Contraception before and after diabetes diagnosis

“Public health data tell us that patients with diabetes have lower levels of family planning, including lower levels of effective contraception use and more unintended pregnancies,” said principal investigator Mara Murray Horwitz, MD, MPH, a primary care physician in internal medicine at Boston Medical Center in Massachusetts. “As a primary care physician, I know that it is a constant struggle to balance care for patients' active medical issues and their preventive care needs.”

Mara Murray Horwitz, MD, MPH

Murray Horwitz and her colleagues sought to determine if the negative connection between diabetes and family planning was due to confounding or pre-existing conditions, or if it resulted from the diabetes diagnosis itself.

The study gleaned data from a large national private health insurance provider for non-pregnant women, aged 15 to 49, from the years 2000 to 2014.

In total, 75,355 women with a new diabetes diagnosis were compared to 7.5 million women without a diabetes diagnosis (control group).

Overall rates of contraception use did not increase in the first year after diagnosis (absolute difference-in-difference: 0.4% (99.9% confidence interval [CI]: -2.1% to 2.9%) (P < 0.001).

However, in method-specific analyses, there was a decline in estrogen-containing and injectable contraceptives in the first year after diagnosis (absolute difference-in-difference: -2.2% (99.9 CI: -4.0% to -0.4%) and -0.8% (99.9 CI: -1.5% to -0.1%), respectively (P < 0.001)).

This decline may be due to concerns that estrogen may increase cardiovascular risk, according to the authors. They provided reassurance that diabetes need not influence contraceptive method choice, citing guidance from the American Diabetes Association (Standards of Medical Care in Diabetes—2020), which states “Women with diabetes have the same contraceptive options and recommendations as women without diabetes. The risk of an unplanned pregnancy outweighs the risk of any given contraception option.”

The study investigators found that a diabetes diagnosis is associated with a net neutral or negative change in contraception use, “when the opposite is recommended; guidelines actually emphasize the importance of family planning for patients with diabetes,” Murray Horwitz told Contemporary OB/GYN. “Our finding was disappointing, but not surprising, because it can take years, even decades, to translate health care policy into practice.”

The study provides a snapshot “of where we stand right now and where we need to go next,” Murray Horwitz said. “Currently, on a population level, and contrary to clinical practice recommendations, a diabetes diagnosis is not triggering an increase in family planning or contraception use.”

Murray Horwitz, an assistant professor of medicine at Boston University School of Medicine, said the time of a diabetes diagnosis and immediately thereafter “is a missed opportunity to help patients plan healthy pregnancies.”

The next steps are to understand how to ensure timely and accessible family planning services for all patients with diabetes who may become pregnant, according to Murray Horwitz. “What patient, clinician and health systems factors are at play?” she said. “Are services not being offered because of a lack of time, information, priority or bandwidth; or, most likely, some combination of them? How can we support patients and clinicians around the time of a diabetes diagnosis to guarantee that all patients' family planning needs are met?”

She is hopeful that the study will lead to more comprehensive care, including family planning with the full range of safe and effective contraceptive options, for persons with diabetes who may become pregnant. “Ultimately, I want everyone to be able to choose when and if they become pregnant, and to have the information, tools and support as needed to optimize their pregnancy outcomes,” she said.

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Disclosure

Murray Horwitz reports no relevant financial disclosures.

Reference

Murray Horwitz ME, Pace LE, Schwarz EB, et al. Use of contraception before and after a diabetes diagnosis: an observational matched cohort study.

Prim Care Diabetes. Printed online March 18, 2021. doi:org/10.1016/j.pcd.2021.02.012