UCSF Bixby Center LARC Project

Since 2008, the UCSF Bixby Center has conducted a major project to improve access to long-acting reversible contraception (LARC)—intrauterine devices and the subdermal contraceptive implant—in the United States. These methods are safe for nearly all women to use, but providers do not routinely offer them and women have misinformation about them. Use of IUDs has increased in the last decade, but remains below the rates of other developed countries.

 

Our cluster randomized trial

To explore ways to improve LARC access, the UCSF Bixby Center conducted a large national trial in partnership with 40 Planned Parenthood health centers—the UCSF and Planned Parenthood National Trial of Contraceptive Acceptability. The trial tested the impact of a clinic-wide training about LARC. The training included information geared for health educators, clinicians, front desk staff, clinic managers, and billing experts. Twenty health centers received the training intervention, and twenty control health centers offered standard care.

Health centers enrolled clients ages 18-25 who received contraceptive counseling for one year of follow-up. The study had 500 participating staff and 1,500 participating patients. The 12-month follow-up rate for clients was 84%. Health centers also collected service statistics for over 200,000 annual female contraceptive clients.

Our research questions will compare outcomes in intervention versus control health centers. We'll focus on questions such as:

  • What proportion of clients selected LARC versus other contraceptive methods?
  • What proportion of clients continued to use their selected contraceptive after one year?
  • What was the client rate of unintended pregnancy at one year?
  • Are there differences in provider LARC knowledge, attitudes, or practices?
  • What were clients' experiences with method acceptability, side effects and complication rates?
  • How did providers influence clients' method choice, acceptability, and continuation?

Study data collection is complete and the UCSF Bixby Center and collaborators will conduct analyses in the summer and fall of 2013.

 

Our findings

While the primary analysis is underway, we have completed several other LARC studies and preliminary analyses of the trial.

  • Contraceptive care providers in California have restrictive criteria for IUD use that are not evidence-based. They often exclude women who are appropriate IUD candidates, including young, nulliparous, and post-abortion women.
  • Nationally, most family physicians providing contraceptive care were not offering LARC methods to clients, although they reported interest in updating contraceptive skills through training.
  • In the context of abortion care, restrictive state policies, high cost to patients, and the ongoing need for clinician training in LARC methods hinder provision and patient uptake.
  • Despite evidence about the safety and cost-effectiveness of immediate post-abortion LARC provision, many clinics are not offering it because of financial and logistical concerns, resulting in missed opportunities for preventing unintended pregnancies.
  • In the context of family planning care, women covered by private insurance, Medicaid, or a Medicaid family planning expansion program were more likely to use LARC methods compared to women without such coverage.
  • Young women with accurate knowledge about contraceptive effectiveness were more likely to use LARC compared to women with inaccurate knowledge.
  • Very few young women had heard of the most effective form of emergency contraception—the copper IUD—but a majority would like to learn more about this option from healthcare provider should they need emergency contraception.

 

Concrete ways to improve LARC access in your practice

Clinic staff can take some important steps to improve patient access to LARC methods:

  • Discuss LARC with all clients. Many women do not know about LARC methods, or have misinformation about the methods. Health care providers are women's most trusted source of information about contraception, so visits for birth control counseling are a critical opportunity to provide accurate and evidence-based information about these methods.
  • Offer same-day placement. Research has shown that it is safe to place IUDs and implants on the same day a client makes the request. You can screen for STIs, place the IUD, and ask a client to return for treatment if there is a positive result. You can also prepare kits with all the needed equipment to make the placement process even faster. Providing same-day placement is the only way to offer your clients the most effective form of emergency contraception—the copper IUD.
  • Help clients manage high up-front costs. Most insurance plans are now required to cover IUDs and implants as benefits with no out-of-pocket costs to patients. If a client's plan denies coverage, she can call the National Women's Law Center (1-866-PILL4US) for help. Medicaid and Medicaid family planning expansion programs all cover LARC methods at no or low cost to the client. The IUD manufacturers also offer discount programs.
  • Train all staff on LARC. Each person in a practice can contribute to improving client access to LARC methods. The front desk staff can ask clients if they are interested in the methods when scheduling an appointment. Health education staff can help address common client concerns. Clinicians can help clients manage transient side effects. Billing experts can ensure that the practice is adequately reimbursed. Managers can support all their staff to get the training they need. The UCSF Bixby Center is offering in-service LARC trainings to qualifying practices.

 

In-service UCSF Bixby Center LARC training

This CME/CEU-accredited training is a half-day program with components for all staff. The training includes information on client eligibility for IUDs and implants, common misunderstandings about these methods, and billing and clinic flow troubleshooting. A health educators' practicum provides opportunities to role play client counseling scenarios and build counseling skills. A clinician practicum provides hands-on insertion practice with pelvic models and clinical pearls for insertion and removal. Past participants have given the training an average rating of "excellent" for overall quality, faculty quality, selection of topics, educational content, and relevance to practice.

If your agency has over 10,000 family planning clients annually, you may qualify for an in-service LARC training. Contact the training coordinator, Jennifer Grand, for further information.

 

Acknowledgements

The LARC Project Principal Investigators are Drs. Cynthia Harper and Joseph Speidel. The Project Director is Kirsten Thompson. The research team includes Maya Blum, Jennifer Grand, Lily Loew, Caitlin Quinlivan, Racquel Enad, Helen Helfand and Laura Elena Mendoza, with interns Rose Burnam and Melanie Zamora. Additional investigators include Drs. Suzan Goodman, Corinne Rocca, Julia Steinberg, Jessica Morse, Dan Grossman, Tina Raine, and Debbie Postlethwaite. Drs. Phil Darney and Chuck McCollough have also provided invaluable support.

Thanks to our project partners, including the Planned Parenthood Federation of America, the American College of Obstetricians & Gynecologists' LARC Program, Cardea Services, and Bedsider.

We gratefully acknowledge the support of the William and Flora Hewlett Foundation, the JPB Foundtation, and the National Campaign to Prevent Teen and Unplanned Pregnancy.