Suzan Goodman

Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion

BACKGROUND Of the 1.3 million abortions performed annually in the United States, approximately half are repeat procedures. Immediate postabortal intrauterine device (IUD) insertion is a safe, effective, practical and underutilized intervention that we hypothesize will significantly decrease repeat unintended pregnancy and abortion. STUDY DESIGN All women receiving immediate postabortal IUD insertion in eight clinics of a Northern California Planned Parenthood agency during a 3-year period comprise the IUD cohort. We selected a cohort of controls receiving abortions but choosing other, non-IUD contraception on the day of the abortion visit in a 2:1 ratio matched by date of abortion. We obtained follow-up data on repeat abortions within the agency for both cohorts through 14 months after the 3-year period. We evaluated differences in repeat abortion between cohorts. All analyses were intent-to-treat. RESULTS Women who received an immediate postabortal IUD had a lower rate of repeat abortions than controls (p<.001). Women who received a postabortal IUD had 34.6 abortions per 1000 woman-years of follow-up compared to 91.3 for the control group. The hazard ratio for repeat abortion was 0.38 [95% confidence interval (CI), 0.27-0.53] for women receiving a postabortal IUD compared to controls. When adjusted for age, race/ethnicity, marital status, and family size, the hazard ratio was 0.37 (95% CI, 0.26-0.52). CONCLUSION Immediate postabortal intrauterine contraception has the potential to significantly reduce repeat abortion.

Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion

BACKGROUND We hypothesize that barriers to IUD insertion are central to low utilization in the USA. This study evaluates methods to minimize barriers, including post-abortal insertion, staff training and simplified screening. STUDY DESIGN We obtained data on IUD utilization during three study periods: a control period (Period 1), a period after initiating post-abortal insertion and staff training (Period 2), and a period with these interventions plus simplified screening for interval insertions (Period 3). We evaluated IUD utilization, associated complications and utilization at a similar local agency in which the interventions were not implemented. RESULTS We inserted 2172 IUDs during the study, including 1493 interval and 679 post-abortal insertions. In the control period, there were 28 monthly IUD insertions on average, compared to 71 (a 151% increase) and 122 (a 334% increase) in Periods 2 and 3, respectively. IUD utilization at the nearby agency remained relatively constant. Complications remained low. CONCLUSIONS IUD utilization can be substantially increased through relatively simple, low-cost interventions, with significant potential to reduce unintended pregnancy.

Counseling women with early pregnancy failure: Utilizing evidence, preserving preference

OBJECTIVES To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management. METHODS Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice. RESULTS Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management. CONCLUSION Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options. PRACTICE IMPLICATIONS Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.

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.

Beyond education and training: making change stick.

This editorial focuses on how to effectively introduce a new service or make a change on a systematic level beyond education and training. It summarizes the required common steps to achieve a successful implementation which include: aligning goals providing methods for training and piloting a program setting clear performance indicators and communicating effectively.

Training in aspiration abortion care: An observational cohort study of achieving procedural competence

BACKGROUND Studies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states. OBJECTIVES This study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence. DESIGN In this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion. SETTINGS Trainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training. PARTICIPANTS California-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support. METHODS A standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees. RESULTS Essentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46-2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5). CONCLUSIONS A standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.

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.