Summary Background Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible ...contraceptives (LARCs) on pregnancy rates. Methods We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011–13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18–25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. Findings Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 71% of 797 vs 271 39% of 693, odds ratio 3·8, 95% CI 2·8–5·2) and more selected LARCs during the clinic visit (224 28% vs 117 17%, 1·9, 1·3–2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34–0·85). Interpretation The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. Funding William and Flora Hewlett Foundation.
Inpatient insertion of long-acting reversible contraception and immediate postpartum tubal ligation allow women to initiate highly effective contraception before hospital discharge.
We measured rates ...of intrauterine device and contraceptive implant initiation and tubal ligations performed during delivery hospitalizations from 2016 to 2018 from a representative sample of US hospital discharges.
We used the 2016 to 2018 National Inpatient Sample database, a 20% sample of all community hospital discharges in the United States, to identify delivery hospitalizations with concomitant intrauterine device insertion, contraceptive implant insertion, or tubal ligation. We performed weighted multivariable logistic regression to examine associations between possible predictors (age, delivery mode, payer, geographic region, and year) and odds of long-acting reversible contraception and tubal ligation, and to compare characteristics of users.
This sample included 2,216,638 discharges, representing 20% of 11,083,180 delivery hospitalizations across the United States. Intrauterine device insertion increased from 2.2 per 1000 deliveries (2016) to approximately 5.0 per 1000 deliveries (2018; P<.0001); implant insertion increased from 0.3 per 1000 deliveries (2016) to 2.5 per 1000 deliveries (2018; P<.0001); tubal ligation procedures decreased (64.2 to 62.1 per 1000 deliveries; P<.0001).
Women who underwent a cesarean delivery had higher odds of having a tubal ligation than those who had a vaginal delivery (adjusted odds ratio, 8.83; 95% confidence interval, 8.73–8.97). Women aged <25 years had 7 times higher odds of receiving long-acting reversible contraception than of receiving tubal ligation (adjusted odds ratio, 7.38; 95% confidence interval, 6.90–7.90). Women with public insurance had almost 5 times the odds of receiving long-acting reversible contraception compared with those with commercial insurance (adjusted odds ratio, 4.83; 95% confidence interval, 4.59–5.06).
Rates of long-acting reversible contraception insertion continue to increase while the rates of inpatient postpartum tubal ligations slowly decline. Variations in patient characteristics are associated with receiving long-acting reversible contraception or tubal ligation.
To describe patient-reported quality of care for virtual contraceptive counseling, using the four-item Person-Centered Contraception Counseling (PCCC) scale. Secondary analyses evaluated PCCC scores ...by patient subgroups.
From December 2021 to May 2022, we offered an anonymous web-based survey, to English and Spanish-speaking female patients 18 to 45 years old who had virtual visits through two Family Planning offices affiliated with Columbia University/New York Presbyterian Hospital in New York City.
Among 196 respondents, 133 (68%) respondents gave the top score. The proportion who gave the top PCCC score was higher for the faculty-based practice vs. community-based practice (62% vs. 38% respectively, p = 0.02), video vs. telephone (84% vs. 16% respectively, p = 0.01), and English vs. Spanish (86% vs. 14% respectively, p = 0.02); but did not differ for ethnicity (p = 0.34).
Patient-perceived quality of contraceptive counseling in virtual visits was high, with some disparities seen in the subgroups.
This exploratory study about contraceptive counseling during virtual visits showed that 68% of survey respondents gave the top box PCCC score. Our work also suggests disparities in patient experiences based on several factors. Future work may expand on nuances of disparities and how these influence care.
In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits ...have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.
To review the rate, setting, and demographic characteristics of tubal sterilization and its current trend within contraceptive practice in the United States.
Review of U.S. health care statistics, ...NCHS publications, English-language literature searched using MEDLINE and PubMed, and bibliographies of key references.
Total annual cases of tubal sterilization have declined from 687,000 in 1995 to 643,000 in 2006, despite a 4% population growth. Interval sterilizations decreased by 12%. Postpartum sterilizations remained stable and follow 8%-9% of all live births. Tubal sterilizations remain more common in black and Hispanic women; women with lower income, lower education, and higher parity; and among women living in the South. From 1981 to 1995, inpatient interval sterilizations fully migrated to ambulatory surgery care.
After two decades of stable rates, there is a recent decline in sterilization. Improved access to a wide range of highly effective reversible contraceptives gives women flexibility when deciding how to manage their reproductive ability.
•Pregnancy options counseling is a necessary competency in medical education.•Narrative Medicine can promote self-reflection among students.•Students participating in a narrative medicine workshop ...performed better in patient counseling.
Pregnancy options counseling, or nondirective counseling of patients with unintended pregnancy, is a “necessary competency” for medical students according the Association of Professors of Gynecology and Obstetrics. Narrative Medicine (NM) utilizes stories of illness to inform clinical practice and promotes self-reflection in medical education. The authors analyzed the effect of a NM workshop on medical students’ ability to provide pregnancy options counseling.
The authors randomized students in the major clinical year at Columbia University Medical Center (CUMC) to either a 2-hour NM workshop or to a control intervention. The NM group participated in reading and reflective writing exercises addressing varying perspectives on pregnancy. Students then completed a video-taped and numerically-scored OSCE (Objective Structured Clinical Examination) regarding pregnancy options counseling. The authors compared mean OSCE scores between the groups.
The study analyzed 103 participants. Overall mean OSCE scores were higher in the NM group (11.9 ± 1.5, n = 51) than the control group (11.3 ± 1.6, n = 52) (p = 0.049).
Students undergoing a NM workshop had higher scores on a pregnancy options counseling OSCE.
This brief intervention may aid future physicians in providing nondirective pregnancy options. This novel approach to teaching is an easily shared learning tool.
Objective
To describe factors associated with subsequent abortions in Colombia and evaluate whether high‐efficacy contraceptive availability (IUD) post‐index abortion was associated with higher ...efficacy contraceptive initiation and fewer subsequent abortions within 2 years.
Methods
The study population comprised patients aged 15–44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2‐year follow‐up (2017–2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi‐square and multivariate logistic regression.
Results
Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017–2019). IUD availability (adjusted odds ratio aOR, 1.64; 95% confidence interval CI, 1.39–1.93) and insurance use (aOR, 5.03; 95% CI, 4.37–5.78) were associated with high‐efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22–0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59–6.80) or moderate‐efficacy (injection: aOR, 4.21 95% CI, 3.14–5.62; oral contraceptive pill: aOR, 4.60 95% CI, 3.21–6.59) methods were associated with subsequent abortion.
Conclusion
Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.
Synopsis
Access to and initiation of high‐efficacy postabortion contraceptives are associated with lower rates of subsequent abortion in Colombia.
Prescribing information for the levonorgestrel-releasing intrauterine system allows placement when the clinician is reasonably certain the patient is not pregnant. A 6 item checklist aids clinicians ...in determining pregnancy risk but may be too restrictive, resulting in delaying placement for many women. Same-day placement, however, may risk placement during an unrecognized luteal-phase pregnancy, that is, a preimplantation fertilized ovum not yet detectable by urine pregnancy test.
We assessed the applicability of pregnancy checklist criteria in 2 gynecology practices that routinely provide same-day placements following a negative urine pregnancy test.
In this retrospective cohort study, we reviewed electronic medical records of all women who underwent levonorgestrel-releasing intrauterine system placement from July 2009 to August 2012. We evaluated each record to identify whether the woman met any of the checklist criteria to exclude pregnancy. We ascertained luteal-phase pregnancies and other outcomes within 12 months following placement.
Of 885 placements, 293 (33%) were immediately after abortion. Of the remaining 592 placements, 353 (60%) met at least 1 pregnancy checklist criterion to rule out pregnancy but 239 (40%) met none. Two percent received levonorgestrel emergency contraception at the time of placement. One luteal-phase pregnancy occurred in the group not meeting pregnancy checklist criteria. Removals and expulsions were rare and similar whether or not patients met checklist criteria.
In 2 practices that provide same-day intrauterine system placements, strict adherence to pregnancy checklist criteria would have resulted in 239 patients (40%) not receiving a same-day intrauterine system. Twelve month outcomes were similar whether or not patients met pregnancy checklist criteria. Providers need not withhold intrauterine system placement based on the pregnancy checklist criteria.
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