Effect of staff training and cost support on provision of long-acting reversible contraception in community health centers

Abstract

Objective: To compare the proportion of women receiving same-day long-acting reversible contraception (LARC) between two different models of contraceptive provision adapted from the Contraceptive CHOICE Project.

Study design: We used a controlled time-trend study design to compare 502 women receiving structured contraceptive counseling in addition to usual care ("Enhanced Care") to 506 women receiving counseling plus healthcare provider education and cost support for LARC ("Complete CHOICE") at three federally qualified health centers. We provided funds to health centers to ensure an "on-the-shelf" supply and no-cost LARC for uninsured women. We recorded the contraceptive method chosen after contraceptive counseling and the healthcare provider appointment as well as the contraceptive method received that day. Among women choosing LARC, we calculated proportions and performed Poisson regression with robust error variance to estimate relative risks for same-day insertion.

Results: Participant demographics reflected the health center populations; 69% were black, 66% had a high school diploma or less, 57% were publicly insured, and 75% reported household income less than 101% federal poverty line. There were 153 (30.5%) women in "Enhanced Care" and 273 (54.0%) in "Complete CHOICE" who chose LARC (p<0.01). Among women who chose LARC (n=426), those in "Complete CHOICE" were more likely to receive a same-day insertion, 53.8% vs. 13.7% (RR_adj 4.73; 95%CI 3.20-6.98) compared to "Enhanced Care."

Conclusions: A contraceptive care model that included healthcare provider education and cost support for LARC in addition to structured contraceptive counseling resulted in higher rates of same-day LARC insertion compared to contraceptive counseling and usual care alone.

Implications: Contraceptive care provision which includes contraceptive counseling, healthcare provider education, and "on-the-shelf", long-acting reversible contraception facilitate same-day initiation of these methods. Interventions that focus solely on contraceptive counseling do not address other structural barriers to same-day contraceptive provision of all methods including cost and provider practice.

Trial registration: ClinicalTrials.gov NCT02364037.

Keywords: Contraceptive counseling; Contraceptive implant; Intrauterine device; Long-acting reversible contraception; Same-day insertion.