Britt Lunde, MD MPH The Mount Sinai School of Medicine

Goal: increase proportion of intended pregnancies by 10% (from 51% to 56%)

Finer, 2011

For Women Adequate Prenatal care Smoking Domestic violence Depression And babies Birth defects Birth weight Childhood health Educational attainment CDC MMWR 2007 Cheng, Contracept 2009 Logan, Child Trends 2007

Pregnancy rate in first 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 18 th Report, Sept 2007 Cope, J Gen Inter Med 2006 Rosenblatt, 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, 2001 Millar M, Public Opinion Quarterly, 2011 Mode1 st response2 nd responseFinal response Web42.3%7.8%50.2% Mail Choice

Web (n = 538) Paper (n = 324) Total (n = 862) Response rate, % Age, years ±SD*46.8 ± ± ±11.0 Insert IUDs, %* Insert Implant, %* Interview, %* Gender, specialty no significant difference * p<0.05

All respondentsPlace IUDsAdjusted OR Total sample n= Female (%) Male (1.3 – 3.7) ref Age, mean ±SD48.3 ± ± 10.6ns Family Medicine (%) Internal Medicine (0.8 – 20.2) ref Practice Ob (%) (4.3 – 12.7) Training post residency (%) in residency (1.0 – 4.5) ref

All respondentsPlace ImplantAdjusted OR Total sample n= Female (%) Male (0.5 – 5.4) ref Age (mean ± SD) 48.3 ± ± (1.3 – 4.3) /10 years ↓ Family Medicine (%) Internal Medicine (0.2 – 34.4) ref Practice Ob (%) (2.8 – 34.3) Training post residency (%) in residency (2.0 – 42.7) ref

WI (n = 1359) IL (n = 1078) p value Eligible Response, n (%)401 (29.5)198 (18.4)<0.001 Insert IUDs, n (%)164 (40.9)43 (21.7)<0.001 Insert Implant, n (%)29 (7.2)23 (11.6)0.10

Family Medicine (n=483) Internal Medicine (101) Eligible Response rate, %* % female physicians* Prescribe OCPs in practice, %* Referral for IUD, %* Primary care MD Gynecologist Distance to referral, % in same office <25 miles * 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, MMWR Weekly 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): 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 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 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): 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): Rosenblatt R, Mattis R, and Hart LG. Abortions in rural Idaho: physicians’ attitudes and practices. Am J Public Health 1995;85:

MethodRural (%)Urban (%) Sterilization Female Male IUD Implant Oral contraceptives Injectable Condoms Withdrawal None

Adjusted OR Rural no hs degree Rural hs degree Urban no hs degree Urban hs degree Rural 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 % ≥200% 1.8 (1.0 – 3.0) 1.5 (1.0 – 2.3) ref Insurance Public None Private 0.8 (0.5 – 1.2) ref Adjusted for age, parity, relationship status