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INTRODUCTION — Contraception provides control over pregnancy timing and prevention of unintended pregnancy. In selecting a contraceptive method, individuals weigh factors such as efficacy, access, prevention of sexually transmitted infections, side effects, convenience, and noncontraceptive benefits. Contraceptive counseling provides education, dispels misinformation, facilitates selection of a method that will be successful for the individual, and encourages patient involvement in healthcare decisions and life goals. Discussing contraception brings the clinician and patient together to create a tailored care plan that meets the individual's reproductive needs over a lifetime.
This topic will review factors influencing contraceptive selection, guide the clinician through the selection process, review issues that impact compliance, and provide information on special populations. Information specific to each contraceptive method is presented in detail separately.
●(See "Contraceptive vaginal ring".)
●(See "Male condoms".)
●(See "Female condoms".)
GOALS OF CONTRACEPTION COUNSELING — The goals of contraceptive counseling are to educate women about contraception, discuss current and future contraceptive needs, and select a contraceptive modality, if needed, thereby avoiding the risks of unintended pregnancy.
Discuss reproductive life plan — Discussing a reproductive life plan allows the clinician to address any knowledge deficits, misperceptions, or exaggerated concerns about the safety of contraceptive methods, all of which are barriers to contraceptive use . Such planning also provides an opportunity to discuss interpregnancy interval (ie, birth spacing) and preconceptual care. (See "Interpregnancy interval and obstetrical complications" and "The preconception office visit".)
As stated by the American College of Obstetricians and Gynecologists (ACOG), a reproductive life plan is "a set of personal goals regarding whether, when, and how to have children based on individual priorities, resources, and values" . To encourage women to create a reproductive life plan, ACOG and others advise clinicians to ask women who are between the ages of 18 and 50 years, at every visit, "Would you like to become pregnant in the next year?" [2,3].
●For women who do not desire pregnancy, the clinician then discusses options for pregnancy prevention and helps the woman select an appropriate choice based on her health status, personal values, and preferences. (See 'Assess timeframe for pregnancy' below.)
●For women who desire pregnancy, the clinician provides preconceptual counseling, discusses folate supplements, and educates the woman on optimal lifestyle choices for pregnancy (eg, smoking cessation, alcohol avoidance, weight management). (See "The preconception office visit".)
Reduce unintended pregnancy — An unintended pregnancy is a mistimed or unwanted pregnancy . In 2011, nearly half (45 percent or 2.8 million) of the 6.1 million pregnancies in the United States were unintended . Unintended pregnancies are associated with maternal depression, increased risk of physical violence to the mother, late prenatal care, reduction in breastfeeding, and financial burden [6,7]. Infants born of unintended pregnancies are more likely to have birth defects, low birth weight, and poor mental and physical functioning in early childhood . Unintended pregnancies account for most of the 1.1 million abortions performed annually in the United States [9,10]. The negative impact of unintended pregnancy is greatest for teen parents and their children, as 82 percent of pregnancies in women ages 15 to 19 are unintended . For all of these reasons, the United States Department of Health and Human Services' Healthy People 2020 objectives call for a 10 percent reduction in the rate of unintended pregnancy by 2020 .
The high rate of unintended pregnancy in the United States highlights the need for effective contraceptive education. In a survey study of 7800 women who had unprotected intercourse that led to an unintended pregnancy, women reported the following reasons for unprotected intercourse :
●33 percent believed they could not get pregnant at the time of conception
●30 percent did not really mind if they got pregnant
●22 percent stated their partner did not want to use contraception
●16 percent cited side effects
●10 percent believed they or their partner were sterile
●10 percent cited access problems
●18 percent selected "other"
The fact that one-third of these women did not perceive themselves to be at risk of becoming pregnant emphasizes the need for more and effective education.
CONTRACEPTIVE EFFICACY — Women are encouraged to select one of the most effective contraceptive options. In practice, contraceptive methods can be divided into three tiers based upon their theoretical and actual effectiveness (figure 1) [12,13]:
●Most effective – Long-acting reversible contraception (LARC: intrauterine contraception and contraceptive implants) and sterilization are associated with the lowest pregnancy rates regardless of the population studied because their effectiveness is minimally influenced by the patient's actions or adherence (figure 1 and table 1). (See "Intrauterine contraception: Devices, candidates, and selection" and "Etonogestrel contraceptive implant" and "Overview of female sterilization" and "Overview of vasectomy".)
●Effective – Injectable contraceptives have the highest effectiveness in this tier. Oral contraceptives, the transdermal patch, and the vaginal ring are also associated with a very low pregnancy rate if they are used consistently and correctly, but actual pregnancy rates are substantially higher because of inconsistent/incorrect use (figure 1 and table 1). (See "Depot medroxyprogesterone acetate for contraception" and "Overview of the use of estrogen-progestin contraceptives" and "Progestin-only pills (POPs) for contraception" and "Transdermal contraceptive patch" and "Contraceptive vaginal ring".)
●Least effective – Other methods of contraception, including diaphragms, cervical caps, sponges, male and female condoms, spermicides, periodic abstinence, and withdrawal are associated with actual pregnancy rates that are much higher than perfect use rates (figure 1 and table 1). The overall pregnancy rates associated with these methods vary considerably among studies. (See "Diaphragm, cervical cap, and sponge" and "Male condoms" and "Female condoms" and "Fertility awareness-based methods of pregnancy prevention".)
Contraceptive efficacy is expressed as both the theoretical (perfect use) and the actual (typical use) effectiveness (table 1). The former refers to the pregnancy rate among those who use the method correctly on every occasion (ie, inherent effectiveness as demonstrated in a carefully monitored clinical trial); actual effectiveness is usually lower due to inconsistent or incorrect use. Actual effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles, as pregnancy is less likely in women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles. Explanations for the apparent failure of other contraceptive methods when used by the typical patient include inconsistent adherence to method requirements, incorrect use, gaps in use, discontinuation of the method, as well as failure of the method itself.
The effectiveness categories above (figure 1) are more clinically useful for informing patients about contraceptive effectiveness than the Pearl Index, which is typically reported in clinical studies . The Pearl Index is defined as the number of unintended pregnancies per 100 women per year (ie, the number of pregnancies in 1200 observed months of use). One problem with this index is that it does not account for the fact that contraceptive failure rates typically decline with continued use; therefore, a Pearl Index determined by a study of new and short-term users of a method will likely be higher than in a study of long-term users . Demographic factors are also not considered, although they influence method adherence and, in turn, efficacy.
Assess patient preferences — As no method of contraception is perfect, each woman must balance the advantages of each method against the disadvantages and side effects, and decide which method she prefers (table 2) . Women are counseled to choose the most effective method that they will likely use successfully (figure 1). We ask the woman if she will be able to adhere to the requirements of using the method, adhere to the method despite these requirements, and likely tolerate the method's potential side effects. Women who choose methods inconsistent with their preferences may be less likely to adhere to or continue the method . Successful contraceptive counseling also addresses the woman's concerns, expectations, and sociocultural needs. (See "Cross-cultural care and communication", section on 'The patient-based approach'.)
●Personal preferences, including privacy, tolerance of side effects, and speed to return of fertility after method cessation
●Effect on menstrual pattern and bleeding
●Childbearing plans (number of children, timing of next pregnancy) and attitudes about an unintended pregnancy
●Pattern of sexual activity (frequency of sex, number of partners)
●Partner (and family, eg, mother) influences and concerns
●Social and cultural factors (eg, religious beliefs)
●Ability to acquire and use the method successfully
●Method-specific experiences or concerns
●Tolerance for daily, vaginal, transdermal, injectable, or coital-related medication
●Concomitant need to prevent sexually transmitted infections
●Supportive care from the healthcare provider
Discussing the above preferences helps the patient and clinician prioritize the contraceptive characteristics that are most important to that individual. Contraceptive characteristics that we discuss include :
●Type and frequency of side effects
●Duration of action and ability to discontinue use
●Protection against sexually transmitted infections
●Cost per month and total cost during the time period the contraceptive is used
●Convenience, including need for refills
●Reversibility and time to return of fertility
●Effect on uterine bleeding
In a survey of over 2500 women asking about contraceptive attributes at the time of contraception initiation, the method attributes that received the highest importance scores were effectiveness, affordability, long duration, and no maintenance (described as "forgettable" in the study) . When respondents were asked to rank their top three attributes, the attributes most likely to be among the top three were effectiveness, safety, and side effects. (See 'Contraceptive efficacy' above.)
Assess timeframe for pregnancy — We begin contraceptive selection by assessing the woman's reproductive plans and the time frame for pregnancy, if desired. In addition, we have samples of the methods in the office to show the patient and facilitate the counseling process. We ask the woman :
●Do you want to be pregnant in the future?
●If yes, when do you want to be pregnant?
Women who desire pregnancy within one year — For women who desire pregnancy within the year, we provide information about reversible contraceptives, assess the need for protection from sexually transmitted infections (STIs), and discuss basic health interventions prior to conception. It is important to note that the one-year time interval is not an absolute cut-off, but rather provides a simple question that differentiates women who desire long-acting contraception from those who do not. We advise women who are at risk for STIs to use condoms every time they have oral, anal, or vaginal sex, in addition to using whatever contraceptive method they choose. We also advise women who have given birth within the past year that pregnancy intervals of less than 18 months are associated with complications for mother and newborn such as anemia and prematurity. (See "Interpregnancy interval and obstetrical complications".)
For medically uncomplicated women, we typically use the following approach.
•For women who find a daily standard schedule helpful, we discuss the pills. (See "Overview of the use of estrogen-progestin contraceptives", section on 'Available preparations'.)
●For women who cannot use or do not want hormonal methods, or for women who desire contraception only when they need it, we discuss the barrier methods: male condom (with and without spermicide), female condom, diaphragm, sponge, and cervical cap) (table 2). (See "Diaphragm, cervical cap, and sponge" and "Female condoms" and "Male condoms".)
●For women who choose a short-acting method, we educate about use of and access to emergency contraception. (See 'Emergency contraception' below.)
●For women who desire pregnancy relatively soon but express a desire for long-acting reversible contraception (LARC), we counsel women that the high initial cost of a LARC may not be cost-effective if the method is going to be used for a relatively short period of time. However, if cost is not an issue, then LARC methods are reviewed. (See "Intrauterine contraception: Devices, candidates, and selection" and "Etonogestrel contraceptive implant".)
Additionally, we avoid depot medroxyprogesterone acetate (DMPA) injections in women who desire pregnancy in the near future because this medication can be associated with a delayed return to fertility. (See "Depot medroxyprogesterone acetate for contraception", section on 'Return to fertility after discontinuation'.)
For women with medical issues, we follow the table published by the United States Centers for Disease Control and Prevention (CDC).
The noncontraceptive benefits, risks, and side effects of reversible contraceptives are reviewed separately by contraceptive type (table 2).
Women who do not desire pregnancy within one year — For women who desire long-term contraception, we provide information on reversible and permanent contraceptive options as well as assess the need for protection from STIs (table 4). We advise women at risk for STIs to use condoms every time they have oral, anal, or vaginal sex in addition to their contraceptive method. Although we encourage women to use the most effective contraceptives, individual preferences play an important role in method selection, and the patient makes the final contraceptive choice. As an example, a woman with heavy menstrual bleeding and dysmenorrhea may prefer contraceptive pills to the copper intrauterine device (IUD) to treat her symptoms, although the IUD is the more effective contraceptive (table 2).
For medically uncomplicated women, we typically take the following approach:
●We begin our discussion by reviewing the most effective and longest-acting contraceptives: the implant, IUDs, and sterilization (figure 1). We use the Centers for Disease Control and Prevention Medical Eligibility Criteria for Contraceptive Use, which shows LARC and permanent methods to be of comparable efficacy, and the brief script below. (See 'Brief script for long-acting reversible contraceptive methods' below.)
•For women who desire a reversible method or who have no preference, we discuss LARC (IUDs and contraceptive implant) because these methods are highly effective and do not require surgery. Factors impacting the choice of copper- or levonorgestrel-releasing IUDs or the contraceptive implant are reviewed individually. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'Who should use an IUD?' and "Etonogestrel contraceptive implant", section on 'Candidates'.)
•For couples who desire permanent contraception (sterilization), options include female tubal occlusion and male vasectomy (table 4). We educate patients that vasectomy is equally effective, but less morbid and costly, than female tubal occlusion. Patients who desire sterilization are also counseled about availability of LARC because these methods have no surgical risk and offer women high contraceptive efficacy. (See "Overview of vasectomy" and "Overview of female sterilization".)
●For women who desire reversible contraception but do not want one of the LARC methods, we then continue the discussion listed above for short-acting reversible contraception. (See 'Women who desire pregnancy within one year' above.)
For women with medical issues, we follow the table published by the United States Centers for Disease Control and Prevention (CDC).
The noncontraceptive benefits, risks, and side effects of specific LARCs are reviewed separately. (See "Intrauterine contraception: Devices, candidates, and selection" and "Etonogestrel contraceptive implant".)
Role of long-acting contraceptives — Of the reversible contraceptives, LARC is the most effective [18,19], associated with higher method-continuation rates , and therefore the preferred option [21-23]. LARCs (ie, intrauterine contraceptives and progestin implants) do not require ongoing effort on the part of the user, are safe, are economical when used over as little as a two-year period, provide prompt return of fertility after removal, do not require surgery, and do not change sexual function or satisfaction . In addition, almost all women are eligible for use of one of the LARCs, including nulliparous women, adolescents, and women who need or prefer to avoid exogenous estrogen . For these reasons, LARCs are discussed with all women seeking contraception who are appropriate candidates for these methods. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'Candidates for intrauterine contraception' and "Intrauterine contraception: Devices, candidates, and selection", section on 'Types of IUDs' and "Etonogestrel contraceptive implant".)
LARC effectiveness was demonstrated in a United States study, including nearly 7500 women who received free contraceptives for three years, that reported the contraceptive failure rate was substantially higher among participants using pills, patch, or ring compared with participants using LARCs (4.55 versus 0.27 per 100 participant-years) .
For LARC, proven approaches to improve uptake include LARC-specific counseling, affordable cost, and insurance coverage.
●In a trial of 1500 women who were randomly assigned to receive either standardized counseling for LARC or routine contraceptive counseling, standardized counseling resulted in increased LARC use (28 versus 17 percent) and, more importantly, a reduction in unintended pregnancies (8 versus 15 percent) compared with routine counseling .
●When the state of Colorado offered affordable LARC methods from 2009 to 2013, the teen birth rate decreased 40 percent and the abortion rate dropped by 42 percent compared with previous years , in part because teen LARC continuation rates are higher than with less-effective methods .
●In a study of nearly 650 women who underwent abortion, those who had public insurance were twice as likely to initiate a LARC method compared with uninsured women .
Because LARC methods are the most effective, we ask women who present for a prescription refill of their current short-acting contraceptive about their plans for pregnancy. For women who do not want to be pregnant within the year, we then ask if they are interested in learning about the most effective methods available. For women who are satisfied with their short-acting method and do not want to change, we refill the prescription for a one-year supply. For women who are interested in learning about more effective methods, we use the chart of tiered efficacy (figure 1) and the script below for LARC. (See 'Brief script for long-acting reversible contraceptive methods' below.)
Brief script for long-acting reversible contraceptive methods — One counseling objective is to ensure women are aware of all relevant contraceptive options, especially the most effective, reversible, long-acting methods. These methods include IUDs and the contraceptive implant (commercial name Nexplanon). We find the following script helpful in counseling women:
●IUDs are completely reversible contraceptive methods placed in the uterus. There are two types of IUDs. Hormonal IUDs release progestin and last up to three or five years. Nonhormonal IUDs release copper and can last up to 10 years. Either type can be removed at any time if you wish to become pregnant or want to switch to a new method. They are very safe and have the highest satisfaction and continuation rates of any contraceptive method.
●The contraceptive implant is a single flexible plastic rod placed under the skin of your upper arm. It is hormonal and lasts up to three years. It can also be removed if you wish to become pregnant or would like to switch to a different method.
●Would you like to hear more about these most effective methods?
Additional issues to consider
Noncontraceptive benefits — The noncontraceptive benefits of the various birth control options can help guide the selection process (table 5). A summary of efficacy, advantages, and disadvantages of all contraceptive options can be found at The Contraceptive Choice Project and Planned Parenthood.
●Estrogen-progestin contraceptives (ie, pills, patch, and vaginal ring) have multiple noncontraceptive benefits that are listed in the table (table 6). (See "Overview of the use of estrogen-progestin contraceptives", section on 'Noncontraceptive benefits'.)
●Progestin-only contraceptives (ie, pills, injection, and implant) result in lighter menstrual bleeding and reduced iron deficiency anemia, protection against endometrial cancer, and possibly a reduction in risk of upper genital tract infections. Women who are unable to use estrogen-containing contraception often can safely use progestin-only contraception . (See "Progestin-only pills (POPs) for contraception", section on 'Risks and benefits'.)
●Condoms provide the best protection against acquisition or transmission of STIs. There are more data for male condoms than female condoms, but female condoms appear to prevent STIs as well. (See "Prevention of sexually transmitted infections", section on 'Male condom use' and "Male condoms", section on 'Protection from STIs' and "Female condoms", section on 'Sexually transmitted infections'.)
●Intrauterine contraceptives reduce heavy menstrual bleeding, anemia, dysmenorrhea, endometriosis-related pain, endometrial hyperplasia, and pelvic inflammatory disease (levonorgestrel-releasing IUDs) and possibly reduce the risk of endometrial cancer (copper- and levonorgestrel-releasing devices). (See "Intrauterine contraception: Devices, candidates, and selection", section on 'Noncontraceptive benefits' and "Intrauterine contraception: Devices, candidates, and selection", section on 'Noncontraceptive benefits'.)
Protection from sexually transmitted infections — We assess a woman's risk of acquiring an STI as a routine part of contraceptive counseling. All women at risk for acquiring an STI are advised to use condoms (male or female) in addition to their contraceptive method. There are more data on the efficacy of male condoms in preventing infection transmission than for female condoms. (See "Male condoms", section on 'Protection from STIs' and "Female condoms", section on 'Sexually transmitted infections'.)
We ask women:
●Have you and your partner(s) (and their partners if applicable) been tested for STIs?
●Will you use condoms for every act of sexual intercourse unless you know your partner's status and you are mutually monogamous?
Additionally, concern has been raised that hormonal contraception could increase the risk of a woman acquiring human immunodeficiency virus (HIV) infection [31,32]. In the absence of definitive data, we agree with the World Health Organization and CDC assessments that women at high risk of and living with HIV can continue to use all existing hormonal contraceptive methods without restriction [25,33]. The data are reviewed in detail separately. (See "Depot medroxyprogesterone acetate for contraception", section on 'Effect on HIV acquisition and transmission'.)
Adolescents — Adolescent and young adult women have unique contraceptive needs because of variations in individual development, barriers to contraceptive access, and lack of information. The contraceptive issues specific to adolescents are reviewed separately. (See "Contraception: Overview of issues specific to adolescents".)
Obesity — Obesity can affect the safety and efficacy of various contraceptive methods. However, no contraceptive method is restricted from use in obese women . Contraception in obese women is reviewed separately. (See "Contraception counseling for obese women".)
Medical issues — In 2016, the CDC published the United States Medical Eligibility Criteria for Contraceptive Use, which provides contraceptive recommendations based on medical conditions or personal characteristics (eg, lactating women) . When possible, we prefer LARCs for medically complex women because they are as effective as permanent contraception but do not have the risks of surgery. Estrogen-free options include both copper and levonorgestrel IUDs and the etonogestrel implant. Women who need or prefer to avoid all hormones can use the copper-releasing IUD. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'Candidates for intrauterine contraception' and "Etonogestrel contraceptive implant", section on 'Candidates'.)
Choosing contraception is more complicated in women with medical disorders because the physiologic changes or side effects associated with some contraceptive methods can increase the risk of morbidity or mortality. Additionally, the risks of any contraceptive method must be balanced against the potential consequences of an unplanned or ill-timed pregnancy. Several of the absolute and relative contraindications to hormonal contraception listed in the United States Medical Eligibility Criteria for Contraceptive Use are discussed in detail in the following topics:
●(See "Postpartum contraception".)
History of cancer — In 2012, the Society of Family Planning (SFP) published clinical guidelines for contraception in women with cancer . While the subsequent 2016 United States Medical Eligibility Criteria for Contraceptive Use and 2015 World Health Organization Medical Eligibility Criteria approved hormonal contraception for most non-hormone-dependent cancers (ie, except for breast cancer), the SFP guidelines contain additional considerations that we believe are important.
For the following groups of women, the SFP advised :
●Women with active cancer or who have been treated for cancer within six months – Avoid estrogen-progestin contraceptives because both cancer and combined hormonal contraception are risk factors for venous thrombosis. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on 'Venous thromboembolic disease'.)
●Women who have a history of chest wall irradiation for cancer – Avoid systemic estrogen and/or progestin contraceptives because these women are at increased risk of developing breast cancer and the risk could be greater in women who take exogenous hormones. (See "Risks and side effects associated with estrogen-progestin contraceptives", section on 'Breast cancer'.)
●Women with a history of breast cancer – Use a copper IUD unless they are taking tamoxifen. In the latter case, off-label use of a levonorgestrel-releasing IUD is preferred to reduce the risk of tamoxifen-induced endometrial changes without increasing the risk of breast cancer recurrence. (See "Approach to the patient following treatment for breast cancer", section on 'Contraception after breast cancer' and "Intrauterine contraception: Devices, candidates, and selection", section on 'Endometrial protection'.)
●Women with anemia – Use a levonorgestrel-releasing IUD to minimize menstrual blood loss. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'IUD selection'.)
●Women with osteopenia or osteoporosis – Avoid injectable progestin-only contraception (eg, DMPA). Unless contraindicated, women with osteopenia or osteoporosis benefit from the effects of an estrogen-containing contraceptive on bone mineral density. (See "Depot medroxyprogesterone acetate for contraception", section on 'Reduction in bone mineral density' and "Postmenopausal hormone therapy in the prevention and treatment of osteoporosis", section on 'Efficacy of estrogen therapy'.)
●Women who are immunosuppressed – Intrauterine contraception is not contraindicated. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'Immunocompromised women'.)
●Women at risk of breast cancer or recurrence – Emergency contraceptive pills are not contraindicated. (See "Emergency contraception".)
The need for contraceptive counseling among cancer survivors was highlighted by a prospective cohort study of nearly 300 female survivors that reported only 34 percent were using reliable contraception (sterilization or hormonal methods) compared with 53 percent in the general population .
Intellectual or physical disability — Women with intellectual or physical disabilities have unique needs. The contraceptive selection process may involve a guardian as well as the patient. Data to guide the decision-making process are often lacking, and the benefits, risks, side effects, and consequences of an unintended pregnancy must be balanced against one another. As an example, the magnitude of thrombotic risk from estrogen-containing hormonal contraceptives in women with limited mobility (eg, patient in wheelchair) is not known. However, hormonal contraceptives can be desirable for these women because they reduce menstrual frequency or flow in addition to preventing pregnancy. (See "Hormonal contraception for suppression of menstruation".)
Additional challenges can include the patient's limited capacity (intellectual, physical, or both) to use a method, problems with menstrual hygiene, and inability to undergo an office-based examination or procedure. Some women with intellectual disabilities cannot tolerate pelvic examinations, making pelvic examination or placement of an IUD in an office setting unrealistic. For women with spinal cord injuries above the T6 level, a pelvic examination can trigger autonomic dysreflexia, an abnormal autonomic system response that can cause a rapid and potentially life-threatening rise in blood pressure . (See "Chronic complications of spinal cord injury and disease", section on 'Autonomic dysreflexia'.)
Sterilization in women with intellectual or physical disabilities raises the ethical issues of patient autonomy and informed consent . Sterilization in women with disabilities is reviewed separately. (See "Overview of female sterilization", section on 'Women with mental illness or disability'.)
Examination and testing — For healthy women, most contraceptives can be started on the same day as the visit and require minimal examination or testing prior to initiation (table 7). While breast and pelvic exams, cervical cancer screening, and screening for sexually transmitted diseases are important, most groups agree that these procedures are not necessary before a first or renewed prescription for hormonal contraception [38-40]. Prior to insertion of an intrauterine device, a bimanual pelvic examination with cervical inspection is performed. Screening for sexually transmitted infections is done per the United States (US) Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guideline. The US Selected Practice Recommendations for Contraceptive Use provides an overview of factors to review when initiating contraception in healthy women, such as how to help a woman initiate use of a contraceptive method, what regular follow-up is needed, and how to address problems that often arise during use . Some groups recommend documentation of weight or body mass index when initially prescribing hormonal contraceptives to monitor changes over time and counsel women who might incorrectly assume that weight gain is associated with their contraceptive method [40,41].
Exclude pregnancy — Pregnancy can be reasonably excluded in women who meet any of the criteria in the table (table 8). For women who do not meet any of these criteria, a pregnancy test can be performed, but should be obtained two or more weeks after the woman's last episode of unprotected intercourse to exclude the possibility of a preimplantation pregnancy. (See "Clinical manifestations and diagnosis of early pregnancy".)
For women who desire pills, patch, vaginal ring, or injectable contraception, the benefits of starting contraception immediately likely exceed any risk to a developing fetus because hormonal contraceptives are not teratogenic or abortifacient [42,43]. Therefore, same-day or quick-start approaches can be used for women who desire these hormonal contraceptives and are reasonably likely to not be pregnant (algorithm 1). A follow-up pregnancy test can be performed two to four weeks later. (See "Overview of the use of estrogen-progestin contraceptives", section on 'Initiation'.)
STRATEGIES FOR ENHANCING COMPLIANCE AND CONTINUATION
Rates of continuation — To prevent unintended pregnancies, contraception must be used correctly, consistently, and continuously. Nearly one-half of all unintended pregnancies occur among women using contraception , and 90 percent of these pregnancies are estimated to result from incorrect or inconsistent method use [45-48]. External factors that influence continuation rates include cost, insurance coverage, copayments and deductibles, and insurance requirements for monthly refills (as opposed to dispensing a year-long supply) .
Among women attempting to avoid pregnancy, the percentage who continue to use a method for one year is approximately [50-52]:
●Levonorgestrel-releasing intrauterine device (IUD): 88 to 93 percent
●Copper-releasing IUD: 85 percent
●Etonogestrel implant: 83 to 84 percent
●Ring or patch or pill: 50 to 67 percent
●Depo-Provera: 56 to 58 percent
●Diaphragm: 57 percent
●Fertility awareness-based methods: 47 percent
●Male condom: 43 percent
●Female condom: 41 percent
Based on the above data, an alternate solution to improve compliance is to counsel women on switching to long-acting reversible contraception (LARC: contraceptive implant or IUD) when appropriate [53-55]. In a study of over 9000 United States women ages 14 to 45 years of age using a LARC method, the one-year discontinuation rates were 12 percent for the levonorgestrel-releasing IUD, 15 percent for the copper IUD, and 17 percent for the contraceptive implant, all of which were significantly lower than the hormonal contraception discontinuation rates (range 42 to 50 percent) . The higher continuation rates appear to reflect higher satisfaction rates with these methods but could also be due partly to the need to see a clinician to discontinue and the higher upfront costs. (See 'Role of long-acting contraceptives' above.)
While observational studies tend to report contraception counseling increases use and continuation of contraception [56-58], data from randomized trials are limited. In a 2013 systematic review of five trials that assessed the impact of direct counseling on adherence to and continuation of hormonal contraception, three trials reported a benefit from enhanced counseling compared with routine care . Trial limitations included small sample sizes, high loss to follow up, and differing interventions. A cluster randomized trial performed in 40 reproductive health clinics across the United States reported that more women received LARC counseling and more women selected LARC methods at sites that received evidence-based training than the control sites . Although the optimal strategies for contraception counseling are not known [14,59], effective strategies and training are available at LARC First: Training New Counselors.
Patient strategies — Among users of hormonal contraception, forgetting or mistiming doses is common and plays a factor in unintended pregnancy. Studies suggest that reminder systems for hormonal contraceptive methods, such as smartphone apps or alarms, could be helpful in improving compliance [60-64]. For women who miss a contraceptive pill or mistime a patch, ring, or injection, either partner can use a condom to enhance pregnancy protection as well as protect against sexually transmitted infections. (See "Male condoms" and "Female condoms".)
Clinician strategies — A report by the Guttmacher Institute recommended that clinicians provide ongoing support for contraceptive use by regularly assessing the woman's sexual activity, relationship status, attitude about pregnancy, and life events such as changes in partners, job, school, housing, personal crises, and loss of health insurance coverage . In addition, clinicians can educate women about the use, potential challenges, noncontraceptive benefits, and possible side effects of the selected method, which might lower the rate of discontinuation. In the 2002 United States National Survey of Family Growth study of over 6700 women using reversible contraception, 46 percent of women reported discontinuing at least one method because they were dissatisfied with it . Two-thirds of women who discontinued hormonal methods did so because of side effects, while almost 40 percent of those who discontinued the condom did so because of partner dissatisfaction.
Additionally, clinicians can improve contraceptive initiation and compliance by reducing unnecessary medical barriers . Examples of removing barriers include using quick-start or same-day start methods (algorithm 1), eliminating office visits for contraception renewal or switch, eliminating pelvic exams prior to beginning hormonal contraception (table 7), and prescribing a one-year supply of hormonal contraceptives, and supporting over-the-counter access of oral contraceptive pills [38,40,66-70]. However, barriers persist. In a 2015 United States survey study of over 2000 sexually active adult women who did not desire pregnancy, nearly 30 percent of the women who had ever tried to get a prescription for hormonal contraception reported access barriers . The most commonly cited barriers were cost (14 percent), challenges obtaining an appointment (13 percent), the clinician requiring an examination or Pap smear (13 percent), not having a regular doctor or clinic (10 percent), difficulty accessing a pharmacy (4 percent), and other (4 percent).
System strategies — Public health strategies to improve the uptake and continuation of contraceptive methods have included improved education [72,73], training for providers [74,75], and funding . Conversely, programs that reduce public funding for contraception are associated with reduced contraceptive use and an increased pregnancy rate. After Texas defunded Planned Parenthood affiliates in 2013, there was an estimated 35 percent reduction in claims for long-acting reversible contraception and an estimated 31 percent reduction in claims for injectable contraception in counties with Planned Parenthood sites . During the same time period, the counties with Planned Parenthood affiliates reported a 1.9 percentage point higher rate of childbirth covered by Medicaid, which represented a relative increase of 27 percent from baseline.
EMERGENCY CONTRACEPTION — Emergency contraception (EC) is intended for occasional or back-up use and not as a primary contraceptive method. Women who have had recent unprotected intercourse or had a failure of another contraceptive method (eg, broken condom) are candidates for EC. We educate all women about the availability of EC during routine contraceptive counseling. (See "Emergency contraception".)
RESOURCES FOR PATIENTS AND CLINICIANS
●bedsider.org: A free website developed by the National Campaign to Prevent Teen and Unplanned Pregnancy, a private nonprofit group.
●CHOICE Project: A free website sponsored by the Washington University School of Medicine in St. Louis that provides resources on contraceptive options and training resources for clinicians.
●Center for Young Women's Health: A free website run by Boston Children's Hospital that addresses reproductive health needs of teens and young adults.
●Beyond the Pill: A free website run by the University of California San Francisco.
●SexualityandU.ca: An educational site run by the Society of Obstetricians and Gynaecologists of Canada that includes descriptions of various methods and a tool to help with selection of birth control.
●Planned Parenthood: A nonprofit organization dedicated to reproductive health with resources for patients and clinicians.
●Association of Reproductive Health Professionals: A nonprofit organization that provides resources for patients including an interactive tool to compare birth control methods.
●ACOG Contraceptive FAQs: American College of Obstetricians and Gynecologists frequently asked questions about contraception.
●ACOG LARC Program: American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception Program.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Choosing birth control (The Basics)" and "Patient education: Vasectomy (The Basics)")
●Beyond the Basics topics (see "Patient education: Birth control; which method is right for me? (Beyond the Basics)" and "Patient education: Vasectomy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●The goals of contraceptive counseling are to educate women about contraception, discuss current and future contraceptive needs, select a contraceptive method, and avoid the risks of unintended pregnancy. (See 'Goals of contraception counseling' above.)
●Women are encouraged to select one of the most effective contraceptive options. In practice, contraceptive methods can be divided into three categories based upon their theoretical and actual effectiveness (figure 1). (See 'Contraceptive efficacy' above.)
•The most effective methods are long-acting reversible contraception (LARC: intrauterine contraception and contraceptive implants) and sterilization. These methods are associated with the lowest pregnancy rates regardless of the population studied because their effectiveness is minimally influenced by the patient's actions or adherence (figure 1 and table 1). (See 'Contraceptive efficacy' above.)
-For women who desire reversible contraception, we prefer LARC. Pregnancy rates are comparable to sterilization (table 1), with the highest satisfaction and continuation rates. (See 'Contraceptive efficacy' above.)
-For women who request sterilization, we counsel about LARC as well because LARC is comparable to sterilization in terms of effectiveness (table 1), but is nonsurgical and reversible. For couples who desire permanent contraception (sterilization), we prefer vasectomy of the male partner. Vasectomy is as effective, but less morbid and costly than tubal occlusion. (See 'Contraceptive efficacy' above.)
•Effective contraceptive methods include combined estrogen-progesterone hormonal methods (pills, patch, vaginal ring), progestin injections, and diaphragms. These methods are less effective than long-acting reversible contraception, although still highly effective when used properly (table 1). (See 'Contraceptive efficacy' above.)
•The least effective methods of contraception, including male and female condoms, cervical caps, sponges, spermicides, periodic abstinence, and withdrawal, are associated with actual pregnancy rates that are much higher than perfect use rates (figure 1 and table 1). (See 'Contraceptive efficacy' above.)
●Selection of a contraceptive method must take into account the woman's preferences, her time frame for pregnancy, and contraceptive efficacy, safety, and side effects. We ask the woman if she will be able to adhere to the requirements of using the method, adhere to the method despite these requirements, and likely tolerate the method's potential side effects. The noncontraceptive benefits of the various birth control options can help guide the selection process. (See 'Method selection' above and 'Noncontraceptive benefits' above.)
●In addition to any method of contraception, we recommend use of condoms for individuals at risk of sexually transmitted infections (Grade 1B). (See 'Protection from sexually transmitted infections' above and "Male condoms", section on 'Protection from STIs' and "Female condoms", section on 'Sexually transmitted infections'.)
●Women are informed about emergency contraception in case of contraceptive failure, which can include incorrect use or non-use. (See 'Emergency contraception' above.)
●For healthy women, most contraceptives can be started on the same day as the visit and require minimal examination or testing prior to initiation (table 7). Pregnancy can be reasonably excluded in women who meet any of the criteria in the table (table 8). (See 'Starting contraception' above.)
●Unique contraceptive needs exist in adolescents, patients with medical issues or disabilities, and patients with cancer. (See 'Special populations' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Mimi Zieman, MD, who contributed to an earlier version of this topic review.
- Committee on Health Care for Underserved Women. Committee opinion no. 615: Access to contraception. Obstet Gynecol 2015; 125:250.
- Committee Opinion No. 654 Summary: Reproductive life planning to reduce unintended pregnancy. Obstet Gynecol 2016; 2:415.
- Oregon Foundation for Reproductive Health. "One Key Question" Initiative. 2012. http://www.onekeyquestion.org/ (Accessed on January 29, 2016).
- Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001-2008. Am J Public Health 2014; 104 Suppl 1:S43.
- Finer LB, Zolna MR. Declines in Unintended Pregnancy in the United States, 2008-2011. N Engl J Med 2016; 374:843.
- Singh S, Sedgh G, Hussain R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann 2010; 41:241.
- Healthy People 2020: Family Planning http://www.healthypeople.gov/2020/topics-objectives/topic/family-planning (Accessed on January 28, 2016).
- Conde-Agudelo A, Rosas-Bermúdez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol 2007; 196:297.
- Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84:478.
- Jones RK, Kavanaugh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol 2011; 117:1358.
- Nettleman MD, Chung H, Brewer J, et al. Reasons for unprotected intercourse: analysis of the PRAMS survey. Contraception 2007; 75:361.
- Kost K, Singh S, Vaughan B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception 2008; 77:10.
- Steiner MJ. Contraceptive effectiveness: what should the counseling message be? JAMA 1999; 282:1405.
- Lopez LM, Steiner M, Grimes DA, et al. Strategies for communicating contraceptive effectiveness. Cochrane Database Syst Rev 2013; :CD006964.
- Trussell J, Hatcher RA, Cates W Jr, et al. A guide to interpreting contraceptive efficacy studies. Obstet Gynecol 1990; 76:558.
- Madden T, Secura GM, Nease RF, et al. The role of contraceptive attributes in women's contraceptive decision making. Am J Obstet Gynecol 2015; 213:46.e1.
- Trussel J. Choosing a contraceptive: efficacy, safety, and personal consideration.. In: Contraceptive Technology, 19, Hatcher RA, Trussell J, Nelson AL, et al. (Eds), Ardent Media, Inc., New York 2007. p.19.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118:184.
- Reeves MF, Zhao Q, Secura GM, Peipert JF. Risk of unintended pregnancy based on intended compared to actual contraceptive use. Am J Obstet Gynecol 2016; 215:71.e1.
- Hubacher D, Spector H, Monteith C, et al. Long-acting reversible contraceptive acceptability and unintended pregnancy among women presenting for short-acting methods: a randomized patient preference trial. Am J Obstet Gynecol 2016.
- ACOG strengthens LARC recommendations http://www.acog.org/About-ACOG/News-Room/News-Releases/2015/ACOG-Strengthens-LARC-Recommendations (Accessed on January 28, 2016).
- Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol 2015; 126:e44.
- National Institute for Health and Care Excellence. Contraception. Quality Standard (QS) 129. September 2016. https://www.nice.org.uk/guidance/qs129 (Accessed on September 19, 2016).
- Higgins JA, Sanders JN, Palta M, Turok DK. Women's Sexual Function, Satisfaction, and Perceptions After Starting Long-Acting Reversible Contraceptives. Obstet Gynecol 2016; 128:1143.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366:1998.
- Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015; 386:562.
- Reducing unintended teen pregnancy in Colorado https://www.colorado.gov/pacific/sites/default/files/HPF_FP_UP-Reducing-Teen-Pregnancy.pdf (Accessed on July 06, 2015).
- Abraham M, Zhao Q, Peipert JF. Young Age, Nulliparity, and Continuation of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol 2015; 126:823.
- Rocca CH, Thompson KM, Goodman S, et al. Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial. Am J Obstet Gynecol 2016; 214:716.e1.
- Morrison CS, Chen PL, Kwok C, et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med 2015; 12:e1001778.
- Blish CA, Baeten JM. Hormonal contraception and HIV-1 transmission. Am J Reprod Immunol 2011; 65:302.
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use, 5th Edition, World Health Organization, 2015.
- Patel A, Schwarz EB, Society of Family Planning. Cancer and contraception. Release date May 2012. SFP Guideline #20121. Contraception 2012; 86:191.
- Dominick SA, McLean MR, Whitcomb BW, et al. Contraceptive Practices Among Female Cancer Survivors of Reproductive Age. Obstet Gynecol 2015; 126:498.
- Fouquier KF, Camune BD. Meeting the Reproductive Needs of Female Adolescents With Neurodevelopmental Disabilities. J Obstet Gynecol Neonatal Nurs 2015; 44:553.
- Committee on Ethics. ACOG Committee Opinion. Number 371. July 2007. Sterilization of women, including those with mental disabilities. Obstet Gynecol 2007; 110:217.
- Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001; 285:2232.
- Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Physical examination prior to initiating hormonal contraception: a systematic review. Contraception 2013; 87:650.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Clinical Effectiveness Unit. Combined hormonal contraception. London (UK): Faculty of Sexual and Reproductive Healthcare; 2011 Oct. 28 http://guideline.gov/content.aspx?f=rss&id=36071 (Accessed on June 25, 2012).
- Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstet Gynecol 1990; 76:552.
- Jellesen R, Strandberg-Larsen K, Jørgensen T, et al. Maternal use of oral contraceptives and risk of fetal death. Paediatr Perinat Epidemiol 2008; 22:334.
- Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84:478.
- Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health 2008; 40:94.
- Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception 2007; 76:267.
- Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. J Reprod Med 1995; 40:355.
- Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90.
- Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception 2008; 77:1.
- Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397.
- Backman T, Huhtala S, Blom T, et al. Length of use and symptoms associated with premature removal of the levonorgestrel intrauterine system: a nation-wide study of 17,360 users. BJOG 2000; 107:335.
- Birgisson NE, Zhao Q, Secura GM, et al. Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. J Womens Health (Larchmt) 2015; 24:349.
- Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1105.
- Lewis LN, Doherty DA, Hickey M, Skinner SR. Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 81:421.
- Thurman AR, Hammond N, Brown HE, Roddy ME. Preventing repeat teen pregnancy: postpartum depot medroxyprogesterone acetate, oral contraceptive pills, or the patch? J Pediatr Adolesc Gynecol 2007; 20:61.
- Upson K, Reed SD, Prager SW, Schiff MA. Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy. Contraception 2010; 81:427.
- Weisman CS, Maccannon DS, Henderson JT, et al. Contraceptive counseling in managed care: preventing unintended pregnancy in adults. Womens Health Issues 2002; 12:79.
- Lee JK, Parisi SM, Akers AY, et al. The impact of contraceptive counseling in primary care on contraceptive use. J Gen Intern Med 2011; 26:731.
- Halpern V, Lopez LM, Grimes DA, et al. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database Syst Rev 2013; :CD004317.
- Gal N, Zite NB, Wallace LS. Evaluation of smartphone oral contraceptive reminder applications. Res Social Adm Pharm 2015; 11:584.
- Zapata LB, Tregear SJ, Tiller M, et al. Impact of Reminder Systems in Clinical Settings to Improve Family Planning Outcomes: A Systematic Review. Am J Prev Med 2015; 49:S57.
- Trent M, Thompson C, Tomaszewski K. Text Messaging Support for Urban Adolescents and Young Adults Using Injectable Contraception: Outcomes of the DepoText Pilot Trial. J Adolesc Health 2015; 57:100.
- Hou MY, Hurwitz S, Kavanagh E, et al. Using daily text-message reminders to improve adherence with oral contraceptives: a randomized controlled trial. Obstet Gynecol 2010; 116:633.
- Castaño PM, Bynum JY, Andrés R, et al. Effect of daily text messages on oral contraceptive continuation: a randomized controlled trial. Obstet Gynecol 2012; 119:14.
- Improving Contraceptive Use in the United States. Guttmacher Institute. 2008. https://www.guttmacher.org/pubs/2008/05/09/ImprovingContraceptiveUse.pdf (Accessed on March 03, 2016).
- Shelton JD, Angle MA, Jacobstein RA. Medical barriers to access to family planning. Lancet 1992; 340:1334.
- Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol 2007; 109:1270.
- Foster DG, Parvataneni R, de Bocanegra HT, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol 2006; 108:1107.
- Foster DG, Hulett D, Bradsberry M, et al. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol 2011; 117:566.
- Steenland MW, Rodriguez MI, Marchbanks PA, Curtis KM. How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review. Contraception 2013; 87:605.
- Grindlay K, Grossman D. Prescription Birth Control Access Among U.S. Women at Risk of Unintended Pregnancy. J Womens Health (Larchmt) 2016; 25:249.
- Travasso C. App helps to improve contraception uptake in rural India. BMJ 2016; 352:i667.
- Siveregi A, Dudley L, Makumucha C, et al. Does counselling improve uptake of long-term and permanent contraceptive methods in a high HIV-prevalence setting? Afr J Prim Health Care Fam Med 2015; 7:779.
- Dermish A, Turok DK, Jacobson J, et al. Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians. Contraception 2016; 93:533.
- Thompson KM, Rocca CH, Kohn JE, et al. Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial. Am J Public Health 2016; 106:541.
- Stevenson AJ, Flores-Vazquez IM, Allgeyer RL, et al. Effect of Removal of Planned Parenthood from the Texas Women's Health Program. N Engl J Med 2016; 374:853.