Ounce of training worth a pound of pregnancy prevention

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Women are more likely to choose to get IUDs and other highly effective contraceptives at family planning clinics if the clinicians there have been educated about these methods, according to a new study.

The increase in the use of long-acting reversible contraceptives — IUDs (intrauterine devices) and single-rod hormonal implants in the arm — were associated with nearly 50% fewer unintended pregnancies among the women in the study.

Long-acting reversible contraceptives (LARCs) are considered the most effective method of contraception, associated with failure rates of less than 1%, whereas birth control pills and condoms have failure rates of 9% and 18%, respectively. However, LARCs are often not available or discussed in clinics, said Cynthia C. Harper, professor at obstetrics, gynecology and reproductive sciences at the University of California, San Francisco School of Medicine.

Harper and her colleagues tested whether educating providers about LARCs, how to insert them and how to talk with women about them would lead to increased use of this method and decreased rates of unintended pregnancies among their patients. The researchers gave half-day training sessions to providers at 20 Planned Parenthood clinics in 15 states across the U.S.; they compared these intervention sites to another 20 control clinics where the staff did not receive training.

The researchers looked at the effects in 1,500 women ages 18 to 25. The women were either visiting the clinics for help with family planning or there to get an abortion, and were thus at high risk of having an unintended pregnancy.

“Our main impetus for doing this study was to try to address the very high rates of unintended pregnancies in the U.S., over half of all pregnancies, and that’s been the case for decades with no progress,” said Harper who is the lead author of the study, published this week in the Lancet journal.

Twenty-eight percent of the women in the study who visited an intervention clinic decided to get an IUD or implant compared with 17% of the women who visited a control clinic. “I was happy with that [increase]”, Harper said. “I think a lot of women were learning about these methods for the first time [and] if they hear about them from a few different places and people, they might become more familiar with them and want to use them.”

Along with the increase in use of LARCs, the researchers saw a decrease of nearly 50% in the number of unintended pregnancies in the following year among the women who visited an intervention clinic for family planning compared with a control clinic. But there was no difference in the number of unintended pregnancies among women who visited an intervention clinic for an abortion.

The study found that 56% of the women who just got an abortion were not able to get a LARC, compared with 27% of women in the family planning group. It may have been difficult for women to afford the procedure to implant a LARC on the same day as paying for an abortion, or clinics may not have been willing to do the implantation and abortion in the same visit, Harper said.

Although Planned Parenthood clinics often have sliding scales to help cover the implantation procedure, which can be $800 to $1,000 out of pocket, the cost can still be substantial, Harper said. Still, the contraception lasts three to five years and is more affordable over that time than birth control pills, she said.

The inconvenience of having to come back on another day to receive a LARC could keep a lot of women who just got an abortion, and who are at high risk of having another unintended pregnancy, from getting the device, Harper said.

“This intervention is very encouraging,” said Laureen Lopez, scientist at fhi360, a nonprofit human development organization that conducts research and programing in health, education and other areas.

It was “impressive” that the researchers trained the providers not just in how to implant a LARC but also in how to counsel women about them, what they are, how effective they are and their side effects, Lopez said. It would probably not take too much time for providers to talk with women about LARC as they get more used to having the discussion, and they could make up the time by talking less about less effective methods like condoms, unless they are worried about disease transmission, Lopez said.

One of the most common side effects of LARCs is that they may cause a woman to bleed more (as with the copper IUD) or stop bleeding at all (as with the levonorgestrel-releasing IUDs), Harper said.

“It was really wonderful to find an intervention that helped. We developed a curriculum and now it’s been tested so we can bring it to other practice settings,” Harper said. She and her colleagues are now training more providers and disseminating a video about LARCs that women can watch in the waiting room. (The group used the video in the current study, although they were not sure if it helped educate women about LARCs.)

The American Congress of Obstetricians and Gynecologists recommends the use of LARCs to reduce the rate of unintended pregnancies among women and adolescents.