The ACCORd Trial

The Australian Contraceptive Choice pRoject: increasing the uptake of long-acting reversible contraception in general practice.

In Australia, 1 in 4 women experience an unintended pregnancy, and a third of those end in abortion. This rate is disproportionately higher amongst women aged 18-32 years and those living in non-urban areas. Long-acting reversible contraception (defined as intrauterine devices (IUDs) and contraceptive implants) are the most effective contraception and can reduce unintended pregnancy rates across all stages of a woman’s reproductive life. They have a much lower failure rate compared to condoms or oral contraceptives. However, uptake is low in Australia and is only used by around 11% of women aged between 15-44 years.

The purpose of the ACCORd trial was to evaluate if a complex intervention in general practice can increase LARC uptake among women attending a general practice. General practice clinics involved in the trial were provided:

• A six-hour online training course for general practitioners on how to deliver effectiveness-based contraceptive counselling
• Access to a rapid referral service for insertion of long-acting reversible contraception.

Study findings

Increased uptake of LARC

At the beginning of the trial, three out of four women who had an unintended pregnancy were not using a LARC.

After four weeks, six months, and twelve months, there was an increase in the uptake of long-acting reversible contraception among women who consulted with general practitioners that delivered efficacy-focused contraception counselling and had rapid referral pathways for insertion of long-acting reversible contraception. The most commonly chosen method was the levonorgestrel intrauterine system (Mirena or Kyleena) was the most commonly chosen method. Women were also more satisfied and more likely to continue with using a hormonal LARC than an oral contraceptive at 12 months. They were also appreciative of providers who understood the evidence, and better informed about effective contraception.

Benefits to general practitioners

General practitioners who received the training saw the value of increasing the uptake of long-acting reversible contraception and understood that they had a responsibility to talk to women about this form of contraception.

The trial also found that most general practitioners can routinely insert implants and most women are able to access implants through their own general practitioner. Therefore, the rapid referral service was not utilised for implant insertion.

For IUDs, however, only a small number of general practitioners in the trial were trained to insert IUDs, and an even smaller number routinely inserted IUDs. Therefore, the majority of IUD insertions will take place at a LARC rapid referral clinic if a GP is given the option to refer. However, even without a rapid referral pathway through the ACCORd study, GPs would still have referred patients to other health professionals within their network to insert IUDs.

Providing education to general practitioners and access to a rapid referral service is efficient at the primary care level, and has a positive financial effect on the health system.

What do the study findings suggest?

Providing training to general practitioners on how to deliver efficacy-based contraceptive counselling and access to free rapid referral pathways can improve the accessibility and uptake of long-acting reversible contraception. This trial was conducted in metropolitan Melbourne and involved a small cohort of GPs and their patients. It remains to be seen if the results will be similar in a larger cohort and in regional/rural/remote areas.

Follow-up study

There is currently a study underway to follow up women participants who were enrolled in the original ACCORd trial. The follow up survey will examine the long-term outcomes of ACCORd such as contraceptive continuation rates and reproductive history, any unintended pregnancies, satisfaction and concerns with their current contraceptive method, and an assessment of quality of life.

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