Regional variation in health care substitution for intrauterine device insertion: a retrospective cohort study.

BACKGROUND: Rising health care costs are a major concern in most Western countries. The substitution of healthcare stands as a strategic approach aimed at mitigating costs while offering medical services in proximity to patients' residences. An illustrative instance involves the migration of outpatient hospital care to primary care settings. Notably, the insertion of intrauterine devices (IUDs) can be safely executed within primary care contexts. In order to establish a pragmatic objective for the rate of IUD substitution, we conducted an evaluation of regional disparities in healthcare substitution pertaining to the insertion of intrauterine devices. Furthermore, we investigated disparities in the follow-up ultrasound and reinsertion of IUDs between primary and secondary healthcare environments. METHODS: All women who underwent IUD insertion in Dutch primary care (by general practitioners and midwives) and secondary care (by hospital physicians) between January 1, 2016, and December 31, 2020 were included. The main outcome measures were the case-mix adjusted IUD insertion rates at the regional level by care setting and the proportions requiring follow-up ultrasound and IUD reinsertion within three months. RESULTS: Of the 840,766 IUD placements, 74% were inserted in primary care and 26% in secondary care. The proportion inserted in primary care increased from 70% in 2016 to 77% in 2020. The observed substitution rate ranged from 58 to 82% between regions. Compared with health care professionals in primary care, those in secondary care performed more ultrasounds to verify IUD placement (23% vs. 3%; p-value < 0.01) and more IUD reinsertions within three months (6% vs. 2%; p-value < 0.01). CONCLUSIONS: IUDs are increasingly being inserted in Dutch primary care, with peak regional IUD insertion care substitution rates at ≥ 80%. IUD insertion care substitution to primary care appears to be associated with significantly fewer women having follow-up ultrasound or IUD reinsertion within three months.

Expanding access to postpartum contraception.

PURPOSE OF REVIEW: Women are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field. RECENT FINDINGS: Current models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness. SUMMARY: Antenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid.

PURPOSE: Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation. METHODS: This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018. RESULTS: Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001). DISCUSSION: We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.

Efficacy of intrauterine device procedural analgesics.

ABSTRACT: Nearly half of all pregnancies worldwide are unintended. Intrauterine devices are an effective, long-acting form of pregnancy prevention that require minimal maintenance, and also can be used in patients with menorrhagia. However, they are underused because of pain associated with their insertion. Topical and local anesthesia are good options for reducing procedural pain in select patients. IUD placement falls within the scope of practice for physician associates/assistants (PAs) practicing in family medicine, internal medicine, and women's health. PAs should be aware of these additional analgesia options available to patients in order to increase use of effective contraception.

Expanding Access to Contraceptive Services in a Family Medicine Residency Clinic: The Rapid Access to Contraception Clinic Model.

BACKGROUND AND OBJECTIVES: Learning to provide long-acting reversible contraception (LARC) during family medicine residency is an important step in building capacity for the primary care workforce to meet the reproductive health care needs of communities. We aimed to measure the impact of adding a contraceptive visit type (CVT) allowing for rapid access to contraception (RAC) on family medicine resident LARC procedure numbers. METHODS: Our program created a CVT in which patients were seen only for contraceptive services. We added the CVT to third-year family medicine resident continuity clinic schedules and a block of CVTs (the RAC clinic) to the third-year gynecology rotation. Residents self-reported LARC procedure numbers performed throughout residency, and the totals were compared for graduating residents from 2023 (post-RAC cohort) to 2022 graduates and 2018-2022 graduates (pre-RAC cohort). RESULTS: Post-RAC cohort residents reported a statistically significant increase in intrauterine device (IUD; P=.015) and contraceptive implant (P=.010) removals compared to the 2022 pre-RAC cohort. Insertions of IUDs and contraceptive implants were unchanged when compared to the pre-RAC cohort. IUD removals (P=.004) and insertions (P=.034), and contraceptive implant removals (P=.028) were significantly increased for post-RAC compared to 2022 graduates, with no difference in contraceptive implant insertions (P=.211). CONCLUSIONS: The addition of the CVT and RAC clinic contributed to an increase in LARC removals in both comparisons, and IUD insertions between 2022 and 2023. This clinic model offers an opportunity for other family medicine residency programs to improve access to contraceptive services and increase resident training in LARC management.

Colonoscopic removal of an intrauterine device with rectal perforation: A case report.

RATIONALE: The intrauterine device is one of the effective, safe, convenient, economical, and reversible contraceptive methods. Although its contraceptive effect is definite, some female patients may experience complications such as expulsion, bleeding, and pregnancy with the device in place. Rectal perforation is one of the rare and serious complications, which can lead to complications such as abdominal infection and intestinal adhesions, severely affecting the quality of life of patients. PATIENT CONCERNS: A 34-year-old female was sent to the Department of Gastroenterology with noticeable left lower quadrant abdominal pain. She had presented with abdominal discomfort and anal tenesmus 1 year earlier. Two months ago, her abdominal pain had gradually worsened and she was presented to our hospital. DIAGNOSES: Investigations, including colonoscopy and computed tomography scan, had revealed an intrauterine device migrated and perforated into the rectum. INTERVENTIONS AND OUTCOMES: The patient underwent successful colonoscopic removal of the intrauterine device. She recovered well after the treatment. LESSONS: This case proves that endoscopic therapy can be considered the preferred method for removing intrauterine devices displaced into the digestive tract lumen.

Ease of removal of malpositioned intrauterine devices: A retrospective cohort study.

OBJECTIVE: This study aimed to compare removal timing, techniques, and success of malpositioned intrauterine device (IUDs) to nonmalpositioned IUDs. STUDY DESIGN: We performed a retrospective cohort study of IUD users with ultrasound performed between July 2014 and July 2017 within one medical system. We used Fisher exact and Wilcoxon rank-sum tests to compare clinical characteristics and IUD removal details between patients with malpositioned and nonmalpositioned IUDs. RESULTS: Of 1759 ultrasounds reporting the presence of an IUD, 436 described IUD malposition. Of these, 150 described the IUD as embedded and 16 as partially perforated. IUDs were more likely to be removed and removed sooner for patients with malpositioned compared with nonmalpositioned IUDs (281/436 vs 545/1323, p < 0.001 and median 17 days vs 236 days from the index ultrasound, p < 0.001). Most IUDs, malpositioned and nonmalpositioned, were removed on the first attempt (82%, 85%), by a generalist obstetrician and gynecologist (75%, 70%), using a ring forceps (73%, 65%). Most embedded and partially perforated IUDs were removed (68%, 69%), using a ring forceps (59%, 67%), on the first attempt (84%, 91%). CONCLUSIONS: Malpositioned IUDs were more likely to be removed and removed sooner than nonmalpositioned IUDs. Most IUDs, even IUDs labeled as partially perforated or embedded, were removed by a generalist obstetrician and gynecologist, using ring forceps, on first attempt. IMPLICATIONS: Ultrasound findings of IUD malposition are not associated with difficult IUD removal.

Patient Preferences for Immediate Compared With Delayed Postpartum Intrauterine Device Placement.

OBJECTIVE: To use choice-based conjoint survey methodology to evaluate patient values and decision making regarding immediate compared with delayed placement of postpartum intrauterine devices (IUDs). METHODS: We conducted a cross-sectional study in which we surveyed 200 nonpregnant, parous patients. Participants chose between hypothetical postpartum IUDs varying in multiple attributes (hormonal or nonhormonal IUD type, placement timing, 1-year efficacy, expulsion risk, risk of lost strings, and malposition risk). The primary outcome was preference for immediate compared with delayed postpartum IUD placement and importance of placement timing relative to other attributes. Secondarily, we evaluated whether demographic and neighborhood characteristics were associated with timing preference and attribute importance. RESULTS: We included 190 participants for analysis. Most participants (62.6%) preferred delayed placement. There was no significant difference in timing preference by race ( P =.28) or block-level Area Deprivation Index score ( P =.27). Patients who preferred immediate placement were more likely to have public insurance than private insurance (70.4% vs 29.6%, P =.04); however, the majority of patients (55.1%) with public insurance still preferred delayed placement. Attributes of IUD type, malposition risk, 1-year efficacy, and expulsion risk all had greater effects on patient decision making than placement timing. There was no difference in attribute importance by race ( P =.30), Area Deprivation Index score ( P =.88), or insurance type ( P =.22). CONCLUSION: Patients preferred the higher efficacy and lower complication rates of delayed postpartum IUD placement over the convenience of immediate placement. Insurance considerations may affect these timing preferences. There was no difference in attribute importance between demographic groups or based on neighborhood-level factors, indicating that, although both immediate and delayed postpartum IUD placement should be offered, counseling should not vary according to individual demographic characteristics.

One-year continuation of postpartum intrauterine contraceptive device: Findings from a prospective cohort study in India.

OBJECTIVE(S): To estimate continuation rates for postpartum intrauterine contraceptive device (PPIUD) at 6 weeks, 6 months and 1-year within existing programs in an under-resourced setting, and to identify determinants of discontinuation, removal and expulsion. STUDY DESIGN: We used a prospective cohort design and enrolled recent PPIUD adopter women across 100 public healthcare facilities in Odisha and Chhattisgarh, India. We collected their socio-demographic information and followed them up telephonically at 6 weeks, 6 months and 1 year for complications and continuation status. We assessed PPIUD continuation rates and factors associated with PPIUD discontinuation, removal, and expulsion using Cox proportional hazards modelling. RESULTS: We enrolled 916 participants (579 (63.2%) from Odisha and 337 (36.8%) from Chhattisgarh). The continuation rate of PPIUD was 88.7% at 6 weeks, 74.8% at 6 months 60.1% at one year. Once discontinued, chances of not opting for any family planning method was high (up to 81.2%). Participants with education of 6th to 12th class and those experiencing complications (pain abdomen, bleeding and discharge per vaginum) were more likely to remove the IUD with adjusted hazard ratio of 1.82 (95% CI: 1.18-2.79) and 4.39 (95% CI: 3.25-5.93) respectively. For expulsion, we did not find any factor that was statistically significant. CONCLUSION(S): PPIUD continuation rates declined considerably after the initial 6 weeks. Counselling and follow-up services for managing complications must be strengthened, especially in the first 6 weeks of PPIUD insertion, to enhance and sustain programmatic impact. IMPLICATIONS: Our findings emphasize on the need to strengthen client counseling and follow-up for management of complications, especially in the first 6 weeks of insertion of PPIUDs. Ongoing programs need to address comprehensive capacity building efforts in this regard.

Choice and factors associated to the use of contraceptive methods among postpartum women: A prospective cohort study.

OBJECTIVES: To assess women's contraceptive preferences in the immediate postpartum period and identify factors associated with use of their desired contraceptive method six months later. MATERIAL AND METHODS: This prospective cohort study included women ≤48 h after delivery at a single public Brazilian hospital. The women's interview took place in two different momentsbefore hospital discharge (in-person interview) and six months after delivery (by telephone contact). For data collection and management, we used the REDCap electronic tool. Univariate and multivariate analyses (unadjusted and adjusted Odds Ratio and 95 % confidence intervals) were used to identify factors associated with higher use of their desired contraceptive method six months after delivery. RESULTS: A total of 294 women (166 adolescents) were included. Initial contraceptive preferences were especially intrauterine devices (IUDs) (39.1 %), implants (33.0 %) and injectable hormonal contraceptives (17.0 %). Six months later, 42.5 % (n = 125) were using their desired contraceptive method. Younger age, white race and contraceptive initiation prior to hospital discharge were associated with use of their desired contraceptive at six months. CONCLUSION: Long-acting reversible contraception (LARC) methods were the most desired contraceptives among women after delivery. Providing and initiating free contraception prior to discharge from a birthing unit is important with regard to use of their desired method.

Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis.

This article aims to report the comprehensive and up-to-date analysis and evidence of the insertion rate, expulsion rate, removal rate, and utilization rate of immediate placement of intrauterine devices (IUDs) versus delayed placement after artificial abortion. PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang databases were comprehensively searched up to January 12, 2024 for studies that compared immediate versus delayed insertion of IUDs after abortion. The evaluation metrics included the number of IUD insertion after surgical or medical abortions, the frequency of expulsion and removal at 6 months or 1 year, the number of continued usage, pain intensity scores, the number of infections, the duration of bleeding, and instances of uterine perforation during or after IUD insertion. Ten randomized controlled articles were eligible, comprising 11 research projects, of which 3 projects involved the placement of an IUD after surgical abortion, and 8 projects involved the placement of an IUD after medical abortion. This included 2025 patients (977 in the immediate insertion group and 1,048 in the delayed insertion group). We summarized all the extracted evidence. The meta-analysis results indicated that for post-surgical abortions, the immediate insertion group exhibited a higher IUD placement rate than the delayed insertion group. After medical abortions, the immediate insertion group showed higher rates of IUD placement, utilization, and expulsion at 6 months or 1 year. The two groups showed no statistically significant differences in the removal rate, post-insertion infection rate, pain scores during insertion, and days of bleeding during the follow-up period. Compared to delayed placement, immediate insertion of IUDs can not only increase the usage rate at 6 months or 1 year but also enhance the placement rate.

Permanent and long-acting reversible contraception volumes at a multihospital system in Ohio before and after Dobbs.

OBJECTIVES: Immediately following the Dobbs decision, Ohio prohibited abortion after the detection of fetal cardiac activity. We aimed to characterize changes in the uptake of long-acting reversible contraception (LARC) and permanent contraception following the abrupt enactment of restrictive abortion legislation. STUDY DESIGN: We conducted a retrospective cohort study using electronic medical record data of patients aged 15 to 55 who underwent permanent contraception (tubal ligation, vasectomy) or LARC placement (intrauterine device, contraceptive implant) at a multihospital system in northeast Ohio from January 1, 2022 to Decemeber 31, 2022, 6 months before and after Dobbs. We compared procedure volumes and patient characteristics. RESULTS: We identified 4247 tubal ligation and LARC procedures pre-Dobbs, including 725 (17.1%) permanent contraception and 3522 (82.9%) LARC. Post-Dobbs, the total number of tubal ligation and LARC procedures increased by 15.8% (4916), and there was a significant increase in the proportion of permanent contraception, (p < 0.001). Vasectomy volume increased by 33.3% post-Dobbs, from 1193 to 1590 procedures. Compared to pre-Dobbs, patients undergoing contraceptive procedures post-Dobbs were younger (tubal ligation and LARC, 30.9 median years [24.5, 36.8] vs 31.5 [25.2, 36.9], p = 0.011; vasectomy, median 36.6 years [32.9, 39.6] vs 37.2 [34.2, 40.4], p < 0.001) and more likely to report single relationship status (57.4% vs 55.9% for tubal ligation and LARC, p = 0.028% and 23.0% vs 18.1% for vasectomy, p = 0.002). CONCLUSIONS: This study demonstrates increased uptake of contraceptive procedures following the Dobbs decision. This rise in permanent contraception suggests a relationship between abortion policy and contraceptive decision-making, especially among younger patients. IMPLICATIONS: Increased permanent and long-acting reversible contraception procedures following Dobbs reveal shifting contraceptive choices, particularly among younger individuals, indicating a connection between abortion policy and reproductive decisions.

Contraceptive uptake among gender-expansive individuals in the HER Salt Lake Contraceptive Initiative.

OBJECTIVES: We examined differences in contraceptive uptake and discontinuation between gender-expansive individuals and cis-women in the HER Salt Lake Contraceptive Initiative. STUDY DESIGN: We used self-reported survey data to assess associations between gender identity, contraceptive uptake, and discontinuation. RESULTS: Of participants (n = 4289), 178/4289 (4%) identified as gender-expansive with 157/178 (88%) reporting recent sexual activity with men. Selection of IUD or Implant was most common, with 109/178 (61%) of gender-expansive individuals choosing these options. We observed similar methods selected (p = 0.2) and discontinuation rates at three years between participants (OR: 0.93, p = 0.8). CONCLUSION: Gender-expansive individuals had similar method selection and discontinuation rates as cis-women. IMPLICATIONS: Our finding of no difference in the uptake of contraception between cis-women and gender-expansive individuals should empower providers to openly discuss contraception with patients regardless of gender identity.

Couple-Years of Protection Indicator: New Global Guidance for Updating Existing Methods and Adding New Methods.

BACKGROUND: Couple-years of protection (CYP) is an indicator that allows for monitoring and evaluating of family planning (FP) program performance through simple calculations. The CYP for each contraceptive method is calculated by multiplying the number of contraceptive commodity units distributed to clients over a 1-year period by a conversion factor that quantifies the duration of contraceptive protection provided per unit distributed. CYP calculations across methods were previously updated in 2000 and 2011, resulting in changes in methodology, factor inclusion, and specific methods. Since the 2011 update, changes and additions to the modern contraceptive method mix required new CYP conversion factors for 4 methods of contraception: Levoplant implant, progestin-only pills (POPs), Caya diaphragm, and the hormonal intrauterine device. METHODS: We conducted literature reviews of both published and gray literature and consulted with experts to identify updated data on continuation rates, duration of efficacy, and method effectiveness for the 4 methods. New CYP conversion factors were calculated for the 4 methods either by using the same calculation used previously for the method considering new data or, for new methods, using calculations for similar methods. RESULTS: New CYP conversion factors were assigned to the 4 methods of contraception covered in this update: Levoplant, 2.5 CYP per implant inserted; POPs, 0.0833 CYP per pack (i.e., 12 cycles per CYP); Caya diaphragm, 1 CYP per device, and hormonal intrauterine device, 4.8 CYP per device inserted. CONCLUSIONS: CYP is an important indicator for FP programs. As new methods of contraception are developed and new evidence is generated for current methods, the indicator may need to be updated. A standard process for updating and documenting future CYP updates is recommended.

IUD Insertion Under Conscious Sedation: Patient Characteristics with Clinical Decisions.

STUDY OBJECTIVE: Uptake of intrauterine devices (IUDs) in the adolescent population may be limited by anxiety and pain anticipated during the insertion procedure. Our institution offers conscious sedation for IUD insertion to mitigate this concern. The objective of this study was to identify characteristics and outcomes of teens choosing between two types of conscious sedation for insertion of a levonorgestrel IUD. METHODS: This was a single-site, retrospective cohort study over a one year period, reviewing the electronic medical records of patients who had undergone an attempted IUD insertion using conscious sedation. Conscious sedation included nitrous gas (termed "light" sedation) or intravenous midazolam and fentanyl (termed "moderate" sedation). Patient demographic characteristics and medical and gynecological histories were analyzed. RESULTS: There were 69 attempted IUD insertions during the study period. Most patients (75.36%) were placed under light sedation, and 92.75% were successfully inserted. The only significant factor associated with choice in the type of conscious sedation was previous sexual activity, which increased the odds by 10.0 that the patient would choose light sedation (95% CI, 1.23-81.34; P = 0.031). Differences between other factors (age, history of sexual assault, tampon use, and gender identity) were not statistically significant between successful and failed insertions. CONCLUSION: In conclusion, history of sexual activity significantly differed between patients in our cohort who selected light sedation over moderate sedation. No other factors influenced the choice in sedative or success of IUD insertion. Knowing the characteristics of patients who choose nitrous versus intravenous sedation, and how it relates to successful insertion, may help guide pre-procedural counseling for patients regarding sedation for IUD insertion.

Effects of Hormonal Contraception and the Menstrual Cycle on Fatigability and Recovery From an Anaerobic Exercise Test.

ABSTRACT: Cabre, HE, Ladan, AN, Moore, SR, Joniak, KE, Blue, MNM, Pietrosimone, BG, Hackney, AC, and Smith-Ryan, AE. Effects of hormonal contraception and the menstrual cycle on fatigability and recovery from an anaerobic exercise test. J Strength Cond Res 38(7): 1256-1265, 2024-This study sought to evaluate the effects of oral contraceptive (OC) and hormonal intrauterine device (H-IUD) use, compared with a eumenorrheic (EUM) cycle, on fatigability and recovery between hormone the phases. Peak power (PP), average power (AP), fatigue index (FI), blood lactate, vessel diameter, and blood flow (BF) were measured from a repeated sprint cycle test (10 × 6 seconds) in 60, healthy, active women (mean ± SD ; age: 26.5 ± 7.0 years, BMI: 22.5 ± 3.7 kg·m -2 ) who used monophasic OC (≥6 months; n = 21), had a H-IUD (≥6 months; n = 20), or had regular naturally occurring menstrual cycle (≥3 months) or had a nonhormonal IUD (EUM; n = 19). Subjects were randomly assigned to begin in either the low-hormone phase (LHP) or high-hormone phase (HHP) and were tested once in each phase. Separate univariate analyses of covariances assessed the change from HHP to LHP between the groups, covaried for progesterone, with significance set at p ≤ 0.05. All groups demonstrated similar changes in PP, AP, FI, blood lactate, vessel diameter, and BF between the phases ( p > 0.05). Although not significant, AP was higher in LHP for OC (Δ -248.2 ± 1,301.4 W) and EUM (Δ -19.5 ± 977.7 W) and higher in HHP for H-IUD (Δ 369.3 ± 1,123.0 W). Oral contraceptive group exhibited a higher FI (Δ 2.0%) and reduced blood lactate clearance (Δ 2.5%) in HHP. In recreationally active women, hormonal contraception and hormone phases may minimally impact fatigue and recovery. Individual elite female athletes may benefit from understanding hormonal contraception type as performance and recovery may slightly vary across the cycle.