Patient and counselor satisfaction with structured contraceptive counseling by health center staff in federally qualified health centers.

OBJECTIVES: To characterize patient and counselor satisfaction with structured, tier-based contraceptive counseling provided by a nonclinician. STUDY DESIGN: We conducted a planned secondary analysis of patient and counselor surveys from a study that enrolled women in 2 contraceptive care programs. All participants received structured contraceptive counseling from trained staff members. Women and counselors completed a confidential post-visit survey regarding satisfaction with counseling and medical mistrust. We used univariate and multivariable regressions to examine differences in high satisfaction with counseling (top score), perceived counselor influence, and perceived counselor judgment by participant characteristics. RESULTS: Nine hundred forty-two participants completed surveys; most reported they felt respected (100.0%), trusted the counseling information (99.5%), and that counseling helped them choose a contraceptive method (83.8%). Black race, high school education, public insurance, an income below the federal poverty level, and enrollment site were associated with high medical mistrust. Participants with high medical mistrust were less likely to be highly satisfied with counseling (adjusted relative risk (RR) 0.72; 95% confidence interval [CI] 0.63-0.82), more likely to perceive influence (RR 1.77; 95% CI 1.37-2.28), and more likely to perceive judgment (adjusted odds ratio 8.91; 95% CI 3.61-22.01). Mostly, counselors felt they were able to answer participant questions (98.8%), establish good rapport (95.9%), and that participants understood the information presented (98.0%). CONCLUSIONS: Overall, participants were satisfied with tier-based contraceptive counseling delivered by nonclinician staff members. Those with high levels of medical mistrust were less likely to be satisfied. The majority of women found the information beneficial in contraceptive decision making. IMPLICATIONS: Overall, women reported high satisfaction with tier-based contraceptive counseling delivered by a nonclinician in 3 federally qualified health centers. However, women with high medical mistrust were less likely to report high levels of satisfaction and more likely to report perceived influence or judgment from the counselor.

Evaluation of a computerized contraceptive decision aid: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a contraceptive decision aid in reducing decisional conflict among women seeking reversible contraception. STUDY DESIGN: We conducted a randomized trial of a computer-based decision aid compared to a control group for women presenting for reversible contraception at two clinics affiliated with an academic medical center. The primary outcome was change in decisional conflict, measured before and after the healthcare visit using the validated Decisional Conflict Scale. We hypothesized the decision aid would reduce the decisional conflict score by 10 points on a 100-point scale (0 = no conflict, 100 = high conflict) compared to the control group. Secondary outcomes included contraceptive method chosen and satisfaction with the healthcare visit. RESULTS: We enrolled and randomized 253 women, and 241 had complete data for our primary outcome. Overall, pre-visit decisional conflict scores were low, reflecting low levels of decisional conflict in our sample; median score 15 (range 0-80) in the decision aid and 10 (0-85) in the control group (p = 0.45). Both groups had a similar reduction in median decisional conflict after the healthcare visit: -10 (-80 to 25) and -10 (-60 to 5) in the decision aid and control groups respectively (p = 0.99). Choice of contraception (p = 0.23) and satisfaction with healthcare provider (p = 0.79) also did not differ by study group. CONCLUSIONS: Decisional conflict around contraception was low in both groups at baseline. Use of a computerized contraceptive decision aid did not reduce decisional conflict, alter method choice, or impact satisfaction compared to the control group among women choosing reversible contraception. IMPLICATIONS: Use of a computerized contraceptive decision aid did not reduce decisional conflict or alter method choice compared to the control group among women choosing reversible contraception. Future studies could focus on testing the decision aid in different clinical settings, especially where barriers to providing comprehensive contraceptive counseling exist.

Familiarity and acceptability of long-acting reversible contraception and contraceptive choice.

BACKGROUND: Contraceptive choice is a preference-sensitive decision that is affected by contraceptive attributes, patient experience, and reproductive history. Familiarity with and acceptability of specific contraceptive methods may influence patient decisions. OBJECTIVE: The purpose of this study was to describe the acceptability of and previsit familiarity with long-acting reversible contraception (intrauterine devices and contraceptive implants) compared with depo-medroxyprogesterone acetate and oral contraceptive pills in women seeking contraceptive care and to investigate the relationship between acceptability and contraceptive choice. STUDY DESIGN: This was a secondary analysis of a study that was designed to compare 2 contraceptive care programs conducted at 3 Midwest federally qualified health centers. After contraceptive counseling, participants completed a baseline interviewer-administered survey before the healthcare provider visit. We asked participants questions about previsit familiarity with and acceptability of the intrauterine device, implant, depo-medroxyprogesterone acetate, and oral contraceptive pills. We assessed familiarity using 2 questions: (1) Before today have you ever heard of the [method]? (2) Do you know any woman who has/has used the [method]? Acceptability was assessed for each method on a 0-10 scale, with 0 being "strongly dislike" and 10 being "strongly like." We dichotomized the scores into high acceptability (7-10) and low/moderate acceptability (0-6) for analysis. We examined differences in demographic and reproductive characteristics between women with high and low long-acting reversible contraception acceptability using the chi-square test. We used univariate and multivariable Poisson regressions to examine the relationship among participants' characteristics, method acceptability, and method choice. We adjusted for any covariate that changed the effect size of acceptability by >10%. RESULTS: There were 1007 women included in the analysis: 900 women (89%) reported that they had heard of the intrauterine device, and 592 women (59%) knew someone who had used the intrauterine device. Eight hundred sixty-five (86%) women had heard of the implant, and 636 women (63%) knew someone who had used it. Knowledge of depo-medroxyprogesterone acetate and oral contraceptive pills was high (>98% for both). Five hundred seventy-six women (57%) found 1 or both long-acting reversible contraception methods highly acceptable. Women with high long-acting reversible contraception acceptability were more likely to be adolescents or aged 30-45 years, white, Hispanic, married/cohabitating, and uninsured and were less likely to desire a child in the next 1-3 years. They were more likely to desire a hormonal intrauterine device (90.5% vs 9.5%), copper intrauterine device (81.1% vs 18.9%), or implant (89.8% vs 10.2%) compared with women with low acceptability (P<.001). In adjusted analyses, women with high acceptability of an intrauterine device were more likely to desire an intrauterine device (adjusted relative risk, 9.62; 95% confidence interval, 6.42-14.42). Women with high acceptability of an implant were also more likely to desire one (adjusted relative risk, 8.74; 95% confidence interval, 6.17-12.38). Women were more likely to desire an intrauterine device or an implant if they knew someone who used the method. Previous use of the method and demographic factors were not associated with method choice. CONCLUSION: Previsit familiarity with intrauterine devices and implants was high in our federally qualified health centers population, although not as high as depo-medroxyprogesterone acetate and oral contraceptive pills. In adjusted analyses, women who found an intrauterine device or implant highly acceptable and who knew someone who had used the method were more likely to choose those respective methods at the end of their visit.

Comparison of unintended pregnancy at 12 months between two contraceptive care programs; a controlled time-trend design.

OBJECTIVES: To compare unintended pregnancy rates at 12 months between women receiving structured contraceptive counseling plus usual contraceptive care and women receiving structured contraceptive counseling, healthcare provider education and cost support for long-acting reversible contraceptive (LARC) methods. STUDY DESIGN: Using a controlled time-trend study design, we first enrolled 502 women receiving structured contraceptive counseling in addition to usual care ("Enhanced Care") and subsequently enrolled 506 women receiving counseling plus healthcare provider education and cost support for LARC methods ("Complete CHOICE") at three federally qualified health centers (FQHCs). Cost support included funds to health centers for "on-the-shelf" LARC methods and no-cost LARC methods for uninsured women. Participants completed in-person baseline surveys and follow-up surveys by telephone at 3, 6 and 12 months. We used Kaplan-Meier survival function to estimate 12-month unintended pregnancy rates and Cox proportional-hazards regression to compare unintended pregnancy rates between the two groups. We imputed pregnancy outcomes for women lost to follow-up (9%) prior to 12 months. RESULTS: "Complete CHOICE" participants were less likely to report an unintended pregnancy at 12 months compared to "Enhanced Care"; 5.3 vs. 9.8 pregnancies per 100 women-years (p=.01). After adjusting for confounders (recruitment site, race, age and federal poverty level), women in "Complete CHOICE" had a 40% lower risk of unintended pregnancy at 12 months (adjusted hazard ratio 0.60; 95% confidence interval 0.37-0.99). CONCLUSIONS: Contraceptive provision that includes cost support and healthcare provider education in addition to patient counseling reduced unintended pregnancy at 12 months compared to counseling plus usual contraceptive care. IMPLICATIONS: A program of contraceptive care that includes comprehensive counseling; healthcare provider education; cost support; and on-the-shelf, long-acting reversible contraception can reduce unintended pregnancy compared to contraceptive counseling in addition to usual health center care in the FQHC setting.

Effect of staff training and cost support on provision of long-acting reversible contraception in community health centers.

OBJECTIVE: To compare the proportion of women receiving same-day long-acting reversible contraception (LARC) between two different models of contraceptive provision adapted from the Contraceptive CHOICE Project. STUDY DESIGN: We used a controlled time-trend study design to compare 502 women receiving structured contraceptive counseling in addition to usual care ("Enhanced Care") to 506 women receiving counseling plus healthcare provider education and cost support for LARC ("Complete CHOICE") at three federally qualified health centers. We provided funds to health centers to ensure an "on-the-shelf" supply and no-cost LARC for uninsured women. We recorded the contraceptive method chosen after contraceptive counseling and the healthcare provider appointment as well as the contraceptive method received that day. Among women choosing LARC, we calculated proportions and performed Poisson regression with robust error variance to estimate relative risks for same-day insertion. RESULTS: Participant demographics reflected the health center populations; 69% were black, 66% had a high school diploma or less, 57% were publicly insured, and 75% reported household income less than 101% federal poverty line. There were 153 (30.5%) women in "Enhanced Care" and 273 (54.0%) in "Complete CHOICE" who chose LARC (p<0.01). Among women who chose LARC (n=426), those in "Complete CHOICE" were more likely to receive a same-day insertion, 53.8% vs. 13.7% (RRadj 4.73; 95%CI 3.20-6.98) compared to "Enhanced Care." CONCLUSIONS: A contraceptive care model that included healthcare provider education and cost support for LARC in addition to structured contraceptive counseling resulted in higher rates of same-day LARC insertion compared to contraceptive counseling and usual care alone. IMPLICATIONS: Contraceptive care provision which includes contraceptive counseling, healthcare provider education, and "on-the-shelf", long-acting reversible contraception facilitate same-day initiation of these methods. Interventions that focus solely on contraceptive counseling do not address other structural barriers to same-day contraceptive provision of all methods including cost and provider practice.

Long-acting reversible contraception use among residents in obstetrics/gynecology training programs.

BACKGROUND: The objective of the study was to estimate the personal usage of long-acting reversible contraception (LARC) among obstetrics and gynecology (Ob/Gyn) residents in the United States and compare usage between programs with and without a Ryan Residency Training Program (Ryan Program), an educational program implemented to enhance resident training in family planning. MATERIALS AND METHODS: We performed a web-based, cross-sectional survey to explore contraceptive use among Ob/Gyn residents between November and December 2014. Thirty-two Ob/Gyn programs were invited to participate, and 24 programs (75%) agreed to participate. We divided respondents into two groups based on whether or not their program had a Ryan Program. We excluded male residents without a current female partner as well as residents who were currently pregnant or trying to conceive. We evaluated predictors of LARC use using bivariate analysis and multivariable Poisson regression. RESULTS: Of the 638 residents surveyed, 384 (60.2%) responded to our survey and 351 were eligible for analysis. Of those analyzed, 49.3% (95% confidence interval [CI]: 44.1%, 54.5%) reported current LARC use: 70.0% of residents in Ryan Programs compared to 26.8% in non-Ryan Programs (RRadj 2.14, 95% CI 1.63-2.80). Residents reporting a religious affiliation were less likely to use LARC than those who described themselves as non-religious (RRadj 0.76, 95% CI 0.64-0.92). Of residents reporting LARC use, 91% were using the levonorgestrel intrauterine device. CONCLUSION: LARC use in this population of women's health specialists is substantially higher than in the general population (49% vs. 12%). Ob/Gyn residents in programs affiliated with the Ryan Program were more likely to use LARC.

Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the U.S. Food and Drug Administration-approved duration.

OBJECTIVE: To evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device (IUD) in women using the method beyond the current U.S. Food and Drug Administration (FDA)-approved duration of 3 and 5 years, respectively. METHODS: Women willing to continue using their implant or 52-mg levonorgestrel IUD beyond the FDA-approved duration were followed prospectively for contraceptive effectiveness. Unintended pregnancy rate per 100 women-years was calculated. Implant users are offered periodic venipuncture for analysis of serum etonogestrel levels. The Kruskal-Wallis test was used to compare the etonogestrel levels across body mass index (BMI) groups. RESULTS: Implant users (n=237) have contributed 229.4 women-years of follow-up, with 123 using the etonogestrel implant for 4 years and 34 using it for 5 years. Zero pregnancies have been documented, for a failure rate of 0 (one-sided 97.5% confidence interval [CI] 0-1.61) per 100 women-years. Among 263 levonorgestrel IUD users, 197.7 women-years of follow-up have been completed. One pregnancy was confirmed, for a failure rate of 0.51 (95% CI 0.01-2.82) per 100 women-years. Among implant users with serum etonogestrel results, the median and range of etonogestrel level at 3 years of use was 188.8 pg/mL (range 63.8-802.6 pg/mL) and 177.0 pg/mL (67.9-470.5 pg/mL) at 4 years of use. Etonogestrel levels did not differ by BMI at either time point (3 years: P=.79; 4 years: P=.47). CONCLUSION: Preliminary findings indicate the contraceptive implant and 52-mg hormonal IUD continue to be highly effective for an additional year beyond the FDA-approved 3 and 5 years. Serum etonogestrel levels indicate the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use. LEVEL OF EVIDENCE: II.

Sexually transmitted infection prevalence in a population seeking no-cost contraception.

BACKGROUND: We used universal screening to determine the prevalence rates of Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) in 9256 women enrolling into a contraceptive study. METHODS: We offered screening using nucleic acid amplification or culture to all participants enrolling into the Contraceptive CHOICE Project. Demographic characteristics were collected through staff-administered questionnaires. Univariate and multivariable analyses were performed to assess the risk of sexually transmitted infection at baseline and to compare risk profiles of CT and TV. RESULTS: Results were available for 8347 consenting women with satisfactory results; 656 (7.9%) were tested positive for 1 or more infections. Approximately one third of participants were older than 26 years, and half were identified as African American. There were 35 cases of GC for a prevalence of 0.4% (95% confidence interval [CI], 0.3-0.6), 260 cases of CT for a prevalence of 3.1% (95% CI, 2.8-3.5), and 410 cases of TV for a prevalence of 4.9% (95% CI, 4.4-5.4). Black women were more likely to be tested positive (odds ratio, 3.95; 95% CI, 3.08-5.06) compared with white women and accounted for 81.3% of cases. T. vaginalis was more prevalent in black women (8.9%) compared with white women (0.9%). Older age was a risk factor for TV, whereas younger age was associated with CT. Of the 656 positive cases, 106 (16%) were diagnosed in women older than 25 years, falling outside traditional screening guidelines. CONCLUSION: We found GC, CT, and TV to be more prevalent than current national statistics, with TV being the most prevalent. Current screening recommendations would have missed 16% of infected women.