Research to Improve the Nurse-Family Partnership in Community Practice: The Nurse Family Partnership Contraceptive Study
By Alan Melnick, MD, MPH and
Marni Storey-Kuyl, RN, MS
Clark County (WA) Public Health
Unintended and short interval pregnancies are associated with adverse health effects for women, children and families.1-7 Increasing access to effective contraceptives could prevent unintended pregnancy and, if provided soon after delivery, could reduce short-interval unintended pregnancy.8
Unfortunately, many women at high risk for unintended pregnancy face difficulties receiving contraceptive services from publicly funded family planning programs. Cost, inadequate access to childcare and transportation, time of available services, and geographic location can inhibit a woman’s ability to obtain and use contraceptives.8, 9, 10, 11,12 Waiting times at clinics, delays in obtaining appointments, fear of side effects, the belief that clinics offer less personalized and lower quality care, and the pelvic exam requirement lead to reduced effective contraceptive use.8,12
Our research team, including members from Oregon Health and Science University and the University of Colorado, has worked collaboratively with the NFP Program and several local health departments in the state of Washington to study whether it is possible to eliminate these barriers and increase effective contraceptive use by dispensing hormonal contraceptives during nurse home visits. The NFP is a voluntary nurse home visiting program found in randomized clinical trials to improve pregnancy outcomes, child health and development, and parent economic self-sufficiency. Nurses visit homes of low-income women, including adolescents, during their first pregnancy and throughout their child’s first two years of life. Although studies have shown that the NFP has reduced unintended pregnancy and increased spacing, populations the NFP serves still experience high rates of unintended pregnancy and short pregnancy intervals.13,14,15,16,17
Our study was a randomized clinical trial of adding a contraceptive dispensing component to the NFP program at three local health departments. We designed the study to determine whether NFP clients who received contraceptives from nurses during home visits had fewer gaps in effective contraceptive coverage and fewer unintended pregnancies compared to women receiving the usual NFP care. Women were eligible for participation in the study if they were NFP clients, less than 33 weeks pregnant, English or Spanish speaking and interested in participating.
Usual NFP care included education and counseling focused on pregnancy planning and contraceptive use, with referrals to clinical settings for contraception. Participants in the enhanced intervention group received the same services, but during home visits following delivery, the nurses also offered women their choice of up to a 12-month supply of hormonal contraceptives, including oral contraceptives, vaginal rings, contraceptive patches or a depomedroxyprogesterone injection at no cost. The nurses followed clinical protocols, approved by their health department medical director.
For both study groups, blinded research staff conducted phone surveys at enrollment and at three-month intervals three months after delivery and continuing until 12 to 24 months following delivery. The surveys gathered data related to gaps in effective contraceptive use, specifically days without contraceptive use (gap days) and repeat pregnancy, and factors that could influence the rates and timing of subsequent pregnancy, such as pregnancy intention, perceived barriers to contraceptive use, and self-efficacy related to contraceptive use.
Preliminary results are promising. The mean age at enrollment for the 337 participants was 19.0 (range 14.3 – 42.8). Women in the enhanced group had fewer contraceptive gap days up to 15 months postpartum (p < 0.001). However, by 18-months postpartum, the enhanced care group had more gaps, and beyond 18 months, there was no difference between groups.
Based on these early results, we believe that giving NFP nurses the ability to dispense contraceptives during home visits can improve contraceptive use for up to 15-months postpartum. This is significant, because increasing spacing of subsequent pregnancies improves birth outcomes, child health outcomes and the mothers’ opportunities for economic self-sufficiency. The findings after 15 months might be due to changes in pregnancy intention or other moderating variables such as domestic partner/family influence and perceived barriers to continued effective contraceptive use. Our next steps include exploring potential moderating and mediating variables such as race, ethnicity, income, education, perceived barriers, contraceptive use self-efficacy and pregnancy intention.
If further analysis confirms our findings, we intend to work with other sites to add hormonal contraceptive dispensing to the NFP model. Considering that the NFP program reaches more than 26,000 participants in hundreds of sites, the potential health impact of the intervention is significant.17
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