Factors Influencing the Provision of Long-Acting Reversible Contraception in California

Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review

Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits

INTRODUCTION

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics.

METHODS

Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects.

RESULTS

The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services.

CONCLUSIONS

Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

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.

Evidence-based family planning services among publicly funded providers in Texas

BACKGROUND

Healthy Texas Women (HTW) is a fee-for-service family planning program that excludes affiliates of abortion providers. The HTW network includes providers who participate in Title X or the state Family Planning Program (FPP) and primary care providers without additional family planning funding (HTW-only). The objective of this study is to compare client volume and use of evidence-based practices among HTW providers.

METHODS

Client volume was determined from administrative data on unduplicated HTW clients served in fiscal year (FY) 2017. A sample of 114 HTW providers, stratified by region, completed a 2018 survey about contraceptive methods offered, adherence to evidence-based contraceptive provision, barriers to offering IUDs and implants, and counseling/referrals for pregnant patients. Differences by funding source were assessed using t-tests and chi-square tests.

RESULTS

Although HTW-only providers served 58% of HTW clients, most (72%) saw < 50 clients in FY2017. Only 5% of HTW providers received Title X or FPP funding, but 46% served ≥ 500 HTW clients. HTW-only providers were less likely than Title X providers to offer hormonal IUDs (70% vs. 92%) and implants (66% vs 96%); offer same-day placement of IUDs (21% vs 79%) and implants (21% vs 83%); and allow patients to delay cervical cancer screening when initiating contraception (58% vs 83%; all p < 0.05). There were few provider-level differences in counseling/referrals for unplanned pregnancy (p > 0.05).

CONCLUSIONS

HTW-only providers served fewer clients and were less likely to follow evidence-based practices. Program modifications that strengthen the provider network and quality of care are needed to support family planning services for low-income Texans.

Effectiveness of training primary care internal medicine residents in etonogestrel implants and impact on their future practice: A cross-sectional study

OBJECTIVE

To evaluate the impact of an etonogestrel implant training program within a primary care Internal Medicine residency training program.

STUDY DESIGN

We surveyed graduates of our primary care Internal Medicine residency program in the Bronx, New York who performed implant procedures though the first 32 months after implementation of a monthly faculty-supervised resident implant clinic. We assessed the number of implants placed and removed per graduate, and surveyed graduates' satisfaction with the implant training program, perceived competence with implant procedures, and intent and ability to perform implant procedures and barriers to performing implant procedures postgraduation.

RESULTS

Between July 2017 and February 2020, 14 residents placed a total of 34 devices and removed four. All 14 program graduates completed the survey in August 2020. All but one respondent felt this training was valuable and 11 felt competent placing implants without supervision. Although 10 planned to provide implants following graduation, none have been able to, largely because of credentialing and clinic-practice level barriers.

CONCLUSIONS

The primary care Internal Medicine program graduates we surveyed (n = 14) valued our etonogestrel implant training program and perceived competence, particularly with implant placement. However, even those who intended to provide etonogestrel implants postgraduation were unable to do so.

IMPLICATIONS

Internal Medicine residents trained to place and remove etonogestrel implants are most comfortable with implant placement. However, these physicians may face barriers related to credentialing and ambulatory practice scope when attempting to provide this care in clinical practice.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis

Introduction:

Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care.

Materials and Methods:

Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.

Results:

Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling.

Conclusions:

A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Association of rural location and long acting reversible contraceptive use among Oregon Medicaid recipients

OBJECTIVE

To evaluate whether the use of long-acting, reversible contraception (LARC) is equitably accessible to Medicaid recipients in rural and urban areas. We also determined whether women's health specialists' availability was associated with the type of LARC used.

STUDY DESIGN

We used claims data for 242,057 adult women who were continuously enrolled in Oregon Medicaid for at least one year and at risk of pregnancy from January 1, 2015, through December 31, 2017 to assess the association between LARC utilization and (1) rurality and (2) provider supply. Our primary analysis included 430,918 person-years. Regression models adjusted for patient age, whether the patient was newly eligible for Medicaid due to Medicaid expansion, and health status. We also examined differences in the caseload of implants and IUD by provider type (women's health specialist vs other).

RESULTS

Among all women, 11.6% had at least one claim indicating LARC use. There was no significant difference in overall LARC use by location (urban residence +0.66%, 95% CI [-0.12%, 1.43%]), although urban residents were slightly more likely to have an IUD (+0.72%, 95% CI [0.11%, 1.33%]). An increase of one women's health specialty provider per 10,000 women was associated with a 0.14 percentage point increase in the rate of IUD utilization (95% CI: 0.02, 0.26). Compared to other providers, women's health specialty providers supplied 62% of all IUDs and 43% of all implants.

CONCLUSION

Among Oregon's Medicaid enrollees, LARC is equitably used in rural areas; however, IUD use is slightly more frequent in urban areas.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial

STUDY OBJECTIVE

Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.

DESIGN

Secondary analysis of a cluster-randomized provider educational trial.

SETTING

Forty US-based reproductive health centers.

PARTICIPANTS

We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.

INTERVENTIONS

The parent study assessed the effect of provider training on evidence-based contraceptive counseling.

MAIN OUTCOME MEASURES

We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.

RESULTS

Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).

CONCLUSION

In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

The Fine Line Between Informing and Coercing: Community Health Center Clinicians' Approaches to Counseling Young People About IUDs

CONTEXT

While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care.

METHODS

As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians' contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects.

RESULTS

Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher-efficacy methods and respecting patients' choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects.

CONCLUSIONS

Providers try to promote their young patients' autonomous decision making, but their support for high-efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient-centered counseling approaches, including honoring patient requests for removals.

Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter?

AIM

The intrauterine device (IUD) is highly effective birth control, but US IUD usage lags. Barriers to usage, including patient attitudes and lack of knowledge, are not well-characterized. This study sought to investigate how attitudes and knowledge about IUD vary by age and race.

METHODS

A survey was distributed to all women in the outpatient obstetrics and gynecology office of a large, urban, academic medical center in Philadelphia. Exclusion criteria included inability to read English or age less than 14 years. Surveys queried participant demographics, knowledge about and opinions of IUD. The authors performed exploratory bi-variable analysis using t tests and chi-square testing to determine which outcomes differed by age and race. For those differing significantly, the authors performed regression analysis to assess for confounding by other factors.

RESULTS

Of 1366 women approached, 521 completed the survey (38% response rate). After controlling for confounding, only responses to the statement 'Hormonal birth control is safe and effective' differed significantly by age. Knowledge about IUD did not differ significantly by race, but black women were significantly more likely to perceive that they had insufficient knowledge about IUD compared to white women (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.06-3.46). Black women had a more negative opinion of IUD safety (OR: 5.0; 95% CI: 2.35-10.66) and reliability (OR: 5.5; 95% CI: 2.20-14.13) than white women.

CONCLUSION

Attitudes and knowledge about IUD do not differ significantly by age. While knowledge about IUD is similar between races, black women may have more negative opinions of IUD.

Adolescent Self-Reported Use of Highly Effective Contraception: Does Provider Counseling Matter?

STUDY OBJECTIVE

To examine associations between provider counseling about specific contraceptive methods and method choices reported by adolescents.

DESIGN

A cross-sectional, secondary analysis of the local 2015 Youth Risk Behavior Survey, to which we added 2 new/modified questions about long-acting reversible contraception (LARC).

SETTING

Rochester, New York.

PARTICIPANTS

Female students in 9th-12th grade in the Rochester City School District.

INTERVENTIONS

An anonymous, standardized survey was administered to collect data.

MAIN OUTCOME MEASURES

We studied associations between students' reported contraceptive use and counseling (LARC, short-acting contraception [SAC], neither), health care factors, and potential risk/protective factors. Data were analyzed using bivariate and multivariate methods.

RESULTS

Among 730 sexually active female respondents, 353/730 (49%) were African American and 182/730 (25%) were Other/Mixed race. 416/730 (57%) used no hormonal method at last sex, and 95/730 (13%) used LARC. 210/730 (29%) of participants recalled any LARC-specific counseling, and 265/730 (36%) any counseling on SAC. Recall of LARC and SAC counseling and use were significantly associated with speaking privately with a provider, but were not related to personal risk/protective factors. Multivariate analyses showed that recollection of LARC counseling was significantly associated with higher odds of using either LARC (adjusted odds ratio, 14.3; P < .001) or SAC (adjusted odds ratio, 2.1; P = .007). Recollection of either LARC or SAC counseling was associated with significantly lower odds of using no contraception.

CONCLUSION

Adolescents' use of LARC was only 13%, but those who recalled contraceptive counseling had higher odds of using some hormonal method. Efforts are needed to improve provider counseling, maintain confidentiality, and identify effective methods to engage adolescents in meaningful, memorable discussions of LARC.

A Pilot Study of a Top-Tier Contraception Simulation Program to Improve Long-Acting Reversible Contraception Practices Among Health Care Trainees

BACKGROUND AND OBJECTIVES

Long-acting reversible contraception methods are effective tools in family planning. However, resident physicians and other health care trainees may experience knowledge gaps and low utilization because of limited opportunity for training. The purpose of this pilot study is to evaluate self-assessed knowledge, counseling, and long-acting reversible contraception (LARC) device placement skills among health care trainees who attended a 1-day simulation-based training. In addition, we describe a simulation-based training program we developed to facilitate the use of LARC among health professionals.

METHODS

We conducted a cross-sectional evaluation of health care trainees attending simulation-based training on 2 occasions in 2017 and one occasion in 2018 in Chicago, Illinois. Participants rated their experience, comfort providing counseling, and placement skills with all LARC methods. Knowledge was measured using a series of multiple-choice questions. Responses to the survey were summarized using frequencies and percentages.

RESULTS

A total of 253 health care professionals attended the simulations, and 244 completed the presurvey (96.4% response rate). Of those, 172 respondents were health care trainees, of which a majority were resident physicians. More than half reported never using top-tier methods in practice. Most indicated moderate to low knowledge to counsel patients and low skills to place each of the devices before training; self-reported knowledge and skills increased after completing training. Presimulation knowledge scores ranged from 0 to 19, with a median score of 14 of 19 correct responses. After training, average scores increased by 3 points (P < 0.0001).

CONCLUSIONS

One-day training events can provide didactic education and simulation-based skills training in device placement that may result in increased access among the patients served by these providers.

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.

Quality of postpartum contraceptive counseling and changes in contraceptive method preferences

OBJECTIVES

We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum.

STUDY DESIGN

We used data from 1167 postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics.

RESULTS

Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18-0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17-0.68).

CONCLUSIONS

High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High-quality counseling appears to reinforce preferences for effective contraception.

IMPLICATIONS

Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.

Intrauterine Device Insertion Before and After Mandated Health Care Coverage: The Importance of Baseline Costs

OBJECTIVE

To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost.

METHODS

We conducted a cross-sectional pre-post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year.

RESULTS

Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6-13.4%) and 2014 (13.8%, 95% CI 13.0-14.7%; P<.001). When plans were grouped by out-of-pocket cost level, significant differences in plan utilization over time were observed. Plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%, 95% CI 0.04-4.5%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (-1.0%, 95% CI -3.3 to 1.4%, P=.02). Among all women in all plans, the 75th percentile of out-of-pocket cost in 2009 was $368; this number dropped to $0 in 2014.

CONCLUSION

Women in plans with the greatest reduction in out-of-pocket cost after mandated coverage of contraception had the greatest gains in IUD insertion. This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost.

Health Care Barriers to Provision of Long-Acting Reversible Contraception in Wisconsin

INTRODUCTION

Long-acting reversible contraceptives (LARC), specifically implants and intrauterine devices (IUD), are highly effective, low maintenance forms of birth control. Practice guidelines from the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics recommend that LARC be considered first-line birth control for most women; however, uptake remains low. In this study, we sought to understand practices and barriers to provision of LARC in routine and immediate postpartum settings as they differ between specialties.

METHODS

We surveyed 3,000 Wisconsin physicians and advanced-practice providers in obstetrics-gynecology/women's health (Ob-gyn), family medicine, pediatrics, and midwifery to assess practices and barriers (56.5% response rate). This analysis is comprised of contraceptive care providers (n=992); statistical significance was tested using chi-square and 2-sample proportions tests.

RESULTS

More providers working Ob-gyn (94.3%) and midwifery (78.7%) were skilled providers of LARC methods than those in family medicine (42.5%) and pediatrics (6.6%) (P < .0001). Lack of insertion skill was the most-cited barrier to routine provision among family medicine (31.1%) and pediatric (72.1%) providers. Among prenatal/delivery providers, over 50% across all specialties reported lack of device availability on-site as a barrier to immediate postpartum LARC provision; organizational practices also were commonly reported barriers.

CONCLUSIONS

Gaps in routine and immediate postpartum LARC practice were strongly related to specialty, and providers' experience heightened barriers to immediate postpartum compared to routine insertion. Skills training targeting family medicine and pediatric providers would enable broader access to LARC. Organizational barriers to immediate postpartum LARC provision impact many providers.

Postpartum intrauterine devices: clinical and programmatic review

The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.

Pediatricians' Knowledge and Practices Related to Long-Acting Reversible Contraceptives for Adolescent Girls

STUDY OBJECTIVE

A 2014 American Academy of Pediatrics (AAP) policy statement identified long-acting reversible contraceptives (LARCs) as first-line choices for adolescents, but pediatricians' current knowledge and practices about intrauterine devices (IUDs) and subdermal contraceptive implants (Implants) is unknown. We aimed to characterize pediatricians' knowledge and practices about LARCs for adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional online survey emailed to a convenience sample of AAP member pediatricians in New York, Utah, Illinois, and Kansas in 2015 and 2016. The study included 561 practicing pediatricians.

MAIN OUTCOME MEASURES

We measured knowledge about the suitability of IUDs and Implants for adolescents using two 7-item scales; a score of 7 indicates all correct. We dichotomized participants' scores as high and low knowledge if they scored ≥85% correct or <85%, respectively.

RESULTS

Mean age was 47.4 (±11) years; 73% were female; and 72% general pediatricians. Almost all, 88%, counsel about contraception; 64% counsel about IUDs, and Implants, but only 4.1% insert them; 72% prescribe short-acting hormonal contraceptives; 44% had read the AAP policy statement. Mean score on the knowledge scale was lower for IUDs than for Implants (4.2 vs 5.1, respectively; P < .001). Multivariable regression analysis indicated that female pediatricians, adolescent medicine subspecialists, agreeing that pregnancy is a serious problem for adolescents in their practice, and having read the AAP policy statement predicted high knowledge about IUDs as well as Implants for adolescents.

CONCLUSION

Most pediatrician respondents provided reproductive health care for adolescents and counseled about LARCs, but few inserted the devices. We identified knowledge deficits about suitability of IUDs for adolescents.

Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence

OBJECTIVE

To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas.

DATA SOURCES

Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors.

STUDY DESIGN

Interviews addressed organizational capacities to expand family planning and integrate services with primary care.

DATA EXTRACTION

Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations.

PRINCIPAL FINDINGS

Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based.

CONCLUSIONS

Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided.

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

BACKGROUND

US unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods.

OBJECTIVE

We sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care.

STUDY DESIGN

We measured the impact of a continuing medical education-accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later.

RESULTS

Overall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13-5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44-4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04-3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28-4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003-0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09-0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02-3.80).

CONCLUSION

Professional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.

The Availability and Use of Postpartum LARC in Mexico and Among Hispanics in the United States

Objectives In the 1980s, policy makers in Mexico led a national family planning initiative focused, in part, on postpartum IUD use. The transformative impact of this initiative is not well known, and is relevant to current efforts in the United States (US) to increase women's use of long-acting reversible contraception (LARC). Methods Using six nationally representative surveys, we illustrate the dramatic expansion of postpartum LARC in Mexico and compare recent estimates of LARC use immediately following delivery through 18 months postpartum to estimates from the US. We also examine unmet demand for postpartum LARC among 321 Mexican-origin women interviewed in a prospective study on postpartum contraception in Texas in 2012, and describe differences in the Mexican and US service environments using a case study with one of these women. Results Between 1987 and 2014, postpartum LARC use in Mexico doubled, increasing from 9 to 19 % immediately postpartum and from 13 to 26 % by 18 months following delivery. In the US, <0.1 % of women used an IUD or implant immediately following delivery and only 9 % used one of these methods at 18 months. Among postpartum Mexican-origin women in Texas, 52 % of women wanted to use a LARC method at 6 months following delivery, but only 8 % used one. The case study revealed provider and financial barriers to postpartum LARC use. Conclusions Some of the strategies used by Mexico's health authorities in the 1980s, including widespread training of physicians in immediate postpartum insertion of IUDs, could facilitate women's voluntary initiation of postpartum LARC in the US.

Access to long-acting reversible contraception among US publicly funded health centers

OBJECTIVES

Access to a full range of contraceptive methods, including long-acting reversible contraception (LARC), is central to providing quality family planning services. We describe health center-related factors associated with LARC availability, including staff training in LARC insertion/removal and approaches to offering LARC, whether onsite or through referral.

STUDY DESIGN

We analyzed nationally representative survey data collected during 2013-2014 from administrators of publicly funded U.S. health centers that offered family planning. The response rate was 49.3% (n=1615). In addition to descriptive statistics, we used multivariable logistic regression to identify health center characteristics associated with offering both IUDs and implants onsite.

RESULTS

Two-thirds (64%) of health centers had staff trained in all three LARC types (hormonal IUD, copper IUD, implant); 21% had no staff trained in any of those contraceptive methods. Half of health centers (52%) offered IUDs (any type) and implants onsite. After onsite provision, informal referral arrangements were the most common way LARC methods were offered. In adjusted analyses, Planned Parenthood (AOR=9.49) and hospital-based (AOR=2.35) health centers had increased odds of offering IUDs (any type) and implants onsite, compared to Health Departments, as did Title X-funded (AOR=1.55) compared to non-Title X-funded health centers and centers serving a larger volume of family planning clients. Centers serving mostly rural areas compared to those serving urbans areas had lower odds (AOR 0.60) of offering IUD (any type) and implants.

CONCLUSIONS

Variation in LARC access remains among publicly funded health centers. In particular, Health Departments and rural health centers have relatively low LARC provision.

IMPLICATIONS

For more women to be offered a full range of contraceptive methods, additional efforts should be made to increase availability of LARC in publicly-funded health centers, such as addressing provider training gaps, improving referrals mechanisms, and other efforts to strengthen the health care system.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

BACKGROUND

Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling.

OBJECTIVE

The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool.

METHODS

This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention.

RESULTS

We are currently enrolling practices and anticipate study completion in 15 months.

CONCLUSIONS

This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

Using Program Data to Improve Access to Family Planning and Enhance the Method Mix in Conflict-Affected Areas of the Democratic Republic of the Congo

Analysis of program data and a formative assessment informed several program changes, including improved coaching and supportive supervision, introduction of postpartum IUDs and the levonorgestrel-releasing intrauterine system, and enhanced behavior change communication. These changes substantially increased family planning adoption, from a monthly average of 14 adopters per facility to 37 per facility. Implants continued to be the most popular method, but the percentage of adopters choosing the IUD increased from 2% in 2012 to 13% in 2016, and it was the most popular method among postabortion care clients.

Unmet need for family planning in the conflict-affected area of eastern Democratic Republic of the Congo (DRC) has been reported to be as high as 38%, and women in such conflict settings are often the most at risk for maternal mortality. The International Rescue Committee implements the Family Planning and Post-Abortion Care in Emergencies program in 3 provinces of eastern DRC to provide women and couples access to family planning, including long-acting reversible contraceptives (LARCs). This article presents routine program data from June 2011 through December 2013 from 2 health zones as well as results from a qualitative assessment of family planning clients and of male and female non-users, conducted in 2013. It then describes how these findings were used to make program adjustments to improve access to family planning services and client informed choice and assesses the effects of the program design changes on family planning uptake and method mix using routine program data from January 2014 through December 2016. Between 2011 and 2013, 8,985 clients adopted family planning, with an average 14 clients adopting a method per facility, per month. The method mix remained stable during this period, with implants dominating at 48%. Barriers to uptake identified from the qualitative research were both supply- and demand-related, including misconceptions about certain modern contraceptive methods on the part of providers, users, and other community members. The program implemented several program changes based on the assessment findings, including clinical coaching and supportive supervision to improve provider skills and attitudes, introduction of immediate postpartum insertion of the intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS), and behavior change communication campaigns to raise awareness about family planning. After these program changes, the mean number of clients adopting modern family planning per facility, per month increased from 14 to 37 and the percentage of family planning adopters choosing LARCs increased from 50% to 66%. While implants continued to be the most dominant method, reaching 60% of the method mix in 2016, the percentage of clients adopting IUDs increased each year, from 3% in 2014 to 13% in 2016. In total, 39,399 clients started family planning methods during the post-program design change period (2014–2016). Our experience in eastern DRC demonstrates that women and their partners affected by conflict want family planning, and that it is feasible to deliver the full range of modern contraceptive methods when programs are adapted and sensitive to the local context.

The Power and Pitfalls of Big Data Research in Obstetrics and Gynecology: A Consumer's Guide

IMPORTANCE

Research in obstetrics and gynecology (OB/GYN) increasingly relies on "big data" and observational study designs. There is a gap in practitioner-relevant guides to interpret and critique such research.

OBJECTIVE

This guide is an introduction to interpreting research using observational data and provides explanations and context for related terminology. In addition, it serves as a guide for critiquing OB/GYN studies that use observational data by outlining how to assess common pitfalls of experimental and observational study designs. Lastly, the piece provides a compendium of observational data resources commonly used within OB/GYN research.

EVIDENCE ACQUISITION

Review of literature was conducted for the collection of definitions and examples of terminology related to observational data research. Data resources were collected via Web search and researcher recommendations. Next, each data resource was reviewed and analyzed for content and accessibility. Contents of data resources were organized into summary tables and matched to relevant literature examples.

RESULTS

We identified 26 observational data resources frequently used in secondary analysis for OB/GYN research. Cost, accessibility considerations for software/hardware capabilities, and contents of each data resource varied substantially.

CONCLUSIONS AND RELEVANCE

Observational data sources can provide researchers with a variety of options in tackling their research questions related to OB/GYN practice, patient health outcomes, trends in utilization of medications/procedures, or prevalence estimates of disease states. Insurance claims data resources are useful for population-level prevalence estimates and utilization trends, whereas electronic health record-derived data and patient survey data may be more useful for exploring patient behaviors and trends in practice.

Pregnancy Ambivalence and Long-Acting Reversible Contraceptive (LARC) Use Among Young Adult Women: A Qualitative Study

CONTEXT

Many young adults are unclear about how much they want to have, or prevent having, a baby. However, pregnancy ambivalence is an underexamined factor in the uptake of long-acting reversible contraceptive (LARC) methods-IUDs and implants-the most effective methods available.

METHODS

In 2014, investigators conducted six focus groups and 12 interviews with 50 women aged 18-29 in Dane County, Wisconsin; participants were either university students or community residents receiving public assistance. A modified grounded theory approach was used to analyze the data.

RESULTS

Four themes emerged. First, participants described a pregnancy desire spectrum: Those strongly motivated to avoid pregnancy were most receptive to LARC methods, while those with less clear or mixed desires worried that these methods would prevent "accidental" pregnancies that might not be unwelcome. Second, women within a few years of wanting children perceived LARC methods as too "permanent," despite awareness of their reversibility. Third, age and life stage were important factors: Younger women and those attending school or beginning careers were more likely than others to consider these methods because they had clearer motivations to avoid pregnancy. Finally, relationship stage influenced receptiveness to LARC methods: Women in newer relationships were more receptive than were those in longer term relationships who imagined having a baby with their partner someday.

CONCLUSION

Effectiveness is not the only factor in women's selection and use of contraceptive methods. Individual preferences will lead some women to choose non-LARC methods even when fully informed of their options.

Contraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference

OBJECTIVE

To assess women's preferences for contraception after delivery and to compare use with preferences.

METHODS

In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision.

RESULTS

Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51).

CONCLUSION

Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study

BACKGROUND

Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.

OBJECTIVE

To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans.

DESIGN AND PARTICIPANTS

We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months.

MAIN MEASURES

Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG).

KEY RESULTS

Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended.

CONCLUSIONS

While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

Implementing Immediate Postpartum Long-Acting Reversible Contraception Programs

OBJECTIVE

To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program.

METHODS

This was a qualitative study. We interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. Data were analyzed using directed qualitative content analysis principles. We used the Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. We compared this guide to hospitals' implementation experiences.

RESULTS

At the completion of the study, LARC was available for immediate postpartum placement at 7 of 10 study hospitals. Participants identified common themes for the implementation experience: team member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Participants expressed a need for anticipatory guidance throughout the process. Key first steps to immediate postpartum LARC program implementation were identifying project champions, creating an implementation team that included all relevant departments, obtaining financial reassurance, and ensuring hospital administration awareness of the project. Potential barriers included lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork. Although the implementation guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not all hospitals required every step to succeed.

CONCLUSION

Hospital teams report that implementing immediate postpartum LARC programs involves multiple departments and a number of important steps to consider. A stage-based approach to implementation, and a standardized guide detailing these steps, may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting.

Patient Education About the Affordable Care Act Contraceptive Coverage Requirement Increases Interest in Using Long-Acting Reversible Contraception

BACKGROUND

The Patient Protection and Affordable Care Act (ACA) requires health insurance to cover all Food and Drug Administration-approved contraceptives at no cost to patients, including highly effective long-acting reversible contraception (LARC). Our objective was to determine whether a brief educational intervention about these provisions would increase interest in LARC use.

METHODS

This is a cross-sectional survey of women seeking contraceptive care in an urban outpatient obstetrics/gynecology clinic. We collected baseline contraceptive attitudes and knowledge of the ACA's contraceptive coverage provisions before the intervention. Our primary outcome was interest in using a LARC method before and after reading a short description of the ACA's contraceptive coverage provisions.

RESULTS

Surveys were completed by 316 participants. Most participants (52.8%) could not correctly identify any of the contraception coverage stipulations protected under the ACA. We observed a significant increase in LARC interest after the intervention in all participants (37.3% vs. 44.3%; p = .038), primarily among participants who did not originally identify any ACA provisions correctly (n = 167; 38.3% vs. 48.5%; p = .030). This subset also demonstrated a greater adjusted odds ratio of post-intervention LARC interest (odds ratio, 2.889; 95% CI, 1.234-6.723; p = .014). Interest in short-acting reversible contraception and contraception overall remained unchanged.

CONCLUSIONS

Most women seeking birth control lack comprehensive understanding of the contraceptive coverage protected by the ACA. Incorporating patient education about the ACA's no-cost contraception provision into routine contraceptive counseling may increase interest in LARC use and better enable women to make informed family planning decisions unrestrained by financial considerations.

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.

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.

Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods

BACKGROUND

The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA's mandate has impacted long-acting reversible contraceptives (LARC) use is unknown.

OBJECTIVE

The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA's contraceptive mandate.

DESIGN

A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013.

SUBJECTS

Women aged 18-45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010-2013 (N=3,794,793).

MEASURES

Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics.

RESULTS

The proportion of claims with $0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (β coefficient for trend, -0.004; P<0.001).

CONCLUSIONS

The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.

State of family planning

Family planning and reproductive health services are uniquely impacted by policy and politics in the United States. Recent years have witnessed an unprecedented number of abortion restrictions, and research funding has decreased in related areas. Despite this, both the science and the implementation of improved family planning and abortion methods have progressed in the past decade. This article reviews the current state of family planning, as well as technologies and patient care opportunities for the future.

US family physicians' intrauterine and implantable contraception provision: results from a national survey

OBJECTIVE

Establish a current cross-sectional national picture of intrauterine device (IUD) and implant provision by US family physicians and ascertain individual, clinical site and scope of practice level associations with provision.

STUDY DESIGN

Secondary analysis of data from 2329 family physicians recertifying with the American Board of Family Medicine in 2014.

RESULTS

Overall, 19.7% of respondents regularly inserted IUDs, and 11.3% regularly inserted and/or removed implants. Family physicians provided these services in a wide range of clinical settings. In bivariate analysis, almost all of the individual, clinical site and scope of practice characteristics we examined were associated with provision of both methods. In multivariate analysis, the scope of practice characteristics showed the strongest association with both IUD and implant provision. For IUDs, this included providing prenatal care with [adjusted odds ratio (aOR) 3.26, 95% confidence interval (95% CI)=1.93-5.49] or without (aOR=3.38, 95% CI=1.88-6.06) delivery, performance of endometrial biopsies (aOR=16.51, 95% CI=11.97-22.79) and implant insertion and removal (aOR=8.78, 95% CI=5.79-13.33). For implants, it was providing prenatal care and delivery (aOR=1.77, 95% CI=1.15-2.74), office skin procedures (aOR=3.07, 95% CI=1.47-6.42), endometrial biopsies (aOR=3.67, 95% CI=2.41-5.59) and IUD insertion (aOR=8.58, 95% CI=5.70-12.91).

CONCLUSIONS

While a minority of family physicians regularly provided IUDs and/or implants, those who provided did so in a broad range of outpatient settings. Individual and clinical site characteristics were not largely predictive of provision. This connotes potential for family physicians to increase IUD and implant access in a variety of settings. Provision of both methods was strongly associated with scope of practice variables including performance of certain office procedures as well as prenatal and/or obstetrical care.

IMPLICATIONS

These data provide a baseline from which to analyze change in IUD and implant provision in family medicine, identify gaps in care and ascertain potential leverage points for interventions to increase long-acting reversible contraceptive provision by family physicians. Interventions may be more successful if they first focus on sites and/or family physicians who already provide prenatal care, obstetrical care, skin procedures and/or endometrial biopsies.

A Qualitative Study of Prescription Contraception Use: The Perspectives of Users, General Practitioners and Pharmacists

BACKGROUND

The oral contraceptive pill (OCP) remains the most popular form of prescription contraception in many countries, despite adherence difficulties for many. Uptake of long acting reversible contraceptives (LARCs), which are less reliant on user adherence, remains low. The aim of this study was to explore the experiences of, and attitudes towards, prescription contraception amongst samples of contraception users, general practitioners (GPs) and pharmacists.

METHODOLOGY AND FINDINGS

We conducted a qualitative study using semi-structured interviews with 18 contraception users, 18 GPs and 9 pharmacists. The study took place in Galway, Republic of Ireland between June and September 2014. Thematic analysis was used to analyse the data. Overall, contraception users were more familiar with the OCP, and all the women interviewed began their prescription contraception journey using this method. All participants identified episodes of poor adherence throughout the reproductive life course. The identified barriers for use of LARCs were lack of information, misconceptions, lack of access and high cost. In contrast, GPs believed that adherence to the OCP was good and stated they were more likely to prescribe the OCP than other methods, as they were most familiar with this option. Barriers to prescribing LARCSs were time, cost to practice, training and deskilling. Pharmacists also believed that adherence to the OCP was generally good and that their role was limited to dispensing medication and providing information when asked.

DISCUSSION AND CONCLUSION

There are contrasting perspectives between contraception service providers and contraceptive users. Training for healthcare providers is required to support informed contraceptive choice and adherence. It is necessary to address the practice barriers of cost and lack of time, to promote better communication around adherence issues and prescription contraception options. There is a need for more easily-accessible public health information to promote awareness on all methods of prescription contraception.

Projections and opinions from 100 experts in long-acting reversible contraception

OBJECTIVE

This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods.

STUDY DESIGN

We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions.

RESULTS

The most commonly identified barrier was the cost of the device (63%), followed by women's knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25-29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion.

CONCLUSIONS

Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women's contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women's individual needs.

IMPLICATIONS

Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women's reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.

Intrauterine device use in an urban university clinic: safety of use in a population at high risk for sexually transmitted infections

OBJECTIVE

The objective was to describe infection rates after intrauterine device (IUD) placement at an urban teaching hospital that did not restrict IUD eligibility based on risk factors for sexually transmitted infections (STIs).

METHODS

We reviewed charts of patients undergoing IUD placement at the University of Chicago obstetrics and gynecology resident clinic from July 2007 to June 2008 (n=283). The primary outcome was diagnosis of pelvic inflammatory disease (PID) within 12 months.

RESULTS

Almost half (49.5%) of patients reported a history of any STI. Two patients (0.7%) were diagnosed with PID.

CONCLUSION

Postplacement infection in this unrestricted population was infrequent and comparable to reported rates in previous studies.

Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review

The Contraceptive CHOICE Project (CHOICE) sought to reduce unintended pregnancies in the St. Louis Region by removing cost, education, and access barriers to highly effective contraception. CHOICE was a prospective cohort study of over 9,000 women 14-45 years of age who received tiered contraceptive counseling to increase awareness of all reversible methods available, particularly long-acting reversible contraceptive (LARC) methods. Participants were provided with contraception of their choice at no cost for 2-3 years. We studied contraceptive method choice, continuation, and population outcomes of repeat abortion and teen pregnancy. Seventy-five percent of study participants chose one of the three LARC methods (46% levonorgestrel intrauterine system, 12% copper intrauterine device, and 17% subdermal implant). LARC users reported greater continuation than non-LARC users at 12 months (87% versus 57%) and 24 months (77% versus 41%). In our cohort, LARC methods were 20 times more effective than non-LARC methods. As a result, we observed a reduction in the percent of repeat abortions from 2006 to 2010 in St. Louis compared with Kansas City and nonmetropolitan Missouri and found substantial reductions in teen pregnancy, birth, and abortion (34.0, 19.4, and 9.7 per 1000 teens, respectively) compared with national rates among sexually experienced teens (158.5, 94.0, and 41.5 per 1000, respectively). Improved access to LARC methods can result in fewer unintended pregnancies and abortions and considerable cost savings to the health care system.

Contraception for Adolescents: Focusing on Long-Acting Reversible Contraceptives (LARC) to Improve Reproductive Health Outcomes

Adolescent pregnancy rates in the U.S. have reached an all-time low from their peak in the 1980s and 1990s. However, the U.S. maintains the highest rate of teenage pregnancy among developed nations. Adolescents experience higher typical use failure rates for user-dependent contraceptives compared to their adult counterparts. Long-acting reversible contraception (LARC), IUDs and implants, have failure rates that are both very low and independent of user age. In settings where the most effective methods are prioritized and access barriers are removed, the majority of adolescents initiate LARC. Use of LARC by adolescents significantly reduces rates of overall and repeat teen pregnancy. All methods of contraception are safe for use in teens, including IUDs and DMPA. Dual use of LARC and barrier methods to reduce risk of sexually transmitted infection, is the optimal contraceptive strategy for most adolescents. Adolescent access to evidence-based and confidential contraceptive services, provided in a manner that respects autonomy, is a vital public health goal.

Pelvic inflammatory disease in the adolescent: a poignant, perplexing, potentially preventable problem for patients and physicians

PURPOSE OF REVIEW

The present review considers recent pelvic inflammatory disease literature. It remains a difficult condition to accurately diagnose and manage in the adolescent woman. Failure of accurate diagnosis and prompt management leads to complications, including chronic pelvic pain and infertility.

RECENT FINDINGS

Annual chlamydia screening of sexually active adolescents is an important method for early identification of this common cause of this disorder. Youth with positive screens can be lost for treatment if effective follow-up plans are not in place in clinical practice. The intrauterine device is not a risk factor for this condition in adolescents and is a recommended contraceptive device in sexually active adolescent women. A variety of chlamydial antigens are being used to help differentiate lower genital infection from upper genital disorder. Clinicians are not following established protocols for its diagnosis and management.

SUMMARY

Sequelae can be reduced in adolescent women if clinicians continue with regular chlamydia screening in sexually active adolescent women, have a low index of suspicion for pelvic inflammatory disease, carefully follow accepted treatment protocols, and teach youth comprehensive sexuality education including regular condom use. Funded research is needed to develop improved diagnosis and management tools as well as a chlamydia vaccine.