OBJECTIVE AND DESIGN:Some studies suggest that specific hormonal contraceptive methods particularly depot medroxyprogesterone acetate (DMPA) may increase womenʼs HIV acquisition risk. We updated a ...systematic review to incorporate recent epidemiological data.
METHODS:We searched for articles published between 15 January 2014 and 15 January 2016 and hand-searched reference lists. We identified longitudinal studies comparing users of a specific hormonal contraceptive method against either nonusers of hormonal contraception or users of another specific hormonal contraceptive method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus non-use of hormonal contraception.
RESULTS:We identified 10 new reports of which five were considered ‘unlikely to inform the primary question’. We focus on the other five reports, along with nine from the previous review, which were considered ‘informative but with important limitations’. The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate, and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher quality studies on DMPA (or nondisaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher quality studies of hazard ratio 1.4.
CONCLUSION:Although confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely hazard ratio 1.5 or less. Data for other hormonal contraceptive methods, including norethisterone enanthate, are largely reassuring.
BACKGROUND
Intrauterine devices (IUDs) have been studied for use for emergency contraception for at least 35 years. IUDs are safe and highly effective for emergency contraception and regular ...contraception, and are extremely cost-effective as an ongoing method. The objective of this study was to evaluate the existing data to estimate the efficacy of IUDs for emergency contraception.
METHODS
The reference list for this study was generated from hand searching the reference lists of relevant articles and our own article archives, and electronic searches of several databases: Medline, Global Health, Clinicaltrials.gov, Popline, Wanfang Data (Chinese) and Weipu Data (Chinese). We included studies published in English or Chinese, with a defined population of women who presented for emergency contraception and were provided with an IUD, and in which the number of pregnancies was ascertained and loss to follow-up was clearly defined. Data from each article were abstracted independently by two reviewers.
RESULTS
The 42 studies (of 274 retrieved) that met our inclusion criteria were conducted in six countries between 1979 and 2011 and included eight different types of IUD and 7034 women. The maximum timeframe from intercourse to insertion of the IUD ranged from 2 days to 10 or more days; the majority of insertions (74% of studies) occurred within 5 days of intercourse. The pregnancy rate (excluding one outlier study) was 0.09%.
CONCLUSIONS
IUDs are a highly effective method of contraception after unprotected intercourse. Because they are safe for the majority of women, highly effective and cost-effective when left in place as ongoing contraception, whenever clinically feasible IUDs should be included in the range of emergency contraception options offered to patients presenting after unprotected intercourse. This review is limited by the fact that the original studies did not provide sufficient data on the delay between intercourse and insertion of the IUD, parity, cycle day of intercourse or IUD type to allow analysis by any of these variables.
Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, ...and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States.
This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation.
We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau’s American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons.
Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15–44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty.
This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.
Objective Disparities in unintended pregnancy in the United States are related, in part, to black and Hispanic women being overall less likely to use effective contraceptive methods. However, the ...fact that these same groups are more likely to use female sterilization, a highly effective method, suggests there may be variability in disparities in contraceptive use across a woman's life course. We sought to assess the relationship between race/ethnicity and contraceptive use in a nationally representative sample and to approximate a life course perspective by examining effect modification on these disparities by women's age, parity, and history of unintended pregnancy. Study Design We conducted an analysis of the 2006 through 2010 National Survey of Family Growth to determine the association between race/ethnicity and: (1) use of any method; (2) use of a highly or moderately effective method among women using contraception; and (3) use of a highly effective method among women using contraception. We then performed analyses to assess interactions between race/ethnicity and age, parity, and history of unintended pregnancy. Results Our sample included 7214 females aged 15-44 years. Compared to whites, blacks were less likely to use any contraceptive method (adjusted odds ratio, 0.65); and blacks and Hispanics were less likely to use a highly or moderately effective method (adjusted odds ratio, 0.49 and 0.57, respectively). Interaction analyses revealed that racial/ethnic disparities in contraceptive use varied by women's age, with younger women having more prominent disparities. Conclusion Interventions designed to address disparities in unintended pregnancy should focus on improving contraceptive use among younger women.
Background
Young women, especially adolescents, often lack access to modern contraception. Reasons vary by geography and regional politics and culture. The projected 2015 birth rate in 'developing' ...regions was 56 per 1000 compared with 17 per 1000 for 'developed' regions.
Objectives
To identify school‐based interventions that improved contraceptive use among adolescents
Search methods
Until 6 June 2016, we searched for eligible trials in PubMed, CENTRAL, ERIC, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP.
Selection criteria
We considered randomized controlled trials (RCTs) that assigned individuals or clusters. The majority of participants must have been 19 years old or younger.
The educational strategy must have occurred primarily in a middle school or high school. The intervention had to emphasize one or more effective methods of contraception. Our primary outcomes were pregnancy and contraceptive use.
Data collection and analysis
We assessed titles and s identified during the searches. One author extracted and entered the data into RevMan; a second author verified accuracy. We examined studies for methodological quality.
For unadjusted dichotomous outcomes, we calculated the Mantel‐Haenszel odds ratio (OR) with 95% confidence interval (CI). For cluster randomized trials, we used adjusted measures, e.g. OR, risk ratio, or difference in proportions. For continuous outcomes, we used the adjusted mean difference (MD) or other measures from the models. We did not conduct meta‐analysis due to varied interventions and outcome measures.
Main results
The 11 trials included 10 cluster RCTs and an individually randomized trial. The cluster RCTs had sample sizes from 816 to 10,954; the median number of clusters was 24. Most trials were conducted in the USA and UK; one was from Mexico and one from South Africa.
We focus here on the trials with moderate quality evidence and an intervention effect. Three addressed preventing pregnancy and HIV/STI through interactive sessions. One trial provided a multifaceted two‐year program. Immediately after year one and 12 months after year two, the intervention group was more likely than the standard‐curriculum group to report using effective contraception during last sex (reported adjusted ORs 1.62 ± standard error (SE) 0.22) and 1.76 ± SE 0.29), condom use during last sex (reported adjusted ORs 1.91 ± SE 0.27 and 1.68 ± SE 0.25), and less frequent sex without a condom in the past three months (reported ratios of adjusted means 0.50 ± SE 0.31 and 0.63 ± SE 0.23). Another trial compared multifaceted two‐year programs on sexual risk reduction and risk avoidance (abstinence‐focused) versus usual health education. At 3 months, the risk reduction group was less likely than the usual‐education group to report no condom use at last intercourse (reported adjusted OR 0.67, 95% CI 0.47 to 0.96) and sex without a condom in the last three months (reported adjusted OR 0.59, 95% CI 0.36 to 0.95). At 3 and after 15 months, the risk avoidance group was also less likely than the usual‐education group to report no condom use at last intercourse (reported adjusted ORs 0.70, 95% CI 0.52 to 0.93; and 0.61, 95% CI 0.45 to 0.85). At the same time points, the risk reduction group had a higher score than the usual‐education group for condom knowledge. The third trial provided a peer‐led program with eight interactive sessions. At 17 months, the intervention group was less likely than the teacher‐led group to report oral contraceptive use during last sex (OR 0.57, 95% CI 0.36 to 0.91). This difference may not have been significant if the investigators had adjusted for the clustering. At 5 and 17 months, the peer‐led group had a greater mean increase in knowledge of HIV and pregnancy prevention compared with the control group. An additional trial showed an effect on knowledge only. The group with an emergency contraception (EC) session was more likely than the group without the EC unit to know the time limits for using hormonal EC (pill) and the non‐hormonal IUD as EC.
Authors' conclusions
Since most trials addressed preventing STI/HIV and pregnancy, they emphasized condom use. However, several studies covered a range of contraceptive methods. The overall quality of evidence was low. Main reasons for downgrading the evidence were having limited information on intervention fidelity, analyzing a subsample rather than all those randomized, and having high losses.
Same-day start removes barriers to contraceptive initiation and may reduce the risk of unintended pregnancy. It may be appropriate for all contraceptive methods, but we lack data comparing methods.
...This study aimed to assess the frequency of same-day start with 6 contraceptive methods among new contraceptive users and describe the efficacy of same-day start in terms of first-cycle pregnancy risk overall and by each method.
Using prospective data from the HER Salt Lake Contraceptive Initiative, we identified and assessed outcomes for participants initiating a new method of contraception beyond the first 7 days of their menstrual cycle (same-day start). Enrolled participants at 4 family planning clinics in Salt Lake County, Utah between September 2015 and March 2017 received their method of choice regardless of their cycle day or recent unprotected intercourse. All participants self-reported last menstrual period data and unprotected intercourse events in the previous 2 weeks. We excluded participants who received care immediately after or within 2 weeks of abortion care. Clinical electronic health records provided information on contraceptive method initiation and use of oral emergency contraception. Participants reported pregnancy outcomes in 1-, 3-, and 6-month follow-up surveys with clinic verification to identify any pregnancy resulting from same-day initiation. The primary outcomes report the frequency of same-day start use and first-cycle pregnancy risk among same-day start users of all contraceptive methods. The secondary outcomes include frequency of and pregnancy risk in the first cycle of use among same-day start contraception users by method. We also report the frequency of unprotected intercourse within 5 days and 6 to 14 days of contraception initiation, frequency of concomitant receipt of oral emergency contraception with initiation of ongoing contraception, and pregnancy risk with these exposures. We analyzed pregnancy risk for each contraceptive method initiated on the same day and assessed the simultaneous use of oral emergency contraception.
Of the 3568 individuals enrolled, we identified most as same-day start users (n=2575/3568; 72.2%), with 1 in 8 of those reporting unprotected intercourse in the previous 5 days (n=322/2575; 12.5%) and 1 in 10 reporting unprotected intercourse 6 to 14 days before contraceptive method initiation (n=254/2575; 9.9%). We identified 11 pregnancies among same-day start users (0.4%; 95% confidence interval, 0.2–0.7), as opposed to 1 (0.1%; 95% confidence interval, 0.002–0.6) among those who initiated contraception within 7 days from the last menstrual period. Users of oral hormonal contraception and vaginal hormonal methods reported the highest first-cycle pregnancy rates (1.0–1.2). Among same-day start users, 174 (6.8%) received oral emergency contraception at enrollment in conjunction with another method. Among the same-day start users who received emergency contraception at initiation, 4 (2.3%) pregnancies were reported.
Same-day start is common and associated with a low pregnancy risk. Using the “any method, any-time” approach better meets contraceptive clients’ needs and maintains a low risk of pregnancy.
To investigate the influence of sexual activity and contraceptive use on the decline in adolescent birth rates and pregnancy rates since 2007.
We estimated trends in pregnancy risk from 2007 to 2014 ...using national data on behaviors of women aged 15–19.
In 2007–2014, increases occurred in use of one or more contraceptive methods at last sex (78%–88%), dual method use (24%–33%), long-acting reversible contraception including intrauterine device and implant (1%–7%), withdrawal (15%–26%), and withdrawal in combination with other methods (7%–17%). Pill use rose and then fell over time. Level of sexual activity did not change over time. The decline in pregnancy risk among women aged 15–19 was entirely attributable to improvements in contraceptive use.
Improvements in contraceptive use—including increases in use of long-acting reversible contraception and withdrawal in combination with another method—appear to be driving recent declines in adolescent birth and pregnancy rates.
Introduction
Provision of long‐acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to ...explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders.
Material and Methods
This was a register‐based cross‐sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs).
Results
The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre‐ or post‐abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08–1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders.
Conclusions
Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.
Method-related concerns represent an important cause of contraceptive non-use and discontinuation. User preferences must be incorporated into the design of new contraceptive technologies to ensure ...product success and improve family planning outcomes. We assessed preferences among potential users in Burkina Faso and Uganda for six contraceptive methods currently under development or ready for introduction: a new copper intra-uterine device (IUD), a levonorgestrel intra-uterine system, a new single-rod implant, a biodegradable implant, a longer-acting injectable, and a method of non-surgical permanent contraception. Questions were added to nationally-representative PMA2020 household surveys that asked 2,743 and 2,403 women in Burkina Faso and Uganda, respectively, their interest in using each new method. We assessed factors associated with interest through multivariable logistic regression models. We conducted qualitative interviews and focus groups with 398 women, 78 men, and 52 family planning providers and key informants to explore perceived advantages and disadvantages of the methods. Respondents expressed interest in using all new methods, with greatest interest in the longer-acting injectable (77% in Burkina Faso, 61% in Uganda), followed by a new single-rod implant. Least interest was expressed in a new copper IUD (26% Burkina Faso, 15% in Uganda). In both countries, women with less education had higher odds of interest in a longer-acting injectable. Interest in most new methods was associated with desiring a method lasting longer than one year and acceptance of lack of menstrual bleeding as a contraceptive side effect. Perceived advantages and disadvantages were similar between countries, including concerns about menstrual side effects and fear of the biodegradable nature of the biodegradable implant. Potential users, their partners, and providers are interested in new longer-acting methods, however, familiar forms including the injectable and implant may be the most immediately acceptable. A biodegradable implant will require clear counseling messages to allay potential fears.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
The PULSE survey investigated contraceptive decision making, focusing on the use of long‐acting reversible contraceptives (LARCs) to determine reasons for their low adoption rates.
Methods
...An online questionnaire was sent to women aged 18–49 years in 14 European countries who were considering starting or changing contraceptive method and asked questions based on four stages of contraceptive decision making: awareness, consideration, consultation, and adoption.
Results
Overall, 7221 women responded. LARC awareness was high (~73%) but current usage was low (11.3%). Only 24% of LARC‐aware women would consider switching to them. Factors associated with decision making differed depending on the stage: e.g. at the awareness phase, women were concerned with suitability, reversibility, and whether the method is hormonal; and at the consideration phase, the efficacy, convenience, and adverse‐effect profile were important. Healthcare professionals (HCPs) were the most trusted information source for women’s contraceptive decision making. LARCs were discussed less frequently during consultations than other contraceptives and HCPs may be perceived to hold negative opinions on LARCs.
Conclusion
A lack of knowledge about the features and benefits of LARCs can contribute to misconceptions and low adoption rates. HCPs play an important role in addressing this, as information conveyed during consultations influences women’s contraceptive choices.
European women are usually aware of long‐acting reversible contraceptives but often do not choose these methods, perhaps through misinformation about their effectiveness, suitability, and safety profile.
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