Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians' perceived barriers and facilitators.

BACKGROUND: The etonogestrel contraceptive implant is currently approved by the United States Food and Drug Administration (FDA) for the prevention of pregnancy up to 3 years. However, studies that suggest efficacy up to 5 years. There is little information on the prevalence of extended use and the factors that influence clinicians in offering extended use. We investigated clinician perspectives on the barriers and facilitators to offering extended use of the contraceptive implant. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured qualitative interviews. Participants were recruited from a nationwide survey study of reproductive health clinicians on their knowledge and perspective of extended use of the contraceptive implant. To optimize the diversity of perspectives, we purposefully sampled participants from this study. We used content analysis and consensual qualitative research methods to inform our coding and data analysis. Themes arose deductively and inductively. RESULTS: We interviewed 20 clinicians including advance practice clinicians, family medicine physicians, obstetrician/gynecologist and complex family planning sub-specialists. Themes regarding barriers and facilitators to extended use of the contraceptive implant emerged. Barriers included the FDA approval for 3 years and clinician concern about liability in the context of off-label use of the contraceptive implant. Educational materials and a champion of extended use were facilitators. CONCLUSIONS: There is opportunity to expand access to extended use of the contraceptive implant by developing educational materials for clinicians and patients, identifying a champion of extended use, and providing information on extended use prior to replacement appointments at 3 years.

Barriers and Facilitators of Extended Use of the Contraceptive Implant: A Cross-Sectional Survey of Clinicians.

BACKGROUND: The U.S. Food and Drug Administration (FDA) approved the etonogestrel contraceptive implant for 3 years of use. Evidence suggests that it may be used for up to 5 years for pregnancy prevention, also known as extended use. METHODS: We conducted a national cross-sectional survey among a group of reproductive health clinicians. We developed an online survey using the Consolidated Framework for Implementation Research (CFIR) and distributed it through e-mail listservs and social media groups from May to June 2021. We analyzed results using multivariable logistical regression. RESULTS: Among the 300 respondents, 195 (65.0%) reported that they always offer extended use, and 50 (16.7%) reported that they sometimes offer extended use. Fifty-five respondents (18.3%) reported that they never offer extended use. After adjusting for age, gender, and clinical setting, we found that complex family planning sub-specialists (adjusted odds ratio [aOR] = 9.32; 95% confidence interval [CI] [1.81, 48.03]) and family medicine physicians (aOR = 4.37, 95% CI [1.58, 12.10]) were significantly more likely to recommend extended use compared with general obstetrics and gynecology (OBGYN) physicians. Clinicians from private practices or health maintenance organizations were significantly less likely to offer extended use than those from academic centers (aOR = 0.19, 95% CI [0.07, 0.51]; aOR = 0.06, 95% CI [0.01, 0.31]). The most common barriers to offering extended use were concerns about pregnancy risk, bleeding, and lack of FDA approval in the past 3 years. Meanwhile, clinicians identified strong published evidence supporting extended use as a key facilitator for offering it, and they perceived that prior counseling on extended use from a past clinician was a key facilitator for patients to adopt it. CONCLUSIONS: One-third of clinicians in this study did not consistently offer extended use of the contraceptive implant. An opportunity exists to expand access to extended use by focusing on education interventions for clinicians and seeking FDA approval for 5 years of use.

Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial.

Importance: The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. Objective: To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. Design, Setting, and Participants: In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Interventions: Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. Main Outcomes and Measures: The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Results: Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Conclusions and Relevance: Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. Trial Registration: ClinicalTrials.gov Identifier: NCT03462758.

Time from first clinical contact to abortion in Texas and California.

OBJECTIVE: To assess whether having an abortion in Texas, a U.S. state with many restrictive abortion laws, is associated with increased time between contacting an abortion provider and receiving an abortion, compared to having an abortion in California, a less restrictive U.S. state. STUDY DESIGN: This is a multisite, cross-sectional survey of 434 patients in 12 abortion facilities (ambulatory surgical centers and clinics) in Texas (n = 291) and three abortion clinics in California (n = 143) from 2018 to 2019. At 11 facilities in Texas the response rate was 76%. The response rate was not collected at other sites. We compare the clinical-contact-to-abortion time interval between the facilities in these two states using mixed-effects multivariable logistic regression, adjusting for age, race, education, household income, parity, marital status, and insurance status. We also compare barriers to scheduling and traveling to abortion appointments. RESULTS: Median clinical-contact-to-abortion time is similar among respondents in Texas and California [(9 vs 8 days, p = 0.86). The odds of having a clinical-contact-to-abortion time ≥7 days is similar among respondents in Texas compared to California (adjusted odds ratio 1.0 (95% confidence interval, 0.4-2.6, p = 0.98). Respondents in Texas travel farther for their abortion (mean 22.1 vs 13.5 miles, p < 0.01), are more likely to sell something of value or delay paying another expense to pay for their abortion (49.7% vs 11.4%, p < 0.01), and to miss work to attend their abortion (73.9% vs 61.3%, p = 0.03). CONCLUSIONS: In this study, we found no difference in clinical-contact-to-abortion time between respondents in Texas and those in California. Respondents in Texas, however, face other significant barriers in obtaining abortion care, which result in life disruptions and financial hardship. IMPLICATIONS: Patients face greater financial barriers when seeking abortion in Texas compared to California. Though we found no significant difference in clinical-contact-to-abortion time in this sample between the two states, clinical-contact-to-abortion time may be a useful measure of facility congestion and the obstacles patients face obtaining abortion care.

Exploring emergency contraception prescribing by pharmacists in California.

OBJECTIVE: To understand knowledge, current practices, barriers and facilitators for pharmacists prescribing emergency contraception (EC). STUDY DESIGN: We conducted a cross-sectional survey among California community pharmacists. We distributed the online survey, consisting of 34 close-ended questions, to members of the California Pharmacists Association via its email listserve. RESULTS: We collected a survey response rate of 7%. Although 95% of respondents were aware of the statewide protocol allowing pharmacists to prescribe EC, only 36% of respondents reported prescribing EC in the previous year. Prescribing practices within the past year differed by type of pharmacy. We found no correlation between EC knowledge and prescribing practices. The most frequently reported facilitators of EC prescribing by pharmacists were the statewide protocol, a continuing education training program, and patient need or demand for EC. The most reported barriers to prescribing EC were lack of payment for pharmacist patient care services by insurers, increased responsibility or liability concerns, and time constraints. When asked about their intention to prescribe in the upcoming year, responses differed based on whether or not their pharmacies currently stocked EC. CONCLUSION: This exploratory study identifies key facilitators, such as the statewide protocol, and key barriers, such as lack of payment by insurance companies for pharmacist services. IMPLICATIONS: The findings of this study could guide future multi-component implementation strategies such as academic detailing that specifically address concerns about increased responsibility, liability and time constraints. In addition, payment for pharmacist services could be addressed at a policy level since this was a barrier to pharmacist EC prescribing.