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The role of patient-perceived autonomy in regard to long-acting reversible contraceptive methods
Abstracts / Contraception 94 (2016) 387–434
Conclusions: Women with LARC insurance coverage have higher uptake of a LARC method postabortion. Although we found no difference in LARC method uptake after the mandate, possibly due to extensive LARC insurance coverage before the mandate, 7% of women with private insurance still lacked coverage. http://dx.doi.org/10.1016/j.contraception.2016.07.111
P71 WHY DO NOT WOMEN IN TEXAS GET CONTRACEPTION AT THE FIRST POSTPARTUM VISIT? Coleman-Minahan K University of Texas at Austin, Austin, TX, USA Dillaway CH, Canfield C, Khun DM, Strandberg KS, Hopkins KL, White K, Grossman D, Potter JE Objectives: We examine contraceptive access at the first postpartum visit, barriers to obtaining postpartum contraception after the first visit and contraceptive use at 3 months postpartum. Methods: We conducted a prospective cohort study of 1700 postpartum women in Texas who wished to delay childbearing for at least 2 years and whose deliveries were covered by public insurance. To date, 1412 women have completed the 3month interview, 23% of whom received the IUD, implant, injectable or sterilization before discharge. Women who did not receive a method in the hospital were asked if they received a method at their first postpartum visit. To capture the additional steps required of women who did not receive a method at this visit, we asked an openended question about their plan to get their method. Finally, we asked about current contraceptive use at 3 months. Results: Among women who were discharged without contraception (n= 1089), some 20% had not discussed contraception with a provider by 3 months postpartum. Among those who had done so (n= 868), 74% did not receive a method at their first postpartum visit. These women described multiple steps needed to obtain a method, including returning for another visit, applying for discount programs, and finding a provider offering a wider range of methods. By 3 months postpartum, two thirds of these women had still not obtained their planned method. Conclusions: Women who do not receive a method immediately postpartum or at the first postpartum visit face barriers to accessing contraception that may be too burdensome to overcome. http://dx.doi.org/10.1016/j.contraception.2016.07.112
P72 DOES A TWO-VISIT PROTOCOL FOR LONG-ACTING REVERSIBLE CONTRACEPTION DIFFERENTIALLY IMPACT SOCIOECONOMICALLY DISADVANTAGED WOMEN? Higgins T University of Vermont College of Medicine, Burlington, VT, USA Dougherty A, Heil S Objectives: Long-acting reversible contraceptive (LARC) methods are highly effective but underutilized. One barrier to greater use is the multiple visits required for device insertion. The present study examines if this disproportionally undermines the efforts of socioeconomically disadvantaged women who have public insurance (Medicaid) to obtain these methods. Methods: We conducted a retrospective chart review of 447 women who requested LARC method insurance precertification for contraception in 2013 at the University of Vermont obstetrics and gynecology clinic, which requires multiple visits for device insertion. LARC method insertion rates and pregnancy rates were compared among women with private versus public insurance.
413
Results: Patients with Medicaid were younger, less likely to be married, less likely to be nulliparous, more likely to be recently postpartum and more likely to choose the implant. In univariate analysis, privately insured women were more likely to have a LARC method placed than those with Medicaid (79% vs. 66%, pb.01). In multivariate analysis, private insurance was an independent predictor of receiving a LARC method (OR, 1.8; 95% CI, 1.05–3.14), as was being nonpostpartum (OR, 2.1; 95% CI; 1.10– 3.86). Among women who did not receive a LARC method, Medicaid patients were more likely to become pregnant in the following year (27% vs. 12%, pb.001). Conclusions: Requiring multiple visits for LARC method insertion disproportionately impacts socioeconomically disadvantaged women. These women likely simultaneously face other barriers, such as being more likely to be postpartum at the time of request. Finally, this population may suffer more severe consequences of not having the device inserted, as shown here by the increased pregnancy rate. http://dx.doi.org/10.1016/j.contraception.2016.07.113
P73 CONTRACEPTIVE COUNSELING FOR REPRODUCTIVE-AGED WOMEN TREATED AT STANFORD CANCER INSTITUTE: A RETROSPECTIVE ANALYSIS Johansen S Stanford University, Stanford, CA, USA Lerma K, Henry S, Tamaresis J, Wood D, Shaw K
Objectives: Our objective was to assess the frequency of documented contraception counseling and fertility preservation counseling for women treated for breast cancer and patient characteristics associated with likelihood of counseling. Methods: We conducted a retrospective chart analysis of female breast cancer patients (n=211) aged 18–45 treated at Stanford Cancer Institute from 2010 to 2014. Primary outcomes of contraceptive counseling and fertility preservation counseling documentation were assessed for frequency. Secondary outcomes included demographic characteristics, sexual activity, pregnancy testing, contraceptive use and abortion history. Descriptive statistics were performed. Associations between patient characteristics and the likelihood of receiving counseling were assessed in logistic regression. Results: Among the sample, sexual activity was undocumented in 75.8% of patients (n=160). Some 51.2% (n=108) of patients received a pregnancy test prior to initiation of chemotherapy treatment; 73.9% of patients had documented past contraceptive use (n=156), while only 25.1% had documentation of current use (n=53). Some 37.4% of patients received fertility preservation counseling (n=79), and 22.3% received contraceptive counseling (n=47). Patients were significantly more likely to receive contraceptive counseling if they were using contraceptives at the time of diagnosis (p=.04). Two patients had an unplanned pregnancy followed by abortion during treatment (1.2%), and neither patient was using contraceptives or received counseling. Conclusions: Fertility preservation counseling is more frequently documented than contraceptive counseling, but both occur at suboptimal rates. Although lack of documentation does not mean counseling did not occur, it suggests that more work is needed to increase education for patients and providers and increase provision of this important aspect of reproductive health and cancer care. http://dx.doi.org/10.1016/j.contraception.2016.07.114
P74 THE ROLE OF PATIENT-PERCEIVED AUTONOMY IN REGARD TO LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS Zeal C University of Wisconsin, Madison, WI, USA Higgins J, Newton S
414
Abstracts / Contraception 94 (2016) 387–434
Objectives: An important but underexamined determinant of LARC method use is young women's perceptions of autonomy and control in relationship to these methods. The aim of this study is to explore the role of patient-perceived autonomy in regard to LARC methods among young women in Madison, WI. Methods: Investigators conducted focus group discussions and interviews regarding LARC method barriers and facilitators with 50 women aged 18–29, both university students and women in the community receiving public assistance. We used a modified grounded theory approach to analyze young women's impressions of autonomy in relationship to LARC methods. Results: Four themes emerged regarding women's perceived autonomy in their contraceptive choices: control over pregnancy, physical, tangible control of one's method, control over hormones and autonomy in the provider–patient relationship. Within these themes, women made both positive and negative associations between perceived autonomy and LARC methods. Women reported that the provider– patient relationship could act as a positive or negative modifier of all other themes. Ever users were more likely to report increased control in relationship to their LARC method use, whereas never users were more likely to express concerns about loss of autonomy with LARC methods. Conclusions: The reports of increased control by ever users suggest that patients' perceived autonomy may influence uptake of LARC methods. Within each of the identified themes, women reported both positive and negative associations between LARC methods and perceived autonomy. However, it was significant that women's sense of control could be altered depending on the provider–patient relationship, regardless of other factors. Future studies should focus on the provider–patient relationship in contraceptive counseling and communication methods. http://dx.doi.org/10.1016/j.contraception.2016.07.115
P75 “IT’S SAFE, RIGHT?” WHAT COMMUNITY COLLEGE STUDENTS KNOW, DO NOT KNOW AND THINK THEY KNOW ABOUT BIRTH CONTROL Cabral M Princeton University, Princeton, NJ, USA Armstrong E, Blum M, Schroeder R, Lesyna K, Harper C Objectives: Community college students comprise almost half of all undergraduates; they are of diverse backgrounds, and many are immigrants or first-generation students. Strengthening opportunities for these students is a current national policy priority. We conducted qualitative research to guide a contraceptive educational intervention among this population at high risk of unintended pregnancy. Methods: We conducted in-depth interviews among 61 community college students (35 female, 27 male) aged 18–25 to explore the roles of contraception and unintended pregnancy in their lives. We used a semistructured topic guide. Data were coded with content analysis, and themes were identified. Results: Most students were sexually active and had had unprotected intercourse. They worried that unintended pregnancy might obstruct educational goals and were familiar with condoms. However, confusion about contraception abounded and was shared by friends and partners. Several students thought the implant and IUD caused “mini abortions,” which explained the spotting, menstrual changes and why it “messed up fertility” later. About half also confused Plan B and those menstrual changes with abortion. Students perceived the pill as being 100% effective, and women in general had more positive views of this method, while men focused on hormones and side effects, and thought a condom was better because it was a visible form of protection. Conclusions: An educational intervention for this population to increase contraceptive knowledge should include peer voices and address not only medical features of contraceptives but also common worries and fears that prevent use among this age group. http://dx.doi.org/10.1016/j.contraception.2016.07.116
P76 HOSPITAL STAKEHOLDER KNOWLEDGE AND ATTITUDES ABOUT IMMEDIATE POSTPARTUM LONG-ACTING REVERSIBLE CONTRACEPTIVE (LARC) METHODS Hofler L Emory University, Atlanta, GA, USA Cordes S, Cwiak C, Goedken P, Jamieson D, Kottke M
Objectives: While research exists on office-based and postabortion placement of long-acting reversible contraceptive (LARC) methods, little is known regarding perceptions about immediate postpartum LARC method provision. This study sought to understand the knowledge and attitudes about immediate postpartum LARC methods among key stakeholders in hospitals implementing immediate postpartum LARC methods in Georgia. Methods: We interviewed 32 key stakeholders from 10 Georgia hospitals undertaking immediate postpartum LARC method implementation. A codebook developed from a theory-based interview guide was used for initial analysis, followed by analysis of emerging inductive themes and finally interpretation and integration of deductive and inductive themes. Results: Key stakeholders included physicians, nursing administrators, pharmacists, billing personnel and lactation consultants. More than half reported no training, education or familiarity with LARC devices despite being integral to immediate postpartum LARC method implementation at their institution. Many stakeholders viewed immediate postpartum LARC method placement as a lesser alternative to office-based LARC method placement. Although attitudes toward LARC method effectiveness were positive overall, most stakeholders mentioned higher risk of IUD expulsion immediately postpartum. Patient selection and trust factored into stakeholders' opinions about ideal timing for LARC method placement. Concerns that stakeholders raised about immediate postpartum placement of a method's potential negative effects on patients included decreased condom use, infection and lost motivation for women to return for postpartum visits. Conclusions: These findings highlight a considerable need for LARC method education among hospital staff involved in immediate postpartum LARC method placement programs. Accurate information addressing commonly raised concerns is critical for stakeholder buy-in to create sustainable immediate postpartum LARC method placement programs. Immediate postpartum LARC method placement should be contextualized as a valuable opportunity for all postpartum women to access contraception. http://dx.doi.org/10.1016/j.contraception.2016.07.117
P77 WHO MATTERS MOST IN POSTPARTUM BIRTH CONTROL COUNSELING? EVALUATING THE CREDIBLE SOURCES Mullen M Washington University, St. Louis, MO, USA Paul R, Frisse A, Wan L, Camaryn CR Objectives: More one third of women have unfulfilled contraceptive needs during their first year postpartum. Providers agree that contraceptive counseling increases uptake, but no studies demonstrate which source women trust most when it comes to postpartum counseling. This study aimed to assess whose advice women rely on most when making postpartum birth control choices. Methods: Eligible women were recruited from the postpartum service of a large, urban hospital between December 2015 and March 2016. Subjects completed the surveys electronically. Data were analyzed using SAS and SPSS. Results: Surveys were administered to 179 women. Women were aged 26 on average at delivery; 57% were Black, 34% of women were married and 57%
Conclusions: Women with LARC insurance coverage have higher uptake of a LARC method postabortion. Although we found no difference in LARC method uptake after the mandate, possibly due to extensive LARC insurance coverage before the mandate, 7% of women with private insurance still lacked coverage. http://dx.doi.org/10.1016/j.contraception.2016.07.111
P71 WHY DO NOT WOMEN IN TEXAS GET CONTRACEPTION AT THE FIRST POSTPARTUM VISIT? Coleman-Minahan K University of Texas at Austin, Austin, TX, USA Dillaway CH, Canfield C, Khun DM, Strandberg KS, Hopkins KL, White K, Grossman D, Potter JE Objectives: We examine contraceptive access at the first postpartum visit, barriers to obtaining postpartum contraception after the first visit and contraceptive use at 3 months postpartum. Methods: We conducted a prospective cohort study of 1700 postpartum women in Texas who wished to delay childbearing for at least 2 years and whose deliveries were covered by public insurance. To date, 1412 women have completed the 3month interview, 23% of whom received the IUD, implant, injectable or sterilization before discharge. Women who did not receive a method in the hospital were asked if they received a method at their first postpartum visit. To capture the additional steps required of women who did not receive a method at this visit, we asked an openended question about their plan to get their method. Finally, we asked about current contraceptive use at 3 months. Results: Among women who were discharged without contraception (n= 1089), some 20% had not discussed contraception with a provider by 3 months postpartum. Among those who had done so (n= 868), 74% did not receive a method at their first postpartum visit. These women described multiple steps needed to obtain a method, including returning for another visit, applying for discount programs, and finding a provider offering a wider range of methods. By 3 months postpartum, two thirds of these women had still not obtained their planned method. Conclusions: Women who do not receive a method immediately postpartum or at the first postpartum visit face barriers to accessing contraception that may be too burdensome to overcome. http://dx.doi.org/10.1016/j.contraception.2016.07.112
P72 DOES A TWO-VISIT PROTOCOL FOR LONG-ACTING REVERSIBLE CONTRACEPTION DIFFERENTIALLY IMPACT SOCIOECONOMICALLY DISADVANTAGED WOMEN? Higgins T University of Vermont College of Medicine, Burlington, VT, USA Dougherty A, Heil S Objectives: Long-acting reversible contraceptive (LARC) methods are highly effective but underutilized. One barrier to greater use is the multiple visits required for device insertion. The present study examines if this disproportionally undermines the efforts of socioeconomically disadvantaged women who have public insurance (Medicaid) to obtain these methods. Methods: We conducted a retrospective chart review of 447 women who requested LARC method insurance precertification for contraception in 2013 at the University of Vermont obstetrics and gynecology clinic, which requires multiple visits for device insertion. LARC method insertion rates and pregnancy rates were compared among women with private versus public insurance.
413
Results: Patients with Medicaid were younger, less likely to be married, less likely to be nulliparous, more likely to be recently postpartum and more likely to choose the implant. In univariate analysis, privately insured women were more likely to have a LARC method placed than those with Medicaid (79% vs. 66%, pb.01). In multivariate analysis, private insurance was an independent predictor of receiving a LARC method (OR, 1.8; 95% CI, 1.05–3.14), as was being nonpostpartum (OR, 2.1; 95% CI; 1.10– 3.86). Among women who did not receive a LARC method, Medicaid patients were more likely to become pregnant in the following year (27% vs. 12%, pb.001). Conclusions: Requiring multiple visits for LARC method insertion disproportionately impacts socioeconomically disadvantaged women. These women likely simultaneously face other barriers, such as being more likely to be postpartum at the time of request. Finally, this population may suffer more severe consequences of not having the device inserted, as shown here by the increased pregnancy rate. http://dx.doi.org/10.1016/j.contraception.2016.07.113
P73 CONTRACEPTIVE COUNSELING FOR REPRODUCTIVE-AGED WOMEN TREATED AT STANFORD CANCER INSTITUTE: A RETROSPECTIVE ANALYSIS Johansen S Stanford University, Stanford, CA, USA Lerma K, Henry S, Tamaresis J, Wood D, Shaw K
Objectives: Our objective was to assess the frequency of documented contraception counseling and fertility preservation counseling for women treated for breast cancer and patient characteristics associated with likelihood of counseling. Methods: We conducted a retrospective chart analysis of female breast cancer patients (n=211) aged 18–45 treated at Stanford Cancer Institute from 2010 to 2014. Primary outcomes of contraceptive counseling and fertility preservation counseling documentation were assessed for frequency. Secondary outcomes included demographic characteristics, sexual activity, pregnancy testing, contraceptive use and abortion history. Descriptive statistics were performed. Associations between patient characteristics and the likelihood of receiving counseling were assessed in logistic regression. Results: Among the sample, sexual activity was undocumented in 75.8% of patients (n=160). Some 51.2% (n=108) of patients received a pregnancy test prior to initiation of chemotherapy treatment; 73.9% of patients had documented past contraceptive use (n=156), while only 25.1% had documentation of current use (n=53). Some 37.4% of patients received fertility preservation counseling (n=79), and 22.3% received contraceptive counseling (n=47). Patients were significantly more likely to receive contraceptive counseling if they were using contraceptives at the time of diagnosis (p=.04). Two patients had an unplanned pregnancy followed by abortion during treatment (1.2%), and neither patient was using contraceptives or received counseling. Conclusions: Fertility preservation counseling is more frequently documented than contraceptive counseling, but both occur at suboptimal rates. Although lack of documentation does not mean counseling did not occur, it suggests that more work is needed to increase education for patients and providers and increase provision of this important aspect of reproductive health and cancer care. http://dx.doi.org/10.1016/j.contraception.2016.07.114
P74 THE ROLE OF PATIENT-PERCEIVED AUTONOMY IN REGARD TO LONG-ACTING REVERSIBLE CONTRACEPTIVE METHODS Zeal C University of Wisconsin, Madison, WI, USA Higgins J, Newton S
414
Abstracts / Contraception 94 (2016) 387–434
Objectives: An important but underexamined determinant of LARC method use is young women's perceptions of autonomy and control in relationship to these methods. The aim of this study is to explore the role of patient-perceived autonomy in regard to LARC methods among young women in Madison, WI. Methods: Investigators conducted focus group discussions and interviews regarding LARC method barriers and facilitators with 50 women aged 18–29, both university students and women in the community receiving public assistance. We used a modified grounded theory approach to analyze young women's impressions of autonomy in relationship to LARC methods. Results: Four themes emerged regarding women's perceived autonomy in their contraceptive choices: control over pregnancy, physical, tangible control of one's method, control over hormones and autonomy in the provider–patient relationship. Within these themes, women made both positive and negative associations between perceived autonomy and LARC methods. Women reported that the provider– patient relationship could act as a positive or negative modifier of all other themes. Ever users were more likely to report increased control in relationship to their LARC method use, whereas never users were more likely to express concerns about loss of autonomy with LARC methods. Conclusions: The reports of increased control by ever users suggest that patients' perceived autonomy may influence uptake of LARC methods. Within each of the identified themes, women reported both positive and negative associations between LARC methods and perceived autonomy. However, it was significant that women's sense of control could be altered depending on the provider–patient relationship, regardless of other factors. Future studies should focus on the provider–patient relationship in contraceptive counseling and communication methods. http://dx.doi.org/10.1016/j.contraception.2016.07.115
P75 “IT’S SAFE, RIGHT?” WHAT COMMUNITY COLLEGE STUDENTS KNOW, DO NOT KNOW AND THINK THEY KNOW ABOUT BIRTH CONTROL Cabral M Princeton University, Princeton, NJ, USA Armstrong E, Blum M, Schroeder R, Lesyna K, Harper C Objectives: Community college students comprise almost half of all undergraduates; they are of diverse backgrounds, and many are immigrants or first-generation students. Strengthening opportunities for these students is a current national policy priority. We conducted qualitative research to guide a contraceptive educational intervention among this population at high risk of unintended pregnancy. Methods: We conducted in-depth interviews among 61 community college students (35 female, 27 male) aged 18–25 to explore the roles of contraception and unintended pregnancy in their lives. We used a semistructured topic guide. Data were coded with content analysis, and themes were identified. Results: Most students were sexually active and had had unprotected intercourse. They worried that unintended pregnancy might obstruct educational goals and were familiar with condoms. However, confusion about contraception abounded and was shared by friends and partners. Several students thought the implant and IUD caused “mini abortions,” which explained the spotting, menstrual changes and why it “messed up fertility” later. About half also confused Plan B and those menstrual changes with abortion. Students perceived the pill as being 100% effective, and women in general had more positive views of this method, while men focused on hormones and side effects, and thought a condom was better because it was a visible form of protection. Conclusions: An educational intervention for this population to increase contraceptive knowledge should include peer voices and address not only medical features of contraceptives but also common worries and fears that prevent use among this age group. http://dx.doi.org/10.1016/j.contraception.2016.07.116
P76 HOSPITAL STAKEHOLDER KNOWLEDGE AND ATTITUDES ABOUT IMMEDIATE POSTPARTUM LONG-ACTING REVERSIBLE CONTRACEPTIVE (LARC) METHODS Hofler L Emory University, Atlanta, GA, USA Cordes S, Cwiak C, Goedken P, Jamieson D, Kottke M
Objectives: While research exists on office-based and postabortion placement of long-acting reversible contraceptive (LARC) methods, little is known regarding perceptions about immediate postpartum LARC method provision. This study sought to understand the knowledge and attitudes about immediate postpartum LARC methods among key stakeholders in hospitals implementing immediate postpartum LARC methods in Georgia. Methods: We interviewed 32 key stakeholders from 10 Georgia hospitals undertaking immediate postpartum LARC method implementation. A codebook developed from a theory-based interview guide was used for initial analysis, followed by analysis of emerging inductive themes and finally interpretation and integration of deductive and inductive themes. Results: Key stakeholders included physicians, nursing administrators, pharmacists, billing personnel and lactation consultants. More than half reported no training, education or familiarity with LARC devices despite being integral to immediate postpartum LARC method implementation at their institution. Many stakeholders viewed immediate postpartum LARC method placement as a lesser alternative to office-based LARC method placement. Although attitudes toward LARC method effectiveness were positive overall, most stakeholders mentioned higher risk of IUD expulsion immediately postpartum. Patient selection and trust factored into stakeholders' opinions about ideal timing for LARC method placement. Concerns that stakeholders raised about immediate postpartum placement of a method's potential negative effects on patients included decreased condom use, infection and lost motivation for women to return for postpartum visits. Conclusions: These findings highlight a considerable need for LARC method education among hospital staff involved in immediate postpartum LARC method placement programs. Accurate information addressing commonly raised concerns is critical for stakeholder buy-in to create sustainable immediate postpartum LARC method placement programs. Immediate postpartum LARC method placement should be contextualized as a valuable opportunity for all postpartum women to access contraception. http://dx.doi.org/10.1016/j.contraception.2016.07.117
P77 WHO MATTERS MOST IN POSTPARTUM BIRTH CONTROL COUNSELING? EVALUATING THE CREDIBLE SOURCES Mullen M Washington University, St. Louis, MO, USA Paul R, Frisse A, Wan L, Camaryn CR Objectives: More one third of women have unfulfilled contraceptive needs during their first year postpartum. Providers agree that contraceptive counseling increases uptake, but no studies demonstrate which source women trust most when it comes to postpartum counseling. This study aimed to assess whose advice women rely on most when making postpartum birth control choices. Methods: Eligible women were recruited from the postpartum service of a large, urban hospital between December 2015 and March 2016. Subjects completed the surveys electronically. Data were analyzed using SAS and SPSS. Results: Surveys were administered to 179 women. Women were aged 26 on average at delivery; 57% were Black, 34% of women were married and 57%