Exploring the Uptake of Long-Acting Reversible Contraception in South Dakota Women and the Importance of Provider Education

Abstract

Background

Long-acting reversible contraception (LARC) methods, including the intrauterine device (IUD) and the birth control implant, are the most effective form of prescribed birth control for pregnancy prevention. However, uptake of this highly effective form of birth control is slow. The purpose of this study was to explore use of the LARC methods in South Dakota women prescribed contraception and the importance of the provider in promoting this type of contraception.

Methods

This was a cross-sectional study of female patients who had been prescribed contraception at one of five locations in a South Dakota hospital system. Records were obtained through electronic health records for a six-month period. Descriptive analysis was performed using chi-square with counts and percentages. Logistic regression was used to determine differences in LARC prescriptions by patient age and provider title.

Results

A total of 2,174 individual patients were included in analysis. Of the 378 (17.4 percent) who were prescribed LARC methods, most (78.6 percent) were prescribed an IUD. Younger women (aged 11–19) were less likely to be prescribed LARCs compared to women aged 30–34. There were also significant differences in LARC prescriptions by provider type. We also noted differences in LARC prescriptions for a provider who received a specific education and training on LARC from the American College of Obstetrics and Gynecology.

Conclusions

There are many important factors to considered by the patient when choosing the most appropriate contraceptive method, including safety, effectiveness, accessibility, and affordability. Provider education may play an important role in promoting LARC methods.

Introduction

Long-acting reversible contraception (LARC) methods are recommended by the American Congress of Obstetrician and Gynecologists (ACOG) as the most effective form of prescribed birth control for pregnancy prevention. LARC methods include the intrauterine device (IUD) and the birth control implant. The IUD is a small, T-shaped device that is inserted into and left inside the uterus for three or five (hormonal IUD) to ten (copper IUD) years. The birth control implant, from the brand Nexplanon, is a single flexible rod (the size of a matchstick) that is inserted under the skin in the inside of the upper arm.

LARC methods prevent pregnancy by preventing fertilization of the egg by sperm, and hormonal IUDs and implants thicken cervical mucus and thin the lining of the uterus to further prevent pregnancy. According to ACOG, during the first year of typical use, fewer than one in 100 women using an IUD or an implant will become pregnant, which is the same range as that for sterilization.^{1, 2} As with all prescribed birth control methods, there are some potential risks and side effects; with LARC methods, side effects/risks include abnormal bleeding (Nexplanon) and risk of perforation (IUDs). However, LARC methods are 20 times more effective than oral contraception, the patch, or the ring.² Another benefit is that LARC methods prevent pregnancy for years without a need to remember to take a daily pill. In other words, LARCs remove the possibility of human error. They can be inserted immediately after childbirth or an abortion or miscarriage; and they do not interfere with breastfeeding success. LARC methods are not permanent, and pregnancy can occur soon after the LARC method is removed.

LARC Uptake

While LARC methods are highly recommended by many major medical organizations, such as ACOG, the uptake of this highly effective form of birth control is slow. Use of LARC methods in the U.S. has increased nearly five-fold in the last decade;^3–5 however, uptake in the U.S. still low compared to other countries,⁴ and LARC use is higher among women born outside the U.S.^3,6 In addition, LARC uptake varies by geographic location where the highest percentage of LARC users in the U.S. are in the west (17.3 percent), followed by the northeast (10.1 percent), Midwest (10 percent), and South (9.3 percent).⁶ Interestingly, the Midwest is among the highest rates of LARC use among teens (6.4 percent, 15–19 years).⁵ However, only 2.2 percent of South Dakota teens in the same age group use LARC methods, the fifth lowest in the nation.⁵

Race and ethnicity also affect LARC uptake. Nationally, although minority patients are also less likely to be aware of different contraception methods,⁷ Hispanic women have the highest rates of LARC uptake (15.1 percent) followed by non-Hispanic white and non-Hispanic black women (11.4 and 8.6 percent respectively).⁸ Women aged 25–29 continue to have the highest percentage of LARC uptake (16.7 percent), with the lowest percentage of uptake among teens (age 15–19, 4.3 percent).⁶ Married or cohabitating women are more likely to use LARC methods, as well as women who have had one to two children.^3,6,8 LARC uptake is lower among women of higher socioeconomic statuses.^6,8 Furthermore, those with Medicare have the highest percentage of LARC use (15.6 percent) and those with private insurance have the lowest uptake (2 percent).⁸ There were no available demographic data on LARC uptake for the state of South Dakota.

Barriers of LARC use include cost, patient interest, provider interest, or provider knowledge and/or training.^1,2,9 Studies show that medical providers play a significant and vital role in the promotion and uptake of LARCs.^10–12 Women who have heard about LARC methods from their obstetrician -gynecologists are more likely to be interested compared to women who have not.⁹ However, provider training of insertion of LARCs may be lacking, especially in residency training, which may affect LARC promotion.⁹ Furthermore, providers may overly restrict criteria of qualifying candidates.^9,12

Objective

The purpose of this study was to explore the uptake of LARC methods in women prescribed contraception in five clinical settings in South Dakota. This study will identify possible patient or provider characteristics that may affect LARC uptake, concluding by discussing the importance of provider training in inserting LARC methods and education on discussing this particular method with patients.

Methods

This was a cross-sectional study of female patients who had been prescribed any form of contraception at one of five individual locations (one city) in a South Dakota hospital system. Institutional review board (IRB) approval was not required for this study. Patient data were pulled from the electronic health record (EHR) system over a six-month period (Jan. 1, 2016–June 1, 2016). Duplicate patient IDs were removed by using the most recent contraception prescription. Data were classified based on type of contraception: oral contraception (22 unique types), Depo-Provera, vaginal ring (i.e., Nuvaring), and then LARC methods, including IUDs (i.e., Paragard, Skyla, and Mirena) and the Nexplanon arm implant.

The primary outcome of interest was a LARC prescription. Patient characteristics included in the analysis were age and type of birth control prescribed. The prescribing provider’s title (i.e., doctor, nurse midwife, nurse practitioner, physician assistant or other) was also included in analysis. Descriptive statistics were performed using chi-square with counts and percentages. Logistic regression was used to determine differences in LARC prescriptions by patient age (11–60 years) and provider title. All statistical analyses were performed using SAS version 9.4.

Results

A total of 2,174 patients were included in analysis (Table 1). The mean age of patients was 30.3 (± 8.9). Most were prescribed non-LARC methods (82.6 percent) while 17.4 percent were prescribed LARC methods. Of those prescribed a LARC method, 78.6 percent were prescribed an IUD. The majority of prescribing providers were physicians (n = 1259, 57.9 percent), followed by nurse practitioners (n = 622, 28.6 percent), and nurse midwives (n = 261, 12.0 percent). Thirty-two (1.5 percent) were physicians assistants or not listed.

Table 1.

Type of contraception prescribed by age and provider

Type of contraception
		LARC	Non-LARC	p-value
Age Group				0.1014
Mean = 30.3 (± 8.9)
11–19		30 (7.94)	209 (11.64)
20–24		71 (18.78)	305 (16.98)
25–29		79 (20.90)	360 (20.04)
30–34		97 (25.66)	382 (21.27)
35–39		54 (14.29)	247 (13.75)
40–44		24 (6.35)	138 (7.68)
45–60		23 (6.08)	155 (8.63)
Provider Title				<0.0001
Physician		232 (61.38)	1027 (57.18)
Nurse practitioner		74 (19.58)	548 (30.51)
Midwife		66 (17.46)	195 (8.97)
PA, or not listed		6 (1.59)	26 (1.45)
Type of LARC
		IUD	Implant	p-value
Age Group				<0.0001
Mean = 30.2 (± 8.2)
11–19		17 (5.72)	13 (16.05)
20–24		37 (12.46)	34 (41.98)
25–29		63 (21.21)	16 (19.75)
30–34		84 (28.28)	13 (16.05)
35+		96 (32.32)	5 (6.17)
Provider Title				0.0025
Physician		182 (61.28)	50 (61.73)
Nurse practitioner		49 (16.50)	25 (30.86)
Midwife		60 (20.20)	6 (7.41)
PA, or not listed		6 (2.02)	0

In the multivariate model there was an association between age and LARC prescription, where younger women (ages 11–19) were less likely to be prescribed LARC methods compared to age group 30–34 (odds ratio [OR] = 0.57 confidence interval [CI] = 0.37–0.90) (Table 2). When comparing the types of LARC methods (IUD versus implant), younger women were less likely to be prescribed an IUD (age 11–19 OR = CI = 0.08–0.47, age 20–24 OR = 0.15 CI = 0.07–0.33) (Table 2).

Table 2.

Logistic regression contraception methods, LARC vs. non-LARC

LARC vs. Non-LARC
		Odds Ratio	95% Confidence Interval
Age Group
11–19		0.57	0.37 – 0.90
20–24		0.94	0.67 – 1.33
25–29		0.88	0.63 – 1.23
30–34		ref	-
35–39		0.91	0.63 – 1.32
40–44		0.76	0.47 – 1.25
45–60		0.65	0.40 – 1.06
Provider Title
Physician		ref	-
Nurse practitioner		0.60	0.45 – 0.80
Midwife		1.46	1.07 – 2.00
PA, not listed		0.99	0.402 – 2.435
IUD vs. Implant
		Odds Ratio	95% Confidence Interval
Age Group
11–19		0.174	0.065 – 0.462
20–24		0.149	0.069 – 0.324
25–29		0.548	0.241 – 1.245
30–34		ref	-
35+		3.177	1.077 – 9.374
Provider Title
Physician, PA, not listed		ref	-
Nurse practitioner		0.468	0.244 – 0.898
Midwife		3.651	1.421 – 9.383

We looked at data by site between the five locations but numbers varied widely and several of the providers saw patients at multiple sites; therefore, we focused on provider type. There was also significant association between LARC prescription and provider title, where nurse practitioners were less likely to prescribe LARCs (OR = 0.60 CI = 0.45–0.80) and nurse midwives were more likely to prescribe LARCs (OR = 1.46 CI = 1.07–2.00) when compared to physicians or physician assistants. Comparing types of LARCs prescribed, nurse practitioners were less likely to prescribe IUDs (OR = 0.47 CI = 0.24–0.98) and midwives were more likely to prescribe IUDs (OR = 3.66 CI = 1.43–9.40).

Anecdotally, while these data were not significant, a total of 10 patients switched from LARC to non-LARC methods; nine were prescribed oral contraceptive pills and one switched to Nuvaring. The average age of “switchers” from LARC to non-LARC methods was 24 year (13–50 years). Fifteen patients switched from non-LARC to LARC methods. Of those who switched to LARC methods, two were prescribed the implant while the remaining were prescribed an IUD. The average age of switchers from non-LARC to LARC was 28 years (13–56 years) Finally, data were looked at for three specific providers who began their practice at around the same time period. One of these providers received a specialized training from ACOG on LARC, both on the technical aspects of insertion but also how to talk to patients about the different types. The focus of this analysis was on comparing LARC prescription rates over time for specific six-month periods (Jan. 1 to June 1) over the course of several years to evaluate if the ACOG specialized training did indeed influence prescriptions. While anecdotal, Table 3 highlights changes in prescription rates over time of the provider who received the training as compared to two providers who began their practices around the same time but who did not receive the training.

Table 3.

LARC prescriptions over time, comparing trained vs. non-trained providers

	Provider 1*	Provider 2	Provider 3
LARC	N(%)	N(%)	N(%)
2011	26 (17.6%)	27 (16.5%)	17 (8.2%)
2013	40 (44.4%)	31 (19.9%)	25 (18.7%)
2016	24 (42.9%)	25 (18.4%)	12 (11.8%)
Non-LARC
2011	122 (82.4%)	137 (83.5%)	191 (91.8%)
2013	50 (55.6%)	125 (80.1%)	109 (81.3%)
2016	32 (57.1%)	111 (81.6%)	90 (88.2%)

^*Received ACOG training on LARC methods

Discussion

Among women prescribed contraception at one of the five clinics from one health system that were included in this study, significant differences were found between LARC and non-LARC methods, and varied significantly among age groups. Women aged 11–19 were significantly less likely to use LARC methods compared to women age 30–35. This is consistent with previous findings that showed teens, age 15–19, have the lowest LARC uptake.^5,6 This is also consistent with state-level data, where 29.8 percent of high school females used oral contraception and only 3.1 percent used an IUD.¹³ However, relatively new national recommendations on LARC methods for teens from groups such as ACOG and the American Academy of Pediatrics state that use of LARCs with teens and adolescents are safe for this age group, and other research finds that use of LARC methods by adolescents can significantly reduce rates of teen pregnancy.¹⁴

Among our participants who were prescribed LARC methods, there were also differences by type. For example, the use of an IUD was significantly higher than the implant method, which is important to note as IUDs can last up to 10 years, while implants last three years. However, analysis showed that younger women, ages 11–19 and 20–24, were less likely to use IUD than women age 30–34. Previous research has shown a similar trend, where younger patients tend to prefer an implant over IUD.¹⁵ This may be due in part to the lack of knowledge of LARC methods. Furthermore, since most adolescents don’t need a pap test until age 21, they may be uncomfortable with a pelvic exam, which is necessary for IUD but not for the implant. Frost et al. reported that only 7 percent of women 18–29 years felt they knew “a lot of everything about IUDs and their use.”⁷ Teenagers in this study were also found to be less aware of IUD compared to women age 20–29,⁷ pointing to an opportunity to increase use through expanding awareness about different LARC options.

In addition, medical providers play an important role in uptake of LARC methods,^9,12 and our data highlights firsthand the importance of a formal training on LARC methods and communication. Using references such as one available from the Centers for Disease Control and Prevention, contraceptive counseling uses a tier-based approach, presenting all methods in order of most to least effective. Our data showed that an ACOG education on LARC methods increased prescription of this type of contraception, at least for one provider when compared to others who did not receive the education. One national project called the Contraceptive CHOICE Project found that during counseling where the most effective contraception methods (i.e., LARC) were discussed first, 72 percent of adolescents chose a LARC method.¹¹ This points to the importance of provider education in discussing LARC as a viable birth control method with all participants, especially when considering our significant findings of prescription differences by type of provider.

Regionally, South Dakota is among the lowest in the nation for LARC uptake.⁵ Previous research suggests that rurality may affect contraception use, influenced by barriers such as lack of privacy, stigma, accessibility and affordability.¹⁶ While one previous study found no significant difference in contraception use between rural and urban participants, significant barriers were noted among those living in rural areas.¹⁷ The clinics in our study were not of a rural nature, but overall the state of South Dakota is extremely rural/frontier, and considerations need to be made for how to increase use of LARCs among rural women. This is especially important as there is greater difficulty in accessing preventive health care due to long distances to clinics and weather-related barriers. A LARC method provides a perfect solution in that it is inserted in-clinic and can last up to 10 years, depending on the type. However, rural providers are often limited in getting trained in LARC methods because they need to have another provider “proctor” them, especially if they are the first provider “learning” the procedure (ex. IUD placement or Nexplanon placement). Along with this, there is a required certain number of placements that must be proctored before a doctor can do these on their own. This significantly limits women’s access to LARC in the rural setting.

In sum, many factors should be considered by the patient and provider when choosing the most appropriate contraceptive method, including safety, effectiveness, accessibility, affordability, and acceptability.^{1, 2} However, patients should be fully informed about pros and cons of each type of contraception, with providers playing such a key role in contraception decisions. There are education opportunities available through ACOG which focus on LARC methods, led by ACOG’s Long-Acting Reversible Contraception (LARC) program. The aim of this group lower the unintended pregnancy rate in the U.S. by “connecting providers, patients, and the public with the most up-to-date information and resources on LARC methods and increasing access to the full range of contraceptive methods.” Part of this mission is to create and provide educational and practice support tools to improve LARC uptake. As shown in our data, this type of training can be highly successful in improving LARC rates of patients.