Same-Day Access to Highly Effective Reversible Contraception: Moving from Plan B to Happily Ever After

Transcription

1 Same-Day Access to Highly Effective Reversible Contraception: Moving from Plan B to Happily Ever After Eleanor Bimla Schwarz, MD, MS Director, Women s Health Services Research Unit Center for Research on Health Care Associate Professor of Medicine, Epidemiology, Obstetrics, Gynecology, and Reproductive Sciences University of Pittsburgh schwarzeb@upmc.edu Funded by HHS OPA R01 PG

2 Once Upon a Time Rodriguez MI et al Contraception 2013

3 A drop of EC in the ocean of unprotected sex

4 The limits of efficacy of EC pills On average, American women weigh 166 lbs For Plan B: Weight=70 kg (154 lb) For ella: Weight=88 kg (194 lb) Glasier A et al Contraception 2011

5 Relative effectiveness of EC options 12 Pregnancies expected per 1000 women who had unprotected sex in the last week Plan B pills Ella pills Paragard IUD

6 ECWIP Project Goals To ensure that all women who seek emergency contraception (EC) or walk in pregnancy (WIP) testing are equipped with the knowledge and services they need to avoid unintended pregnancy.

7 Research Questions Is it possible for a Title X clinic to routinely offer women seeking EC or WIP same-day placement of highly effective reversible contraception (HER-c)? How does brief structured counseling about HER-c combined with the offer of same-day contraceptive placement affect: Knowledge of IUDs and implants? Contraceptive use? (Unintended pregnancy??)

8 Methods Overview Design: pre-intervention vs. intervention period Pre-intervention period: January to August 2011 Intervention period: August 2011to May 31, 2013 Data sources: Survey on day of clinic visit (in person) Survey 3-months after clinic visit (online or by phone) Survey 12-months after clinic visit (online or by phone) Electronic Medical Record data HHS OPA R01PG000859

9 Participant Criteria Inclusion Women Aged years Seeking EC or walk-in pregnancy testing Inner-city Title X clinic Pregnancy desired in next 6 months Positive pregnancy test Using an IUD or implant the day of clinic visit

10 Intervention

11 Brief Scripted Counseling The birth control methods that work best to prevent pregnancy are the implant and the IUD. These methods are more effective than condoms, pills or the depo shot. The implant and IUD are as effective as having your tubes tied, but can be reversed at any time if you decide to become pregnant or want to switch to a different method. The birth control implant is called Implanon or Nexplanon. It is a small flexible rod that is placed under the skin of the upper arm and can be used for 3 years. An IUD is a small, flexible, T-shaped device that is slid into the uterus and can be used for at least 5 years. There are 2 types that you may have heard of: the Mirena IUD and the copper IUD, sometimes called Paragard. If you have had sex without a condom or other type of birth control in the last 7 days and do not want to become pregnant, the copper IUD may be your best option today because it is more effective than emergency contraceptive pills. Do you have any questions about Implants, IUDs, or any other types of birth control?

12 Routine Offer of Convenience (Not Coercion)

13 RESULTS

14 Proportion Counseled by Quarter 80% 70% 60% 50% 40% 30% 20% 10% No Method Implant IUD EC 0% Quarter

15 Knowledge Increased 3mo after EC or WIP visit Correct answers on Pre-intervention (n=117) Intervention (n=232) IUD effectiveness 11% 40% P<0.001 IUD duration 48% 69% IUD reversal 43% 57% P<0.001 P=0.02 Some IUDs are hormone free 41% 58% P=0.003

16 Women provided EC by Method and Quarter ParaGard ella Plan B

17 Contraception at Last Sex (3 month Fup) Pre-Intervention N=119 Intervention N=221 P-value None 26% 19% Withdrawal 6% 3% 0.82 Male condoms 28% 33% 0.38 Pills 13% 8% 0.09 Ring 7% 5% 0.68 Depo shot 14% 16% 0.36 Implant 0% 1.4% 0.21 IUD 4% 13% 0.01

18 Multiple episodes of unprotected sex Intervention Period: Significantly fewer women reported multiple episodes of unprotected sex Overall: 55% 38%, p= WIP: 59% 41%, p= EC: 44% 27%, p=0.04 Pre-intervention: No sig change between enrollment and 3 month fup Overall: 55% 48%, p=0.30 WIP: 57% 48%, p=0.27 EC: 47% 48%, p=0.88

19 EMR Data on Same Day IUD if seeking EC During baseline period, NO women got an IUD on the day of their clinic visit. With intervention, 10.5% of women had an EC IUD inserted.

20 Pregnancy after seeking EC (Survey Data) Pregnancy within 3 months of seeking EC from clinic Pre-Intervention 16.0% (n=4) Intervention 9.4% (n=5) (p=0.40)

21 Pregnancy by method of EC (survey data) Came to clinic for EC Pregnant by 3 months No EC (n=1) n=1 100% (22%-100%) Levonorgestrel pills (n=95) n=7 7% (3%-15%) Ella EC pills (n=10) n=3 30% (10%-60%) ParaGard (n=25) n=0 0% (0%-12%)

22 EMR Data on Pregnancy Rates Following visit for EC 3 months 6 months Pre-Intervention 18.8% 18.8% Intervention 17.6% 18.0%

23 How long do EC-IUDs last? IUD placed within 5 Days of clinic visit: 77% (20/26) who completed 3 month fup 83% (5/6) who completed 12 month fup Same Day: 76% (16/21) who completed 3 month fup 80% (5/12) who completed 12 month fup NO indication that women felt coerced

24 Is Same-Day IUD placement safe? PID Diagnosis in 3 months after clinic visit: Survey Data: Baseline (1.7%, n=2) Intervention (5.7%, n=12) NO same day IUDs Most to women with no IUDs Chart review: One woman with an IUD placed within 5 days No evidence of PID on chart review EMR Data: Baseline (1.1%, n=6) Intervention (2.6%, n=32) Among women with same-day IUD, n=2/39 (5%, 95% CI=0%-17%)

25 Conclusions Timely info about and access to HER contraception is needed by those seeking EC/WIP Offering same-day placement does not waste IUDs Same-day placement does not increase risk of PID If we are serious about helping women live happily ever after It s time to move beyond Plan B

26 Questions?

27 Of women seeking EC (n=86) 29% got an IUD within 5 days 34% had an IUD within 3 months That is, another 5% of women got IUDs >5 days after seeking EC

28 What about those seeking pregnancy testing? Eligible for EC according to survey responses? Sex within past 5 days: pre=40% 43% post Sex within past 7 days: pre=47% 50% post Got EC the day of their visit (survey data) Pre-Intervention: survey data, Pre-Intervention: EMR data Intervention: survey Intervention: EMR 6% (0% got IUD) 6% (0% got IUD) 20% (2% got IUD, n=6) 10% (1% got IUD, n=11)

29 Pregnancy within 3mo of seeking WIP Survey data Pre-Intervention 11.0% Intervention 9.5% EMR data Pre-Intervention 16.0 % Intervention 19.1 %

30 Challenges Staff Turnover 7 MAs 12 RNs 4 CRNP/PAs 21 Residents 3 Fellows 14 Attendings Maintaining contraceptive inventory Clinic flow Open rooms

31 EMR data Study Data Pre-Intervention months EC 85 WIP 450 EC 176 Intervention months WIP 1060 Visit day Survey (28%) mo Survey (68%)

32 ECWIP placement of IUD (Survey Data) 25.00% 20.00% 15.00% 10.00% Same Day IUD Within 5 Days Within 3 Months 5.00% 0.00%

33 Intervention effect on women seeking EC Of women who came to clinic seeking EC Day of visit, report talking about IUD or implant Pre19% Intervention 84% At 3 mo Fup, recall talking about birth control at visit Pre 84.0% Intervention 96.7% P=0.04 Counseling prompted switch to an IUD by 3 months Pre 0.0% Intervention 18.6% P=0.02

34 Pregnancy within 3mo of seeking EC or WIP Survey data Pre-Intervention 11.0% (n=13) Intervention 9.5% (n=20) EMR data Pre-Intervention 16.5 % (n=88) Intervention 18.9 % (n=234)

35 ECWIP Respondent Characteristics Age: 22±5 years Race: 72% black,17% white, 10% bi-racial, 1% other Health Insurance: 74% (10% private, 64% public) Education: 29% <HS, 37% HS/GED, 34% some college Employment: 23% full-time, 25% part-time, 52% not Relationship: 4% married, 55% committed, 41% single Prior pregnancy: 58%

36 Is Same-Day IUD placement Safe? KPNC Data on 57,728 IUD insertions Low risk of PID within 3 months of IUD placement 0.54% (95% CI %) overall 47% were unscreened within 1 year of insertion 19% were screened on the same day Nonscreening equivalent to any screening in risk of PID (risk difference , 95% CI to ), Same-day screening was equivalent to prescreening (risk difference , 95% CI to ). Equivalence persisted when adjusted for age and race Sufrin CB et al Obstet Gynecol. 2012