The Contraceptive CHOICE Project Enter Presenter’s Name Enter Presenter’s Organization Enter Presentation Date

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 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 Cohort ELIGIBLE ExposureOutcome 2–3 y LNG-IUS Cu-IUD Implant DMPA Pills Patch Ring Other Unintended pregnancy Teen pregnancy Repeat abortion Abortion Continuation Satisfaction STI

Study Inclusion Criteria 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

Study Timeline

Screening & Enrollment Introduce study Eligibility screen LARC 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 P 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

Contraceptive “Menu of Options”

Study Recruitment Location9,256 2 Abortion clinics17% 8 Community clinics14% University-based research clinic Word-of-mouth Provider referrals 69%

Study Follow-Up Rates %94%87%81% Survey

Pre-CHOICE Survey Results

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 Pain36% – Infertility30% – Cancer14% – STDs 11% 61% underestimate the effectiveness Hladky Obstet Gynecol 2011

Knowledge About IUDs

STL Population Survey Results

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% – 16% after % completed residency at a Catholic institution Contraceptive patients each week – 35%: 0–25 – 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

CHOICE Project Results

CHOICE Study Participants Peipert Obstet Gynecol 2012

Baseline Chosen Method % LNG-IUS46.0 Copper IUD11.9 Implant16.9 DMPA6.9 Pills9.4 Ring7.0 Patch1.8 Other<1.0 75% Peipert Obstet & Gynecol 2012

Choice of LARC Methods among Adolescents Mestad Contraception 2011

12-Month Continuation MethodContinuation Rate (%) LNG-IUS87.5 Copper IUD84.1 Implant83.3 Any LARC86.2 DMPA56.2 OCPs55.0 Ring54.2 Patch49.5 Non-LARC54.7 Peipert Obstet Gynecol 2011

12-month Continuation: Adolescents Compared to Older Women Rosenstock Obstet Gynecol 2012

Unintended Pregnancy by Contraceptive Method HR adj = % CI 14.0, 35.4 Winner NEJM 2012

Method Failure by Age 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 Peipert Obstet Gynecol 2012 Test of Trend : STL, p=.002; KC, p=.003; Non-metro MO, p=.18

CHOICE Compared to U.S. Teen birth rate (age 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

Dissemination & Translating Research into Practice

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 BarrierFacilitator Education Limited 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 FirstLARC 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

Online Resource Center

Examples of Dissemination Courtesy of Mary Alexander, Healthy Start Indianapolis

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

Pathway to Choice Video

What method is right for you?

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