Contraception after medication abortion in the United States: results from a cluster randomized trial.

BACKGROUND: Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care. OBJECTIVE: The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients. STUDY DESIGN: This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year. RESULTS: Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28-0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients. CONCLUSION: Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.

Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial.

OBJECTIVES: We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods. METHODS: We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011-2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty. RESULTS: Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance. CONCLUSIONS: Public funding and provider training substantially improve LARC access.

Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial.

BACKGROUND: Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. METHODS: We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. FINDINGS: Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85). INTERPRETATION: The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. FUNDING: William and Flora Hewlett Foundation.

Counseling for IUDs and implants: are health educators and clinicians on the same page?

CONTEXT: Low knowledge of long-acting reversible contraceptives (LARC) and restrictive counseling practices have been documented among contraceptive care clinicians. However, little is known about health educators' counseling on LARC, how their practices compare with clinicians' and their specific training needs. METHODS: A survey conducted in 2011-2012 assessed knowledge and practices related to LARC counseling and provision among 410 staff at 40 Planned Parenthood clinics. Clinicians' and health educators' knowledge and practices were compared via chi-square tests; use of evidence-based criteria was assessed in multivariable logistic regression analyses. RESULTS: At least half of both types of staff routinely discussed LARC with clients, and nearly all considered the methods safe. Health educators considered a smaller proportion of clients candidates for LARC than did clinicians (57% vs. 77%), and they were less likely to consider IUDs for teenagers (79% vs. 96%), nulliparous women (82% vs. 98%) and unmarried clients (90% vs. 99%). In a multivariable model, health educators were less likely than clinicians to counsel clients using the least restrictive evidence-based criteria (odds ratio, 0.1). Sixty-four percent of health educators and 40% of clinicians desired additional LARC training. CONCLUSION: Even in clinics that specialize in reproductive health care, health educators are less likely than clinicians to apply current evidence-based criteria in counseling about LARC. To provide evidence-based contraceptive counseling, health educators need training on LARC eligibility and indications.

Counseling and provision of long-acting reversible contraception in the US: national survey of nurse practitioners.

OBJECTIVE: Nurse practitioners (NPs) provide frontline care in women's health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants. METHOD: A US nationally representative sample of nurse practitioners in primary care and women's health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. RESULTS: Two-thirds of women's health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in women's health and 10% in primary care. Half of NPs desired training in these methods. CONCLUSION: Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Access to levonorgestrel emergency contraception: science versus federal politics.

Past US FDA decisions about emergency contraception (EC) have been subject to undue political influence, and last year's barring of over-the-counter access to Plan B One-Step(®) for those under the age of 17 years is no exception. The US Department of Health and Human Services cited insufficient data on EC use for females aged 11-12 years. These youngest adolescents, however, rarely need EC: data from California (USA) show that in 2009, fewer than one in 10,000 females under the age of 13 years received EC. Maintaining barriers to safe and effective EC is not medically necessary and conflicts with national goals to decrease teenage and unintended pregnancies.

Evidence-based IUD practice: family physicians and obstetrician-gynecologists.

BACKGROUND AND OBJECTIVES: Family physicians and obstetrician-gynecologists provide much of contraceptive care in the United States and have a shared goal in preventing unintended pregnancy among patients. We assessed their competency to offer women contraceptives of the highest efficacy levels. METHODS: We conducted a national probability survey of family physicians and obstetrician-gynecologists (n=1,192). We measured counseling and provision practices of intrauterine contraception and used multivariable regression analysis to evaluate the importance of evidence-based knowledge to contraceptive care. RESULTS: Family physicians reported seeing fewer contraceptive patients per week than did obstetrician-gynecologists and were less likely to report sufficient time for counseling. While 95% of family physicians believed patients were receptive to learning about intrauterine contraception, fewer than half offered counseling or the method. Only half were trained to competence to offer intrauterine contraception, while virtually all obstetrician-gynecologists were. Both family physicians and obstetrician-gynecologists were unlikely to have adequate knowledge of the women who would be good candidates for intrauterine contraception-as gauged by the Centers for Disease Control and Prevention Medical Eligibility Criteria for contraception-and consequently did not offer the method to a wide range of eligible patients. CONCLUSIONS: Most family physicians providing contraceptive care were not offering methods with top-tier effectiveness, although they reported interest in updating contraceptive skills through training. Obstetrician-gynecologists had technical skills to offer intrauterine contraception but still required education on patient selection. Greater hands-on training opportunities for family physicians, and complementary education on eligible method candidates for obstetrician-gynecologists, can increase access to intrauterine contraception by women seeking contraceptive care.

Postabortion contraception: qualitative interviews on counseling and provision of long-acting reversible contraceptive methods.

CONTEXT: Long-acting reversible contraceptive (LARC) methods (IUDs and implants) are the most effective and cost-effective methods for women. Although they are safe to place immediately following an abortion, most clinics do not offer this service, in part because of the increased cost. METHODS: In 2009, telephone interviews were conducted with 20 clinicians and 24 health educators at 25 abortion care practices across the country. A structured topic guide was used to explore general practice characteristics; training, knowledge and attitudes about LARC; and postabortion LARC counseling and provision. Transcripts of the digitally recorded interviews were coded and analyzed using inductive and deductive processes. RESULTS: Respondents were generally positive about the safety and effectiveness of LARC methods; those working in clinics that offered LARC methods immediately postabortion tended to have greater knowledge about LARC than others, and to perceive fewer risks and employ more evidence-based practices. LARC methods often were not included in contraceptive counseling for women at high risk of repeat unintended pregnancy, including young and nulliparous women. Barriers to provision were usually expressed in terms of financial cost--to patients and clinics--and concerns about impact on the smooth flow of clinic procedures. Education and encouragement from professional colleagues regarding LARC, as well as training and adequate reimbursement for devices, were considered critical to changing clinical practice to include immediate postabortion LARC provision. CONCLUSIONS: Despite evidence about the safety and cost-effectiveness of postabortion LARC provision, many clinics are not offering it because of financial and logistical concerns, resulting in missed opportunities for preventing repeat unintended pregnancies.

Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers.

OBJECTIVE: The copper intrauterine device (IUD) is the most effective emergency contraceptive available but is largely ignored in clinical practice. We examined clinicians' recommendations of the copper IUD for emergency contraception in a setting with few cost obstacles. METHODS: We conducted a survey among clinicians (n=1,246; response rate 65%) in a California State family planning program, where U.S. Food and Drug Administration-approved contraceptives are available at no cost to low-income women. We used multivariable logistic regression to measure the association of intrauterine contraceptive training and evidence-based knowledge with having recommended the copper IUD for emergency contraception. RESULTS: The large majority of clinicians (85%) never recommended the copper IUD for emergency contraception, and most (93%) required two or more visits for an IUD insertion. Multivariable analyses showed insertion skills were associated with having recommended the copper IUD for emergency contraception, but the most significant factor was evidence-based knowledge of patient selection for IUD use. Clinicians who viewed a wide range of patients as IUD candidates were twice as likely to have recommended the copper IUD for emergency contraception. Although more than 93% of obstetrician-gynecologists were skilled in inserting the copper IUD, they were no more likely to have recommended it for emergency contraception than other physicians or advance practice clinicians. CONCLUSION: Recommendation of the copper IUD for emergency contraception is rare, despite its high efficacy and long-lasting contraceptive benefits. Recommendation would require clinic flow and scheduling adjustments to allow same-day IUD insertions. Patient-centered and high-quality care for emergency contraception should include a discussion of the most effective method. LEVEL OF EVIDENCE: III.

Addressing global health, economic, and environmental problems through family planning.

Although obstetrician-gynecologists recognize the importance of managing fertility for the reproductive health of individuals, many are not aware of the vital effect they can have on some of the world's most pressing issues. Unintended pregnancy is a key contributor to the rapid population growth that in turn impairs social welfare, hinders economic progress, and exacerbates environmental degradation. An estimated 215 million women in developing countries wish to limit their fertility but do not have access to effective contraception. In the United States, half of all pregnancies are unplanned. Voluntary prevention of unplanned pregnancies is a cost-effective, humane way to limit population growth, slow environmental degradation, and yield other health and welfare benefits. Family planning should be a top priority for our specialty.

Contraceptive policies affect post-abortion provision of long-acting reversible contraception.

BACKGROUND: Placement of long-acting reversible contraceptives (LARC) - intrauterine devices (IUDs) and the implant - directly after an abortion provides immediate contraceptive protection and has been proven safe. STUDY DESIGN: We conducted a survey of National Abortion Federation member facilities (n=326; response rate 75%) to assess post-abortion contraceptive practices. Using multivariable logistic regression, we measured variations in provision of long-acting contraception by clinic factors and state contraceptive laws and policies. RESULTS: The majority (69%) of providers surveyed offered long-acting methods, but fewer offered immediate post-abortion placement of intrauterine devices (36%) or implants (17%). Most patients were provided with contraception; 6.6% chose LARC methods offering the highest level of protection. Post-abortion provision of these methods was lower in stand-alone abortion clinics (p ≤.001), but higher with recent clinician training (p ≤.001) and in the absence of clinic flow barriers (p ≤.001). State policies had a significant impact on how women paid for contraception and the likelihood of LARC use. Patient use was higher in states with contraceptive coverage mandates (p ≤.01) or Medicaid family planning expansion programs (p ≤.05). CONCLUSIONS: Use of the most effective contraceptives immediately post-abortion is rare in the United States. State policies, high cost to patients, and the ongoing need for clinician training in the methods hinder provision and patient uptake. Contraceptive policies are an important component of abortion patient access to the most effective methods.

Population policies, programmes and the environment.

Human consumption is depleting the Earth's natural resources and impairing the capacity of life-supporting ecosystems. Humans have changed ecosystems more rapidly and extensively over the past 50 years than during any other period, primarily to meet increasing demands for food, fresh water, timber, fibre and fuel. Such consumption, together with world population increasing from 2.6 billion in 1950 to 6.8 billion in 2009, are major contributors to environmental damage. Strengthening family-planning services is crucial to slowing population growth, now 78 million annually, and limiting population size to 9.2 billion by 2050. Otherwise, birth rates could remain unchanged, and world population would grow to 11 billion. Of particular concern are the 80 million annual pregnancies (38% of all pregnancies) that are unintended. More than 200 million women in developing countries prefer to delay their pregnancy, or stop bearing children altogether, but rely on traditional, less-effective methods of contraception or use no method because they lack access or face other barriers to using contraception. Family-planning programmes have a successful track record of reducing unintended pregnancies, thereby slowing population growth. An estimated $15 billion per year is needed for family-planning programmes in developing countries and donors should provide at least $5 billion of the total, however, current donor assistance is less than a quarter of this funding target.

Challenges in translating evidence to practice: the provision of intrauterine contraception.

OBJECTIVE: Intrauterine contraception is used by many women worldwide, however, it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California, only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. METHODS: We conducted a survey among physicians, nurse practitioners, and physician assistants (n=1,246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N=816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. RESULTS: Forty percent of providers did not offer intrauterine contraception to contraceptive patients, and 36% infrequently provided counseling, although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision, as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. CONCLUSION: Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women, including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects, including differences between hormonal and nonhormonal devices. LEVEL OF EVIDENCE: III.