Family Planning and Contraception Use by Women With Rheumatic Diseases

Mehret Birru Talabi, MD, PhD, is a physician-scientist who studies aspects of family planning and pregnancy in women who have various rheumatic and autoimmune diseases. Dr. Birru Talabi has several long-term research projects ongoing that are focused on the creation of a family planning framework in rheumatology to better guide the care and management 
of what can be exceptionally complex cases for physicians to navigate.

Dr. Birru Talabi also has been involved with the creation of international guidelines for reproductive health management that were unveiled in the latter part of 2018 by the American College of Rheumatology.

Dr. Birru Talabi’s background is in internal medicine and rheumatology, and she has a particular interest in issues related to women’s health, having published numerous papers on the subject.

“During my residency training, I concentrated on family planning and women’s health. When I started my fellowship in rheumatology, I had a good deal of experience in supporting women as they made reproductive decisions. Whether it was preparing for pregnancy, optimizing their preconception health, or helping them to avoid an unwanted pregnancy, I received intensive training in how to initiate and hold these types of conversations with patients,” says Dr. Birru Talabi.

Upon entering her rheumatology fellowship, Dr. Birru Talabi felt that there was less conversation in the field of rheumatology regarding family planning, pregnancy, and potential complications for women dealing with rheumatic diseases. Many, if not all, rheumatic diseases are associated with an increased risk of complications during pregnancy if they are not well-controlled on pregnancy-compatible medications at the time of conception.

“While we may think of lupus and antiphos-pholipid antibody syndrome as diseases in which pregnancy complications are relatively common, past studies have shown that almost every rheumatic disease, when not controlled at baseline, is associated with suboptimal pregnancy outcomes. Furthermore, women whose diseases are well-controlled tend to do relatively well during pregnancy. When I first started training, some investigators were promoting an international conversation in our field about how to improve pregnancy outcomes among these patients. My area of interest has been to explore how we can better provide and optimize family planning care for these patients,” says Dr. Birru Talabi.

Family Planning in Cases of Rheumatic Disease Is Vitally Important

While women with rheumatic diseases are at a much higher risk for pregnancy complications and adverse maternal, fetal, and pregnancy outcomes, if their diseases are well-managed, and if patients are well-educated and plans are in place to navigate a pregnancy, most women with a rheumatic disease can do so safely. There are risks, of course, but comprehensive women-focused preconception care and peripartum management can make a vitally important difference in outcomes, and not just for those individuals desiring to start a family. While the current literature is limited, what is known is suggestive that women with autoimmune diseases who plan their pregnancies tend to have better outcomes. They have better outcomes from a pregnancy perspective and a fetal perspective.

Contraception Use: Findings From a New Study

As a fellow, Dr. Birru Talabi conceived of a project to learn more about contraception use among women with rheumatic disease. Would rates of contraception use by these women be higher than the general population because of the known pregnancy risks for women with these conditions? Alternatively, would the findings point to a different outcome? 

Past studies have indicated that nearly two-thirds of reproductive-age women who are sexually active in the United States use some form of contraception on a regular basis.

At any given time in the United States, approximately eight to 10 percent of women are actively trying to become pregnant. This statistic points to an immediate discrepancy between the number of women who are sexually active and who are using contraception, and the number of women who want to get pregnant. There’s a gap between women who are not using contraception but who are sexually active and don’t want to get pregnant. Dr. Birru Talabi was curious to see if this gap was smaller or more significant for women with rheumatic diseases.

“In other words, are women of reproductive age who have rheumatic diseases using contraception? With this study, I wanted to obtain a bird’s eye view of what is happening with contraception use in the patient popu-lation I help to treat. Contraception use has clear benefits in this population of women. Obviously, it helps to prevent pregnancy among any women who do not wish to become pregnant. It also can help women who wish to become pregnant but who have an active disease state to delay pregnancy until their disease becomes quiescent. We know this probably helps pregnancy outcomes. Contraception also affords time as women transition off of fetotoxic medications in preparation for pregnancy. This is a much better scenario than having to tell a woman who is on a fetotoxic medication that she is pregnant. That is a very tough conversation that no one wants to have with a patient,” says Dr. Birru Talabi.

Study Design

Dr. Birru Talabi and her research team analyzed administrative data from the UPMC electronic medical record between 2013 and 2014 to ascertain how many reproductive- age women with rheumatic diseases treated within UPMC were using contraception over a two-year study timeframe. The study also examined patient medication use with the hypothesis being that women who were using potentially fetotoxic medications might be more likely to use contraception.

“We hypothesized that those who had more visits with primary care providers, gynecologists, or rheumatologists also would be more likely to use contraception than other women who appeared to be less engaged with the health system,” says Dr. Birru Talabi.

Dr. Birru Talabi’s analysis identified women who saw a rheumatologist at least twice, and who were between the ages of 18 and 50. Knowing the number of rheumatology visits was vital because the researchers wanted to include only women who were receiving some degree of longitudinal care for their rheumatic condition.

The analysis next looked at contraceptive methods used by the women and categorized them as either highly effective or less effective. Highly effective methods were those deemed comparable to sterilization in their efficacy, for example, an intrauterine device (IUD) or subdermal implant.

Medications were categorized by the former FDA risk category, which ascribes most medica tions a letter designation corresponding to the degree of fetal risk posed by the drug; this was the national medical risk classification system used at the time of the study (2013-2014). This was done to stratify the degree of risk by medication type for pregnancy complications.

Findings and Outcomes

Close to 2,500 individuals met the inclusion criteria for the study. The average age was 39.4 years. Over the two-year period of the study, almost two-thirds of women used at least one type of fetotoxic medication.

“In our cohort, about one-third of women were using some form of prescription contraception. This tells us that in a high-risk population of women, nearly two-thirds do not have a prescribed form of contraception, putting them at risk for unintended pregnancy. Some of those women, of course, may be getting their contraception needs fulfilled elsewhere. This number uncovered by our analysis shows there is potentially a large group of high-risk individuals who may be at risk for unintended pregnancy,” says Dr. Birru Talabi.

What this study ultimately tells Dr. Birru Talabi is that we may need to do a better job with contraception management in this patient population.

“An important finding from our study is that women who were prescribed medications considered unsafe during pregnancy were no more likely to be prescribed contraception. In other words, women who were using high-risk medications were no more likely than women who were using safer medications to obtain contraception. We would have hoped that women using high-risk medications also would be using contraception, but our analysis showed otherwise,” says Dr. Birru Talabi.

“While this is the largest study on this topic to date, the available research on this subject suggests that these data are also very representative for women with rheumatic diseases outside of our health care system and as a whole. This underscores the need for a national conversation about how we meet the contraceptive and family-planning needs of this vulnerable, high-risk group of women.”

References

Birru Talabi M, Clowse MEB, Bialock SJ, Moreland L, Siripong N, Borrero S. Contraception Use Among Reproductive-Age Women With Rheumatic Diseases. Arthritis Care Res. 2018 Aug 14. Epub ahead of print.