Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial

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.

Introduction

Healthy People 2020 recognises unintended pregnancy as an important public health challenge in the USA.¹ National estimates reveal persistently high unintended pregnancies (51% of pregnancies) and they disproportionately occur in women aged 18–24 years with low incomes and from racial or ethnic minority groups.² The Centers for Disease Control and Prevention (CDC) recommends increasing access to long-acting reversible contraceptives (LARCs) to reduce unintended pregnancy.³ Intrauterine devices (IUDs) and contraceptive implants are seldom used in the USA, compared with in other developed countries (eg, 9% in the USA vs 23% in France).4, 5 Almost all clinicians provide oral contraceptives and condoms, which have failure rates of 9% and 18%, respectively,6, 7 but fewer offer IUDs or implants, which both have failure rates lower than 1%.⁶ Thus US women have little knowledge of LARCs.⁸ IUDs are generally offered to a highly restricted subgroup of patients, such as parous, married women, rather than to young women at highest risk of unintended pregnancy.9, 10 National data show that, contrary to the evidence-based CDC recommendations on medical eligibility criteria for contraceptive use,¹¹ only 38% of physicians providing contraception in the USA offer IUDs to adolescents, 53% to nulliparous women, and 25% immediately after abortion.9, 10

We designed a clinic intervention to educate providers to integrate IUDs and implants into routine contraceptive care. The intervention was designed to be cost effective and replicable, and, ultimately, to reach a large number of at-risk women. Clinic-based interventions are particularly important for increasing use of contraception and reducing unintended pregnancy because highly effective methods are only available from health-care providers. Nevertheless, no clinic-based intervention has yet effectively reduced pregnancy in randomised trials.12, 13 Our training intervention was based on formative research that identified priorities in translating evidence on LARCs into clinical practice.⁹ These priorities included increasing providers' knowledge of eligibility, indications for different methods, insertion skills, and introducing the WHO tiers-of-effectiveness evidence-based approach to contraceptive counselling to increase women's knowledge of method effectiveness.¹⁴

Small non-randomised studies of interventions for provider education and counselling have shown improved outcomes of family planning and abortion patients.15, 16 The CHOICE Project observational cohort study in St Louis, MO, USA, showed reductions in pregnancy rates when trained providers offered no-cost LARCs and counselling on method effectiveness to at-risk women.¹⁷ In this study we investigated whether a clinic-level intervention in a randomised trial could improve access to LARCs and reduce pregnancy rates.