Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial

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. Findings 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). Interpretation The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits.