1. 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

2. 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

3. 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
Edward Bliss Foote promotes the “Womb Veil” a rubber diaphragm
FDA approves hormonal birth control pill for contraceptive use

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

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

6. Question
What proportion of pregnancies in year olds are unintended?
51%
77%
12%
34%

7. Question
What proportion of pregnancies in year olds are unintended?
51%
77%
12%
34%

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

9. 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):

10. 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 Gutmacher Institute

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

12. 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
benefits of family planning: cost effective, increase birth spacing, decrease newborn deaths, increase health of children, increase educational opportunites,

13. 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

14. Birth control works when used consistently

17. 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)

18. 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.

19. 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

20. 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

21. 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:
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.

22. 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

24. 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

25. 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

26. 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

28. 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.

29. Cost Balance financial short term vs long term
MSWR, student not returning
Assistance programs:
ARCH Patient Assistance Program: (Skyla and Mirena)
Paragard Patient direct

30. Questions?