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The Contraceptive CHOICE Project
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Objectives
• Describe the study design and methods• Review key findings from Pre-CHOICE surveys• Review important findings from CHOICE• Discuss dissemination and translation of
results into practice
Unintended Pregnancy in the U.S.
• Over 3 million unintended pregnancies– 59% mistimed– 39% unwanted
• 1.2 million abortions• 367,752 births to teens 15-19 years• Contraception
– 52% non-use– 43% incorrect use
Finer Contraception 2011; Hamilton NCHS 2012; Frost Guttmacher Inst 2008
Long-acting Reversible Contraception (LARC)
LNG-IUS• 99% effective• 20 mcg
levonorgestrel/day• Up to 5 years
Copper T IUD• 99% effective• Copper ions
• Up to 10 years
Subdermal Implant• 99% effective• 60 mcg
etonogestrel/day• Up to 3 years
Study Primary Objectives
• To increase the acceptance and use of long-acting reversible contraceptive (LARC) methods among women of childbearing age
• To measure acceptability, satisfaction, side-effects, and rates of continuation across a variety of reversible contraceptive methods, including long-acting reversible methods
Study Hypotheses
• Increase IUD use– Sentinel clinics from <2% to 6% or more– Post-abortion insertion <1% to 10% or more
• Increase implant use to 3% or more• Observe higher 12-month continuation rates for
LARC vs. other methods• Population outcomes
– Teen pregnancy decline by 10%– Repeat abortion decline by 10%
Study Design: Prospective CohortE
LIG
IBL
E
Exposure Outcome2–3 y
LNG-IUSCu-IUDImplantDMPAPills
PatchRing
Other
Unintended pregnancy
Teen pregnancyRepeat abortion
AbortionContinuationSatisfaction
STI
Study Inclusion Criteria
• 14-45 years• Primary residency in STL City or County• Sexually active with male partner
(or soon to be)• Does not desire pregnancy during next 12
months• Desires reversible contraception• Willing to try a new contraceptive method
Screening & Enrollment
Introduce study
Eligibility screenLARC Blurb
Offer participation
Enroll participant!
Eligible
Agrees
• Contraceptive Counseling• Informed Consent • Contact Information• Medical Record Authorization• Clinical Forms and
Evaluation• Baseline STI• Baseline Survey• Method Allocation
Contraceptive Counseling• P000001• Development and training included
– Counseling Framework– Standard Script– Contraception 101 Lecture– Counseling and Medical History Forms– Testing & Observation
• Provided by 53 research staff & volunteers– 37 staff, 14 medical, 1 graduate and 1 undergraduate students
• Additional resource for managing patient calls
Madden Contraception 2012
Study Recruitment
Aug 07Dec 07
Dec 08Dec 09
Dec 10Sep 11
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Location 9,256
2 Abortion clinics 17%
8 Community clinics 14%
University-based research clinic• Word-of-mouth• Provider referrals
69%
STL Population Survey• Objective: Survey knowledge and attitudes about
IUDs among women in St. Louis area• Methods:
– 8-page written survey– Mailed to 12,500 randomly selected households
• One adult female in household asked to complete survey• 1,665 of 7,722 (22%) deliverable and eligible surveys returned
– Measures:• Obstetric & contraceptive history• Knowledge regarding method effectiveness• Knowledge regarding appropriate candidates, side effects, and
myths of IUD
Hladky Obstet Gynecol 2011
STL Population Survey Results• Respondents overall:
– Mean age = 31.9– 57% white– 82% had insurance (83% private)– 70% greater than high school education– 18% history of abortion
• 127 (8%) were currently using or had used IUD– Slightly older (mean age = 32.4)– More likely to be parous– More likely to be receiving public assistance
Hladky Obstet Gynecol 2011
MYTHS Regarding IUDs• 50% of women surveyed believe IUD is SAFE• Common safety concerns:
– Pelvic Pain 36% – Infertility 30%– Cancer 14%– STDs 11%
• 61% underestimate the effectiveness
Hladky Obstet Gynecol 2011
STL Provider Survey
• Objective: Survey knowledge and attitudes about IUD among providers in St. Louis area
• Methods:– Written self-administered survey– Mailed to 250 providers
• Medical directories and electronic searches• 137/186 (73.7%) delivered and eligible surveys returned
– Measures:• Demographic characteristics• Graduate medical training• Contraceptive patients seen and willingness to insert IUD
Madden Contraception 2010
STL Provider Survey Results• 99% physicians• 85% white, 4% black, 10% other• Residency training:
– 44% completed before 1989– 41% 1989-1999– 16% after 1999
• 56% completed residency at a Catholic institution• Contraceptive patients each week
– 35%: 0–25 – 50%: 26-50 – 15%: 50+
Madden Contraception 2010
STL Provider Survey Results• 36% not trained in IUD insertion during residency
or clinical training• Discussed IUD with patients
– 18% “always”– 75% “most or some of the time”
• 66% reported inserted >10 IUD in past year• GC/CT testing prior to IUD insertion
– 40% always – 52% sometimes
Madden Contraception 2010
STL Provider Survey Results• Appropriate candidates for IUDs
– 62% nulliparous– 31% adolescent– 45% STI in past 2 years– 37% PID in past 5 years– 37% non-monogamous relationship
• Offer IUD– 98% if 35 y.o., married, with 3 children– 50% if unmarried 17 y.o., monogamous, and one child– 19% if unmarried 17 y.o., never been pregnant
Madden Contraception 2010
Baseline Chosen Method%
LNG-IUS 46.0Copper IUD 11.9Implant 16.9DMPA 6.9Pills 9.4Ring 7.0Patch 1.8Other <1.0
75%
Peipert Obstet & Gynecol 2012
12-Month ContinuationMethod Continuation Rate (%)
LNG-IUS 87.5
Copper IUD 84.1
Implant 83.3
Any LARC 86.2
DMPA 56.2
OCPs 55.0
Ring 54.2
Patch 49.5
Non-LARC 54.7
Peipert Obstet Gynecol 2011
Unintended Pregnancy by Contraceptive Method
1 2 30%
2%
4%
6%
8%
10%
12%LARC DMPA PPR
Year
Parti
cipa
nts
with
Con
trac
eptiv
e Fa
ilure
(%) HRadj = 22.3
95% CI 14.0, 35.4
Winner NEJM 2012
Repeat Abortion in St. Louis Region
• Data obtained from MO DHHS– Represents women who reside in Missouri at time of
abortion• Repeat abortion measured as ever had a
previous abortion• Compared to Kansas City & non-metro MO
– KC: One abortion clinic– KC: Similar demographic characteristics to STL
Repeat Abortion 2006 - 2010
2006 2007 2008 2009 201025%
30%
35%
40%
45%
50%
55%
St. Louis City/CountyKansas CityNon-Metro Missouri
Perc
ent o
f rep
eat a
borti
ons
Peipert Obstet Gynecol 2012
Test of Trend 2006-2010: STL, p=.002; KC, p=.003; Non-metro MO, p=.18
CHOICE Compared to U.S.• Teen birth rate (age 15-19 years)
– 6.3 per 1,000 teens (first year use rate)– 16.3 per 1,000 teens (average annual rate)– Compared to 34.3 per 1,000 nationally
• Abortion rate (women ages 15-44)– 6.0 per 1,000 women (average annual rate)– Compared to 19.6 per 1,000 nationally
• Unintended pregnancy rate– 15.0 per 1,000 women (average annual rate)– Cumulative: 35.0 per 1,000 women– Compared to 52.0 per 1,000 nationally
Peipert Obstet Gynecol 2012
Main Findings from CHOICE
• Women overwhelmingly choose LARC• LARC methods associated with higher
continuation & satisfaction than shorter-acting methods– Regardless of age
• LARC methods associated with lower rates of unintended pregnancy
• Increasing LARC use can decrease unintended pregnancy in the population
The Secret: 3 Key Ingredients
• Education regarding all methods, especially LARC– Reframe the conversation to start with the most
effective methods• Access to providers who will offer & provide LARC
– Dispel myths and increase the practice of evidence-based medicine
• Affordable contraception– Institute of Medicine recommendation, Affordable
Care Act, Medicaid Expansion
Successful Implementation of CHOICE Model
Key Element Barrier Facilitator
EducationLimited time for contraceptive counseling during appointment
Counseling provided by non-clinician trained in tiered-based counseling
Access Outdated myths regarding teens as LARC candidates
Identify local “champion clinician” who is LARC proficient, trusted, and can dispel myths
Cost
Lack of reimbursement for contraceptive method, insertion & removal
Network with clinics that have identified how best to manage cost issue through effective billing or payer mix
Up-front cost of stocking LARC methods for same-day insertions
Investigate ways to purchase a few methods that serve as temporary supply
Dissemination Strategies• Create online Resource Center to disseminate
CHOICE materials LARC First– The Evidence– Contraceptive Counseling– Advanced Practitioner Resources– Patient Management– Effective Staffing & Management
• Provide technical assistance to end users– >100 national & international requests
• Evaluate how CHOICE materials are adopted and adapted for successful use– PCORI Funding
40
Dissemination Strategies• National forums & grand rounds• Community presentations & festivals/events
Dissemination Strategies• Website transitioned from recruitment to
resource guide
• Social media
• Lay Press
• Short videos
Open the Dialog Video
http://www.youtube.com/watch?v=VAsdg7f7M7w
Pathway to Choice Video
http://www.youtube.com/watch?v=cd46pXtMHOo
What method is right for you?
http://www.youtube.com/watch?v=u9SHoy1C3tU
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