Contraception

Mamas on Bedrest: Pregnancy Spacing Improves Long Term Health Of Mamas and Babies

September 23rd, 2011

According to a February 1999 New England Journal of Medicine article, separating pregnancies by 18-23 months is optimum to ensure the health of both mamas and babies.

The authors,  Bao-Ping Zhu and colleagues found that incidences of adverse pregnancy outcomes such as premature birth and low birth weight were less likely to occur in pregnancies in which conception occurred 18-23 months after a prior pregnancy and delivery. They also found that there were lower incidences of pregnancy complications, such as pre-eclampsia, in pregnancies which occurred 18-23 months after a previous pregnancy and delivery. Interestingly, rates of complications went up when the pregnancy intervals were longer than 23 months between pregnancy and subsequent conception. The authors admitted that while this was a first assessment, there may be likely confounding variables such as maternal age, socioeconomic status, reproductive history and others that may exert an influence on pregnancy outcome.

As you can imagine, this has not always been well received. Many people simply balk at the notion of “planning” pregnancies and feel like pregnancies occur when they are supposed to occur. Others contend that the failures of contraception account for most of the pregnancy failures and that this cannot be helped as not contraceptive method, except for abstinence, is 100% effective at preventing pregnancy.

At the 2011 Association of Reproductive Health Professions Annual Meeting, this topic was discussed and the position of the Reproductive Health professionals present is to recommend long acting contraception (LARC) to women, especially those in the highest risk groups. Robert Hatcher, MD, MPH reviewed the currently available forms of reversible contraception.

  1. Depro Provera Injection
  2. Paragard IUD
  3. Mirena IUS
  4. Implanon implants

The recommendation for LARC comes as unintended pregnancies in the United States account for approximately half of all pregnancies annually. 60% of unintended pregnancies are what is called “Mistimed Pregnancies” meaning women admit that they would have had (another) child, just not at the time of this particular pregnancy. Most women cited contraceptive failure as the primary reason for unintended pregnancy. But a closer look at contraceptive use habits revealed some interesting statistics.

James Trussell, PhD, Office of Population Research at Princeton University and The Hull York Medical School shared statistics that showed that while the rates of unintended pregnancy has dropped amongst teens, the rates have increased in women in their 20’s. Women of lower education and lower socioeconomic status account for the greatest numbers of unintended pregnancies and African American and Latina Women have the highest rates of unintended pregnancies.

What was even more alarming is that in 2001, 52% of unintended pregnancies were to women who were using no method of birth control. Further, when interviewed for a study between 2006 and 2008, 10.6% of women at risk for unintended pregnancy weren’t using any contraceptive method.

Contraceptive problems arise mostly from “typical use”. What this means is how women typically use the contraceptive method vs. “Perfect use” i.e. how the method is intended to be used. Below is a table taken from the 2011 Contraceptive Technology Handbook outlining the failure rates of contraceptives with “typical use” and “perfect use”.

Method      Typical Use      Perfect Use

Chance 85%                   85%   (Percentages are effective rates)

Condom                     18%                      2%

Pill, Patch, Ring        9%                     0.3%

Depo Provera            6%                     0.2%

Paragard IUD         0.8%                   0.6%

Mirena IUS            0.2%                    0.2%

Implanon               0.05%                0.05%

What this table shows is that methods that require consistent (daily) use have a significant failure rate and significant difference between “typical use” and “perfect use”. However, the more “reliable” methods provide no protection against sexually transmitted infections (STI’s).

Anita Nelson, MD, Professor at the David Geffen School of Medicine at Harbor-UCLA Medical Center in Manhattan Beach, CA looked specifically at the oral contraceptives or birth control pills. What she shared both from the research and from her years in clinical practice is that in a 12 month cycle, women rarely take their pills as prescribed. Women on average miss 3 pills a month and as many as 60 pills a year. Even if they take a pill when they remember, for many women, this is days later and they are already at risk for unintended pregnancy.

Nelson also reiterated a little known fact amongst many women. Pregnancy is more dangerous to a woman’s health than hypertension, blood clots in the legs or diabetes and yet pregnancy increases the risk of all of these conditions occurring and persisting throughout a woman’s life.  Pregnancy related mortality (death) in the United States between 1998 and 2005 has been higher than at any other time in the previous 20 years. 14.5 women die annually for every 100, 00o births and the rates for African American women is 3-4 times higher. Unintended pregnancy also has a higher risk of “sicker babies”.  Nelson and other researchers advocate continuous (or long acting) oral contraceptives and condoms as a way for,

  • Women to control their fertility
  • Pregnancy to occur when desired, lowering risk for complications
  • Unwanted fertility to be eliminated

Family Planning is seen by the US Centers for Disease Control and Prevention as one of the top 10 most important contributions to public health in the 20th century.

Family Planning is also seen as an important global health issue asserts Willard Cates, Jr., MD, MPH of Family Health International and The UNC Gillings School of Global Public Health. Cates presented data and information from the United Nations Population Fund, an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. Sharing statistics from the Guttmacher Institute, family planning averts 187 million unintended pregnancies and in turn prevents:
• 54 million unplanned births
• 112 million induced abortions
• 1.2 million infant deaths
• 230,000 maternal deaths
• 71 million DALYs saved

(WHO Definition of DALY’s: DALYs = Disability Adjusted Life Years. The sum of years of potential life lost due to prematuremortality and the years of productive life lost due to disability)

Cates reiterated that Family Planning contributes to the Millinium Development Goals for the world which are:

1. End Poverty and Hunger
2. Universal Education
3. Gender Equality
4. Child Health
5. Maternal Health
6. Combat HIV/AIDS
7. Environmental Sustainability
8. Global Partnerships

Cates makes the case that only with widely available, long acting reversible family planning will the world’s goals of economic equality for women, increased educational opportunities for women, improved health and mortality for women and babies, reduced unintended pregnancy rates, reduced abortion rates, increased economic growth and stability for all nations.

What are your thoughts on contraception and unintended pregnancy? Would you ever use a long acting reversible contraceptive (LARC)? Share your comments below.

Mamas on Bedrest: It’s Time to Consider Your Birth Control Options

July 20th, 2011

I had a tubal ligation at the same time I delivered my son. I had a c-section and my OB and I both decided to get it done while she was there. Worked for me.

As I have openly said, my reproductive history was fraught with complications and I am forever thankful that I have the two beautiful children that I have. And when it became evident that my son (my second child and 4th pregnancy) was a healthy boy, I didn’t want to tempt fate. I had a girl and now would have a boy. At 40 and with my history, I was done. Nip/Tuck away!!

Mamas on Bedrest, although you may be on bed rest now, it’s time to consider your birth control options and to choose a birth control method.

The Centers for Disease Control and Prevention, in conjunction with the World Health Organization, have updated their recommendations for post partum contraception.

“The revised guidelines affirm the importance of starting contraception during the postpartum period to prevent unintended pregnancy and short birth intervals, which are associated with adverse health outcomes for the mother as well as for the infant. These include greater risks for low birth weight and preterm birth”.

The World Health Organization and CDC both emphasize the importance of women NOT using combination hormonal contraception for the first 21-42 days post partum due to the increased risk of blood clots forming and migrating to the heart, lungs and brain. (VTE).

“Compared with control participants, women in the first 42 days of the postpartum period have a 22-fold to 84-fold increased risk for VTE.”

The CDC and WHO recommend that women who choose to use hormonal contraception use progestin only injections, implants, mini pills or IUD’s.  All can be started immediately post partum and all are safe for use with breastfeeding. (Combination hormonal contraception can hinder successful breastfeeding.)

Condoms can be safely used at any time, but use of the diaphragm and cervical cap should be delayed until 6 weeks postpartum.  And of course, for women who have all they children they desire, they can consider permanent sterilization. 

It my seem strange to even ponder contraception while working so hard to grow this baby. But in the interest of your own health and the health of subsequent children, adequate time should be allowed for you to recover so that (if you choose) you can enter your next pregnancy healthy, strong and doing all that you can to avoid another high risk pregnancy and potentially, bed rest.  

Sources:

MMWR Morbidity and Mortality Weekly Report. 2011;60:878-883.
The World Health Organization – Position Statement on Post Partum Contraception and Combined Hormonal Contraception in the Early Post Partum. (PDF)