Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial

Clinician perspectives on adolescent contraceptive counseling following Dobbs v. Jackson: Implications for young people's contraceptive autonomy

OBJECTIVE

The objective of this study is to understand whether clinicians who provide contraceptive counseling to adolescent patients perceive that the Dobbs decision has influenced their counseling.

STUDY DESIGN

We conducted in-depth interviews with a convenience sample of 16 clinicians who provide contraceptive counseling to adolescents at the American Academy of Pediatrics annual conference in October 2022. We used thematic content analysis and an iterative process of constant comparison to identify themes inductively. This analysis focused on participants' perception of if and how the Dobbs decision has or will influence their contraceptive counseling with adolescents.

RESULTS

Most clinicians in our study reported that the Dobbs decision influenced their contraceptive counseling. This included promoting long-acting, reversible methods more so than pre-Dobbs, and explicitly considering changing state-level abortion laws and restrictions. Many clinicians openly noted that their personal preferences influence their counseling, such as prioritizing pregnancy prevention and encouraging patients to use particular methods.

CONCLUSION

We found that most clinicians in our sample acknowledged that the Dobbs decision has influenced their contraceptive counseling practices with adolescents. Clinicians' responses demonstrate that, in many instances, the Dobbs decision motivated them to focus on method effectiveness, leading to tiered and directive contraceptive counseling. We recommend practice changes to support comprehensive contraceptive care provision, provider trainings in unbiased counseling, and developmentally tailored decision aids are needed to ensure that adolescent patients' autonomy is prioritized over a singular focus on pregnancy prevention.

Exploring adolescent-facing US clinicians' perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study

BACKGROUND

Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

METHODS

We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.

RESULTS

We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using "ask then explain" or "explain then ask" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.

CONCLUSION

Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.

Impact of the hands-on clinical training program for subdermic implant on contraceptive counseling and users' choice in Spain: A 6-month follow-up study

OBJECTIVES

The study aimed to evaluate the impact of a structured subdermic implant training program on healthcare providers and its effect on the integration of this contraceptive method into patient counselling.

STUDY DESIGN

The study was a longitudinal experiment with an intervention group, assessing changes at three points: before the training, immediately after, and six months later. The training consisted of a four-hour session combining theory and practical application, conducted by experts in contraception.

RESULTS

Out of the participants, 376 healthcare professionals (a 34.3% response rate) completed the training and subsequent questionnaires. Post-training, there was an increase in the inclusion of the implant in contraceptive advice and a rise in the monthly number of implants. Knowledge about the implant, including insertion, positioning, removal, and replacement, significantly improved after six months (p<0.05), particularly among general practitioners.

CONCLUSIONS

The training program successfully enhanced knowledge and handling of the contraceptive implant, leading to its increased recommendation by healthcare providers and selection by patients. Theoretical and practical training in contraception should be compulsory for healthcare providers involved in contraceptive counselling.

IMPLICATIONS

A training program that includes lectures, video material, and hands-on demonstrations is effective for developing skills in administering the subdermic implant and its integration into contraceptive counselling. Such training should be regular and required for all healthcare professionals providing contraceptive advice.

Is there a difference in the clinical profile and outcome of women using levonorgestrel IUD for abnormal uterine bleeding and those using it for contraception?: A comparative cross-sectional study

Objective

The most common indications for Levonorgestrel intrauterine device (LNG-IUD) are contraception and management of abnormal uterine bleeding (AUB). This study was conducted with the aim of exploring the differences in the clinical profile and outcome of women using LNG-IUD for contraception and AUB.

Materials and Methods

This was a retrospective comparative cross-sectional study of women who underwent LNG-IUD (52 mg) between 2012 and 2017. Their electronic health records were reviewed until the last documented follow-up or until December 2021.

Results

A total of 235 women had LNG-IUD with an age range of 21 to 62 years and a mean of (37.98 years±6.76). Of these women, 153/235 (65.1%) had it for contraception and 82/235 (34.89%) had it for AUB. The follow-up was 1-94 months with (mean ± SEM) follow-up for the AUB group of (21.48±2.31) months and for contraception group was (20.74±1.76) months (p-value of 0.80). There was a significant difference between the two groups in the age and body mass index (BMI), where women who had LNG-IUD for AUB were older (mean of 42.54±6.49 years, p-value <0.001) and had higher BMI (31.88±7.52 kg/m2, p-value =0.011). All LNG-IUDs that were indicated for contraception were inserted in an outpatient setting. However, 68.3% in the AUB, the insertion was in the operating theater in conjunction with hysteroscopy. After combining both expulsion and removal of LNG-IUD during the follow-up period, there was no significant difference between the 2 groups in the overall retention rate during the follow-up (p-value =0.998).

Conclusion

this study shows that women using LNG-IUD for the management of AUB are older and have a higher BMI compared with those using it for contraception. AUB women experienced more expulsion compared with the contraception group, but there was no difference between the 2 groups in the overall survival/retention of LNG-IUD.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Knowledge, beliefs and practices of nurses with long-acting reversible contraception, Cape Town

BACKGROUND

Implanon and copper intrauterine contraceptive device (IUCD) are long-acting reversible contraceptives (LARC) available in public primary health care (PHC) South Africa. These methods are the most effective forms of contraception.

AIM

To evaluate the knowledge, beliefs and practices on provision of LARC.

SETTING

Primary health care facilities within the Khayelitsha Eastern Substructure, Cape Town.

METHODS

A descriptive survey of all permanent nurses who provided contraception. Data were collected from 72/90 (80% response rate) via a validated questionnaire and evaluated using Statistical Package for Social Sciences (SPSS).

RESULTS

Knowledge of eligibility for LARC was tested. The mean knowledge scores for Implanon were 8.56/11 (s.d. 1.42) for the trained and 7.16/11 (s.d. 2.83) for the untrained (p = 0.007). The mean knowledge scores for IUCD were 10.42/12 (s.d. 1.80) for the trained and 8.03/12 (s.d. 3.70) for the untrained (p = 0.019). Participants believed that inaccessibility to training courses (29%), no skilled person available (24%) and staff shortages (35%) were barriers. Less than 50% of women were routinely counselled for LARC. Forty-one percent of nurses were trained and performed IUCD insertion, and 64% were trained and performed Implanon insertion, while 61% and 45% required further training. Confidence was low, with 32% trained and confident in IUCD and 56% trained and confident in Implanon insertion.

CONCLUSION

Lack of training, poor confidence and deficient counselling skills were barriers to effective LARC provision. The identified system-specific barriers must be addressed to improve uptake.Contribution: The first study to evaluate knowledge, beliefs and practices on LARC in providers in the Western Cape.

Increasing Access to Intrauterine Devices and Contraceptive Implants: ACOG Committee Statement No. 5

Everyone who desires long-acting reversible contraception should have timely access to contraceptive implants and intrauterine devices. Obstetrician-gynecologists and other reproductive health care clinicians can best serve those who want to delay or avoid pregnancy by adopting evidence-based practices and offering all medically appropriate contraceptive methods. Long-acting reversible contraceptive devices should be easily accessible to all people who want them, including adolescents and those who are nulliparous and after spontaneous or induced abortion and childbirth. To achieve equitable access, the American College of Obstetricians and Gynecologists supports the removal of financial barriers to contraception by advocating for coverage and appropriate payment and reimbursement for all contraceptive methods by all payers for all eligible patients.

Providers' approaches to contraceptive provision in Cape Town

Background

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs.

Methods

Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach.

Results

Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services.

Discussion

Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

US "Safety Net" Clinics Provide Access to Effective Contraception for Adolescents and Young Women, 2017-2019

Objectives. To describe patterns of providing moderately effective versus the most effective contraception and of providing implants versus intrauterine devices in US community health centers. Methods. We conducted a historical cohort study (2017-2019). Outcomes were woman-level receipt of most effective contraception (long-acting reversible contraception; implants and intrauterine devices) or moderately effective contraception. We used logistic regression to identify patient and clinic factors associated with providing (1) most versus moderately effective methods, and (2) implants versus intrauterine devices. We calculated adjusted probabilities for both outcomes by age group. Results. We included 199 652 events of providing contraception to 114 280 women in 410 community health centers. Adjusted probabilities were similar across age groups for moderately versus most effective methods. However, the adjusted marginal means for receiving an implant compared with an intrauterine device were highest for adolescents (15-17 years: 78.2% [95% confidence interval (CI) = 75.6%, 80.6%]; 18-19 years: 69.5% [95% CI = 66.7%, 72.3%]). Women's health specialists were more likely to provide most versus moderately effective contraception. Conclusions. Community health centers are an important access point for most effective contraception for women of all ages. Adolescents are more likely to use implants than intrauterine devices. (Am J Public Health. 2022;112(S5):S555-S562. https://doi.org/10.2105/AJPH.2022.306913).

Exploring and Monitoring Privacy, Confidentiality, and Provider Bias in Sexual and Reproductive Health Service Provision to Young People: A Narrative Review

Purpose: Poor privacy and confidentiality practices and provider bias are believed to compromise adolescent and young adult sexual and reproductive health service quality. The results of focus group discussions with global youth leaders and sexual and reproductive health implementing organizations indicated that poor privacy and confidentiality practices and provider bias serve as key barriers to care access for the youth. Methods: A narrative review was conducted to describe how poor privacy and confidentiality practices and provider bias impose barriers on young people seeking sexual and reproductive health services and to examine how point of service evaluations have assessed these factors. Results: 4544 peer-reviewed publications were screened, of which 95 met the inclusion criteria. To these articles, another 16 grey literature documents were included, resulting in a total of 111 documents included in the review. Conclusion: Poor privacy and confidentiality practices and provider bias represent significant barriers for young people seeking sexual and reproductive health services across diverse geographic and sociocultural contexts. The authors found that present evaluation methods do not appropriately account for the importance of these factors and that new performance improvement indicators are needed.

Educational Multimedia Tool Compared With Routine Care for the Uptake of Postpartum Long-Acting Reversible Contraception in Individuals With High-Risk Pregnancies: A Randomized Controlled Trial

OBJECTIVE

To assess whether an intervention with a multimedia educational tool, compared with routine care, would increase the use of long-acting reversible contraceptives (LARC) at 12 weeks postpartum in individuals with high-risk pregnancies.

METHODS

In this single-center randomized trial, we assigned individuals aged 13-50 years with high-risk pregnancies to either a multimedia educational tool or routine care. Participants were included during pregnancy through postpartum day 1. Those randomized to the multimedia educational tool (MET) group were provided a tablet with the preloaded 3-5-minute multimedia presentation (https://prezi.com/view/jpFrXaPnnxuqRkcI3A4a/), which was viewed without the presence of research staff and resent by secure email every 4 weeks if undelivered. The primary outcome was uptake of LARC (implant or intrauterine device) within 12 weeks of delivery. The secondary outcomes included overall use of any method of contraception and composite maternal and neonatal adverse outcomes. A priori estimates indicated that 380 participants were needed to detect a 40% difference in use of LARC (baseline 40%; alpha=0.05, power=0.8, assumed loss to follow-up 20%). Relative risk (RR) and number needed to treat (NNT), along with 95% CIs, were calculated.

RESULTS

From July 2020 through December 2020, 536 persons were screened and 380 randomized as follows: 190 for the multimedia educational tool and 190 for routine care. Demographic characteristics were similar between groups. The primary outcome-available for more than 90% of participants-was higher in the MET group (32.4%) than in the routine care (RC) group (20.9%) (RR 1.55; 95% CI 1.09-2.21; NNT nine, with 95% CI 5-42). Overall use of contraception was also higher in the MET group than in the RC group (RR 1.16; 95% CI 1.03-1.32).

CONCLUSION

Among individuals with high-risk pregnancies, compared with routine care, use of a multimedia-based educational tool increased the uptake of postpartum LARC by 55%.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04291040.

FUNDING SOURCE

Funded in part by Investigator-Initiated studies of Organon.

Evaluation of satisfaction with a model of structured contraceptive counseling: Results from the LOWE trial

INTRODUCTION

Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers' and participants' satisfaction with an intervention used in a large trial in Sweden.

MATERIAL AND METHODS

A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03269357).

RESULTS

Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package.

CONCLUSIONS

The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods.

Practical training of health care providers in insertion of contraceptive implants: findings from two Brazilian centres

BACKGROUND AND OBJECTIVES

Lack of information and myths or inadequate training of health care providers in the guidance and management of contraceptives could negatively affect choice and eventually continuation rates. Our objectives were to evaluate the impact of clinical and theoretical training of health care professionals on insertion and removal of etonogestrel (ENG)-implant regarding this contraceptive, including pre- and post-training knowledge about insertion and removal techniques, clinical characteristics, side effects and outcomes.

MATERIAL AND METHODS

We conducted a cross-sectional study in which a questionnaire was sent to health care providers after they received clinical training in the management of ENG-implant.

RESULTS

After training, 78.2% of the 139 participants initiated to offer and inserted up to 5 implants/month and 17.6% between 6 to 10/month. None of the interviewees reported having difficulty with insertions after training, and 87.9% reported feeling very confident for removal.

CONCLUSION

Theoretical and practical training appeared important to prepare health care professionals, clarify doubts and promote higher rates of use of contraceptive implants in Brazil, contributing to reduce the rates of unintended pregnancies.

The Reproductive Health Priorities, Concerns, and Needs of Women in Midlife: A Feminist Poststructuralist Qualitative Analysis

Reproductive health research rarely involves the inclusion of women over 40, creating a large knowledge gap regarding women in midlife. Women continue to have reproductive health needs, concerns, and priorities up to the point of menopause that should be examined to improve reproductive health outcomes and provide individualized care. In-depth, individual, semi-structured interviews were conducted with 20 women between the ages of 40 and 55 who had not reached menopause and did not have a permanent method of sterilization. Using the feminist poststructuralist tenets, three major themes were identified: (a) knowledge acquisition during the perimenopause, (b) subjectivity regarding family planning, and (c) the agency of aging. Participants spoke to a need for reproductive health that listens to their lived experience, addresses menopause clinically and positively, and encourages autonomously driven health priorities. Further research on effective nonhormonal contraception, education on perimenopausal symptoms, and healthy aging is necessary.

Assessing knowledge, attitudes, and practice of health providers towards the provision of postpartum intrauterine devices in Nepal: a two-year follow-up

Background

Health service providers play a key role in addressing women’s need for postpartum pregnancy prevention. Yet, in Nepal, little is known about providers’ knowledge, attitudes, and practice (KAP) on providing postpartum family planning (PPFP), particularly the immediate postpartum intrauterine device (PPIUD). This paper assesses providers KAP towards the provision of PPIUDs in Nepal prior to a PPIUD intervention to gain a baseline insight and analyzes whether their KAP changes both 6 and 24 months after the start of the intervention.

Methods

Data come from a randomized trial assessing the impact of a PPIUD intervention in Nepal between 2015 and 2017. We interviewed 96 providers working in six study hospitals who completed a baseline interview and follow-up interviews at 6 and 24 months. We used descriptive analysis, McNemar’s test and the Wilcoxon signed-rank test to assess KAP of providers over 2 years.

Results

The PPIUD KAP scores improved significantly between the baseline and 6-month follow-up. Knowledge scores increased from 2.9 out of 4 to 3.5, attitude scores increased from 4 out of 7 to 5.3, and practice scores increased from 0.9 out of 3 to 2.8. There was a significant increase in positive attitude and practice between 6 and 24 months. Knowledge on a women’s chance of getting pregnant while using an IUD was poor. Attitudes on recommending a PPIUD to different women significantly improved, however, attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Practice of PPIUD counseling and insertion improved significantly from baseline to 24 months, from 10.4 and 9.4% to 99% respectively.

Conclusions

Although KAP improved significantly among providers during the PPIUD intervention, providers’ knowledge on a women’s chance of getting pregnant while using an IUD and attitudes towards recommending a PPIUD to unmarried women and women who have had an ectopic pregnancy improved the least. Provider KAP could be improved further through ongoing and more in-depth training to maintain providers’ knowledge, reduce provider bias and misconceptions about PPIUD eligibility, and to ensure providers understand the importance of birth spacing.

Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services

STUDY OBJECTIVES

Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods.

DESIGN

Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes.

SETTING

Eleven contraceptive trainings at SBHCs across the United States from 2016-2019.

PARTICIPANTS

A total of 260 providers from 158 SBHCs serving 135,800 students.

INTERVENTIONS

On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services.

MAIN OUTCOME MEASURES

The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills.

RESULTS

At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36).

CONCLUSIONS

Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.

Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.

Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional

OBJECTIVE

We evaluated clinical performance when the TCu380A intrauterine device (IUD) and the levonorgestrel (LNG) 52-mg intrauterine system (IUS) were inserted by different categories of healthcare professionals.

METHODS

A retrospective study was conducted at the University of Campinas, Brazil. The medical records were reviewed of all women in whom an IUD was inserted between January 1980 and December 2018, with data for at least 1 year, and for whom information on the healthcare provider who inserted the device was available.

RESULTS

Overall, 19 132 (76.9%) IUD and 5733 (23.1%) LNG-IUS insertions were included, with residents/interns performing 13 853 (55.8%), nurses 7024 (28.2%), and physicians 3988 (16.0%). Removals for pregnancy and infection were significantly higher when physicians inserted the device, while removals for bleeding/pain and other medical reasons were more common when nurses performed the insertion. Expulsion and removals for personal reasons were similar for all three categories.

CONCLUSION

Clinical outcomes were similar regardless of whether trained nurses, residents/interns, or physicians inserted the device, and were irrespective of users' age and parity. These results could stimulate other healthcare services, particularly in regions where there is a shortage of physicians, to invest in training nurses to perform insertions of IUDs.

Use of contraception among reproductive-aged women in the United States, 2014 and 2016

Objective

To examine current levels, correlates of, and changes in contraceptive use among reproductive-age women in the United States between 2014 and 2016.

Design

We conducted simple and multivariable logistic regression analyses to identify associations between user characteristics and contraceptive use, with specific attention to methods requiring a visit to a health care provider.

Setting

Not applicable.

Patient(s)

All self-identified female respondents to the surveys. Secondary analysis of two rounds of the National Survey of Family Growth, an in-home, nationally representative survey of people ages 15–44 years (2013–2015) and 15–49 years (2015–2017).

Intervention(s)

None.

Main Outcome Measure(s)

Current use of a contraceptive method, including use of individual methods and grouped method use in 2016, and change in use from 2014.

Result(s)

Contraceptive use remained steady between 2014 and 2016 among sexually active females not seeking pregnancy (88%). Among users, use of long-acting reversible contraceptive (LARC) methods increased from 14% to 18%, as use of short-acting reversible contraceptive (SARC) methods fell from 32% to 28%. Implant use among 15- to 19-year-olds rose from 6% to 16% and represents one of the largest increases observed. Access to sexual and reproductive health care was strongly associated with use of all LARC and SARC methods except for the implant (adjusted odds ratios ranged from 3.21 to 13.53).

Conclusion(s)

Contraceptive users are shifting primarily among the most and moderately effective method groups, and not from contraceptive nonuse to use. Reductions in access to sexual and reproductive health care could have implications for individuals’ ability to use their preferred contraceptive methods.

•

Contraceptive use in the United States remained steady between 2014 and 2016.

•

Increases in use of long-acting reversible contraceptive methods paralleled a decrease in use of short-acting reversible contraceptive methods.

•

Contraceptive users are shifting primarily among the most and moderately effective method groups and not from contraceptive nonuse to use.

•

Access to sexual and reproductive health care is strongly associated with use of most long- and short-acting reversible contraception.

Intrauterine Devices in the Context of Gonococcal Infection, Chlamydial Infection, and Pelvic Inflammatory Disease: Not Mutually Exclusive

The use of long-acting reversible contraception, namely, intrauterine device (IUDs) and the subdermal implant, has been recommended to address the high rate of the unintended pregnancy in the United States. IUDs are a safe, highly effective contraceptive method, suitable for most women. The underutilization of IUDs arises in part from the lack of translation of best practices in the clinical setting as well as fears and misperceptions about this contraceptive method held by health care providers and women. This article reviews screening and management of Neisseria gonorrhoeae and Chlamydia trachomatis infection and pelvic inflammatory disease (PID) in women who are using or want to use an IUD. An IUD may be inserted without prior screening for N gonorrhoeae or C trachomatis in women who are at low risk for sexually transmitted infections and asymptomatic. An in situ IUD may remain in the uterus during and after treatment for gonococcal infection, chlamydial infection, or PID. The risk of PID with an IUD in situ is less than 1%. Following IUD best practices, including their use in the context of sexually transmitted infections, can increase the availability of this method for suitable candidates and decrease the unintended pregnancy rate.

How Long-Acting Reversible Contraception Knowledge, Training, and Provider Concerns Predict Referrals and Placement

Context

Providing long-acting reversible contraception (LARC; eg, subdermal implants and intrauterine devices [IUDs]) can help mitigate rates of unintended pregnancy because they are the most effective reversible contraceptive methods. However, many varied barriers to LARC placement are reported. Medical education and training can be tailored if there is a better understanding of how barriers predict LARC referral and to predicting LARC placement.

Objective

To understand how a variety of key barriers to LARC placement are related to one another; to identify which of the barriers, when considered simultaneously, predict LARC referral and LARC placement; and to assess the barriers to LARC placement that persist, even when a major barrier, training, is removed.

Methods

We recruited providers (obstetricians and gynecologists, family physicians, pediatricians, internal medicine physicians, certified nurse practitioners, and certified nurse midwives) across the state of Ohio. Participants were compensated with a $35 Amazon gift card for completing an online survey comprising 38 Likert-type items, an 11-item knowledge test, LARC placement and referral questions, and demographic questions. We conducted data analyses that included correlations, odds ratios, and independent samples t tests.

Results

A total of 224 providers participated in the study. Long-acting reversible contraception knowledge, training, and provider concerns were correlated with one another. Training was found to positively predict placement and negatively predict referral when other barriers, such as knowledge and provider concerns, were considered simultaneously. Of providers who were trained to place implants, 18.6% (n=16) said they referred implant placement, and 17.4% (n=15) said they did not place implants. Of providers who were trained to place IUDs, 26.3% (n=26) said they referred IUD placement, and 27.3% (n=27) said they did not place IUDs. Those who referred placement and those who did not place LARCs reported greater barriers (in type and magnitude) to LARC placement than those who did place LARCs.

Conclusion(s)

Long-acting reversible contraception knowledge, training, and provider concerns about barriers to LARC placement were interdependent. Even when providers were trained to place LARCs, a significant portion referred or did not place them. Efforts to increase LARC placement need to address multifaceted barriers.

Medicaid and receipt of interval postpartum long-acting reversible contraception

OBJECTIVE

We sought to evaluate the impact of insurance type on receipt of an interval postpartum LARC, controlling for demographic and clinical factors.

STUDY DESIGN

This is a retrospective cohort study of 1072 women with a documented plan of LARC for contraception at time of postpartum discharge. This is a secondary analysis of 8654 women who delivered at 20 weeks or beyond from January 1, 2012, through December 31, 2014, at an urban teaching hospital in Ohio. LARC receipt within 90 days of delivery, time to receipt, and rate of subsequent pregnancy after non-receipt were compared between women with Medicaid and women with private insurance. Postplacental LARC was not available at the time of study completion.

RESULTS

One hundred eighty-seven of 822 Medicaid-insured and 43 of 131 privately insured women received a LARC postpartum (22.7% vs 32.8%, P=.02). In multivariable analysis, private insurance status was not significantly associated with LARC receipt (OR 1.29, 95% C.I. 0.83-1.99) though adequate prenatal care was (OR 2.33, 95% C.I. 1.42-4.00). Of women who wanted but did not receive a LARC, 208 of 635 (32.8%) Medicaid patients and 19 of 88 (21.6%) privately insured patients became pregnant within 1 year (P=.02).

CONCLUSION

Differences in receipt of interval postpartum LARC were not significant between women with Medicaid insurance versus private insurance after adjusting for clinical and demographic factors. Adequate prenatal care was associated with LARC receipt. Medicaid patients who did not receive a LARC were more likely to become pregnant within one year of delivery than those with private insurance.

IMPLICATIONS

While insurance-related barriers have been reduced given recent policy changes, access to care remains an important determinant of postpartum LARC provision and subsequent unintended pregnancy.

[The contraception consultation: CNGOF Contraception Guidelines]

OBJECTIVE

Determine the most accurate information to give to women, the most efficient way of doing it, the physical examination during a contraceptive visit and the most appropriate follow-up.

METHODS

A systematic review of French-speaking or English-speaking evidence-based literature about contraception and its visit was performed using Pubmed, Cochrane and international recommendations.

RESULTS

Showing a contraceptive preference decreases women's satisfaction (EL1) and may decrease contraceptive persistence (EL4). A GATHER's like structured consultation is recommended (Grade A). It allows a contraceptive choice improvement (EL2). Contraceptive knowledge improvement associated with a structured consultation allows a decrease in unplanned pregnancies (EL1) compared to a traditional non-personalized consultation. The main expectations of women are slightly different from what is expected by practitioners (EL2). The main topics to be addressed are efficiency, risks, cost, duration of action and practicality (EL2). The quality of interpersonal communication could allow greater contraceptive persistence (EL2). A careful behavior at the beginning of the consultation and facilitating the expression of the woman's point of view could increase the persistence of the initially prescribed contraception (EL2). Explaining the chosen contraception's adverse effect is recommended because it could allow a better persistence (Grade B). Decision aids has shown interest in the therapeutic choice (EL1). Computerized modules or slide shows in the waiting room before consultation could make the contraceptive choice easier (EL2). The presentation of contraception by effectiveness categories is better than pregnancy numbers for comparing the methods (EL1). Performing a blood pressure measurement prior to an estroprogestative contraception prescription is recommended (Grade C). In women without risk factors, literature data do not allow specific recommendations regarding breast, pelvic examination, laboratory screening and follow-up (Professional agreement).