ArticlesReductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial
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.
Section snippets
Study design
We did a cluster randomised trial in 40 clinics across the USA. A cluster design was necessary to avoid contamination among providers (unintentional overspill of the effects of educational intervention to control patients) that might occur with randomisation within individual clinics. All study sites were Planned Parenthood Federation of America (PPFA) health centres, whose patients include young and low-income women from diverse racial or ethnic groups. Eligible clinics saw at least 400 women
Results
55 clinics were assessed for participation, of which 45 were randomised (five of which were replacement clinics) and 40 participated (figure 1). Clinics were located in 15 US states, covering all regions (California, Colorado, Connecticut, Florida, Hawaii, Idaho, Michigan, Minnesota, New Jersey, New Mexico, North Carolina, Ohio, Oregon, Pennsylvania, and Washington). 23 clinics recruited women attending family planning visits (12 in the intervention group, 11 in the control group) and 17
Discussion
The study intervention increased women's choice of highly effective methods without impinging on decision-making autonomy. The rate of unintended pregnancy was substantially reduced among women who attended family planning visits, although not among those who attended abortion care visits. Many young women in the USA want to delay childbearing, but report having unprotected intercourse, as in our study population.25 Clinic visits are important opportunities for education of patients, especially
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Group allocation
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