Long-acting Reversible Contraception Uptake Research Articles

Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal

BackgroundAlthough long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients.MethodsThe intervention used prominently displayed monthly posters comparing the health clinic’s previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention’s impact on LARC uptake while controlling for client- and clinic-level characteristics.ResultsThe intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers’ counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved.ConclusionWe find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

Association Between Proximity to Delivery Hospital and Postpartum Contraception Choice [ID 2683622

INTRODUCTION: Proximity to prescribers may present a barrier to postpartum contraceptive care. We examine associations between postpartum contraceptive choice and residential proximity to the prescribing, delivery hospital. METHODS: After IRB approval, we collected electronic medical record data from 2020 to 2022 at an inner-city, academic hospital and used CDXGeoData to determine residential distance to the hospital. Contraceptive choice at delivery, 2 weeks, and 6 weeks postpartum, focusing on long-acting reversible contraception (LARC) versus other contraceptives, was compared across distance to hospital. RESULTS: We identified 3,705 births: 53.5% Black, 30.3% Hispanic, and 73.7% utilizing public health insurance. Residential distance to the hospital was 0–1,724 miles with 74.2% living within 10 or fewer miles. Those residing within 10 miles were more likely to be non-Black (X2 (2)=12.02; P&lt;.01), Hispanic (X2 (2)=83.91; P&lt;.001), single (X2 (3)=33.54; P&lt;.001) and primiparous (X2 (3)=13.09; P&lt;.01). Cesarean section was more frequent (32.5% versus 28.1%; X2 (2)=6.58; P&lt;.01) and gestational age shorter (U=1171108; P&lt;.05) for those living further from the hospital. Postpartum tubal ligation did not differ across groups. LARC uptake at discharge and 2 weeks postpartum trended towards being higher for women who lived further (X2 (1)=3.49; P=.06; aOR 1.15; 95% CI, 0.96–1.39). CONCLUSION: There is a trend towards increased LARC uptake if the patient resides further from their delivery hospital after controlling for confounding factors. Our findings add to understanding of patient preferences and barriers to care.

Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review

Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.

The Impact of Get It? on Long-Acting Reversible Contraception Use Among Adolescents and Young Adults

Long-acting reversible contraceptives (LARCs) are the most effective contraceptive method to decrease pregnancy rates among adolescents and young adults (AYAs). Get It? (www.getitnobaby.com) is an innovative peer-based digital intervention that aims to increase LARC awareness and use among AYAs. The purpose of this study was to describe the impact of Get It? on LARC awareness and use among AYAs after exposure. A randomized controlled trial was conducted between 2 different Baylor College of Medicine Teen Health Clinics. Using a block randomization method, clinics were randomized to either the intervention or control group by week. Baseline and post-intervention surveys were conducted in addition to a 6-month post-intervention chart review to determine the primary outcome of LARC uptake and secondary outcomes including other LARC-specific behaviors and LARC attitudes. A total of 233 AYAs agreed to participate in the study, of which 134 were randomized to the control group and 99 to the intervention group. Initiation of LARC discussion with the provider was significantly higher in the intervention group than in the control group. Additionally, LARC uptake within 6 months after study was almost significantly higher in the intervention group than in the control group. Finally, intervention group respondents exhibited strong positive attitudes toward Get It? with regard to specific intervention components. This study supports Get It? as a tool to educate and motivate AYA girls to use the most effective form of birth control available to them. The digital format of this novel peer-based approach also contributes to the potential of this educational intervention by decreasing barriers to both dissemination and uptake. We recommend a larger multi-institutional study to confirm these results and determine the most efficient method of dissemination to reach at-risk AYAs before coitarche.

Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis.

To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. PROSPERO, CRD42021279233.

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

Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels. We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other. Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n=12) and cost support (n=12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use. Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.

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.

Mixed-methods Exploration of Telehealth-supported Long-acting Reversible Contraceptive Services in School-based Health Centers: How Much Added Value?

This study explored adolescent and young adult preferences and experiences with telehealth-supported long-acting reversible contraceptive (LARC) services in New York City school-based health centers (SBHCs) during COVID-19. Sequential mixed methods included post-LARC insertion surveys and in-depth interviews. Survey respondents (n=45) were aged 14-21 years and predominantly Hispanic (53.3%). Only four respondents completed a postinsertion visit via telehealth. Most (82.2%) preferred in-person for future LARC visits; none preferred telehealth. Four themes emerged in interviews (n=15): LARC self-efficacy and autonomy; SBHC convenience and accessibility; comfort with SBHC providers; and preference for in-person visits despite telehealth benefits. Although telehealth theoretically adds value to LARC service delivery, uptake and preference for telehealth in the SBHC context were low. Despite the perceived acceptability of telehealth, adolescents and young adults prefer in-person SBHC visits, suggesting SBHC access may eliminate barriers to care that telehealth seeks to overcome.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence.

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Immediate Postpartum Long-Acting Reversible Contraception Uptake and Outcomes [ID: 1371558

INTRODUCTION: Tennessee Medicaid began covering immediate postpartum (IPP) long-acting reversible contraception (LARC) in November 2017 with the goal of reducing the rate of short-interval births (SIBs) (defined as less than 24 months after a previous birth). In 2014, 22.7% of births in Tennessee were SIBs. We sought to determine IPP LARC uptake and SIB outcomes for women who received IPP LARC after this policy was implemented. METHODS: A retrospective chart review of women who delivered from March to December 2018 and received IPP LARC was conducted. LARC receipt and SIB outcomes were determined utilizing local, regional, and state records (IRB: 4768, 2021-0303). RESULTS: Among the 406 IPP LARC recipients, the average age was 25.9 (15–42), and the average number of living children was 1.28 (0–6). LARC type elected was 4.7% copper intrauterine system (Cu-IUS), 39.9% levonorgestrel-releasing intrauterine system (LNG-IUS), and 55.4% contraceptive implant. Subsequent SIB was identified in only 5.4% (22). Of these, 2 received Cu-IUS, 10 received LNG-IUS, and 10 received contraceptive arm implants. Timing and reason for removal were documented for 7 of these. Expulsion was identified in 1 copper and 1 hormonal IUD. Removals due to side effects were reported in 3 implant and 2 hormonal IUD users. CONCLUSION: The rate of SIB among the IPP LARC recipients was much lower than the general rate among Tennessee women, highlighting the benefit of IPP LARC provision. Additionally, the high preference for contraceptive implants may reflect provider counseling on the increased risk of IUD expulsion when placed IPP or other factors that may be elucidated by future studies.

Continuous quality improvement strategy for increasing immediate postpartum long-acting reversible contraceptive use at Jimma University Medical Center, Jimma, Ethiopia

BackgroundEven though the immediate postpartum period is a golden time and a great opportunity to provide long-acting reversible contraceptives to prevent unintended pregnancy, its utilisation is very low in Ethiopia....

Exploring women's preferences for attributes of long-acting reversible contraceptive (LARC) methods: A discrete choice experiment

There is low LARC uptake in Nigeria and not much is documented about Nigerian women's preferences for these products and how these preferences affect women's choices. Therefore, the purpose of this study is to provide empirical evidence on the decision-making behavior of Nigerian women regarding LARCs. Three hypothetical LARCs were presented. Informed by results obtained from the review of relevant literature and focus group discussion held with selected family planning services providers, the identified attributes were effect on weight, cost, LARC effectiveness and effect on bleeding patterns, each at three levels. A d-optimal design was used to construct nine choice sets. An additional choice set was included to conduct the test-retest stability test. The choice sets and other socio-demographic questions formed the discrete choice experiment questionnaire. A random sample of 150 eligible women was selected from women who enrolled and attended family planning clinics in public healthcare facilities in Ibadan, Nigeria through a three-stage sampling technique. Mixed logit modeling was used to obtain estimates of the parameters and willingness to pay (WTP) for each attribute was calculated. The test-retest stability result showed that 76.7% of the respondents responded in a consistent and rational manner. The women preferred LARCs that have no effect on their weights compared to LARCs that cause either slight weight loss or gain. Also, they preferred LARCs that offer 1/1000 level of effectiveness in a year. The most preferred attribute level, ‘women experience infrequent bleeding’, increases WTP by NGN 13,984.584 (USD 33.68) while the least preferred level, ‘women experience frequent/prolonged bleeding’, has a negative mean WTP (-NGN 19,598.378 (-USD 47.20)) indicating dispreference for the level. Furthermore, women derived higher utilities from very cheap LARCs. Evidence-based information on women's preferences regarding LARC usage would help policymakers in the deployment of strategies that would ensure that preferred LARCs are procured and made readily available to women.

Interest in and Uptake of Postabortion Long-Acting Reversible Contraception After Counseling at a Free-Standing Abortion Care Ambulatory Surgery Center, Atlanta, Georgia, 2017‒2018.

We sought to determine the impact of brief previsit counseling on long-acting reversible contraception (LARC) interest and uptake immediately after abortion. We conducted a randomized controlled trial at a free-standing abortion care ambulatory surgery center in metro-Atlanta, Georgia (2017-2018). Among 1270 women, a brief previsit counseling intervention increased interest in LARC by 4.5 percentage points, and interest in LARC after the intervention increased uptake by 9.6 percentage points. Providing brief previsit counseling significantly increased postabortion LARC uptake. (Am J Public Health. 2022;112(9):1257-1260. https://doi.org/10.2105/AJPH.2022.306940).

Uptake of Immediate Postpartum LARCs and Associated Factors among Mothers Who Gave Birth at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia.

Background Postpartum family planning is an effective strategy for reducing maternal and childhood morbidity and mortality by preventing unintended pregnancy and short interpregnancy intervals. Despite the paramount advantages of long-acting reversible contraceptives (LARC), their uptake remains low in Ethiopia. Therefore, the aim of this study was to assess the uptake of immediate postpartum LARC methods and its associated factors among women who gave birth in Hawassa University Comprehensive Specialized Hospital, Hawassa city, Southern Ethiopia. Methods An institution-based cross-sectional study was conducted among 418 eligible mothers who were in the immediate postpartum period. Data were collected using a pretested structured questionnaire before their discharge from the hospital and analyzed by using SPSS version 20. The statistical significance was declared at P value less than 0.05. Results The uptake LARCs among immediate postpartum mothers was 25.4%. The most commonly reported reasons for not using LARC were preference to start contraception after six weeks of delivery (43.3%) and the need to use other methods of contraception (26%). Having unplanned birth (AOR: 1.97; 95% CI: 1.04-3.71) and receiving family planning counselling on LARCs during the postpartum period (AOR: 21.1; 95% CI: 6.49-68.66) were factors significantly associated with immediate postpartum LARC use. Conclusion Low utilization of immediate postpartum LARC uptake was found in the current study setting. There was increased utilization of immediate postpartum LARC among mothers who received family planning counselling during the postpartum period. Therefore, strengthening family planning counselling during the immediate postpartum period is crucial to enhance postpartum LARC use.

Provision of postpartum long-acting reversible contraception: A quality improvement intervention with pre- and postintervention evaluation.

Background. Unintended pregnancies remain an important health challenge in South Africa (SA) and worldwide. Improving access to contraception and long-acting reversible contraception in particular, may reduce the number of unintended pregnancies.Objective. To determine the impact of a training and supportive mentoring programme on postpartum uptake of long-acting reversible contraceptive (LARC) methods.Methods. A quality-of-care improvement intervention with pre- and post-intervention evaluation of LARC uptake was conductedat a midwife-led, on-site obstetric unit in the Eastern Cape, SA. Midwives were trained in contraceptive counselling and postpartum etonorgestrel implant insertion. The researcher provided counselling and postpartum intrauterine device (IUD) insertion services.Results. In the 10 weeks prior to the intervention, neither the IUD nor the implant were provided in the unit. In the 10 weeks after the intervention, uptake of the IUD was n=27/289 (9.3%) and the implant n=21/289 (7.3%). Use of no contraception or condoms increased from n=22/273 (8.1%) to n=41/289 (14.2%) (p&lt;0.02). The increase was accounted for by a change in staff in the last 4 weeks of the intervention period (n=33/105 (31.4%) v. n=8/184 (4.4%) during the first 6 weeks; p&lt;0.00).Conclusion. Competing responsibilities of maternity staff may limit the contraceptive options offered to postpartum women. Aprogramme of training and supportive supervision resulted in a substantial increase in levels of LARC uptake. Strategies are needed to institutionalise comprehensive postpartum contraceptive provision nationally.

Uptake of long-acting reversible contraception after telemedicine delivered abortion during Covid-19

Background During COVID-19, early medical abortion (EMA) at home in Scotland was largely delivered by telemedicine. Short-acting post-abortion contraception was provided with EMA medications, but long-acting reversible contraception (LARC) (implant, injectable and intrauterine device) required an in-person visit. We wished to assess LARC uptake following telemedicine abortion, and factors associated with method receipt. Methods A prospective observational cohort study of patients accessing abortion via NHS Lothian (October 2020 to February 2021). Patients were offered contraception at telemedicine consultation and their choice was recorded in their clinical notes. Those wishing LARC were directed to the service’s rapid-access LARC clinic. We reviewed electronic patient records six weeks post-abortion to determine whether patients received their chosen method. Results 944 patients had an abortion; 768 (81.4%) had EMA, 131 (13.9%) had a medical or surgical abortion in hospital. The most popular contraceptive method was the progestogen-only pill (n = 324, 34%). 330 patients (35%) requested LARC but less than half (153/330; 46%) received this. Of patients choosing LARC, those who attended the clinic for a pre-abortion ultrasound, or had an abortion in hospital, were more likely to initiate LARC than those having full telemedicine EMA. Nulliparity, gestation over 7 weeks, and age under-26 years were also positively associated with initiating LARC. Conclusion During COVID-19 there was demand for post-abortion LARC but less than half of patients received this by six weeks. Provision was enhanced when in-person clinical interactions took place. Interventions are required to facilitate timely access and initiation of LARC with telemedicine delivered abortion care.

Medicaid reimbursement program for immediate postpartum long-acting reversible contraception improves uptake regardless of insurance status

ObjectiveTo evaluate whether a Medicaid reimbursement program for immediate postpartum long-acting reversible contraception (LARC) is associated with an increased rate of LARC uptake. Study designWe conducted a retrospective cohort study comparing patients who delivered at a large, urban, tertiary medical center one year before and after Missouri Medicaid coverage changed to reimburse immediate postpartum LARC in October 2016. Patients were identified through the electronic medical record and excluded if they delivered prior to 24 weeks gestation or had a contraindication to immediate postpartum LARC. The primary outcome was placement of immediate postpartum LARC, which we examined overall and stratified by insurance type. We used multivariable logistic regression to determine the impact of the policy change while adjusting for appropriate confounders. ResultsA total of 6,233 eligible patients delivered during the study period: 3105 before and 3128 after the change in reimbursement for immediate postpartum LARC. Patients delivering after the policy change were more likely to be Hispanic, have commercial insurance or be uninsured, and have a BMI >30. Placement of immediate postpartum LARC increased from 0.7% pre- to 9.7% postpolicy change (aOR 15.6; 95% CI 10.1–24.2). In our stratified analysis, immediate postpartum LARC uptake increased for patients with Medicaid (aOR 15.8; 95% CI 9.9–25.4) and commercial insurance (aOR 9.7; 95% CI 3.0–31.8). ConclusionThe change in Missouri Medicaid reimbursement for placement of immediate postpartum LARC had systemic impact with an increase in postpartum LARC uptake in all patients, regardless of insurance provider. ImplicationsInsurance reimbursement has the power to influence hospital policy and patient care. Overall, changes to Medicaid reimbursement increased access to postpartum LARC for all patients at a large academic institution, regardless of insurance status.

The Impact of the COVID-19 Pandemic on Postpartum LARC: A Retrospective Cohort Study [A20

INTRODUCTION: At the onset of the COVID-19 pandemic, providers were encouraged to counsel patients interested in long-acting reversible contraception (LARC) about immediate postpartum placement to decrease in-person postpartum visits. We assessed the impact of this COVID-related hospital policy on postpartum LARC uptake. METHODS: In this retrospective cohort study, we compared patients who delivered a live born infant(s) during two periods, one immediately prior to the COVID pandemic (“pre-COVID cohort” (December 16, 2019 to March 1, 2020)), and one at the onset of the pandemic (“COVID cohort” (March 16-May 31, 2020)). We collected electronic medical record data, including sociodemographic characteristics and contraception choices, in the antenatal and postpartum periods for 649 patients. Odds ratios were adjusted for age and race. RESULTS: We found an increase in immediate postpartum LARC use during COVID (13% vs. 9%, P=.12, aOR 1.44, CI 0.87-2.39). The etonogestrel implant was the most placed form of immediate postpartum LARC in both cohorts (67% and 71% in pre- and during COVID cohorts, respectively). In general, contraceptive choices at discharge differed between the cohorts (P=.01), with fewer patients desiring LARC placement at the postpartum visit during COVID (13% vs. 6% in pre- and during COVID cohorts). There was no difference between the average number of postpartum visits attended in each cohort (OR 0.93, CI 0.68-1.28). CONCLUSION: Changes in contraceptive counseling during COVID were accompanied by differences in postpartum contraceptive choices at discharge. Targeted contraceptive counseling can influence patient choices in the setting of expected barriers to routine postpartum care.

The effects of interventions to integrate long-acting reversible contraception with treatment for incomplete abortion: Results of a 6-year interrupted time series analysis in hospitals in mainland Tanzania and Zanzibar.

To evaluate an intervention that aimed at strengthening voluntary access to long-acting reversible contraception (LARC) within postabortion care (PAC) in hospitals in mainland Tanzania and Zanzibar. From 2016 to 2018, we conducted PAC quality improvement interventions, emphasizing family planning (FP) counseling and voluntary access to LARC. Researchers conducted an interrupted time-series analysis of service statistics compiled from 2014 to 2020 using segmented linear mixed effects regression models to assess the interventions' effect on postabortion contraceptive uptake. The intervention in mainland Tanzania was associated with an immediate 38% increase in postabortion LARC uptake, a trend that declined from late 2016 to mid-2020 to 34%. In Zanzibar, the intervention was associated with a gradual increase in LARC uptake that peaked in late 2018 at 23% and stabilized at approximately 15% by mid-2020. Whereas the interventions in mainland facilities did not generate significant changes in postabortion FP uptake overall, the launch of interventions in Zanzibar in mid-2016 was associated with a precipitous rise in that outcome over time, which plateaued at approximately 54% by 2019. Increased voluntary uptake of postabortion contraception was associated with the introduction of training in PAC, including FP, and quality improvement interventions and gains were sustained over time.

Patient-provider power relations in counselling on long-acting reversible contraception: a discursive study of provider perspectives

Contraceptive providers play an essential role in shaping contraceptive decision-making and care, with the potential to constrain patients’ agency. This is a particular concern given the rising hegemony of Long-Acting Reversible Contraception (LARC) and growing evidence of negative patient experiences of LARC promotion and provision. Despite this evidence, little research has considered health providers' perspectives. Drawing on interviews with 22 contraceptive health providers in Aotearoa New Zealand, this paper explored their professional identity construction, focusing on meaning-making in instances of conflict between providers' and patients' priorities and agendas. Guided by feminist poststructuralist theory, the discursive analysis highlights common rhetorical strategies used by participants to (1) justify the use of coercive practices to encourage LARC uptake, and (2) in turn, negotiate positive identities. Findings show how participants grapple with the reproductive politics structuring contraceptive care, including established understandings of the purpose of (long-acting) contraception and contraceptive providers' roles vis-à-vis provision and promotion. The findings point to limitations on contraceptive agency, despite the unanimous endorsement of rights-based voluntary care. Extending the critical literature on LARC and contributing to the under-researched area of contraceptive coercion and agency, the findings of this study have important implications for the delivery of contraceptive care.