Global survey of healthcare practitioners’ beliefs and practices around intrauterine contraceptive method use in nulliparous women

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Safety and efficacy of a suction cervical stabilizer for intrauterine contraceptive device insertion: Results from a randomized, controlled study

OBJECTIVES

To compare patient-reported pain, bleeding, and device safety between intrauterine contraceptive device (IUD) insertion procedures employing a suction cervical stabilizer or single-tooth tenaculum.

STUDY DESIGN

This was a randomized, prospective, single-blinded study conducted at two centers, enrolling women aged 18 years or older, eligible for IUD insertion. The primary end point measure was patient-reported pain, measured on a 100-mm Visual Analogue Scale. Safety was assessed on the amount of bleeding, adverse events, and serious adverse events.

RESULTS

One hundred women were randomized, 48 to the investigational device and 52 to control. There were no statistically significant differences between the groups in factors potentially associated with pain on IUD insertion. IUD insertion was successful in 94% of all subjects. Subjects in the investigational device group reported pain scores ≥14 points lower than in the control group at cervix grasping (14.9 vs 31.3; p < 0.001) and traction (17.0 vs 35.9; p < 0.001), and smaller differences in pain scores at the IUD insertion (31.5 vs 44.9; p = 0.021) and cervix-release (20.6 vs 30.9; p = 0.049) steps. Nulliparous women experienced the greatest pain differences to control. Mean blood loss was 0.336 (range 0.022-2.189) grams in the investigational device group and 1.336 (range 0.201-11.936) grams in the control group, respectively (p = 0.03 for the comparison). One adverse event (bruising and minor bleeding) in the investigational device group was considered causally related to the study device.

CONCLUSIONS

The suction cervical stabilizer had a reassuring safety profile and its use was associated with significant reductions in pain during the IUD insertion procedure compared with standard single-tooth tenaculum use, particularly among nulliparous women.

IMPLICATIONS

Pain can be an important barrier to greater use of IUD devices among prescribers and users, particularly nulliparous women. The suction cervical stabilizer may provide an appealing alternative to currently available tenacula, filling an important unmet need.

Can an online educational video broaden young women's contraceptive choice? Outcomes of the PREFER pre-post intervention study

INTRODUCTION

Contraceptive knowledge mediates access and use. We aimed to assess whether an online educational video describing all methods and their benefits, side effects and mode of action increased young women's contraceptive knowledge and their long-acting reversible contraception (LARC) preference and uptake.

METHOD

We used Facebook advertising to recruit young women aged 16-25 years. Participants completed the pre-video survey (S1), watched the 11-min video, then completed surveys immediately after (S2) and 6 months later (S3). Outcomes were analysed using McNemar tests and multivariate logistic regression (generalised estimating equations).

RESULTS

A total of 322 participants watched the video, completed S1 and S2, and 88% of those completed S3. At S1 only 6% rated their knowledge about every method as high. Knowledge improved at S2 for all methods (OR 10.0, 95% CI 5.9 to 17.1) and LARC (OR 4.2, 95% CI 3.1 to 5.7). LARC preference increased at S2 (OR 1.7, 95% CI 1.4 to 2.1) and S3 (OR 1.4, 95% CI 1.2 to 1.7), as did LARC uptake at S3 (OR 1.3, 95% CI 1.11 to 1.5). LARC uptake was driven by a 4.3% (n=12) absolute increase in intrauterine device (IUD) use, but there was no change in contraceptive implant use (p=0.8). The use of non-prescription methods such as condoms and withdrawal did not change (OR 0.92, 95% CI 0.76 to 1.11).

CONCLUSIONS

Many young women in Australia do not feel well informed about their contraceptive options. The contraceptive education video, delivered via social media, increased their self-reported contraceptive knowledge and IUD preference immediately after viewing, and their IUD uptake 6 months later. Focus should be given to how young women navigate contraceptive access after internet-based education, and strategies to increase access to preferred methods.

Perspectives of health care providers regarding the levonorgestrel-releasing intrauterine system

OBJECTIVES

The aims of the study were to assess the number of insertions per month of the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) and gauge the knowledge and opinions of health care providers with regard to some of its characteristics and the reasons why women liked using the method.

METHODS

An online questionnaire survey was conducted between January and July 2021 at the University of Campinas, Brazil. The survey comprised physicians and nurses from centres that had requested and received donated devices.

RESULTS

A total of 65 health care providers answered the questionnaire (41 physicians and 24 nurses). The main misconceptions were related to insertion after an ectopic pregnancy: 60/65 (92.3%) answered that users with previous ectopic pregnancy must have frequent follow-up. Wrong answers were also given on the occurrence of acne (37/65, 56.9%) and depression (32/65, 49.2%). Participants reported that the LNG-IUS was highly effective (100%), long-acting (93.9%) and an appropriate method for controlling uterine bleeding (90.8%) and that it had few side effects (86.2%).

CONCLUSION

Our study suggests that health care providers from centres that requested and received LNG-IUS donations, even though they reported adequate knowledge about the device, still had misconceptions with regard to its clinical management.

Satisfaction and continuation with LNG-IUS 12: findings from the real-world kyleena® satisfaction study

PURPOSE

The Kyleena^® Satisfaction Study (KYSS) aimed to assess satisfaction and continuation with levonorgestrel-releasing intrauterine system (LNG-IUS) 12 (Kyleena^®) in routine clinical practice and to evaluate factors that influence satisfaction.

MATERIALS AND METHODS

This prospective, observational, multicentre, single-arm cohort study, with 1-year follow-up, was conducted in Belgium, Canada, Germany, Mexico, Norway, Sweden, Spain and the United States from 2017 to 2018. During routine counselling, women who independently selected to use LNG-IUS 12 were invited to participate in the study. KYSS assessed LNG-IUS 12 satisfaction, continuation and safety.

RESULTS

Overall, there were 1126 successful LNG-IUS 12 placements, with insertion attempted in 1129 women. Most participants (833/968, 86.1%, 95% CI 83.7-88.2%, with satisfaction outcome data available) reported satisfaction with LNG-IUS 12 at 12 months (or at the final visit if the device was discontinued prematurely). Satisfaction was not associated with age, parity or motivation for choosing LNG-IUS 12. The majority of women (919/1129, 81.4%) chose to continue after 12 months. Discontinuation was not correlated with age or parity. Overall, 191 women (16.9%) reported a treatment-emergent adverse event.

CONCLUSIONS

Results from KYSS provide the first real-world evidence assessing LNG-IUS 12, and demonstrate high satisfaction and continuation rates irrespective of age or parity. Clinical trial registration: NCT03182140.

A systematic review of the views of healthcare professionals on the provision of long-acting reversible contraception

RESEARCH QUESTION

What are the views of healthcare professionals outside of the general practice setting on long-acting reversible contraception?

BACKGROUND

Despite global sexual health organisations advocating for widespread prescription of long-acting reversible contraception, uptake in developed countries remains relatively low. The role of healthcare professionals outside of the general practice setting in long-acting reversible contraception provision requires further attention.

DESIGN

Systematic review.

METHODS

Five electronic databases were searched for existing qualitative findings using terms related to long-acting reversible contraception and healthcare professional views for the period 2013-2018. A rigorous protocol was applied following the Preferred Reporting Items for Systematic Meta-Analyses checklist and flow diagram. The Critical Appraisal Skills Programme tool was used to assess the quality of studies. A total of six studies were included for thematic analysis.

RESULTS

Three key themes emerged through analysis that had significant impact on healthcare professional views of long-acting reversible contraception: (a) contraceptive counselling practices and constraints; (b) knowledge and training about long-acting reversible contraception; and (c) concerns and personal beliefs about long-acting reversible contraception.

CONCLUSIONS

Healthcare professional views on long-acting reversible contraception are shaped by practical time constraints, levels of knowledge and training, and personal beliefs and concerns. Further research is required to address these issues in order to improve clinical training and guidelines for all settings, not just general practice.

RELEVANCE TO CLINICAL PRACTICE

Settings outside of general practice need to be included within the scope of initiatives that aim to improve clinical practice around access to new and emerging contraceptive methods. Further research could inform models of clinical practice that enable healthcare professionals to take enough time to talk through all contraceptive options with patients in a way that both focuses on their individual needs and is fully informed by up-to-date evidence and training.

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.

How do women and health care professionals view hormonal long-acting reversible contraception? Results from an international survey

Purpose: Evidence from real-world settings is important to provide an accurate picture of health care delivery. We investigated use of long-acting reversible contraception (LARC) in women aged 15-49 years.Materials and methods: Two surveys, one of women and one of health care professionals (HCPs), were conducted in parallel across seven countries. Participating women completed an online survey to assess contraceptive awareness, current method of contraception, age, and experience with current contraceptive method. HCPs participated in an online survey to provide practice-level information and three anonymous charts of hormonal LARC users.Results: Of 6903 women who completed the survey, 3225 provided information about their current primary contraception method. Overall, 16% used LARC methods, while 52% used oral contraceptives (OCs). Of hormonal intrauterine system users, 72% described their experience as 'very favourable', compared with only 53% of women using OCs. Anonymous patient records (n = 1605) were provided by 550 HCPs who completed the online survey. Most women (64%) had used short-acting reversible contraception before switching to LARC. Physicians perceived 56-84% of LARC users to be highly satisfied with their current form of contraception.Conclusions: Although usage of LARC was low, most women using LARC were highly satisfied with their method of contraception.

Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review

Intrauterine contraceptive devices (IUCD) are a safe and cost-effective contraceptive method for medically eligible women. Despite this, the utilisation rate for IUCDs is relatively low in many high-income countries, including Australia. Provision of education and training regarding IUCDs to healthcare providers, including nurses and midwives, is one approach to overcome some of the barriers that may prevent wider uptake of IUCDs. This study aims to explore the types and impact of IUCD insertion training for healthcare providers. A systematic review was undertaken in January 2017 to determine the effectiveness of IUCD training for healthcare providers in relation to provision of IUCDs to women. The databases MEDLINE, EMBASE, CINAHL, COCHRANE and SCOPUS were searched to identify studies from high-income countries relating to IUCD training for healthcare providers and relevant outcomes. A total of 30 studies were included in the review. IUCD training for healthcare providers contributed to increased knowledge and improved positive attitudes towards IUCDs, high rates of successful insertions, low complication rates, and increased provision of IUCDs. Successful insertions and low complication rates were similar across different healthcare provider types. No notable differences between provider types in terms of knowledge increase or insertion outcomes were observed. Different training programs for healthcare providers were found to be effective in improving knowledge and successful provision of IUCDs. Increasing the number of healthcare providers skilled in IUCD insertions in high-income countries, including nurses and midwives, will enhance access to this method of contraception and allow women greater contraceptive choice.

Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review

A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure‐related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement‐related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement‐related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.

Improving Physician Knowledge: A Necessary but Not Sufficient Requirement of Improving Intrauterine Contraception Access in Canada

OBJECTIVE

This study sought to identify knowledge gaps and attitudinal barriers to prescribing intrauterine contraception (IUC).

METHODS

A national, Web-based survey of Canadian gynaecology (GYN) and family medicine (FM) physicians was conducted. The survey was distributed through several channels, including physicians' databases, invitations through a commercial email aggregating service, and contacting residency programs. For knowledge-based questions, correct answers were those consistent with Canadian practice guidelines. Ethics approval was granted through Queen's Health Sciences Research Ethics Board. Project funding was through a research grant from Bayer, Inc. (Canadian Task Force Classification III).

RESULTS

A total of 600 responses were received. GYN physicians' knowledge about IUC (number correct / 40) was better than that of the FM and FM with additional women's health training (FMWH) groups (median [interquartile range] 39 [37-40], 36 [32-38], and 37 [35-39]; P < 0.0001). Factors associated with lower scores included rural practice location, lack of affiliation with medical trainees, extremes of practice duration, and self-perceived lack of knowledge about IUC. Most respondents prescribed IUC (93.7%). Among prescribers, 97.0% inserted IUC. The most common reasons for not prescribing or inserting IUC included lack of training, lack of comfort, and referral to other physicians to provide this service. Respondents indicated that they would be more likely to prescribe and/or insert IUC if cost barriers were removed, patient interest was increased, or if there was improved access to patient-centred educational materials and hands-on training modules.

CONCLUSION

This study suggests that although many GYN and FM physicians are offering IUC, misconceptions regarding contraindications still exist, and several barriers are related to deficiencies in providers' knowledge. Therefore, educational efforts should be prioritized to increase the usage of IUC.

Provider and lay perspectives on intra-uterine contraception: a global review

BACKGROUND

Intra-uterine contraception (IUC) involves the use of an intra-uterine device (IUD), a highly effective, long-acting, reversible contraceptive method. Historically, the popularity of IUC has waxed and waned across different world regions, due to policy choices and shifts in public opinion. However, despite its advantages and cost-effectiveness for programmes, IUC's contribution to contraceptive prevalence is currently negligible in many countries. This paper presents the results of a systematic review of the global literature on provider and lay perspectives on IUC. It aims to shed light on the reasons for low use of IUC and reflect on potential opportunities for the method's promotion.

METHODS

A systematic search of the literature was conducted in four peer-reviewed journals and four electronic databases (MEDLINE, EMBASE, POPLINE, and Global Health). Screening resulted in the inclusion of 68 relevant publications.

RESULTS

Most included studies were conducted in areas where IUD use is moderate or low. Findings are similar across these areas. Many providers have low or uneven levels of knowledge on IUC and limited training. Many wrongly believe that IUC entails serious side effects such as pelvic inflammatory disease (PID), and are reluctant to provide it to entire eligible categories, such as HIV-positive women. There is particular resistance to providing IUC to teenagers and nulliparae. Provider opinions may be more favourable towards the hormonal IUD. Some health-care providers choose IUC for themselves. Many members of the public have low knowledge and unfounded misconceptions about IUC, such as the fear of infertility. Some are concerned about the insertion and removal processes, and about its effect on menses. However, users of IUC are generally satisfied and report a number of benefits. Peers and providers exert a strong influence on women's attitudes.

CONCLUSION

Both providers and lay people have inaccurate knowledge and misconceptions about IUC, which contribute to explaining its low use. However, many reported concerns and fears could be alleviated through correct information. Concerted efforts to train providers, combined with demand creation initiatives, could therefore boost the method's popularity. Further research is needed on provider and lay perspectives on IUDs in low- and middle-income countries.

Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion

BACKGROUND

Australia's abortion rates are among the highest in the developed world. Efficacy of the most commonly used form of contraception (oral contraceptives and condoms) relies on regular user compliance. Long-acting reversible contraception (LARC) virtually eradicates contraceptive failure as it is not user-dependent; however, its uptake has been low.

AIM

To provide an overview of barriers to LARC use in Australia and potential strategies to overcome these barriers.

METHOD

A roundtable of Australian experts was convened to share clinical perspectives and to explore the barriers and potential strategies to increase LARC use.

RESULTS

Three broad barriers to LARC uptake were identified. (i) A paucity of Australian research exists that impedes closure of evidence gaps regarding contraceptive prescription and use. Systematic data collection is required. (ii) Within primary care, lack of familiarity with LARC and misperceptions about its use, lack of access to general practitioners (GPs) trained in LARC insertion/removal and affordability impede LARC uptake. Potential strategies to encourage LARC use include, GP education to promote informed choice by women, training in LARC insertions/removals, effective funding models for nurses to perform LARC insertions/removals, and rapid referral pathways. (iii) At the health system level, primary care incentives to provide LARC to women and health economic analyses to inform government policy changes are required.

CONCLUSIONS

Although LARC decreases unintended pregnancies by eliminating user compliance issues, its uptake is low in Australia. Strategies that promote LARC uptake by targeting specific barriers may effectively reduce Australia's high unintended pregnancy rate.

Barriers and myths that limit the use of intrauterine contraception in nulliparous women: a survey of Brazilian gynaecologists

OBJECTIVE

To understand the extent to which barriers and misperceptions about intrauterine contraception (IUC) remain among Brazilian gynaecologists, particularly for nulliparous women.

METHODS

An online survey was developed to assess Brazilian gynaecologists' knowledge and attitudes towards IUC. Data collected included demographic and professional data, main barriers when considering IUC for women in general and/or nulliparous women, attitudes towards inclusion of IUC in contraceptive counselling, and opinions on what could increase IUC prescription for nulliparous women. A question regarding knowledge about WHO medical eligibility criteria (WHO MEC) was also included in the survey.

RESULTS

101 gynaecologists completed the survey. The insertion rate in nulliparous women was 79.2%. Brazilian gynaecologists were more likely to consider IUC in counselling or provide it on request for parous than for nulliparous women (p<0.05) and perceived more complications in nulliparous women. 74.2% of gynaecologists recognised a higher risk of pelvic inflammatory disease (PID)/infertility associated with IUC use in nulliparous women than in parous women. Difficult and painful insertion were also relevant for 83.2% and 77.3% of the gynaecologists, respectively. Respondents showed a high level of awareness of the WHO MEC classification.

CONCLUSIONS

The three most commonly reported barriers to considering IUC as a contraceptive option for nulliparous woman were concerns about PID and difficult or painful insertion. The challenge is to ensure that gynaecologists understand the evidence and do not disregard IUC as a potential option for nulliparous women.

User characteristics, experiences and continuation rates of copper intrauterine device use in a cohort of Australian women

BACKGROUND

Copper intrauterine device (Cu-IUD) use in Australia is low despite being a highly effective, cost effective non-hormonal contraceptive with reported 12-month continuation rates of 85% compared to 59% for oral contraception.

AIMS

To describe the characteristics of Cu-IUD users in the Australian context, their experiences of side effects, continuation rates and reasons for discontinuation.

METHODS

Between August 2009 and January 2012 we undertook a prospective cohort study of consecutive women presenting for Cu-IUD insertion to three family planning clinics in Queensland and New South Wales. We used survival analysis for continuation rates and univariate and multivariable analyses to characterise users, their experiences up to three years and reasons for discontinuation.

RESULTS

Of the 211 enrolled women, a third (36.0%) were aged under 30 and a third were nulliparous (36.5%). Efficacy and lack of hormones were the most frequently cited reasons to choose the method. Four women were lost to follow-up. Overall continuation rates were 79.1% at one year and 61.3% at three years. Early discontinuation was reduced in those with two or more children (adjusted hazards ratio 0.22, 95% CI 0.09-0.50). Heavy menstrual bleeding was the commonest reason for removal in 28 of 59 (47.5%) discontinuations due to complications or side effects. One uterine perforation and one method failure resulting in an ectopic pregnancy occurred.

CONCLUSIONS

Cu-IUDs were chosen for their efficacy and lack of hormones by a range of Australian women, including young and nulliparous women. While bleeding-related side effects were relatively common, overall continuation rates were high. Serious complications and failures were rare.

Targeting factors for change: contraceptive counselling and care of female adolescents

INTRODUCTION

Sexual and reproductive health care should empower and enable all individuals to have a sex life that is as safe and pleasurable as possible. Achievement of this goal for adolescents is often impeded by regional and sociocultural barriers.

OBJECTIVES

To review global barriers to provision of effective counselling and care of adolescents seeking advice on contraception and sexual and reproductive health and identify elements of best practice that can be adapted to meet their needs at regional level.

METHODS

Experts with clinical experience and a scholarly background in the provision of contraceptive services to adolescents participated in a stepwise process of literature review and discussion according to the agreed objectives.

RESULTS

The Global CARE (Contraception: Access, Resources, Education) group identified barriers to the access, availability and acceptance of contraception by adolescents, not only at the political and sociocultural level but also within health care practice. The group collected and summarized successful local strategies and tools suitable for adaptation in other regions. Elements of best practice for providing contraception regardless of setting or regional constraints, including required skills, knowledge, and attitudes, were also proposed.

CONCLUSION

Sharing of evidence-based best practice in delivering contraceptive services, improvements in health care provider education, and sharing of experience between countries will hopefully help to overcome the barriers to appropriate and effective counselling and care of adolescents.

Increasing Use of Long-Acting Reversible Contraception to Decrease Unplanned Pregnancy

Unintended pregnancy remains high in the United States, accounting for one-half of pregnancies. Both contraceptive nonuse and imperfect use contribute to unplanned pregnancies. Long-acting reversible contraception (LARC) have greater efficacy than shorter acting methods. Data from large studies show that unplanned pregnancy rates are lower among women using LARC. However, overall use of LARC is low; of the reproductive age women using contraception, less than 10% are LARC users. Barriers include lack of knowledge and high up-front cost, and prevent more widespread use. Overcoming these barriers and increasing the number of women using LARC will decrease unplanned pregnancies and abortions.

A review of intrauterine contraception in the Asia-Pacific region

BACKGROUND

Across the Asia-Pacific region, approximately 38% of pregnancies are unintended. Long-acting reversible contraception, such as intrauterine contraception (IUC), is effective in reducing unintended pregnancy.

OBJECTIVE

This study aims to review access to, uptake of and influencing factors on IUC use in the Asia-Pacific region.

METHODS

We searched PubMed and MEDLINE for articles published between 1990 and 2015. We identified and reviewed primary studies that examined the following points and were relevant to the Asia-Pacific region: available types and utilization rates of IUC and factors that influence these. We also obtained the opinions of local experts to gain a better understanding of the situation in specific countries.

RESULTS

Types of IUC used and utilization rates vary widely across the region. Factors influencing rates of utilization relate to healthcare systems, such as government policy on and subsidization of IUC, types of healthcare providers authorized to place IUC and local guidelines on preinsertion screening. Healthcare provider factors include concerns around pelvic inflammatory disease and the suitability of IUC in certain groups of women, whereas end-user factors include lack of awareness of IUC, concerns about safety, cultural or religious attitudes, access to IUC and costs.

CONCLUSIONS

Across the Asia-Pacific region, clear data gaps and unmet needs exist in terms of access to and uptake of IUC. We believe that several recommendations are necessary to update future practice and policy for enhanced IUC utilization so that women across this region have better access to IUC.

Improving Access to Long-Acting Contraceptive Methods and Reducing Unplanned Pregnancy Among Women with Substance Use Disorders

Much has been written about the consequences of substance use in pregnancy, but there has been far less focus on the prevention of unintended pregnancies in women with substance use disorders (SUDs). We examine the literature on pregnancy incidence for women with SUDs, the clinical and economic benefits of increasing access to long-acting reversible contraceptive (LARC) methods in this population, and the current hurdles to increased access and uptake. High rates of unintended pregnancies and poor physical and psychosocial outcomes among women with SUDs underscore the need for increased access to, and uptake of, LARC methods among these women. A small number of studies that focused on improving access to contraception, especially LARC, via integrated contraception services predominantly provided in drug treatment programs were identified. However, a number of barriers remain, highlighting that much more research is needed in this area.

Postabortion Initiation of Long-Acting Reversible Contraception by Adolescent and Nulliparous Women in New Zealand

PURPOSE

To describe changes in receipt of immediate postabortion long-acting reversible contraception (LARC) by adolescent and nulliparous women in New Zealand.

METHODS

Nationally collected data on immediate postabortion receipt of an intrauterine method (intrauterine device [IUD]/intrauterine system [IUS]) or contraceptive implant were analyzed to describe proportions and demographic characteristics of women receiving LARC between 2007 and 2013. Changes in uptake over time were presented for adolescent, nulliparous, and parous women.

RESULTS

Postabortion LARC uptake increased between 2007 and 2013, rising from 7.9% to 42.7% for adolescents and from 8.8% to 36.9% for nulliparous women. The increase was highest among nulliparous adolescents with a seven-fold increase in LARC uptake between 2007 and 2013. Adolescents had a five-fold increase and nulliparous women (of all ages) a four-fold increase. In 2013, IUD/IUS use was lowest among adolescents (22.4%) and increased with increasing age (43% by ages 40+ years), whereas implant use was highest among adolescents (20.3%) and decreased with increasing age (to 4.6% by age 40+ years). Nulliparous women had the lowest use of both IUD/IUS and implants in 2013, with 24.6% receiving an intrauterine method (compared with 43.2% for para 3+), and 12.3% an implant (compared with 17.5% for para 3+).

CONCLUSIONS

Despite an overall trend toward increased uptake of postabortion LARC by adolescent and nulliparous women, uptake in these groups still lags behind that of parous and older women. Reasons for differential uptake need to be explored and addressed if necessary to ensure all women have equitable access to the most effective methods of contraception.

Barriers and Misperceptions Limiting Widespread Use of Intrauterine Contraception Among Canadian Women

Unintended pregnancy is a major social and public health problem with adverse effects on neonatal and developmental outcomes, as well as maternal health and wellbeing. Traditionally, family planning policies have focused on increasing contraceptive uptake in non-users; however, rates of non-use are low in many developed nations. A high proportion of unintended pregnancies are attributable to contraceptive failure, particularly when using barrier and short-acting hormonal contraceptives. Intrauterine contraceptive devices (IUCDs) are highly effective and have been shown to reduce unintended pregnancy rates. Despite this, global utilization rates are low, and IUCD uptake in Canada has been particularly low. In this review we explore why IUCDs are not more widely used, and specifically focus on barriers and misperceptions that may influence IUCD uptake, particularly in Canada. We reviewed relevant articles published in English between 1990 and 2014, through searches of PubMed and Medline, including primary studies of any design containing information on the knowledge and attitudes of health care providers and women. Providing education to care providers, women, and policy makers may help overcome misperceptions about the use of IUCDs, and may facilitate greater use. Increased support from federal and provincial health programs may also encourage the use of IUCDs in Canadian women, and help to reduce unintended pregnancy rates.

Worldwide use of intrauterine contraception: a review

BACKGROUND

Globally, 14.3% of women of reproductive age use intrauterine contraception (IUC), but the distribution of IUC users is strikingly nonuniform. In some countries, the percentage of women using IUC is <2%, whereas in other countries, it is >40%. Reasons for this large variation are not well documented. The aims of this review are to describe the worldwide variation in IUC utilization and to explore factors that impact utilization rates among women of reproductive age in different continents and countries.

STUDY DESIGN

Published literature from 1982 to 2012 was reviewed, using Medline and Embase, to identify publications reporting diverse practices of IUC provision, including variation in the types of IUC available. Local experts who are active members of international advisory groups or congresses were also consulted to document variations in practice regulations, published guidelines and cost of IUC in different countries.

RESULTS

Multiple factors appear to contribute to global variability in IUC use, including government policy on family planning, the types of health care providers (HCPs) who are authorized to place and remove IUC, the medicolegal environment, the availability of practical training for HCPs, cost differences and the geographical spread of clinics providing IUC services.

CONCLUSIONS

Our review shows that the use of IUC is influenced more by factors such as geographic differences, government policy and the HCP's educational level than by medical eligibility criteria. These factors can be influenced through education of HCPs and greater understanding among policy makers of the effectiveness and cost-effectiveness of IUC methods.

IMPLICATIONS

Globally, 14.3% of women of reproductive age use IUC, but the percentage of women using IUC is in some countries <2%, whereas in other countries, it is >40%. This paper reviews the reasons for this diverse and highlights possible starting points to improve the inclusion of IUC in contraceptive counseling.