Use of Long Acting Reversible Contraceptives (LARC) in Job Corps Sara Mackenzie, MD, MPH Pills patches rings and things/ put a ring on it alt title

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 center

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 use

Question What proportion of all US pregnancies are unintended? 51% 77% 12% 34%

Question What proportion of all US pregnancies are unintended? 51% 77% 12% 34%

Question What proportion of pregnancies in 15-25 year olds are unintended? 51% 77% 12% 34%

Question What proportion of pregnancies in 15-25 year olds are unintended? 51% 77% 12% 34%

Disparities in unintended pregnancy: Highest rates in: Younger age groups Low income women Minority women Women without high school degree

Finer, L. B. (2010) Unintended Pregnancy Among U. S Finer, L.B. (2010) Unintended Pregnancy Among U.S. Adolescents: Accounting for Sexual Activity. Journal of Adolescent Health. 47(3):312-314

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. Gutmacher Institute http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html#10

What can we do? Complex problem – not one way to solve

Adolescent Brain Development Impulsivity Risk Taking Sensation Seeking Impatience (preference for immediate reward over delayed gratification) Makes delayed benefits vs immediate reward decision-making hard impulsivity is when you act without thinking. theres individual variation in impulsivity and some people are better than others at controlling their impulses; there is a linear development in increased impulse control as you age MIGHT WANT TO FINISH school be more financially stable etc https://www.guttmacher.org/pubs/AddingItUp2014.html benefits of family planning: cost effective, increase birth spacing, decrease newborn deaths, increase health of children, increase educational opportunites,

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 discussing some complications associated with achieving goal of unintended pregnancy watch tv and they seldom show process of partners discussing sex before engaging in this act, rarely show a condom or dental dam being pulled out creates this misleading, counterintuitive and highly problematic message that safe sex isnt sexy

Birth control works when used consistently www.gutmacher.org

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)

Long-Acting Reversible Contraception Intrauterine Device (IUD) Hormonal IUDs - Mirena, Skyla & Liletta Nonhormonal Copper IUD - Paragard Contraceptive Implant Nexplanon Called LARCs. All IUDs are small T-shaped devices that are inserted into the uterus by a health-care professional and serve to block sperm from moving through the uterus toward the egg. ParaGard also releases copper, which some experts believe creates a substance toxic to sperm. In addition, Mirena, Skyla, and now Liletta all release levonorgestrel, a hormone similar to those found in birth control pills. This means that they also thicken cervical mucus (creating a barrier to sperm) and may suppress ovulation in some women. ParaGard lasts for ten years, Mirena for five, and Skyla and Liletta for three—but all can be removed by a health-care provider at any point if a woman decides she wants to become pregnant or switch methods.

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 year Perfect Use: <1 per 100 women become pregnant in a year

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 year Perfect Use: <1 per 100 women become pregnant in a year

Emergency Contraception: Copper IUD More 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.pdf As emergency contraception, the Copper-T IUD is much more effective than either type of emergency contraceptive pill (or “morning after pill”) because it reduces your risk of getting pregnant by more than 99%. Another advantage to the Copper-T IUD is that you can keep it in place to prevent pregnancy for up to ten years.

Hormonal IUD (Mirena) What is it? How does it work? 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 year

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 lining 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 year

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 IUD Reduces heavy menstrual bleeding (on average by 90%) menses may cease; decrease cramps No weight gain May decrease endometriosis Can be used if can’t take estrogen Irregular bleeding Rare: breast tenderness, acne, headaches Cannot be used if hx breast cancer or severe liver disease Implant Reduces heavy menstrual bleeding; menses may cease (1 in 3 women); decrease cramps Cannot be used if history breast cancer or severe liver disease Rare: infection at site, headaches, nausea, breast tenderness https://www.plannedparenthood.org/learn/birth-control

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.pdf

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.

Cost Balance 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 direct

Questions?