1. Presenter NameEnter Name on Title MasterMonth / Day / Year Neena Qasba, M.D., John Stutsman, M.D., Greta Weaver, Katherine Weber, Joanne Daggy, PhD., Velvet Miller, Ph.D., R.N., 6/10/20151 Rapid Repeat Pregnancy and Birth Spacing in Adolescents

2. 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 6/10/20152

3. Content Background Research Project Objective Methods Results Conclusion Question & Answer 6/10/20153

4. 4 Background- Adolescent Pregnancy in Indiana

5. 6/10/20155 Background- Adolescent Pregnancy in Indiana AgeIndianaU.S. Under 15933,974 15-172,13295,538 18-195,785234,234 15-197,917329,772 Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

6. 6/10/20156 Background- Adolescent Pregnancy in Indiana Teen Birth Rate (births per 1,000 females aged 15-19) IndianaU.S. Age 15-1934.831.3 Age 15-1716.015.4 Age 18-1961.254.1 Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

7. 6/10/20157 Background- Adolescent Pregnancy in Indiana Race/EthnicityIndianaU.S. White (non- Hispanic) 5,566 (69%)130,198 (39%) Black (non- Hispanic) 1,531 (19%)79,936 (24%) Asian42 (1%)5,773 (2%) Hispanic832 (10%)111,236 (33%) Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

8. 6/10/20158 Background- Adolescent Pregnancy in Indiana % Repeat Births*IndianaU.S. Females under 20 years of age 16%18% White (non-Hispanic)15%14% Black (non-Hispanic)19%20% Hispanic23%20% Reference: http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/states/in.html

9. 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 6/10/20159 Background- Repeat Pregnancy and Socioeconomic Consequences http://www.cdc.gov/teenpregnancy/aboutteenpreg.htm

10. 6/10/201510 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 Low Birth Weight Increased perinatal mortality Congenital anomalies Cerebral palsy Infant death Maternal mortality Management of chronic medical conditions Infection Anemia Increase risk of uterine rupture with RPR following C-Section References 1-7

11. 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 6/10/201511

12. 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.) 6/10/201512 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.e1-8. Baldwin M, Edelman A. The effect of long-acting reversible contraception in rapid repeat pregnancy in adolescents: A review. J Adolesc Health. 2013;52:S47-S53.

13. 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 IUD 6/10/201513 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.

14. Effectiveness of LARC Methods (CHOICE) 6/10/201514 Winner B, Peipert JF, Zhao Q, et al. Effectiveness of Long-Acting Reversible Contraception. N Engl J Med. 2012;366:1998-2007

15. 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, McNicholas C, Mullersman, J, Buckel, C, Zhao Q, Peipert, J. Provision of No-Cost, LARC and Teen Pregnancy. NEJM. Oct 2014. 371(14): 1316-23. 6/10/201515 Mean annual rate per 1000 teens CHOICE participants Typical U.S Teen pregnancy rate34.0158.5 birth rate19.494.0 abortion rate9.741.5

16. 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 postpartum implant 6/10/201516 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.e1-7. http://www.washingtonpost.com/news/morning-mix/wp/2014/08/12/how-colorados-teen-birthrate-dropped-40-in-four-years/

17. Cost Effectiveness of LARC 6/10/201517 Han. Cost-effectiveness of immediate postpartum Etonogestrel implants. Am J Obstet Gynecol 2014.

18. 6/10/201518

19. 6/10/201519 Study Design and Methods

20. 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. 6/10/201520

21. 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. 6/10/201521

22. Variables 6/10/201522 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

23. 6/10/201523 Results

24. Demographics 6/10/201524 RRP N= 79 N (%) No RRP N=198 N (%) P-value 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 Previous pregnancy Yes No 58/277 (20.9%) 219/277 (79.1%) 27 (34.2%) 52 (65.8%) 31 (15.7%) 167 (84.3%) 0.001

25. Method Type 6/10/201525 Method Immediate postpartum contraception 28.9%80/277 Immediate postpartum ETN implant 9.8%27/277 Immediate postpartum DMPA 19.1%53/277

26. RRP by Method 6/10/201526 MethodRRPRRP (%) (p-value 0.001) Immediate postpartum ETN implant 1/27*3.7% Immediate postpartum DMPA 12/5322.6% No immediate postpartum contraception 66/19733.5% *the one pregnancy that occurred in this group resulted after removal of the ETN implant

27. Odds of RRP- Logic Regression Model 6/10/201527 VariableOdds Ratio95% CI* p-value Immediate postpartum DMPA (No vs. Yes)2.33[1.11, 5.18].031 Immediate postpartum ETN implant (No vs. Yes) 16.0[3.11, 293.2].008 Attendance Post-partum visit (No/not documented. vs. Yes) 1.45[0.77, 2.75].250 Postpartum DMPA (No vs. Yes)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

28. 6/10/201528 On average, patients need to receive 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.

29. 6/10/201529 Summary

30. Conclusions 6/10/201530 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

31. Future Steps 6/10/201531 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

32. 6/10/201532 Contact us at: Neena Qasba, MD nqasba@iupui.edu John W. Stutsman, MD jostutsm@iupui.edu nqasba@iupui.edujostutsm@iupui.edu

33. References 6/10/201533 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/topicsobjectives2020/objectiveslist.aspx?topicId=13. Retrieved on May 15, 2014.http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13 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.e1-7. 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:S47-S53. 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;72:426e9 Wilson EK, Fowler CI, Koo HP. Postpartum contraceptive use among adolescent mothers in seven states. J Adolesc Health. 2013;52(3):278-83.

34. 6/10/201534 Questions?

35. 6/10/201535

36. 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. 6/10/201536 Background- Cost Effectiveness of LARC

37. 6/10/201537 Background- Contraceptive Use in Adolescents in Indiana Contraceptive UseIndianaU.S. Used DMPA, vaginal ring, ETN implant, or IUD 11%7% Used OCPs28%23% No method13%15% 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].http://nccd.cdc.gov/youthonline/