By Rebecca Bowers

EXECUTIVE SUMMARY

Research from the Bixby Center for Global Reproductive Health at the University of California, San Francisco, and Planned Parenthood Federation of America indicates that a four-hour training intervention can significantly affect the likelihood that healthcare providers will integrate long-acting reversible contraceptives into their clinical care.

  • A year following the training course, clinicians who participated in the training were more likely to have knowledge about which patients are eligible, to feel experienced enough to talk about long-acting reversible contraceptives, and to discuss such options routinely in contraceptive counseling sessions.
  • The American College of Obstetricians and Gynecologists’ LARC Work Group recently has launched the ACOG LARC Program Help Desk, an online platform through which both ACOG members and nonmembers who provide contraceptive care can receive individualized, expert technical assistance.

New research from the Bixby Center for Global Reproductive Health at the University of California, San Francisco, and Planned Parenthood Federation of America indicates that a four-hour training intervention can significantly affect the likelihood that healthcare providers will integrate long-acting reversible contraceptives (LARC) into their clinical care.1

To conduct the study, providers and health educators in the intervention group at Planned Parenthood health centers in 15 states (California, Colorado, Connecticut, Florida, Hawaii, Idaho, Michigan, Minnesota, North Carolina, New Jersey, New Mexico, Ohio, Oregon, Pennsylvania, and Washington) were offered a four-hour accredited continuing education course with updated evidence on intrauterine devices (IUDs) and implants. The course also included hands-on training on IUD insertion and contraceptive counseling.

Results of the study indicate significant changes in providers’ attitudes, knowledge, and practices in the group that received the training. A year following the training course, clinicians who participated in the training were more likely to have knowledge about which patients are eligible, to feel experienced enough to talk about long-acting reversible contraceptives, and to discuss such options routinely in contraceptive counseling sessions, results suggest.1

“Patients deserve evidence-based information about all options to choose the birth control method that’s best for them,” notes Cynthia Harper, PhD, professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, and lead investigator for the study. “This efficient training offers a model that can help providers around the country offer high-quality, effective contraceptive care.”

Training clinicians to inform women that different birth control methods have different levels of effectiveness proved key in reducing the number of unintended pregnancies among young women seeking family planning services, according to a 2015 study published by Bixby Center researchers.2 By educating young women about the safety and effectiveness of long-acting reversible contraception, the researchers found that unintended pregnancy rates dropped by nearly half from 15 to eight per 100 women among women seeking family planning services.2

The Bixby Center/Planned Parenthood project stressed the same three issues often highlighted as reasons for the success of the CHOICE Project in St. Louis, says Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. The issues included:

  • education about the effectiveness of LARC methods;
  • emphasis on providing LARC methods on same-day visits or as soon as possible; and
  • cost.

Although LARC methods were not provided free of charge in the Bixby Center/Planned Parenthood project, efforts were made to provide LARC as inexpensively as possible, Hatcher notes.

Check Your Knowledge Base

While obstetrician/gynecologists and women’s health nurse practitioners are more familiar with IUDs and implants compared to other providers, it is not uncommon that even expert providers have some misinformation when it comes to LARC methods, the researchers note. For example, some providers believe IUD placement is inappropriate in nulliparous women, adolescents, and women immediately following abortion, while others think that IUDs and implants have the same contraindications as combined hormonal contraceptive methods.3-5

The U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 (U.S. MEC) classifies IUD use in nulliparous women and in adolescents (women 20 years of age or younger) as Category 2 (advantages outweigh the risks), and use of implants as Category 1 (no restrictions). Immediate insertion of the copper IUD or levonorgestrel IUD after a first-trimester induced or spontaneous abortion is classified as Category 1, and is Category 2 for second-trimester postabortion insertion. Contraceptive implant insertion immediately after an induced or spontaneous first-trimester abortion or second-trimester abortion (through medication, uterine aspiration, or dilation and evacuation) is classified as Category 1.6

The study also assessed providers about whether they would consider a copper IUD, levonorgestrel IUD, or an implant for a woman with obesity, diabetes, or hypertension, or a smoker. All methods can be used safely with these conditions, according to the U.S. MEC.6

Get On-site Training

The Bixby Center’s “Beyond the Pill” program offers on-site training for improving women’s access to LARC methods. The core curriculum of its on-site training includes a general session for all staff, followed by separate sessions for health educators and clinicians.

The all-staff session provides updated information on IUDs and implants, including the latest science and professional recommendations. Participants take part in a brainstorming session to identify barriers to provision and develop strategies to streamline access.

During the health educator practicum, participants receive training on education and counseling techniques, with a focus on patient-centered counseling and educating women on method effectiveness. A counseling skills and role-playing session for health educators provides an opportunity to refine counseling approaches and practice delivering patient education points specific to IUDs and implants. This session is designed specifically for health educators, counselors, clinicians, social workers, and administrative staff.

During the clinician practicum, a hands-on insertion technique session allows participants to gain or refine their skills placing different IUD models. This session is designed specifically for clinicians. Continuing medical education is available; clinicians can earn up to 7.5 credit hours toward continuing education requirements. (For more information, contact Abigail Smith at abigail.smith@ucsf.edu.)

Check the “Help Desk”

Do you have questions on LARC clinical issues, contraceptive counseling, resources, and assistance with reimbursement and payment issues? The American College of Obstetricians and Gynecologists’ LARC Work Group recently launched the ACOG LARC Program Help Desk, an online platform through which both ACOG members and nonmembers who provide contraceptive care can receive individualized, expert technical assistance on LARC.

Clinicians may receive answers to their questions by submitting a ticket on the help desk home page at www.acog.org/LARChelpdesk. Through the help desk, providers will receive status updates and responses to questions at their provided email address. By creating an ACOG LARC Program Help Desk account, providers can view their current ticket and can review answers to past tickets at any time. Use of the help desk is free and open to the public. While ACOG member questions will receive priority, ACOG membership and login information are not required for help desk access.

The ACOG LARC Program Help Desk also contains a knowledge base of resources that can be accessed and downloaded free of charge, with items such as ACOG LARC Program materials, ACOG clinical guidance on LARC, patient education materials, and billing and reimbursement resources.

“The ACOG LARC Program remains committed to supporting ACOG members and the broader women’s health community,” said Eve Espey, MD, MPH, Chair of the LARC Work Group, in a statement. “We hope the new ACOG LARC Program Help Desk will support [clinicians’] work to provide the full range of contraceptive methods to patients so they can achieve their reproductive health goals.”

REFERENCES

  1. Thompson KMJ, Rocca CH, Stern L, et al. Training contraceptive providers to offer intrauterine devices and implants in contraceptive care: A cluster randomized trial. Am J Obstet Gynecol 2018; doi:10.1016/j.ajog.2018.03.016. [Epub ahead of print].
  2. Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: A cluster randomised trial. Lancet 2015;386:562-568.
  3. Harper CC, Henderson JT, Raine TR, et al. Evidence-based IUD practice: Family physicians and obstretrician-gynecologists. Fam Med 2012;44:637-645.
  4. Tyler CP, Whiteman MK, Zapata LB, et al. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol 2012;119:762-771.
  5. Harper CC, Stratton L, Raine TR, et al. Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners. Prev Med 2013;57:883-888.
  6. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.