Kirsten M.J. Thompson

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.

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

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

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

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.

Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial.

BACKGROUND Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting. OBJECTIVE We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion. STUDY DESIGN This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year. RESULTS Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43). CONCLUSIONS The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.

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

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

Current and past depressive symptoms and contraceptive effectiveness level method selected among women seeking reproductive health services

RATIONALE More thoroughly understanding the association between elevated depressive symptoms and effectiveness level of contraceptive method selected at a reproductive health visit could help women prevent unintended pregnancy. OBJECTIVE This study examined how the association between both current and past depressive symptoms and effectiveness level of contraceptive method selected at a clinic visit varies by type of reproductive health visit. METHODS Current and past depressive symptoms and contraceptive method selected were assessed among 1215 women aged 18-25 years seeking general reproductive health or abortion services at 40 community clinics throughout the United States. Using standard categories of effectiveness based on pregnancy rates during typical use, womens contraceptive method selected was coded as a low (e.g., no method, withdrawal, condoms), moderately (pill, patch, ring, or shot), or highly effective method (IUD, sterilization, implant). Depression status was divided into four categories: 1) no elevated depressive symptoms ever, 2) current elevated depressive symptoms only, 3) past elevated depressive symptoms only, and 4) past and current elevated depressive symptoms. Visit type, general reproductive health versus abortion care, was a moderator. The interaction effect between depressive symptoms and visit type on contraceptive method effectiveness level chosen was estimated with multinomial logistic regression analyses. RESULTS In general reproductive health visits, having both elevated current and past depressive symptoms increased womens likelihood of choosing low versus moderately effective methods (RRR = 5.63, 95% CI = 2.31 to 13.71, p < .0005). In contrast, among abortion patients, only current elevated depressive symptoms were associated with choosing high versus moderate effectiveness methods (RRR = 1.74, 95% CI = 1.06 to 2.86, p = .029). CONCLUSION Results suggest that considering both womens current and past elevated depressive symptoms and the type of reproductive health visit may assist providers in helping women prevent unintended pregnancy.

Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: a cluster randomized trial

Background US unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods. Objective We sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care. Study Design We measured the impact of a continuing medical education–accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1‐year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference‐in‐differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later. Results Overall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1‐year follow‐up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow‐up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13–5.4). Likewise, for the implant, the proportion increased from 57‐77% in intervention, compared to 61‐65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44–4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53‐67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04–3.44), and for the implant increased more in intervention (41‐62%) compared to control sites (48‐50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28–4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77‐0.86) 6% more over time compared to control sites (from 0.78‐0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003–0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65‐0.79) compared to control sites (0.67‐0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09–0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71‐87%, compared to in control sites, 76‐82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02–3.80). Conclusion Professional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.

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

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

Pregnancy: not a disease but still a health risk

In a landmark decision to advance public health, the Obama to modern medical care, about 1/10,000 US births results in a Administration accepted an Institute of Medicine recommendation to include contraceptive care as a critical preventive service in the Patient Protection and Affordable Care Act [1]. Private health insurance plans in the US are now required to include contraceptive care without out-of-pocket costs. This requirement has incited controversy, with some opponents arguing that contraceptive care is not a preventive service because pregnancy is not a disease. Yet, the promotion of public health addresses many conditions that are not diseases, including pregnancy and childbirth, because they entail substantial health risks. Contraceptives are not without risk, but they are far safer than pregnancy and childbirth and are fundamental to protecting the health of women and infants.