Pediatricians' beliefs and prescribing patterns of adolescent contraception: a provider survey

Body Mass Index Changes Among Adolescents and Young Adults Using the Etonogestrel Contraceptive Implant

OBJECTIVE

To evaluate body mass index (BMI) over 36 months among adolescents and young adults using the etonogestrel implant compared with those using depot medroxyprogesterone acetate (DMPA) and a control group.

METHODS

We conducted a retrospective longitudinal cohort study of postmenarchal adolescents and young adults assigned female at birth. The etonogestrel implant and DMPA groups initiated etonogestrel or DMPA between January 1, 2010, and December 31, 2017. Adolescents and young adults in the control group were prescribed a weight-neutral contraceptive or no contraceptive during the same timeframe. The primary outcome of BMI over time was estimated and compared between study groups with inverse probability of treatment weighting linear mixed-effects modeling. Changes in BMI weight category (underweight or normal weight, overweight, obesity) at 12, 24, and 36 months were also explored.

RESULTS

Among the 20,409 eligible patients, 860 initiated etonogestrel, 1,817 initiated DMPA, and 17,732 made up the control group. Compared with individuals in the control group, those in the etonogestrel group had a significantly higher mean BMI difference at 9 months (+0.5, P <.01); at 36 months, the mean BMI difference was +1.0 ( P <.01). Compared with individuals in the control group, those in the DMPA group had higher mean BMI at 6 months (+0.3, P <.01); at 36 months, the mean BMI difference was +1.3 ( P <.01). Regardless of weight changes, increases in BMI weight categories were rare in all groups.

CONCLUSION

Adolescent and young adult patients who initiated the etonogestrel implant demonstrated BMI changes like those on DMPA and higher than control patients; however, these differences may not be clinically concerning. This study provides important information that can help in counseling adolescent and young adult patients about expectations when starting and using etonogestrel.

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment

OBJECTIVES

Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents.

METHODS

We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6).

CONCLUSIONS

Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.

Pediatric hematology providers' contraceptive practices for female adolescents and young adults with sickle cell disease: A national survey

BACKGROUND

Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy-related health risks and are prescribed potentially teratogenic medications, yet limited data are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers' beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD.

METHODS

Guided by the Health Belief Model (HBM), we developed a 25-question, web-based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.-accredited Pediatric Hematology-Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi-square analysis, and logistic regression.

RESULTS

Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest.

CONCLUSION

Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision-making tools may be tested to assess whether provider contraceptive practices could be improved.

Developing a Youth Contraception Navigator Program: A Human-Centered Design Approach

PURPOSE

To determine key elements of a contraception navigator program that provides a personalized approach to overcoming patient-specific barriers by a trained navigator in central Indiana.

METHODS

A human-centered design approach was used to engage adolescents and community stakeholders in co-design sessions. Sessions incorporated techniques, such as divergent brainwriting and journey maps, which led to the exploration of various themes that were ultimately used to inform key elements of the contraception navigator program.

RESULTS

Adolescents aged 15-17 years (N = 35) and community stakeholders (N = 11) participated in co-design sessions. Analysis verified that the process of obtaining contraception for pregnancy prevention could be intimidating for young people. The importance of language, the presence of stigma, and the knowledge of side effects were all discussed. Essential elements of a contraceptive navigator program included building trust to ultimately co-create a plan that can overcome patient-specific barriers. Having a variety of communication methods available, as well as contraceptive side-effect support, will be essential.

DISCUSSION

Using human-centered design techniques to engage adolescent and community stakeholders can help inform the development of a contraceptive navigator program. A trusted navigator that can address patient-specific barriers to contraception access both before and after contraception is obtained is a key element identified by stakeholders.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis

Introduction:

Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care.

Materials and Methods:

Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.

Results:

Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling.

Conclusions:

A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Teen pregnancy in the setting of familial dilated cardiomyopathy: a case report

Background

Women with pre-existing forms of familial cardiomyopathy are at increased risk for morbidity and mortality due to hemodynamic changes of pregnancy. There is a lack of consensus about the management and care for these patients given the rarity of this condition. This case represents possibly the youngest pregnant familial dilated cardiomyopathy patient to deliver and the youngest patient to be fitted for a wearable cardiac defibrillator in the postpartum period.

Case Presentation

A 14-year-old gravida 1 with familial dilated cardiomyopathy presented late for prenatal care at 38 weeks, which precluded typical care plans including baseline and serial echocardiograms, medication management, and routine prenatal care. An echocardiogram showed severely decreased left ventricular systolic function compared to studies from one year prior. Three days later the patient presented in labor and had a spontaneous vaginal delivery complicated by postpartum hemorrhage. Her postpartum course was notable for persistence of decreased cardiac function testing and placement of a wearable cardiac defibrillator for prevention against life threatening arrhythmias.

Conclusion

This case report adds to the literature on pregnancy complicated by familial dilated cardiomyopathy and describes management best practices and considerations during the antepartum, intrapartum, and postpartum periods.

A systematic review of the views of healthcare professionals on the provision of long-acting reversible contraception

RESEARCH QUESTION

What are the views of healthcare professionals outside of the general practice setting on long-acting reversible contraception?

BACKGROUND

Despite global sexual health organisations advocating for widespread prescription of long-acting reversible contraception, uptake in developed countries remains relatively low. The role of healthcare professionals outside of the general practice setting in long-acting reversible contraception provision requires further attention.

DESIGN

Systematic review.

METHODS

Five electronic databases were searched for existing qualitative findings using terms related to long-acting reversible contraception and healthcare professional views for the period 2013-2018. A rigorous protocol was applied following the Preferred Reporting Items for Systematic Meta-Analyses checklist and flow diagram. The Critical Appraisal Skills Programme tool was used to assess the quality of studies. A total of six studies were included for thematic analysis.

RESULTS

Three key themes emerged through analysis that had significant impact on healthcare professional views of long-acting reversible contraception: (a) contraceptive counselling practices and constraints; (b) knowledge and training about long-acting reversible contraception; and (c) concerns and personal beliefs about long-acting reversible contraception.

CONCLUSIONS

Healthcare professional views on long-acting reversible contraception are shaped by practical time constraints, levels of knowledge and training, and personal beliefs and concerns. Further research is required to address these issues in order to improve clinical training and guidelines for all settings, not just general practice.

RELEVANCE TO CLINICAL PRACTICE

Settings outside of general practice need to be included within the scope of initiatives that aim to improve clinical practice around access to new and emerging contraceptive methods. Further research could inform models of clinical practice that enable healthcare professionals to take enough time to talk through all contraceptive options with patients in a way that both focuses on their individual needs and is fully informed by up-to-date evidence and training.

Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics

OBJECTIVES

Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18 months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery.

METHODS

We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis.

RESULTS

While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm.

CONCLUSIONS FOR PRACTICE

Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

Barriers and Solutions to Improve Adolescent Intrauterine Device Access

Professional organizations agree that adolescents are good candidates for intrauterine device (IUD) use. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists affirm that IUDs should be considered first-line as contraceptive methods for adolescents. Although the number of teens using IUDs is growing, multiple barriers remain, including systems, and patient- and provider-level obstacles. Only through concerted efforts and a committed action plan will adolescents achieve better access to IUDs.

Effectiveness of the Adolescent Medicine Rotation in Improving Pediatric Residents Self-Assessed Skill and Confidence Caring for Youth

PURPOSE

Practicing and resident pediatricians report inadequate skill in caring for adolescents, despite adolescents comprising roughly one-quarter of most general and subspecialty practices. This study examined the effectiveness of participation in an adolescent medicine rotation at improving pediatric residents' self-perceived skills and confidence across nine key adolescent health domains. We also evaluated the impact of didactic instruction during the rotation.

METHODS

Resident and recent-graduate participants (n = 34) completed milestone-based self-assessment of their skill and confidence caring for adolescent patients in nine key adolescent health-related domains. This study employed a post-test then retrospective pretest, an educational study design used to minimize response-shift bias whereby participants rate their skill and confidence at the end of the intervention (post-test), and then reflect back to retrospectively rate their preintervention skill (retrospective pretest). Additionally, differences in gains between those who did and did not participate in didactic instruction were evaluated. Didactic instruction was delivered during the adolescent medicine rotation utilizing a flipped-classroom model; participants received standardized preparatory materials and participated in active-learning workshops.

RESULTS

Participants demonstrated a significant (p ≤ .0001) increase in self-perceived skill levels for all assessed domains after the rotation as compared to before the rotation, whether or not they received didactic instruction. Participation in didactic instruction did not yield significant (p ≤ .05) additional benefit for any of the assessed domains.

CONCLUSIONS

Participation in an adolescent medicine rotation is of value to pediatric resident trainees and leads to increased self-assessed skill and confidence in caring for youth.

Pediatric Provider Education and Use of Long-Acting Reversible Contraception in Adolescents

INTRODUCTION

Pediatric primary care providers prescribe the majority of contraception to adolescents, but they often lack training in long-acting reversible contraception (LARC). Our objective was to assess whether a provider education initiative was associated with a change in LARC use for adolescents.

METHOD

Using electronic medical records, we examined LARC use for 7,331 women ages 15 to 21 years with an established primary care provider before and after a provider education initiative on LARC. We used an interrupted time series design to examine trends in LARC use related to the intervention.

RESULTS

Before the intervention, 3.4% to 3.8% of adolescents were using a LARC method, and LARC use was declining by 4 devices/10,000 adolescents per month (95% confidence interval = [-5, -2] per 10,000 adolescents). After the intervention, LARC use stabilized. The number of adolescents using a LARC method increased nonsignificantly at 3, 6, 9, and 12 months after the intervention.

DISCUSSION

Education of pediatric primary care providers reversed a trend toward decreased use of long-acting reversible contraception.

Can Pediatricians Provide Long-Acting Reversible Contraception?

STUDY OBJECTIVE

In the United States, 40% of high-school students have sex; few use highly effective and safe long-acting reversible contraceptives (LARCs): intrauterine devices and implants. Pediatricians are key health providers for many adolescents, yet few provide LARCs. Our objective was to understand the pragmatics of provision of LARCs (rather than beliefs or attitudes) and identify barriers to and opportunities for LARC provision by community-practicing pediatricians.

DESIGN

We conducted a qualitative descriptive study using semistructured interviews. Qualitative methods are valuable for generating conceptual models of complex phenomena.

SETTING

Set in a midsized Midwestern city, our study was community-based.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

We interviewed 23 pediatricians to understand their views about providing contraception (including LARCs) to adolescents. For analysis, we developed a coding schema and applied it using a priori and open coding.

RESULTS

Several inter-related themes regarding challenges to provision of LARC emerged: limited motivation for on-site LARC provision or referral streams, low pediatric patient interest in LARC, lack of pediatrician training about LARC provision, and inadequate structural elements for on-site placement of LARCs in pediatric offices. Each challenge could be remedied, because pediatricians were motivated to provide adolescent patients with high-quality care. Improvements in these inter-related conditions could facilitate pediatrician provision of LARC.

CONCLUSION

Pediatricians and their patients want to prevent pregnancy, but current practice norms limit LARC provision by pediatricians. To increase LARC access in pediatrician offices, we suggest training in LARC provision and patient education for medical students, residents, and pediatricians; communicating about LARC methods with adolescents to increase patient demand; and systemic changes to improve referral processes and/or allow on-site LARC placements.

Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents

PURPOSE

Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents.

METHODS

We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year.

RESULTS

The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20).

CONCLUSIONS

While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.

Use of Long-Acting Reversible Contraception (LARC) and the Depo-Provera Shot in Adolescents

The intrauterine devices (IUDs) and the subdermal implant, collectively known as long-acting reversible contraceptives (LARC), along with the Depo-Provera shot, represent highly efficacious methods of birth control for all reproductive-age women, including adolescents. They are also safe, private, and convenient, and can be used for their noncontraceptive benefits. Additionally, LARC and Depo-Provera represent methods of contraception that do not contain estrogen and may be safely used in young women who have contraindications to estrogen-containing medications. The LARC methods have traditionally been underused by adolescents due to lack of knowledge and misperceptions about safety and effects on future fertility. However, studies have found that when barriers to the use of LARC are removed, adolescents have increasingly chosen the IUD and implant for birth control and most continue to use these methods with satisfaction. This chapter will provide an overview of IUDs, the subdermal implant and Depo-Provera, address barriers to care for adolescents, efficacy, continuation rates, common side effects and reasons for discontinuation, contraindications, and noncontraceptive benefits.

Pediatricians' Knowledge and Practices Related to Long-Acting Reversible Contraceptives for Adolescent Girls

STUDY OBJECTIVE

A 2014 American Academy of Pediatrics (AAP) policy statement identified long-acting reversible contraceptives (LARCs) as first-line choices for adolescents, but pediatricians' current knowledge and practices about intrauterine devices (IUDs) and subdermal contraceptive implants (Implants) is unknown. We aimed to characterize pediatricians' knowledge and practices about LARCs for adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional online survey emailed to a convenience sample of AAP member pediatricians in New York, Utah, Illinois, and Kansas in 2015 and 2016. The study included 561 practicing pediatricians.

MAIN OUTCOME MEASURES

We measured knowledge about the suitability of IUDs and Implants for adolescents using two 7-item scales; a score of 7 indicates all correct. We dichotomized participants' scores as high and low knowledge if they scored ≥85% correct or <85%, respectively.

RESULTS

Mean age was 47.4 (±11) years; 73% were female; and 72% general pediatricians. Almost all, 88%, counsel about contraception; 64% counsel about IUDs, and Implants, but only 4.1% insert them; 72% prescribe short-acting hormonal contraceptives; 44% had read the AAP policy statement. Mean score on the knowledge scale was lower for IUDs than for Implants (4.2 vs 5.1, respectively; P < .001). Multivariable regression analysis indicated that female pediatricians, adolescent medicine subspecialists, agreeing that pregnancy is a serious problem for adolescents in their practice, and having read the AAP policy statement predicted high knowledge about IUDs as well as Implants for adolescents.

CONCLUSION

Most pediatrician respondents provided reproductive health care for adolescents and counseled about LARCs, but few inserted the devices. We identified knowledge deficits about suitability of IUDs for adolescents.

Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers' Perspective

OBJECTIVES

To assess pediatric providers' attitudes and barriers to initiating a contraceptive method in the inpatient setting.

METHODS

Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting.

RESULTS

In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan.

CONCLUSIONS

Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers.

Provider and Health System Factors Associated with Usage of Long-Acting Reversible Contraception in Adolescents

STUDY OBJECTIVE

Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents. Surveys of primary care providers suggest that physician and clinic factors might influence LARC counseling, but their effect on usage is unknown. Our objective was to explore provider and clinic characteristics associated with LARC usage in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional study of 5363 women ages 15-21 years receiving primary care within a large health system in Massachusetts in 2015. We used data abstracted from electronic medical records to characterize rates of LARC usage. We analyzed the association of provider (specialty, degree, gender, resident status, LARC credentialing) and clinic (Title X funding, onsite LARC provision, onsite obstetrician-gynecologist) factors with adolescents' LARC usage using multivariate logistic regression.

RESULTS

Overall, 3.4% (95% confidence interval [CI], 2.9-3.9) of adolescents were documented as currently using a LARC method. Older adolescents were significantly more likely to use a LARC method (adjusted odds ratio, 2.41; 95% CI, 1.62-3.58 for women ages 20-21 years compared with ages 15-17 years). Adolescents whose primary care provider was a resident were significantly more likely to use a LARC method (adjusted odds ratio, 1.65; 95% CI, 1.02-2.68). Provider specialty, degree, gender, onsite LARC provision, and onsite obstetrician-gynecologist were not significantly associated with LARC usage in adolescents.

CONCLUSION

Being older and having a primary care provider early in their training increased the odds of LARC usage among adolescents in a large Massachusetts health system. Across primary care specialties, educating providers about the appropriate uses of LARC methods in nulliparous adolescents might facilitate LARC usage.

Contraceptive counseling among pediatric primary care providers in Western Pennsylvania: A survey-based study

OBJECTIVES

Data suggest that adolescents in the United States receive inadequate contraceptive counseling. This study sought to determine factors affecting pediatricians' discussion of contraception with adolescent patients, with a specific focus on long-acting reversible contraception-implantable contraception and intrauterine devices.

METHODS

A cross-sectional survey was sent via email to a convenience sample of pediatric residents and pediatric primary care providers in Western Pennsylvania. Self-reported contraceptive counseling and prescribing practices in response to clinical vignettes were assessed.

RESULTS

Of potential participants (287), 88 (31%) responded. Younger providers and providers who had received contraceptive training were significantly more likely to discuss long-acting reversible contraception methods. Discussion of contraceptive methods also varied by both the age and the sexual history of the patient.

CONCLUSION

Variation in contraceptive counseling potentially results in missed opportunities to counsel about and provide the most effective contraceptive methods. More uniform, universal provider training might alleviate some of these inconsistencies.

Pediatricians' Attitudes and Beliefs about Long-Acting Reversible Contraceptives Influence Counseling

STUDY OBJECTIVE

Adolescents are at high risk for unintended pregnancy. Because of pediatricians' potential role in contraceptive counseling, understanding their attitudes and beliefs and counseling practices about use of long-acting reversible contraceptives (LARC; ie, etonogestrel implant and intrauterine devices [IUDs]) is vital. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We interviewed primary care pediatricians (N = 23) in a Midwestern city in June-August 2014. We transcribed the interviews, developed a coding schema, and analyzed these qualitative data using a priori and open coding of transcripts.

RESULTS

Few pediatricians had favorable views on adolescent IUD use and most did not include IUDs in routine contraception counseling. Pediatricians perceived IUDs to impose significant risks for adverse reproductive outcomes and to be poorly tolerated by adolescents. Poor and/or outdated knowledge influenced inaccurate beliefs and unsupportive attitudes. Whereas some pediatricians were advocates for adolescent use of IUDs, many others had concerns that IUDs were not appropriate and not favored by adolescents. In contrast, participants viewed the etonogestrel implant more favorably and often included it in routine counseling. Some pediatricians focused on the familiar and readily available methods (injectable and oral contraceptives) or assumed patients had predetermined expectations for those methods. Time spent counseling on LARC was also perceived as a barrier. Pediatricians described how education and increased familiarity with LARC changed viewpoints.

CONCLUSION

A variety of beliefs and attitudes, as well as factors such as time and personal habits, influence pediatricians' contraceptive counseling practices. Until knowledge deficits are addressed, uninformed viewpoints and unfavorable attitudes will limit adolescents' access to LARC, especially IUDs.

Barriers and Facilitators to Adolescents' Use of Long-Acting Reversible Contraceptives

Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse. The etonogestrel implant and intrauterine devices, referred to as long-acting reversible contraceptives, or LARCs, are the most effective reversible contraceptive methods. These methods are safe for use by adolescents, yet the number of LARC users remains low among adolescents in the United States. In this review we examine recent literature about barriers and facilitators to LARC use among adolescent women. Factors that influence decision-making and provision are organized into 4 categories: (1) cost and clinical operations; (2) adolescent awareness and attitudes; (3) confidentiality, consent, and parental attitudes; and (4) health care provider knowledge, attitudes, and counseling. Knowledge deficits and misconceptions among adolescents and their health care providers are key barriers to adolescent LARC use.

A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement

BACKGROUND

Misperceptions persist that intrauterine device placement is related to pelvic infections and Chlamydia and gonorrhea testing results are needed prior to placement.

OBJECTIVE

We sought to evaluate the relationship of Chlamydia and gonorrhea screening to pelvic infection for up to 2 years following placement of the levonorgestrel 52-mg intrauterine system.

STUDY DESIGN

A total of 1751 nulliparous and multiparous females 16 to 45 years old enrolled in a multicenter trial designed to evaluate the efficacy and safety of a new levonorgestrel intrauterine system for up to 7 years. Participants had Chlamydia screening at study entry and yearly if they were age ≤25 years. Women also had baseline gonorrhea screening if testing had not been performed since starting their current sexual relationship. Those who changed sexual partners during the trial had repeated Chlamydia and gonorrhea testing. Intrauterine system insertion could occur on the same day as screening. Participants did not receive prophylactic antibiotics for intrauterine system placement. Investigators performed pelvic examinations after 12 and 24 months and when clinically indicated during visits at 3, 6, and 18 months after placement and unscheduled visits. Pelvic infection included any clinical diagnosis of pelvic inflammatory disease or endometritis.

RESULTS

Most participants (n = 1364, 79.6%) did not have sexually transmitted infection test results available prior to intrauterine system placement. In all, 29 (1.7%) participants had positive baseline testing for a sexually transmitted infection (Chlamydia, n = 25; gonorrhea, n = 3; both, n = 1); 6 of these participants had known results (all with Chlamydia infection) prior to intrauterine system placement and received treatment before enrollment. The 23 participants whose results were not known at the time of intrauterine system placement received treatment without intrauterine system removal and none developed pelvic infection. The incidence of positive Chlamydia testing was similar among those with and without known test results at the time of intrauterine system placement (1.9% vs 1.5%, respectively, P = .6). Nine (0.5%) participants had a diagnosis of pelvic infection over 2 years after placement, all of whom had negative Chlamydia screening on the day of or within 1 month after intrauterine system placement. Infections were diagnosed in 3 participants within 7 days, 1 at 39 days, and 5 at ≥6 months. Seven participants received outpatient antibiotic treatment and 2 (diagnoses between 6-12 months after placement) received inpatient treatment. Two (0.1%) participants had intrauterine system removal related to infection (at 6 days and at 7 months after placement), both of whom only required outpatient treatment.

CONCLUSION

Conducting Chlamydia and gonorrhea testing on the same day as intrauterine system placement is associated with a low risk of pelvic infection (0.2%). Over the first 2 years of intrauterine system use, infections are infrequent and not temporally related to intrauterine system placement. Pelvic infection can be successfully treated in most women with outpatient antibiotics and typically does not require intrauterine system removal. Women without clinical evidence of active infection can have intrauterine system placement and sexually transmitted infection screening, if indicated, on the same day.

Louisiana and Mississippi Family Physicians' Contraception Counseling for Adolescents with a Focus on Intrauterine Contraception

STUDY OBJECTIVE

The adolescent pregnancy rate in Louisiana (LA) and Mississippi (MS) is one of the highest in the United States. One approach to decrease that rate is to increase contraceptive use. We sought to characterize LA and MS family physicians' (FPs) contraception counseling for adolescents with a focus on the intrauterine contraceptive device (IUD). DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Online survey of resident and practicing physician members of the LA and MS Academy of FPs.

RESULTS

Three hundred ninety-eight of 1616 invited FPs responded; 244 were included in our analysis. When counseling adolescents about contraception, respondents "frequently discussed" oral contraceptives and condoms 87.5% (210/240) and 83.8% (202/241) of the time, respectively. Newer and more highly effective contraceptives such as the ring, patch, IUD, and implant were "frequently discussed" only 34.6% (82/237)-39.3% (92/234) of the time. In the previous 6 months, 56% (136/243) of respondents ever discussed an IUD with an adolescent. Respondents were more likely to have discussed IUDs if they learned IUD insertion during residency, had on-site access to IUD inserters, believed they were competent and/or comfortable with IUD counseling. In 5 clinical scenarios asking whether the respondent would recommend an IUD to a 17- or a 27-year-old patient (in all scenarios patients were eligible for an IUD), respondents were restrictive overall and significantly fewer would recommend an IUD for the adolescent.

CONCLUSION

Our results suggest that there are missed opportunities for full-scope contraception counseling by LA and MS FPs. When these FPs counsel adolescents about contraception they less frequently discuss newer methods and more highly effective methods. Additionally many LA and MS FPs use overly restrictive eligibility criteria when considering IUDs.

Access Barriers to Long-Acting Reversible Contraceptives for Adolescents

The United States continues to have the highest adolescent birth rate of any industrialized country. Recently published guidelines by the American Academy of Pediatrics create a new consensus among professional organizations around the suitability of long-acting reversible contraceptives as first-line contraception for adolescents. Through a narrative review of U.S. studies published after 2000, this study seeks to summarize existing access barriers to long-acting reversible contraceptives for adolescents and highlight areas that warrant further intervention so that the recommendations of these professional organizations can be effectively integrated into clinical practice. Existing barriers include costs for institutions providing contraceptive care and for recipients; consent and confidentiality for adolescent patients; providers' attitudes, misconceptions and limited training; and patients' lack of awareness or misconceptions. Systemic policy interventions are required to address cost and confidentiality, such as the Affordable Care Act's mandate that contraceptive coverage be a part of essential health benefits for all insurance providers. Individual-level access barriers such as providers' misconceptions and gaps in technical training as well as patients' lack of awareness can be addressed directly by professional medical organizations, health care training programs, and other interventions.

Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting

OBJECTIVE

The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation.

STUDY DESIGN

A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ(2)/Fisher's Exact Tests and backwards stepwise logistic regression.

RESULTS

Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p<.01) of method discontinuation.

CONCLUSION

The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers.

IMPLICATIONS

The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Counseling Adolescents About the Intrauterine Contraceptive Device: A Comparison of Primary Care Pediatricians With Family Physicians and Obstetrician-Gynecologists in the Bronx, New York

BACKGROUND

The intrauterine device (IUD) is a highly effective contraceptive, yet not all primary care providers (PCPs) counsel adolescents about IUDs. We sought to describe PCPs' frequency of counseling adolescents about IUDs and identify whether different factors are associated with frequent counseling by pediatricians compared with family physicians and gynecologists.

METHODS

Surveyed PCPs affiliated with a Bronx, New York academic institution.

MAIN OUTCOME

Frequent counseling of female adolescents about IUDs.

RESULTS

Frequent counseling was lower in pediatricians compared with family physicians and gynecologists (35.8% and 81.6%, respectively, P < .001). Among all PCP types, frequent counseling was associated with feeling more competent counseling and managing expected IUD side effects (P < .001). Other significant variables included inserting IUDs themselves (P < .001, family physicians and gynecologists) or having access to an inserter in their office (P = .04, pediatricians).

CONCLUSIONS

Correlates of frequent IUD counseling differed according to PCP specialty. Our results suggest that interventions to increase IUD counseling should focus on improving PCPs' competency around counseling and side effect management as well as increasing access to IUD inserters.

Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States

Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.