Long-acting Reversible Contraception Research Articles

Tennessee Medicaid patient immediate postpartum long-acting reversible contraception utilization

ObjectiveTo understand immediate postpartum long-acting reversible contraception (IPP LARC) desire and utilization trends among publicly insured patients delivering at one academic hospital in a state with healthcare barriers and high short-interval birth rates. MethodsWe conducted a retrospective cohort study of electronic delivery records between March 2018-June 2023 for publicly insured patients. Patient demographics, IPP LARC desire and utilization trends were compared using chi-square or Fisher’s exact tests. Binary logistic regression explored the relationship between IPP LARC utilization and demographics. Multivariable logistic regression was performed on all statistically significant variables. ResultsAnalysis included 10,472 delivery encounters; 2,459 (23.5%) requested IPP LARC on admission and 464 (4.4%) changed contraception to IPP LARC after admission. Among those obtaining IPP LARC (n=2,523, 24.1%), 1,224 (48.5%) selected arm implants and 1,299 selected IUDs. Patients who self-reported as non-Hispanic Black and non-Hispanic Other or multiple races utilized IPP LARC less (aOR=0.84, 95% CI: 0.72-0.98, aOR=0.68, CI 95%: 0.48-0.97, respectively). Patients with cesarean delivery (aOR=1.45, 95% CI: 1.31-1.61) or inadequate prenatal care (aOR=1.54, CI 95%: 1.35-1.75) were more likely to utilize IPP LARC. Maternal age and years of education were inversely associated with utilization. Primiparous patients were less likely to utilize IPP LARC. ConclusionLARC utilization was 24.1% during the immediate postpartum period; higher than the 11% nationally reported interval LARC use among publicly insured patients. Understanding the demographics of those desiring IPP LARC could highlight accessibility gaps. The impact of IPP LARC utilization on rates of short-interval birth is being evaluated. Funding SourceOrganon IIS #60719 Implications StatementUnderstanding the demographics of IPP LARC utilizers may contribute to understanding accessibility gaps and facilitate discernment of factors impacting patient initiation. Evidence suggests that comprehensive contraception access during delivery admission is feasible, patient-desired, and essential.

Examining the impact of an online educational video on the contraceptive knowledge, awareness and choices of young women living in rural and remote Australia

ObjectiveTo assess whether an online educational video, tailored to young women living in rural and remote areas, increases their contraceptive knowledge, preference for and uptake of long-acting reversible contraception (LARC). Study DesignA single group pre-post survey design, in which participants completed the pre-video survey (S1), watched the 13-min video, then completed a survey immediately after (S2) and 6 months later (S3). Outcomes were analysed using McNemar tests and multivariate logistic regression. ResultsA total of 153 participants watched the video and completed S1 and S2; 56 % of these completed S3. Prevideo (S1) 33 % of participants were unaware of LARC methods. Only 3 % rated their knowledge about every method as high. Knowledge improved immediately post video (S2) for all methods (aOR 12.5, 95 % CI 5.2 to 29.8) and LARC methods (aOR 7.9, 95 % CI 4.3 to 11.8). Overall method preference for LARC increased from 23.5 % (n = 36) at S1 to 48 % (n = 74) at S2. Likelihood of using a LARC increased at S2 (aOR 2.1, 95 % CI 1.5 to 2.9). The overall proportion of participants using a LARC increased from 18 % at S1 to 21 % at S3, however, this increase was not significant (p = 0.3). ConclusionOur findings underscore the effectiveness of tailored online educational videos in enhancing contraceptive knowledge and preference for LARCs amongst young women living in rural and remote areas. However preference did not translate into uptake, suggesting that structural and other barriers may be prominent. ImplicationsThis study emphasises the need for a multifaceted approach to facilitating young womens’ access to effective methods of contraception, including LARC. Efforts to promote knowledge should be coordinated with place-based initiatives and policies that directly address the structural barriers to accessing critical sexual and reproductive health services unique to women in rural and remote areas.

Effects of structured contraceptive counseling in young women: Secondary analyses of a cluster randomized controlledtrial (the LOWE trial).

Unwanted pregnancy constitutes a huge health issue. Long-acting reversible contraception (LARC) are the most effective methods for preventing unwanted pregnancy, especially among young women. This study evaluates the intervention effect of structured contraceptive counseling on the choice, initiation, and use of LARC in young women. This is a secondary analysis of women aged 18-25, enrolled in a multicenter cluster randomized controlled trial performed in abortion, youth, and maternal health clinics across the Stockholm County in Sweden. Clinics were randomized (1:1) to provide structured contraceptive counseling (intervention) or standard counseling (control). Surveys were administered at the clinic visit and follow-ups at 3, 6, and 12 months. Primary outcome focused on the choice of LARC among women 18-25 years of age. Secondary outcomes included initiation, and use of LARC at 3 and 12 months, satisfaction with the counseling received and information on extended use of combined hormonal contraceptives. The study was registered at Clinicaltrials.gov (NCT03269357). From September 2017 to May 2019, 770 women aged 18-25 years from 28 clinics/clusters were recruited. There was a significant intervention effect on LARC choice (aOR 5.96, 95% CI 3.25-10.94), initiation (aOR 4.43, 95% CI 2.32-8.46), and use at 12 months (aOR 2.21, 95% CI 1.31-3.73). The odds of LARC choice at pre-booked visits were higher and more women received information about extended-use regimen for short-acting reversible contraception in the intervention group compared to the control group. The intervention package was well received, but with higher satisfaction at pre-booked compared to drop-in visits. Our study demonstrates that comprehensive structured contraceptive counseling significantly increases LARC choice, initiation and use, with high satisfaction among young participants, especially at pre-booked visits. The results highlight an approach that merits implementation to increase quality of care in contraceptive services, to enhance reproductive health for adolescents and young adults.

Association between Abortion and Acceptance of Post abortion Contraception

Post-abortion contraceptive uptake is essential in reproductive health, as it helps to identify women’s contraceptive needs, reduce unintended pregnancies and prevent subsequent abortions. Integrating abortion services with family planning counselling at all levels of health facilities can enhance contraceptive acceptance. This study aimed to evaluate the acceptance of various family planning methods following different abortion services over one year period, at a family planning center, Department of Obstetrics and Gynecology Tribhuvan University Teaching Hospital. This study analyzed the women who participated in contraceptive counselling and accepted different types of contraceptives following different methods of first and second trimester abortions services. The study included women who received post-abortion contraceptive counselling and services, excluding those with termination beyond the second trimester or those seeking only postpartum contraceptive counselling or post-abortion care. It aimed to analyze the association between different methods of abortion and contraception acceptance post-abortion. Among 100 women who had spontaneous and induced abortions, 89% received post-abortion counselling and 75% accepted various types of contraception immediately after abortion. About one third of women were aged 25–29 years (30%), 99% were married, 40% were graduates and 48% were housewives. Abortion methods included medical abortion (62%), manual vacuum aspiration (MVA) (35%) and dilatation and evacuation (3%). Contraceptive acceptance rates were: short-acting reversible contraception (SARC) 60%, long-acting reversible contraception (LARC) 14%, and permanent methods 1%. Among medical abortion recipients, most chose SARC (43%) followed by LARC (4%). For those undergoing MVA, 16% chose SARC, and 9% chose LARC. Condoms were the most accepted SARC method (22%). The study demonstrated that post-abortion counseling significantly increases acceptance of various contraceptive methods, with SARC being the predominant choice, especially condoms among users.

Concurrent use of hormonal long-acting reversible contraception by women of reproductive age dispensed teratogenic medications, Australia, 2013-2021: a retrospective cohort study.

To examine patterns in the dispensing of category X medications (Therapeutic Goods Administration categorisation system for prescribing medicines in pregnancy) to women aged 15-49 years in Australia during 2008-2021, and patterns of concurrent use of hormonal long-acting reversible contraception (LARC) and other hormonal contraception. Retrospective cohort study; analysis of 10% random sample of national Pharmaceutical Benefits Scheme dispensing data. Women aged 15-49 years dispensed category X medications, Australia, 1 January 2013 - 31 December 2021. Incident and prevalent dispensing of category X medications, by medication class, age group, and year; contraceptive overlap (proportions of women dispensed hormonal LARC or other hormonal contraception that overlapped the first dispensing of category X medications), by medication class. Among 15 627 women aged 15-49 years dispensed category X medications during 2013-2021, the prevalence of dispensing increased from 4.6 in 2013 to 8.7 per 1000 women aged 15-49 years in 2021; the largest increase was for the dispensing of dermatological agents, from 3.9 to 7.9 per 1000 women aged 15-49 years. LARC overlap was inferred for 2059 women at the time of first dispensing of category X medications (13.2%); 3441 had been dispensed any type of hormonal contraception (22.1%). The proportion with LARC overlap was smallest for those dispensed dermatological agents (1806 of 14 331 women, 12.6%); for this drug class, both LARC overlap (adjusted odds ratio [aOR], 0.17; 95% confidence interval [CI], 0.14-0.20) and any hormonal contraception overlap (aOR, 0.28; 95% CI, 0.25-0.32) were less likely for those aged 15-19 years than for women aged 25-29 years. Concurrent use of highly effective hormonal contraception at the time of first dispensing of category X medications is low in Australia, raising concerns about potential fetal harms during unintended pregnancies. Awareness of the importance of hormonal contraception and its uptake by women prescribed category X medications should be increased.

General practitioners' views and experiences of postpartum contraception counselling and provision: a qualitative-descriptive study.

To explore Australian general practitioners' views and experiences of undertaking postpartum contraception counselling and provision during the 6-8-week postnatal check. Qualitative-descriptive study; semi-structured online interviews. General practitioners who provide postnatal care in Australian primary health care, recruited using purposive, convenience, and snowball methods, 16 June - 6 July 2023. Views and experiences of postpartum contraception counselling and provision. Twenty-three general practitioners from six states were interviewed; the mean interview time was 30 minutes (range, 21-47 minutes), twenty-two participants were women, and twenty-one worked in metropolitan areas. All participants provide postnatal checks and had the training and facilities needed for providing contraceptive implant insertions. Twelve participants had training in intrauterine device (IUD) insertion, and twenty-one worked in practices with facilities for IUD insertions. Three themes were constructed: views and preferences regarding postnatal contraception counselling; postpartum provision of long-acting reversible contraception (LARC); and opportunities for improving postpartum contraception care in general practice. While most participants recommended LARC methods at postnatal checks, only twelve were trained to insert IUDs. Time constraints, limited access to training, limited financial support, and the lack of guidelines for postnatal checks and contraception care were seen as impeding postpartum contraception counselling. Participants highlighted the importance of access to education and training, appropriate remuneration for general practitioners, multidisciplinary collaboration among health professionals, the inclusion of practice nurses, and raising awareness among mothers of the importance of postnatal checks and postpartum contraception care. General practitioners are well placed to facilitate discussions about contraception with women who have recently given birth. Postpartum contraception care in general practice could be improved by better access to contraception training, appropriate remuneration for contraception procedures, greater multidisciplinary collaboration, and national postnatal check and postpartum contraception guidelines.

Utilization of Immediate Postpartum Contraception and Its Association with Interpregnancy Interval: 10-Year Experience at a Single Center.

Increasing availability of immediate postpartum long-acting reversible contraception (LARC) has added contraceptive alternatives to bilateral tubal ligation (BTL) in the immediate postpartum period. The resultant access to long-term contraception has provided patients with improved control over the timing of pregnancies. Our objective is to evaluate changes in the utilization of immediate postpartum contraceptive methods over a 10-year period and its association with interpregnancy interval (IPI). Retrospective cohort study of 36,445 patients delivered at a single academic hospital center from 2012 to 2020. Deliveries <23 weeks gestation and patients who underwent a cesarean hysterectomy or postpartum hysterectomy for obstetric indications were excluded. The primary outcome was the utilization of postpartum BTL, intrauterine devices, contraceptive implants, and Depo-Provera over the study time period. The secondary outcomes were IPI and interdelivery interval (IDI). Outcomes were compared using appropriate tests of trend. We adjusted for significant covariates as assessed in baseline characteristics. A total of 35,281 patients were included in our study. Groups were different in baseline characteristics including age, race/ethnicity, parity, BMI, insurance status, comorbidity risk, and attendance at postpartum exam. Over the study period, there was a significant difference in utilization of Depo-Provera, LARC, intrauterine device (IUD), and implant (p < 0.001). There was a significant increase in IPI (p < 0.001) and IDI (p < 0.001). We observed a significant increase in utilization of immediate postpartum LARC over the study period which corresponded to a significant increase in IPI and IDI. Our findings emphasize the importance of the availability of immediate postpartum contraception as well as its effectiveness in improving family planning options for reproductive-aged patients. We found significantly increased IPI and IDI associated with increased utilization of long-acting reversible contraceptives immediately postpartum. Our findings emphasize the importance of providers offering these options to patients as well as being comfortable initiating immediate postpartum contraception. · Immediate postpartum LARC access has increased over the past 10 years.. · Access to more methods of contraception allows patients more options for family planning.. · Increased utilization of LARC led to increased IPI and IDI..

Selection of long acting reversible contraception methods by emergency contraception clients: A prospective observational study

ObjectivesTo describe long acting reversible contraception (LARC) initiation in emergency contraception (EC) visits. Study designEC clients age 18–35 years at four Utah family planning clinics between February 2021 and April 2023 chose between oral EC and three LARC options. ResultsOf 2106 EC clients approached, 306 (14.5%) requested LARC and 293 initiated a device: 160 (55%) an etonogestrel implant+ oral levonorgestrel (LNG), 72 (25%) a copper intrauterine device (IUD), and 61 (21%) a 52 mg levonorgestrel IUD (p < 0.001). ConclusionsIn this observational study, one in seven EC clients initiated a LARC method and more frequently selected the etonogestrel implant with oral levonorgestrel over an IUD. Clinical Trial RegistrationClinicaltrials.gov NCT04678817; registered 12/16/20.

Contraceptive counseling training experiences and behaviors among obstetrics and gynecology residents in California and Florida

ObjectiveTo describe experiences with contraception counseling training and provision of obstetrics and gynecology residents training in California and Florida. Study designWe conducted a mixed-methods study of obstetrics and gynecology residents training across 19 programs (with approximately 428 residents) in California and Florida from September 2022 through February 2023. We asked participants how often they use tiered-effectiveness counseling, their satisfaction with contraception counseling practices, and experiences with witnessing and recognizing contraception coercion. We asked about personal disappointment when patients decline long-acting reversible contraception (LARC) and pressure from faculty to prescribe LARC. To further explore resident contraception counseling education and behaviors, we conducted semi-structured telephone interviews with a subset of 20 survey volunteers. ResultsWe received survey responses from 155 (36.2%) participants. Most (n = 113 [76.4%]) often or always reported using tiered-effectiveness counseling. While few participants (n = 17 [11.3%]) reported feeling pressure from faculty to convince a patient to keep a LARC, some (n = 34 [22.1%]) reported they often or always feel disappointed when a patient chooses LARC removal, with more Florida participants reporting disappointment (n = 19 [37.3%]) compared to California (n = 15 [14.6%], p = 0.01). We identified two main themes from the telephone interviews. First, residents feel they have limited formal education on how to provide contraceptive counseling and commonly learn these practices by emulating supervising faculty or peer counseling styles. Second, residents are informally taught, through feedback and interactions with supervising faculty and peers, that successful contraception counseling is the ability to convince patients to use highly effective contraception. ConclusionWhen residents lack formalized contraception counseling education, they adopt counseling behaviors that may not be patient centered. ImplicationsWhen obstetrics and gynecology residents lack formalized contraception counseling education, they learn practices that may lead to coercive counseling behaviors during training. Resident education should include recognition and mitigation of contraception coercion and patient-centered counseling both through a formalized curriculum and socialization of trainees during their medical education.

Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT.

Endometriosis affects 1 in 10 women, many of whom have surgery for persistent pain. Recurrence of symptoms following an operation is common. Although hormonal treatment can reduce this risk, there is uncertainty about the best option. To evaluate the clinical and cost-effectiveness of long-acting progestogen therapy compared with the combined oral contraceptive pill in preventing recurrence of endometriosis-related pain and quality of life. A multicentre, open, randomised trial with parallel economic evaluation. The final design was informed by a pilot study, qualitative exploration of women's lived experience of endometriosis and a pretrial economic model. Thirty-four United Kingdom hospitals. Women of reproductive age undergoing conservative surgery for endometriosis. Long-acting progestogen reversible contraceptive (either 150 mg depot medroxyprogesterone acetate or 52 mg levonorgestrel-releasing intrauterine system) or combined oral contraceptive pill (30 µg ethinylestradiol, 150 µg levonorgestrel). The primary outcome was the pain domain of the Endometriosis Health Profile-30 questionnaire at 36 months post randomisation. The economic evaluation estimated the cost per quality-adjusted life-years gained. Four hundred and five women were randomised to receive either long-acting reversible contraceptive (N = 205) or combined oral contraceptive pill (N = 200). Pain scores improved in both groups (24 and 23 points on average) compared with preoperative values but there was no difference between the two (adjusted mean difference: -0.8, 95% confidence interval -5.7 to 4.2; p = 0.76). The long-acting reversible contraceptive group underwent fewer surgical procedures or second-line treatments compared with the combined oral contraceptive group (73 vs. 97; hazard ratio 0.67, 95% confidence interval 0.44 to 1.00). The mean adjusted quality-adjusted life-year difference between two arms was 0.043 (95% confidence interval -0.069 to 0.152) in favour of the combined oral contraceptive pill, although this cost an additional £533 (95% confidence interval 52 to 983) per woman. Limitations include the absence of a no-treatment group and the fact that many women changed treatments over the 3 years of follow-up. Use of telephone follow-up to collect primary outcome data in those who failed to return questionnaires resulted in missing data for secondary outcomes. The COVID pandemic may have affected rates of further surgical treatment. At 36 months, women allocated to either intervention had comparable levels of pain, with both groups showing around a 40% improvement from presurgical levels. Although the combined oral contraceptive was cost-effective at a threshold of £20,000 per quality-adjusted life-year, the difference between the two was marginal and lower rates of repeat surgery might make long-acting reversible contraceptives preferable to some women. Future research needs to focus on evaluating newer hormonal preparations, a more holistic approach to symptom suppression and identification of biomarkers to diagnose endometriosis and its recurrence. This trial is registered as ISRCTN97865475. https://doi.org/10.1186/ISRCTN97865475. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/114/01) and is published in full in Health Technology Assessment; Vol. 28, No. 55. See the NIHR Funding and Awards website for further award information. The NIHR recognises that people have diverse gender identities, and in this report, the word 'woman' is used to describe patients or individuals whose sex assigned at birth was female, whether they identify as female, male or non-binary.

The association between socio-economic deprivation and receipt of long-acting reversible contraception at a single clinic visit

ObjectivesTo determine the relationship between area deprivation index (ADI) and obtaining single-visit long-acting reversible contraception (LARC). Study designWe utilized Poisson regression to determine the association between area deprivation and single-visit LARC insertion within a state-wide healthcare system between 2019–2021. ResultsAmong our cohort (N = 4417), 68.60% of patients desiring LARC obtained single-visit LARC. Participants living in high deprivation areas were less likely to receive single-visit LARC (aRR 0.72, 95% CI 0.65–0.80). ConclusionsLiving in areas of high deprivation is independently negatively associated with obtaining a single-visit LARC. ImplicationsWhile access to single-visit LARC should be universally improved, reducing barriers for patientswith a higher ADI may help limit inequities in reproductive healthcare.

Exploring primary care physician biases in adolescent contraceptive counseling

Objective(s)While previous literature has shown clinician bias in adult contraceptive counseling, less is known on the biases clinicians may exhibit when counseling adolescents about contraception. Our study aimed to describe long-acting reversible contraception (LARC) counseling and prescribing practices of adolescent-serving clinicians. Study designThis study used a cross-sectional discrete choice experiment mixed methods design. We sent a survey containing vignettes and items pertaining to demographics and beliefs to a convenience sample of adolescent-serving clinicians across the United States. ResultsOf 296 clinicians, 80% were in pediatrics, and had geographic, practice setting, gender, and racial diversity. Most clinicians reported being up-to-date with current literature regarding contraception. Sixty-eight percent of respondent’s practices administer contraceptive injections, but only 17% place intrauterine devices (IUDs). Of those who do insert IUDs, nearly half inserted five or fewer within the last year. Patients’ younger age and Hispanic ethnicity were associated with lower odds, and history of pregnancy was associated with higher odds, of clinicians’ recommending LARC. Across all vignettes, the top five reasons clinicians chose their first-choice method for the patient were adherence or compliance, efficacy, side effects, patient age, and reversibility. Conclusion(s)Clinicians often recommend contraceptives based on adherence, efficacy, and age, and we found younger age, minoritized race or ethnicity, and history of pregnancy were all associated with LARC recommendations, indicating potential biases against teen parents and assumptions about adolescents’ priorities. This may impede the provision of patient-centered contraceptive counseling for adolescents, and highlights the need for improved education and practice changes post-Dobbs. ImplicationsWe found that clinicians demonstrated several biases in how they provide contraceptive recommendations to adolescent patients. These biases were often associated with their personal beliefs and experiences. Our findings can guide the development of future interventions aimed at improving adolescent reproductive health counseling and care delivery in primary care settings.

Factors associated with long-acting reversible contraceptives usage among sexually active adolescent girls and young women in Zimbabwe.

Despite the benefits of long-acting reversible contraceptives (LARCs), they are not being utilized in Zimbabwe as much as the short-acting reversible contraceptives (SARCs). The aim of the study was to explore factors associated with LARC usage among Zimbabwean adolescent girls and young women, using data from the 2015 Zimbabwe Demographic and Health Survey. Cross tabulations and chi-square tests were used initially to describe associations. Odd ratios were then used to measure the strength of association between LARCs usage and the independent variables using stepwise multinomial logistic regression. From the 2132 sexually active females included in the study 9.1% were LARCs users and 42% were SARCs users at the time of the survey. Secondary and primary education had increased odds of not using any method (OR: 5.032, 95% CI: 2.136-11.8512 and OR: 5.799, 95% CI: 2.327-14.453 respectively) compared to tertiary education. Women with no living children had increased odds of not using any method (OR 66.543, 95% CI: 25.784-171.7381). Being not married was associated with decreased odds of SARCs usage (OR 0.399, 95% CI: 0.285-0.558). Desire for no more children was associated with reduced odds of SARCs usage (OR: 0.448, 95% CI: 0.304-0.66). Being a member of the Apostolic Faith church was associated with increased odds of not using any method (OR 1.423517, 95% CI: 1.018-1.990309). In conclusion, acquiring a tertiary education, having children, a desire to cease bearing children altogether, being unmarried and belonging to the highest wealth class were generally associated with an increased likelihood of using LARCs. Being a member of the Apostolic Faith church was associated with a decreased likelihood of LARCs usage. Findings from the study are relevant in the Zimbabwean context and highlights the relevant factors essential to focus on, when carrying out interventions aimed at increasing LARCs uptake in the country.

A post-abortion contraception text-and-call service to support patients to access effective contraception after telemedicine abortion

BackgroundMost abortions in Scotland are conducted at home before 12 weeks’ gestation using telemedicine. The volume of information given at a pre-abortion consultation may feel overwhelming and contraception may not...

Expanding access to postpartum contraception.

Women are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field. Current models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness. Antenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

Immediate Postpartum Long-Acting Reversible Contraception for Preventing Severe Maternal Morbidity: A Cost-Effectiveness Analysis.

To estimate the cost effectiveness of Medicaid covering immediate postpartum long-acting reversible contraception (LARC) as a strategy to reduce future short interpregnancy interval (IPI), severe maternal morbidity (SMM), and preterm birth. We built a decision analytic model using TreeAge software to compare maternal health and cost outcomes in two settings, one in which immediate postpartum LARC is a covered option and the other where it is not, among a theoretical cohort of 100,000 people with Medicaid insurance who were immediately postpartum and did not have permanent contraception. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost increase per an incremental quality-adjusted life-years (QALY) gained from one health intervention compared with another. Secondary outcomes included subsequent short IPI, defined as time between last delivery and conception of less than 18 months, as well as SMM, preterm birth, overall costs, and QALYs. We performed sensitivity analyses on all costs, probabilities, and utilities. Use of immediate postpartum LARC was the cost-effective strategy, with an ICER of -11,880,220,102. Use of immediate postpartum LARC resulted in 299 fewer repeat births overall, 178 fewer births with short IPI, two fewer cases of SMM, and 34 fewer preterm births. Coverage of immediate postpartum LARC resulted in 25 additional QALYs and saved $2,968,796. Coverage of immediate postpartum LARC at the time of index delivery can improve quality of life and reduce health care costs for Medicaid programs. Expanding coverage to include immediate postpartum LARC can help to achieve optimal IPI and decrease SMM and preterm birth.

Social Determinants of Health and Patient-Reported Difficult Discontinuation of Long-Acting Reversible Contraception.

Background: Some individuals who receive long-acting reversible contraception (LARC) face barriers to discontinuation. The inability to discontinue a contraceptive method when desired negatively impacts a person's reproductive autonomy. Persons impacted by social determinants of health (SDH) may be disproportionately affected. The objective of this study is to evaluate the association of SDH with patient-reported difficult LARC discontinuation. Methods: A retrospective cross-sectional analysis of data from the 2017-2019 cycle of the National Survey of Family Growth was conducted. The main outcome was patient-reported difficulty discontinuing a LARC method (intrauterine device or implant) in the last 10 years. Descriptive statistics were used to identify demographic characteristics and SDH domains. Multivariable logistic regression models were used to estimate associations across SDH domains with difficult LARC removal. Results: A total of 754 respondents reported wanting to have their LARC removed, and 105 (11%) reported difficulty discontinuing LARC methods. One-third of respondents experienced one or more SDH, notably food insecurity (26%) or transportation barriers (30%). After adjusting for age, race, education, geographic location, parity, and body mass index (BMI), persons with one or more SDH had an increased adjusted odds ratio (aOR) for difficultly discontinuing LARCs compared with respondents without any SDH (2.11; 95% confidence interval [CI]: 1.21, 3.69). Transportation barriers demonstrated the largest aOR of 2.90 (95% CI: 1.07, 7.87). Conclusions: SDH are associated with challenges to LARC discontinuation. SDH are unique risk factors that can impact one's entire contraceptive experience. A nuanced discussion of SDH at the time of contraceptive counseling may be a critical step in addressing the intersectionality of method selection and reproductive agency.

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.

Changes in male permanent contraception as partner access to long-acting reversible contraception (LARC) increases: an analysis of the National Survey for Family Growth, 2006-2010 versus 2017-2019.

Male permanent contraception (PC), that is, vasectomy, is an effective way of preventing pregnancy. In the United States, male PC use has historically been concentrated among higher-educated/higher-income males of White race. In the last decade, use of long-acting reversible contraception (LARC) has increased dramatically. We sought to understand how sociodemographic patterns of male PC have changed in the context of rising LARC use. We examined the nationally representative male public use files of the National Survey for Family Growth (NSFG) across five survey waves. Our outcome was primary contraceptive use at last sexual encounter within 12 months. Using four-way multinomial logistic regressions (male PC, female PC, LARC, lower-efficacy methods), we compared sociodemographic factors predictive of male PC use versus reported partner LARC use between 2006-2010 (early) and 2017-2019 (recent) waves. We included 15 964 participants. From 2006 to 2019, there were absolute declines in male PC from 8.0% to 6.8%, while male-reported partner LARC use increased three-fold, from 3.4% to 11.0%. Among the highest economic strata, use of LARC converged with male PC. In adjusted analyses, high income significantly associated with male PC use in the early wave (OR 4.6 (1.4, 14.8)), but no longer in the recent wave (OR 0.9 (0.2, 4.2)). Marital status remained a significant but declining predictor of male PC across survey waves, and instead, by 2019, number of children newly emerged as the strongest predictor of male PC use. Sociodemographic variables associated with vasectomy use are evolving, especially among high-income earners.

Long-Acting but Reversible: Opportunities to Address Provider Bias in Contraceptive Care.

Jasmine is an 18-year-old Black female bringing her infant to the pediatrician for a newborn weight check. She asks her pediatrician's opinion about hormonal contraceptive injections, sharing that they were strongly recommended after she gave birth. The recommending health care provider told her, "We don't want you to end up back here any time soon." Rosita, a 16-year-old Latina female, visits her pediatrician for a well check. She reports a history of vaginal sex with 2 male partners and agrees to have a hormonal subcutaneous implant placed to avoid pregnancy. After 4 months of bothersome spotting, Rosita returns to have the implant removed. Rosita's provider strongly counsels against removal. Jasmine and Rosita are members of populations that have been systematically marginalized throughout American history. Their stories are derived from real cases and reveal how structural racism impacts modern contraceptive care. Specifically, their cases are examples of statistical discrimination, wherein the tendency to disproportionately recommend long-acting reversible contraception to historically marginalized communities does not follow the central tenants of sexual and reproductive justice, including acknowledging historical harms in health care and honoring bodily autonomy for all people. By sharing Jasmine and Rosita's stories, we use a reproductive justice lens to (1) examine the historical roots of disproportional prescription of long-acting reversible contraception to historically marginalized individuals, (2) discuss provider bias related to sexual and reproductive health care, and (3) illustrate how trauma-informed care with a recognition of historical trauma and the use of individuation can facilitate positive and equitable health outcomes.