Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents

Review of Publicly Available State Reimbursement Policies for Removal and Reinsertion of Long-Acting Reversible Contraception

Purpose

We examined reimbursement policies for the removal and reinsertion of long-acting reversible contraception (LARC).

Patients and Methods

We conducted a standardized, web-based review of publicly available state policies for language on reimbursement of LARC removal and reinsertion. We also summarized policy language on barriers to reimbursement for LARC removal and reinsertion.

Results

Twenty-six (52%) of the 50 states had publicly available policies that addressed reimbursement for LARC removal. Of these 26 states, 14 (28%) included language on reimbursement for LARC reinsertion. Eleven (42%) of 26 states included language on additional requirements for reimbursement for removal and/or reinsertion: five state policies included language with other requirements for removal only, three policies included language with additional requirements for reinsertion only, and three included language with additional requirements for both. Three state policies specified no restrictions be placed on reimbursement for removal and one specified no restrictions be placed on reimbursement for reinsertion.

Conclusion

Half of the states in the US do not have publicly available policies on reimbursement for the removal and reinsertion of LARC devices. Inclusion of unrestricted access to these services is important for contraceptive choice and reproductive autonomy.

Postpartum long-acting reversible contraceptive adoption after a statewide initiative

OBJECTIVES

To examine the effects of a comprehensive, multiyear (2015-2020) statewide contraceptive access intervention in Delaware on the contraceptive initiation of postpartum Medicaid patients. The program aimed to increase access to all contraceptives, including long-acting reversible contraceptives (LARC). The program included interventions specifically targeting postpartum patients (Medicaid payment reform and hospital-based immediate postpartum (IPP) LARC training) and interventions in outpatient settings (provider training and operational supports).

DATA SOURCES AND STUDY SETTING

We used Medicaid claims data between 2012 and 2019, from Delaware and Maryland (a comparison state), to identify births and postpartum contraceptive methods up to 60 days postpartum among patients aged 15-44 years who were covered in a full-benefit eligibility category.

STUDY DESIGN

Using difference-in-differences, we assessed changes in LARC, tubal ligation, and short-acting methods (oral contraceptive, injectable, patch/ring). LARC rates were assessed at 60 days after delivery and on an immediate postpartum basis. Other methods were only assessed at 60 days. Analyses were conducted separately for an early-adopting high-capacity hospital (that delivers approximately half of all Medicaid financed births) and for all other later-adopting hospitals in the state.

DATA COLLECTION/EXTRACTION METHODS

Data were extracted from administrative claims.

PRINCIPAL FINDINGS

The program increased postpartum LARC insertions by 60 days after delivery by 11.7 percentage points (95% CI: 10.7, 12.8) in the early-adopting hospital and 6.9 percentage points (95% CI: 4.8, 5.9) in later-adopting hospitals. Increases in IPP versus outpatient LARC drove the change, but we did not find evidence that IPP crowded-out outpatient LARC services. We observed decreases in short-acting methods, suggesting substitution between methods, but the share of patients with any method increased at the early-adopting hospital (5.2 percentage points; 95% CI: 3.5, 6.9) and was not statistically significantly different at the later-adopting hospitals.

CONCLUSIONS

Direct reimbursement for IPP LARC, in combination with provider training, had a meaningful impact on the share of Medicaid-enrolled postpartum women with LARC claims.

Cost Savings and Effectiveness of Long-Acting Reversible Contraception (LARC) on the Prevention of Pregnancy in Adolescents: A Systematic Review

Adolescent pregnancy is a major public health issue with profound implications for health and socioeconomic factors. The use of long-acting reversible contraception (LARC) could be an interesting strategy to reduce the unintended pregnancy rate. However, the cost of LARC is still a barrier to widespread adoption. This study aimed to analyze the effectiveness and economic impact of LARC compared with non-LARC methods in preventing unintended pregnancy among adolescent girls. This systematic review was registered in PROSPERO (CRD42023387735) and conducted following the PRISMA guidelines. We included articles covering adolescents aged 10-19 years without language restrictions that evaluated the use of LARC compared with non-LARC in terms of effectiveness and the public health costs of unintended pregnancy. The search for articles included the databases MEDLINE/PubMed, Cochrane Library, Embase, and Lilacs, using the entry terms "Adolescent" and "Long-Acting Reversible Contraception." We evaluated the risk of bias and the certainty of the evidence for each outcome of interest. The search retrieved a total of 1,169 articles and, after the title and abstract, we identified 40 articles for full-text analysis. Out of the 40 studies evaluated, 4 articles met the eligibility criteria for cost evaluation, and 1 met the eligibility criteria for effectiveness as an outcome. In conclusion, LARC emerges as the most effective and cost-effective contraceptive method. The cost of utilizing LARC, especially the copper IUD, is significantly lower than the costs attributable to unintended pregnancies in adolescence.

Abortion and contraception for incarcerated people: A scoping review

BACKGROUND

Women experiencing incarceration have higher rates of unmet contraceptive needs and rates of abortion than the public. Incarceration presents multiple potential barriers to accessing abortion and contraception care, including prison security protocols, prison locations, lack of access to care providers, stigma, and low health literacy. The objective of this scoping review is to understand the extent and type of evidence in relation to contraception and abortion access for people experiencing criminalization and incarceration.

METHODS

We used the Joanna Briggs Institute methodology for scoping reviews and include empirical research with people experiencing criminalization or incarceration and/or with prison staff; with respect to prescription contraception or abortion access, while in custody or after having experienced incarceration/criminalization. Databases searched include CINAHL, APA PsycInfo, Gender Studies, Medline (Ovid), Embase, Sociological Abstracts, and Social Services Abstracts. The search yielded 6096 titles of which 43 were included in the review.

RESULTS

Our search yielded 43 studies published between 2001 and 2021 across six countries. The studies included qualitative, quantitative, and mixed methods designs. The main outcomes of interest included contraceptive use; attitudes towards abortion, contraception, and pregnancy; and barriers to care. Barriers identified included lack of onsite access to options, contraceptive coercion by providers, financial costs, and disruptions to medical coverage and insurance status which incarcerated.

DISCUSSION

Evidence indicates that people in prison face significant barriers to maintaining continuity of contraceptive methods, abortion access, and reproductive health guidance. Some studies articulated participants felt judged when discussing contraception with prison-based health care providers. Geographic location, out-of-pocket payments, and trust in health care providers were reported as barriers to access.

CONCLUSION

Incarceration presents considerable challenges to the access of contraception and abortion care. Future research should examine the interaction between institutional security policies and procedures on care seeking, the experiences of underserved and hyper-incarcerated groups, and the impact of being denied access to contraception and abortion and experiences of criminalization.

A qualitative study of influences on the uptake of contraceptive services among people of reproductive age in Uganda

BACKGROUND

Uganda has registered an increased investment in family planning (FP) programs, which has contributed to improvement in knowledge of modern contraceptive methods being nearly universal. However, this has not matched the uptake of modern methods or the reduction in the unmet need for FP. This may be explained by the different influences which include health workers, family, and friends. Due to the limited uptake of contraceptive methods, a program on improving awareness, access to, and uptake of modern contraceptives is being implemented in selected regions in Uganda. We, therefore, conducted a formative study to determine the influences on contraceptive uptake at the onset of this program.

METHODS

Using a qualitative study design, we conducted thirty-two focus group discussions and twenty-one in-depth interviews involving men and women of reproductive age. We also carried out twenty-one key informant interviews with people involved in FP service delivery. Data was collected in four districts where implementation of the program was to take place. Audio recorders were used to collect data and tools were translated into local languages. A codebook was developed, and transcripts were coded in vivo using the computer software Atlas-ti version 7 before analysis. Ethical clearance was obtained from institutional review boards and informed consent was sought from all participants.

RESULTS

From the study, most married people mentioned health workers as their main influence while adolescents reported their peers and friends. Religious leaders and mothers-in-law were reported to mainly discourage people from taking up modern contraceptive methods. The cultural value attached to having many children influenced the contraceptive use decision among people in rural settings. Other influences included a person's experience and housing.

CONCLUSIONS

Health workers, religious leaders, and mothers determine the uptake of contraceptive services. The study recommends the consideration of the role of these influences in the design of FP program interventions as well as more involvement of health workers in sensitization of communities about contraceptive methods.

Low-income women and use of prescribed contraceptives in the context of full health insurance coverage in France, 2019

OBJECTIVE

Major socioeconomic differences in contraceptive use are observed in high-income countries. Cost is often cited as a main factor to explain these differences but other barriers may also exist. Our aim was to compare prescribed contraceptive use among low-income and non-low-income women in a national context of full health insurance coverage.

STUDY DESIGN

In the French national health insurance database, we selected all women (14.8 million) aged 15-49 years living in France in 2019. We compared the prevalence of use of each prescribed contraceptive between low-income and non-low-income women: oral contraceptives, copper intrauterine devices (IUDs), the levonorgestrel intrauterine system (LNG-IUS), and implants.

RESULTS

In the study population, 11% had a low income. Fewer low-income women used prescribed contraceptives than non-low-income women (36% vs. 46%, p < 0.001). When using a contraceptive, low-income women used a different method: at 20-24 years old, they used less oral contraceptives (60% vs. 77%, p < 0.001) and more implants (22% vs. 9%, p < 0.001), while at 40-44 years, they used less levonorgestrel intrauterine systems (18% vs. 30%, p < 0.001).

CONCLUSIONS

Even in a national context of free access to medical care for low-income women, they use less and different prescribed contraceptives than non-low-income women. These results could reflect barriers other than financial cost to the use of prescribed contraceptives by low-income women.

IMPLICATIONS

Financial barriers need to be removed in order to increase contraceptive use. However, this may not be sufficient and further research should explore barriers that low-income women may encounter in accessing and choosing their contraception.

Making the financial case for immediate postpartum intrauterine device: a budget impact analysis

BACKGROUND

Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement.

OBJECTIVE

The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing.

STUDY DESIGN

Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost.

RESULTS

Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.

CONCLUSION

For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

Hypertension and contraceptive use among women of child-bearing age in the United States from 2001 to 2018

BACKGROUND

Hypertension (HTN) in pregnancy is a leading cause of maternal mortality in the United States. Contraception is widely used, and estrogen-based combined hormonal forms are known to increase blood pressure (BP). With nearly half of pregnancies unplanned and many antihypertensive medications teratogenic, appropriate contraception is critical in child-bearing age women with HTN.

METHODS

Using the National Health and Nutrition Examination Surveys (NHANES) from 2001 to 2018, we evaluated contraception and antihypertensive medication use in women of child-bearing age (20-50 years). Women who had undergone sterilization or menopause were excluded. HTN was defined based on a self-reported provider diagnosis and BP ≥130/80 mm Hg or antihypertensive medication use. Contraception included non-barrier methods (pills/patch/ring, injections, long-acting reversible contraceptives) or consistent condom use. Multivariable logistic regression was used to model the odds of contraception use. Temporal trends in contraception use were reported.

RESULTS

Of the 8726 women, 12.4% had HTN with mean age (standard error) 36.0 (0.3) years. In women with HTN, 9.2% used non-barrier contraception and 10.4% used condoms only. Over half (52.7%) of women with HTN on antihypertensive medications were taking medications contraindicated in pregnancy, with no difference seen by contraceptive status. In logistic regression models, contraceptive use was lower in the older-aged women. In women with HTN on non-barrier contraception, combined hormonal contraceptive use declined, from 100% (2001-2006) to 81.4% (2013-2018, P < 0.001).

CONCLUSIONS

Many women with self-reported HTN are not using adequate contraception. Of the small proportion on non-barrier contraceptives, the majority are using estrogen-based, BP-raising methods.

Assessing the cost-effectiveness of contraceptive methods from a health provider perspective: case study of Kiambu County Hospital, Kenya

BACKGROUND

Kenya's contraceptive prevalence rate at 53% is low, with wide disparity among the 47 counties that make up the country (2-76%). Significant financial investment is required to maintain this level of contraceptive use and increase it to levels seen in more developed countries. This is in the context of a growing population, declining donor funding, limited fiscal space and competing health challenges. Studies have shown that long-term contraceptive methods are more cost-effective than short-term methods. However, it is unclear if this applies in Sub-Saharan Africa; with limited financial resources, lower social economic status among users, and publicly managed commodity supply chains, in vertical programs largely dependent on donor funding. This study assessed the cost-effectiveness of contraceptive methods used in Kenya.

METHODS

A cross-sectional study was undertaken in a county referral hospital in mid-2018. Purposive sampling of 5 family planning clinic providers and systematic sampling of 15 service delivery sessions per method was done. Questionnaire aided interviews were done to determine inputs required to provide services and direct observation to measure time taken to provide each method. Cost per method was determined using activity based costing, effectiveness via couple year protection conversion factors, and cost-effectiveness was expressed as cost per couple year protection.

RESULTS

The intra-uterine copper device was most cost-effective at 4.87 US dollars per couple year protection followed by the 2-Rod Implant at 6.36, the 1-Rod Implant at 9.50, DMPA at 23.68, while the combined oral contraceptive pills were least cost-effective at 38.60 US dollars per couple year protection. Long-term methods attracted a higher initial cost of service delivery when compared to short-term methods.

CONCLUSION

Long-term contraceptive methods are more cost-effective. As such, investing in long-term contraceptives would save costs despite higher initial cost of service delivery. It is recommended, therefore, that Sub-Saharan Africa countries allocate more domestic financial resources towards availability of contraceptive services, preferably with multi-year planning and budget commitment. The resources should be invested in a wide range of interventions shown to increase uptake of long-term methods, including reduction of cost barriers for the younger population, thereby increasing contraceptive prevalence rates.

Reasons for Intent to Discontinue and Remove Long-Acting Reversible Contraceptives: National Survey of Family Growth 2017-2019

Background: Long-acting reversible contraceptives (LARCs) are highly effective forms of contraception, which can reduce the risk of unintended pregnancy. Despite LARC effectiveness, women may desire to discontinue this method. This study will examine reasons for intent to discontinue and remove LARCs among U.S. women 15-49 years of age from 2017 to 2019. Methods: The National Survey of Family Growth 2017-2019 was utilized with a sample of 6141 female respondents. Descriptive statistics for intention to discontinue LARCs, difficulty removing LARCs, and reasons for LARC discontinuation and removal were examined. Rao-Scott chi-square tests were conducted in SAS. Results: Overall, 22.9% of women reported ever using LARCs. Among LARC users, most women (81.2%) reported using LARC in the past 10 years. Among these women, 63.9% intended to discontinue LARCs, and 11.5% had difficulty removing LARCs. Reasons for wanting to discontinue LARCs include side effects (29.6%), LARC expiration (26.8%), LARC complications (19.3%), and decided to get pregnant (15.9%). Primary reasons reported for difficulty removing LARCs included: complications (68.3%), other reasons (13.4%), discouragement by provider (5.8%), and provider's inability to remove (4.9%). Conclusion: Given that women who use a LARC method rely on providers to remove this contraceptive method, understanding the reasons for discontinuation and difficulties encountered is needed. Findings from this nationally representative sample identified provider-level and system-level barriers for LARC removal. To respect the reproductive autonomy of LARC users' method for pregnancy prevention, these barriers must be overcome.

Experiences of women with Zika virus (ZIKV) versus the provision of health services in two cities in Colombia: A qualitative study

BACKGROUND

In February 2016, the World Health Organization (WHO) declared the epidemic of the ZIKA virus (ZIKV) in Latin America to be a public health emergency. In Colombia, 11,944 pregnant women registered a ZIKV infection during the epidemic. So far, little is known about the experiences of women infected with ZIKV during their pregnancy, especially those relating to the provision of health services during the period of the epidemic.

OBJECTIVE

To explore the experiences of pregnant women diagnosed with ZIKV infection about the provision of health services in two Colombian cities, considering the perspective of sexual and reproductive rights.

METHODS

Qualitative study under the grounded theory approach, which uses semi-structured interviews as tools to explore the biographical experience of mothers during their gestation process and ZIKV infection, dividing the interview into two broad categories: before and during pregnancy.

RESULTS

Twenty-two women were interviewed, 10 in Cali and 12 in Villavicencio. The average age at the time of pregnancy was 27.6 years. Most women were not planning at the time of pregnancy and the pregnancy was unwanted. Most campaigns focused on mosquito eradication rather than on sexual and reproductive health campaigns. The quality of health care was not sufficient, adequate, or appropriate. Also, the breakdown of the health system to deal with the pandemic was also noted. Some women were treated with disrespect by health professionals. Voluntary termination of pregnancy was inadequately advised, and women lost autonomy regarding decisions about their health.

CONCLUSIONS

In the health care of ZIKV epidemics, it is necessary to include the gender perspective, more specifically, sexual and reproductive rights. In addition, these epidemics must be addressed through a comprehensive, appropriate, and not fragmented health system, in which sexual and reproductive rights must be mainstreamed in all health promotion and prevention programs.

Initiation of Long-Acting Reversible Contraception in Hospitalized Adolescents in the United States

OBJECTIVES

To analyze factors associated with the initiation of long-acting reversible contraception (LARC) among adolescent patients in inpatient settings in the United States.

METHODS

This study is a secondary data analysis of the national Kids' Inpatient Database 2016 data (N = 4200 hospitals). Eligible patients were hospitalized girls 10 to 20 years old. The primary outcome was initiation of LARC (ie, subdermal implant and/or intrauterine device [IUD]) while hospitalized. Covariables included age, race or ethnicity, insurance type, postpregnancy status, geographic region, hospital type (rural or urban), hospital size, and children's hospital status. Bivariable statistics were calculated by using survey-weighted analysis, and a design-based logistic regression model was used to determine the adjusted odds of LARC initiation and of implant versus IUD initiation.

RESULTS

LARC initiation occurred in 0.4% (n = 3706) of eligible hospital admissions (n = 874 193). There were differences in LARC initiation by patient age, insurance type, race or ethnicity, postpregnancy status, hospital type, and hospital status (all P < .01). In the adjusted model, older age, public insurance, nonwhite race or ethnicity, postpregnancy status, and urban, teaching or larger hospitals were independently associated with LARC initiation (all P < .01). Smaller hospital size and postpregnancy status increased the odds of implant versus IUD initiation after stratifying by hospital region.

CONCLUSIONS

LARC initiation occurred in <1% of adolescent hospitalizations, with 90% of those occurring in postpregnancy adolescents. Addressing LARC capacity in rural, nonteaching, and smaller hospitals is important in increasing access. Future research is needed to identify and close gaps in the number of adolescents desiring and initiating LARC in hospital settings.

An Educational Intervention to Raise Awareness of Contraceptive Options Among Young People

Background: Young people in the United States know little about contraceptive options available to them, although method use is sensitive to individual preferences, and method switching is common. For young people to gain reproductive autonomy, a first step is to be aware of different contraceptives, including hormonal and nonhormonal methods. We tested whether an educational intervention delivered on community college campuses was effective in increasing contraceptive awareness. Materials and Methods: We developed a low-cost educational intervention featuring youth-friendly visual tools and tested its impact on method awareness and knowledge among 1,051 students of all genders, aged 18-25 years, at five community colleges. We used generalized estimating equations to test changes in awareness of a range of methods, including male and female (internal) condoms, the pill, patch, vaginal ring, shot, intrauterine devices, implant, and emergency contraception. Results: Over 90% of participants were aware of male condoms and the pill at baseline, but fewer had heard of other options (ranging from 31% to 76% for different methods). Across all methods, awareness increased to a mean of 88% among female participants and 82% among male participants postintervention. Awareness of the full range of methods increased from 31% to 55% (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 3.1-6.2]) among female participants and 11% to 36% (aOR: 10.8, 95% CI: 5.3-21.8) among male participants postintervention. The intervention was similarly effective by sexual orientation, race/ethnicity, nativity, or insurance coverage. Conclusion: This educational intervention significantly improved all students' awareness of a range of contraceptives, supporting one important aspect of reproductive health for young people in community settings.

Concerns About the Cost of Contraception Among Young Women Attending Community College

INTRODUCTION

Contraceptive use is lower among students attending community college than 4-year college students, which may be due to financial barriers to accessing contraceptives. This study examined insurance coverage, access to free or low-cost birth control, and concerns about contraceptive costs among women in community college.

METHODS

We analyzed data from a study conducted at five community colleges in California and Oregon, which have expanded Medicaid coverage of family planning services for low-income individuals. Participants were students aged 18-25 years who self-identified as female, had vaginal sex, and were not pregnant or trying to become pregnant (N = 389). Multivariate analyses were conducted to examine concerns about the cost of contraception among these young women and how cost concerns varied by insurance coverage and access to free or low-cost birth control.

RESULTS

Nearly one-half of participants (49%) were concerned about the cost of contraception. In multivariate models, privately insured women had lower odds of being concerned about the cost of birth control than the uninsured (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.83), yet women with public insurance had cost concerns similar to those of women without insurance. Women who reported they knew where to get free or low-cost birth control had lower odds of reporting cost concerns (adjusted odds ratio, 0.42; 95% confidence interval, 0.24-0.75), as did the few women enrolled in a state family planning program (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-1.00).

CONCLUSIONS

Even in states with publicly funded services for young people, concerns about the affordability of contraception were common among women, particularly the uninsured or publicly insured. Addressing students' cost concerns is an important aspect of ensuring access to contraception during their pursuit of higher education.

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.

Training of healthcare providers and use of long-acting reversible contraception in low- and middle-income countries: A systematic review

INTRODUCTION

Unintended pregnancy, a major global health issue resulting in unsafe terminations of pregnancy and maternal deaths in low- and middle-income countries, could be significantly reduced through increased use of modern contraception, including long-acting reversible contraceptives (LARC). Training of healthcare providers to administer such contraceptives may improve uptake. We conducted a systematic review to collate the end-user uptake data following training of healthcare providers in low- and middle-income countries.

MATERIAL AND METHODS

We searched PubMed, Embase, the Global Health Library and the Cochrane Library up to 23 May 2020. The review was restricted to low- and middle-income countries and focused on healthcare providers who had received training in LARC. Studies that reported contraceptive uptake among women, preference of LARC among healthcare workers and/or women, and unplanned pregnancies within 12 months of LARC initiation were included. All included studies underwent quality assessment using either the Cochrane Risk of Bias Tool or the Newcastle-Ottawa Scale. PROSPERO registration number CRD42020185291.

RESULTS

A total of 28 studies (end-users n = 6 112 544) were included (27 cohort studies and one randomized trial). Nineteen studies were set in Africa, five in Asia, one in Central America and four were multi-country studies. Twenty-eight studies reported LARC use among women, and 25 studies found an increase in uptake of LARC by women using short-acting methods switching to longer-acting methods or by recruiting new users of LARC. The randomized controlled trial was assessed as high quality and reported positive findings; however, there was great heterogeneity in the type of intervention and of how outcomes were measured among the other included studies. Further, the quality of these studies varied, although it should be noted that the poor-quality studies reflected the trends of those of higher quality.

CONCLUSIONS

Despite heterogeneity, current evidence indicates that training of healthcare providers in LARC may increase the uptake among women in low- and middle-income countries. More robust studies are warranted to inform policy.

Ovarian stimulation for fertility preservation in an oncology patient with etonogestrel implant in place

PURPOSE

To describe a case of a young woman who presented for fertility preservation and underwent ovarian stimulation with an etonogestrel implant in place.

METHODS

A 24-year old, gravida 0, with an etonogestrel implant and newly diagnosed lower extremity sarcoma and DVT desiring oocyte cryopreservation prior to adjuvant chemotherapy and radiation. To avoid delay in her oncologic care and allow for continued use of contraception post-retrieval, the patient underwent controlled ovarian hyperstimulation (COH) without removal of the etonogestrel implant.

RESULTS

Baseline labs included follicle-stimulating hormone 9 mIU/mL, luteinizing hormone 4.9 mIU/mL, estradiol 42 pg/mL, anti-Müllerian hormone 5.1 ng/mL, and antral follicle count greater than 40. The patient was placed on an antagonist protocol and stimulated with 125 IU Gonal-F and 75 IU Menopur. She received a total of 12 days of gonadotropin stimulation. On the day of trigger, her estradiol was 1472 pg/mL, lead follicle 21.5 mm with a total of 25 follicles measured > 12 mm. She was triggered with 5000 U hCG. She had a total of 23 oocytes retrieved, 17 of which were metaphase II and vitrified.

CONCLUSIONS

COH and successful oocyte cryopreservation can be achieved in patients with an etonogestrel implant in situ without apparent detrimental effects to oocyte yield or maturity. Due to the etonogestrel implant's inhibitory effects on LH, it is recommended to use an hCG trigger for final oocyte maturation.

"Nobody's Ever Told Me That:" Women's Experiences with Shared Decision-making when Accessing Contraception

Half of all pregnancies in the United States are unintended. Contraceptive methods are effective in reducing unintended pregnancy burden. The shared decision-making model serves as best practice when choosing among healthcare options, and may be appropriate when considering contraceptive options. This study examined women's experiences with shared decision-making in contraceptive use dynamics. Researchers analyzed 38 interviews with women of reproductive age (range: 19-50 years) living in South Carolina (May-November 2016). Researchers completed a constant comparative method of data analysis using HyperRESEARCH 3.7.3 to explore reproductive-aged women's contraceptive decision-making. Shared decision-making provided a conceptual framework for analysis. Gaps in contraceptive knowledge, especially method effectiveness, impacted participants' experiences with contraception. Although participants believed they had adequate information, findings suggest they may not be fully informed about existing contraceptive options. Participants wanted options; however, results indicated women may not be actively involved in choosing contraception. Nuanced beliefs about contraception demonstrated preferences for patient-provider communication within the broader context of reproductive health and individual lifestyle needs. Findings from this study offer theoretical and practical recommendations to guide shared decision-making during contraceptive consultations to empower women in making informed and lifestyle-appropriate contraceptive choices.

Contraceptive Preference, Continuation Rates, and Unintended Pregnancies in Patients with Comorbidities: A Prospective Cohort Study

Background: Patients with comorbidities are more susceptible to adverse pregnancy outcomes, morbidity, and mortality than healthy patients. The goal of this study was to evaluate how comorbidities influence contraceptive choice, continuation rates, and the unintended pregnancy rate in reproductive-age participants. Methods: We analyzed data from the Contraceptive CHOICE Project. Baseline data included demographic, reproductive, and medical history, including self-reported hypertension (HTN), venous thromboembolism (VTE), migraines, cerebrovascular accidents (CVA), transient ischemic attack (TIA), or stroke. Participants were provided contraceptive counseling and their method of choice at no cost. Results: Among 9253 participants included in our analysis, 659 participants reported a history of HTN (7%), 20 participants reported a history of CVA/TIA/stroke (<1%), 1803 participants reported a history of migraine (19%), and 85 reported a history of VTE (<1%). Compared to baseline, use of long-acting reversible contraceptive methods (long-acting reversible contraception [LARC]: intrauterine devices and implants) increased for participants with all comorbidities: HTN 2.3%-84.2%; CVA/TIA/stroke 0%-85%; migraines 1.7%-77%, and VTE 1.2%-88.2%. Participants with HTN, VTE, and migraines were more likely to choose LARC than those without those conditions: HTN: relative risk (RR) = 1.14, 95% confidence interval (CI) 1.10-1.18; migraines RR = 1.04, 95% CI 1.01-1.07; and VTE RR = 1.18, 95% CI 1.09-1.28. Twelve-month continuation and unintended pregnancy rates did not differ significantly based on comorbidity status. Conclusions: Participants with serious comorbidities were more likely to choose LARC than healthy participants. Contraceptive counseling should always be individualized to the patient. Clinical Trials.gov Identifier: NCT01986439.

Reasons Why Young Women in the United States Choose Their Contraceptive Method

Background: Understanding reasons for birth control method choice may inform interventions that help young women choose the best method for them. The purpose of this study was to examine why young women in the general population select their method of contraception. Methods: An online survey was advertised through social media in 2017. After consenting, participants were gated through questions that ensured they were female, within the age range (16-25 years old), lived in the 50 U.S. states, and using intrauterine devices (IUDs), hormonal birth control, or barrier methods specified in the survey. Surveys with incompatible responses were excluded. Satisfaction, plans to discontinue, and primary reason for using current contraceptive method were examined and compared by contraception types using chi-square analyses. Multivariable binary logistic regression was used to examine satisfaction between contraceptive methods and races/ethnicities. Results: A total of 2632 responses were included. A high frequency of women using less effective methods (48.6% of nonhormonal birth control) chose them primarily to prevent pregnancy (20.6% of Copper T IUD, 23.0% of hormonal IUD, and 30.9% of Mirena IUD users), while other more effective birth control methods were often chosen primarily for other reasons. Recommendations from family or friends (14.6%) were used by some to make their contraception decision. Black respondents were less likely and Hispanic respondents were more likely to be satisfied with their birth control compared to white women. Conclusion: Providers should consider that their young patients may want to better understand benefits and side effects of their birth control outside of pregnancy prevention. Furthermore, young women may utilize their friends and family to make their contraceptive choice, which should be taken into consideration when counseling patients.

Awareness and Use of Contraceptive Methods and Perceptions of Long-Acting Reversible Contraception Among White and Non-White Women

Background: Unintended pregnancies continue to account for half of all pregnancies in the United States, primarily due to incorrect or inconsistent use of contraception methods. Long-acting reversible contraception (LARC) methods are safe and highly effective, yet underutilized. Low uptake of LARC may be due to inadequate education, misconceptions, and cultural factors such as race, ethnicity, or religion. This study examined racial differences in contraceptive awareness and use among women seeking care at family health centers. Materials and Methods: Focus groups were used to identify recurrent themes in contraceptive choice of participants and develop a survey, completed by nonpregnant female patients 18-45 years of age from seven family health centers. Results: Among a total of 465 participants, 210 (46.2%) of whom were non-white, awareness of most types of birth control was generally high. Awareness of all types of contraceptives was significantly higher among white than non-white women (p < 0.001). Across most types of contraceptives, use was significantly higher among white women than non-white women with the exception of injectable hormones which were used significantly more often by non-white women (46.0% vs. 28.5%; p < 0.001). Reasons for using LARC did not vary by type nor by race but reasons for not using LARC varied by race and by specific method. Conclusions: Differing patterns of awareness, use, and perceptions of contraceptive methods between white and non-white women were revealed. By understanding factors that influence contraceptive awareness, use, and perceptions, clinicians can better address the contraceptive needs and concerns of their female patients. Clinical Trial # NCT03486743.

Insights in Public Health: Insurance Coverage for Long-Acting Reversible Contraception Placed in Office: A Buy and Bill Demonstration Project in Hawai'i

Access to the full range of contraceptive options for all people is critical in allowing individuals to make decisions that are consistent with their reproductive goals and values, which, in turn, enables them to achieve educational, social, and economic goals. In 2010, the Patient Protection and Affordable Care Act mandated that health plans must cover contraceptive supplies and services, including drugs and devices approved by the US Food and Drug Administration without any out-of-pocket costs to patients. This federal mandate was similar to a law passed by the Hawai'i state legislature in 1999. Despite the Affordable Care Act, access barriers continue to prevent people from obtaining their preferred methods upon request. Same day access to long-acting reversible contraceptive (LARC) devices is a particular challenge in many clinical settings due to the high upfront cost of the device for providers. This Insights article describes the context of this issue in Hawai'i and information about a pilot test of a "buy and bill" program for LARC devices in an outpatient obstetrics and gynecology practice in Honolulu, Hawai'i. Ultimately, the majority of LARC devices were paid for fully by insurance, resulting in increased access to same day insertion with limited financial risk for the clinic.

The effect of an educational video on long-acting reversible contraception (LARC) utilization at 6-8 weeks postpartum period: a randomized controlled trial

PURPOSE

Long-acting reversible contraception is highly effective in preventing unintended pregnancy and unsafe abortion. An educational video administered during early postpartum period might be an effective tool to improve postpartum LARC use. The objectives were to evaluate whether a postpartum educational video about LARC could increase postpartum LARC utilization at 6-8 weeks postpartum and to assess why postpartum women did not receive LARC.

METHODS

This randomized-controlled trial was conducted at the postpartum unit of a university Hospital between August 2016 and February 2017. Postpartum women who were aged > 20 years and willing to participate were recruited. Participants allocated to the study group watched the 7-min educational video on LARC methods while the control group did not. To assess LARC utilization, data were collected at 6-8 weeks postpartum using telephone calls and/or medical record review to determine postpartum contraception use and reasons for not using LARC.

RESULTS

Two-hundred and seventy participants were enrolled, and the video (135) and non-video (135) groups had similar baseline characteristics. In the video group, 57.8% (95% CI 49.0-66.2) reported using a LARC method, compared to 25.9% (95% CI 18.8-34.2) in the non-video group (p < 0.05). The reasons for not using LARC in both groups were inconvenience of access (42.0-43.8%) and uncertainty about methods (17.0-24.6%).

CONCLUSION

The educational video introduced at immediate postpartum period was efficacious in increasing the utilization of LARC at 6-8 weeks postpartum. Inconvenience of access was the most common reason cited for not using LARC.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.in.th TCTR20171225001 "retrospectively registered".

Understanding the Acceptability of Subdermal Implants as a Possible New HIV Prevention Method: Multi-Stage Mixed Methods Study

Background

A long-acting implant for HIV pre-exposure prophylaxis (PrEP) is in development in the Sustained Long-Action Prevention Against HIV (SLAP-HIV) trial. This could provide an alternative to oral PrEP.

Objective

Our mixed methods study aimed to understand (1) users’ experiences with a similar subdermal implant for contraception and (2) factors influencing the likelihood that gay and bisexual men (GBM) would use a proposed PrEP implant.

Methods

Work was completed in 4 stages. In stage 1, we conducted a scientific literature review on existing subdermal implants, focusing on users’ experiences with implant devices. In stage 2, we reviewed videos on YouTube, focusing on the experiences of current or former contraceptive implant users (as these implants are similar to those in development in SLAP-HIV). In stage 3, individuals who indicated use of a subdermal implant for contraception in the last 5 years were recruited via a web-based questionnaire. Eligible participants (n=12 individuals who liked implants a lot and n=12 individuals who disliked implants a lot) completed in-depth phone interviews (IDIs) about their experiences. In stage 4, results from IDIs were used to develop a web-based survey for HIV-negative GBM to rate their likelihood of using a PrEP implant on a scale (1=very unlikely and 5=very likely) based on likely device characteristics and implant concerns identified in the IDIs.

Results

In the scientific literature review (stage 1), concerns about contraceptive implants that could apply to the PrEP implants in development included potential side effects (eg, headache), anticipated high cost of the device, misconceptions about PrEP implants (eg, specific contraindications), and difficulty accessing PrEP implants. In the stage 2 YouTube review, individuals who had used contraceptive implants reported mild side effects related to their device. In stage 3, implant users reported that devices were comfortable, unintrusive, and presented only minor discomfort (eg, bruising) before or after insertion and removal. They mainly reported removing or disliking the device due to contraceptive-related side effects (eg, prolonged menstruation). Participants in the stage 4 quantitative survey (N=304) were mainly gay (204/238, 85.7%), white (125/238, 52.5%), cisgender men (231/238, 97.1%), and 42.0% (73/174) of them were on oral PrEP. Not having to take a daily pill increased the likelihood of using PrEP implants (mean 4.13). Requiring >1 device to achieve 1 year of protection (mean range 1.79-2.94) mildly discouraged PrEP implant use. Participants did not mind moderate bruising, a small scar, tenderness, or bleeding after insertion or removal, and an implant with a size slightly larger than a matchstick (mean ratings 3.18-3.69).

Conclusions

PrEP implants are promising among GBM. Implant features and insertion or removal-related concerns do not seem to discourage potential users. To ensure acceptability, PrEP implants should require the fewest possible implants for the greatest protection duration.

Acceptability of the copper intrauterine device as a form of emergency contraception in New South Wales, Australia

Background: The copper-intrauterine device (Cu-IUD) is the most effective emergency contraception (EC), and the only method providing ongoing contraception; however, it is underutilised in Australia.Methods: An online cross-sectional survey of clients and clinicians at a family planning service was undertaken. Clients aged 16-55 and identifying as female or transgender male were eligible. The survey explored previous experience with and knowledge of the Cu-IUD as EC among clients, current EC practices among clinicians, and barriers and enablers among clients and clinicians.Results: Of 470 clients, 64.5% had previously used EC. Only 12.7% knew the Cu-IUD was a form of EC and 2% had used it. When given information on effectiveness, side-effects and costs, 46.8% reported they would consider the Cu-IUD for EC. However, 40% viewed cost and possible side-effects as barriers. Of the 58 clinicians surveyed, 55% reported discussing Cu-IUD as EC with clients versus 94% discussing oral EC, with time pressures reported as the main barrier.Conclusion: Low awareness among clients, and limited discussion by clinicians, highlights a need for increased education and promotion strategies for the Cu-IUD as EC. With greater knowledge, demand for this option may increase. This will require processes to ensure timely access to insertions.

Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service

OBJECTIVES

To determine the frequency of sexual history taking and the associated characteristics of hospitalized adolescents in the pediatric hospitalist service.

METHODS

A retrospective chart review of adolescents 14 to 18 years old who were admitted to the pediatric hospitalist service at an urban, academic children's hospital in the Northeast from 2013 to 2015 was conducted. Repeat admissions, admissions to specialty services, and charts that noted impairment because of psychosis, cognitive delay, or illness severity were excluded. For charts that met the criteria, the admission history and physical was carefully reviewed for a notation of sexual history. For those with documentation, sexual activity status and a risk level assessment were recorded. Patient demographics and admission characteristics were extracted. χ² tests and logistic regression were used to examine differences between those with sexual history and those without.

RESULTS

A total of 752 charts met the criteria for inclusion. The majority of adolescents were girls (n = 506; 67.3%); the mean age was 15.7 years (SD = 1.2). Girls had 2.99 (95% confidence interval [CI] 2.18-4.11) higher odds of documentation than boys, and older adolescents had 1.41 (95% CI 1.03-1.91) higher odds than younger adolescents. Documentation did not differ significantly on the basis of admission type (medical or psychiatric), admission time, patient race and/or ethnicity, or provider gender. Among those with a documented sexual history, risk-level details were often omitted.

CONCLUSIONS

Sexual history taking does not occur universally for hospitalized adolescents. Girls were screened more often than boys despite similar rates of sexual activity. The inpatient admission may be a missed opportunity for harm-reduction counseling and adherence to sexually transmitted infection testing guidelines.

Healthcare system indicators associated with modern contraceptive use in Ghana, Kenya, and Nigeria: evidence from the Performance Monitoring and Accountability 2020 data

Background

Public health literature is replete with evidence on individual and interpersonal indicators of modern contraceptive use. There is, however, limited knowledge regarding healthcare system indicators of modern contraceptive use. This study assessed how the healthcare system influences use of modern contraceptive among women in Ghana, Kenya, and two large population states in Nigeria.

Methods

This study used data from Phase 1 of the Performance Monitoring and Accountability 2020. The analytical sample was limited to women with a need for contraception, defined as women of reproductive age (15 to 49 years) who wish to delay or limit childbirth. Therefore, this analysis consisted of 1066, 1285, and 1955 women from Nigeria, Ghana, and Kenya respectively. Indicators of healthcare assessed include user-fees, visit by health worker, type of health facility, multiple perinatal services, adolescent reproductive healthcare, density of healthcare workers, and regularity of contraceptive services. All analyses were conducted with SAS (9.4), with statistical significance set at p < 5%.

Results

The prevalence of modern contraceptive was 22.7, 33.2, and 68.9% in Nigeria, Ghana, and Kenya respectively. The odds of modern contraceptive use were higher among Nigerian women who lived within areas that provide adolescent reproductive healthcare (OR = 2.05; 95% C.I. = 1.05—3.99) and Kenyan women residing in locales with polyclinic or hospitals (OR = 1.91; 1.27—2.88). Also, the odds of contraceptive use were higher among Kenyan women who lived in areas with user-fee for contraceptive services (OR = 1.40; 1.07–1.85), but lower among Ghanaian women residing in such areas (OR = 0.46; 0.23—0.92). Lastly, the odds of modern contraceptive use were higher among women visited by a health-worker visit among women in Ghana (OR = 1.63; 1.11—2.42) and Nigeria (OR = 2.97; 1.56—5.67) than those without a visit.

Conclusion

This study found an association between country-specific indicators of healthcare and modern contraceptive use. Evidence from this study can inform policy makers, health workers, and healthcare organizations on specific healthcare factors to target in meeting the need for contraception in Ghana, Kenya, and Nigeria.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Implementation of Recommendations for Long-Acting Contraception Among Women Aged 13 to 18 Years in Primary Care

OBJECTIVE

Clinical specialty societies recommend long-acting reversible contraceptives (LARCs) as first-line contraception for adolescent women. We evaluated whether a combined educational and process improvement intervention enhanced LARC placement in primary care within an integrated health care system.

METHODS

The intervention included journal clubs, live continuing education, point-of-care guidelines, and new patient materials. We conducted a retrospective cohort study across 3 time periods: baseline (January 2013-September 2015), early implementation (October 2015-March 2016), and full implementation (April 2016-June 2017). The primary outcome was the proportion of LARCs placed by primary care clinicians among women aged 13 to 18 years compared with gynecology clinicians.

RESULTS

Kaiser Foundation Health Plan of Colorado cared for approximately 20,000 women aged 13 to 18 years in each calendar quarter between 2013 and 2017. Overall, LARC placement increased from 7.0 per 1000 members per quarter at baseline to 13.0 per 1000 during the full intervention. Primary care clinicians placed 6.2% of all LARCs in 2013, increasing to 32.1% by 2017 (P < .001), including 45.5% of contraceptive implants. Clinicians who attended educational sessions were more likely to adopt LARCs than those who did not (17.9% vs 6.4% respectively, P = .009). Neither overall LARC placement rates (relative risk, 1.9; 95% confidence interval, 0.7-5.6) nor contraceptive implant rates (relative risk, 3.0; 95% confidence interval, 0.9-9.8) increased significantly in clinicians who attended educational activities.

CONCLUSIONS

This multimodal intervention was associated with increased LARC placement for adolescent women in primary care. The combination of education and process improvement is a promising strategy to promote clinician behavior change.

A Pediatric Emergency Department Intervention to Increase Contraception Initiation Among Adolescents

BACKGROUND

The pediatric emergency department (PED) provides care for adolescents at high risk of unintended pregnancy, but little is known regarding the efficacy of PED-based pregnancy prevention interventions. The objectives of this PED-based pilot intervention study were to 1) assess the rate of contraception initiation after contraceptive counseling and appointment facilitation in the PED during the study period, 2) identify barriers to successful contraception initiation, and 3) determine adolescent acceptability of the intervention.

METHODS

This pilot intervention study included females 14 to 19 years of age at risk for unintended pregnancy. Participants received standardized contraceptive counseling and were offered an appointment with gynecology. Participants were followed via electronic medical record and phone to assess contraception initiation and barriers. Chi-square tests were used to examine the association between contraception initiation and participant characteristics.

RESULTS

A total of 144 patients were eligible, and 100 were enrolled. In the PED, 68% (68/100) expressed interest in initiating hormonal contraception, with 70% (48/68) of interested participants indicating that long-acting reversible contraception (LARC) was their preferred method. Twenty-five percent (25/100) of participants initiated contraception during the study period, with 19 participants starting LARC. Thirty-nine percent (22/57) of participants who accepted a gynecology appointment attended that appointment. Barriers to follow-up include transportation and inconvenient follow-up times. Participants were accepting of the intervention with 93% agreeing that the PED is an appropriate place for contraceptive counseling.

CONCLUSIONS

PED contraceptive counseling is acceptable among adolescents and led to successful contraception initiation in 25% of participants. The main barrier to contraception initiation was participant follow-up with the gynecology appointment.

Community Understanding of Contraception During the Zika Virus Outbreak in Puerto Rico

In response to the Zika virus outbreak in Puerto Rico (2015-2016), the Zika Contraception Access Network (Z-CAN) was established to provide same-day access to the full range of reversible contraception at no cost to women. Formative research was conducted to inform the development of a communication campaign about Z-CAN. Ten focus groups with women and men, aged 18 to 49 years, in Puerto Rico were conducted to collect data on contraception awareness, use, and decision making during the Zika outbreak, as well as culturally appropriate messaging and outreach strategies. Thematic analysis was conducted using the constant comparative method. Data showed that there was community awareness regarding Zika in Puerto Rico. However, it was not a motivating factor in contraception decision making; instead, economic factors were the major drivers. Most participants preferred to receive information on contraception, potential side effects, and where to access contraceptive services via Internet-based channels and health care providers. Based on these findings, the Ante La Duda, Pregunta [When in Doubt, Ask] campaign was launched to promote awareness of Z-CAN services among those who chose to prevent pregnancy during the Zika outbreak. Our results underscore the importance of conducting formative research to develop communication initiatives, while also demonstrating that it is feasible to perform these activities as part of an emergency response.

Long-acting reversible contraceptives: Addressing adolescents' barriers to use

NPs caring for adolescent females have an opportunity to reduce US teen pregnancy rates through unbiased counseling on contraception options, including highly effective long-acting reversible methods. Intrauterine devices and subdermal implants are safe, effective contraception options for adolescents, but their rates of use remain low among this patient population. This article discusses current adolescent contraceptive practices, barriers to access, and current recommendations for long-acting reversible contraceptive use.

Is Long-Acting Reversible Contraceptive Use Increasing? Assessing Trends Among U.S. College Women, 2008-2013

Objective To assess LARC use trends among college women (18-24 years) and identify groups that have increased LARC use. Methods Data were extracted from the National College Health Assessment-II (NCHA-II) fall 2008-2013 surveys. Logistic regression statistics were used to assess LARC use. Results Although LARC use increased from 2008 to 2013 (aOR = 2.62; 95% CI 2.23-3.07), less than half of the sample (44%) reported using contraception at last vaginal sex. Only 2.5% of college women in this study reported using a LARC method; of LARC users, 90% reported using an intrauterine device. Nearly all sociodemographic factors were significantly associated with increases in LARC use including: age, sexual orientation, and insurance status. Conclusions LARC use significantly increased among college women. However, less effective methods such as condoms and short-acting reversible contraceptives are used more frequently. Promoting LARC use for women who desire to effectively prevent pregnancy can reduce unintended pregnancy and improve health outcomes for women while in college. Future work should examine the importance of individual and lifestyle factors that influence college women's decision to choose a LARC method and seek to eliminate barriers to college women choosing a contraceptive method they believe works best for them.

Low-Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit

CONTEXT

Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use.

METHODS

In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum.

RESULTS

Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum.

CONCLUSION

Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.

High parity predicts use of long-acting reversible contraceptives in the extended postpartum period among women in rural Uganda

Background

The use of implants and Intra-uterine devices (IUD) during the post-partum period is very low in Uganda especially in rural settings. Long-acting reversible contraceptives (LARC) are known to be the most cost-effective for prevention of unintended pregnancy and unsafe abortions. This study aimed at determining the factors associated with long-acting reversible contraceptive use among women in the extended postpartum period in rural Uganda.

Methods

We conducted a household-based, cross-sectional study among 400 women in two rural communities in Mityana district, central Uganda. Eligible women were aged 15 to 45 years who had childbirth within 12 months of study enrollment in September 2014. The outcome variable was self-reported use of a LARC method, either IUD or implants in the extended postpartum period. The main independent variables were previous childbirths (parity), fertility desire, willingness to use modern contraception, duration of postpartum period and previous pregnancies (gravidity). A logistic regression model was run in STATA v12.0 to compute adjusted odds ratios (AOR) for factors that predicted LARC use statistically significant at p < 0.05.

Results

Four hundred respondents had a mean age of 27 years (SD = 12) and only 8.5% reported using a LARC method. Use of IUD and implant was 1.8% and 10.4% respectively. Most women using LARC (44.1%) had five or more childbirths (p = 0.01), 70.8% of non-LARC users were willing to use modern contraceptives (p = 0.07) and 2.5% ever had an induced abortion. Having five or more childbirths was independently associated with LARC use in the extended postpartum period (AOR = 4.07, 95%CI 1.08–15.4). Willingness to use modern contraception, desire for more children and postpartum duration had no significant association with LARC use in the extended postpartum period.

Conclusion

This study revealed low use of LARC within twelve months of child birth despite women’s willingness to use them. High parity (≥5 childbirths) predicted LARC use. The next logical step is to identify barriers to using LARC in the extended postpartum period and design appropriate interventions to increase access and use especially in multi-parous women.

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.

SMFM Special Report: Putting the "M" back in MFM: Reducing racial and ethnic disparities in maternal morbidity and mortality: A call to action

Racial and ethnic disparities in maternal morbidity and mortality rates are an important public health problem in the United States. Because racial and ethnic minorities are expected to comprise more than one-half of the US population by 2050, this issue needs to be addressed urgently. Research suggests that the drivers of health disparities occur at 3 levels: patient, provider, and system. Although we have recognized this issue and identified elements that contribute to it, knowledge must be converted into action to address it. In addition, despite available funding and databases, research directed towards understanding and reducing these disparities is lacking. This document summarizes findings of a workshop convened at the 2016 Society for Maternal-Fetal Medicine's 36th Annual Pregnancy meeting in Atlanta, GA, to review and make recommendations about immediate actions in clinical care and research that will serve to reduce racial and ethnic disparities in maternal morbidity and mortality rates in the United States.

Injectable contraception: updates and innovation

PURPOSE OF REVIEW

Injectable contraception is a highly effective form of birth control that is globally popular. Recent research has focused on ways to make injectables such as depot medroxyprogesterone acetate (DMPA) more accessible and to improve the side-effect profile of injectables. This review will focus on new directions and approaches to the use of injectable contraception.

RECENT FINDINGS

Research in the area of injectable contraception has focused on improving access for women through home or self-injection, and also task-shifting and community-based distribution in low-resource areas. Specific to DMPA, studies have focused on lowering the overall dose of medication while maintaining efficacy, and improving drug-delivery systems. More research into the association between DMPA and HIV is needed, and also the effects of administration of DMPA at the time of medication abortion.

SUMMARY

Injectable contraceptives are an important part of the global method mix of highly effective birth control. Improving the accessibility and side effect profile of commodities such as DMPA will make injectables even more valuable for women seeking effective contraception.

Why Didn't You Text Me? Poststudy Trends From the DepoText Trial

OBJECTIVE

To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT).

STUDY DESIGN

Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention.

RESULTS

Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015).

CONCLUSION

Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.

Exploring maternal attitudes towards adolescent contraception: implications for use of LARC

Introduction Maternal attitudes have been shown to impact adolescent girls' sexual decision making and attitudes towards contraception. Given the potential for maternal influence on adolescent contraceptive use, we undertook an exploratory study of mothers' perceptions of the maternal role in adolescent contraceptive decision making, and maternal perceptions of long acting reversible contraceptives (LARC) for adolescent girls. Materials and methods We utilized a mixed methods study design. Acceptability of contraceptive methods and attitudes towards adolescent contraceptive use were assessed using a paper survey of 162 mothers of girls aged 11-19 years in Cleveland, Ohio, USA. Seven survey participants completed subsequent semi-structured interviews, which were analyzed using grounded theory methodology. Results Pills, condoms and injections were most frequently selected as acceptable by 55.4%, 55.4%, and 51.6% of women, respectively. One or more LARC methods were selected by 16.6% of the women. Of those (94.4%) agreed or strongly agreed that, "It is expected of me to make sure that my daughter knows about birth control methods." Important themes that emerged during interviews were the responsibility mothers felt to help their daughters navigate contraception options, appreciation of the effectiveness of LARC methods and concerns about the use of those methods by teenagers due to the invasiveness. Conclusion Our data suggest that mothers want to be involved and support adolescent decision making about contraceptives. We also found that mothers viewed LARC as less acceptable than other forms of birth control for adolescents and have specific concerns about LARC. These results suggest directions for future work to better characterize the impact of maternal attitudes on adolescent LARC use.