Pathways to IUD and implant insertion in general practice: a secondary analysis of the ACCORd study
Danielle Mazza A * , Cathy J. Watson A B , Angela Taft C , Jayne Lucke D , Kevin McGeechan E F , Marion Haas E F , Kathleen McNamee G , Jeffrey F. Peipert H and Kirsten I. Black I JA Department of General Practice, School of Public Health, Monash University, Melbourne, Vic. 3004, Australia.
B Department of Population and Global Health, University of Melbourne, Carlton, Vic. 3052, Australia.
C Judith Lumley Centre, La Trobe University, Melbourne, Vic. 3086, Australia.
D Australian Research Centre in Sex, Health and Society in the School of Psychology and Public Health at La Trobe University, Melbourne, Vic., Australia.
E School of Public Health, University of Sydney, Camperdown, NSW 2006, Australia.
F The University of Technology, Centre for Health Economics Research and Evaluation, Ultimo, NSW 2007, Australia.
G Sexual Health Victoria, Box Hill, Vic. 3128, Australia.
H Department of Obstetrics & Gynecology, Indiana University, School of Medicine, Indianapolis, IN 47906, USA.
I Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
J The University of Sydney, Sydney, NSW 2006, Australia.
Australian Journal of Primary Health - https://doi.org/10.1071/PY22265
Submitted: 4 December 2022 Accepted: 4 April 2023 Published online: 1 May 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of La Trobe University. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: Despite recommendations, long-acting reversible contraceptives (LARC) are not always offered as first-line contraceptives in general practice. This study aimed to describe pathways used by women for insertion of LARC.
Methods: This is a secondary analysis of data from the Australian Contraceptives ChOice pRoject (ACCORd), a cluster randomised controlled trial set in 57 general practices in Melbourne, Australia. We investigated whether an educational intervention for general practitioners (GPs) and a rapid LARC insertion clinic increased LARC uptake. The main outcome measures were the type of health service, location/provider of intrauterine device (IUD) insertion; time to insertion; and distance travelled for IUD insertion.
Results: During ACCORd, 149 women had LARC insertion. IUD training was reported by 37% of GPs, but only 12% inserted them. In contrast, 70% of GPs inserted implants and 95% of women accessed implant insertion through their own general practice. LARC rapid referral clinics were used by 52% (13/25) of intervention GPs, where 71% (41/56) of IUD insertions occurred in these clinics (but no implants). There was no difference in the mean time from referral to IUD insertion between women attending intervention and control GPs (mean days 37.6 vs 32.7; P = 0.61). GPs (including IUD inserters) used a variety of referral pathways for IUD insertion, including public and private clinics, and other GPs. Women travelled up to 90 km for IUD insertion.
Conclusions: Although implant insertion has been integrated into general practice, few GPs insert IUDs. Where the option exists for GPs to refer to a LARC rapid referral clinic, the majority of IUD insertions will take place there. Establishing a network of such clinics Australia wide may both increase IUD uptake and address the extensive need for GP training in IUD insertion.
Keywords: contraceptive implants, general practice, GPs, intrauterine device, IUD, LARC, pathways.
References
American College of Obstetricians and Gynecologists (ACOG) (2009) ACOG Committee Opinion No. 450: increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstetrics & Gynecology 114, 1434–1438.| ACOG Committee Opinion No. 450: increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy.Crossref | GoogleScholarGoogle Scholar |
American College of Obstetricians and Gynecologists (ACOG) (2011) Practice Bulletin No. 121: long-acting reversible contraception: implants and intrauterine devices. Obstetrics & Gynecology 118, 184–196.
| Practice Bulletin No. 121: long-acting reversible contraception: implants and intrauterine devices.Crossref | GoogleScholarGoogle Scholar |
American College of Obstetricians and Gynecologists (ACOG) (2018) ACOG Committee Opinion No. 735: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstetrics & Gynecology 131, e130–e139.
| ACOG Committee Opinion No. 735: adolescents and long-acting reversible contraception: implants and intrauterine devices.Crossref | GoogleScholarGoogle Scholar |
Bergin A, Tristan S, Terplan M, et al. (2012) A missed opportunity for care: two-visit IUD insertion protocols inhibit placement. Contraception 86, 694–697.
| A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.Crossref | GoogleScholarGoogle Scholar |
Bingham AL, Garrett CC, Bayly C, et al. (2018) The levonorgestrel intrauterine device in Australia: analysis of prescribing data 2008–2012. BMC Women’s Health 18, 194
| The levonorgestrel intrauterine device in Australia: analysis of prescribing data 2008–2012.Crossref | GoogleScholarGoogle Scholar |
Campbell MK, Piaggio G, Elbourne DR (2012) Consort 2010 statement: extension to cluster randomised trials. BMJ 345, e5661
| Consort 2010 statement: extension to cluster randomised trials.Crossref | GoogleScholarGoogle Scholar |
Chelvakumar M, Jabbarpour Y, Coffman M, et al. (2019) Long-acting reversible contraception (LARC) provision by family physicians: low but on the rise. The Journal of the American Board of Family Medicine 32, 10–12.
| Long-acting reversible contraception (LARC) provision by family physicians: low but on the rise.Crossref | GoogleScholarGoogle Scholar |
Family Planning Alliance Australia (2014) Long acting reversible contraception (LARC) Position statement. Available at http://familyplanningallianceaustralia.org.au/wp-content/uploads/2014/11/24448-Family-Planning-A4-Flyer_Proof3.pdf [Accessed November 2022]
Fleming K, Cheng Y, Botfield J, et al. (2019) Inclusion of intrauterine device insertion to registered nurses’ scope of clinical practice. Collegian 26, 28–32.
| Inclusion of intrauterine device insertion to registered nurses’ scope of clinical practice.Crossref | GoogleScholarGoogle Scholar |
Garrett CC, Williams H, Keogh L, et al. (2016) Is there a role for practice nurses in increasing the uptake of the contraceptive implant in primary care?: survey of general practitioners and practice nurses. Sexual Health 13, 241–247.
| Is there a role for practice nurses in increasing the uptake of the contraceptive implant in primary care?: survey of general practitioners and practice nurses.Crossref | GoogleScholarGoogle Scholar |
Gyllenberg FK, Saloranta TH, But A, et al. (2018) Induced abortion in a population entitled to free-of-charge long-acting reversible contraception. Obstetrics & Gynecology 132, 1453–1460.
| Induced abortion in a population entitled to free-of-charge long-acting reversible contraception.Crossref | GoogleScholarGoogle Scholar |
Harper CC, Speidel JJ, Drey EA, et al. (2012) Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers. Obstetrics & Gynecology 119, 220–226.
| Copper intrauterine device for emergency contraception: clinical practice among contraceptive providers.Crossref | GoogleScholarGoogle Scholar |
Kavanaugh ML, Jerman J (2018) Original research article: Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. Contraception 97, 14–21.
| Original research article: Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014.Crossref | GoogleScholarGoogle Scholar |
Kemeny F, Digiusto E, Bateson D (2016) Insertion of intrauterine contraceptive devices by registered nurses in Australia. Australian and New Zealand Journal of Obstetrics and Gynaecology 56, 92–96.
| Insertion of intrauterine contraceptive devices by registered nurses in Australia.Crossref | GoogleScholarGoogle Scholar |
Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF (2013) Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 88, 243–249.
| Structured contraceptive counseling provided by the Contraceptive CHOICE Project.Crossref | GoogleScholarGoogle Scholar |
Mavranezouli I, on behalf of the LARC Guideline Development Group (2008) The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline. Human Reproduction 23, 1338–1345.
| The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline.Crossref | GoogleScholarGoogle Scholar |
Mazza D, Harrison C, Taft A, et al. (2012) Current contraceptive management in Australian general practice: an analysis of BEACH data. The Medical Journal of Australia 197, 110–114.
| Current contraceptive management in Australian general practice: an analysis of BEACH data.Crossref | GoogleScholarGoogle Scholar |
Mazza D, Black K, Taft A, et al. (2016) Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial protocol (2016). BMJ Open 6, e012491
| Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial protocol (2016).Crossref | GoogleScholarGoogle Scholar |
Mazza D, Bateson D, Frearson M, et al. (2017) Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: an expert roundtable discussion. Australian and New Zealand Journal of Obstetrics and Gynaecology 57, 206–212.
| Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: an expert roundtable discussion.Crossref | GoogleScholarGoogle Scholar |
Mazza D, Watson CJ, Taft A, et al. (2020) Increasing long-acting reversible contraceptives: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomized trial. American Journal of Obstetrics & Gynecology 222, S921.e1–S921.e13.
| Increasing long-acting reversible contraceptives: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomized trial.Crossref | GoogleScholarGoogle Scholar |
Piantadosi S (2005) ‘Clinical trials: a methodologic perspective.’ 2nd edn. (John Wiley & Sons: Hoboken, NJ, USA)
Richters J, Fitzadam S, Yeung A, et al. (2016) Contraceptive practices among women: the second Australian study of health and relationships. Contraception 94, 548–555.
| Contraceptive practices among women: the second Australian study of health and relationships.Crossref | GoogleScholarGoogle Scholar |
Stewart M, Digiusto E, Bateson D, et al. (2016) Outcomes of intrauterine device insertion training for doctors working in primary care. Australian Family Physician 45, 837–841.
Winner B, Peipert JF, Zhao Q, et al. (2012) Effectiveness of long-acting reversible contraception. New England Journal of Medicine 366, 1998–2007.
| Effectiveness of long-acting reversible contraception.Crossref | GoogleScholarGoogle Scholar |
World Health Organization (2017) Summary brief: task sharing to improve access to Family Planning/Contraception WHO/RHR/17.20. Available at https://apps.who.int/iris/bitstream/handle/10665/259633/WHO-RHR-17.20-eng.pdf?sequence=1 [Accessed November 2022]
