1. Britt Lunde, MD MPH The Mount Sinai School of Medicine

2. Goal: increase proportion of intended pregnancies by 10% (from 51% to 56%) www.healthypeople.gov/2020

3. Finer, 2011

4. For Women Adequate Prenatal care Smoking Domestic violence Depression And babies Birth defects Birth weight Childhood health Educational attainment CDC MMWR 2007 Cheng, Contracept 2009 Logan, Child Trends 2007

5. Pregnancy rate in first year of use

6. Majority of rural physicians practice primary care IUD provision associated with gynecologist on site Patient recommendations vary by specialty 1995 rural Idaho majority providing LARC COGME 18 th Report, Sept 2007 Cope, J Gen Inter Med 2006 Rosenblatt, Am J Public Health 1995

8. Rural Primary Care Physicians Current provision of LARC Perceived barriers to provision Opportunities for further support and education

9. Cross sectional survey of physicians Family Medicine and Internal Medicine RUCA code ≥4 for practice zip code in IL and WI Development of survey WI Research and Education Network UIC Survey Research Lab Pilot interviews with rural physicians

10. Physicians have low response rates Web surveys have low response rates Survey literature on mixed-mode: Kellerman, Am J Prev Med, 2001 Millar M, Public Opinion Quarterly, 2011 Mode1 st response2 nd responseFinal response Web42.3%7.8%50.2% Mail51.31.953.2 Choice47.74.652.3

11. Web (n = 538) Paper (n = 324) Total (n = 862) Response rate, %23.314.037.3 Age, years ±SD*46.8 ±10.550.9 ±11.248.3 ±11.0 Insert IUDs, %*38.727.934.6 Insert Implant, %*10.85.48.7 Interview, %*22.72.215.1 Gender, specialty no significant difference * p<0.05

12. All respondentsPlace IUDsAdjusted OR Total sample n=59934.6 Female (%) Male 34.2 64.8 50.7 26.1 2.2 (1.3 – 3.7) ref Age, mean ±SD48.3 ±11.045.8 ± 10.6ns Family Medicine (%) Internal Medicine 80.6 16.9 42.2 1.8 4.0 (0.8 – 20.2) ref Practice Ob (%)28.372.57.4 (4.3 – 12.7) Training post residency (%) in residency 8.2 50.9 69.4 55.7 2.1 (1.0 – 4.5) ref

13. All respondentsPlace ImplantAdjusted OR Total sample n=5998.7 Female (%) Male 34.2 64.8 14.1 5.8 1.7 (0.5 – 5.4) ref Age (mean ± SD) 48.3 ±10.943.8 ±10.22.3 (1.3 – 4.3) /10 years ↓ Family Medicine (%) Internal Medicine 80.6 16.9 10.3 0.9 2.6 (0.2 – 34.4) ref Practice Ob (%)28.519.99.8 (2.8 – 34.3) Training post residency (%) in residency 9.4 3.7 71.4 39.1 9.2 (2.0 – 42.7) ref

14. WI (n = 1359) IL (n = 1078) p value Eligible Response, n (%)401 (29.5)198 (18.4)<0.001 Insert IUDs, n (%)164 (40.9)43 (21.7)<0.001 Insert Implant, n (%)29 (7.2)23 (11.6)0.10

15. Family Medicine (n=483) Internal Medicine (101) Eligible Response rate, %*29.720.9 % female physicians*36.423.8 Prescribe OCPs in practice, %*93.459.4 Referral for IUD, %* Primary care MD Gynecologist 25.5 57.9 6.1 77.8 Distance to referral, % in same office <25 miles 49.8 38.6 57.3 36.7 * p<0.05

16. % of Physicians *=p <0.05

17. Distance, miles *=p<0.05

18. More likely to provide LARC Female Practice OB Training post-residency Providers’ perceived barriers Patient interest and knowledge Not physician’s practice pattern

19. Thank you!

20. Centers for Disease Control and Prevention. Preconception and interconception health status of women who recently gave birth to a live-born infant—pregnancy risk assessment monitoring system (PRAMS), United States, 26 Reporting Areas, 2004. MMWR Weekly. 2007 Dec 14;56(SS-10):1-40. Cheng D, Schwarz E, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contracept 2009;79(3):194-8. Cope JR, Yano EM, Lee ML, Washington Dl. Determinants of contraceptive availability at medical facilities in the Department of Veterans Affairs. J Gen Intern Med. 2006 Mar;21 Suppl 3:S33-9. Council on Graduate Medical Education (COGME). Eighteenth report: new paradigms for physician training and improving access to health care. September 2007. Finer LB and Zolna MR. Unintended pregnancy in the United States: incidence and disparities. Contracept 2011; 84(5):478–85. Kellerman SE, Herold J. Physician response to surveys; a review of the literature. Am J Prev Med 2001;20(1):61-67. Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: A white paper [Internet]. Washington: Child Trends, Inc.; 2007 May. Millar M and Dillman D. Improving response to web and mixed-mode surveys. Public Opinion Quarterly 2011;75(2):249-269. Rosenblatt R, Mattis R, and Hart LG. Abortions in rural Idaho: physicians’ attitudes and practices. Am J Public Health 1995;85:1423-5.

21. MethodRural (%)Urban (%) Sterilization Female Male 47.2 9.6 35.6 8.8 IUD Implant 5.0 0.3 4.9 0.3 Oral contraceptives Injectable 24.3 4.0 24.5 3.0 Condoms9.315.9 Withdrawal3.84.8 None8.211.8

22. Adjusted OR Rural no hs degree Rural hs degree Urban no hs degree Urban hs degree Rural and urban, >hs degree 7.9 (4.3 – 14.5) 3.4 (2.0 – 5.8) 2.0 (1.3 – 3.0) 1.8 (1.2 – 2.8) ref Income <100% of FPL 100-199% ≥200% 1.8 (1.0 – 3.0) 1.5 (1.0 – 2.3) ref Insurance Public None Private 0.8 (0.5 – 1.2) ref Adjusted for age, parity, relationship status