Tag Archives: long-acting reversible contraceptives (LARC)

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

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  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.
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  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.
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  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.
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  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.
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  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.
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Interventions to increase LARC acceptances, with a focus on IUCs

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Long-acting reversible contraceptives, or LARC, are growing in popularity because they are highly effective, safe, and well tolerated. In addition, LARC methods require virtually no effort on the part of users besides seeing their healthcare provider (HCP) for insertion and removal. The authors describe their experience in “getting to yes”—that is, in encouraging HCPs to offer LARC methods in a patient-friendly environment and patients to consider using them—so that teens and women have access to all methods, autonomy over their method decision, and decreased risk of unintended pregnancy.

Key words: long-acting reversible contraceptives, LARC, intrauterine contraceptive, IUC, IUD, LNG-IUS

Of the 6.1 million pregnancies in the United States each year, 45% are unintended—either mistimed (27%) or unwanted (18%).1,2 Ninety-five percent of unintended pregnancies occur in females who do not use contraceptives (54%) or who use them inconsistently (41%).These unintended pregnancies may end in abortion (42%) or birth (58%),both of which have socioeconomic, fiscal, and health-related consequences. Births resulting from unintended or closely spaced pregnancies can have a variety of adverse maternal and child health outcomes.1 Furthermore, females who have children before they are ready are less likely to reach their educational, career, financial, and/or family-related goals.

Unintended pregnancies can be avoided by correct and consistent use of a birth control method. Among all reversible methods, those that require the least amount of effort by the user have been demonstrated to be the most effective at pregnancy prevention.

Background information on LARC

Long-acting reversible contraceptives, or LARC, include the subdermal implant and intrauterine contraceptives (IUCs).Both implants and IUCs are highly effective in preventing pregnancy and are FDA-approved for 3-10 years of use. In addition, these methods are reversible and do not impair fertility once they are removed; users who wish to become pregnant can have them removed at any time. LARC methods are the most effective forms of reversible birth control available: During the first year, fewer than 1% of implant or IUC users will become pregnant.4 Failure rates associated with the use of other contraceptives are considerably higher.

Devices

The implant is a single, matchstick-sized, etonogestrel-containing rod that is placed in the subdermal tissue of the inside aspect of the upper non-dominant arm.5 The implant, which is marketed as Nexplanon®, contains barium, allowing localization with radiography. The implant is FDA-approved for 3 years of use.

Intrauterine contraceptives, either an intrauterine device (IUD) or an intrauterine system (IUS), are T-shaped devices containing copper or levonorgestrel (LNG).Four IUCs are available, the Copper T 380A (ParaGard®) and three LNG-IUS products: Mirena®, Skyla®, and Liletta®. The copper IUD is effective immediately following placement7 and is FDA approved for 10 years of use.Mirena is FDA approved for 5 years of use, and Skyla and Liletta for 3 years of use.6 Data collection for Liletta is ongoing; it is expected that the manufacturer will ultimately seek approval for up to 7 years of use. If an LNG-IUS product is placed during the first 7 days of the menstrual cycle or immediately following birth, a miscarriage, or a first-trimester abortion, then back-up contraception is not needed.6,8 Otherwise, a backup method is recommended for the first 7 days.

Of note, LARC methods do not protect users against sexually transmitted infections (STIs). Condoms are needed for protection against STIs.

Medical eligibility criteria

All teenagers and women should be considered candidates for LARC use until proven otherwise.9-11 Readers can access the CDC’s Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. Information from the CDC is also available as a free iPhone or iPad app at the iTunes store or as an eBook available on an eReader app.

Trends in LARC use

LARC methods are gaining in popularity for many reasons, but mainly because of their high efficacy.12 According to an analysis of National Survey for Family Growth (NSFG) data, the proportion of female U.S. contraceptors using the IUD or implant increased from 2.4% in 2002 to 3.7% in 2007 and to 8.5% in 2009.13 According to a more recent analysis of the NSFG data, the prevalence of LARC use among contraceptors rose from 8.5% in 2009 to 11.6% in 2012, a significant increase.14,15 Much of this trend was driven by IUC use, which increased from 7.7% to 10.3%; implant use remained low (1.3%) and did not change significantly between these two time periods.

The Contraceptive CHOICE Project

Although increased use of LARC methods has been encouraging, uptake is still relatively low—especially considering the high rate of unintended pregnancy in this country, the superior efficacy of these methods, and the many non-contraceptive benefits they offer. The next logical question is, What can be done to increase education about and access to LARC methods for reproductive-aged females who wish to prevent pregnancy?

Purpose and methods

The Contraceptive CHOICE Project was undertaken to remove educational, financial, and access barriers to contraception; to promote the most effective methods of birth control; and to reduce unintended pregnancy in the St. Louis, Missouri, area.16 Objectives of the project were to increase uptake of LARC; to measure/analyze method choice, satisfaction, side effects, and continuation across all reversible contraceptive methods; and to provide enough no-cost contraception to exert a population impact on unintended pregnancies particularly with respect to teen pregnancy and repeat abortion.

Enrollment began in August 2007 and ended in September 2011. Prospective enrollees ranged in age from 14-45 years, wanted to avoid pregnancy for ≥1 year, and were willing to initiate a new form of reversible contraception.17,18 Recruitment was done via word of mouth, referral from private and community healthcare providers (HCPs), and from the two abortion facilities in the St. Louis region. Participants underwent standardized evidencebased contraceptive counseling by trained non-clinicians. The counseling was structured on effectiveness tiers, and included the risk and benefits of each method. Tier 1 contraceptives—the most effective methods, which include LARC (IUCs and the implant)— were described first. Next, the counselor described tier 2 methods or refillables: depot medroxy-progesterone acetate (DMPA), and the pill/patch/ring (PPR). Tier 3 methods, including the diaphragm, the condom, the sponge, spermicide, withdrawal, and fertility awareness-based methods, were described last. Participants received their chosen contraceptive free of charge, and they could switch methods as frequently as they wanted for the duration of their study participation (2-3 years).

Results

Contraceptive choices of the entire cohort and of the teen cohort alone are shown in the FigureAmong 9,256 adult and teen participants, 75% chose a LARC method; among teens alone, 71% chose a LARC method.

Continuation rates

Among LARC users, adults and teens had high continuation rates—87% and 82%, respectively— at 12 months.19,20 Non- LARC users had much lower 12- month continuation rates: 59% for adults and 49% for teens. Among LARC users, continuation rates at 24 months were still high: 78% for adults and 67% for teens.20 Only 42% of adult non-LARC users and 37% of teen non-LARC users continued using the contraceptive method they chose at baseline for 24 months. At 3 years, continuation rates were 67.2% among LARC users and 31.0% among non-LARC users.21

Satisfaction levels

Twelve-month satisfaction levels mirrored continuation rates. A greater proportion of LARC users than non-LARC users reported being very satisfied or somewhat satisfied with their method (81.2% vs. 48.8%).19 This differential in satisfaction between LARC users and non-LARC users held true for adults (82% vs. 50%) and for teens (75% vs. 42%). Satisfaction was similarly high among users of the subdermal implant, copper IUD, or LNG-IUS (range, 72% for teen users of the copper IUD to 84% for adult users of the LNG-IUS) and similarly low among users of DMPA or PPR (range, 31% for teen users of the ring to 52% for adult users of DMPA or the ring).

Unintended pregnancy and abortion rates

Even more important, among 7,486 participants included in this analysis, 334 (4.5%) experienced unintended pregnancies.4 Failure rates among PPR users were 4.8%, 7.8%, and 9.4% in years 1, 2, and 3, respectively; corresponding rates among LARC users were 0.3%, 0.6%, and 0.9%
(P <.001). Failure rates among DMPA users were similar to those of the LARC users. LARC methods were highly effective in preventing pregnancy regardless of a user’s age, whereas teen PPR users were twice as likely as adult PPR users to become pregnant.

One of the primary outcomes of interest was the percentage of abortions that were repeat abortions.18 Using vital statistics data from Missouri’s state health department, the investigators found a significant difference in the proportion of repeat abortions between the St. Louis region and Kansas City in 2009 (respective rates, 46% vs. 49%; P = .02) and 2010 (respective rates, 44% vs. 51%; P <.01). In addition, they detected a significant decline in the proportion of repeat abortions over time in the St. Louis region (= .002). Another analysis revealed that pregnancy, birth, and abortion rates among teens in the CHOICE Project were substantially lower than national rates among sexually experienced teens.22 Respective annual rates of pregnancy, birth, and abortion were 34.0, 19.4, and 9.7 per 1,000 teen CHOICE Project participants, as compared with 158.5, 94.0, and 41.5 per 1,000 sexually experienced U.S. teens in 2008.

Summary of main findings

LARC methods, as compared with shorter-acting methods, were associated with higher continuation rates and user satisfaction levels, regardless of age. In addition, LARC methods were associated with lower rates of unintended pregnancy and, as a consequence, lower rates of birth and abortion. An informative video about the Contraceptive CHOICE Project is available at Pathway to Choice. Box 1 shows how CHOICE got to yes.

Barriers to IUC use, and how to overcome them

In order for the encouraging results of the CHOICE Project to translate to other populations throughout the country, barriers must be overcome. From this point onward, this article focuses on IUCs.

The National Committee for Quality Assurance has issued a White Paper, Women’s Health: Approaches to Improving Unintended Pregnancy Rates in the United States, that describes numerous barriers that impede our nation’s ability to reduce the rate of unintended pregnancy. To read a summary of these barriers, click here. To read the entire White Paper, click here.

Provider barriers

Many HCPs have concerns about prescribing and placing IUCs. Many of these concerns are easily addressed.

Lack of training

If an HCP’s training occurred prior to 2001, she or he may not have received instruction in IUC placement. To acquire such training, HCPs can seek out instructors provided by product manufacturers or academic institutions, or they can attend conferences where such training is provided. HCPs need not be certified by the manufacturer to place IUCs; any HCP who feels comfortable with the instructions and the procedure may place them.

Too few patients to gain competency

An HCP such as a primary care provider or a rural health provider may not see enough patients to maintain a comfortable competency in IUC placement. This barrier may or may not be surmountable; each HCP has her or his own threshold for a feeling of competency. One approach is to form a collaborative relationship with a high-volume provider who can offer ongoing support and training. In addition, if HCPs view each patient encounter with a reproductive-aged female as an opportunity to address her goals with respect to pregnancy and/or pregnancy prevention, then they will likely be providing many more contraceptive services than they think.

Fear of litigation

Some HCPs may fear litigation if complications arise; some of the items in the bulleted list in the next section can help dispel this fear. Concerns based on myths Each of these myths surrounding IUCs is debunked.

Teenagers and nulliparous women are not appropriate candidates for IUCs. Evidence shows that these females are excellent candidates for IUCs, which are highly effective regardless of age or parity.10

Young women won’t like IUCs because placement is too painfulPlacement comfort varies from patient to patient. Many young women tolerate the placement procedure very well.23

Most patients cannot afford IUCsMany women have coverage for IUCs.24 More will be able to get them as the Affordable Care Act (ACA) continues to implement the 2011 Institute of Medicine recommendations.

Women should have IUC counseling at one visit and return for IUC placement at the next visitTwo-thirds of women prefer to have the IUC placed on the same day it is prescribed.25 Adding a second visit places an extra barrier between the patient and her receiving the desired contraceptive, thereby increasing her risk for unintended pregnancy.

Patients won’t keep their IUCsIUCs had the highest continuation rates of any method offered in the CHOICE Project.26

Patients already know what they want. When CHOICE Project participants were advised of all their birth control options and allowed to choose what they wanted, 58% chose an IUC. In the real world, only 10% of U.S. females choose an IUC.14,15 Many females are unfamiliar with LARC methods or harbor misconceptions about them. They cannot know what they want unless they are fully informed about the options.

HCPs don’t have time to tell patients about every methodTrained staff members can inform patients of their options, starting with the most effective methods.27 In addition, HCPs can provide decision aids that patients can use in the waiting room before their visits.

High upfront cost

The high cost to stock IUCs, with a delay in reimbursement, may keep some HCPs from offering them. The ACA has helped in that the cost of a contraceptive and its placement should be fully covered, with no cost share to the patient. However, barriers do remain: Some health insurance plans exclude contraceptive coverage for religious reasons, small companies need not comply, and some state plans do not cover at 100% or have restrictions on use.

Concern about a prospective IUC user being pregnant 

According to the U.S. Selected Practice Recommendations for Contraceptive Use, an HCP can be reasonably certain that a patient is not pregnant if she has no signs or symptoms (S/S) of pregnancy, has a negative urine pregnancy test result, and meets any one of these criteria8:

• ≤7 days after the start of her normal menses;

• abstinence since the start of her last normal menses;

• correct and consistent use of contraception;

• ≤7 days after spontaneous or induced abortion;

• within 4 weeks postpartum; or

• fully or nearly fully breastfeeding, amenorrheic, and <6 months postpartum.

Concern about a prospective IUC user having an STI

At-risk patients can be tested for gonorrhea and chlamydia at IUC placement.10 If a positive result is noted, the device can still remain in place. The HCP can treat the infection, offer expedited partner therapy as per CDC guidelines, inform patients about the warning S/S of pelvic inflammatory disease (PID; e.g., new-onset abdominal or pelvic pain, foul-smelling vaginal discharge, pain during or shortly after sex, fever, abnormal uterine bleeding), and retest in 3 months. However, if an HCP suspects active infection at the time, the device should not be placed. Instead, the patient is tested and treated as needed. No evidence suggests that IUCs increase the risk for developing an STI.

Patient barriers

These barriers include lack of knowledge about IUCs, negative influence of friends or the media, lack of access to HCPs who can provide IUCs, and cost concerns. The CHOICE Project overcame these barriers by having non-clinicians educate participants about all birth control methods. HCPs provided same-day LARC placement as per the U.S. Selected Practice Recommendations for Contraceptive Use guidelines.The birth control methods were provided free of charge. In Open the Dialogue, CHOICE Project participants describe how they felt when education, access, and cost barriers were removed and they could choose any birth control method they wanted.

IUC risks and side effects

One of the main concerns about IUC placement is uterine perforation, which occurs in about 1 in 1,000 placements.3 Red flags indicating acute uterine perforation include the uterus sounding to a depth greater than that appreciated on bimanual examination, sudden loss of resistance, and patient pain disproportionate to that expected. Vaginal bleeding is unlikely.

Another concern is PID, which develops in fewer than 1% of IUC users, usually during the first 20 days post-placement. Appropriate precaution—screening highrisk women at the time of placement and delaying placement in those with active cervicitis—is the best way to minimize this risk. In very rare cases, pregnancy may occur with the IUC in place; if so, there is a higher chance that it will be an ectopic pregnancy. IUC users with a positive pregnancy test result need to be promptly evaluated to rule out ectopic pregnancy and undergo pregnancy options counseling.

With the copper IUD, menstrual pain and bleeding may increase at first.3 Intermenstrual bleeding may occur as well. These side effects are common in the first few months of use and tend to subside within a year. The LNG-IUS may be associated with spotting, irregular bleeding, and menstrual cramping in the first few months of use. Again, these side effects tend to diminish over time. Some users may experience LNG-related effects such as headache, nausea, depression, and breast tenderness.

Creating a LARC-friendly practice

Healthcare providers who wish to create a LARC-friendly practice know that LARC methods are the most effective reversible methods. They know that every patient is a LARC candidate until proven otherwise. They have ensured that all office staffers are knowledgeable about LARC, can follow an effectiveness tier-based counseling approach as per the CDC guidelines, and promote LARC use. After all, support staff members’ perceptions can greatly affect patients’ decisions. Other tenets of a LARC-friendly practice include the following:

• Every effort is made to help patients obtain the method of their choice.

• Same-day LARC placement is the standard.

• All HCPs have received proper LARC training.

• LARC methods are stocked if possible.

More information about setting up a LARC-friendly practice, including an introductory video, is available at the LARC First website. A message from the authors appears in Box 2.

Conclusion

Long-acting reversible contraceptives are the most effective birth control methods on the market. As shown in the CHOICE Project, IUCs and implants are superior to other methods in terms of continuation rates and satisfaction levels. As such, LARC methods should be considered first-line options for all females, including adolescents and nul liparous women. LARC method efficacy does not depend on user compliance. HCPs should provide counseling and reassurance so that patients know what to expect at the time of placement, as well as possible side effects. Same-day IUC placement should be the standard. As providers of healthcare to teenage girls and women, HCPs are privileged to be able to have a dramatic impact on patients’ lives with such a simple intervention.

References

1. Guttmacher Institute. Unintended Pregnancy in the United States. Fact Sheet. March 2016.

2. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843-852.

3. American Congress of Obstetricians and Gynecologists. Long-Acting Reversible Contraception (LARC): IUD and Implant. May 2016.

4. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007.

5. Association of Reproductive Health Professionals. Choosing a Birth Control Method. Implant. Updated June 2014.

6. Association of Reproductive Health Professionals. Choosing a Birth Control Method. Intrauterine Contraception. Updated June 2014.

7. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

8. Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. July 29, 2016.

9. ACOG Practice Bulletin. Long-Acting Reversible Contraception. #121, July 2011.

10. CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. July 29, 2016.

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15. Guttmacher Institute. Use of Long-Acting Reversible Contraceptive Methods Continues to Increase in the United States. Press release. October 8, 2015.

16. Contraceptive CHOICE Project.

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19. Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120(6):1298-1305.

20. O’Neil-Callahan M, Piepert JF, Zhao Q, et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol. 2013;122(5): 1083-1091.

21. Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol2015;213(5):662.e1-8.

22. Birgisson NE, Zhao Q, Secura GM, et al. Preventing unintended pregnancy: the Contraceptive CHOICE Project in review. J Womens Health (Larchmt). 2015;24(5):349-353.

23. McNicholas CP, Madden T, Zhao Q, et al. Cervical lidocaine for IUD insertional pain: a randomized controlled trial. Am J Obstet Gynecol. 2012;207(5):384.e1-6.

24. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press; 2011.

25. Stanek AM, Bednarek PH, Nichols MD, et al. Barriers associated with the failure to return for intrauterine device insertion following firsttrimester abortion. Contraception2009;79(3):216-220.

26. Peipert JF, Madden T, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-1113.

27. Madden T, Mullersman JL, Omvig KJ, et al. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013;88(2):243-249.