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Today, an ever-increasing variety of effective methods is available for fertility regulation. Although none is completely without side effects or potential danger, it remains axiomatic that contraception poses fewer risks than pregnancy (Table 5-1). Contraceptive availability is paramount for the care of women as many as half of pregnancies in the United States are unintended. Moreover, in half of these, women were using contraception at the time of conception (Henshaw, 1998). These statistics have prompted a reexamination of contraceptive counseling to prevent unplanned pregnancy (American College of Obstetricians and Gynecologists, 2009b; Grimes, 2009a; Steiner, 2006).

Table 5-1. Pregnancy-Related or Method-Related Deaths Per 100,000 Fertile Women by Age Group

Methods are now grouped according to their effectiveness rather than by type of contraception. 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 only minimal user motivation or intervention and have an unintended pregnancy rate of less than 2 per 100 women during the first year of use (Table 5-2). 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 intrauterine contraceptive devices, contraceptive implants, and various methods of male and female sterilization. A reduction in unintended pregnancies can be better achieved by increasing the use of these top-tier methods. Thus, although counseling is provided for all contraceptive methods, common misperceptions regarding some of the top-tier methods—especially intrauterine contraception—can also be dispelled (Picardo, 2003).

Table 5-2. Percentage of Women Experiencing an Unintended Pregnancy during the First Year of Typical Use and the First Year of Perfect Use of Contraception and the Percentage Continuing Use at the End of the First Year. United States

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