Focus on Research January 2014

Research to Improve the Nurse-Family Partnership in Community Practice: The Nurse Family Partnership Contraceptive Study

Alan Melnick, MD, MPHAlan Melnick, MD, MPH
Adjunct Associate Professor

Unintended and short interval pregnancies are associated with adverse health effects for women, children and families. Increasing access to effective contraceptives could prevent unintended pregnancy and reduce short-interval unintended pregnancy.

Unfortunately, many women at high risk for unintended pregnancy face difficulties receiving contraceptive services.Cost, inadequate access to childcare and transportation, time of available services, and geography can inhibit a woman's ability to obtain contraceptives. Waiting times, 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.

OHSU Family Medicine researchers have worked collaboratively with the Nurse Family Partnership (NFP) Program, the University of Colorado, and three local health departments in Washington State to study whether it is possible to eliminate barriers and increase effective contraceptive use by allowing nurses to dispense hormonal contraceptives during 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. While the NFP has reduced unintended pregnancy and increased spacing, populations the NFP serves still experience high rates of unintended pregnancy and short pregnancy intervals.

Our study was a randomized clinical trial of adding a contraceptive dispensing component to the program. We designed the study to determine whether NFP clients offered contraceptives 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 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 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, the nurses offered women their choice of up to a twelve-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.

Blinded research staff conducted phone surveys at enrollment and at three-month intervals three months after delivery and continuing until twelve to twenty-four months following delivery. The surveys gathered data related to 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 post-partum (p < 0.001). However, by 18 months post-partum, the enhanced care group had more gaps, and beyond 18 months, there was no difference between groups. 

Based on these early results, we believe the intervention can improve contraceptive use for up to 15 months post-partum. This is significant, because increasing spacing of subsequent pregnancies improves birth outcomes, child health outcomes and the mothers’ opportunities for economic self-sufficiency. 

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 hope other sites will add the intervention to the NFP model. Considering that the NFP program reaches over 26,000 participants in hundreds of sites, the potential impact is significant.