Better contraceptives and improved family planning service delivery systems have great potential to help stem the global epidemic of unintended pregnancy. Every year, of 179 million pregnancies, 79 million are unplanned or unwanted—a number about equal to annual world population growth.
The Global Health Council estimated that between 1995 and 2000 there were more that 300 million unintended pregnancies in developing countries that led to nearly 700,000 deaths from unsafe childbirth and unsafe abortion.
Unintended pregnancies also contribute to the rapid population growth that impairs desperately needed social and economic progress. If family planning programs are not strengthened and more successful, and if current fertility were to remain unchanged, world population would increase in size from the current 6.2 billion to 13 billion in 2050, rather than to the 8.9 billion estimated by the UN.
The reasons for high fertility in developing countries are complex but past experience makes it clear that improved contraceptive technology and improved delivery of family planning information and services can help lower fertility and make an important contribution to reproductive health in all countries.
As is the case in developing countries, almost half of all pregnancies in the U.S. are unintended. And, as in poor countries, unintended births often deprive young women of educational and occupational opportunities.
An important goal of the Center is to conduct sound research to allow evidenced based decisions relating to contraception, family planning and other preventive reproductive health methods.
The Potential of Expanded Contraceptive Choices
Many women and men will not use contraception because of their fears about contraceptive safety or side effects. Many others discontinue use because they did not find a method suitable—often because of unpleasant side effects. And many others have an unintended pregnancy because of contraceptive failure relating to difficulty of proper use or unreliability of the method.
Development of new and improved contraceptives that are more effective, safer and free from undesirable side effects would make an important contribution to helping individuals gain full control over the number and timing of childbearing. Experience shows that each new contraceptive method increases overall use because a greater variety of options increases the odds that every individual will find a method that meets his or her needs.
The Role of Improved Contraceptive Delivery Systems
An extensive body of research to evaluate family planning service delivery systems has brought about improvements in both the efficiency and effectiveness of family planning and reproductive health programs.
The Center is contributing to a 25-year record of clinical research at UCSF to develop new contraceptives and to ascertain their effectiveness, safety, patient acceptability and best use. New ways of distributing emergency contraceptives, of reaching male clients, and of serving immigrants and other diverse populations are just a few of the many important advances developed and proven by the Center through delivery system research.
Studies have made major contributions to the development and introduction of most of the new contraceptives that have been introduced since 1970. They have included:
- A decade of study of vaginal contraceptive rings that contributed to recent FDA approval of the first ring to be introduced for general use in any country, NuvaRing®.
- Studies of contraceptive steroids that can be delivered transdermally through skin patches resulted in approval of Ortho Evra®. A current study is comparing use of the patch and oral contraceptives when used by adolescents.
- A comparison of the cervical cap to the diaphragm that led to FDA approval of the cavity-rim cervical cap.
- A study of the acceptability and effectiveness of the polyurethane condom.
- Studies of various types of contraceptive implants, two of which are approved by the FDA (6 capsule Norplant® and 2 rod Jadelle®) and a third implant which should be approved soon (single rod Implanon®). Long-term studies are evaluating use of implants.
- Studies that led to FDA approval of a once-a-month injectable contraceptive with improved bleeding control, Lunelle®. Studies of the self-administration of injectables are underway.
- Center clinicians have helped to evaluate a frameless copper IUD that is now in use in Europe, that should increase use of the IUD, a safe and effective method that is underused.
- Emergency contraception (Plan B®) reduces the risk of pregnancy by 89% if taken within 72 (or even 120) hours of unprotected intercourse. The Center demonstrated that easier access to EC does not adversely affect adolescents’ and young women’s routine contraceptive method use, sexual risk behaviors, or sexually transmitted infection risk. Data from these studies was critical to the FDA decision to allow over-the-counter (OTC) provision of EC in the U.S. Related Bixby Center research demonstrates the benefits of direct pharmacy access to EC. The Bixby Center completed a series of briefs that provide evidence-based responses to misinformation promulgated by EC opponents on topics including efficacy, safety, sexual risk behaviors, adolescent use, mechanism of action, OTC availability, and cost effectiveness.
- Center studies demonstrated that provision of oral contraceptives without a mandatory pelvic exam does not appear to substantially place women at higher risk of cervical cancer. This streamlined policy for access to oral contraceptives expands access to this effective method. These finding have been widely disseminated and are changing clinical protocols and policies.
- Involving young men in family planning and reproductive health programs has never been easy but by offering culturally appropriate services, a Male Clinic at the New Generation Health Center has successfully attracted increasing numbers of male clients.
Despite the high efficacy of intrauterine contraceptives (IUCs) and contraceptive implants, only two percent of U.S. women use these LARC methods. The Bixby Center is conducting research on provider practices and barriers to LARC use, and is providing devices for medical training programs. Research projects include nationwide surveys of family planning providers and a cluster, randomized trial of a provider education and training intervention. The trial will measure the contraceptive choices of women at participating family planning and abortion clinics and will compare one-year pregnancy rates of women at intervention and control clinic sites. The trial intervention includes education and counseling training for clinicians and health educators, hands-on LARC insertion training for clinicians, tools to enhance health system and third-party payer support for LARC, and LARC information for contraceptive patients. The tools and training materials used in the trial will be available to professional organizations and clinicians upon completion of data collection.