Long-acting Reversible Contraception Insertion Research Articles

Relationship between long-acting reversible contraception and acne in a cohort of adolescents and young adults.

The use of progestin-only long-acting reversible contraception (LARC) may be a risk factor for acne. Few studies have focused primarily on the effects of hormonal LARC on the development or exacerbation of acne in adolescents and young adults. We sought to understand the incidence and management of acne following hormonal LARC insertion in this adolescent/young adult population. A secondary data analysis was conducted of prospectively collected quality improvement (QI) data from the Adolescent Medicine LARC Collaborative. Subjects were evaluated by clinicians in adolescent medicine clinics at participating study sites, and acne severity was documented using a standardized recording instrument and scale. Descriptive statistics were reported as frequencies and percentages for categorical variables or mean and standard deviation (SD) for continuous variables. We compared demographic and clinical characteristics by those who had worsening acne, accounting for site inter-correlation using Cochran-Mantel-Haenszel chi-square tests for categorical variables and linear generalized estimating equation (GEE) regression for continuous variables. Of 1319 subjects who completed LARC insertion, 28.5% (376/1319) experienced worsening acne following use of progestin-only LARC. Acne was a contributing factor to LARC removal in only 3% (40/1319), and the sole reason for removal in 0.4% (5/1319) of all subjects. As this was a secondary analysis of prospectively collected QI data, limitations of this study include incomplete or inaccurate documentation of acne severity. Moreover, LARC insertions without follow-up/removal visits or with only follow-up/removal within 8 weeks of insertion were excluded from our study, which may also bias results. Adolescents and young adults seeking progestin-only LARC should be counseled about the potential for developing acne or experiencing a worsening of existing acne during LARC use. However, acne was not a common reason for LARC discontinuation.

Long-Acting Reversible Contraception Initiation Among Adolescents After an American Academy of Pediatrics Policy Statement

This cross-sectional study compares monthly rates of long-acting reversible contraception (LARC) insertions among adolescents before and after an American Academy of Pediatrics (AAP) policy statement recommending LARC for this age group.

Adolescent and young adult long-acting reversible contraception post-insertion visit attendance before and after COVID-19.

Widespread use of telemedicine for contraceptive care, including long-acting reversible contraception (LARC), was adopted in the United States in response to the COVID-19 pandemic. Given the rapid implementation of these services, little is known about the use of telemedicine for adolescent and young adult (AYA) contraceptive care. This study examined the routine use of telemedicine for LARC post-insertion care by comparing visit attendance between AYAs receiving LARC before and after the COVID-19 pandemic onset. This analysis included LARC insertions 3/1/19-11/30/19 (pre-pandemic onset cohort) and 4/1/20-12/31/20 (post-pandemic onset cohort) from three Adolescent Medicine subspecialty clinics in the United States. De-identified data were collected via review of the electronic health record. Descriptive statistics, χ2 tests, and t-tests described and compared groups. Adjusted logistic regression models examined factors associated with attending a post-insertion visit and attending this visit via telemedicine. This analysis included 525 LARC insertions (279pre- and 246 post-pandemic onset). The proportion of AYAs attending a post-insertion visit increased after the COVID-19 pandemic onset (pre 30 % vs. post 46 %; p≤0.001). Adjusted models revealed that the post-pandemic onset cohort was nearly twice as likely to attend a post-insertion visit as the pre-pandemic onset cohort (OR=1.90; 95 % CI=1.68-2.15). Of those attending this visit in the post-pandemic onset cohort (n=112), 42 % utilized telemedicine. AYAs were more likely to attend post-insertion visits after the COVID-19 pandemic onset than before. Telemedicine may have influenced this change in visit attendance.

Impact of the Affordable Care Act on Prescription Contraceptive Use and Costs Among Privately Insured Women, 2006–2020

BackgroundIn the years immediately following the Affordable Care Act (ACA)'s contraceptive coverage requirement, out-of-pocket costs fell for all Food and Drug Administration–approved contraceptive methods and use of long-acting reversible contraception (LARC) increased. This analysis examines whether these trends have continued through 2020 for privately insured women. MethodsUsing 2006–2020 MarketScan data, we examined trends in prescription contraceptive use and out-of-pocket costs among women 13 to 49 years old. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-ACA requirement (vs. pre-ACA requirement) for contraception, controlling for age group, U.S. region, urban versus rural, and cohort year. ResultsThe likelihood of LARC insertion increased post-ACA requirement (adjusted odds ratio [aOR] 1.127, 95% confidence interval [CI] 1.121–1.133), with insertion rates peaking at 3.73% for intrauterine devices (IUDs) and 1.08% for implants in 2019, before declining with the onset of the COVID-19 pandemic in 2020. Although the likelihood of paying $0 for LARC increased after the ACA requirement (IUD: aOR 5.495, 95% CI 5.278–5.716; implant: aOR 7.199, 95% CI 6.992–7.412), the proportion of individuals paying $0 declined to 69% for IUDs and 73% for implants in 2020, after having peaked at 88% in 2014 and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026–1.030) and paying $0 (aOR 20.399, 95% CI 20.301–20.499) increased significantly after the ACA requirement. ConclusionWith the exception of oral contraceptives, the proportion of individuals paying $0 for all contraceptive methods declined after peaking in 2014 for IUDs, 2016 for the implant, and 2019 for non-LARC methods. Future monitoring is needed to understand the continuing impact of the ACA requirement on prescription contraceptive use and costs.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PurposeSingle-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic. MethodsThis retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10–19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19. ResultsOne thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01). DiscussionIncidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Service trends among non-obstetrics/gynecology providers in the U.S.: Long-acting reversible contraception insertions, removals, and re-insertions

This study evaluates trends in long-acting reversible contraception (LARC) services among obstetrician/gynecologists (OB/GYNs) and non-OB/GYNs in the U.S. during 2012–2018. Using public and private insurance claims from the Symphony Health database, we calculated the percentage of LARC insertions, removals, and reinsertions performed by OB/GYNs and non-OB/GYNs. We then assessed time trends with linear regression. The proportion of LARC services that were performed by non-OBGYNs increased modestly between 2012 and 2018. Increases were similar for insertions, removals, and reinsertions. Further research is needed to understand trends in LARC service provision within primary care to better tailor medical training and policy interventions.

Long-acting reversible contraception in gender-diverse adolescents and young adults: Outcomes from a multisite collaborative

ObjectivesThis study aimed to describe the clinical experience of gender-diverse adolescents and young adults receiving long-acting reversible contraception (LARC). Study designThis was a secondary analysis of prospectively collected quality improvement data among gender-diverse adolescents and young adults receiving LARC in four adolescent medicine clinics. ResultsMost attempted insertions (59/63) were successful. A majority (54%) chose LARC for both contraception and menstrual management. Pelvic pain/cramping and unsatisfactory bleeding were reported side effects. One known expulsion and six known LARC removals occurred. ConclusionsGender-diverse adolescents and young adults had high rates of successful LARC insertion and demonstrated a side effect profile similar to a broader adolescent and young adult population seeking LARC care. ImplicationsLARC is an important and well-tolerated method of menstrual management and contracention in gender-diverse adolescents and young adults, although more investigation is needed to understand how gender-affirming testosterone therapy may impact the LARC experience in this population.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative

ObjectiveTo compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative. MethodsA 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15–18 years who used contraception before (2014–2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic. ResultsPreintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44–2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93–2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds. DiscussionA multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Bibliometric Analysis of Global Research on Long-Acting Reversible Contraception and Healthcare Workers

INTRODUCTION: Long-acting reversible contraception (LARC) is a feasible solution to reduce unintended pregnancy and abortion rates. Nonetheless, the worldwide prevalence of LARC remains low. The LARC uptake depends heavily on healthcare workers because every LARC insertion requires a clinician’s visit, and they are a trusted source of contraceptive information. The study is aimed to explore the trend and distributions of global publications related to LARC and healthcare workers. MATERIALS AND METHODS: Articles related to LARC and healthcare workers were retrieved from the Scopus database. Eligible publications were limited to research articles, reviews, and conference papers published in the English language with no date restriction. The bibliometric data was analysed using Biblioshiny to obtain distributions in terms of the number of publications, journals, countries, institutions, citations, and keywords. RESULTS: A total of 681 eligible publications related to LARC and healthcare workers were retrieved from the Scopus database between 1967 to 2022. The number of publications was low for the first four decades but increased steadily from 2010 onwards. The leading country in this research area was the United States of America and the majority of the most productive institutions were from this country. Half of the frequently cited publications highlighted healthcare workers’ bias, attitude, and practice on LARC provision to clients. CONCLUSION: This bibliometric analysis can guide scholars to understand the global overview of research about LARC and healthcare workers. It may be useful for health practitioners and researchers who are interested in exploring this research area.

Results of Immediate Postpartum Long Acting Reversible Contraception Provision After Expanded Reimbursement Policy Implementation at an Academic Medical Institution.

Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Increasing Contraception Options Immediately After Birth: Did Immediate Postpartum Long-Acting Reversible Contraception (IPP LARC) Utilization Increase During the COVID-19 Pandemic? [ID: 1377847

INTRODUCTION: Preliminary research indicates prenatal and postpartum care decreased during the COVID-19 pandemic. Models also indicate increases in unintended pregnancies after 2020. The goal of this study was to assess whether immediate postpartum long-acting reversible contraception (IPP LARC) insertions and desire for IPP LARC increased during COVID-19 among patients insured under TennCare Medicaid (TennCare or CoverKids) with access to coverage for this type of contraception. METHODS: Deliveries in patients insured under TennCare Medicaid Programs (n=6,922) in one East Tennessee hospital were assessed before and during the COVID-19 pandemic (January 2019 to May 2020 and June 2020 to December 2021, respectively). Data from electronic health records were securely collected in Excel and analyzed using SPSS software. Comparisons were made using chi-square tests. RESULTS: During COVID, increased uptake of IPP LARC was statistically significant: 18.0% (CI 16.9–19.1%) before the COVID-19 pandemic and 22.0% (CI 20.6–23.3%) during (P&lt;.001). In addition, desire for IPP LARC increased significantly among patients: 20.0% (CI 19.1–21.3%) before COVID-19 and 22.3% (CI 21.0–23.7%) during COVID-19 (P=.016). Significant increases in desire for IPP LARC during the pandemic occurred among adolescent patients (&lt;20 years of age) (P=.003), those living HRSA-defined nonrural areas (P=.024), non-Hispanic women (P=.036), and White women (P=.027). CONCLUSION: IPP LARC is a highly effective, convenient contraception option for women, especially during times with possible increased limitations in accessing postpartum care. Perhaps because of shelter-at-home orders, limitations in “nonessential” health care being practiced, or personal preferences and desires during the pandemic, IPP LARC was more highly utilized and desired by those wishing to avoid unintended pregnancy after the pandemic began.

Single-visit insertion of long-acting reversible contraception in a single health system

ObjectiveTo identify patient and practice characteristics associated with single-visit placement of long-acting reversible contraception (LARC) across the University of North Carolina Health system. Study designWe conducted a retrospective observational study using existing electronic health records. We abstracted data from charts of individuals ages 15–50 years who received a LARC device between March 15, 2019, and March 14, 2021. Our primary outcome was whether a patient received LARC at one, or after multiple, outpatient visits. We used descriptive statistics to examine patient, clinician, and practice characteristics. We used bivariate analysis and generalized estimating equation to examine relationships between characteristics and single-visit LARC receipt. ResultsMost of the 4599 individuals received care at obstetrics and gynecology clinics (3411/4599; 74%), and received their LARC device in a single visit (3163/4599; 69%). More intrauterine devices (3151) were placed than implants (1448). The adjusted odds of receiving a LARC in a single visit was highest for those who self-paid (aOR (adjusted odds ratio) 1.83, 1.19–2.82) and those who received an implant (aOR 1.25, 1.07–1.46). Patients seen by advanced practice practitioners (aOR 0.67, 0.56–0.80) or by an internal medicine specialty clinician (aOR 0.13, 0.00–0.35) had lower odds of receiving a single-visit LARC compared to those seen by a specialist obstetrician-gynecologist physician. ConclusionMost single-visit LARC placements were performed by clinicians in obstetrician-gynecologist specialty practices. ImplicationsAmong individuals seeking long-acting reversible contraceptives from clinics in a single health system in North Carolina, most received a device at a single visit and most single-visit insertions were done by an obstetrician-gynecologist.

Evaluation of a Hands-On Graduate Training Curriculum in Contraception Care

As advanced practice registered nurses (APRNs) take on a greater role assisting women with their reproductive needs, particularly in medically underserved areas, opportunities for hands-on training in long-acting reversible contraception (LARC) while in graduate school are needed. Reporting is also needed by nursing schools that elect to provide these training opportunities to enhance workforce preparedness. A postgraduation survey of 161 APRNs from 4 universities in South Carolina indicated that simulation and opportunities to reinforce learning through clinical placement contributed to greater knowledge, skills, and abilities in LARC insertion and removal, as well as a strong level of satisfaction with the training curriculum.

Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.

P083The impact of federal and state-level contraceptive coverage policies on contraceptive cost and use among privately insured women

<h3>Objectives</h3> The landscape of contraceptive coverage has greatly changed in recent years due to federal- and state-level policymaking, yet the long-term effects on contraceptive use and costs remain largely unknown. <h3>Methods</h3> A retrospective analysis was performed using the IBM MarketScan® Commercial Claims and Encounters database to identify contraceptive claims and out-of-pocket costs among privately insured women aged 13–49 between 2006 and 2018. Long-acting reversible contraception (LARC) and non-LARC contraception claims were determined. Out-of-pocket costs included both contraceptive and insertion fees. Policies were categorized at the national level as pre-post Affordable Care Act (ACA), and at the state level as pre-post having a parity law requiring contraceptive coverage and pre-post having a law codifying the ACA at the state level. Descriptive statistics and visual plots assessed for trends between policies and outcomes. <h3>Results</h3> By 2018, seven states had both contraceptive parity laws and codification of the ACA contraceptive coverage; 22 states and the District of Columbia had only a parity law; and 21 states had neither policy. Claims data showed an upward trend in LARC insertion rates from 0.7% in 2006 to 4.6% in 2018, while non-LARC use remained relatively unchanged. The mean out-of-pocket expenditures for each contraceptive method declined each year after the ACA took effect, and there was an increase in the percentage of users who paid $0 for contraception. <h3>Conclusions</h3> This is the first study to investigate the impact of federal and state policies regarding contraceptive coverage. Findings show that contraceptive policies have an impact on use of the most effective contraceptive methods and on costs to the consumer.

Update on incidence of inpatient tubal ligation and long-acting reversible contraception in the United States

Inpatient insertion of long-acting reversible contraception and immediate postpartum tubal ligation allow women to initiate highly effective contraception before hospital discharge. We measured rates of intrauterine device and contraceptive implant initiation and tubal ligations performed during delivery hospitalizations from 2016 to 2018 from a representative sample of US hospital discharges. We used the 2016 to 2018 National Inpatient Sample database, a 20% sample of all community hospital discharges in the United States, to identify delivery hospitalizations with concomitant intrauterine device insertion, contraceptive implant insertion, or tubal ligation. We performed weighted multivariable logistic regression to examine associations between possible predictors (age, delivery mode, payer, geographic region, and year) and odds of long-acting reversible contraception and tubal ligation, and to compare characteristics of users. This sample included 2,216,638 discharges, representing 20% of 11,083,180 delivery hospitalizations across the United States. Intrauterine device insertion increased from 2.2 per 1000 deliveries (2016) to approximately 5.0 per 1000 deliveries (2018; P<.0001); implant insertion increased from 0.3 per 1000 deliveries (2016) to 2.5 per 1000 deliveries (2018; P<.0001); tubal ligation procedures decreased (64.2 to 62.1 per 1000 deliveries; P<.0001). Women who underwent a cesarean delivery had higher odds of having a tubal ligation than those who had a vaginal delivery (adjusted odds ratio, 8.83; 95% confidence interval, 8.73-8.97). Women aged <25 years had 7 times higher odds of receiving long-acting reversible contraception than of receiving tubal ligation (adjusted odds ratio, 7.38; 95% confidence interval, 6.90-7.90). Women with public insurance had almost 5 times the odds of receiving long-acting reversible contraception compared with those with commercial insurance (adjusted odds ratio, 4.83; 95% confidence interval, 4.59-5.06). Rates of long-acting reversible contraception insertion continue to increase while the rates of inpatient postpartum tubal ligations slowly decline. Variations in patient characteristics are associated with receiving long-acting reversible contraception or tubal ligation.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative

To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative. LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience. Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1year was 87% (range, 86%-91% across sites; P=.63), 66% at 2years (range, 62%-84%; P=.01), and 42% at 3years (range, 36%-60%; P=.004). The pooled IUD continuation rate at 1year was 88% (range, 87%-90% across sites; P=.82), 77% at 2years (range, 76%-78%; P=.94), and 60% at 3years (range, 57%-62%; P=.88). LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine.

Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use. We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states. In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17). Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.

Associations of anticipated prescribing of long-acting reversible contraception by general practice registrars: A cross-sectional study.

Long-acting reversible contraception (LARC) is highly effective, but uptake in Australia is low. The aim of this study was to establish general practice registrars' LARC training/insertion experience, as well as frequency of and factors associated with choosing LARC in response to clinical vignettes. This was a cross-sectional questionnaire-based study of general practice registrars inNSW or ACT. The questionnaire elicited acontraceptive management response to three clinical vignettes. The outcome factor in each of three multivariate logistic regression analyses was: 'LARC chosen' or'LARC not chosen'. Of 223 registrars, 18.5% had received intrauterine device (IUD) insertion training, and 9.4% had inserted IUD in general practice. For contraceptive implants, these figures were 64.3% for training and 50.3% for insertion. Significant multivariate associations (all odds ratios >2.5) of choosing LARC in at least one vignette included Australian medical graduate, female gender and confidence in knowledgeregarding IUD/implant. Modest proportions of general practice registrars have training in, and in-practice experience of, LARC insertion. The most notable association with choice of LARC was confidence in knowledge regarding LARC.

Cross-sectional assessment of government health center needs to implement long-acting reversible contraception services in rural Rwanda

BackgroundThere is unmet need for family planning in Rwanda. We previously developed an evidence-based couples’ family planning counseling (C)FPC program in the capital city that combines: (1) fertility goal-based family planning counseling with a focus on long-acting reversible contraceptive (LARC) for couples wishing to delay pregnancy; (2) health center capacity building for provision of LARC methods, and (3) LARC promotion by community health workers (CHW) trained in community-based provision of oral and injectable contraception. From 2015 to 2016, this service was integrated into eight government health centers in Kigali, reaching 6072 clients and resulting in 5743 LARC insertions.MethodsFrom May to July 2016, we conducted cross-sectional health center needs assessments in 30 rural health centers using surveys, key informant interviews, logbook extraction, and structured observations. The assessment focused on the infrastructure, materials, and human resources needed for LARC demand creation and provision.ResultsFew nurses had received training in LARC insertion [41% implant, 27% intrauterine device (IUD)]. All health centers reported working with CHW, but none trained in LARC promotion. Health centers had limited numbers of IUDs (median 10), implants (median 39), functional gynecological exam tables (median 2), and lamps for viewing the cervix (median 0). Many did not have backup power supplies (40%). Most health centers reported no funding partners for family planning assistance (60%). Per national guidelines, couples’ voluntary HIV counseling and testing (CVCT) was provided at the first antenatal visit at all clinics, reaching over 80% of pregnant women and their partners. However, only 10% of health centers had integrated family planning and HIV services.ConclusionsTo successfully implement (C)FPC and LARC services in rural health centers across Rwanda, material and human resource capacity for LARC provision will need to be greatly strengthened through equipment (gynecological exam tables, sterilization capacity, lamps, and backup power supplies), provider trainings and follow-up supervision, and new funding partnerships. Simultaneously, awareness of LARC methods will need to be increased among couples through education and promotion to ensure that demand and supply scale up together. The potential for integrating (C)FPC with ongoing CVCT in antenatal clinics is unique in Africa and should be pursued.