Long-acting Reversible Contraception Training Research Articles

Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees

PurposeAlthough pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training. MethodsPediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans. ResultsSix hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374). DiscussionAlthough most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.

What Providers Know vs. What Providers Do: Barriers to Contraception in Adolescents

INTRODUCTION The teenage birth rate in West Virginia (WV) remains among the highest in the United States. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend long-acting reversible contraception (LARC) as first-line contraception. Because WV teenagers' LARC use is exceptionally low, the objective of this study was to gain insight into the current knowledge, practice, and beliefs of health care providers (HCP) in WV regarding LARC for adolescent patients. METHODS An electronic survey using Qualtrics.com was distributed to WV HCPs. Of the 2,196 HCPs contacted, 132 respondents returned the survey, and 109 completed usable data. RESULTS A majority of HCPs were aware that LARC (i.e., intrauterine devices and implantable devices) is the first line recommendation of the ACOG and AAP for adolescent birth control. However, HCPs most frequently prescribed combination oral contraceptives and injectables, which are not first-line recommendations. Notably, 59% of HCPs prescribing combination oral contraceptives believed they were prescribing according to COG and AAP recommendations. Forty-one percent of HCPs knew that combination oral contraceptives were not a first-line recommendation but prescribed them most often. The most frequently identified most important reason for not prescribing LARC was that the HCP did not know how to place them (16.5% of respondents), followed by litigious or malpractice action if there is a malfunction or complication (4.6% of respondents). DISCUSSION These results indicate a need to provide adequate LARC training to HCPs in WV.

Are Wisconsin resident physicians trained in immediate postpartum long acting reversible contraception?

ObjectivesTo characterize perceived proficiency in immediate postpartum long-acting reversible contraception (LARC) provision among resident physicians in obstetrics and gynecology and family medicine in Wisconsin. Study DesignWe queried 254 Wisconsin obstetrics and gynecology or family medicine residents about competency and attitudes regarding family planning services via a confidential electronic survey. We used logistic regression to identify factors associated with the primary outcome of self-reported proficiency in immediate postpartum LARC. ResultsWe recruited participants from 3 of 3 (100%) obstetrics and gynecology and 9 of 15 (60%) family medicine residency programs, achieving a 74% response rate among trainees (187/254 individuals). Seven of 12 programs (58%) offered immediate postpartum LARC training [100% (3/3) obstetrics and gynecology; 44% (4/9) family medicine]. Forty-eight percent of residents [68% (27/40) obstetrics and gynecology and 60/141 (43%) family medicine, p < 0.01)] reported immediate postpartum LARC proficiency (subdermal implant placement: 48%; immediate postpartum intrauterine device (IUD) placement: 16%). Residents (versus interns), who were younger, training in a program without religious affiliation, and who hoped to provide immediate postpartum LARC provision in practice, were more likely to report subdermal implant proficiency. Interns and family medicine trainees were less likely to report immediate postpartum IUD proficiency. ConclusionsOnly 44% of participating family medicine programs provide immediate postpartum LARC training. Two-thirds of obstetrics and gynecology residents report proficiency in immediate postpartum LARC, compared to fewer than half of family medicine residents. Given that many Wisconsin counties do not have a practicing obstetrician/gynecologist, improving immediate postpartum LARC training among family medicine residents is paramount. Implications StatementFamily medicine physicians provide a significant portion of obstetric care, especially in rural areas. Family medicine residency programs should be supported to ensure that all trainees are proficient in placing subdermal implants and family physicians planning to provide obstetric care are trained in postpartum IUD placement.

Obstetrics–gynecology resident long-acting reversible contraception training: the role of resident and program characteristics

Obstetrics-gynecology residents should graduate with competence in comprehensive contraceptive care, including long-acting reversible contraception. Lack of hands-on training and deficits in provider education are barriers to long-acting reversible contraception access. Identifying the number of long-acting reversible contraception insertions performed by obstetrics-gynecology residents could provide insight into the depth and breadth of long-acting reversible contraception training available to obstetrics-gynecology residents in Accreditation Council for Graduate Medical Education-accredited residency programs. Our study investigates long-acting reversible contraception-specific training in obstetrics-gynecology residency programs across the United States, including the self-reported number of long-acting reversible contraception insertions per resident and the impact of resident demographic characteristics and residency program characteristics on training. Obstetrics-gynecology residents completed a voluntary electronic survey during the 2016 Council on Resident Education in Obstetrics and Gynecology examination. The survey included resident demographic characteristics and residency program characteristics as well as resident education and training in long-acting reversible contraception (number of intrauterine devices and implants inserted, training in immediate postpartum intrauterine device placement). A binary "long-acting reversible contraception insertion experience" variable dichotomized respondents as having a low level of long-acting reversible contraception insertions (0 implants and/or 10 or fewer intrauterine devices ) or a high level of long-acting reversible contraception insertions (1 or more implants and/or 11 or more intrauterine devices). χ2 tests were used to compare the presence of long-acting reversible contraception insertion experience by postgraduate year, resident demographic characteristics, and residency program characteristics. Adjusted logistic regression was performed to ascertain the independent effects of gender, race/ethnicity (non-Hispanic white vs other), residency program type (university vs community), and residency program geographic region on the likelihood of "low" overall long-acting reversible contraception insertion experience. In total, 5055 obstetrics-gynecology residents completed the survey (85%); analysis included only residents in United States obstetrics-gynecology programs (N=4322). Of the total analytic sample, 1777 (41.2%) had low long-acting reversible contraception insertion experience. As expected, the number of intrauterine device insertions, implant insertions, and overall long-acting reversible contraception experience increased as residents progressed through training. Long-acting reversible contraception insertion experience varied by residency program geographic region: 169 (27.1%) residents in programs in the West had low long-acting reversible contraception insertion experience compared with 498 (39.0%) in the South, 473 (45.3%) in the Midwest, and 615 (46.0%) in the Northeast. Only 152 (14.9%) of all postgraduate year 4 residents had low long-acting reversible contraception insertion experience. Among postgraduate year 4 residents, low long-acting reversible contraception insertion experience was significantly associated racial/ethnic minority status and community-based residency program type (compared with university-based). Postgraduate year 4 residents in programs located in the Northeast and Midwest had 4.25 (95% confidence interval, 2.04-8.85) and 2.75 (95% confidence interval, 1.27-5.97) times the odds of low long-acting reversible contraception experience compared with those in residency programs in the West, even after adjusting for other respondent characteristics and other residency program characteristics. Obstetrics-gynecology residents experience a range of long-acting reversible contraception training and insertions, which differed according to resident race/ethnicity and residency program characteristics (program type and geographic region). Residency programs with low long-acting reversible contraception training experience should consider opportunities to improve competence in this fundamental obstetrics-gynecology skill.

Community health worker promotions increase uptake of long-acting reversible contraception in Rwanda

BackgroundWe coordinated community health worker (CHW) promotions with training and support of government clinic nurses to increase uptake of long-acting reversible contraception (LARC), specifically the copper intrauterine device (IUD) and the hormonal implant, in Kigali, Rwanda.MethodsFrom August 2015 to September 2016, CHW provided fertility goal-based family planning counseling focused on LARC methods, engaged couples in family planning counseling, and provided written referrals to clients expressing interest in LARC methods. Simultaneously, we provided didactic and practical training to clinic nurses on LARC insertion and removal. We evaluated: 1) aggregate pre- versus post-implementation LARC uptake as a function of CHW promotions, and 2) demographic factors associated with LARC uptake among women responding to CHW referrals.Results7712 referrals were delivered by 184 CHW affiliated with eight government clinics resulting in 6072 family planning clinic visits (79% referral uptake). 95% of clinic visits resulted in LARC uptake (16% copper IUD, 79% hormonal implant). The monthly average for IUD insertions doubled from 29 prior to service implementation to 61 after (p < 0.0001), and the monthly average for implant insertions increased from 109 to 309 (p < 0.0001). In adjusted analyses, LARC uptake was associated (p < 0.05) with the CHW referral being issued to the couple (versus the woman alone, adjusted odds ratio, aOR = 2.6), having more children (aOR = 1.3), desiring more children (aOR = 0.8), and having a religious affiliation (aOR = 2.9 Protestant, aOR = 3.1 Catholic, aOR = 2.5 Muslim each versus none/other). Implant versus non-LARC uptake was associated with having little or no education; meanwhile, having higher education was associated with IUD versus implant uptake.ConclusionsFertility goal-based and couple-focused family planning counseling delivered by CHW, coupled with LARC training and support of nursing staff, substantially increased uptake of LARC methods.

Integration of Onsite Long-Acting Reversible Contraception Services Into School-Based Health Centers.

With recent recommendations from professional organizations, long-acting reversible contraception (LARC) methods are considered appropriate first-line contraception for adolescents. Many school-based health centers (SBHCs) in New York City (NYC) have recently added onsite LARC insertion and management to their contraceptive options. We aimed to explore key elements needed to implement LARC training and services into the SBHC setting and to identify successful factors for program implementation. Semistructured qualitative interviews were conducted with 19 providers and staff at 7 SBHCs in high schools in the Bronx and analyzed using Dedoose. Support and leadership from administration; comprehensive onsite training of providers and staff; developing an effective staffing model for procedure sessions; and patient-centered contraceptive counseling were 4 key themes named by respondents as crucial to the program implementation process. Integrating LARC services onsite at SBHCs is feasible and positively received by providers and staff. With good leadership, staffing, training, and appropriate contraceptive counseling, both SBHCs and other primary clinics that serve adolescents can integrate LARC insertion, removal, and management into routine contraceptive care. This in turn can increase youth access to these methods.

Establishing and Conducting a Regional, Hands-on Long-Acting Reversible Contraception Training Center in Primary Care.

Establishing and Conducting a Regional, Hands-on Long-Acting Reversible Contraception Training Center in Primary Care.

Long-Acting Reversible Contraception Counseling and Use for Older Adolescents and Nulliparous Women

PurposeThe majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention. MethodsSexually active women aged 18–25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering. ResultsWomen in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63–1.15), select LARC (aOR = .86; 95% CI: .64–1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69–1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42–.79) and to select LARC (aOR = .53; 95% CI: .37–.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48–.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41–.85). ConclusionsContinued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.

Preparing for HIV Prevention Trials: From Training to Service Delivery-lessons Learned with Long Acting Reversible Contraception (LARC) in Zambia

Background: Zambia has a high burden of mother-to-child transmission of HIV. The provision of long-acting reversible contraceptives (LARC) specifically intra-uterine devices (IUDs) and Jadelle implants is critical to prevent unplanned pregnancy and perinatal transmission in HIV+women and is also necessary to prevent pregnancy in HIV- prevention trial participants. The UK Department for International Development has funded a program to avert an estimated 13900 new HIV infections through integrated PMTCT with LARC and HIV couples-focused HIV testing. Methods: LARC training for providers began with a 3-day didactic training followed by supervised IUD and Jadelle insertion and removal practicums. Those showing proficiency in all 4 categories were considered fully certified. Practicums were conducted at government clinics in Copperbelt Lusaka and Southern Province. Results: From June 2013 to March 2014 ZEHRP trained 199 LARC providers from 45clinics. 91% were certified in Jadelle insertions 70% in Jadelle removals 55% in IUD insertions 46% in IUD removals and 43% were fully certified. The main obstacles to completion of practicums were not being assigned to the family planning department when one of the few trainers was available and coordinating these times with availability of interested LARC clients. A Training-of-Trainers was held for the fully certified nurses who were high performers meetings were held with clinic in-charges to coordinate trainee schedules and satisfied clients were recruited to give personal testimonials. Conclusions: IUD and implants are rarely used in Africa primarily because lack of supply leads to lack of demand. This model illustrates an effective way to harness successful LARC trainees as trainers and work with clinic administrators and satisfied clients to coordinate practicum training and demand creation. Repeating this cycle leads to a snowball effect of progressive and simultaneous increase in supply and demand resulting in PMTCT and trial-ready clients with LARC.

Pregnancies Reduced by Long-Acting Reversible Contraception Training in Family Planning Clinics

Although approximately half of all pregnancies in the United States are unintended, the use of highly effective contraceptives, such as intrauterine contraceptives and implants, is low. Many health care providers in the United States lack knowledge of current scientific information on long-acting reversible contraception (LARC) and do not routinely offer these methods when counseling patients at the highest risk for unintended pregnancy, including adolescents, nulliparous patients, and patients who have undergone abortions. This article discusses the National Trial of Contraceptive Acceptability [Harper CC et al. Obstet Gynecol 2014; NCT01360216].

Factors Influencing the Provision of Long-Acting Reversible Contraception in California

To assess long-acting reversible contraception (LARC) beliefs and practices among site directors who represent the family planning services delivered in their practices. Medical directors from 1,000 sites listed in the Family Planning Access Care and Treatment program (California's family planning Medicaid program) provider database were mailed a survey in the fall of 2011 regarding their LARC beliefs and practices. Participants responded by mail, online, or telephone. Data on family planning clients served and LARC dispensing were obtained from administrative claims data. All analyses were limited to advanced practice clinician respondents. General estimating equation models identified the respondent and practice characteristics associated with LARC provision. After three follow-up mailings and telephone calls, 68% of eligible sites responded to the survey (636/939). Most respondents were physicians (448/587). They were most likely to consider women with a history of pelvic inflammatory disease unsuitable for hormonal (27%, n=161) and copper (26%, n=154) intrauterine devices. Smokers were the most likely to be considered unsuitable for the implant (16%, n=96). Nearly three fourths of respondents routinely discussed intrauterine devices (413/561) and half (271/558) discussed implants with their contraceptive patients. Characteristics that predicted onsite LARC provision included LARC training, beliefs, and health care provider type. Although there has been significant progress in expanding access and understanding about LARC, many clinicians from sites offering family planning services held beliefs limiting the provision of intrauterine devices and were unfamiliar with the implant, suggesting the need for targeted trainings aimed at informing clinicians of recent developments in LARC recommendations.