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Today, the variety of effective fertility regulation methods continues to grow. Contraceptive availability is paramount for the care of women, as approximately half of pregnancies in the United States are unintended (Finer, 2016). And related, in 2014, nearly 11 percent of sexually active fertile women in the United States not pursuing pregnancy did not use any birth control method (Kavanaugh, 2018). These statistics have prompted a reexamination of contraceptive counseling to prevent unplanned pregnancy.

Contraceptive methods are grouped according to their effectiveness. Top-tier or first-tier methods are those that are most effective and are characterized by their ease of use (Fig. 5-1). These methods require minimal user motivation or intervention and have a typical-use pregnancy rate <1 per 100 women during the first year of use (Table 5-1) (Guttmacher Institute, 2018; Trussell, 2018). As expected, these first-tier methods provide the longest duration of contraception after initiation and require the fewest number of return visits. Top-tier methods include various methods of male and female sterilization, intrauterine contraceptive devices, and contraceptive implants. The last two are considered long-acting reversible contraceptives (LARCs). Although counseling is provided for all contraceptive methods, a reduction in the unintended pregnancy rate may be better achieved by increasing top-tier method use.


Contraceptive methods arranged by effectiveness.

TABLE 5-1Contraceptive Failure Rates During the First Year of Method Use in Women in the United States

Second-tier methods include systemic hormonal contraceptives that are available as oral tablets, intramuscular injections, transdermal patches, or transvaginal rings. In sum, their typical-use pregnancy rate is 4 to 7 per 100 users during the first year (see Table 5-1). Perfect-use rates reflect the pregnancy rate if a method is used flawlessly. With second-tier methods, the greater difference between perfect- and typical-use rates most likely stems from a failure to redose at the appropriate interval. Automated reminder systems for these second-tier methods have shown limited efficacy (Halpern, 2013).

Third-tier methods include condoms for men and ...

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