsic merits of a contraceptive system play a role in these decisions. Cost and accessibility can both inhibit the use of intrauterine systems, which are a large upfront investment and require physician insertion. Peers, the media and providers all influence contraceptive decision-making and may also contribute their own bias. We advocate for providing public funding for all contraceptive options as well as engaging in open discussion with both patients and the public to improve our delivery of reproductive health care.
Highlights
Every woman should possess the power to decide whether or not she chooses to become pregnant at any given point in her life
There are many reversible contraceptive options, which can provide a woman with the freedom to decide if and when she will become pregnant without permanently altering her reproductive potential
Reversible contraceptives are categorized into barrier methods, short-acting reversible contraceptives (SARCs), and long-acting reversible contraceptives (LARCs)
Summary
Laura J McLeod, Helene Baldwin, Vanessa DeMelo Faculty Reviewer: Shannon Arntfield, MD, FRCSC (Department of Obstetrics and Gynecology) abstract. Despite the existence of highly effective contraception, 41% of 208 million pregnancies worldwide were unintended in 2008, with the highest rates occurring in Eastern and Middle Africa.[2] In Canada there are greater than 180 000 unplanned pregnancies per year with an estimated health-care cost of $320 million.[3] Unintended pregnancies can be associated with negative mental, physical, social and economic outcomes for women and their families. Estrogen-containing SARCs may increase a woman’s thromboembolic risk.[11] With perfect use, SARC failure rates are 0.2% to 0.3% With typical use, those failure rates rise to 9% for the OCP, patch, and ring, and 6% for injections (Table 1).[10] Narrowing the gap between perfect and typical use failure rates with quarterly injections suggests that decreasing the level of user action increases a method’s real-world efficacy. It is worth noting that Canada’s 1% prevalence is on par with that of the WHO’s 48 least developed countries.[13]
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