Tag Archives: contraception counseling

Position Statement: Expanding Access to Hormonal Contraception

The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the right of each individual or couple who desire to use contraception to be able to do so. Barriers to obtaining and successfully using contraception must be eliminated, particularly for the most vulnerable individuals and populations. NPWH advocates for federal- and state-level policies that remove barriers and increase access to affordable, safe, and effective contraceptive methods for all reproductive-aged individuals. Multiple strategies involving legislation, regulations, consumer education, and innovation are necessary. Over-the-counter (OTC) access to hormonal contraceptives (HCs) and pharmacist-provided HCs are two specific strategies that can lower barriers to obtaining safe, effective contraception.

NPWH will provide leadership through policy advocacy, consumer and healthcare provider (HCP) education, and support of research on outcomes related to innovative strategies to expand access to HCs. NPWH supports the right of all individuals to access comprehensive sexual and reproductive health services and to make choices that meet their own needs. Continue reading »

Increasing access to comprehensive contraception: An ongoing battle to remove barriers

woman’s right to use the contraceptive method of her choice is an integral part of women’s healthcare and equality. Despite this constitutional right, barriers to contraceptive access still exist, as reflected by the high rate of unintended pregnancy in the United States each year.I believe that the federal government and state governments, not to mention insurance companies, should not have the right or the power to decide which type of contraception, if any, a woman may use. This decision should be solely up to a woman and her healthcare provider (HCP).

Statement of the problem

As a women’s health nurse practitioner for almost 20 years, I have educated reproductive-aged women about a variety of birth control methods. Although many of my patients know a lot about these methods, others are inadequately informed and undecided about them. As their HCP—and therefore their mentor and advocate—I teach them about all of the contraceptives available and guide them in making the best choices for them.

Through comprehensive contraceptive counseling, women are empowered to make their own decisions about their reproductive lives, including whether and when to have children. Even if women are adequately informed, many of them still face a daunting obstacle to accessing birth control—a lack of health insurance coverage for the particular contraceptive they want to use. It is not unusual to hear a patient say, “My insurance won’t cover that pill” or “The co-pays are too high for certain types of pills in my plan.”

Some women try several types of oral contraceptives before finding one that suits them. It is discouraging when a patient complains that she received a letter from her insurance company stating that it will “no longer cover pill X; you are being dispensed pill Y instead.” But after the patient switches to pill Y, she starts to have side effects that she never experienced with pill X. Many brand-name hormonal contraceptive products are not covered under insurance plans or they require high co-pays. If a woman wants to use a given product, she may need to get prior authorization for it, and prove that she is unable to tolerate alternative products. For a woman who chooses a long-acting reversible contraceptive (LARC), her insurance may cover the product itself but not the services of the HCP who prescribes and places it. These barriers can create undue stress and increase the risk for an unplanned pregnancy.

Overcoming the barriers

To overcome these barriers, HCPs need to advocate for complete contraceptive access for their patients. One form of advocacy involves awareness of public health policy at both the national level and the state level. HCPs can also intervene on their patients’ behalf at a very local level—in their own practices.

On the national level*

The Affordable Care Act (ACA) has a contraceptive coverage requirement giving millions of women who otherwise could not afford to pay for contraceptives the ability to make their own healthcare decisions about the use of such products and to obtain these products for free or at reduced cost. Despite this contraception coverage requirement, many insurance providers, politicians, and religious organizations have opposed the policy, creating further obstacles for women to reach full contraceptive access.

With the election and inauguration of Donald Trump and a continuing Republican majority in both the Senate and the House of Representatives, the status of the ACA was in greater jeopardy than ever. Trump’s very first act as President was to issue an Executive Order aiming to repeal and replace the ACA.But the Executive Order wasn’t sufficient to dismantle the law, and an attempt to repeal the ACA and replace it with the American Health Care Act failed. If the ACA had been repealed, more than 55 million women would have lost access to vital preventive care at no cost,4,5 including access to annual exams, birth control, cancer screening, and testing for sexually transmitted infections.

Of interest, right after the 2016 presidential election, there was a surge in contraceptive consultation visits around the country because women were concerned about the new administration’s goal to repeal the ACA.Women rushed in to get LARC methods out of fear that their insurance would drop contraceptive coverage completely.

On the state level

Some states are making it easier for underinsured or uninsured women who cannot afford to pay for healthcare visits and contraceptives to access these services and products. In 2015, I worked at a local non-profit clinic in New York where almost 18,000 women made family planning-related visits that offered full gynecologic examinations, contraceptive education, and birth control products.During this same year, these services and products were covered by a diverse payor mix: At least 50% of the patients had state-funded insurance, 26% had commercial insurance, and 16% were eligible for free services, including contraception.

An example of family planning advocacy in New York is proposed legislation to ensure that residents have access to affordable contraception. The Comprehensive Contraception Coverage Act (CCCA), an extension of the ACA, introduced by New York Attorney General Eric T. Scheiderman, would codify the requirement under the ACA that all health insurers provide cost-free contraceptive coverage as a part of their insurance policies.8,9  Under the proposal, insurance companies would have to provide cost-free coverage for at least one type of all FDA-approved contraceptives, including emergency contraception. The bill would also apply to voluntary sterilization procedures, extending coverage to both men and women, and would prohibit insurance companies from using medical management review restrictions to delay contraceptive coverage. In addition, the measure would allow patients to receive a 12-month supply of contraceptives at a time.8,9

In 2010, New York was among the top three states in the nation in terms of the rate of unintended pregnancy.10 Public health policies such as the CCCA, which would improve access to contraception, could help reduce unintended pregnancy and abortion and improve health outcomes. As of January 2017, the New York State Assembly voted to pass this critical piece of reproductive healthcare legislation ensuring access to affordable contraception.9 This situation in New York State exemplifies why we need to continue to lobby our legislators on behalf of our patients to ensure their constitutional right to acquire contraception and ultimately uphold and protect their reproductive freedom.

On the local level

Healthcare providers can use certain strategies on their own to try to reduce economic barriers for their patients. For some of my patients who have commercial insurance with high co-pays, I’ve asked pharmaceutical representatives who promote hormonal and non-hormonal contraceptive products to provide discounts and/or coupons to help reduce the cost burden. I also ask the representatives to provide product starter samples, if available, to help reduce the annual cost of contraception. However, these starter samples are of minimal use if a woman cannot afford to pay full price for the product itself once the samples are gone. I also continue to encourage pharmaceutical representatives to provide cost-containment measures for their products if possible—again, to improve contraceptive access for as many women as possible.

Conclusion

It is disheartening that, in our current times, women still have the ongoing fight for reproductive freedom and have a government that creates barriers to this fundamental right. I am proud to live and work in a state that acknowledges the importance of safeguarding women’s health. Creating full access to reproductive health services is a human right that should never have to be challenged or placed in jeopardy by politicians or laws.

Rewa N. Thompson is a women’s health nurse practitioner at Planned Parenthood of Nassau County, Hempstead, New York, and a Clinical Assistant Professor at Stony Brook University, School of Nursing, Stony Brook, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Disclaimer

The findings and conclusions in this article are those of the author and do not necessarily represent the views of Planned Parenthood Federation of America, Inc. The author is an employee of Planned Parenthood of Nassau County.

* Addendum: As this issue of the journal goes to press, we know that the House of Representatives has voted to repeal and replace the Affordable Care Act with the American Health Care Act. The measure now goes to the Senate.

References

  1. Center for Reproductive Rights. Contraceptive Access in the United States. n.d.
  2. Center for Reproductive Rights. The Contraception Controversy: A Comprehensive Reply. April 2012.
  3. National Law Review. Status of the Affordable Care Act Repeal Efforts. January 23, 2017.
  4. Center for American Progress. How Women Would Be Hurt by ACA Repeal and Defunding of Planned Parenthood. January 18, 2017. americanprogress.org/issues/ women/news/2017/01/18/296705/how-women-would-be-hurt-by-aca-repeal-and-defunding-of-planned-parenthood/
  5. Planned Parenthood. Why Americans Are So Angry About Threats to Repeal Obamacare. March 2, 2017.
  6. PBS News Hour. Trump’s Vow to Repeal Obamacare Spurs Women’s Rush to Get Birth Control. November 22, 2016.
  7. Planned Parenthood of Nassau County. 2015 Annual Report.
  8. Comprehensive Contraception Coverage Act (CCCA).
  9. Assembly to Pass Legislation Protecting Women’s Reproductive Health Rights and Access to Affordable Family Planning.
  10. Guttmacher Institute. Unintended Pregnancy in the United States. September 2016.

Incorporating features of the Bedsider website into contraceptive counseling

Traditional contraceptive counseling has involved provider and patient discussion during office visits. This pilot study sought to introduce a technology-enhanced counseling intervention utilizing features of the Bedsider websiteA. This article describes the experiences of patients and clinic staff in a Title X family planning clinic in the northeastern United States during implementation of this project.

Key words: contraception counseling, bedsider.org, family planning, long-acting reversible contraceptives, LARC

In the United States, approximately 50% of pregnancies are unintended; the U.S. continues to have one of the highest rates of unintended pregnancy among all developed countries. Although unintended pregnancies occur among women of all demographic groups, those who are young, unmarried, poor, and from an ethnic or racial minority group have the highest rates of unintended pregnancy.For women aged 18-29 years, high unintended pregnancy rates have been associated with a low level of contraceptive knowledge, low use, and fear of side effects, as well as ambivalence regarding pregnancy and mistrust of government-supported family planning services.3,4 To reduce these high rates, the CDC now recommends counseling patients about the use of long-acting reversible contraceptives (LARC), including intrauterine contraceptives (IUCs) and the subdermal implant, as first-line, highly effective options for pregnancy prevention.5,6

Researchers have documented the superiority of LARC methods over short-acting methods (pills, patches, rings, barrier methods) in lowering rates of unintended pregnancy.7,8 The short-acting contraceptives are less effective than LARC methods because they are more likely to be used incorrectly or inconsistently or to not be used at all.9 If 10% of women aged 20-29 years switched from oral contraceptives to LARC, total costs would be reduced by about $288 million per year.10 Also, LARC methods could reduce disparities associated with unintended pregnancy by enabling women to have greater control over the timing of their pregnancies.11

According to researchers who analyzed data from the 2011-2013 cycle of the National Survey of Family Growth, LARC use increased five-fold over the past decade among females aged 15-44 years.12 Even with this increase, overall rates of LARC use are low, with only 7.2% of women choosing them. For females aged 15-24, LARC use is even lower, accounting for only 5% of the contraceptive methods in this age group.12 Low utilization has been ascribed to a variety of barriers, including high cost (especially higher initial cost), lack of awareness and knowledge about LARC, lack of access to a healthcare provider (HCP) trained in LARC insertion, and restrictive clinic protocols.13-16

With recent advances in technology and new approaches to healthcare delivery, patient education has moved from passive delivery of healthcare information to a more interactive approach. These changes allow patients to be more knowledgeable and active participants in the healthcare decision-making process. This model of patient education has resulted in technology-based patient decisional-aid tools and a plethora of Internet-based applications (apps) and mobile health apps, including apps focused on contraceptive methods and choices. These decisional-aid tools can assist HCPs in delivering health education content that is visible, colorful, auditory, and interactive, facilitating the transfer and retention of information.17

Based on learning theories, the most effective decisional-aid tools are available in multiple languages, are suitable for patients with low literacy, are readily available for repeated use, and require limited knowledge of technology.18 Researchers have demonstrated that these decisional-aid tools are effective, increase patient knowledge, are acceptable both to patients and HCPs, and are cost effective.19-22

Considering the low rate of LARC use and the consistently high rate of unintended pregnancy in the U.S., the authors sought to implement a pilot trial of technology-enhanced contraceptive counseling to increase LARC use among young women who sought care at a Title X family planning clinic in the northeastern U.S. For the purpose of this study, LARC methods were defined as either the subdermal implant or an IUC (progesterone or copper).

Purpose

Specific aims of the study were (1) to incorporate a technology-enhanced counseling intervention utilizing features of the Bedsider website23 at family planning visits to increase LARC use, (2) to determine the feasibility and acceptability of the technology-enhanced counseling intervention for both patients and HCPs, and (3) to measure the difference in LARC use between the intervention and control groups.

Methods

Setting

The participating clinic in this study was Health Quarters, Inc., a non-profit, Title X provider of confidential reproductive healthcare. Services include contraceptive care, testing and treatment of sexually transmitted infections, gynecologic examinations, and sexual health education services for adolescents, women, and men in northeastern Massachusetts. This clinic provides care to uninsured and underinsured patients regardless of their ability to pay for services. Approximately 93% of patients who seek care at this site are at 250% below the federal poverty level. The clinic is located in a city in which nearly 75% of residents identify as Hispanic or Latino. It employs multilingual and multicultural staff members who reflect the community: the medical director is fluent in Spanish and the medical assistants (MAs), office assistant, and nurse practitioner (NP) are bilingual in English and Spanish.

Institutional Review Board approval to conduct the study was granted through the university of the principal investigator and supported by the clinic’s board of directors. All clinic staff members who interacted with study participants were trained in the ethical conduct of research. Data were collected from February 2015 through December 2015.

Sample

A convenience sample who met inclusion criteria—female gender; age, 18-29 years; a person seeking contraceptive services; and an English speaker—were asked to participate. At the time of the study, the Bedsider website was in English only, so women who could not read, speak, or understand English were excluded. Because the study incorporated features of the Bedsider website into contraceptive counseling, women who were pregnant or seeking pregnancy were excluded. Females younger than 18 years were excluded to ensure delivery of confidential services without parental notification of study participation.

Measures

Limited demographic information was collected to increase participant confidentiality. Contraceptive information, including history, use, and questions relating to reproductive and pregnancy coercion, were assessed via standardized questions adapted from the CDC.24,25

Procedure

Women who met inclusion criteria were recruited at the time of registration for their clinic visit and were asked by a front desk staff member if they wanted to participate in a study about contraceptive methods. Those who were interested were referred to the MA, who provided a brief overview of the study, obtained informed consent, and allowed the participant to join either the intervention group or the control group. All participants completed a pre-test study questionnaire on an iPad® prior to receiving any contraceptive counseling.

Women in the intervention group received the Bedsider website-based intervention. Specific Bedsider website features used in this intervention included the Method Explorer page, with emphasis on the most effective methods—that is, LARC—and the Compare Methods page, a side-by-side comparison of methods with respect to effectiveness, side effects, hormones, and cost. Participants were instructed to view information about the different methods while they waited for the NP to begin the visit (typical wait, 10-15 minutes). The NP reviewed the webpages with the patient as part of the contraceptive counseling process, which also included a discussion about the effectiveness, risks, benefits, method of action, medical eligibility, and instructions on use for the various contraceptives. The final choice of method was recorded. Post-intervention study questionnaires that measured contraceptive behaviors were completed at a 6-week follow-up appointment.

Women in the control group received usual care, which entailed a brief discussion with the MA about contraceptive methods and then face-to-face counseling with the NP, who discussed the effectiveness, risks, benefits, method of action, medical eligibility, and instructions on use for the various contraceptives. The final choice of method was recorded. Post-study questionnaires were completed at the 6-week follow-up.

Results

A total of 44 women enrolled in the study, 24 in the Bedsider intervention group and 20 in the control group. Twenty-five women completed the 6-week follow-up measures. Mean age for all participants was 22.2 years. Most participants self-identified as white/Caucasian (n = 24; 54.5%) or multiracial (n = 13; 29.5%). All participants reported their ethnicity as Hispanic, which is representative of the city and clinic populations. At enrollment, 20 participants (45.4%) reported using no contraceptive. In the previous year, 13 participants (29.5%) reported using emergency contraception one or more times. The Table provides demographic and contraceptive history information.

Aim 1

At the beginning of the study, 11% of the women were using an IUC or implant. Regardless of whether women chose to join the intervention group or to receive usual care, LARC use increased during the study. Of the 25 women who returned for the 6-week follow-up, 29% of those in the intervention group and 36.6% of those in the control group had chosen a LARC method. Overall contraceptive use increased. At enrollment, 45.4% of the participants reported not using any form of contraception. At the 6-week follow-up, only 12% of the 25 women were still undecided about their contraceptive method.

Aim 2

Technology-enhanced counseling using the Bedsider website was both feasible and acceptable. Although no formal qualitative interviews were conducted, study meetings with the clinic staff (MAs and NP) elicited positive feedback and no reports of technology-related problems from staff or participants. Staff members thought that the Bedsider website was a helpful adjunct to counseling. It neither shortened nor lengthened the total amount of time spent discussing contraceptive methods.

Aim 3

Overall LARC use increased with contraceptive counseling, regardless of whether it was traditional face-to-face counseling by the NP or traditional counseling enhanced by use of the Bedsider website. The intervention and control groups did not differ significantly with respect to LARC use.

Clinical implications

Although the results of this small pilot study were not statistically significant for an increase in LARC use, they are clinically interesting and have important implications for NPs who work with women at risk for unintended pregnancy. Of note, almost half the participants were not using any form of contraception at study enrollment even though they were sexually active and at risk for pregnancy. At follow-up, only 12% of participants were still undecided about their contraceptive method. Contraceptive counseling, whether done in a traditional face-to-face format with the NP or enhanced with technology, was effective in helping women choose a method.

Initial aims of this study were to incorporate technology-enhanced contraceptive counseling into practice and determine the feasibility and acceptability of this process. Use of digital media as an adjunct to traditional conversations about contraception has been noted to fill gaps that women experience when trying to access contraceptive information.26 The clinic did not previously use any technology-based counseling for patients who were trying to choose a contraceptive method. Because of their ease of use, iPads were the electronic devices chosen to access the Bedsider website. To eliminate possible distractions, all preloaded applications were removed; only a shortcut to the Bedsider website was visible to participants. The Methods Explorer and Compare Methods webpages were chosen for inclusion in the study because of their application to clinical practice in helping patients understand available methods, as well as the benefits and limitations of each method. These webpages are colorful and easy to understand, and provide pictures and brief text describing the main features of each method.

No technology-related problems were reported during the study. Prior to data collection, the iPads were connected to the clinic’s password-protected wireless Internet. Webpages loaded quickly, and participants were able to navigate the Bedsider website easily after orientation by the MA. Tablets were stored in a locked cabinet when not in use and the MAs were responsible for distributing and collecting the devices when participants were done with their visit. Although clinic staff initially expressed concerns about damaged or stolen tablets, no instances of theft or breakage occurred during the study.

Consistent with existing research, the participants were receptive to using the Bedsider website. In the past, patients have found the website convenient and easy to navigate and appreciated feature formats such as videos and pictures.27 Decisions about contraceptives are complex, multifaceted, and personal. Aids such as the Bedsider website can facilitate contraceptive decision making by allowing women to consider their own needs, values, and personal preferences, and may be particularly useful in low-resource settings.28

At enrollment, LARC use was low (11%). The authors noted an increase in LARC use for both the intervention group (29%) and the control group (36.6%)—the difference between groups was not significant—highlighting that either technology-enhanced counseling or usual care delivered by an NP favorably affected LARC use rates. The control group had slightly higher LARC uptake, but the reasons for this difference are unclear. It may have been related to individual women’s preferences or selection bias (the women self-selected into the intervention or control group). Other researchers have reported that use of the Bedsider website over a 12-month period increased the likelihood that women would use a more effective birth control method.29 Those findings were not statistically supported by this study, but the small sample size and shorter (6-week) measurement point must be considered when interpreting the results.

Although the overarching aim of the study was to increase the use of LARC methods by women attending a family planning clinic, attention was paid to each woman’s preferences and concerns. HCPs need to ensure that all contraceptive counseling is provided in a respectful manner that supports each woman in identifying the method that best suits her needs, whether or not it is a LARC method. In this study, participants received non-biased contraceptive counseling regardless of whether they joined the intervention group or the control group. Their final choice of method was supported irrespective of the method selected.

Limitations

Results of this pilot study must be viewed in terms of several limitations. The study was conducted at one clinical site. At the time of the study, the Bedsider website was in English only, thereby excluding women who were not English proficient. Likewise, in order to complete the questionnaires, participants needed to be proficient in reading English, another limitation. The final sample was small, and included only women aged 18-29 years. Also, only 57% of the participants returned for 6-week follow-up measures.

Additional recruitment difficulties revolved around the weather and the political climate at the time. In January and February 2015, the northeastern Massachusetts region of the country received historic snowfall amounts, resulting in multiple canceled clinic sessions and transportation challenges that extended into March. Most women who attended the study clinic were of Hispanic descent; some were also undocumented. In addition to the language barrier, some of these women may have been reluctant to participate in the study because of the heated rhetoric regarding Hispanic and Mexican immigrants that was dominating the media at the time.

The ensuing sample characteristics and limited follow-up data restricted generalizability beyond this sample. In addition, as with all self-report measures, issues of social desirability must be considered.

Despite these limitations, important insights were gained. The clinic that served as the research site provides low-cost healthcare, quick-start contraception, and flexible, open-access scheduling. Even with removal of access and cost barriers and the liberal policies for starting the contraceptive methods, women who enrolled in the study reported low levels of contraceptive use. The reasons for this low level of use are unclear. However, NP counseling, with or without the addition of technology, increased LARC use and overall use of contraception.

Conclusion

Providers of today encounter complex and challenging health problems within a multicultural and multilingual patient population. In this environment, patient education can be challenging. Given the move toward greater patient involvement in the healthcare decision-making process, technology-based decisional-aid tools offer an effective and acceptable adjunct for patient health education. The women who participated in this study were receptive to using the Bedsider website as an adjunct to contraceptive counseling with the NP. Participants easily navigated the webpages and did not encounter technology-related problems. Although LARC use did not differ significantly between women who received traditional face-to-face contraceptive counseling and those who received technology-enhanced counseling, the use of online/digital media to enhance contraceptive counseling was both feasible and acceptable to patients. Practice settings should consider novel ways to deliver and reinforce contraceptive teaching that will help women choose the most effective method that reflects their individual needs.

Heidi Collins Fantasia is Assistant Professor at the University of Massachusetts Lowell College of Health Sciences, School of Nursing, in Lowell, Massachusetts. Allyssa L. Harris and Holly B. Fontenot are Assistant Professors at Boston College, William F. Connell School of Nursing, in Chestnut Hill, Massachusetts. All authors practice clinically as women’s health nurse practitioners. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Funding

This study was funded by a grant from Bedsider awarded to Dr. Fantasia and Health Quarters, Inc.

Acknowledgment

The authors thank the staff and patients of Health Quarters, Inc., who graciously agreed to take part in this study.

References

  1. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485.
  2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
  3. Frost JJ, Lindberg LD, Finer LB. Young adults’ contraceptive knowledge, norms and attitudes: associations with risk of unintended pregnancy. Perspect Sex Reprod Health. 2012;44(2):107-116.
  4. Zolna M. Lindberg L. Unintended Pregnancy: Incidence and Outcomes Among Young Adult Unmarried Women in the United States, 2001 and 2008. New York, NY: Guttmacher Institute; 2012.
  5. CDC. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(4):1-66.
  6. CDC. Providing quality family planning services: recommendations of CDC and U.S. Office of Population Affairs. MMWR. 2014;63(4):1-54.
  7. Lotke PS. Increasing use of long-acting reversible contraception to decrease unplanned pregnancy. Obstet Gynecol Clin N Am. 2015;42(4):557-567.
  8. Speidel JJ, Harper CC, Shields WC. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception. 2008;78(3):197-200.
  9. Frost JJ, Darroch JE. Factors associated with contraceptive choice and inconsistent method use, United States, 2004. Perspect Sex Reprod Health. 2008;40(2):94-104.
  10. Trussell J, Henry N, Hassan F, et al. Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception. Contraception. 2013;87(2):154-161.
  11. Parks C, Peipert JF. Eliminating health disparities in unintended pregnancy with long-acting reversible contraception. Am J Obstet Gynecol. 2016;214(6):681-688.
  12. Branum AM, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15-44. NCHS Data Brief. 2015;(188):1-8.
  13. Secura GM, Allsworth JE, Madden T, et al. The contraceptive CHOICE project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010;203(2):115.e1-7.
  14. Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolesc Health. 2013;52(4 suppl):S59-S63.
  15. Biggs MA, Arons A, Turner R, et al. Same-day LARC insertion attitudes and practices. Contraception. 2013;88(5):629-635.
  16. Thompson KMJ, Rocca CH, Kohn JE, et al. Public finding for contraception, provider training, and use of highly effective contraceptives: a cluster randomized trial. Am J Public Health. 2016;106:541-546.
  17. Fox MP. A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs. Patient Educ Couns. 2009;77(1):6-13.
  18. Wofford JL, Smith ED, Miller DP. The multimedia computer for office-based patient education: a systematic review. Patient Educ Couns. 2005;59(2):148-157.
  19. Evans AE, Edmundson-Drane EW, Harris KK. Computer-assisted instruction: an effective instructional method for HIV prevention education? J Adolesc Health. 2000;26(4):244-251.
  20. Homer C, Susskind O, Alpert HR, et al. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics. 2000;106(1 pt 2):210-215.
  21. Martin JT, Hoffman MK, Kaminski PF. NPs vs. IT for effective colposcopy patient education. Nurse Pract. 2005;30(4):52 -57.
  22. Shaw MJ, Beebe TJ, Tomshine PA, et al. A randomized, controlled trial of interactive, multimedia software for patient colonoscopy education. J Clin Gastroenterol. 2001;32(2):142-147.
  23. Bedsider website. 2015.
  24. Groves RM, Mosher WD, Lepkowski J, Kirgis NG. Planning and development of the continuous National Survey of Family Growth. National Center for Vital Health Statistics. Vital Health Stat 1. 2009;(48):1-64.
  25. CDC. Sexual and reproductive health of persons aged 10-24 years – United States, 2002- 2007. MMWR Surveill Summ. 2009;58(6):1-58.
  26. Strasburger VC, Brown SS. Sex education in the 21st century. JAMA. 2014;312(2):125-126.
  27. Gressel GM, Lundsberg LS, Illuzzi JL, et al. Patient and provider perspectives on Bedsider.org, an online contraceptive information tool, in a low income, racially diverse clinic population. Contraception. 2014;90(6):588-593.
  28. Wyatt KD, Anderson RT, Creedon D, et al. Women’s values in contraceptive choice: a systematic review of relevant attributes included in decision aids. BMC Women’s Health. 2014;14(1):1-13.
  29. Antonishak J, Kaye K, Swiader L. Impact of an online birth control support network on unintended pregnancy. Soc Market Q. 2015;21(1):23-36.