Long‐acting reversible contraception: conflicting perspectives of advocates and potential users

Rowlands, Sam; Ingham, Roger

doi:10.1111/1471-0528.14699

Cited by 6 publications

(9 citation statements)

References 23 publications

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“…It has been estimated that more unintended pregnancies would be prevented by increasing the number of contraceptive users overall, rather than encouraging use of a specific methods [ 36 , 37 ]. Financial incentives, target-driven programmes, and strategies that focus on certain demographic subgroups might be effective but may be seen as coercive, particularly if LARC is promoted over other methods [ 38 ]. While we need to carefully consider women’s reproductive autonomy over promotion of LARC methods, these discussions do not diminish the importance of reducing barriers to LARC use for deprived populations [ 39 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

Cecil

Bottle

et al. 2020

PLoS Med

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Background Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions. Methods and findings We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26–5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34–8.47, p < 0.001) and sustained trend increase (3.14, 3.08–3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of −22.8 (−24.5 to −21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; −15.0, −15.5 to −14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of −2.28 (−2.98 to −1.57, p = 0.002) and sustained decrease in trend of −0.88 (−1.12 to −0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change −5.04, −7.56 to −2.51, p = 0.011), women aged 20 to 24 years (step change −4.52, −7.48 to −1.57, p = 0.030), and women from the most deprived group (step change −4.40, −6.89 to −1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of −5.31 abortions per 1,000 women, or −38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings. ...

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Section: Discussionmentioning

confidence: 99%

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

Cecil

Bottle

et al. 2020

PLoS Med

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“…15 There have been examples of promotion being directed at specific demographic groups including young people 16 , those at risk of child removal 17 and those undergoing induced abortion. 18 The concern is that some promoters are mixing up what is good for the public health with what is good for an individual patient. 19 There is some evidence that HCPs have started to 'pull back' from a potentially coercive position to an individual rights-based approach.…”

Section: Contemporary Practicesmentioning

confidence: 99%

“…The potential for conflict between HCPs and potential LARC users has been highlighted. 18 Underlying every contraceptive consultation is a power imbalance, although perhaps not as great as in consultations focusing primarily on illness. 34 Conscious separation of the public health element of HCPs' 'dual agent' role from their professional obligation to an individual service user is needed, giving the latter duty a higher priority.…”

Section: Conflict Bias and Personal Valuesmentioning

confidence: 99%

The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

Wale

Rowlands

2020

BMJ Sex Reprod Health

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ObjectivesTo review ethical aspects of the promotion and provision of long-acting reversible contraception (LARC). Specifically, to examine (1) the tension between informational exchange and the active promotion of LARC methods to new and existing contraceptive users by healthcare professionals; and (2) the distinct ethical issues arising from the promotion of LARC methods by state-sponsored actors and healthcare professionals.MethodsNarrative review and ethical analysis.FindingsThere is an ethical difference between raising awareness/informational provision and actively promoting or prioritising specific contraceptive methods. It matters whether the policy choice is made, or the promotional activity about contraception is undertaken, by individual healthcare professionals at a local level or by more remote state-sponsored actors, because the relationship between the promoter and the (potential) contraceptive user is of a different kind. Imposing a dual responsibility upon healthcare professionals for raising awareness/informational exchange and the active promotion of LARC creates an unnecessary tension and barrier for the delivery of patient-centred care.ConclusionsThis review highlights the need for ethical reflection on the central role of the promoting agent and the distinction between facilitating informational awareness and active promotion of LARC. LARC methods should not be prioritised in isolation and without regard to the wider implications of public promotion. A balanced narrative and information-sharing programme that respects the individual interests of each contraceptive user is called for, especially in direct professional/service user relationships. No assumption should be made that user decision-making will necessarily be determined and influenced solely by the relative effectiveness of the contraceptive method.

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“…A growing body of literature spanning the medical and sexual health fields purports that long‐acting reversible contraception (LARC) is the most effective and efficient methods of preventing unwanted pregnancy without the permanency of sterilisation; thus, LARC is increasingly being put forward as a useful public health strategy (Rowlands & Ingham, ; Secura et al, ). LARC methods provide effective contraception for long periods of time and do not rely on women monitoring their contraceptive method in the prescribed way.…”

Section: Introductionmentioning

confidence: 99%

“…It has been considered that a number of access barriers may be contributing to the reduced uptake of LARC by women, including knowledge gaps, limited access and limited sexual and reproductive health education (Mazza et al, ). A narrative review of literature in the USA published since 2000 suggested that attitudes and perceptions of HCPs towards LARC may be guided by their personal beliefs, preferences and the level of training reached in the provision of LARC methods, which, in turn, may impact on their willingness to suggest or prescribe these methods to women (Kumar & Brown, ), for example, beliefs around side effects such as inconsistent bleeding and menstrual pattern changes, as well as common misconceptions such as interference with future fertility (Rowlands & Ingham, ). Importantly, receiving counselling from HCPs on all contraception is crucial in providing equal reproductive health care to all women, regardless of circumstance, and is central to overcoming some of the barriers restricting women from access to the contraception that is right for them (Higgins, ).…”

Section: Introductionmentioning

confidence: 99%

A systematic review of the views of healthcare professionals on the provision of long‐acting reversible contraception

Welsby

Shipman

Roe

2020

Journal of Clinical Nursing

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Research question: What are the views of healthcare professionals outside of the general practice setting on long-acting reversible contraception? Background: Despite global sexual health organisations advocating for widespread prescription of long-acting reversible contraception, uptake in developed countries remains relatively low. The role of healthcare professionals outside of the general practice setting in long-acting reversible contraception provision requires further attention. Design: Systematic review. Methods: Five electronic databases were searched for existing qualitative findings using terms related to long-acting reversible contraception and healthcare professional views for the period 2013-2018. A rigorous protocol was applied following the Preferred Reporting Items for Systematic Meta-Analyses checklist and flow diagram.The Critical Appraisal Skills Programme tool was used to assess the quality of studies.A total of six studies were included for thematic analysis. Results: Three key themes emerged through analysis that had significant impact on healthcare professional views of long-acting reversible contraception: (a) contraceptive counselling practices and constraints; (b) knowledge and training about long-acting reversible contraception; and (c) concerns and personal beliefs about long-acting reversible contraception. Conclusions: Healthcare professional views on long-acting reversible contraception are shaped by practical time constraints, levels of knowledge and training, and personal beliefs and concerns. Further research is required to address these issues in order to improve clinical training and guidelines for all settings, not just general practice. Relevance to Clinical Practice: Settings outside of general practice need to be included within the scope of initiatives that aim to improve clinical practice around access to new and emerging contraceptive methods. Further research could inform models of clinical practice that enable healthcare professionals to take enough time to talk through all contraceptive options with patients in a way that both focuses on their individual needs and is fully informed by up-to-date evidence and training. K E Y W O R D S contraception, family planning services, long-acting reversible contraception, sexual health, systematic review, women

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Long‐acting reversible contraception: conflicting perspectives of advocates and potential users

Cited by 6 publications

References 23 publications

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

A systematic review of the views of healthcare professionals on the provision of long‐acting reversible contraception

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