Britt Lunde, MD MPH The Mount Sinai School of Medicine.

Britt Lunde, MD MPHThe Mount Sinai School of Medicine

Goal: increase proportion of intended pregnancies by 10%

(from 51% to 56%)

www.healthypeople.gov/2020

Finer, 2011

• For Women• Adequate Prenatal care• Smoking• Domestic violence• Depression

• And babies • Birth defects• Birth weight• Childhood health• Educational attainment

CDC MMWR 2007Cheng, Contracept 2009Logan, Child Trends 2007

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Pre

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cy r

ate

in f

irst

year

of

use

• Majority of rural physicians practice primary care

• IUD provision associated with gynecologist on site

• Patient recommendations vary by specialty• 1995 rural Idaho majority providing LARC

COGME 18th Report, Sept 2007Cope, J Gen Inter Med 2006Rosenblatt, Am J Public Health 1995

• Rural Primary Care Physicians• Current provision of LARC• Perceived barriers to provision• Opportunities for further support and education

• Cross sectional survey of physicians• Family Medicine and Internal Medicine• RUCA code ≥4 for practice zip code in IL

and WI• Development of survey

• WI Research and Education Network• UIC Survey Research Lab• Pilot interviews with rural physicians

• Physicians have low response rates• Web surveys have low response rates• Survey literature on mixed-mode:

Kellerman, Am J Prev Med, 2001Millar M, Public Opinion Quarterly, 2011

Mode 1st response

2nd response

Final response

Web 42.3% 7.8% 50.2%

Mail 51.3 1.9 53.2

Choice 47.7 4.6 52.3

Web(n = 538)

Paper(n = 324)

Total(n = 862)

Response rate, % 23.3 14.0 37.3

Age, years ±SD* 46.8 ±10.5 50.9 ±11.2 48.3 ±11.0

Insert IUDs, %* 38.7 27.9 34.6

Insert Implant, %*

10.8 5.4 8.7

Interview, %* 22.7 2.2 15.1

Gender, specialty no significant difference

* p<0.05

All respondents

Place IUDs Adjusted OR

Total sample n=599

34.6

Female (%)Male

34.264.8

50.726.1

2.2 (1.3 – 3.7)ref

Age, mean ±SD 48.3 ±11.0 45.8 ± 10.6 ns

Family Medicine (%)Internal Medicine

80.616.9

42.21.8

4.0 (0.8 – 20.2)ref

Practice Ob (%) 28.3 72.5 7.4 (4.3 – 12.7)

Training post residency (%) in residency

8.250.9

69.455.7

2.1 (1.0 – 4.5)ref

All respondents

Place Implant Adjusted OR

Total sample n=599 8.7

Female (%)Male

34.264.8

14.15.8

1.7 (0.5 – 5.4)ref

Age(mean ± SD)

48.3 ±10.9 43.8 ±10.2 2.3 (1.3 – 4.3)/10 years ↓

Family Medicine (%)Internal Medicine

80.616.9

10.30.9

2.6 (0.2 – 34.4)ref

Practice Ob (%) 28.5 19.9 9.8 (2.8 – 34.3)

Training post residency (%) in residency

9.43.7

71.439.1

9.2 (2.0 – 42.7)ref

Family Medicine(n=483)

Internal Medicine

(101)

Eligible Response rate, %*

29.7 20.9

% female physicians* 36.4 23.8

Prescribe OCPs in practice, %*

93.4 59.4

Referral for IUD, %* Primary care MD Gynecologist

25.557.9

6.177.8

Distance to referral, % in same office <25 miles

49.838.6

57.336.7

* p<0.05

% of Physicians

*=p <0.05

Distance, miles*=p<0.05

• More likely to provide LARC• Female• Practice OB• Training post-residency

• Providers’ perceived barriers• Patient interest and knowledge• Not physician’s practice pattern

Thank you!

• Centers for Disease Control and Prevention. Preconception and interconception health status of women who recently gave birth to a live-born infant—pregnancy risk assessment monitoring system (PRAMS), United States, 26 Reporting Areas, 2004. MMWR Weekly. 2007 Dec 14;56(SS-10):1-40.

• Cheng D, Schwarz E, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contracept 2009;79(3):194-8.

• Cope JR, Yano EM, Lee ML, Washington Dl. Determinants of contraceptive availability at medical facilities in the Department of Veterans Affairs. J Gen Intern Med. 2006 Mar;21 Suppl 3:S33-9.

• Council on Graduate Medical Education (COGME). Eighteenth report: new paradigms for physician training and improving access to health care. September 2007.

• Finer LB and Zolna MR. Unintended pregnancy in the United States: incidence and disparities. Contracept 2011; 84(5):478–85.

• Kellerman SE, Herold J. Physician response to surveys; a review of the literature. Am J Prev Med 2001;20(1):61-67.

• Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: A white paper [Internet]. Washington: Child Trends, Inc.; 2007 May.

• Millar M and Dillman D. Improving response to web and mixed-mode surveys. Public Opinion Quarterly 2011;75(2):249-269.

• Rosenblatt R, Mattis R, and Hart LG. Abortions in rural Idaho: physicians’ attitudes and practices. Am J Public Health 1995;85:1423-5.

Method Rural (%) Urban (%)

Sterilization Female Male

47.29.6

35.68.8

IUDImplant

5.00.3

4.90.3

Oral contraceptivesInjectable

24.34.0

24.53.0

Condoms 9.3 15.9

Withdrawal 3.8 4.8

None 8.2 11.8

Adjusted OR

Rural no hs degreeRural hs degreeUrban no hs degreeUrban hs degreeRural and urban, >hs degree

7.9 (4.3 – 14.5)3.4 (2.0 – 5.8)2.0 (1.3 – 3.0)1.8 (1.2 – 2.8)ref

Income <100% of FPL 100-199% ≥200%

1.8 (1.0 – 3.0)1.5 (1.0 – 2.3)ref

Insurance Public None Private

0.8 (0.5 – 1.2)0.8 (0.5 – 1.2)ref

Adjusted for age, parity, relationship status