An exploration of the contraceptive counselling practices of midwives who provide postpartum care in Australia

OBJECTIVE

We sought to explore and describe midwives' attitudes and practices relating to their provision of postpartum contraception counselling.

DESIGN

We used an exploratory cross-sectional design. Recruitment used an anonymous online survey using electronic communication platforms of professional, and special-interest organisations, over six months . Descriptive and quantitative analysis was used.

SETTING AND PARTICIPANTS

Australian Midwives who provide postpartum care.

MEANING AND FINDINGS

A total of 289 complete responses were included. Findings from this national survey of midwives showed that almost 75% of Australian midwives reported providing some contraceptive advice to women. Those working in continuity of care models were significantly more likely to fulfil this responsibility. More than half (67%) indicated they had not received any formal contraception education or training. Those working in private obstetric-led settings were significantly less likely to have received education compared to midwives in community settings. Systems barriers preventing the provision of contraceptive counselling included: clinical workload; lack of management support; lack of education; and models of care.

KEY CONCLUSIONS

Most midwives (82%) wanted to provide postpartum contraception counselling as part of their role. They cited barriers from within the health system, ambiguity about roles and responsibilities and offered solutions to improve the provision of postnatal contraception counselling.

IMPLICATIONS FOR PRACTICE

Recommendations include the development of education programs for midwives. Continuity of care models provided the time, autonomy and opportunity for midwives to undertake contraceptive counselling and fulfil this part of their professional scope. Consideration should be given to expanding access and provision of continuity of midwifery care. An urgent investment in the education and skills of midwives is recommended to ensure all women across acute and community services benefit from improved outcomes associated with pregnancy spacing.

Rethinking referral pathways: qualitative evaluation of general practice networks to increase access to intrauterine contraception

BACKGROUND

Long-acting reversible contraceptives are recommended first-line contraception; however, intrauterine device (IUD) uptake remains low in Australia.

OBJECTIVES

To describe the outcomes of an independent evaluation of the General Practitioner IUD Insertion Network (GPIIN), a project designed to address access barriers through formalized referral pathways between general practitioners (GPs) inserting IUDs and noninserters.

METHODS

An independent qualitative pragmatic inductive evaluation, involving 14 in-depth interviews with GPIIN members, was conducted 18 months post-GPIIN implementation in 2 Australian jurisdictions to identify and explore critical success factors and limitations of the model.

RESULTS

Local GP-to-GP IUD referral networks were considered a useful model to assist affordable and timely IUD access, improve noninserters' IUD knowledge and inserters' reflection on best practice. However, pathway simplification is needed to determine optimal integration of the concept into pragmatic GP-to-GP referral arrangements.

CONCLUSIONS

GPIIN provides an opportunity to improve IUD access in Primary Health Care. Further consideration of organizations best positioned and resourced to facilitate sustainable delivery and coordination is necessary.

A Cost Effectiveness Model of Long-Acting Reversible Contraceptive Methods in the Brazilian National Health System

INTRODUCTION

The use of long-acting reversible contraceptives is low among adolescents owing to the high up-front cost. In this study, a 5-year cost-effectiveness model and budget impact analysis were used to compare the use of long-acting reversible contraceptives with the use of combined oral contraceptives among Brazilian adolescents.

METHODS

A Markov model was developed to mirror the clinical and economic effects of long-acting reversible contraceptives among sexually active Brazilian adolescents in the public health system for a 5-year duration, starting from 2018. The costs were expressed in U.S.$, and a 5% discount rate was applied for both costs and benefits. Model inputs included costs of the contraceptive methods, contraceptive discontinuation and adherence rates, abortion, and birth costs associated with unintended pregnancies. The model outcomes were avoided pregnancies, abortions, and births. Univariate and probabilistic sensitivity analyses were conducted.

RESULTS

Copper intrauterine device use was dominant 100% of the time for all outcomes, and a budget impact analysis revealed a cost savings of $422,431,269.10 in the 5-year period. Levonorgestrel intrauterine system and subdermal implant use were cost effective for all outcomes. The budget impact analyses revealed costs of $65,645,417.54 for levonorgestrel intrauterine system and $302,852,972.12 for subdermal implant use during the 5-year study period.

CONCLUSIONS

According to this Brazilian model, copper intrauterine device use is dominant, and levonorgestrel intrauterine systems and subdermal implants are more cost effective than combined oral contraceptives.

Cost-effectiveness of a complex intervention in general practice to increase uptake of long-acting reversible contraceptives in Australia

Objective The aim of this study was to evaluate the cost-effectiveness of the Australian Contraceptive ChOice pRoject (ACCORd) intervention. Methods An economic evaluation compared the costs and outcomes of the ACCORd intervention with usual care (UC). Data from the ACCORd trial were used to estimate costs and efficacy in terms of contraceptive uptake and quality of life. Rates of contraceptive failure and pregnancy were sourced from the literature. Using a Markov model, within-trial results were extrapolated over 10 years and subjected to univariate sensitivity analyses. Model outputs were expressed as the cost per quality-adjusted life years (QALY) gained and cost per unintended pregnancy resulting in birth (UPB) avoided. Results Over 10 years, compared with UC, initiating contraception through the ACCORd intervention resulted in 0.02 fewer UPB and higher total costs (A$2505 vs A$1179) per woman. The incremental cost-effectiveness of the ACCORd intervention versus UC was A$1172 per QALY gained and A$7385 per UPB averted. If the start-up cost of the ACCORd intervention was removed, the incremental cost-effectiveness ratio was A$81 per QALY gained and A$511 per UPB averted. The results were most sensitive to the probability of contraceptive failure, the probability of pregnancy-related healthcare service utilisation or the inclusion of the costs of implementing the ACCORd intervention. Conclusions From a health system perspective, if implemented appropriately in terms of uptake and reach, and assuming an implicit willingness to pay threshold of A$50 000 the ACCORd intervention is cost-effective. What is known about the topic? The uptake of long-active reversible contraceptives (LARC) in Australia is low. The ACCORd trial assessed the efficacy of providing structured training to general practitioners (GPs) on LARC counselling, together with access to rapid referral to insertion clinics. What does this paper add? This study is the first to assess the cost-effectiveness of a complex intervention in the general practice setting aimed at increasing the uptake of LARC in Australia. What are the implications for practitioners? The results show that implementing a complex intervention in general practice involving GP education and the availability of rapid referral to LARC insertion clinics is a cost-effective approach to increase LARC use and its attending efficacy. If the majority of Australian GPs were able to deliver effectiveness-based contraceptive counselling and either insert LARC or use a rapid referral process to a LARC insertion clinic, the additional cost associated with the purchase of LARC products and their insertion would be offset by reductions to health system costs as a result of fewer UPB and abortions. Moreover, the benefits to women's physical and psychological health of avoiding such events is substantial.

Development of a pharmacoeconomic registry: an example using hormonal contraceptives

BACKGROUND

Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives.

METHODS

An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry.

RESULTS

The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files.

CONCLUSION

This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.

Barriers to prescribing of long-acting reversible contraception (LARC) by general practitioner registrars: A cross-sectional questionnaire

Long-acting reversible contraception (LARC) is highly effective but uptake in Australia is low. We aimed to establish general practitioner (GP) registrars' (vocational trainees') perspectives on barriers to prescribing LARC. We conducted a cross-sectional questionnaire-based study of 191 GP registrars in NSW and ACT. Outcome factors were levels of agreement with eight barriers to prescribing LARC. We found the most-reported barriers to prescribing LARC were limited access to training and limited opportunities to maintain skills. Registrars perceived greater barriers to the use of intrauterine devices, compared to contraceptive implants, regarding indemnity insurance, difficulty accessing training, and insufficient insertion opportunities to maintain skills.

Changes in use of hormonal long-acting reversible contraceptive methods in Australia between 2006 and 2018: A population-based study

BACKGROUND

Long-acting reversible contraceptives (LARCs) are promoted internationally as a key strategy for reducing unintended pregnancy and abortion rates.

AIMS

To examine trends in use of hormonal LARCs among reproductive-aged women in Australia between 2006 and 2018 and explore trends according to age groups and state/territory of dispensing.

MATERIALS AND METHODS

Retrospective population-based study using Pharmaceutical Benefits Scheme (PBS) dispensing claims of a 10% random sample of females aged 15-44. We investigated rates and annual trends in dispensing claims of etonorgestrel implant and levonorgestrel intrauterine systems (IUS).

RESULTS

Between 2006 and 2018, annual PBS claims for LARCs increased approximately two-fold from 21.7 to 41.5 per 1000 women, with a plateau observed from 2015 onward. Absolute rate increases were similar for the implant (9.0/1000) and IUS (10.8/1000), with increases observed across all age groups and states/territories. Overall dispensing rates varied by two-fold according to state/territory of dispensing and four-fold according to age groups. Rate increases for the implant were highest among the 15-19 and 20-24 age groups, while rate increases for the IUS were highest among the 35-39 and 40-44 age groups. It is estimated that in 2018, 10.8% of women aged 15-44 were using a LARC; 4.5% for the implant and 6.3% for the IUS.

CONCLUSIONS

Rates of hormonal LARC use have doubled over the past decade. Investigating underlying reasons for the large observed differences in rates of use according to age and state/territory could help further improve uptake for these most effective methods of contraception.