Increasing uptake of long-acting reversible contraception : LARC

Abstract

BACKGROUND: Unintended pregnancies are an inexhaustible source to life-changing decisions and events for individuals and result in enormous costs for societies having to deal with maternal health services, deliveries, hospital care and abortions. Unmet need of contraception is a contributing factor to unintended pregnancies. Women who rely on user-dependent contraceptive methods experience higher failure rates. Increasing uptake of LARCs has proven to reduce unintended pregnancies and abortions, especially among young women. Several opportunities to counsel women about the most effective contraceptive methods are not accurately seized, such as when in need of emergency contraception, during regular contraceptive counselling and after induced abortion. Swedish women have the highest number of induced abortions among countries with robust statistics, and Sweden has the highest number of teenage abortions among Nordic countries. Improving access to facts-based knowledge during contraceptive counselling, and by finding effective methods for pain management with intrauterine device insertion could increase uptake of the most effective contraceptive methods—long-acting reversible contraception.

AIM: This thesis includes original research within three subfields that all represent opportunities for provision of effective contraception. The thesis aims to find pathways to increase uptake of LARC by interventions used to improve the quality of care from both a healthcare provider's and a patient's perspective.

METHODS: Study I was an observational cohort study conducted at one reproductive health clinic in Stockholm, Sweden. This study aimed to compare use of an effective contraceptive method following copper-intrauterine device insertion for emergency contraception or use of an emergency contraceptive pill consisting of ulipristal-acetate. Study II was a double-blinded, randomized, placebo-controlled trial conducted at one youth clinic and one reproductive health clinic in Stockholm. The aim was to investigate pain reduction with intrauterine device insertion among nulliparous women randomized to intrauterine instillation of either 1% mepivacaine (intervention) or 9% sodium-chloride (placebo/control). Study III was a cluster randomized trial conducted at abortion clinics, youth clinics and maternal health clinics (n=28) in Stockholm. The aim was to compare uptake of contraceptive methods, more specifically long-acting reversible contraceptive methods, between women receiving structured contraceptive counselling (intervention) or standard contraceptive counselling (control) (paper III). Satisfaction with the intervention was evaluated from a healthcare provider's and receiver's perspective (paper IV) to gather information on feasibility and implementability.

FINDINGS: More women opting for a Copper-intrauterine device for emergency contraception were using effective contraception at follow-up compared to women opting for an emergency contraceptive pill of ulipristal acetate. The IUD group were also less exposed to subsequent unprotected sexual intercourse, and most IUD-users would recommend the method for emergency contraception to a friend (study I). In an intention-to-treat analysis, the reduction of pain with IUD insertion by the use of intrauterine mepivacaine instillation did not reach our anticipated difference compared to placebo. In an additional per-protocol analysis, the difference in pain between intervention- and control groups was statistically significant. Women receiving mepivacaine had a more positive experience of the insertion procedure compared to women receiving placebo. The use of intrauterine instillation for pain management was well accepted by women (study II). Uptake of long-acting reversible contraception was higher among women receiving structured contraceptive counselling compared to women receiving standard contraceptive counselling. The intervention also led to higher initiation rate of long-acting reversible contraception and fewer cases of subsequent pregnancies at 3 months follow-up, compared to control (study III, paper III). The intervention received high satisfaction rates from both healthcare providers and patients. They found it to be supportive in their contraceptive counselling and choice. Healthcare providers estimated the time consumption for using the intervention outside the study to be time-neutral compared to standard contraceptive counselling (study III, paper IV).

CONCLUSION: At the 6 months follow up, significantly more women opting for a copper-intrauterine device for emergency contraception used an effective contraceptive method. The results of this study support increased promotion and use of copper-intrauterine devices for emergency contraception (study I). Intrauterine instillation of 1% mepivacaine prior to intrauterine device insertion modestly reduces pain; however, the effect size may be clinically significant with fewer women having a "worse than expected" experience (study II). As a stand-alone intervention, structured contraceptive counselling increased uptake of LARCs independent on clinic type and might prevent subsequent unplanned pregnancies (study III, paper III). The intervention had a high provider and receiver satisfaction. The intervention package could be used in several clinical settings to improve quality in contraceptive counselling and to enhance informed decision making regarding contraceptive methods.