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

Intersection between access difficulties and obstetric violence in abortion itineraries

In Brazil, several limitations are imposed upon the access of women undergoing abortion to the healthcare network, primarily caused by the influence of moral and religious values and gender iniquities. In this light, the present study aimed to analyze the experience of women who had an abortion regarding the care provided by healthcare services as part of the abortion itinerary. This is a qualitative study, carried out with 18 women in three cities - one small city, one mid-sized, and one big - in the state of Bahia. Data were produced by face-to-face or online interviews. The empirical material was analyzed using the discourse analysis technique. The results show, in the three municipalities, abortion itineraries under social and gender iniquities, with greater access difficulties for low-income women. Better financial conditions allow access to clandestine private clinics but without guaranteeing humanized care. In the three municipalities, economically disadvantaged women self-induced abortions and delayed seeking services, having faced embarrassing and prejudicial professional attitudes. The results point to the urgency of implementing public policies in which reproductive rights are as effective as human rights.

Mapping Long-acting Reversible Contraceptive Interventions to the Social Ecological Model: A Scoping Review

INTRODUCTION

Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels.

METHODS

We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other.

RESULTS

Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n = 12) and cost support (n = 12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use.

CONCLUSIONS

Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

Increasing Access to Intrauterine Devices and Contraceptive Implants: ACOG Committee Statement No. 5

Everyone who desires long-acting reversible contraception should have timely access to contraceptive implants and intrauterine devices. Obstetrician-gynecologists and other reproductive health care clinicians can best serve those who want to delay or avoid pregnancy by adopting evidence-based practices and offering all medically appropriate contraceptive methods. Long-acting reversible contraceptive devices should be easily accessible to all people who want them, including adolescents and those who are nulliparous and after spontaneous or induced abortion and childbirth. To achieve equitable access, the American College of Obstetricians and Gynecologists supports the removal of financial barriers to contraception by advocating for coverage and appropriate payment and reimbursement for all contraceptive methods by all payers for all eligible patients.

The significant influence of history of induced abortion on the utilisation of long-acting reversible contraceptive methods in the immediate post abortion period, Northern Ethiopia

BACKGROUND

Rapid population growth, untended pregnancy, and related consequences remain the concern of Sub-Saharan African countries, including Ethiopia. Despite this, long-acting reversible contraceptives methods are still underutilised and no studies have sought the factors in this study setting. Therefore, this study conducted to assess the prevalence and determining factors of long-acting reversible contraceptives utilisation following an abortion in Northern Ethiopia.

METHOD

Facility-based cross-sectional study design was employed. A total of340 post aborted women selected by a systematic sampling method from August 1 to October 30, 2018. Data were entered into Epi-Info version 7 software and exported to SPSS version 20 for analysis. Both bivariate and multivariate logistic regression models were used to identify factors associated with the outcome variable.

RESULTS

The overall post-abortion long-acting reversible contraceptives utilisation was 57(16.76%) with 47(82.46%) implantand 10 (17.54%) intrauterine devices. Age range 20-29 years (AOR = 0.09, 95% CI 0.02-0.37), employed (AOR = 5.22, 95% CI 1.99-13.67), had ≥2 alive children (AOR = 7.02, 95% CI 1.58-31.23), induced abortion (AOR = 8.41, 95% CI 3.28-21.59), surgical abortion (AOR = 5.99, 95% CI 2.25-15.94), previous awareness (AOR = 3.18, 95% CI 1.14-8.82) and history of prior utilisation (AOR = 3.59, 95% CI 1.08-11.97) were the factors significantly associated with utilisation of post-abortion long-acting reversible contraceptives.

CONCLUSION

Long-acting reversible contraceptive methods level of utilisation following an abortion in this study was low. Advocating and raising awareness should always consider on benefits and effectiveness of long-acting reversible contraceptives for all type of abortion and methods of termination as an integral part of reproductive health care services.

Contraceptive Method Uptake at Title X Health Centers in Utah

BACKGROUND

The Title X family planning program previously supported contraception for Utah clients with low incomes, yet its contributions may not have been sufficient to allow clients to select their preferred methods, including long-acting reversible contraceptives (LARCs). In this study, we compare the contraceptive method choices of self-paying clients with low incomes at three participating Title X health centers in Salt Lake County, Utah, before and after the removal of additional cost barriers.

METHODS

We used retrospective medical record review to assess clients' contraceptive choices during two 6-month periods: a control period with Title X-assisted sliding scale payment schedules (n = 2,776) and an intervention period offering no-cost contraceptive care (n = 2,065). We used logistic regression to identify the likelihood of selecting a LARC during the intervention period and multinomial regression to identify the selection probability of different types of available LARCs.

RESULTS

During the control period, 16% of participants chose a LARC compared with 26% in the intervention period (p ≤ .001). During the intervention period, participants were 1.8 times more likely to select LARCs (95% confidence interval, 1.65-2.13) compared with non-LARC methods, holding covariates constant. In the multinomial regression, participants were three times more likely during the intervention period to select an implant than a pill, patch, or ring, holding all other covariates constant (odds ratio, 3.08; 95% confidence interval, 2.47-3.83).

CONCLUSIONS

Title X clients offered contraceptive methods without cost more frequently selected a LARC method. Title X funding reductions may impede individuals' access to their contraceptive methods of choice.

Adherence to Swedish national recommendations for long acting reversible contraceptive provision at the time of medical abortion

OBJECTIVE

To investigate if abortion clinics follow Swedish national guidelines regarding early insertion of long-acting reversible contraception (LARC) after medical abortions up to 9 weeks of gestation and, if not, the reasons for not doing so.

STUDY DESIGN

We attempted to survey representatives of all 60 known Swedish abortion clinics by telephone in November 2019, including public hospitals and private clinics. We asked questions about clinic characteristics, clinic routines concerning early insertion of IUDs and implants, adherence to guidelines and, when applicable, perceived reasons for nonadherence. Current guidelines include offering implant placement at the time of mifepristone administration and intrauterine device (IUD) insertion within 7 days of misoprostol treatment.

RESULTS

We obtained responses from 57 (95%) clinics of which 22 (40%) followed guidelines for both implants and IUDs. Slightly more than half (n = 33, 58%) follow implant guidelines and fewer (n = 25, 44%) follow IUD guidelines. Respondents most commonly cited lack of updated local guidelines at the clinic (7/24, 29%) and a perceived lack of time (6/25, 24%) as the most common reasons for nonadherence to guidelines for insertion of implants and insufficient number of nurse midwives for insertion of IUDs 8/32, 25%).

CONCLUSIONS

Less than half of Swedish abortion clinics fully adhere to national evidence-based guidelines regarding early LARC insertion at the time of abortion.

IMPLICATIONS

National guidelines alone are not always sufficient to effect change in practice; awareness of existing guidelines is needed in Swedish abortion clinics and work is needed to address barriers that limit LARC access after abortion.

Women's Reproductive Rights Policies and Adverse Birth Outcomes: A State-Level Analysis to Assess the Role of Race and Nativity Status

INTRODUCTION

Reproductive rights policies can potentially support or inhibit individuals' abilities to attain the highest standard of reproductive and sexual health; however, research is limited on how broader social policies may differentially impact women of color and immigrants in the U.S. This study examines the associations among state-level reproductive rights policies, race, and nativity status with preterm birth and low birth weight in the U.S.

METHODS

This was a retrospective, cross-sectional analysis of all births occurring within all the 50 states and the District of Columbia using vital statistics birth record data in 2016 (N=3,945,875). Modified log-Poisson regression models with generalized estimating equations were fitted to estimate the RR of preterm birth and low birth weight associated with tertiles of the reproductive rights policies index. Analyses were conducted between 2019 and 2020.

RESULTS

Compared with women in states with the most restrictive reproductive rights policies, women living in the least restrictive states had a 7% lower low birth weight risk (adjusted RR=0.93, 95% CI=0.88, 0.99). In particular, low birth weight risk was 8% lower among Black women living in the least restrictive states than among their counterparts living in the most restrictive states (adjusted RR=0.92, 95% CI=0.86, 0.99). In addition, low birth weight risk was 6% lower among U.S.-born Black women living in the least restrictive states than among those living in the most restrictive states, but this was marginally significant (adjusted RR=0.94, 95% CI=0.89, 1.00). No other significant associations were found for race-nativity-stratified models.

CONCLUSIONS

Women living in states with fewer restrictions related to reproductive rights have lower rates of low birth weight, especially for Black women.

Women's Postabortion Contraceptive Preferences and Access to Family Planning Services in Mississippi

BACKGROUND

Women's preferences for postabortion contraceptive care vary, and some may experience difficulties realizing their preferences owing to health systems-level barriers. We assessed Mississippi women's interest in postabortion contraceptive counseling and method use and the extent to which their method preferences were met.

METHODS

In 2016, women ages 18 to 45 completed a self-administered survey at their abortion consultation visit in Mississippi and a follow-up phone survey 4-8 weeks later. Thirty-eight participants were selected for in-depth interviews. We computed the percentage of women who were interested in contraceptive counseling, initiating a method, and who obtained a method at the clinic. We also calculated the percentage who were using their preferred method after abortion and the main reasons they were not using this method. We analyzed transcripts using a theme-based approach.

RESULTS

Of 323 women enrolled, 222 (69%) completed the follow-up survey. Of those completing follow-up, more than one-half (58%) reported that their consultation or abortion visit was the best time for contraceptive counseling, and 69% wanted to initiate contraception at the clinic. Only 10% obtained a method on site, and in-depth interview respondents reported they could not afford or did not like the options available. At the follow-up survey, 23% of respondents were using their preferred method. Women cited cost or lack of insurance coverage and difficulties scheduling appointments with community clinicians as reasons for not using their preferred method.

CONCLUSIONS

Mississippi women have a large unmet demand for postabortion contraception. Policies that support on-site provision of contraception at abortion facilities would help women to realize their contraceptive preferences.

Health insurance coverage and contraceptive use at the state level: findings from the 2017 Behavioral Risk Factor Surveillance System

Objective

To examine associations between health insurance coverage, income level and contraceptive use — overall and most/moderately effective method use — among women ages 18–44 at risk of pregnancy, within and across 41 United States jurisdictions in 2017.

Study design

Using data from the 2017 Behavioral Risk Factor Surveillance System, we calculated the proportions of women using any contraceptive method and using a most or moderately effective method for each state/territory and across all jurisdictions, categorized by health insurance coverage and income groups. For both contraceptive use outcomes, we ran simple and multivariable logistic regression models to test for significant differences in outcomes between insured and uninsured individuals.

Results

Across jurisdictions, compared to uninsured women, those who had health care coverage had higher levels of contraceptive use (65% versus 59%; p < .001) and most/moderately effective contraceptive use (43% compared to 35%; p < .001); low-income women with coverage also had higher levels of contraceptive use (64% versus 61%; p < .05) and most or moderately effective contraceptive use (42% versus 36%; p < .01) than their uninsured counterparts. Controlling for individual-level demographic characteristics, health insurance coverage was associated with increased odds of most or moderately effective contraceptive use across jurisdictions (adjusted odds ratio = 1.33, p < .01). In 11 states, insured women had significantly higher odds of at least one contraceptive use metric than their uninsured counterparts.

Conclusions

Variation in contraceptive use across the states likely reflects broader demographic, social and structural differences across state and local populations. States' political will and support around contraceptive access likely play a role in individuals' ability to obtain and use contraception.

Implications

Our key finding that insurance coverage is significantly associated with use of most/moderately effective contraceptive methods across the states but not any contraceptive use underscores the importance of health insurance in aiding access to methods that are more costly and often require a visit to a health care provider.

Contraceptive counseling practices and patient experience: Results from a cluster randomized controlled trial at Planned Parenthood

OBJECTIVES

Systematic reviews of contraceptive counseling interventions have shown inconsistent impact on patient outcomes. The current study assessed the effects of an evidence-informed contraceptive counseling staff training intervention on patient experience, contraceptive selection, and behavior over three months of follow-up.

STUDY DESIGN

We randomly assigned 10 Planned Parenthood health centers in the Southeastern US to intervention (staff received contraceptive counseling training) and control (usual counseling) groups. From December 2016-June 2017, patients completed surveys immediately post visit (n = 756) and one and three months after. We compared differences in patients' counseling experience (e.g., number of evidence-informed practices experienced, satisfaction with counseling), contraceptive selection, and behavior (e.g., method discontinuation, accurate pill use, condom use) between study groups using mixed effect models with health center specified as a random effect.

RESULTS

Seven hundred and fifty-six participants completed the baseline survey; 579 (77%) completed one or both follow-up surveys. The intervention group was more likely to report experiencing all evidence-informed counseling practices (adj. Prevalence Ratio [aPR] = 2.27, 95% CI 1.27, 4.04) with less variation in the number of practices and higher satisfaction with their counseling than the control group (p < 0.01). We found no sustained differences in contraceptive behaviors at both one- and three-month follow-up.

CONCLUSIONS

We found immediate positive effects of the intervention on patients' perceptions of their counseling experience and no differences in changes in contraceptive behavior over time between the study groups.

IMPLICATIONS

Evidence-based strategies to improve the quality of contraceptive care and subsequent outcomes, while centering patients' needs and preferences, are needed. The contraceptive counseling intervention offers a tool for increasing consistency in contraceptive counseling practices across health centers and improving patient satisfaction.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements

Introduction

Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal.

Methods

This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities.

Findings

Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02–1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01–1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75–8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06–7.75) compared with private sector health facilities.

Conclusion

The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion

OBJECTIVES

To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation.

STUDY DESIGN

We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome.

RESULTS

Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant.

CONCLUSION

About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles.

IMPLICATIONS

Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.

Contraception after Abortion and Risk of Repeated Unintended Pregnancy among Health Plan Members

CONTEXT

Optimizing access to effective contraception at the time of abortion can reduce repeated unintended pregnancies.

OBJECTIVE

To assess contraception initiation and repeated unintended pregnancies among women receiving abortions in Kaiser Permanente Northern California (KPNC) facilities and through outside contracted facilities.

DESIGN

A retrospective cohort study was conducted using a randomized proportional sample of women aged 15 to 44 years having abortions in KPNC, to determine contraception initiation within 90 days. Demographic and clinical characteristics (age, race/ethnicity, gravidity, parity, contraceptive method initiated, and pregnancies within 12 months) were collected from electronic health records. Descriptive statistics, χ² tests, t-tests, and logistic regression models assessed predictors of long-acting reversible contraception (LARC) initiation and having another unintended pregnancy within 12 months of abortion.

RESULTS

Women having abortions from contracted facilities were significantly less likely to initiate LARC within 90 days compared with those receiving abortions in KPNC facilities (11.99% vs 19.10%, p = 0.012). Significant factors associated with 90-day LARC initiation included abortions in KPNC facilities (adjusted odds ratio [aOR] = 1.87, p = 0.007) and gravidity of 3 or more. Women initiating short-acting or no contraception were significantly more likely to have an unintended pregnancy within 12 months of the abortion than those initiating LARC (aOR = 3.66, p = 0.005; no contraception vs LARC, aOR = 3.75, p = 0.005).

CONCLUSION

In response to this study, KPNC now provides reimbursement for LARC in all outside abortion contracts, internalized more abortions in KPNC facilities, and strengthened clinical recommendations for immediate, effective postabortion contraception, especially LARC.

Spatial and socio-economic correlates of effective contraception among women seeking post-abortion care in healthcare facilities in Kenya

Introduction

Information, counseling, availability of contraceptives, and their adoption by post-abortion care (PAC) patients are central to the quality of PAC in healthcare facilities. Effective contraceptive adoption by these patients reduces the risks of unintended pregnancy and repeat abortion.

Methods

This study uses data from the Incidence and Magnitude of Unsafe Abortion Study of 2012 to assess the level and determinants of highly effective contraception among patients treated with complications from an unsafe abortion in healthcare facilities in Kenya. Highly effective contraception was defined as any method adopted by a PAC patient that reduces pregnancy rate by over 99%.

Results

Generally, contraceptive counseling was high among all PAC patients (90%). However, only 54% of them received a modern family planning method—45% a short-acting method and 9% a long-acting and permanent method. Adoption of highly effective contraception was determined by patient’s previous exposure to unintended pregnancies, induced abortion and modern family planning (FP). Facility level factors associated with the uptake of highly effective contraceptives included: facility ownership, availability of evacuation procedure room, whether the facility had a specialized obstetric-gynecologist, a facility that also had maternity services and the number of FP methods available for PAC patients.

Discussion and conclusion

For better adoption of highly effective FP, counseling of PAC patients requires an understanding of the patient’s past experience with contraception and their future fertility intentions and desires in order to meet their reproductive needs more specifically. Family planning integration with PAC can increase contraceptive uptake and improve the reproductive health of post-abortion care patients.

Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial

BACKGROUND

With advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge.

METHODS

This was a pilot randomised controlled trial. Prior to their abortion visit, participants were randomised to the intervention message, a standardised notification about the availability, effectiveness and safety of long-acting (LARC) and short-acting reversible contraception (SARC) on the day of the abortion, or to the control message, a reiteration of appointment logistics without information about contraception. At the visit, participants completed a pre-procedure survey to assess contraceptive knowledge and usefulness of the intervention. The primary outcome was knowledge of LARC availability immediately after surgical abortion. A secondary outcome was contraceptive method uptake.

RESULTS

We enrolled 234 subjects. The pre-visit telephone notification improved knowledge that LARC is available immediately after surgical abortion (71.3% vs 50.9%, P<0.01). Participants in both study arms found the telephone notifications useful. Post-abortion contraceptive method choice did not differ between study arms.

CONCLUSIONS

Advance notice about contraception was acceptable to surgical abortion patients and improved their contraceptive knowledge.

TRIAL REGISTRATION NUMBER

NCT02836561.

Long-Acting Reversible Contraceptive Uptake before and after the Affordable Care Act Contraceptive Mandate in Women Undergoing First Trimester Surgical Abortion

OBJECTIVE

To compare long-acting reversible contraceptive (LARC) uptake before and after the Affordable Care Act (ACA) contraceptive mandate among women undergoing a first trimester surgical abortion.

STUDY DESIGN

We conducted a retrospective chart review of 867 women undergoing a first trimester surgical abortion at an academic gynecology practice between December 2010 and December 2014 (excluding August to December 2012) to evaluate intrauterine device and contraceptive implant uptake before and after the ACA contraceptive mandate.

RESULTS

Before the ACA contraceptive mandate, 79% of privately insured women (213 of 271) had full LARC coverage (no out-of-pocket costs) compared with 92% (298 of 324) after the mandate (p < .001). We found no difference in postabortal LARC uptake before and after the ACA in women with private insurance, Medicaid, or overall. Among all women, 46% chose a postabortal LARC method before the mandate as compared with 48% after the mandate (p = .63). Among privately insured women, 45% used a postabortal LARC method before the mandate as compared with 50% after the mandate (p = .25). One-half of privately insured women (268 of 534) with full or partial LARC coverage used a postabortal LARC method compared with 32% of privately insured women (18 of 56) with no LARC coverage after implementation of the ACA contraceptive mandate (p = .01).

CONCLUSIONS

Despite the significant increase in full coverage of LARC among privately insured women, there was no change in postabortal LARC use after the ACA. However, privately insured women with full or partial LARC coverage were more likely to use a postabortal LARC method compared with privately insured women with no LARC coverage after the implementation of the ACA contraceptive mandate.

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.

Contraceptive Use over Five Years After Receipt Or Denial of Abortion Services

CONTEXT

Nonuse and inconsistent use of contraceptives contribute to a high incidence of unintended pregnancy and abortion among U.S. women. Little is known, however, about how these outcomes shape women's subsequent contraceptive use and unintended pregnancy risk.

METHODS

Contraceptive use was examined among 880 participants in the Turnaway Study, a five-year longitudinal study of women who sought abortions at 30 U.S. facilities in 2008-2010. Multivariable mixed-effects logistic and multinomial regression models assessed differences in use by whether women received the abortion; results were used to calculate predicted percentages of women using each method. The main groups of interest were 415 women who had an abortion at a gestation near their facility's limit and 160 who were denied abortion because they were beyond the limit, and who consequently gave birth.

RESULTS

During each of the approximately five years of follow-up, the predicted percentage using any contraceptive method was 86% among women who had the abortion and 81% among those denied it. Over the entire period, the former women were more likely than the latter to use any method (odds ratio, 1.8). However, they were less likely to rely on female sterilization, rather than no method (risk ratio, 0.5), and more likely to use barrier methods (1.7) or short-acting reversible contraceptives (2.6).

CONCLUSION

Women's elevated risk of unintended pregnancy after abortion is likely due at least partly to reliance on methods with relatively low effectiveness. Factors affecting contraceptive access postabortion, as well as individual characteristics such as fecundability, require research attention.

Long-Acting Reversible Contraception Free of Charge, Method Initiation, and Abortion Rates in Finland

OBJECTIVES

To evaluate whether a public program providing long-acting reversible contraceptive (LARC) methods free of charge increases the LARC initiation rate and reduces the unintended pregnancy rate in the general population.

METHODS

Since 2013, all women in Vantaa, Finland, have been entitled to 1 LARC method free of charge. With time-series analysis between 2000 and 2015, we assessed whether this public program was associated with changes in steady-state mean rates of LARC initiation and abortions.

RESULTS

The initiation rate of LARCs (1/1000 women) increased 2.2-fold from 1.9 to 4.2 after the intervention (P < .001). Concomitantly, the abortion rate (1/1000 women) declined by 16% from 1.1 to 0.9 in the total sample (P < .001), by 36% from 1.3 to 0.8 among those aged 15 to 19 years (P < .001), and by 14% from 2.0 to 1.7 among those aged 20 to 24 years (P = .01).

CONCLUSIONS

The LARC program was associated with increased uptake of LARC methods and fewer abortions in the population. Public Health Implications. Entitling the population to LARC methods free of charge is an effective means to reduce the unmet need of contraception and the need for abortion, especially among women younger than 25 years.

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.

Postabortion Contraceptive Use and Continuation When Long-Acting Reversible Contraception Is Free

OBJECTIVE

To compare preference for long-acting contraception (LARC) and subsequent use, year-long continuation, and pregnancy among women after induced abortion who were and were not eligible to participate in a specialized funding program that provided LARC at no cost.

METHODS

Between October 2014 and March 2016, we conducted a prospective study of abortion patients at Planned Parenthood in Austin, Texas (located in Travis County). We compared our primary outcome of interest, postabortion LARC use, among women who were eligible for the specialized funding program (low-income, uninsured, Travis County residents) and two groups who were ineligible (low-income, uninsured, non-Travis County residents, and higher income or insured women). Secondary outcomes of interest included preabortion preference for LARC and 1-year continuation and pregnancy rates among the three groups.

RESULTS

Among 518 women, preabortion preference for LARC was high among all three groups (low-income eligible: 64% [91/143]; low-income ineligible: 44% [49/112]; and higher income 55% [146/263]). However, low-income eligible participants were more likely to receive LARC (65% [93/143] compared with 5% [6/112] and 24% [62/263], respectively, P<.05). Specifically, after adjusting for age, race-ethnicity, and education, low-income eligible participants had a 10-fold greater incidence of receiving postabortion LARC compared with low-income ineligible participants (incidence rate ratio 10.13, 95% confidence interval [CI] 4.68-21.91). Among low-income eligible and higher income women who received postabortion LARC, 1-year continuation was 90% (95% CI 82-97%) and 86% (95% CI 76-97%), respectively. One-year pregnancy risk was higher among low-income ineligible than low-income eligible women (hazard ratio 3.28, 95% CI 1.15-9.31).

CONCLUSION

Preference for postabortion LARC was high among all three eligibility groups, yet women with access to no-cost LARC were more likely to use and continue these methods. Low-income ineligible women were far more likely to use less effective contraception and become pregnant. Specialized funding programs can play an important role in immediate postabortion contraceptive provision, particularly in settings where state funding is limited.

Contraceptive method preferences and provision after termination of pregnancy: a population-based analysis of women obtaining care with the British Pregnancy Advisory Service

OBJECTIVE

To examine contraceptive choices among women seeking termination of pregnancy (TOP) and the provision of the chosen methods.

DESIGN

Population-based study.

SETTING

British Pregnancy Advisory Service (BPAS) clinics in England and Wales.

POPULATION

Between 1 January 2011 and 31 December 2014, 211 215 women had a TOP at BPAS, were offered contraceptive counselling, and were eligible to obtain contraception at no cost.

METHODS

We examined electronic records from BPAS and assessed the proportions of women who accepted contraceptive counselling and chose a contraceptive method, as well as the distributions of methods chosen, analysed by provider and by TOP type. We calculated the proportions receiving their chosen method and the methods chosen by women using no method at conception. We used logistic regression to examine the factors associated with choice of an intrauterine contraceptive (IUC) or implant.

MAIN OUTCOME MEASURES

Post-TOP contraceptive method choice. Receipt of chosen method post-TOP.

RESULTS

Eighty-five per cent of women accepted contraceptive counselling and 51% chose to obtain a method from BPAS rather than from a GP or contraception and sexual health clinic post-TOP. [correction added on 25 November 2016 after first online publication: 51% has been inserted in the preceding sentence.] Among those who wanted to receive contraception from BPAS, 51% chose an IUC or implant and 19% chose oral contraceptives. Ninety-one per cent of women who obtained contraception from BPAS received their chosen method. Women were more likely to choose an IUC or implant if they obtained contraception from BPAS, had a surgical TOP, were parous, young, white, or had one or more previous TOPs.

CONCLUSIONS

The standards set for patient-centred TOP care should emphasise the need for a full range of contraceptive options to be offered and provided post-TOP.

TWEETABLE ABSTRACT

Uptake targets for long-acting reversible methods do not reflect women's post-TOP contraceptive preferences.

Contraceptive counselling of women seeking abortion - a qualitative interview study of health professionals' experiences

OBJECTIVES

A substantial proportion of women who undergo an abortion continue afterwards without switching to more effective contraceptive use. Many subsequently have repeat unintended pregnancies. This study, therefore, aimed to identify and describe health professionalś experiences of providing contraceptive counselling to women seeking an abortion.

METHODS

We interviewed 21 health professionals (HPs), involved in contraceptive counselling of women seeking abortion at three differently sized hospitals in Sweden. The interviews were recorded and transcribed verbatim and analysed using conventional qualitative content analysis.

RESULTS

Three clusters were identified: 'Complex counselling', 'Elements of counselling' and 'Finding a method'. HPs often experienced consultations including contraceptive counselling at the time of an abortion as complex, covering both pregnancy termination and contraceptive counselling. Women with vulnerabilities placed even greater demands on the HPs providing counselling. The HPs varied in their approaches when providing contraceptive counselling but also in their knowledge about certain contraception methods. HPs described challenges in finding out if women had found an effective method and in the practicalities of arranging intrauterine device (IUD) insertion post-abortion, when a woman asked for this method.

CONCLUSIONS

HPs found it challenging to provide contraceptive counselling at the time of an abortion and to arrange access to IUDs post-abortion. There is a need to improve their counselling, their skills and their knowledge to prevent repeat unintended pregnancies.

Increasing Use of Long-Acting Reversible Contraception to Decrease Unplanned Pregnancy

Unintended pregnancy remains high in the United States, accounting for one-half of pregnancies. Both contraceptive nonuse and imperfect use contribute to unplanned pregnancies. Long-acting reversible contraception (LARC) have greater efficacy than shorter acting methods. Data from large studies show that unplanned pregnancy rates are lower among women using LARC. However, overall use of LARC is low; of the reproductive age women using contraception, less than 10% are LARC users. Barriers include lack of knowledge and high up-front cost, and prevent more widespread use. Overcoming these barriers and increasing the number of women using LARC will decrease unplanned pregnancies and abortions.

Impact of Affordable Care Act coverage expansion on women's reproductive preventive services in the United States

INTRODUCTION

The Affordable Care Act (ACA) expansion mandated the private health plans to cover women's preventive services starting August 2012. With limited and contradictory evidence, this study intends to assess the impact of ACA on the utilization rates and the cost burden of women's reproductive preventive service.

METHODS

A pre-post analysis was conducted using a nationally representative sample of females (aged 15-44years, n=4397) participating in the 2011-2013 National Survey of Family Growth. The utilization rates and cost burdens were compared for six services using bivariate and multivariable logistic regression models.

RESULTS

After the ACA expansion, there wasn't a significant increase in the utilization rates of birth control/prescription (33.7% vs. 30.7%), birth control counseling (17.7% vs. 16.9%), sterilization counseling (3.3% vs. 3.5%), STI counsel/test/treat (15% vs. 14.6%) and HIV screening (24.1% vs. 23.1%). Respondents paying through insurance increased after ACA, but out-of-pocket spending (cost-sharing) didn't decrease for respondents. Type of insurance was an important predictor of utilization rates with publicly insured having significantly higher Odds Ratio (OR) or likelihood of receiving birth control counseling (OR:1.71), sterilization counseling (OR:2.67), STI counsel/test/treat (OR:1.54) and HIV screening (OR:1.69) compared to privately insured.

CONCLUSIONS

The early-on impact of ACA expansion on utilization rates of women's reproductive preventive services didn't appear to be significant. Private health plans, however, might have expanded their coverage but burden of cost sharing still existed. Future research should evaluate the long term impact of ACA expansion on women's health and the economic gains.

Home or office etonogestrel implant insertion after pregnancy: a randomized trial

OBJECTIVES

To evaluate whether home visits for contraceptive implant insertion result in an increase in postpartum uptake compared to clinic insertion and to assess the feasibility of home insertions.

STUDY DESIGN

We randomized women within 10 weeks of a birth or dilation and curettage (D&C) for abortion or miscarriage to home or standard office insertion. The primary outcome was successful insertion of the implant. To achieve 80% power to detect a 40% difference in visit attendance, 20 women were assigned to each group. The secondary outcome was attendance of the 4-week postpartum visit.

RESULTS

From June 2013 through February 2014, we screened 45 women and 40 were randomly assigned to home and office insertion visits. We enrolled 37 postpartum women and 3 women post-D&C. Because of the significant under enrollment of the latter, we chose to report results of only the postpartum women. The results were similar whether we included or excluded post-abortion women. A majority of women desired a home visit for their implant insertion appointment at time of enrollment. Postpartum appointment attendance rates were similar between home and office visits at 53% and 50% (p=1.00), respectively. Home visits resulted in a trend toward increased implant uptake [12/19 (63%) vs 6/18 (33%), p=.10].

CONCLUSION

Home insertion of the contraceptive implant may be a feasible option. Future studies that examine the feasibility and uptake in both postpartum and post-D&C women are warranted.

IMPLICATIONS

Women reported preference for home insertion visits in this pilot study. We also showed that a greater proportion of women received the etonogestrel implant at a home visit compared to the current standard of care, which may warrant larger studies that would have sufficient power to evaluate smaller differences.

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.

Regional variation in postabortion initiation of long-acting reversible contraception in New Zealand

OBJECTIVE

To determine whether there is regional variation in the immediate postabortion initiation of long-acting reversible contraception (LARC) in New Zealand.

MATERIALS AND METHODS

Retrospective analysis of nationally collected data on receipt of intrauterine and implantable contraception at the time of an abortion, together with demographic characteristics and region of residence for the year 2013.

RESULTS

Postabortion LARC initiation varied significantly between the 16 regions of New Zealand, ranging from 32% (95% CI 23.2-42) to 61.4% (95% CI 53.3-69). Implant use ranged from 6.8% to 32.7% across regions, and intrauterine method use ranged from 21.4% to 54.7%. Regional variation in total LARC uptake was most marked for under 20-year-olds (20.3% to 70.9%). The ratio of intrauterine to implant users ranged from 0.7 to 4.1 across regions, with intrauterine methods prescribed two and a half times more frequently nationwide.

CONCLUSIONS

These regional differences in postabortion LARC initiation suggest there are between-clinic differences in prescribing. Reasons for these differences need to be examined to identify and address any barriers faced by clinics in the routine provision of postabortion LARC. Equitable access to LARC at the time of an abortion is needed throughout New Zealand to assist women in the prevention of future unintended pregnancies.

Contraceptive care at the time of medical abortion: experiences of women and health professionals in a hospital or community sexual and reproductive health context

Objective

To examine experiences of contraceptive care from the perspective of health professionals and women seeking abortion, in the contexts of hospital gynaecology departments and a specialist sexual and reproductive health centre (SRHC).

Materials and methods

We conducted in-depth semistructured interviews with 46 women who had received contraceptive care at the time of medical abortion (gestation≤9 weeks) from one SRHC and two hospital gynaecology-department-based abortion clinics in Scotland. We also interviewed 25 health professionals (nurses and doctors) involved in abortion and contraceptive care at the same research sites. We analysed interview data thematically using an approach informed by the Framework method, and comparison was made between the two clinical contexts.

Results

Most women and health professionals felt that contraceptive counselling at abortion was acceptable and appropriate, if provided in a sensitive, nonjudgemental way. Participants framed contraceptive provision at abortion as significant primarily as a means of preventing subsequent unintended conceptions. Accounts of contraceptive decision making also presented tensions between the priorities of women and health professionals, around ‘manoeuvring’ women towards contraceptive uptake. Comparison between clinical contexts suggests that women's experiences may have been more positive in the SRHC setting.

Conclusions

Whilst abortion may be a theoretically and practically convenient time to address contraception, it is by no means an easy time to do so and requires considerable effort and expertise to be managed effectively. Training for those providing contraceptive care at abortion should explicitly address potential conflicts between the priorities of health professionals and women seeking abortion.

Implications

This paper offers unique insight into the detail of women and health professionals' experiences of addressing contraception at the time of medical abortion. The comparison between hospital and community SRHC contexts highlights best practise and areas for improvement relevant to a range of settings.

Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial

BACKGROUND

Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates.

METHODS

We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates.

FINDINGS

Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85).

INTERPRETATION

The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits.

FUNDING

William and Flora Hewlett Foundation.

Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

OBJECTIVE

Women who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.

STUDY DESIGN

Women presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.

RESULTS

A total of 260 women, aged 18-45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.

CONCLUSION

A variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.

IMPLICATIONS

In contraceptive counseling, after screening for IPV, assessing patient's stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient's choice of method.

Repeat abortions in New York City, 2010

This study aims to describe factors associated with the number of past abortions obtained by New York City (NYC) abortion patients in 2010. We calculated rates of first and repeat abortion by age, race/ethnicity, and neighborhood-level poverty and the mean number of self-reported past abortions by age, race/ethnicity, neighborhood-level poverty, number of living children, education, payment method, marital status, and nativity. We used negative binomial regression to predict number of past abortions by patient characteristics. Of the 76,614 abortions reported for NYC residents in 2010, 57% were repeat abortions. Repeat abortions comprised >50% of total abortions among the majority of sociodemographic groups we examined. Overall, mean number of past abortions was 1.3. Mean number of past abortions was higher for women aged 30-34 years (1.77), women with ≥5 children (2.50), and black non-Hispanic women (1.52). After multivariable regression, age, race/ethnicity, and number of children were the strongest predictors of number of past abortions. This analysis demonstrates that, although socioeconomic disparities exist, all abortion patients are at high risk for repeat unintended pregnancy and abortion.

Recent advances in contraception

Focusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives, we review recent advances in contraceptive development and discuss progress in policies to improve access to the most effective methods. We report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, we describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. We also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post-abortion periods, we consider the rationale for this change in practice and review the progress that has been made so far in the United States.

Intra-abortion contraception with etonogestrel subdermal implant

OBJECTIVES

Etonogestrel subdermal implant is a highly effective, reversible and safe form of contraception. Immediate placement during abortion visit could increase contraception use in women at high risk for unintended pregnancy. Our purpose was to evaluate patient acceptability, user continuation rate and efficacy of medical termination of pregnancy when the implant is inserted during medical termination of pregnancy.

STUDY DESIGN

Prospective observational study comparing patients who chose the subdermal implant for post-abortion contraception, inserted at the time of administration of mifepristone, with patients who chose delayed placement after the termination was complete.

RESULTS

After contraceptive counseling 119 women chose the implant as their post-abortion contraceptive method. In the intra-abortion implant insertion group the user continuation rate after 6 months was 73.7% (42/57). In the delayed placement group 59.7% (37/62) missed the follow-up after abortion visit, 24.2% (15/62) chose another method and only 16.1% (10/62) had the implant inserted. The efficacy of medical termination was 96.5% in the group of intra-abortion implant insertion and 98.4% in the delayed placement group.

CONCLUSIONS

Intra-abortion subdermal implant insertion significantly increases the likelihood of effective long-acting contraception use following abortion. The efficacy of medical termination was not significantly changed by intra-abortion implant insertion.

The relationship between contraceptive features preferred by young women and interest in IUDs: an exploratory analysis

CONTEXT

Little research has examined the relationship between women's preferences of contraceptive features and their interest in IUD use. Given high levels of contraceptive discontinuation and dissatisfaction, a better understanding of contraceptive preferences may support women in finding their optimal method and meeting their family planning goals.

METHODS

Data from 382 heterosexual women aged 18-29 were collected via a 2012 Internet survey. Chi-square tests and multivariate, multinomial logistic regression models were used to examine relationships between contraceptive features preferred by women and their interest in IUD use.

RESULTS

Forty-eight percent of women reported being unsure whether they would ever use an IUD; 20% were interested in using one, and 32% were not. In multivariate analyses, characteristics of a contraceptive method found positively associated with IUD interest were the method's not interfering with sexual pleasure (relative risk ratio, 3.4), being 99% effective without user action (2.5) and being effective for up to five years without any user action (3.8). Women who preferred a method that they could see or that would allow them to resume fertility immediately after discontinuation were less likely than those who did not to be interested in using rather than not using an IUD (0.4-0.5).

CONCLUSIONS

The findings of this exploratory analysis indicate that women value a multitude of contraceptive features, which may have implications for their interest in using an IUD. Future research should consider the ways that women's contraceptive preferences can be incorporated into contraceptive counseling.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.