ESSAY: The Contraceptive CHOICE Project

handmade holiday decorations

Today is my last day of work.

I worked for a groundbreaking study, The Contraceptive CHOICE Project [sic], from the Monday after I graduated in 2010 to this month. One year, nine months (and 8 days) after starting, I am a changed person with much more knowledge about women’s health. I have told many people – from strangers at bars to my closest girlfriends – and each has expressed interest in the study’s process and findings.

The CHOICE Project is a clinical research study based at Washington University School of Medicine (which is in St. Louis – not D.C. and not the state). For those not in medicine, a clinical study is one that works directly with patients as opposed to a mixing-liquids-in-a-test-tube type of experiment. The project was born when a wealthy, anonymous donor, whose identity is known only by a handful of people, approached Dr. Jeffrey Peipert and told him to “think big” in designing a project to reduce the number of unplanned pregnancies in St. Louis. The donor chose this city for the study because it is large enough to be riddled with urban health problems but small enough to see results on a population scale. Another perk is that Kansas City, just a four hour drive west on Interstate 70, is comparable in size and demographics to St. Louis, providing researchers with a control population.

Since starting in 2007, the CHOICE Project’s principle goal is to reduce the number of unplanned pregnancies, abortions, and repeat abortions in St. Louis. Our “core” team of donors, doctors, epidemiologists, public health experts, and social workers created a model to deliver no-cost birth control to 10,000 women in St. Louis city and county. We are still collecting data, but hopefully the numbers will show that providing contraception free of charge is more cost-effective than the repercussions of unplanned pregnancies. The study will provide hard evidence that birth control awareness, access, and affordability needs to be increased. This is not a pro-life/pro-choice debate. From a medical standpoint, contraception is about reducing risk to mother and child: unplanned pregnancies result in less prenatal care, higher risk of complications to a woman from being pregnant, and higher incidence of preterm delivery and low birthweight in children. From a social standpoint, unplanned pregnancies are costly to taxpayers and economically difficult for parents. By including a provision for contraception as preventative health care, cost sharing will be eliminated. (source)

Let me repeat: the CHOICE Project does not stand on either side of the abortion debate. It is about allowing women to make choices (hence the name) about their healthcare and family planning. All “opinions” here are based on previously published studies, on scientific facts.

Another goal of the Contraceptive CHOICE Project is to see what types of birth control women choose when financial and educational barriers are removed. Previous to CHOICE, a majority of American women relied on the pill to prevent pregnancy. Though this is still the case, an increasing awareness of long-acting methods has increased use of the most effective methods on the market: Mirena intrauterine device (IUD), ParaGard IUD, and the subdermal implant called Implanon. These last ten, five, and three years, respectively, and are just as effective as sterilization but are reversible. Fertility returns to normal within 14 days of removing either of these three. This contrasts with daily, weekly, monthly, and quarterly methods on the market that have a 8% typical failure rate (3% with the shot) due to user error.

What does a participant do while in the CHOICE Project? She first gives us a call and schedules an enrollment appointment. During that phone call we use a script to introduce the idea of long-acting reversible contraceptives (LARC) to give them something to think about. The enrollment is a two-hour process of counseling women on every single method we have available, which is everything on the market: LARC, injection, pills, patch, ring, and barrier methods. Nothing is experimental - it is all FDA approved and available from physicians across the country. We talk about effectiveness, hormones, side effects, longevity, and how to use them. Every fact we say is scripted - but introduced conversationally - and based on previous research findings. We collect a medical history to make sure she has no contraindications. Most importantly, we do not make the decision for her. It is, after all, called CHOICE. We tell no anecdotes; the closet we come to being biased is saying, "Between the two IUDs, more women in CHOICE choose the Mirena than the ParaGard." Again, an evidence-based fact. It is up to the woman to decide which method best fits her needs and lifestyle. She leaves the clinic with something the day she enrolls. I have completed 195 enrollments between August 2010 and September 2011.

This is about women being educated and armed about the best method for their life. (Lydia Huston)

At the baseline visit and at 3, 6, 12, 18, 24, 30, and 36 months into the study, we conduct a 20-minute questionnaire with participants to ask scores of questions about usage, side effects, satisfaction, and lifestyle. They are usually done over the phone and we mail women a $10 gift card for completing it. Nearly 100,000 gift cards will be given out by the study's end! This is the most tedious part of the study because research assistants, including myself, sit in cubicles and recite the same surveys day in and day out. It is from these surveys that we derive most of the data for the study. It is all self-reported. Few clinical studies have the same magnitude and scope as the CHOICE Project. I have completed over 1,420 surveys!

With nearly 8,000 unique pieces of information per woman, there is a lot to study. Much of the data will be analyzed on the back end after it is cleaned up and someone decides to take time to run analyses on the numbers. A select few of our revolutionary results:

When all financial barriers are removed, nearly 75% of contracepting women will choose a LARC method
After one year of use, 86% of LARC users, versus 55% of refillable method users, are still using their method
Women who use tampons are more likely to select the NuvaRing (duh!)
Women prefer to have STI tests mailed to them than having to come into a clinic
Despite what they tell us during phone surveys, only 30% of women pick up their prescriptions on time (we're sneaky and have pharmacies track refills)

Though some findings seem obvious, the point of research is to have evidence to back up facts. I think it would be wonderful to use the study's results to influence national and medical policy (disclaimer: this is not one of the CHOICE Project's goals). By having cold, hard evidence about side effects and satisfaction, women can make better decisions about their reproductive healthcare. This - searching for more truths - is what science is all about. In part due to this study, doctors are slowly reversing their dated misconceptions about birth control: IUDs do not cause infertility and yes, women who have never been pregnant and are not in committed relationships are eligible to have one. No, most women are not good at taking the pill.

Research shows that of all pregnancies in the United States each year, nearly half are unplanned. That’s 3.2 million unplanned pregnancies; sounds like an epidemic. That is not to say the pregnancies are unwanted, but women expressed that they wished the pregnancies were less of a surprise. Research shows that for every $1 spent on family planning, $4 are saved on the costs of supporting an unplanned birth. Though $1,000 a pop for a LARC may sound ludicrous, consider how much it is when spread over three, five, or ten years. Even refillable methods, which can cost upwards of $100 per month, are less expensive than diapers and doctor's visits. Put into the grand scheme of things, I hope that my 21 months at the Contraceptive CHOICE Project will help millions of men and women across the country lead the lives they plan for themselves without big surprises.

Education, education, education. We emphasize how much education is important in order for one generation to move up, but if they are getting pregnant and they don't graduate, then they don't have that choice. Contraceptive choices give them choices in life. (Dr. Aaron Pile, Ob/Gyn)