Reasons for low utilization of intrauterine device utilisation amongst short term contraceptive users in Hossana town, Southern Ethiopia: a qualitative study.

BACKGROUND: Intrauterine devices (IUDs) are one of the long-acting, safe and effective methods of contraception in women across the world. However, this method is underutilised in many countries, including Ethiopia. Several quantitative studies have been used to address this problem and generated a list of factors associated with this problem. However, this list lacks detailed and local contexts that are necessary to inform local solutions. The current study uses a qualitative method to explore determinants of IUDs underutilization among short term modern contraceptive users from the maternal health services in the study setting. The use of a qualitative study design is necessary to obtain and rich contextual details that can inform the development of locally appropriate strategies to increase the IUDs uptake in the study area and improve women's reproductive health outcomes. METHOD: A qualitative study was conducted in Hossana town public health facilities, Southern Ethiopia from November 1-30, 2019. A total of thirteen in-depth interviews were conducted including with: 11 short term contraceptive users, one health centre head and one health extension worker. The interview guide comprised semi-structured questions. Interviews were audio recorded, transcribed and collected data analysed thematically. RESULT: The main key determinants of IUDs service underutilisation were identified from participants' narratives, including: (1) poor knowledge about the benefits of IUDs, (2) insufficient counselling and ineffective delivery of health information to aid women in decision making, (3) the absence of trained health personals, and shortage of supplies. CONCLUSION: Results indicate that the poor utilisation of IUDs services is determined by both the service provider and the consumer related factors. Poor knowledge of short term users of contraception is a critical factor because without knowledge, clients may not use the available services effectively. The shortage of necessary supplies, poor provider-client relationships, and poor counselling by service providers are also service factors that act as barriers to uptake of IUDs. Efforts should be made to increase IUDs utilization by focusing on educating women about the importance of IUDs, improving counselling of mothers and strengthening the health systems, including allocating more resources to increase access to IUDs among the service users.

Dislocated intrauterine devices: clinical presentations, diagnosis and management.

OBJECTIVE: Intrauterine devices (IUDs) are globally one of the most popular methods of contraception. Uterine perforation is one of the most significant complications of IUD use and commonly occurs at the time of IUD insertion rather than presenting as delayed migration. This paper reports a series of 13 cases of displaced IUDs requiring retrieval by laparoscopy or laparotomy. All the IUDs were copper bearing and most perforations occurred immediately after IUD insertion. CASES: In two patients with sigmoid colon injury and IUD penetration of the appendix, laparoscopic management had failed and laparotomy was necessary owing to severe obliteration of the pelvic cavity. In one patient laparotomy was the preferred surgical approach owing to acute bowel perforation. In the remaining patients, the displaced devices were successfully removed by laparoscopy. CONCLUSION: Uterine perforation and IUD migration to the organs in the abdominopelvic cavity are serious complications of IUD insertion and can be successfully managed by laparoscopy, or by laparotomy in the presence of severe pelvic adhesions or unexpected complications.

The Use of ACOG Guidelines: Perceived Contraindications to IUD and Implant Use Among Family Planning Providers.

Objectives The uptake and actual use of the current guidelines from the American College of Obstetrics and Gynecology (ACOG) is unknown. Methods Family planning providers across Colorado and Iowa were surveyed as part of statewide initiatives to reduce unintended pregnancy in 2010 and 2012, both before and after the release of the guidelines. These initiatives focused on the promotion of intrauterine devices (IUDs) and implants. These surveys included questions on providers' views regarding the suitability and safety of the copper T IUD, hormonal IUD, and single rod implant for various subgroups of clients. The results are contrasted with guidelines provided in July of 2011 by ACOG. This strategy provides both baseline and follow-up models about the methods promoted in these guidelines. Results Findings show that there is some improvement in beliefs that IUDs are suitable and safe for women who are post-partum, post-abortion, have had an ectopic pregnancy, are nulliparous, teenagers, or have a history of STIs. However, these clinicians' views are not entirely in alignment with ACOG recommendations in their beliefs that these methods should not be used immediately post-partum or post-abortion. Notable percentages of these clinicians were hesitant to recommend these effective methods for other groups of patients, approved for use by ACOG. Conclusions While the cost of these methods is a barrier to adoption, these data suggest that there are continuing provider barriers to their use as well. The paper concludes with suggestions for further training for family planning providers.

Trends and determinants of IUD use in the USA, 2002-2012.

STUDY QUESTION: What factors and subgroups have propelled the recent increase in intrauterine device (IUD) use in the USA? SUMMARY ANSWER: The increase in IUD use, from 1.8 to 9.5% in the USA between 2002 and 2012, was driven primarily by a marked uptake among parous women who intended to have more children. WHAT IS KNOWN ALREADY: Recent data suggest an unprecedented increase in IUD use among women in the USA, yet less is known about how this increase has affected the overall proportion of women, at risk of unintended pregnancy, who are using contraception and which social and economic groups are involved. STUDY DESIGN, SIZE, DURATION: Data are drawn from the 2002 and 2011-2013 National Surveys of Family Growth. The surveys were based on cross-sectional, national samples of women of 15-44 years of age in the USA. Women responded to in-person interviews, which lasted an average of 80 min. The response rate was 80% in 2002 and 73% in 2011-2013. The sample included 7643 completed interviews in 2002 and 5601 interviews in 2011-2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: This study was limited to women at risk of unintended pregnancy, i.e. women who were sexually active in the previous 3 months (using contraception or not); it excludes women who were sterile, currently pregnant or trying to conceive. Altogether, 5181 women were at risk in the 2002 sample and 3681 were at risk in the 2012 sample. We used descriptive statistics to investigate trends in contraceptive use patterns by women's sociodemographic characteristics between 2002 and 2012 and used logistic regression to identify current predictors of IUD use in 2012. MAIN RESULTS AND THE ROLE OF CHANCE: IUD use increased from 1.8% in 2002 to 9.5% in 2012 (P < 0.001). The surge was especially marked among parous women who intended to have more children (4.2% in 2002 to 19.3% in 2012; P < 0.001); it occurred to a lesser extent among parous women who did not intend to have more children (2.0-9.7% P < 0.001), suggesting that IUDs are more often used for spacing than for ending childbearing in the USA. The most important predictors of IUD use in 2012 were age, parity and intent to have children. Dissatisfaction with a previous method was also associated with IUD use (adjusted odds ratio = 1.89, P < 0.001). LIMITATIONS, REASONS FOR CAUTION: As with all cross-sectional studies, causal inference is limited. Data are self-reported, but the survey had a high response rate and rigorous quality controls. WIDER IMPLICATION OF THE FINDINGS: This study shows promising trends in the use of highly effective contraceptive methods in the USA, which may help to explain recently reported declines in unintended pregnancy in the USA. STUDY FUNDING/COMPETING INTERESTS: Caroline Moreau was supported by the William Robertson endowment funds. The work of Hannah Lantos and William Mosher on this analysis was supported by the Department of Population Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health. The authors declare that no conflict of interest exists.

The risk of using intrauterine devices to benign reproductive system conditions in postmenopausal women: A case control study.

BACKGROUND: To investigate the effect of using intrauterine devices (IUDs) during the fertile window on women's reproductive system health. MATERIALS AND METHODS: 2,744 postmenopausal women in the Minhang District, Shanghai, China were enrolled. In the IUDs group there were 2,253 women; in the tubal ligation group there were 202 women and there were 289 women in the control group. We selected subjects according to the cases number in different hospital by using step sampling, and, in addition, collected the sociological data and information of the previously used contraceptives by the subjects, which included whether the contraceptives were used appropriately and the effect they had. Kolmogorov-Smirnov test, Levene's test, and logistic regression analysis were used to analyze the data. RESULTS: The prevalence rate of benign reproductive system conditions was significantly different among them (P < 0.05). Further comparison revealed, the rate in Group 1 was significantly lower than that in Group 2 and Group 3 (P < 0.05, respectively). Results of logistic regression analysis show that the risk factors for development of such conditions lie in the women's pregnancy history [odds ratio (OR) = 3.85], reproductive history (OR = 0.5), the use of IUD in fertile window (OR = 0.4), tubal ligation (OR = 1.74), birth control time (OR = 0.9), contraceptive failure history (OR = 1.7), and history of family planning procedures (OR = 1.73). CONCLUSION: IUDs, maybe, can effectively reduce the risk of getting benign reproductive conditions in postmenopausal females.

Synergistic effect of amphotericin B and tyrosol on biofilm formed by Candida krusei and Candida tropicalis from intrauterine device users.

The presence of intrauterine contraceptive devices (IUDs) provides a solid surface for attachment of microorganisms and an ideal niche for the biofilm to form and flourish. Vaginal candidiasis is often associated with the use of IUDs. Treatment of vaginal candidiasis that develops in connection with IUD use requires their immediate removal. Here, we present in vitro evidence to support the use of combination therapy to inhibit Candida biofilm. Twenty-three clinical Candida isolates (10 C. krusei and 13 C. tropicalis) recovered from endocervical swabs obtained from IUD and non-IUD users were assessed for biofilm-formation ability. The rate of isolation of Candida did not differ significantly among IUD and non-IUD users (P = 0.183), but the biofilm-formation ability of isolates differed significantly (P = 0.02). An in vitro biofilm model with the obtained isolates was subjected to treatment with amphotericin B, tyrosol, and a combination of amphotericin B and tyrosol. Inhibition of biofilm by amphotericin B or tyrosol was found to be concentration dependent, with 50% reduction (P < 0.05) at 4 mg/l and 80 µM, respectively. Hence, a combination effect of tyrosol and amphotericin B was studied. Interestingly, approximately 90% reduction in biofilm was observed with use of 80 µM tyrosol combined with 4 mg/l amphotericin B (P < 0.001). This represents a first step in establishing an appropriate antibiofilm therapy when yeasts are present.

Slaughtering sacred cows: six institutional obstacles to advances in family planning.

In order to capitalise on new opportunities to advance contraceptive and reproductive health choices globally, organisations working in these fields will need to overcome six institutional obstacles. These are: (i) committee management; (ii) over-medicalisation; (iii) fear of risk and controversy; (iv) conferences, meetings, and symposia; (v) obsession with coordination; and (vi) fear of sex. The reproductive health community will require energy, innovative approaches, and a sharp focus on service delivery to address these hurdles that will otherwise slow down and misdirect programmatic momentum.

Three cases of ovarian actinomycosis with literature review.

BACKGROUND: Actinomycosis is an actinomycete infection, a rare zoonotic disease characterized by chronic suppurative inflammation and granulomatous inflammation. When injury occurs to the mucosa where parasites are present, actinomycetes can invade the mucosa. Widespread use of intrauterine devices (IUDs) has increased the incidence rate of pelvic actinomycosis among women. The clinical manifestation of ovarian actinomycosis is mostly a solid or cystic ovarian mass, which can invade surrounding tissue and may be accompanied by elevated levels of the tumor marker cancer antigen 125 (CA125). Therefore, ovarian actinomycosis is easily misdiagnosed as a malignant ovarian tumor. CASE DESCRIPTION: Three cases of ovarian actinomycosis diagnosed in the Department of Pathology of the West China Second University Hospital of Sichuan University from January 2020 to March 2022 were retrospectively analyzed. All 3 patients had a history of IUD implantation for more than 10 years. All patients presented with abdominal masses and abdominal pain. One patient had weight loss, and 2 patients had elevated tumor marker CA125. Imaging results showed that all patients had ovarian space-occupying lesions involving the surrounding tissue; therefore, all patients were suspected to have malignant ovarian tumors before surgery. All 3 patients underwent surgical treatment. Specifically, 1 patient underwent bilateral salpingo-oophorectomy, and 2 patients underwent total hysterectomy and bilateral salpingo-oophorectomy. All patients received high-dose antibiotic treatment after surgery, and thus far, relapse has not been observed. Postoperative pathologicexamination showed purulent inflammation and sulfur granules, consistent with ovarian actinomycosis. Anaerobic culture was positive for 1 patient. CONCLUSIONS: Ovarian actinomycosis is closely related to long-term IUD implantation. The clinical manifestations and imaging features of this disease are not specific; therefore, preoperative diagnosis is difficult. The disease is easily misdiagnosed as ovarian cancer. Sulfur granules are signs of ovarian actinomycosis, and thus, those with this manifestation should be carefully screened by pathologic examination. Surgery combined with antibiotic treatment is effective for ovarian actinomycosis, resulting in a good prognosis.

Continuation of post-coital intrauterine contraceptive devices beyond index cycle at Sexual Health Sheffield.

We aimed to observe the continuation of Emergency IUD beyond the index cycle and reasons for removal. We analysed data from the patients' electronic records of fifty consecutive women who had an IUD fitted at Sexual Health Sheffield for emergency contraception. 48 (96%) women continued with the IUD beyond the index cycle and 31 (62%) women for more than 1 year. Heavy menstrual bleeding, dysmenorrhoea and pain were the most frequent reasons cited for removal.

Method of contraception and risk of ovarian cancer data.

The data presented here were obtained for a New Zealand nationwide population-based case-control analysis undertaken to assess the association between ovarian cancer and depot medroxyprogesterone acetate (DMPA), intrauterine contraceptive devices (IUDs), and vasectomy of a woman's sexual partner (Chesang et al., 2021). The research involved women aged 35 to 69 years. Controls were randomly selected from the New Zealand electoral roll. Cases were women with a diagnosis of incident ovarian cancer recruited from the New Zealand Cancer Registry and had to be listed on the electoral roll. Data collection was conducted between 1st May 2013 and 31st October, 2015. A structured postal questionnaire was used to gather information. Data were analysed using IBM Statistical Package for the Social Sciences (IBM SPSS statistics 22). Odds ratios adjusted for age were calculated using the method of Mantel and Haensze (Rosner et al., 2007). For multivariable analyses, binary logistic regression was used. Description of study participants and age-adjusted and multivariable analyses of the association between ever-use and specifics of use of DMPA, IUDs, and vasectomy were presented in a journal article (Chesang et al., 2021). Here, we present data from analyses of the risk of ovarian cancer by histological type associated with the use of DMPA, IUDs and ever having had a vasectomised partner. In addition, analyses assessing the association between ovarian cancer and these contraceptives restricted to ever-users and never-users of hormonal contraceptives (defined as oral contraceptives or DMPA) are presented. Data from analyses of the association between history of tubal ligation and the risk of ovarian cancer are also presented. These data, including the findings of a related study (Chesang et al., 2021) and the raw data, can be included in a collaborative analysis of existing studies undertaken to assess the association between IUDs, long-acting progestogen-based contraceptives, and partner vasectomy and the risk of ovarian cancer.

Association of partner vasectomy, depot medroxyprogesterone acetate and intrauterine contraceptive devices with ovarian cancer.

PURPOSE: To assess the associations between ovarian cancer and depot medroxyprogesterone acetate (DMPA), intrauterine contraceptive devices (IUDs), and partner vasectomy. METHODS: We undertook a New Zealand-wide population-based case-control study. During 2013-2015, 205 eligible cases were identified from the cancer registry (152 [74%] participated) and 1,735 eligible controls were randomly selected from the electoral roll (837 [48%] participated). A postal questionnaire was used to gather information. RESULTS: Ever-use of vasectomy was inversely associated with ovarian cancer in age-adjusted analysis, but not in multivariable analysis (OR = 0.67, 95% CI = 0.46-0.96, and OR = 0.82; 95% CI = 0.54-1.23, respectively). A suggestive trend towards lower risk with longer duration of reliance on partner vasectomy was observed (P-trend = 0.08). Ever-use and duration of use of DMPA were not associated with ovarian cancer. Although ever-use of IUDs was not associated with ovarian cancer, duration of use of IUDs was associated with higher risk (P-trend = 0.04). There were also statistically significant inverse associations between ovarian cancer and use of oral contraceptives, parity, and breastfeeding. CONCLUSIONS: Prolonged use of IUDs may increase the risk of ovarian cancer. It is also possible that an inverse association exists between ovarian cancer and partner vasectomy.

Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services.

STUDY OBJECTIVES: Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods. DESIGN: Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. SETTING: Eleven contraceptive trainings at SBHCs across the United States from 2016-2019. PARTICIPANTS: A total of 260 providers from 158 SBHCs serving 135,800 students. INTERVENTIONS: On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services. MAIN OUTCOME MEASURES: The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills. RESULTS: At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36). CONCLUSIONS: Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.

From training to implementation: Improving contraceptive practices in South Carolina.

OBJECTIVE: Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice. STUDY DESIGN: Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses. RESULTS: Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision. CONCLUSION: The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care. IMPLICATIONS: In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

Influences on Intentions to Place Long-Acting Reversible Contraceptives: A Pilot Study Comparing According to Provider Specialty in Ohio.

STUDY OBJECTIVE: According to the American Academy of Pediatrics, pediatricians are to counsel and provide long-acting reversible contraceptives (LARCs) as first line of defense contraceptives because they are the most effective. We wanted to explore positive influences on LARC placement for pediatricians, particularly compared with providers in other specialties who care for women. DESIGN: Survey methods with data analyzed using analyses of variance and general linear models in statistical software SPSS version 24.0 (IBM Corp). SETTING: Online survey. PARTICIPANTS: Participants were 224 providers across the state of Ohio who specialize in family medicine (51.8%), obstetrics/gynecology (17.9%), pediatrics (16.5%), and internal medicine (13.8%). Most of the sample was female (50.9%) and Caucasian (74.6%). The most frequent provider types were Doctors of Osteopathic Medicine (42.0%), followed by Doctors of Medicine (37.9%), and Certified Nurse Practitioners (8.5%). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Attitudes about LARCs, perceived norms about placing LARCs, perceived behavioral control over placing LARCs, intentions to place LARCs. RESULTS: Means for all of the variables (attitudes, perceived norms, perceived behavioral control, and intentions to place) differed according to provider specialty. A pattern emerged across these variables in which internal medicine and pediatric practitioners reported lower attitudes, perceived norms, perceived behavioral control, and intentions to place LARCs than family medicine and obstetrics/gynecology practitioners, in that order. CONCLUSION: To increase positive attitudes and perceived norms about LARCs, professional organizations should increase communication to providers about the importance and expectations to place, counsel about, and facilitate placement of LARCs, and medical schooling can improve LARC counseling and procedural training to medical students, interns, and residents. Because perceived behavioral control is linked to intentions to place LARCs, perhaps providers would feel more confident to place them if they had more deliberate training. For pediatricians in particular, perhaps encouraging those who do not currently provide LARC methods to begin with training in implant placement would be a way to capitalize on their more favorable attitudes about implants. For pediatricians who do not feel comfortable providing device placement themselves, other strategies should be encouraged to facilitate provision of LARCs.

Prenatal contraceptive counseling and method provision after childbirth.

Postpartum contraception is undergoing major changes, not only in timing, but also in content. Failure to provide immediate postpartum contraception contributes to the problems of unintended pregnancies and rapid repeat pregnancy because often the highest-risk women do not return for postpartum care. If they do attend that visit, they have often lost the insurance coverage that would enable them to use the most effective forms of birth control. Most of the issues surrounding early initiation of progestin-only methods and breastfeeding have been favorably resolved. In some cases, insurance coverage for delivery has been expanded to cover the costs of providing intrauterine devices and implants before the woman is discharged home. All of these new opportunities shift the burden of counseling about postpartum contraception onto the shoulders of the prenatal care provider. This article provides information about the advantages and disadvantages of providing immediate postpartum contraception with each of the eligible methods so clinicians can provide the needed counseling both during pregnancy and during hospitalization for delivery. It also provides guidance for initiation of bridging contraception, if needed, to initiate a method for a woman later in the postpartum period.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

BACKGROUND: Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation. OBJECTIVE: This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD. PROPOSED PROBLEM SOLVING: The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best. CONCLUSION: One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Shared Decision Aids: Increasing Patient Acceptance of Long-Acting Reversible Contraception.

Unintended pregnancies are an important public health issue. Long-acting reversible contraceptive methods (LARCs) are reliable, safe, highly effective methods for most women; however they are underutilized in the United States. Shared decision aids were added to usual care in five public health family planning clinics in the Southeastern United States, staffed by advance practice nurses and registered nurses. All five sites showed an increase in the use of LARCs during the time period that shared decision aids were used (results statistically significant to p < 0.001). It is important for women to make informed choices about contraception, and shared decision aids can be utilized to support this decision making. This resource has been adopted for statewide use in all public health clinics, and implications for practice suggest that the use of shared decision aids is an effective method to support informed patient decision making and acceptance of LARC methods of contraception.