Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners☆,☆☆
Introduction
Nurse practitioners (NP) are important providers of women's preventive care, especially in publicly-funded clinics serving populations at highest risk of unintended pregnancy (Landry et al., 2008). Unintended pregnancy has persisted as a public health challenge in the United States, with significant economic and health-related costs (Finer and Zolna, 2011, Sonfield et al., 2011). The role of nurse practitioners in contraceptive care stands to expand, with the inclusion of contraceptives and counseling as essential preventive care to be covered by insurance plans under the Affordable Care Act (Institute of Medicine, 2011). Up-front costs have been a barrier for women to access contraceptives with the highest efficacy, the IUD and contraceptive implant, or long-acting reversible contraceptives (LARC) (Harper et al., 2012). Use of these methods has been greater in states where women have coverage for contraceptives, such as insurance mandates and Medicaid family planning expansion programs (Thompson et al., 2011). Now that contraceptive coverage is expanding across the country, more women will be able to access these methods. The Centers for Disease Control and Prevention (CDC) points to the importance of increasing access to LARC methods to reach the Healthy People 2020 objective of reduced unintended pregnancy (Centers for Disease Control and Prevention, 2013b, Us Department of Health and Human Services, 2012).
While almost all contraceptive providers currently offer women oral contraceptives and condoms (Landry et al., 2008), these methods have high discontinuation and typical-use failure rates, especially among underserved populations, where failure of oral contraceptives can be as high as 16 pregnancies per 100 person-years (Kost et al., 2008, Raine et al., 2011, Vaughan et al., 2008). LARC methods have extremely low typical use failure rates (< 1%), similar to perfect use failure rates from clinical trials, because the methods require no user action for effectiveness (Trussell, 2011). Many contraceptive providers have inadequate education on LARC methods (Dehlendorf et al., 2010, Harper et al., 2008, Harper et al., 2012). LARC method use is low in the US, compared to some European countries, (US 5%, France 23%, Finland 26%, Norway 27%) where health systems are focused on preventive and primary care (Mosher and Jones, 2010, United Nations Department of Economic and Social Affairs Population Division, 2011). We are not aware of prior research that has examined the nursing profession to assess contraceptive care practices of NPs trained in women's health and in primary care, particularly for the high-efficacy methods. In primary care, patients are seen for a wide range of medical issues, and there are competing demands on provider time. However, primary care NPs, as well as specialists in women's health, will be called upon for women's preventive health needs in our national context of improved contraceptive coverage and access (Cleland et al., 2011, Pace and Cohen, 2011).
This study uses nationally representative survey data to identify counseling and provision practices for LARC methods among nurse practitioners serving women of reproductive age. Nationally representative data can help to reveal the prevalence of evidence-based contraceptive care among nurse practitioners and whether LARC is routinely provided in clinical practice. Study results can be used to help inform training and programmatic efforts to prepare our primary healthcare workforce to address the epidemic of unintended pregnancy. Our hypothesis is that LARC-specific, evidence-based education is required for nurse practitioners to integrate these high-efficacy methods into standard contraceptive care in the US.
Section snippets
Methods
We conducted a national probability survey of nurse practitioners (NPs) specializing in women's health and primary care in 2009. The study was approved by the University of California, San Francisco Committee on Human Research. Our aim was for a sample size of at least 500 eligible respondents to achieve population estimates with ± 5% precision. For a detailed description of methodology, see Henderson et al. (2010). We used the Verispan national database of nurse practitioners, a comprehensive
Results
A total of 586 eligible nurse practitioners responded, including 224 in primary care and 360 in women's health (Table 1). Most of the NPs (86%) were trained in family planning, including almost all working in women's health (97%). All of the NPs surveyed saw female patients in need of contraception, but women's health NPs saw on average more than three times as many contraceptive patients per week as primary care NPs (p ≤ 0.001).
IUD insertion skills were limited among primary care NPs; only 12%
Discussion
Nurse practitioners serve millions of contraceptive patients, and are trained to have skills in counseling and clinical care. The clinic visit is especially important for patient education and counseling on LARC methods. Few U.S. women are familiar with LARC methods, especially younger women at high risk of unintended pregnancy (Kaye et al., 2009, Whitaker et al., 2008). National survey data have shown that young women consider their healthcare providers their most trusted source of
Conclusions
A shift in the current paradigm towards a greater emphasis on prevention and evidence-based care may hold promise to achieve Healthy People 2020 goals (Levi and Dau, 2011, Taylor and James, 2011). NPs provide important care to underserved patient populations, and can make a difference in our nation's health (Grumbach et al., 2003, Kuehn, 2010). NPs offer care to vulnerable women of reproductive age in primary care settings, such as Federally Qualified Health Centers, as well as in community
Conflict of interest statement
Dr. Raine-Bennett and Dr. Cynthia Harper have received grant support for research on emergency contraception from Teva Pharmaceuticals Inc., administered through the University of California, San Francisco. Ms. Debbie Postlethwaite is using research funds provided by Bayer HealthCare Pharmaceutical Inc. for a study, administered through the Kaiser Foundation Research Institute. Dr. J. Joseph Speidel serves as a consultant to Medicines360, WomanCare Global and Bayer Healthcare Pharmaceutical Inc.
Acknowledgments
We would like to acknowledge Ms. Lily Loew and Ms. Cait Quinlivan for their adept research assistance.
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This project was funded by NIH/NICHD R01 HD046027 and the William and Flora Hewlett Foundation. Its contents are solely the responsibility of the authors.
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Data were presented at the North American Forum on Family Planning, Washington, DC, October 2011.