Global Health Interventions: A Review of the Evidence Background Methodology • Glossary

Overview: Unintended Pregnancy

Background

An unintended pregnancy is a pregnancy that is either mistimed or unwanted at the time of conception.[1] Unintended pregnancies particularly among women in developing countries are linked to elevated maternal morbidity and mortality. Furthermore, unintended pregnancies often are associated with short between-birth intervals (<27 month), which can lead to an elevated risk of infant, neonatal, and perinatal mortality. Many women are particularly at risk for unintended pregnancy for reasons related to education and poor access to contraceptives. A variety of safe, affordable and effective methods is available to reduce conception. Family planning programs can thus mitigate medical risks including the acquisition of HIV infection in certain settings and support the economic and social well-being of the entire family.

Epidemiology [2]

• Every day, 1500 women die from pregnancy or health conditions related to giving birth, and a large portion (~50%) of pregnancies is unplanned and unwanted especially in less developed countries.
• The lifetime risk of dying of pregnancy-related conditions is 1 in 60 in developing countries. In Sub-Saharan Africa, maternal mortality occurs in 1 in 160 pregnancies.
• The use of modern contraceptives has grown rapidly over the past 30 years. However, a huge discrepancy remains: only 16% of married women in sub-Saharan Africa use modern contraceptives, versus 60% in Asia and 70% in Western Europe.
• At least 200 million women want to use safe and effective family planning methods, but are unable to do so because they lack access to information and services or the support of husbands and communities.[3]
• More than 50 million of the 190 million women who become pregnant each year have abortions. Many of these are clandestine and performed under unsafe conditions and thus risk greater morbidity and mortality.[3]
• Globally, 6% of female adolescents (age 15-19) give birth each year. Africa has the highest rate (12%) and developed countries the lowest (3%).
• The need for voluntary family planning is growing fast. Unmet need is project to grow by 40 per cent over the next 15 years.[3]

The intervention assessments below summarize the information presented in the "Key Findings" table.

Prevention: What Works?

An array of interventions is effective in reducing the risk of unintended pregnancy. Many of these are contraceptive technologies that do so directly by preventing conception. We also review supportive interventions such as counseling programs intended to reduce the likelihood of risky sexual episodes and improve the use of contraceptives.

Contraceptive technologies. Many technologies designed to avoid impregnation have been developed, and continue to develop. In general, they provide high rates of protection versus no contraception. We divided methods into several categories: hormonal, barrier, intrauterine, and emergency. We considered only reversible methods. We also omitted formal consideration of fertility awareness, for which data are sparse.[4]

• Hormonal methods include oral contraceptives (the birth control pill), patches, and the vaginal ring. Hormonal methods offer protection close to 100% if used as directed, based on evidence from decades ago. We focus our review on comparisons between methods, and of newer to older formulations.  For example, a newer oral contraceptive (Norgestrel) reduces the small residual risk of pregnancies that occur with an older contraceptive (norethindrone) by an estimated 88% (95% confidence interval 1 – 98%; weak evidence). Very strong evidence indicates that newer methods (oral contraceptives, and Implanon vs. Norplant) reduce discontinuation and menstruation s by 29-53%. The hormonal skin patch reduces pregnancy by 28-50% compared with oral contraceptives, although discontinuation risk is 58% higher (both moderate strength evidence). There is no precise evidence comparing the vaginal ring to OCs, and third to second generation OCs. Combination injectable contraceptives require more frequent injections and are more likely to be stopped than single drug injectables (not in table, with low policy relevance).[5] Male steroid contraceptives are exploratory (not in table).[6]
• Barrier methods work well in preventing pregnancy if used properly (which is often harder than for hormonal methods, leading to lower effectiveness in practice). The evidence we reviewed found no significant differences for latex vs other material condoms, diaphragms with vs. without spermacide, and other comparisons.
• Intrauterine devices (IUDs). IUDs are highly effective. We found no difference in pregnancy rate for frameless vs. framed. Moderate strength evidence suggests that copper-containing IUDs reduce discontinuation as compared with depot progestogen (an inserted hormonal method).
• Emergency contraception is used in the hours to days after an unprotected sex episode. An IUD reduces pregnancy by 91% vs no contraception (74-97%, moderate strength evidence). Mifepristone reduces pregnancies by more than half versus levonorgestrel and other drug options (very strong evidence). Ulipristal acetate may lower pregnancy rates vs. levonorgestrel, however we have concerns about manufacturer control of this study.

Supportive interventions

The technologies described above work if used consistently and properly. In this section we review interventions intended to improve the use of contraceptive technologies and more generally to decrease the risk of unprotected sex. We do not discuss the large literature on interventions to reduce sex episodes that are unprotected by condoms, which are instead included in our HIV review.

• Adherence and acceptability support. Structured counseling showed a 73% reduction in discontinuation rates compared with routine counseling (moderately strong evidence). Neither group motivation nor intensive reminders was found to differ from routine counseling or written appointment cards, respectively (weak evidence) Again, studies are predominantly from developed countries, so generalizing to developing countries may be inaccurate.
• Postpartum fertility awareness & interventions. Moderately strong evidence indicates that postpartum education, or education and counseling, can reduce the rate of discontinuation by 38-57%. Weak evidence suggests that special post-partum care reduces pregnancies by 65% (30-83%). Home visiting has no clear advantage over usual care (weak evidence).
• Methods intended for adolescents. Very strong evidence indicates that interventions combining educational approaches with contraception promotion reduce pregnancy by 51-80% among adolescents, although effects on discontinuation and non-use are unclear. Interventions featuring either education or contraceptives alone do not alter pregnancy rates and other outcomes (moderately strong evidence). Home-based mentoring and multiple risk reduction with a parental component appear to reduce pregnancies (weak evidence). Importantly, studies are almost entirely from developed countries; we do not know how results would differ in developing countries.

Summary/Future Directions

Contraceptive technology. Contraceptive methods work, often near 100%. We found that some new formulations, particularly in the hormonal area, further increase efficacy. Mifepristone is a high efficacy emergency contraceptive.
                                                                                                                   
Supportive interventions. Combination strategies, structured counseling, and intervening at a teachable moment (e.g., post-partum) appear to improve contraceptive use and decrease pregnancy rates.

Future directions are focused on expanding access. In recent decades, tremendous advances have been made in the development of safer and more effective contraceptives, and in the provision of affordable and accessible family planning services.[7] Access to family planning is viewed by USAID, the UN family of agencies, and other global health agencies as a central strategy to promote both the short-term health of mothers and children, as well as longer term development goals. Universal access to contraception by 2015 is one of the Millennium Development Goals.

According to the recent MDG Report for 2010, however, progress has stalled in reducing the number of teenage pregnancies. Between 1990 and 2000, the adolescent birth rate was decreasing across all regions, however subsequent decreases have slowed, and some countries have even reported increases.[8] The highest adolescent birth rate is found in sub-Saharan Africa, which has demonstrated little improvement since 1990.[8]

Unintended pregnancy is a public health challenge that can be tackled through the provision of family planning services, information, education, and counseling. Programs to increase access to these services for adolescents are particularly important. However, funding for family planning has decreased over the last decade, dropping from 8.2% of health aid in 2000 to 3.2% in 2008.[8] Because unintended pregnancy increases maternal deaths, donors and governments need to consider increasing resources for family planning if they wish to achieve MDG goal 5.

References

1. CDC. Unintended Pregnancy Prevention Home: Unintended Pregnancy. Available from: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/index.htm.

2. WHO. Sexual and reproductive health: Repositioning family planning – guidelines for advocacy action. Available from: http://www.who.int/reproductivehealth/publications/family_planning/fp_advocacy_tool/en/index.html.

3. UNFPA. Reproductive health: ensuring that every pregnancy is wanted. Available from: http://www.unfpa.org/rh/planning.htm.

4. Grimes DA, Gallo MF, Halpern V, Nanda K, Schulz KF, Lopez LM. Fertility awareness-based methods for contraception. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004860. DOI: 10.1002/14651858.CD004860.pub2.

5. Gallo MF, Grimes DA, Lopez LM, Schulz KF, d'Arcangues C. Combination injectable contraceptives for contraception. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004568. DOI: 10.1002/14651858.CD004568.pub3.

6. Grimes DA, Lopez LM, Gallo MF, Halpern V, Nanda K, Schulz KF. Steroid hormones for contraception in men. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004316. DOI: 10.1002/14651858.CD004316.pub3.

7. WHO. Sexual and reproductive health: Family planning. Available from: http://www.who.int/reproductivehealth/topics/family_planning/en/index.html.

8. United Nations Department of Economic and Social Affairs.  The Millennium Development Goals Report 2010. New York, 2010. Pgs. 30-38. Available from: http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2010/MDG_Report_2010_En_low%20res.pdf

-- Updated June 2011