CHOICE

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Secura GM, et al. "Provision of no-cost, long-acting contraception and teenage pregnancy". The New England Journal of Medicine. 2014. 371(14):1316-1326.
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Clinical Question

Among females aged 14-19 years who had use of long-acting reversible contraception promoted and had free access to their contraception of choice, what were the rates of pregnancy, live birth, and induced abortions when compared to national samples?

Bottom Line

In this single-center cohort study, the rate of pregnancy, live births, and induced abortions was lower than national samples among females aged 14-19 who had promotion of long-acting reversible contraception and subsequent free access to their contraception of choice.

Major Points

The pregnancy rate among women before the age of 20 is approximately 30%. This rate is higher among Black and Hispanic women (~40%) than White women (~20%). Long-acting reversible contraceptive (LARC) therapies (IUDs and implants) are effective therapies for the prevention of unplanned pregnancies, though they are underutilized by this demographic, at least partially because of their cost and lack of access. Whether removing these barriers would reduce rates of pregnancy, live birth, or induced abortion was unknown.

This 2014 publication describes women age 14-19 years old in the CHOICE cohort. Enrollees were given education about various methods of contraception, including their efficacy. The presentation of the different options went from most to least effective. They were then provided with their chosen contraceptive method free of charge. Participants were followed for 2-3 years by phone and the outcome for conception was by self-report. Almost all participants were sexually experienced. Hormonal IUDs and etonogestrel implants were the most popular methods, being selected for use in 66.2% of participants. LARC use was 72% overall.

The rate of pregnancy was lower in the CHOICE cohort (34.0/1000 teens) than in 2010 US teens (57.4/1000 teens) and 2008 US sexually-experienced teens (158.5/1000 teens). There were similar trends for lower rates of live births and induced abortions in the CHOICE cohort. Of the 54 conceptions in the CHOICE cohort, 2 occurred in those with an IUD with levonorgestrel (5.1 failures/1000 teen-years). None occurred with the etonogestrel implant. In contrast, OCPs had 13 associated conceptions (56.8 failures/1000 teen-years).

Guidelines

As of April 2015, no guidelines have been published that reflect the results of this trial.

Design

  • Prospective cohort study
  • N=1,404 (of 9,256 in the entire CHOICE cohort)
  • Setting: St. Louis, MO
  • Enrollment: 2007-2011
  • Follow-up: 716 for 3 years, 688 for 2 years
  • Primary outcomes:
    • Pregnancy
    • Live birth
    • Induced abortion

Population

Inclusion Criteria

  • St. Louis females aged 14-45 years (this analysis only included females aged 14-19 years) who enrolled in the CHOICE trial, which promoted long-acting reversible contraceptive (LARC) therapies
    • LARC includes:
      • IUDs
      • Implants
  • Minors could enroll without parental consent if they didn't know the location of their parents/guardians or if they didn't want their parents/guardians to know that they were pursuing contraception
  • English- or Spanish-speaking
  • Didn't want to become pregnant in the following ≥12 months
  • Sexually active or planning on becoming sexually active in the next 6 months with a male partner
  • No contraceptive method or willing to switch methods of contraception

Exclusion Criteria

  • Hysterectomy or other procedure causing sterilization

Baseline Characteristics

From the total cohort except where specified.

  • Demographics: Black 62%, White 30%, other 8%,
    • Age 14-17 years: 34%
    • Age 18-19 years: 66%
    • Income status:
      • Low: 44%
    • Parity:
      • Zero: 75%
      • One: 21%
      • Two or more: 4%
  • Lifetime male sex partners: 3
    • Sexually-experienced: 97%
  • Prior unintended pregnancy: 48%
  • Chosen contraceptive:
    • IUD with hormones: 32%
    • IUD without hormones: 5%
    • Implanted etonogestrel: 34%
    • Depot medroxyprogesterone acetate injection: 9%
    • OCP: 12%
    • Ring: 5%
    • Patch: 2%

Interventions

  • Enrollees were counseled on contraception choices and chose a preferred method
  • Same-day insertion of LARC unless contraindicated (eg, cervicitis)
    • Those with delayed LARC placement were started on an alternative short-acting agent until their LARC could be placed
  • All patients were screened for STIs
  • Follow up interviews q3-6 months

Outcomes

Comparisons are CHOICE vs. 2010 US teens vs. 2008 US sexually-experienced teens. The 2010 comparison data are from unpublished data from the Guttmacher Institute.

Primary Outcome

Pregnancy
34.0 vs. 57.4 vs. 158.5/1000 teens
Live birth
19.4 vs. 34.4 vs. 94.0/1000 teens
Induced abortion
9.7 vs. 14.7 vs. 41.5/1000 teens

Secondary Outcomes

Conceptions during follow-up by contraception type
Levonorgestrel IUD: 2 (5.1 failures/1000 teen-years)
Copper IUD: 0 (57.3 teen years total)
Etonogesteral implant: 0 (633 teen years total)
DMPA injection: 1 (5.2 failures/1000 teen-years)
OCP: 13 (56.8 failures/1000 teen-years)
Ring: 4 (51.8 failures/1000 teen-years)
Patch: 2 (60.8 failures/1000 teen-years)
Condoms: 9 (rate not given)
No method: 25 (rate not given)

Additional Analyses

Continuation of therapy at 24 months
LARC: 2/3rds
Non-LARC: 1/3rd

Subgroup Analysis

Presented as CHOICE vs. 2010 US teens vs. 2008 sexually experienced teens. (The 2008 results were only presented for pregnancies.)

Pregnancy
Age 15-17 years: 20.9 vs. 30.1 vs. 136.0/1000 teens
Age 18-19 years: 40.1 vs. 96.2 vs. 178.0/1000 teens
White race: 26.9 vs. 37.8 vs. 137.0/1000 teens
Black race: 31.8 vs. 99.5 vs. 253.0/1000 teens
Live birth
Age 15-17 years: 11.4 vs. 17.4/1000 teens
Age 18-19 years: 23.1 vs. 58.5/1000 teens
White race: 11.2 vs. 23.6/1000 teens
Black race: 19.6 vs. 51.4/1000 teens
Abortion
Age 15-17 years: 5.7 vs. 8.4/1000 teens
Age 18-19 years: 11.6 vs. 23.7/1000 teens
White race: 4.5 vs. 8.5/1000 teens
Black race: 9. vs. 34.5/1000 teens

Criticisms

  • Conception information relied on self-report
  • Unclear accuracy of comparative statistics
  • Comparison groups were from different years, pregnancy rates have declined in the interim
  • Frequent follow-up by investigators may have increased compliance with their chosen contraceptive

Funding

  • Susan Thompson Buffet Foundation
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development
  • National Center for Advancing Translational Sciences (NIH)
  • Authors with multiple financial disclosures

Further Reading