J. Joseph Speidel

Challenges in Translating Evidence to Practice: The Provision of Intrauterine Contraception

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

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

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

Population policies, programmes and the environment

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

Postabortion Contraception: Qualitative Interviews On Counseling and Provision of Long-Acting Reversible Contraceptive Methods.

15 billion per year is needed for family-planning programmes in developing countries and donors should provide at least

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

5 billion of the total, however, current donor assistance is less than a quarter of this funding target.

Over-the-counter access to emergency contraception for teens

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

The copper IUD for emergency contraception, a neglected option

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

Addressing Global Health, Economic, and Environmental Problems Through Family Planning

This synopsis of teens and OTC access is part of a series of briefs on emergency contraception, which address the following issues as they relate to EC: Is emergency contraception safe? Is emergency contraception effective at preventing pregnancy? Does emergency contraception promote sexual risk-taking? Is emergency contraception cost-effective? Does emergency contraception cause abortion? The full series can be found at http://crhrp.ucsf.edu.

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

This editorial explains how women seeking emergency contraception (EC) can be offered the copper intrauterine device (IUD) as a safe and effective method of EC as more than 99% effective compared to the less than 90% effectiveness of oral levonorgestrel pills or ulipristal acetate. It discusses the benefits of IUD as a method of EC beyond the high efficacy discusses several barriers and explains the financial side of this type of offering. Copyright

International family-planning budgets in the “new US” era

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