Background: Emergency contraception prevents unwanted pregnancy after sexual intercourse. New evidence has demonstrated that the 52 mg levonorgestrel IUD is a highly effective method of emergency contraception. However, translating this research finding into clinical practice faces existing barriers to IUD access, including costs and provider training, novel barriers of providing IUDs for emergency contraception at unscheduled appointments. The purpose of this study was to identify barriers and facilitators to utilization of the levonorgestrel IUD as emergency contraception from client, provider and health systems perspectives.
Methods: We conducted focus groups of both contraceptive users and providers to examine how levonorgestrel IUD as EC was perceived and understood by these populations and to determine barriers and facilitators of utilization. We used findings from our focus groups to design a high-fidelity in-situ simulation scenario around EC that we pilot tested with clinical teams in three settings (a county health department, a community clinic, and a midwifery clinic). Simulation scenarios examined health systems barriers to provision of levonorgestrel IUD as EC. We coded both focus groups and in-clinic simulations using the modified Consolidated Framework for Implementation Research. We then applied our findings to the CFIR-Expert Recommendations for Implementing Change (ERIC) Barrier Busting Tool and mapped results to implementation recommendations provided by participants.
Results: Ultimately 9 constructs from the CFIR were consistently identified across focus groups and simulations. Main barriers included challenges with knowledge and acceptability of the intervention itself, appropriately addressing knowledge and education needs among both providers and contraceptive clients, and adequately accounting for structural barriers inherent in the health system. The CFIR-ERIC Barrier Busting Tool identified eight strategies to improve levonorgestrel IUD as EC access: identifying implementation champions, conducting educational meetings, preparing educational toolkits, involving patients and their partners in implementation, conducting a local needs assessment, distributing educational materials, and obtaining patient feedback. These solutions can be utilized to design implementation interventions to institute clinical practice changes in EC provision.
Conclusions: To sustainably incorporate IUD as EC into clinical practice, education, health systems strengthening, and policy changes will be necessary.