Nearly a decade ago, a philanthropist approached a group of researchers in St. Louis with an unusual proposal: give away free birth control to thousands of women in the city.
That idea became the CHOICE Project. A program headquartered at Washington University in St. Louis' School of Medicine, it gave nearly 10,000 women no-cost birth control between 2007 and 2013. The CHOICE Project encourages women to use the most effective contraceptives. That is often a long-acting reversible contraceptive, or LARC, that a doctor implants. These contraceptives, like intra-uterine devices and implants, work better than birth control pills that have to be taken every day and leave huge space for user error.
CHOICE Project researchers have conducted numerous studies on the women they serve, trying to better understand the barriers to contraceptive use and how to best present women with the information they need to choose the right birth control. The project's most recent results, published last week in the New England Journal of Medicine, found that the CHOICE Project's teenage participants had significantly lower abortion and birth rates than women nationwide. They use better contraceptives, too: three-quarters of CHOICE Project teens chose LARC methods compared to 4.5 percent of the general population.
I spoke with Gina Secura who, until her retirement this summer, was the project director at CHOICE. We discussed how the project started, what she learned, and how her group is now trying to increase birth control access elsewhere in the country.
Sarah Kliff: Tell me a little bit about how the CHOICE Project got started. What's been the goal of your work?
Gina Secura: We were approached with the funding, and we started the project in 2007. At that point, we thought the only barrier to women using contraceptives was cost. So we got the study up and running really quickly. We assumed women would come in knowing what they wanted, we'd give it to them and then follow them during the research portion of the project.
The first person we saw was a 25-year-old educated women with a career, and the person enrolling her asked her what she wanted. She said she didn't know and asked about her options. The person enrolling her ran upstairs and said, "Gina, what do you want me to tell her?" We hadn't even thought about this, as something we'd need to do.
At that point we had one nurse practitioner and there was no way she was going to counsel the 10,000 women we were supposed to see. We did have research assistants running our surveys, so we decided to train them to do it. And we created a script for them to use.
Now it seems so reasonable but seven years ago, it was a novel idea, which is just so crazy. There's no other medical situation where you'd start without a discussion of the best options. But that happens all the time with birth control. So like I said, we made the script, put it through testing, practice, and counseling, and then we rolled it out.
SK: One of the thing that really stands out about the CHOICE Project population is they choose long-acting, reversible contraceptives (LARCs) at a much higher rate than the general population. What's different about the work that you do that might lead to that decision making?
GS: We found that a lot of women might have known about the IUD but there is so much misinformation. We had the opportunity to educate nearly 10,000 women. We were running our own clinic, and all of our practitioners were very comfortable with IUDs and implants. We started then to partner with other clinics. The idea was our research assistants would go out and travel with the different methods, and leave them at the clinics where clinicians would do insertions.
The research assistants would come back and say "Gina, the clinician wouldn't put it in because the woman has an STD." Or, "She's going to make her wait to come back on her period." [There's a misconception that IUDs are easier to insert during menstruation.]
These were Planned Parenthoods, Title X clinics, and federally-qualified health clinics. It was specific to some providers and some of it was protocol-driven. These were providers who had been working for a very long time, and some were just uncomfortable with IUDs. There were these myths, like the period makes the insertion easier. It was that kind of stuff we stated working on, and removing those barriers.
SK: I'm curious how the CHOICE Project affects your view on how Obamacare's end of cost-sharing for contraceptives will increase access. As you describe it now, it sounds like cost is one barrier but not the only one, that there are all these logistical obstacles that Obamacare doesn't really change at all.
GS: As I've reflected on this over the past couple of years, it seems like a no-brainer now, but what we found was that it's not simply cost that is the barrier to birth control. There are all these other barriers that aren't so simple and obvious. If the clinic manager doesn't want to insert an IUD that day for example, and wants you to come back, that's a road block.
There's nothing like somebody making a decision and acting on it right then. So unless clinics can afford to stock these more expensive methods, we're going to have women and hopefully teens saying, "I heard about this and I would like it," and if it's not available that's going to a problem. How do we get those existing providers trained, comfortable, and confident?
Cost is big and I'm not saying it's not a barrier, but I think practice patterns play an equally important role in increasing the use of more effective contraceptives.
SK: I know one of the things that CHOICE Project has worked on is informing women about the most effective types of contraceptives, which are long-acting reversible contraceptives like intra-uterine devices. Those are used by a pretty small fraction of American women, but by lots and lots of women in CHOICE.
How did you get LARC uptake to be so high? Was that hard? And what was different about what your patients heard, versus other women elsewhere in the country?
GS: It was a complete organizational attitude. I think everybody who worked in our clinic was committed to preventing unintended pregnancy and thought LARCs were a great way to achieve that. When the entire organization believes that, it's hard for anyone to dig their heels in against it.
If there was one champion, provider, or somebody else in management who said, "This is what we're going to do," people usually got on board. For providers, once they say they weren't hurting a patient or putting them at risk: they would try putting an IUD in a 26-year-old and then might see, "Okay, that went fine, I'll try it in a teen." We saw it evolve over time.
SK: You've talked a lot about changing provider practices. What about patients? Did they know much about IUDs going into counseling, and why did they pick them?
GS: What we heard most often was they didn't know about them or, if they knew, it was incorrect information. They'd heard IUDs can move through your body or they can easily fall out or that their boyfriend would be able to feel it. A lot of it was about having a device in your body, and I think that for some women and teens that was just too weird.
One thing we started doing was we would show them models of where the IUD goes. We would say, "This is where it goes and there's no way it can travel to any other place unless you had a perforation. Either it will stay there, or it will fall out, and you'll know when that happens."
This doesn't happen in the United States usually. We would have posters of the reproductive organs, so we can show women what their bodies look like. Our counseling session was taught by health educators who were sitting in an office, not in an exam room, and it was much more of a conversation. We often heard in follow-up surveys patients liked that.
We definitely heard back from our teens that they liked the support. They felt like they could call us. They liked that we checked in on them.
SK: One thing that surprised me in your recent study on teens in your program is that only two-thirds of the patients kept their LARCs for two or more years. Those methods are supposed to last a few years longer. What's going on there?
GS: We looked at that. And we thought it would be great if they kept them for longer, at least for three years. Most of the reasons for discontinuation were for irregular bleeding. Some teens were okay with it and some weren't.
I wish it was 80 percent [who kept their LARCs in for two or more years], honestly. But then if you think about it from the other angle it's like, "Holy cow, most teens will stop their contraceptive method within six months. We have two-thirds of our teens using highly effective methods for two years. We got our 16-year-olds to graduate from high school without getting pregnant."
SK: So you've run this program in St. Louis for about six years now. Are there any plans to scale up, and disseminate what you've learned?
GS: We've spent the last two years putting all of our learning together. We created a protocol for a LARC-first practice. It's really everything from the scripts to who you hire as desk staff. You need to make sure the person on the phone, sitting at the front desk, can answer the question of what methods are available.
The other thing we've done is worked with a number of clinics and organizations who have asked for our help. We learn a lot from them.
I recently retired, but the team is still there. And they've been funded to do some work with a couple of clinics in Memphis and elsewhere in St. Louis. The idea is to see if the CHOICE model can be replicated in a new setting.
SK: It seems like there's some momentum towards more women, particularly teens, using long-acting contraceptives. The American Academy of Pediatricians recently recommended LARCs as the first-line choice for teens, and use has been ticking up slowly. How do you think teenage use of contraceptives is changing?
GS: I think the stars are aligning. I was so excited when the pediatricians' policy came out.
At the same time, it's not just enough to have recommendations and data. We have to get the right tools to people on the ground. Not just the provider, but everyone from the clinic staff to the front desk staff and the financial people.
There's actually a financial challenge for clinics to offer the most effective birth control. And you need a clinic to be stable enough to say, "We're going to stock depo shots and IUDs and hopefully someone is going to show up and buy them." Clinics have to be okay when teens are half an hour late, and not cancel their appointment. The idea is really taking down any barriers that exist right now.
I'm hoping the momentum builds enough where people start chipping away at these barriers.