Resident and Fellow Perspectives on Family Planning and Building During Training.

Importance: Physicians, especially surgeons, delay family building, and face age-related complications of pregnancy. Objective: To explore factors that are associated with family building decisions among residents and fellows and to understand their thoughts on accessing family building supports, workplace culture, and attitudes toward family planning. Design, Setting, and Participants: This qualitative study was conducted from May to August 2022 at postgraduate training sites across Ontario, Canada. Participants included 29 postgraduate learners. Purposive sampling from 80 eligible trainees was used to ensure diverse demographics, including sex, specialty, and institution. Semi-structured individual interviews lasting 30 to 90 minutes were conducted over a virtual platform. Participants were asked to share their thoughts and experiences on family planning in a medical career, family building goals, the role of mentorship, and knowledge of current family planning supports. Main Outcomes and Measures: Themes associated with residents' perception of family planning within the context of a medical career. Results: Twenty-nine trainees, ages 25 to 37 years old (22 [75.9%] were female, 26 [89.7%] were heterosexual; median [range] age, 30 [25-37] years) from various institutions took part in this study. The participants included both 24 residents (82.8%) and 5 fellows (17.2%) and 8 (27.6%) were from surgical specialties, 3 (10.3%) from pediatrics and subspecialties, 4 (13.8%) from internal medicine and subspecialties, 2 (6.9%) from obstetrics and gynecology, 3 (10.3%) family medicine, 2 (6.9%) from anesthesia, and 7 (24.1%) other medical specialties. Four themes were identified: (1) tension between role as a physician and role as a parent; (2) impact of role models and mentorship on family planning choices; (3) family building is discouraged during training, especially in surgical specialties; and (4) need for tangible family planning supports in training. Conclusions and Relevance: In this qualitative study of residents' and fellows' perspectives on family building, trainees did not perceive residency and fellowship programs as supportive for individuals who want to family build during training leading to personal and professional dissonance. Trainees identified that more tangible supports, transparent information, and mentorship may improve a trainees' feeling of support.

Medical Student Perceptions of Family Planning During Residency Training in Surgical Fields.

INTRODUCTION: Several studies have investigated surgical residents' perceptions of family planning, and many have investigated medical students' perceptions of surgical specialties; however, there is limited research on medical students' perceptions of the impact of family planning on the decision to pursue surgical training. This study aims to investigate male and female medical students' perceptions of family planning in residency. METHODS: A survey was distributed to all medical students at a single medical school in the Midwest between February 2023 and June 2023. The survey was adapted from a prior study investigating resident perceptions of family planning. It included questions about parental leave, having children, and perceived barriers to family planning. RESULTS: One hundred students completed surveys. Seventy-four (74%) respondents identified as female and 57 (57%) were interested in surgery. Approximately half (55, 55%) of the respondents were strongly or definitely considering having children during residency. However, only eight (8%) students were aware of policies applicable to having children during residency. A majority (85, 85%) felt the decision to pursue surgical residency would prevent or delay having children at their preferred time. Most students felt they would be negatively perceived by peers (62, 62%) and faculty (87, 87%) if they had children during training. The highest perceived barriers to having children during training were work-time demands, childcare barriers, and time away from training. CONCLUSIONS: Both men and women are interested in having children during residency but are unaware of the relevant parental leave policies and are concerned about how training will be impacted by taking time away or a lack of flexibility. Without transparency and flexibility in surgical residency, both men and women may forgo having children during training or choose a specialty they perceive to be more conducive to childbearing.

Considerations for the Future: Family Planning and Infertility During Psychiatry Training.

During medical school, residency, or fellowship, many trainees struggle to balance their careers with starting a family. Some may feel the optimal time for parenthood is after completion of training, but the effect of increasing age on fertility is a real consideration for female physicians.1 Several studies have explored the impact of pregnancy and parental leave during surgical residency, yet little has been published on these topics during psychiatry training. This is surprising as psychiatry residents often address the challenges of integrating work and parenthood with their patients, yet it has not traditionally been within the culture of medicine to openly discuss this with colleagues. It is critical to address pregnancy and parenthood routinely during training and in the literature to reiterate the importance of work-life integration. In this article, we discuss current practices for psychiatry residents and advocate for the development of a standardized policy across psychiatry training programs that considers multiple aspects of childbearing including maternal mental health, family leave, and infertility.

Post-pregnancy family planning in Southeast Asia with a focus on novel training techniques.

Postpartum Family Planning is a critical strategy in the first 12 months post-childbirth. It aims to prevent unintended, closely spaced pregnancies and thereby help reducing maternal, neonatal as well as child morbidity and mortality. Despite its significance, many women remain without contraception despite a desire to avoid pregnancy. The World Health Organization suggests a 24-month inter-pregnancy interval after delivery, emphasizing the importance of contraceptive counselling from the antenatal to the immediate postpartum period. In South Asia, utilization of PPFP is minimal, even though the inclination towards birth spacing is high. Addressing these needs requires strengthening the capacity of service providers and promoting evidence-based practices. Novel training approaches in South Asia are Competency-Based On-the-Job Training, Group Based Training, Simulation Training, E-Learning, Mentorship Programs, and Continuing Professional Development. Among these, On-the-Job Training and Group Based Training were notably implemented. Emphasizing PPFP and ensuring proper training in this domain is essential for women's health and well-being post-delivery.

Transparency around abortion training on obstetrics and gynecology residency program websites.

OBJECTIVES: The availability of family planning and abortion training in residency is a concern for applicants, particularly following the overturning of Roe v Wade. We aimed to characterize public information on abortion training in obstetrics and gynecology residency programs in states with and without abortion bans. STUDY DESIGN: We abstracted residency program data using a publicly available database of obstetrics and gynecology residency programs. We performed a systematic internet search of each program's website to identify information on abortion training. We defined states with abortion bans as those with total or near-total bans as of November 2022. Using Stata SE 16, we used Student t tests and Fisher exact tests to characterize differences between programs with public abortion training information and those without. RESULTS: Of 293 obstetrics and gynecology residency programs, 197 (67.2%) included online information regarding abortion training. Of 64 programs in states with abortion bans, 34 (53%) had public information regarding abortion training, compared to 163 (71%) of the 229 programs in states with legal abortion. Programs with publicly available abortion training information were more likely to be academic (49.8% vs 26%, p < 0.001) and have a higher percentage of female residents (86.6% vs 82.9%, p = 0.003). Programs in states with legal abortion were more likely to use words like "abortion" (36.2% vs 17.7%, p = 0.05). CONCLUSIONS: Only two-thirds of obstetrics and gynecology residency programs publicize abortion training information. Almost half of all programs in states with abortion bans do not share this information, revealing a need for improved transparency to better inform residency applicant decision-making. IMPLICATIONS: During the 2022-2023 academic cycle, one-third of obstetrics and gynecology residency programs did not include information about family planning or abortion training online. In states with abortion bans, this number increased to almost one-half. These findings serve as a call to action for programs to clarify their commitment to abortion training.

The impact of cascade training-A FIGO and WHO Department of Sexual and Reproductive Health and Research collaboration to improve access to quality family planning globally.

Globally, there are considerable barriers to accessing safe and effective contraceptive methods. Increased awareness and utilization among obstetricians and gynecologists (OB/GYNs) and allied health professionals of the WHO's tools and guidelines on contraception is a possible avenue to changing this. A cascade-training model, based on regional training-of-trainer workshops followed by national workshops, was used to share key WHO global family planning tools and guidelines among OB/GYNs in 29 countries across three regions-Anglophone Africa, Middle East and Mediterraean, and Francophone West Africa. Monitoring and evaluation was performed through pre- and post-knowledge questionnaires as well as in-depth interviews of key informants before and after the training was instituted. The training increased both participants' knowledge and understanding of the relevant guidelines, as well as their confidence in using them. Qualitative data suggested that this improved in-country clinical practice and influenced national policy through dissemination and engagement with country leadership. The cascade-training model was a practical, locally adaptable means of disseminating up-to-date WHO family planning guidelines and tools. It resulted in sustainable changes in many participating countries, including training curriculum updates, policy changes, and increased government engagement with family planning. Future iterations of the initiative would benefit from additional support for multidisciplinary training.

Exploring Family Planning Perspectives Among Men Receiving Medications for Opioid Use Disorder: Implications for Service Development.

OBJECTIVE: Studies have consistently found high rates of unintended pregnancy among women with substance use disorder. While research efforts have begun to focus on understanding needs and providing family planning services for women in treatment, few studies have included men. This has resulted in a gap in the literature regarding men's reproductive health experiences and family planning desires. METHODOLOGY: Between December 2019 and February 2020, we conducted semistructured qualitative interviews with adult men receiving medications for opioid use disorder at a safety-net healthcare system in Denver, Colorado. Interviews were recorded and analyzed using the Rapid Assessment Process. RESULTS: Fifteen men participated in an interview. Overall, men described feeling excluded from family planning education and services as well as from decision making with their partners. Participants desired knowledge and resources related to contraceptive methods, partner communication, and parenting. Additional themes included loss of autonomy around pregnancy decisions, the importance of fatherhood, and the importance of addressing family planning during recovery. Participants expressed interest in a family planning intervention but indicated that engaging men on this topic may be challenging. CONCLUSIONS: Our findings suggest that men in treatment desire education and involvement in family planning. Participants endorsed access to a subject expert within the treatment environment, but engagement strategies that underscore topic relevance to men will be critical. Initiating a conversation involving education and service navigation in the treatment setting may be a promising strategy for engaging men in recovery in family planning and improving men's access to needed services and resources.

An Evaluation of US Medical Schools' Reproductive Health and Family Planning Curricula.

Background and Objectives: Knowledge and competency in the topics of reproductive health and family planning are important for primary care physicians. Given the high rates of unintended pregnancy, increasing rates of infertility and other gynecologic conditions, it is important for medical students, many of whom will become primary care physicians, to receive good foundational knowledge of reproductive health topics. The objective of this research project was to investigate the current curricula at US medical schools to determine the breadth and extent of education that medical students receive in reproductive health. Methods: Medical students and faculty at 20 US medical schools shared all relevant materials from their required reproductive health curriculum used between 2016-2019, including syllabi, PowerPoint lectures, and official class handouts that were available to all students. From these, the number of mentions of 69 reproductive health-related terms were counted, including those related to family planning methods, abortion, ectopic pregnancy, reproductive counseling, and infertility. Results: Of the over 9000 mentions of reproductive health terms, approximately half of mentions were related to family planning, with 10% related to abortion, 10% to infertility, and 6% to reproductive counseling. Family planning strategies emphasized oral contraceptives and long-acting reversible contraceptives with limited mentions of natural or fertility awareness-based methods. Conclusions: This data demonstrates opportunities for broadening reproductive health education in medical school so that future primary care physicians are prepared to discuss the full range of reproductive options for their patients.

Pregnancy Risk Screening and Counseling for Women Veterans: Piloting the One Key Question in the Veterans Healthcare Administration.

OBJECTIVES: Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah. METHODS: We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits. RESULTS: Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling. CONCLUSIONS: Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.

Preferences for family planning education among men and women in rural, highly religious Tanzanian communities: a discrete choice experiment.

Unmet need for family planning (FP) remains prevalent worldwide. In Tanzania, 21.7% of women desire to delay pregnancy, but do not use modern contraception despite its free availability at local clinics. Our prior data suggest that this is related to complex gender and religious dynamics in rural communities. To understand how education about FP could be improved, we developed a discrete choice experiment (DCE) to rank preferences of six attributes of FP education. Results were stratified by gender. Sixty-eight women and 76 men completed interview-assisted DCEs. Participants significantly preferred education by a clinician (men = 0.62, p < .001; women = 0.38, p < .001) and education in mixed-gender groups (men = 0.55, p < .001; women = 0.26, p < .001). Women also significantly preferred education by a religious leader (0.26, p = .012), in a clinic versus church, mosque, or community centre (0.31, p = .002), and by a female educator (0.12, p = .019). Men significantly preferred a male educator (0.17, p = .015), whom they had never met (0.25, p < .001), and educating married and unmarried people separately (0.22, p = .002). Qualitative data indicate women who had not previously used contraception preferred education led by a religious leader in a church or mosque. FP education tailored to these preferences may reach a broader audience, dispel misconceptions about FP and ultimately decrease unmet need.

Quality of family planning services for women of reproductive age in Lao PDR.

BACKGROUND: In Lao PDR, 15% of the married women want to postpone or prevent having a child, yet most are not using contraceptives to achieve this. Literature shows that usage of contraceptives is strongly dependent on the quality of family planning services. However, little is known about the quality of family planning services in Lao PDR. OBJECTIVE: To assess the quality of family planning services provided in public health facilities in Lao PDR. METHODS: Using a cross-sectional study design, public health facilities in three provinces in Lao PDR were assessed on structure, process and outcome measures of quality. Following the Quick Investigation of Quality approach, client exit interviews (n = 393), structured observations (n = 218) and facility audits (n = 17) were conducted. RESULTS: Facility audits, observations and client exit interviews painted different pictures of the overall quality of family planning services. Taking all together, the quality was rated as moderate to high. Only marginal differences in quality were found between family planning services located in different geographical areas. Notably, only married women with children were using these services. Although contraceptives were provided, little attention was given to the information provided during consultations and to the interpersonal relationship between client and provider. CONCLUSION: The results suggest that although improvements are needed to enhance quality of individual consultations, the greatest gain in reducing unwanted pregnancies would be made by ensuring access for all women of reproductive age.

College students responding to the Chinese version of Cardiff fertility knowledge scale show deficiencies in their awareness: a cross-sectional survey in Hunan, China.

BACKGROUND: Fertility knowledge is vital to the fertility health of young people and greatly impacts their fertility choices. Delayed childbearing has been increasing in high-income countries, accompanied by the risk of involuntary childlessness or having fewer children than desired. The aim of this study was to investigate knowledge about fertility issues, the related influencing factors, the method of acquiring fertility knowledge, and the relationship between fertility knowledge and fertility intentions among college students. METHODS: An online cross-sectional survey of Chinese college students was conducted in Hunan Province from March to April 2018. A total of 867 college students from three comprehensive universities responded to a poster invitation utilizing the Chinese version of the Cardiff Fertility Knowledge Scale (CFKS-C). Data were explored and analysed by SPSS (version 22.0) software. Descriptive statistics, chi-squared tests, T-tests, and Pearson's correlations were used for the measurements. RESULTS: The average percent-correct score on the CFKS-C was 49.9% (SD = 20.8), with greater knowledge significantly related to living in a city district, being not single status, majoring in medicine, being in year 4 or above of study, and intention to have children (all p<0.05). A total of 81.9% of the participants reported that they would like to have children, the average score of the importance of childbearing was 6.3 (SD = 2.7), and the female score was lower than the male score (p = 0.001). A small positive relationship was observed between the CFKS-C and the importance of childbearing (r = 0.074, p = 0.035). Respondents indicated that they gained most of their knowledge from the media and internet (41.4%) and from schools (38.2%). CONCLUSION: Yong people in college have a modest level of fertility knowledge, a relatively low intention to have a child, and deficiencies in fertility health education. There is a need to improve the accessibility of fertility health services by developing a scientific and reliable fertility health promotion strategy.

Family planning training at Catholic and other religious hospitals: a national survey.

BACKGROUND: Catholic and other faith-based hospitals often restrict family planning service provision based on institutional doctrine. Approximately 11% of US accredited obstetrics and gynecology residency programs occur at such hospitals, creating a challenge to educational leaders who must ensure comprehensive family planning training. OBJECTIVE: To evaluate and summarize family planning training at obstetrics and gynecology residency programs that are affiliated with Catholic and other faith-based hospitals that restrict reproductive services. MATERIALS AND METHODS: Using an online database search and survey screening questions, we identified 30 of 278 accredited 2017-2018 programs in which at least 70% of resident time is spent in faith-based hospitals that restrict family planning services; Jewish programs were excluded. We queried program leaders between March 2017 and April 2018 about education and training using an online or paper survey, and asked them to report on training settings, provision of family planning services in such settings, and to rate aspects of training as "poor," "adequate," or "strong." We compared responses at Catholic versus other faith-based programs using Fisher exact tests, χ2 analyses, and median tests. RESULTS: Among 30 programs, 25 responded (83%); the majority of respondents were program directors (88%) and represented Catholic hospitals (76%). All reported adequate contraceptive training, with 47% of Catholic programs relying on off-site locations. The majority of Catholic sites (84%) relied on off-site sterilization training sites. Survey respondents from Catholic programs most commonly endorsed concerns for inadequate training in postpartum tubal ligations (53% of Catholic respondents versus 0% of other faith-based program respondents, P = .05). Approximately one-half (56%) offered abortion training as part of the curriculum ("routine"), 32% offered residents the opportunity to arrange training ("elective"), and 12% did not offer; the majority (84%) relied on off-site collaborations. Catholic sites were more likely than other religious programs to report poor abortion training (47% versus 0%, P = .04). Five Catholic programs (26% of Catholic programs) reported that their residents did not meet the graduate training requirement for completion of 20 dilation and curettage procedures. One-third reported a prior Residency Review Committee family planning citation(s), and many commented that these citations helped provide leverage for improved training. CONCLUSION: Although Catholic and other restrictive, faith-based obstetrics and gynecology residency training programs have developed strategies in response to institutional restrictions, many report ongoing deficiencies, and almost one-half reported they were noncompliant with abortion training requirements. Programs with deficient trainings may benefit from strategic approaches, including enhanced onsite education and collaborations with off-site facilities.

Emergency contraception in Jordan: Assessing retail pharmacists' awareness, opinions, and perceptions of need.

OBJECTIVES: Jordan has a robust contraceptive method mix in both the public and private sectors and oral contraceptive pills and the copper-T intrauterine device are widely available. However, Jordan remains one of only a few countries in the world without a registered dedicated product for emergency contraception (EC). We aimed to explore retail pharmacists' knowledge of and attitudes toward EC in six Jordanian governorates. STUDY DESIGN: In 2016, we conducted 100 structured interviews with pharmacists in both urban and rural areas regarding their EC knowledge and provision practices. We interviewed representatives from both chain and independently-owned pharmacies in purposively selected areas of the country. We analyzed interviews for content and themes using deductive and inductive techniques. RESULTS: Our findings reveal a lack of knowledge of all EC modalities as well as misinformation about effectiveness and protocols for use. However, after describing dedicated progestin-only EC pills, study participants expressed tremendous enthusiasm for a dedicated product and the overwhelming majority indicated that they would stock EC pills if and when they were registered. CONCLUSION: The private sector plays a major role in contraceptive service delivery in Jordan. Although pharmacists are not well-versed in post-coital contraception they appear interested in incorporating EC pills into the contraceptive method mix. Redoubling efforts to register a dedicated progestin-only EC pill and supporting initiatives to educate pharmacists about how to use available technologies as EC appear warranted. IMPLICATIONS: Lack of access to emergency contraception has significant implications for women, in general, and refugee and displaced populations in particular. Supporting efforts to incorporate EC pills into the contraceptive mix in Jordan is a first step in supporting adherence to global standards of care and could help address unmet contraceptive needs.

Obstetrics-gynecology resident long-acting reversible contraception training: the role of resident and program characteristics.

BACKGROUND: Obstetrics-gynecology residents should graduate with competence in comprehensive contraceptive care, including long-acting reversible contraception. Lack of hands-on training and deficits in provider education are barriers to long-acting reversible contraception access. Identifying the number of long-acting reversible contraception insertions performed by obstetrics-gynecology residents could provide insight into the depth and breadth of long-acting reversible contraception training available to obstetrics-gynecology residents in Accreditation Council for Graduate Medical Education-accredited residency programs. OBJECTIVE: Our study investigates long-acting reversible contraception-specific training in obstetrics-gynecology residency programs across the United States, including the self-reported number of long-acting reversible contraception insertions per resident and the impact of resident demographic characteristics and residency program characteristics on training. STUDY DESIGN: Obstetrics-gynecology residents completed a voluntary electronic survey during the 2016 Council on Resident Education in Obstetrics and Gynecology examination. The survey included resident demographic characteristics and residency program characteristics as well as resident education and training in long-acting reversible contraception (number of intrauterine devices and implants inserted, training in immediate postpartum intrauterine device placement). A binary "long-acting reversible contraception insertion experience" variable dichotomized respondents as having a low level of long-acting reversible contraception insertions (0 implants and/or 10 or fewer intrauterine devices ) or a high level of long-acting reversible contraception insertions (1 or more implants and/or 11 or more intrauterine devices). χ2 tests were used to compare the presence of long-acting reversible contraception insertion experience by postgraduate year, resident demographic characteristics, and residency program characteristics. Adjusted logistic regression was performed to ascertain the independent effects of gender, race/ethnicity (non-Hispanic white vs other), residency program type (university vs community), and residency program geographic region on the likelihood of "low" overall long-acting reversible contraception insertion experience. RESULTS: In total, 5055 obstetrics-gynecology residents completed the survey (85%); analysis included only residents in United States obstetrics-gynecology programs (N=4322). Of the total analytic sample, 1777 (41.2%) had low long-acting reversible contraception insertion experience. As expected, the number of intrauterine device insertions, implant insertions, and overall long-acting reversible contraception experience increased as residents progressed through training. Long-acting reversible contraception insertion experience varied by residency program geographic region: 169 (27.1%) residents in programs in the West had low long-acting reversible contraception insertion experience compared with 498 (39.0%) in the South, 473 (45.3%) in the Midwest, and 615 (46.0%) in the Northeast. Only 152 (14.9%) of all postgraduate year 4 residents had low long-acting reversible contraception insertion experience. Among postgraduate year 4 residents, low long-acting reversible contraception insertion experience was significantly associated racial/ethnic minority status and community-based residency program type (compared with university-based). Postgraduate year 4 residents in programs located in the Northeast and Midwest had 4.25 (95% confidence interval, 2.04-8.85) and 2.75 (95% confidence interval, 1.27-5.97) times the odds of low long-acting reversible contraception experience compared with those in residency programs in the West, even after adjusting for other respondent characteristics and other residency program characteristics. CONCLUSION: Obstetrics-gynecology residents experience a range of long-acting reversible contraception training and insertions, which differed according to resident race/ethnicity and residency program characteristics (program type and geographic region). Residency programs with low long-acting reversible contraception training experience should consider opportunities to improve competence in this fundamental obstetrics-gynecology skill.

Physician perspectives on routine pregnancy intention screening and counseling in primary care.

OBJECTIVES: To assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative. STUDY DESIGN: We conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year. RESULTS: In this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians. CONCLUSIONS: Most responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success. IMPLICATIONS STATEMENT: Responding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.

Increasing long-acting reversible contraceptives: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomized trial.

BACKGROUND: Long-active reversible contraceptives reduce unintended pregnancy and abortions, but uptake is low. Interventions to increase uptake in family medicine settings are untested. OBJECTIVE: The Australian Contraceptive ChOice pRoject, which was adapted from the successful US Contraceptive CHOICE study, aimed to evaluate whether a complex intervention in family medicine practices resulted in increased long-active reversible contraceptive uptake. STUDY DESIGN: This cluster randomized controlled trial was set in family practices in metropolitan Melbourne, Australia. From April 2016 to January 2017, we recruited 57 family physicians by mail invitation. Each family physician aimed to recruit at least 14 female patients. Eligible family physicians worked ≥3 sessions per week in computerized practices. Eligible women were English-speaking, sexually active, not pregnant, not planning a pregnancy in the next year, 16-45 years old, and interested in discussing contraception or in starting a new, reversible method. With the use of a randomization sequence with permuted blocks that were stratified by whether the family physician performed long-active reversible contraceptive insertion or not, family physicians were assigned randomly to a complex intervention that involved training to provide structured effectiveness-based contraceptive counselling and access to rapid referral to long-active reversible contraceptive insertion clinics. The 6-hour, online educational intervention was based on the US Contraceptive CHOICE Project and adapted for the Australian context. The control family physicians received neither the educational intervention nor access to the long-active reversible contraceptive rapid referral clinics and conducted their usual contraception counselling. We used the chi-square test, which was adjusted for clustering and stratification by whether the family physician inserted long-active reversible contraceptives, and binary regression models with generalized estimating equations and robust standard errors to compare, between the intervention and control groups, the proportions of women who had a long-active reversible contraceptive inserted. The primary outcome was the proportion of women with long-active reversible contraceptives that were inserted at 4 weeks. Secondary outcomes included women's choice of contraceptive method, quality of life, and long-active reversible contraceptive use at 6 and 12 months. Analyses were performed according to intention-to-treat. RESULTS: A total of 25 intervention and 32 control family physicians recruited 307 and 433 women, respectively (N=740). Within 4 weeks, 19.3% of women in the intervention group and 12.9% of women in the control group had long-active reversible contraceptive inserted (relative risk, 2.0; 95% confidence interval, 1.1-3.9; P=.033). By 6 months, this number had risen to 44.4% and 29.3%, respectively (relative risk, 1.6; 95% confidence interval, 1.2-2.17; P=.001); by 12 months, it had risen to 46.6% and 32.8%, respectively (relative risk, 1.5; 95% confidence interval, 1.2-2.0; P=.0015). The levonorgestrel intrauterine system was the most commonly chosen long-active reversible contraceptive by women in the intervention group at all time points. Differences between intervention and control groups in mean quality-of-life scores across all domains at 6 and 12 months were small. CONCLUSION: A complex intervention combination of family physician training on contraceptive effectiveness counselling and rapid access to long-active reversible contraceptive insertion clinics resulted in greater long-active reversible contraceptive uptake and has the potential to reduce unintended pregnancies.