Long-acting reversible contraception (LARC) — the copper T and levonorgestrel intrauterine devices (IUDs) and the birth control implant — are highly effective in preventing pregnancy, last for several years, and are easy to use. Such methods are reversible, which allows women to remove them at any time when they want to become pregnant or stop using them.
Executive Summary
Long-acting reversible contraception (LARC) — the copper T and levonorgestrel intrauterine devices (IUDs) and the birth control implant — are the most effective reversible methods available to prevent unintended pregnancy. They last for several years and are easy to use. Clinicians can draw lessons from the Contraceptive CHOICE project in St. Louis on how to make their clinics "LARC First."
- In the CHOICE Project, non-clinicians were trained to serve as contraceptive counselors.
- Counselors employ a standardized script, which is used with all participants, covering commonly used reversible methods. The most effective methods are presented first.
Research from the Contraceptive CHOICE project in St. Louis, which was designed to evaluate reversible birth control methods, indicates dramatic differences in method effectiveness. Women who used birth control pills, the patch, or vaginal ring were 20 times more likely to have an unintended pregnancy than those who used longer-acting forms such as an IUD or implant.1
Ready to implement the "LARC First" principles of the Contraceptive CHOICE Project at your clinic? Colleen McNicholas, DO assistant professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis and clinical researcher with the Contraceptive CHOICE Project, offered tips during a recent webinar sponsored by the American College of Obstetricians and Gynecologists.2 (To view the webinar, go to http://bit.ly/1pzwZZh. Select "View Presentation.")
In the CHOICE Project, non-clinicians were trained to serve as contraceptive counselors. The process used by the contraceptive counselor and the clinician worked to help each woman receive her desired method, as well as ensure that method was appropriate for her, given her medical history, says McNicholas.
Counselors employ a standardized script, which is used with all participants, regardless of age. The script includes commonly used reversible methods so that all the women hear about the full range of methods, said McNicholas.
Counselors lead off the session by presenting the most effective methods first, using evidence-based data from the Centers for Disease Control and Prevention’s U.S. Medical Eligibility Criteria for Contraceptive Use. Additional teaching aids also are used to help women understand contraceptive effectiveness.3 (Check the "LARC First" web site, www.larcfirst.com, developed by the Contraceptive CHOICE Project, for complete clinic and patient resources.)
To prepare nonclinicians for the counseling role, contraceptive knowledge training and evaluation of competency can be delivered via formal training, mostly through direct lectures, says McNicholas. Prospective counselors then undergo practice contraceptive counseling sessions with physicians for observation.
Once counselors are observed and deemed competent, both through evaluation of observed counseling sessions as well as knowledge based testing, they participate in direct-observation patient counseling. Once counselor trainees have undergone a certain number of directly observed patient counseling sessions, they are allowed to counsel alone, says McNicholas. (Go to the "Counseling" section of the LARC First site, http://bit.ly/1o5VbxA, for complete training resources.)
Counselors also are trained in collecting a medical history, with emphasis on the major medical co-morbidities associated with contraceptive use, McNicholas points out. At the end of each counseling session, every participant’s history and method choice are presented to the clinician for approval. This process is very much in the format of patient presentation taught in the residency training format, observes McNicholas.
Clinician makes call
The CHOICE Project trained 54 contraceptive counselors: 38 CHOICE staff and 16 volunteers. Almost all (96%) of the trained contraceptive counselors had at least an undergraduate degree, and two had professional healthcare degrees (RN and NP). Among the 38 CHOICE staff members, 15 had no prior healthcare experience before joining the pro
ject.
Following the counseling session, the counselor presents a completed baseline clinical form to the clinician. It includes patient information, general health information, and histories of contraception, menstrual cycle, obstetrics, infection, and surgeries, as well as information on allergies, current medications, and general medical information.
The contraceptive method ultimately is dispensed by the clinician, regardless of whether it is a prescription for pills or placement of a device, says McNicholas. This step provides the clinician the opportunity to assess the patient’s comfort with the method choice, as well as check whether she has additional questions about the chosen or any other method.
"There really was a collaborative and non-punitive environment that facilitated a sense of comfort among the counselors, allowing them to ask clinicians questions when issues arose they were not comfortable with," McNicholas observes. "I think this is one strategy that can really help facilitate better and more complete contraceptive counseling in busy clinical practices."
- Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med 2012; 366(21):1998-2007.
- McNicholas C. Lessons from the Contraceptive CHOICE Project: research findings to real-world change. Available at http://bit.ly/1pzwZZh. Select "View Presentation."
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
