title: Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial.
abstract: BACKGROUND
  Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates.
  
  
  METHODS
  We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates.
  
  
  RESULTS
  Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85).
  
  
  CONCLUSIONS
  The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits.
  
  
  BACKGROUND
  William and Flora Hewlett Foundation.
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA. Electronic address: cynthia.harper@ucsf.edu.
authors.forename: Cynthia C
authors.initials: CC
authors.lastname: Harper
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Corinne H
authors.initials: CH
authors.lastname: Rocca
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Kirsten M
authors.initials: KM
authors.lastname: Thompson
authors.affiliation: Planned Parenthood Federation of America, New York, NY, USA.
authors.forename: Johanna
authors.initials: J
authors.lastname: Morfesis
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Suzan
authors.initials: S
authors.lastname: Goodman
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Philip D
authors.initials: PD
authors.lastname: Darney
authors.affiliation: Planned Parenthood Federation of America, New York, NY, USA; Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
authors.forename: Carolyn L
authors.initials: CL
authors.lastname: Westhoff
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: J Joseph
authors.initials: JJ
authors.lastname: Speidel
mesh_terms: D000293:Adolescent; D000328:Adult; D016000:Cluster Analysis; D003267:Contraception; D003271:Contraceptive Agents, Female / Q000008:administration & dosage; D037001:Directive Counseling; D004343:Drug Implants; D005193:Family Planning Services / Q000193:education*; D005260:Female; D006801:Humans; D007434:Intrauterine Devices; D016912:Levonorgestrel; D011247:Pregnancy; D018873:Pregnancy Rate; D049168:Pregnancy, Unplanned; D014481:United States; D055815:Young Adult
chemical_list: D003271:Contraceptive Agents, Female; D004343:Drug Implants; D016912:Levonorgestrel