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

Importance: 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. Objective: To assess 3-year continuation and typical-use contraceptive failure rates for 7 reversible contraceptive methods provided with access barriers removed. Design, Setting, and Participants: 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. Exposure: The exposure was contraceptive method selected at baseline (copper IUD, DMPA, implant hormonal IUD, condoms, pill, or ring). Main Outcomes and Measures: 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. Results: 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. Conclusions and Relevance: 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.