It is estimated that 84.6% of women between the ages of 18 and 49 years old are at risk for unintended pregnancy in the state of Georgia12. As the obesity epidemic continues to drive an increase in chronic disease, the percentage of women at risk for pregnancy-related adverse events is on the rise9. Now more than ever, there is a call to action to promote and optimize health before, during and after pregnancy in reproductive-aged women10.
Contraception continues to be one of the most valuable tools in our arsenal against maternal morbidity and mortality. However, medical barriers and provider bias continue to limit the access to effective contraception, particularly for women with co-morbidities. Unfortunately, this leaves our most high-risk patients vulnerable to the devastating outcomes we are trying to prevent. This makes contraception and reproductive planning an essential part of “Every Visit for Every Woman, Every Time” as stated by Dr. Jeanne Conry, former American College of Obstetrics and Gynecology (ACOG) president.
Starting the conversation about contraception is an important first step. ACOG has simplified the approach to this conversation with their One Key Question Initiative, “Would you like to become pregnant in the next year?”1 This simple question allows the provider to center the discussion about contraception around a patient’s pregnancy intentions and priorities10. Effective contraception should be encouraged when preventing unintended pregnancy, optimizing health or planning for appropriate pregnancy spacing1,10.
All patients, regardless of their medical complexities, ethnicity and socioeconomic status, should have access to contraceptive options. As providers, our knowledge about contraception and how we advocate for their use directly impact what our patients choose.
Many leaders in women’s health maintain the premise that contraceptive counseling should remain non-bias while discussing all options including risks, benefits and failure rates as it compares to unintended pregnancy. However, not all providers feel comfortable with contraceptive counseling, particularly in medically complex patients.
In 2010, the Centers for Disease Control and Prevention (CDC) produced the first U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC). This document was created to assist healthcare professionals and provide some much-needed clarity on the safety of different forms of contraception as they pertain to specific medical conditions6.
The four-tiered classification system (see Box 1) assigns a risk for each contraceptive method based on preexisting medical conditions. If multiple conditions are present, recommendations are to assume the highest-risk category3.
In 2013, the CDC went on to create a document to address complex issues regarding the use of contraception, which they named the U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR). This document provides valuable information regarding initiation, need for back-up method, follow up and how to manage imperfect use and bleeding irregularities associated with each method of contraception5.
The CDC is dedicated to keeping these documents up to date, with anticipated reviews every 5 years or sooner if indicated6. The U.S. MEC/SPR was last updated in 2016 and is available via an easy-to-navigate free mobile application6. This app provides quick access to quality data that is meant to be used as an adjunct to counseling.
Box 1. U.S. MEC Categories for Contraceptive Use
|1||A condition for which there is no restriction on contraceptive use|
|2||A condition where advantages generally outweigh the risks|
|3||A condition where the risks outweigh the advantages|
|4||A condition that represents an unacceptable level of risk|
Healthy People 2030 has included the objectives of not only decreasing the proportion of unintended pregnancy, but also increasing the proportion of women at risk for unintended pregnancy who use effective birth control11. Current methods for contraception fall into the broad categories of permanent sterilization, long-acting reversible contraception (LARC), combined hormonal contraceptives (CHC), progestin-only pills, and depot-medroxyprogesterone acetate (DMPA). Even the highest risk patients can be protected from pregnancy with an acceptable level of risk using one of these options; however, some are more effective than others.
LARCs (IUDs and implants) are regarded as some of the safest and most effective options on the market2. LARCs are considered low maintenance, well tolerated and highly effective at preventing pregnancy with failure rates < 1%2. Few contraindications exist for these devices, making them exceptional choices for patients with the co-morbidities that we see on a daily basis such as obesity, venous thromboembolism (VTE), hypertension and diabetes.
Obesity has become a very common medical condition, accounting for roughly 34% of the adult population in Georgia4. Obesity increases the risk for other co-morbidities; therefore, a careful exploration of a patient’s medical history and plans for future bariatric surgery are important topics to discuss prior to choosing a contraceptive option.
Two areas of concern include efficacy and risk. Based on available data, obesity has not been found to significantly affect the efficacy of hormonal contraception; however, that data is limited in populations with a BMI of 40 or greater3. If oral contraceptives are selected, ACOG suggests strategies for increasing efficacy should include options with 30-35 mcg of ethinyl estradiol and avoiding a 7-day hormone-free interval by selecting a regimen with a 4-day hormone-free interval or utilizing continuous administration3. The risks associated with CHCs in a patient with obesity are largely related to cardiovascular and thromboembolic disease, and if additional risk factors are present, progestin-only options should be favored3.
As VTE events becomes more prevalent, many providers are finding it more difficult to find safe options to protect their patients without increasing their risk. Important points to remember are that although we associate CHCs with risk for VTE, the risk associated with pregnancy is twice as high3. That being said, CHCs should be avoided in women with active or historical VTE, and progestin-only or the copper IUD should be considered in these patients3. A family history of VTE does not warrant screening for thrombophilia or contraceptive limitations, unless other risk factors are present3,6.
Hypertension as it relates to contraception can be complex. The U.S. MEC classification system is “based on the assumption that no other risks factors for cardiovascular disease exist.”6 For those of us practicing in the state of Georgia, we know that frequently other risk factors are present and therefore CHCs should be used with caution.
Although there are no contraceptive restrictions in those women whose blood pressure remains less than 140/90, we have limited data regarding women who remain adequately controlled with antihypertensives3,6. Although controlled disease infers a reduced risk for myocardial infarction and cerebrovascular accident, we have no data to show what that risk is in the setting of an estrogen-containing contraceptive, regardless of the dose3.
ACOG does say that clinical judgement should be used in the case of young, low-risk women who have well-controlled hypertension, without evidence of end organ damage, and that a trial of CHCs can be considered with close follow up3. Otherwise, progestin-only options (IUD, implant, DMPA and progestin pills) and the copper IUD can be used safely in these patients3,6.
Diabetes is another common contraceptive challenge. The U.S. MEC classifies hormonal contraception in uncomplicated diabetes regardless of insulin status as a category 23. However, if vascular complications or more than 20 years of disease are present, CHCs and DMPA should be avoided3,6. DMPA concerns are centered around the theoretical hypoestrogenic lipoprotein changes, which can persist even after discontinuation6. ACOG recommends consideration for LARC or progestin-only pills for those who desire future fertility3.
According to the CDC’s maternal mortality surveillance system, pregnancy-related deaths are on the rise and 700 women die every year in the United States as a result of pregnancy-related complications9. Sixty-five percent of those deaths are considered preventable7.
Goals for reducing maternal mortality set forth by ACOG, the CDC and Healthy People 2030 recommend optimizing maternal health before, during and after pregnancy 9,10,11. Reducing the unintended pregnancy rate, which has remained stable at 45%, is one of the proposed prevention strategies8.
Decreasing the proportion of women at risk for unintended pregnancy is a very attainable goal; however, medical co-morbidities make this a challenge. Any provider, regardless of specialty, can play a vital role in identifying patients at risk for unintended pregnancy. There are many resources available to help providers navigate the risks of contraceptive options as they relate to medical co-morbidities. However, not all providers manage contraceptive care as part of their practice.
For providers who do not manage contraceptive care, a referral to an OB/GYN is appropriate. The task of improving maternal mortality is too large to be undertaken by one provider or one specialty; it’s going to take the entire medical community.
- ACOG Committee Opinion No. 762: Prepregnancy Counseling, Obstetrics & Gynecology: January 2019 – Volume 133 – Issue 1 – p e78-e89.
- ACOG Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices, Obstetrics & Gynecology: November 2017 – Volume 130 – Issue 5 – p 1173-1175.
- ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women with Coexisting Medical Conditions, Obstetrics & Gynecology: February 2019 – Volume 133 – Issue 2 – p e128-e150.
- Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity, and Obesity. Data, Trend and Maps [online]. [Accessed Feb 01, 2022]. URL: https://www.cdc.gov/nccdphp/dnpao/data-trends-maps/index.html.
- Curtis KM, Jatlaoui TC, Tepper NK, et all. U.S. Selected Practice Recommendations for Contraceptive Use, 2016.MMWR Recomm Rep 2016; 65(No. RR-4):1-66.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65(No. RR-3):1-104.
- Davis NL, Smoots AN, Goodman DA. Pregnancy-related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.
- Finer LB, Zolna MR. Declines in Unintended Pregnancy in the United States, 2008-2011. N Engl J Med. 2016 Mar 3; 374(9):843-52.
- “Maternal Mortality.” Centers for Disease Control and Prevention. 13, August, 2020. https://www.cdc.gov/reproductivehealth/maternal-mortality.
- Obstetric Care Consensus No. 8: Interpregnancy Care, Obstetrics & Gynecology: January 2019 – Volume 133 – Issue 1 – p e51-e72.
- Office of Disease Prevention and Health Promotion. (n.d.). Pregnancy and Childbirth. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth.
- Zapata LB, Pazol K, Curtis KM, et al. Need for Contraceptive Services Among Women of Reproductive Age- 45 Jurisdictions, United States, 2017-2019. MMWR Morb Mortal Wkly Rep 2021;70:910-915.
Dr. Williams is an obstetrician-gynecologist who specializes in high-risk obstetrics, adolescent gynecology and gynecologic laparoscopic surgery. She attended the Ross University School of Medicine in Barbados and received her residency training at East Carolina University at Vidant Medical Center. She currently works at Wellstar Medical Group’s South Cobb OBGYN and is affiliated with Wellstar Cobb Hospital.