Starting oral contraceptives immediately or during next menses did not differ for continued contraceptive use or pregnancy at 6 months
Correspondence to: Dr C Westhoff, 630 West 168 St, New York, NY, USA;
In young women, does directly observed, immediate initiation of oral contraceptives (OCs) increase continuation rates and reduce pregnancy compared with standard delayed initiation (during next menses)?
randomised controlled trial.
3 and 6 months.
3 urban family planning clinics in Atlanta, New York, and Dallas, USA.
1720 women <25 years of age who were sexually active, requesting OCs, and had a current negative pregnancy test. Exclusion criteria were use of OCs within 7 days or Depo-Provera within 6 months, desire for pregnancy within the next 6 months, lactational amenorrhoea, or women <18 years of age who were postpartum or postabortion.
864 women were allocated to the Quick Start group. During the initial clinic visit, they opened the OC package and were observed taking the first pill. 856 women were allocated to the conventional start group and instructed to take the first pill during their next menses. All women received standardised pill-taking instructions, a take-home instruction sheet, ⩾1 package of pills, and directions to use condoms during the first week of OC use.
OC continuation, pregnancy, and adverse events. The sample was selected to have >90% power to identify an increase in OC continuation from 50% to 60% at 6 months (2 tailed α = 0.05); it had 63% power to identify a pregnancy rate reduction from 11% to 7%.
87% completed the 3-month interview, and 80% completed the 6-month interview.
The Quick Start and conventional start groups did not differ for rate of OC continuation at 3 months (odds ratio [OR] 1.1, 95% CI 0.9 to 1.4) or 6 months (OR 1.1, 95% CI 0.8 to 1.3). The groups did not differ for number of pregnancies (table) or serious adverse events (15 v 11, respectively) over 6 months.
In young women, directly observed, immediate initiation of oral contraceptives did not differ from initiation during the next menses for continued contraceptive use or pregnancy at 6 months.
*Information provided by author.
Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol 2007;109:1270–6.
Clinical impact ratings: Family/General practice 5/7; Sexual health 6/7; Women’s health 6/7
The study by Westhoff et al addresses an important issue for women who choose birth control. Although there was no difference between the Quick Start and conventional start groups for OC continuation, number of pregnancies, or serious events, the process of initiating the pill during the Quick Start clinic visit is safe. The strengths of the study include stratified randomisation (by age and experience with OCs), the baseline similarities of the groups, and the adequate size of the sample.
Quick Start may reduce costs by eliminating return clinic visits for education about OC use, although this was not specifically examined in this study. When given an OC supply of ⩾3 months at the first visit, women in both groups were more likely to continue OC use at 3 months (OR 1.4, 95% CI 1.1 to 1.9) and 6 months (OR 1.6, 95% CI 1.2 to 2.1). It is important to note that the results of this study may not be generalisable beyond the study sample (ie, poor, mainly Latino women <25 y of age).
Continued study is warranted to support public policy that will better meet the needs of young women seeking safe, reliable birth control.1 2 Multi-site, randomised, clinical trials with long-term follow-up should be considered, as well as the potential effects of ethnicity, culture, ease of access, motivation to comply with contraception, and the context of unwanted pregnancy. In the interim, the evidence from the study by Westhoff et al and at least 1 other study3 supports the safety and effectiveness of a ”Quick Start” approach in clinics where contraceptives are distributed. Systematic collection and analysis of data from these clinics will help to determine the effectiveness of the intervention across a range of settings.