Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal.

BACKGROUND: Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients. METHODS: The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics. RESULTS: The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved. CONCLUSION: We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

Knowledge, attitudes, and perceptions of health care providers regarding the recommendation and use of long-acting reversible contraceptive devices for adolescent patients.

OBJECTIVE: To describe the knowledge, attitudes, and perceptions of healthcare providers in a region in southwestern Colombia regarding the recommendation and use of long-acting reversible contraceptive (LARC) methods for adolescents. STUDY DESIGN: This was a cross-sectional study. An online exploratory survey was designed to assess healthcare providers' knowledge, attitudes, and perceptions of Valle del Cauca hospitals. For the development of this the questionnaire, a literature search and validation of the instrument's appearance were conducted. RESULTS: The survey was completed by 115 people. Knowledge: 62.6% and 33% of the participants did not consider themselves capable of correctly placing an intrauterine device (IUD) or a subdermal implant, respectively. However, 73.9% of the participants had adequate theoretical knowledge. Attitudes: 64.3% of the participants considered that adolescents can acquire contraceptive methods without limitations. Short-acting reversible methods were the least recommended. Perceptions: For IUDs, 40.8% and 16.5% of the participants imposed a minimum age and minimum parity requirement for their use, respectively. Side effects were the main reason for not recommending in health institutions with a lower level of complexity. CONCLUSION: Healthcare providers had positive attitudes and adequate theoretical knowledge concerning to the effectiveness of LARCs. The main areas for improvement were practical knowledge about the insertion and proper use of the devices, indications for referral to gynaecologists for the insertion procedure, and concerns about side effects.

Our research explores healthcare providers' knowledge, attitudes, and perceptions regarding long-acting reversible contraceptives for adolescents. While attitudes were positive, practical knowledge gaps on device, placement and referral indications emerged. Read the full findings to uncover more about LARCs in adolescent healthcare.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse.

BACKGROUND: The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse. METHODS: In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model. RESULTS: Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions. CONCLUSIONS: The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Women's perspectives on long-acting reversible contraception: a critical scoping review of qualitative research.

Long-acting Reversible Contraception (LARC) has significant promise both from a public health outlook and a social justice perspective. However, if women's empowerment is to be supported, then perspectives and experiences of LARC must be considered. This scoping review assesses research about contraceptive users' perspectives and experiences of contraceptive decision-making and practices. A content analysis was conducted to identify research trends in qualitative studies of contraceptive-user perspectives (n = 54), located by means of a systematic search. Interpreting findings through a reproductive justice lens, three main limitations in the scholarship were identified, viz., (1) an instrumentalist, individual-level focus; (2) a lack of consideration for diverse perspectives; and (3) an uncritical focus on young women. While the small body of qualitative research on LARC offers some valuable insights, when viewed from a sexual and reproductive justice perspective, it is not sufficiently user-centered or grounded within the reproductive politics surrounding contraceptive care and provision. Research is needed that draws on appropriate social theory; widens its focus beyond dominant groups; and is cognizant of the multi-level power relations surrounding LARC. Such work provides a nuanced picture of the complex social and contextual factors at play and inform person-centered approaches in sexual and reproductive health policy and programming.

The Comeback of the IUD in Twenty-First Century USA.

From 1995 to 2014, intrauterine devices (IUDs) rose from ranking 10th (out of 11) among contraceptive methods to being the fourth most popular, outnumbered only by the pill, sterilization, and condoms. In 1995, the IUD had been largely abandoned by American doctors; two decades later, major medical associations promoted it as a "first line" method for prospective users of all ages. This paper explains the rapid and dramatic increase in intrauterine contraception by exploring three influential factors from the 1970s-1980s - the Dalkon Shield disaster, the lack of innovation in contraceptive research and development, and the moral panic over teen pregnancy in America - that created circumstances by the early 2000s in which health care providers became more receptive to long-acting reversible contraception. Key thought leaders in obstetrics and gynecology took it upon themselves to rehabilitate the IUD in the court of medical opinion and succeeded in securing professional approval of the device as the initial step in its resurrection.

Association between contraceptive method chosen after induced abortion and incidence of repeat abortion in Northern Portugal.

OBJECTIVES: In Portugal, a country with strong Catholic roots, elective termination of pregnancy at women's request is still stigmatised, especially if it is a repeat abortion. The objectives of this study were to determine the incidence of repeat abortion, taking into account the contraceptive method chosen after the index abortion event, and characterise the risk factors for repeat abortion. METHODS: This was a retrospective cohort study of 988 women who requested termination of pregnancy during 2015 in a Portuguese tertiary care public hospital. Contraception was given free of charge after the index event. The occurrence of a repeat induced abortion was evaluated during a 24 month follow-up period. RESULTS: Forty-nine (5.0%) of the 988 women had a repeat abortion. Users of long-acting reversible contraception (LARC) had fewer repeat abortions compared with users of non-LARC methods. Overall repeat abortion was 0.8% in subcutaneous contraceptive implant users, 1.5% in intrauterine contraceptive device (IUCD) users, 2.8% in vaginal ring users and 5.8% in oral contraceptives users (p < 0.05). Cox hazards ratio (HR) analysis showed that method choice after abortion correlated significantly with the probability of repeat abortion (p < 0.05). Using women choosing oral contraception as the reference group, the HRs (95% CIs) for repeat abortion were as follows: IUCD 0.282 (0.084, 0.942), contraceptive implant 0.142 (0.019, 1.050), vaginal ring 0.508 (0.175, 1.477). CONCLUSION: Even though highly effective contraceptive methods are freely accessible in Portugal, other challenges must be managed to improve outcomes, such as a timely, patient-centred counselling approach.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications.

Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).

Long-acting reversible contraception: A route to reproductive justice or injustice.

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Este artículo presenta información sobre embarazos no intencionales y el continuo esfuerzo de las autoridades para promover LARC (Contracepción Reversible de Larga Actuación) con el fin de reducir el número de tales embarazos. También se discute la tensión entre el aconsejar LARC para promover los intereses públicos de alcanzar esa meta vs. la necesidad de asegurar que todas las mujeres puedan ellas mismas decidir sobre sus cuerpos y necesidades reproductivas. Nuestra discusión incluye información, primariamente de los Estados Unidos (EUA), sobre: (1) riesgos asociados con embarazos no intencionales, (2) objetos de LARC aprobados en EUA (objetos intrauterinos de cobre -IUD-, IUD de hormonas, e implantes), (3) los beneficios públicos y sociales de aumentar el uso de LARC, (4) desventajas y barreras que presenta el uso de LARC, (5) peligros de promover LARC de maneras injustas, y (6) el significado de la justicia reproductiva y su conexión con la justicia social. Al compartir la información con el público de esta revista especializada, esperamos que la misma sea integrada dentro del trabajo clínico y la investigación sobre salud y desarrollo mental. También esperamos que los expertos en esos campos de estudio participarán activamente en la conversación acerca de la salud reproductiva de las mujeres y la justicia social que se lleva a cabo en EUA y otros lugares.

Cet article porte sur les grossesses involontaires et les efforts continus que font les responsables politiques pour promouvoir la contraception à long terme et réversible LARC (en anglais Long Acting Reversible Contraception) de façon à réduire le nombre de ces grossesses. Nous discutons aussi la tension entre l'encouragement de la LARC à promouvoir les intérêts publics pour arriver ce but et le besoin qui existe de s'assurer que toutes les femmes puissent décider d'elles-mêmes ce qu'elles veulent faire avec leur propre corps et leurs besoins sexuels. Notre discussion inclut des renseignements, principalement des Etats-Unis d'Amériques, sur: (1) les risques liés aux grossesses involontaires; (2) les dispositifs de contraception à long terme réversible approuvés aux Etats-Unis d'Amérique (dispositifs intra-utérins au cuivre (DIU), hormones DIU, et implants), (3) les avantages publics et sociaux qu'il y a à augmenter l'utilisation de la LARC, (4) les désavantages et les barrières à l'utilisation de la LARC, (5) les dangers de la promotion de la LARC de manières injustes, et (6) la signification de la justice reproductive et son lien à la justice sociale. En partageant ces informations avec les lecteurs de cette revue, nous espérons qu'elles seront intégrées dans le travail clinique et les recherches sur la santé mentale et le développement. Nous espérons aussi que les experts dans ces domaines pourront ainsi intervenir dans la conversation qui concerne la santé reproductive des femmes et la justice sociale qui se tient aux Etats-Unis et ailleurs.

Two year continuation rates of contraceptive methods in France: a cohort study from the French national health insurance database.

OBJECTIVE: The aim of this study was to evaluate the continuation rates of reimbursed contraceptive methods in French real-world conditions. METHODS: A retrospective cohort study using a representative sample of the national health insurance database, the General Sample of Beneficiaries (Echantillon Généralistes des Bénéficiaires [EGB]), was performed between 2006 and 2012. Selected women were ≥15 years of age and had started a reimbursed contraceptive method between 2009 and 2012 without prior reimbursement for an implant or an intrauterine contraceptive method between 2006 and 2008. The outcome of interest was the continuation rates, defined as the probability of women initiating a contraceptive method and continuing to use the same method over time. Continuation rates were assessed for up to 2 years. Only the first contraceptive method used during the study period was considered in the analysis. Non-parametric Kaplan-Meier survival analysis was used to assess continuation rates. RESULTS: A population of 42,365 women representative of the 4,109,405 French women initiating any reimbursed method between 2009 and 2012 was identified in the EGB: 74.5% of women used oral contraceptives, 12.8% the levonorgestrel-releasing intrauterine system (LNG-IUS), 9.2% the copper intrauterine device (Cu-IUD) and 3.5% the subdermal etonogestrel (ENG) implant. The 2 year continuation rates varied from 9.1% for progestin-only oral contraceptives, 27.6% for first to second generation combined oral contraceptives (COCs) and 33.4% for third generation COCs to 83.6% for the ENG implant, 88.1% for the Cu-IUD and 91.1% for the LNG-IUS. CONCLUSION: This study conducted in real-world conditions showed that long-acting reversible contraceptive (LARC) methods remain rarely used in France despite high continuation rates over 2 years. Increasing the use of LARC methods is therefore a public health priority.

Contraceptive care for Canadian youth.

Sexual and reproductive health is an important component of comprehensive health care for youth. This statement provides guidance for selecting and prescribing contraceptives for youth, including commonly prescribed hormonal contraceptives-the pill, patch, ring and injectable progestin-and long-acting reversible contraceptives (LARCs). LARCs, including subdermal implants (which are not available in Canada) and intrauterine contraceptives (IUCs), are substantially more effective during typical use than hormonal contraceptives. This statement endorses LARCs as the first-line option for contraception for Canadian youth, while emphasizing that providers must collaborate with youth to select a contraceptive method that is acceptable, safe, effective and practical for them. Strategies that eliminate obstacles to initiating and continuing contraception are provided.

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.

Motivations for Interest, Disinterest and Uncertainty in Intrauterine Device Use Among Young Women.

Objective To elucidate salient contraceptive preferences and priorities as they relate to young women's interest or lack thereof in intrauterine device (IUD) use. Methods Qualitative data were drawn from a 2012 survey on contraceptive preferences and IUD interest. Among 413 young (ages 18-29) women, open-ended responses describing reasons for interest, disinterest or uncertainty in future IUD use were examined using a thematic analysis approach. Results Most participants were unsure about (49.2%) or not interested in (30.0%) future IUD use. Themes regarding IUD interest related to specific facets of IUD use (e.g., risks and side effects, ease of use), as well as broader influences on contraceptive decision-making (e.g., social influences, alignment with pregnancy intentions). For interested participants, a sense of empowerment pervaded the responses, with many references to the ease of use and lack of requisite maintenance. Uninterested participants were concerned about the internal nature of the IUD, with many describing "horror stories" and fears that the IUD would cause injury or infertility. Unsure participants provided more detailed and complex responses, carefully weighing the advantages and disadvantages of IUD use. Uncertainty was often driven by an acknowledged need for specific information, rather than overall lack of knowledge. Conclusions for Practice In this analysis, many women had a clear sense of their contraceptive preferences, which frequently did not align with IUDs. While continuing to remove barriers to IUD access is critical, patient-centered counseling approaches offer the opportunity to support women in best matching with a method that aligns with their preferences.

Provider Perspectives on Analgesic Use in Intrauterine Device Insertion Procedures: A Mixed Methods Analysis.

CONTEXT: The intrauterine device (IUD) is one type of long-acting reversible contraceptive that is becoming increasingly popular among patients and healthcare providers alike, though many are deterred from using this option due to pain or fear of pain with IUD insertion. While the IUD insertion process itself is standardized, the use of pain medication is not. There is a lack of research regarding provider preference in analgesic use for IUD insertion procedures, which analgesics are being provided to patients, and under which circumstances. This study aims to explore which analgesics are being used routinely in clinical settings, which patient populations are more likely to receive or benefit from these treatments, and why. Secondarily, this study aims to evaluate the impacts of provider characteristics such as location of training and practice, length of practice, and type of training in analgesic administration. METHODS: Various national organizations were contacted via email and asked to distribute the "IUD Pain Management" survey via discussion board or email newsletter. This survey was developed to gather demographic information on providers of IUD placement procedures and evaluate trends in analgesic methods used based on provider and patient characteristics. Additionally, the survey included an opportunity for participants to agree to participate in a brief interview to further elaborate on their responses via phone. Survey responses were collected and evaluated on the secure QuestionPro platform. Results from the interview were qualitatively assessed by coding recurrent themes between participant interviews. RESULTS: Survey respondents represented physicians from family medicine and OB-GYN specialties, as well as nurse practitioners, registered nurses, physician assistants, and OB-GYN resident physicians. The average length of clinical practice is 6.7 years. The majority of respondents reported offering some sort of analgesic for IUD insertion procedures, with nonsteroidal anti-inflammatory drugs being the most commonly used. Participants also reported an increased likelihood of prescribing analgesics for adolescent and nulliparous patients. Participant interviews included themes such as patient perception of pain, provider training, barriers to access, and alternative analgesic options. CONCLUSIONS: Our study has identified a significant amount of variation in practices regarding analgesic use for IUD insertion procedures and highlighted some underlying causes of these inconsistencies. Future studies should further investigate trends in analgesic administration in IUD insertion procedures with a larger sample size and delve into factors such as provider education and barriers to access.

The Impact of Get It? on Long-Acting Reversible Contraception Use Among Adolescents and Young Adults.

OBJECTIVE: Long-acting reversible contraceptives (LARCs) are the most effective contraceptive method to decrease pregnancy rates among adolescents and young adults (AYAs). Get It? (www.getitnobaby.com) is an innovative peer-based digital intervention that aims to increase LARC awareness and use among AYAs. The purpose of this study was to describe the impact of Get It? on LARC awareness and use among AYAs after exposure. METHODS: A randomized controlled trial was conducted between 2 different Baylor College of Medicine Teen Health Clinics. Using a block randomization method, clinics were randomized to either the intervention or control group by week. Baseline and post-intervention surveys were conducted in addition to a 6-month post-intervention chart review to determine the primary outcome of LARC uptake and secondary outcomes including other LARC-specific behaviors and LARC attitudes. RESULTS: A total of 233 AYAs agreed to participate in the study, of which 134 were randomized to the control group and 99 to the intervention group. Initiation of LARC discussion with the provider was significantly higher in the intervention group than in the control group. Additionally, LARC uptake within 6 months after study was almost significantly higher in the intervention group than in the control group. Finally, intervention group respondents exhibited strong positive attitudes toward Get It? with regard to specific intervention components. CONCLUSION: This study supports Get It? as a tool to educate and motivate AYA girls to use the most effective form of birth control available to them. The digital format of this novel peer-based approach also contributes to the potential of this educational intervention by decreasing barriers to both dissemination and uptake. We recommend a larger multi-institutional study to confirm these results and determine the most efficient method of dissemination to reach at-risk AYAs before coitarche.

Caregivers of youth in foster care in Texas and their role in contraception decision-making for adolescents in care.

OBJECTIVES: This study describes the perspectives of caregivers of youth in foster care in Texas about the caregiver's role in adolescent contraception decision-making for adolescents in their care, particularly for long-acting reversible contraception. The study also explores how providers and foster care agencies can better support pregnancy prevention for youth in care. STUDY DESIGN: Researchers recruited 18 caregivers of youth in care from an academic center in Texas to complete in-person, one-on-one, semistructured interviews from August to December 2019. Two independent coders identified the main concepts with thematic analysis; discrepancies were resolved by consensus. RESULTS: Most caregivers identified as female (88%), Black (59%), and ranged in age from 30 to 69 years old. Half (47%) reported previously caring for an adolescent who was pregnant or parenting. Themes from the interviews included the importance of building relationships before contraception conversations, the balance between adolescent autonomy and strict caregiver oversight in contraceptive decision-making, variation in beliefs about contraception for youth in care, and extreme reactions to long-acting reversible contraception in both directions. Providers and foster care agencies played an important role managing confidential expectations and providing resources or trainings about contraception. CONCLUSIONS: In a region of the country with high rates of adolescent pregnancy, strategies that empower adolescent autonomy allow delicate caregiver oversight, provide comprehensive information about all contraceptive options, and respond to extreme long-acting reversible contraception reactions and trainings that focus on the context of contraception that should inform communication-based interventions to address teen pregnancy prevention among youth in care. IMPLICATIONS: Few studies address the experiences of caregivers of adolescents in foster care. This study highlights a range of caregiver attitudes about contraception for adolescents in care. Provider training regarding contraception should include strategies to manage caregiver beliefs and extreme reactions to contraception use among youth in care.

Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine.

OBJECTIVE: Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine. METHODS: We used the Maine Health Data Organization's All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020-September 2020, April 2020-March 2021) as compared with the reference period (October 2015-March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs. RESULTS: The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated. CONCLUSION: Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.

Impact of the COVID-19 pandemic on women's contraceptive use: a mixed-methods study in South Africa and Zambia.

Background: The COVID-19 pandemic affected global access to health services, including contraception. We sought to explore effects of the pandemic on family planning (FP) service provision and use in South Africa and Zambia, including on implant and intrauterine device (IUD) users' desire and ability to obtain removal. Methods: Between August 2020 and April 2021, we conducted surveys with 537 women participating in an ongoing longitudinal contraceptive continuation study. We also carried out in-depth interviews with 39 of the survey participants and 36 key informants involved in FP provision. We conducted descriptive analysis of survey responses and thematic analysis of interviews. Results: Contraceptive use changed minimally in this sample with the emergence of COVID-19. Fewer than half of women (n=220) reported attempting to access FP since the start of the pandemic, the vast majority of whom were using short-acting methods. Among those who sought services, 95% obtained their preferred method. The proportion of women not using a method before and after pandemic start did not change in Zambia (31%); in South Africa, the proportion increased from 8% to 10%. Less than 7% of implant or IUD users in either country reported wanting removal. Among those who sought removal (n=22), 91% (n=10) in Zambia and 55% (n=6) in South Africa successfully obtained removal. In qualitative interviews, women with challenges accessing FP services mentioned long queues, deprioritization of contraceptive services, lack of transportation, stock-outs, and fear of contracting COVID-19 at a facility. Key informants reported stock-outs, especially of injectables, and staff shortages as barriers. Conclusions: We did not find a substantial impact of COVID-19 on contraceptive access among this sample; however, providers and others involved in service provision identified risks to continuity of care. As the COVID-19 pandemic wanes, it continues to be important to monitor people's ability to access their preferred contraceptive methods.

An Evaluation of Contraceptive Methods After Implementation of a Novel LARC Program in a Residency Primary Care Clinic.

BACKGROUND AND OBJECTIVE: Internal medicine (IM) residency programs have inadequate education and training around contraception, creating and perpetuating a potential barrier for patients. Contraceptive access is a critical part of primary care, yet few IM residency programs offer long-acting reversible contraception (LARC) in their clinic. To address the LARC needs of our patients and education needs of our residents, one attending (MS) created a procedure clinic and provided LARC in our residency clinic in 2015. In this initial study, we sought to determine the use of contraceptive methods among reproductive age women at our residency clinic two years after offering LARC. This data will shape future care provision and resident education. STUDY DESIGN AND METHODS: Data were extracted from 1,182 female patients ages 20-39 years attributed to the Rhode Island Hospital Center for Primary Care (CPC) between February 2017 to August 2018. Of the total, 260 patients were excluded because they had not been seen in the clinic within the preceding 12 months or had left the practice. Descriptive and bivariate methods were used to calculate the proportion of women using any contraception and long-acting reversible contraception (LARC) and to test for associations with demographic characteristics. PRIMARY RESULTS: Fifty-five percent used any contraception and 19% used LARC. LARC use was higher among women ages 20-29 when compared to women 30-39. Demographic characteristics other than age were not associated with contraceptive use. PRINCIPAL CONCLUSIONS: In this clinic, LARC usage exceeds the national average (19.0% v 10.3%). Residency training is ideal for learning skills around this aspect of medical care, providing the ability to ensure appropriate oversight and supervision. This initial study suggests almost one fifth (18%) of patients who utilize LARC find access at an IM residency primary care clinic acceptable. Internal medicine primary care clinics can address the nonsurgical contraceptive needs of their patients by providing access to LARC. To achieve this goal, internal medicine residents should receive training in and exposure to LARC provision.

An educational video on long-acting reversible contraception as a counseling tool for postpartum adolescents.

OBJECTIVE: To assess the effects of using an animated local language educational video to counsel postpartum adolescents on the benefits and use of long-acting reversible contraception (LARC). MATERIALS AND METHODS: A two-stage, single group, experimental study was conducted. A total of 124 female adolescents aged < 20 years who had given birth within the last six weeks participated in the study. An educational video and a questionnaire were developed and validated. Participants were asked to fill out a questionnaire on basic demographic data, contraception preferences, and 10 true/false statements to test general contraceptive knowledge, after which they were shown an educational video in a private room. Following this, participants completed the second part of the questionnaire that assessed their knowledge using the same true/false statements and contraception preferences administered earlier. RESULTS: The mean age (standard deviation) of participants was 18.1 (1.5) years. Participants' mean age (SD) at the time of their first sexual intercourse was 16.2 (1.6) years. Among the 124 participants, 31 (25%) indicated that they would use LARC before viewing the educational video. After viewing the educational video, this number increased to 48 (38.7%). The participants' knowledge score was independently associated with their preference to select LARC (adjusted odds ratio 1.46, 95% confidence interval 1.09- 1.97). CONCLUSION: This study demonstrated that counseling tools such as animated local language educational video might effectively improve contraceptive knowledge and the preference for LARC in postpartum adolescents. An educational video regarding LARC could be used as a counseling tool for postpartum adolescents.

Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal.

Introduction: Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges. Methods: We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals. Results: 72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals. Conclusion: Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.