Rapid Repeat Pregnancy and Birth Spacing in Adolescents

Rapid Repeat Pregnancy and Birth Spacing in Adolescents Neena Qasba, M. D. , John Stutsman, M. D. , Greta Weaver, Katherine Weber, Joanne Daggy, Ph. D. , Velvet Miller, Ph. D. , R. N. , Presenter Name Enter Name on Title Master 11/25/2020 Month / Day / Year 1

Authors • Neena Qasba, M. D. PGY-4 OBGYN Resident at Indiana University – No disclosures • John Stutsman, M. D. Faculty OBGYN and Medical director of Planned Parenthood Indiana and Kentucky – Merck – speakers’ bureau for Nexplanon – Afaxys – Medical Advisory Board – Actavis – Medical Advisory Board • Greta Weaver and Katherine Weber- medical students at Indiana University – No disclosures • Joanna Daggy, Ph. D. Biostatistics Indiana University – No disclosures 11/25/2020 2

Content • Background • Research Project Objective • Methods • Results • Conclusion • Question & Answer 11/25/2020 3

Background- Adolescent Pregnancy in Indiana 11/25/2020 4

Background- Adolescent Pregnancy in Indiana Age Indiana U. S. Under 15 93 3, 974 15 -17 2, 132 95, 538 18 -19 5, 785 234, 234 15 -19 7, 917 329, 772 Reference: http: //www. hhs. gov/ash/oah/adolescent-health-topics/reproductive-health/states/in. html 11/25/2020 5

Background- Adolescent Pregnancy in Indiana Teen Birth Rate (births per Indiana U. S. 1, 000 females aged 15 -19) Age 15 -19 34. 8 31. 3 Age 15 -17 16. 0 15. 4 Age 18 -19 61. 2 54. 1 Reference: http: //www. hhs. gov/ash/oah/adolescent-health-topics/reproductive-health/states/in. html 11/25/2020 6

Background- Adolescent Pregnancy in Indiana Race/Ethnicity Indiana U. S. White (non- 5, 566 (69%) Hispanic) 130, 198 (39%) Black (non. Hispanic) 1, 531 (19%) 79, 936 (24%) Asian Hispanic 42 (1%) 832 (10%) 5, 773 (2%) 111, 236 (33%) Reference: http: //www. hhs. gov/ash/oah/adolescent-health-topics/reproductive-health/states/in. html 11/25/2020 7

Background- Adolescent Pregnancy in Indiana % Repeat Births* Females under 20 years of age White (non-Hispanic) Black (non-Hispanic) Indiana U. S. 16% 18% 15% 19% 14% 20% Hispanic 23% 20% Reference: http: //www. hhs. gov/ash/oah/adolescent-health-topics/reproductive-health/states/in. html 11/25/2020 8

Background- Repeat Pregnancy and Socioeconomic Consequences • High school drop-out rates – Only 50% of teen mothers receive a high school diploma by age 22 • Children of teenage mothers are more likely to have: – lower school attainment themselves – more health problems – increased rates of juvenile incarceration – Give birth as a teenager – unemployment http: //www. cdc. gov/teenpregnancy/aboutteenpreg. htm 11/25/2020 9

Background- Repeat Pregnancy and Fetal-Maternal Outcomes • A short interpregnancy interval (IPI) is an indicator defined by Healthy People 2020 as 18 months between a previous delivery and subsequent last menstrual period • The resulting RRPs are associated with adverse maternal and neonatal outcomes • Preterm Birth • Management of chronic • Low Birth Weight medical conditions • Increased perinatal • Infection mortality • Anemia • Congenital anomalies • Increase risk of uterine • Cerebral palsy rupture with RPR • Infant death following C-Section • Maternal mortality References 1 -7 11/25/2020 10

Background- Long-Acting Reversible Contraception • Intrauterine device (IUD) – Levonorgestrel (LNG) IUD • Mirena ® or Skyla ® • Lasts 5 years or 3 years respectively – Copper IUD • Paraguard ® • Lasts 10 years • Subdermal implant – Etonogestrel subdermal implant • Nexplanon ® • Lasts for 3 years 11/25/2020 11

Background- LARC and Birth Spacing • Women who used LARC had almost 4 times the odds [95% CI, 3. 55 -4. 26] of achieving an optimal birth interval compared with women who used less contraceptive effective methods • One study estimated that the subdermal implant was associated with longer interpregnancy interval in adolescents compared with less effective methods (18. 7 mo vs. 11. 9 mo. ) Thiel de Bocanegra H, Chang R, Howell M, et al. Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol 2014; 210: 311. e 1 -8. Baldwin M, Edelman A. The effect of long-acting reversible contraception in rapid repeat pregnancy in adolescents: A review. J Adolesc Health. 2013; 52: S 47 -S 53. 11/25/2020 12

Background- Adolescent LARC in St. Louis Missouri (CHOICE) • Contraceptive CHOICE Project – Longitudinal, observational study of women’s choice, use, and continuation of available contraceptive methods – All methods were offered to study participants at NO cost • Among adolescents aged 14 -20, 62% choose LARC method (658/1054) • Young women aged 14 -17 years preferred implant over Mestad R, Secura G, Allsworth J, Madden T, Zhao Q, Peipert J. Acceptance of long-acting reversible contraceptive methods by IUD adolescents participants in the Contraceptive CHOICE project. Contraception 2011; 493498: 84. 11/25/2020 13

Effectiveness of LARC Methods (CHOICE) Winner B, Peipert JF, Zhao Q, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J Med. 2012; 366: 1998 -2007 11/25/2020 14

Background- CHOICE project • Longitudinal study from 2008 -2013 that followed 1, 404 teenagers aged 15 to 19 years old for 2 -3 years after choosing their contraceptive method. – 72% chose an IUD or implant Secura, G, Madden, T, Mc. Nicholas C, Mullersman, J, Buckel, C, Zhao Q, Peipert, J. Provision of No-Cost, LARC and Teen Pregnancy. NEJM. Oct 2014. 371(14): 1316 -23. Mean annual rate per CHOICE 1000 teens participants Typical U. S Teen pregnancy rate 34. 0 158. 5 birth rate 19. 4 94. 0 abortion rate 9. 7 41. 5 11/25/2020 15

Background- Case for Adolescent LARC in Colorado • How Colorado’s teen birthrate dropped 40% in four years – “Since 2009, the state has provided 30, 000 contraceptive implants or intrauterine devices (IUDs) at low or no cost. ” – “teen abortion rate fell by 35 percent between 2009 and 2012” – “the state saved $42. 5 million in health-care expenditures associated with teen births. ” • Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? – Prospective longitudinal trial – the relative risk of repeat pregnancy at 12 months after delivery was 5. 0 times greater (95% confidence interval [CI], 1. 9– 12. 7) for the control group compared to those who received an immediate Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol postpartum implant 2012; 206: 481. e 1 -7. http: //www. washingtonpost. com/news/morning-mix/wp/2014/08/12/how-colorados-teen-birthrate-dropped-40 -in-four-years/ 11/25/2020 16

Cost Effectiveness of LARC Han. Cost-effectiveness of immediate postpartum Etonogestrel implants. Am J Obstet Gynecol 2014. 11/25/2020 17

11/25/2020 18

Study Design and Methods 11/25/2020 19

Study Objective The Impact of Immediate Postpartum Contraception on the Rate of Rapid Repeat Pregnancy in Adolescents in downtown Indianapolis hospital systems • The objective of this study is to determine and to compare the rapid repeat pregnancy rates and subsequent abortion rates in our urban Indianapolis hospital system between postpartum adolescents who received immediate postpartum contraception and those who did not. 11/25/2020 20

Study Design • Retrospective Cohort Study • Postpartum adolescents: ages 10 -18 at time of delivery. • Delivery between July 1, 2010 to July 1, 2012. • Received prenatal and postpartum care at Health Net, Coleman Center, or Wishard, and delivered at Methodist, University, or Wishard hospital. • Records available in the electronic record system including INPC and Planned Parenthood. • Of the 330 charts that were reviewed, 277 of them had complete prenatal and postpartum information throughout the study period. 11/25/2020 21

Variables • • • age at time of delivery Gestational age race/ethnicity insurance status zip code of residence clinic where prenatal care was received hospital of delivery Mode of delivery Pregnancy complications If immediate postpartum contraception was given (ETN implant or DMPA) • Attendance at postpartum visit and if contraception given or changed • Date of removal of ETN or IUD • Subsequent repeat pregnancy with documented by UPT, LMP, ultrasound, or pregnancy termination procedure 11/25/2020 22

Results 11/25/2020 23

Demographics RRP N= 79 N (%) No RRP N=198 N (%) Pvalue Race Hispanic Black White Other 60/277 (21. 6%) 114/277 (41. 1%) 80. 277 (28. 9%) 23/277 (8. 4%) 17 (21. 5%) 28 (35. 4%) 27 (34. 2%) 7 (8. 9%) 43 (21. 77) 86 (43. 3%) 53 (26. 8%) 16 (8. 1%) 0. 558 Insurance Status Public Private Unknown 217/277 (78. 3%) 21/277 (7. 6%) 39/277 (14. 0%) 61 (77. 2%) 5 (6. 3%) 13 (16. 5%) 156 (78. 8%) 16 (8. 1%) 26 (13. 1%) 0. 716 58/277 (20. 9%) 219/277 (79. 1%) 27 (34. 2%) 52 (65. 8%) 31 (15. 7%) 167 (84. 3%) 0. 001 Previous pregnancy Yes No 11/25/2020 24

Method Type Method Immediate postpartum contraception 11/25/2020 28. 9% 80/277 Immediate postpartum 9. 8% ETN implant 27/277 Immediate postpartum 19. 1% DMPA 53/277 25

RRP by Method RRP Immediate postpartum ETN implant Immediate postpartum DMPA No immediate postpartum contraception 1/27* RRP (%) (p-value 0. 001) 3. 7% 12/53 22. 6% 66/197 33. 5% *the one pregnancy that occurred in this group resulted after removal of the ETN implant 11/25/2020 26

Odds of RRP- Logic Regression Model Variable 95% CI* p-value Odds Ratio 2. 33 [1. 11, 5. 18] . 031 Immediate postpartum ETN implant (No vs. Yes) Attendance Post-partum visit (No/not documented. vs. Yes) Postpartum DMPA (No vs. Yes) 16. 0 [3. 11, 293. 2] . 008 1. 45 [0. 77, 2. 75] . 250 3. 37 [1. 54, 7. 93] . 004 Postpartum ETN implant (No vs. Yes) 5. 55 [2. 20, 16. 13] . 0006 Age at delivery (years) 1. 51 [1. 12, 2. 08] . 009 Previous pregnancies (Yes vs. No) 2. 08 [1. 05, 4. 12] . 035 Immediate postpartum DMPA (No vs. Yes) 11/25/2020 27

• On average, patients need to receive 4 an implant during the immediate postpartum period to prevent one additional rapid repeat pregnancy. * *3. 6 (95% CI, 3 -5) As this is not an RCT, the NNE has been adjusted for covariates (depo in inpatient, implant at postpartum, depot at postpartum, attendance at PP, age at first delivery, and gravida). Ralf Bender and Volker Vervölgyi, Estimating adjusted NNTs in randomised controlled trials with binary outcomes: A simulation study. Contemporary Clinical Trials. 2010. 31(5): 498 – 505. Ralf Bender and Maria Blettner, Calculating the “number needed to be exposed” with adjustment for confounding variables in epidemiological studies. Journal of Clinical Epidemiology. 2002. 55: 525 – 530. 11/25/2020 28

Summary 11/25/2020 29

Conclusions • Use of LARC is low among adolescents in our hospital systems • Immediate postpartum ETN implant placement is very effective in preventing RRP • Immediate postpartum DMPA is not as effective in preventing RRP • Given low attendance at postpartum visit, the immediate postpartum period is an ideal opportunity to offer effective contraception to adolescents 11/25/2020 30

Future Steps • Share ideas and information with lactation consultants to standardize postpartum patient counseling • Work with CMS for postpartum LARC reimbursement – Develop tool kit for providers and health systems to educate on LARC and proper coding 11/25/2020 31

Contact us at: Neena Qasba, MD nqasba@iupui. edu John W. Stutsman, MD jostutsm@iupui. edu 11/25/2020 32

References • • • • • U. S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Available at: http: //www. healthypeople. gov/2020/topicsobjectives 2020/objectiveslist. aspx? topic. Id=13. Retrieved on May 15, 2014. Shachar BZ , Lyell DJ. Interpregnancy Interval and Obstetrical Complications. Obstet Gynecol Surv. 2012; 67: 584 -96. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta analysis. JAMA 2006; 295: 1809– 23. Conde-Agudelo A, Rosas-Bermudez A, Castaño F, Norton MH. Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms. Stud Fam Plan 2012; 43: 93– 114. Howard EJ, Harville E, Kissinger P et al. The Association Between Short Interpreganacy Interval and Preterm Birth in Louisiana: A Comparison of Methods. Matern Child Health J. 2013; 17: 933 -9. Hussaini KS, Ritenour D, Coonrod DV. Interpregnancy Intervals and the Risk for Infant Mortality: A Case Control Study of Arizona Infants 2003 -2007. Matern Child Health J. 2013; 17: 646 -53 Khoshnood B, Lee KS, Wall S, Hsieh HL, Mittendorf R. Short interpregnancy intervals and the risk of adverse birth outcomes among five racial/ethnic groups in the United States. Am J Epidemiol. 1998; 148: 798– 805. Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to Prevent Unintended Pregnancy: Increasing Use of Long-Acting Reversible Contraception. Hum Reprod Update. 2011; 17: 121 -137. Short Interpregnancy Intervals and Risk of Adverse Birth Outcomes in Indiana: Statistics from the Live Birth Data 1990 – 2005, Indiana State Department of Health, Maternal and Child Special Health Care Services, 2008. Gemmill A, Duberstein Lindberg L. Short Interpregnancy Intervals in the United States. Obstet Gynecol. 2013; 122: 64 -71 Winner B, Peipert JF, Zhao Q, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J Med. 2012; 366: 1998 -2007 Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; 206: 481. e 1 -7. Lewis, L, Doherty, D, Hickey M, Skinner R. Implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception 2010; 421: 426. 81 Baldwin M, Edelman A. The effect of long-acting reversible contraception in rapid repeat pregnancy in adolescents: A review. J Adolesc Health. 2013; 52: S 47 -S 53. Mestad R, Secura G, Allsworth J, Madden T, Zhao Q, Peipert J. Acceptance of long-acting reversible contraceptive methods by adolescents participants in the Contraceptive CHOICE project. Contraception 2011; 493498: 84. Ogburn JA, Espey E, Stonehocker J. Barriers to intrauterine device insertion in postpartum women. Contraception. 2005; 72: 426 e 9 Wilson EK, Fowler CI, Koo HP. Postpartum contraceptive use among adolescent mothers in seven states. J Adolesc Health. 2013; 52(3): 278 -83. 11/25/2020 33

Questions? 11/25/2020 34

11/25/2020 35

Background- Cost Effectiveness of LARC • Cost of the outcomes of unintended pregnancy was estimated at $4. 6 Billion dollars • If 10% of women aged 20 -29 switched from short acting forms of contraception to LARC, there would be an estimated cost savings of $436 million dollars. Trussell J, Henry N, Hassan F, Prezioso A, Law A, Filonenko A. Burden of unintended pregnancy in the US: potential savings with increased use of LARC. Contraception 2013; 87: 154 -61. 11/25/2020 36

Contraceptive Use in Adolescents in Indiana Contraceptive Use Indiana Used DMPA, vaginal ring, 11% ETN implant, or IUD U. S. 7% Used OCPs No method 23% 15% 28% 13% Centers for Disease Control and Prevention (CDC). 1991 -2013 High School Youth Risk Behavior Survey Data. Available at http: //nccd. cdc. gov/youthonline/. Accessed on [9/22/2014]. 11/25/2020 37