Three-Year Contraceptive Failure Rates During the HER Salt Lake Contraceptive Initiative

Differences in typical-use contraceptive failure rates between long-acting reversible contraception (LARC; such as intrauterine devices [IUDs] and implants) and shorter-acting methods (depot medroxyprogesterone acetate [DMPA], pills, rings, and male condoms) are often the focus of contraceptive counseling, but assessments of contraceptive counseling have not focused on contraceptive effectiveness over time.

To assess 3-year continuation and typical-use contraceptive failure rates for 7 reversible contraceptive methods provided with access barriers removed.

The HER Salt Lake Contraceptive Initiative was a 3-year prospective longitudinal cohort study (September 2015 to March 2017, with follow-up data collected through June 2020). Participants (new contraceptive users 18-45 years who indicated they wanted to avoid pregnancy for at least 1 year) enrolled at 4 family planning clinics in Salt Lake County, Utah, and received person-centered contraception counseling and same-day access to the reversible contraceptive method of their choice. Data were analyzed from June 2024 to February 2026.

The exposure was contraceptive method selected at baseline (copper IUD, DMPA, implant hormonal IUD, condoms, pill, or ring).

The outcome was experiencing a contraceptive failure, defined as an unintended pregnancy (self-reported or identified through electronic medical record) experienced while using a contraceptive method in the previous 4 weeks. Method-specific continuation and failure rates were calculated using a life table analysis.

Among 4275 contraceptive users (1759 [41%] aged 20-24 years), 96 pregnancies resulting from contraceptive failures of methods initiated at baseline were identified. Of all participants, 529 (11%) selected a copper IUD, 558 (13%) selected DMPA, 823 selected an implant (19%), 1025 (24%) selected a hormonal IUD, 52 (<1%) selected condoms, 1065 (25%) selected pills, and 223 (5%) selected the ring. Cumulative continuation at 3 years included 741 hormonal IUD users (72%), 455 implant users (55%), 321 copper IUD users (61%), 186 DMPA users (33%), 75 ring users (34%), 376 pill users (35%), and 8 male condom (15%). Three-year contraceptive failure rates per 100 person-years were 0.7 (95% CI, 0.4-1.1) for hormonal IUD users, 0.8 (95% CI, 0.5-1.3) for implant users, 1.1 (95% CI, 0.6-1.8) for copper IUD users, 1.1 (95% CI, 0.6-2.1) for DMPA users, 1.4 (95% CI, 0.6-3.2) for ring users, 1.6 (95% CI, 1.1-2.3) for pill users, and 2.6 (95% CI, 0.5-10.0) for male condom users.

In this cohort study of individuals initiating a contraceptive method following person-centered contraceptive counseling and removal of access barriers, low 3-year contraceptive failure rates were observed for all methods, and shorter-acting methods had lower failure rates than previously reported typical use rates. These findings suggest that removing access barriers to preferred contraceptive methods may support access to clinician-dependent LARC methods, like IUDs and implants, and improve the contraceptive effectiveness of user-controlled, shorter-acting methods.