Estimated economic impact of the levonorgestrel intrauterine system on unintended pregnancy in active duty women

Unintended pregnancy is reportedly higher in active duty women; therefore, we sought to estimate the potential impact of the levonorgestrel-containing intrauterine system (LNG-IUS) could have on unintended pregnancy in active duty women. A decision tree model with sensitivity analysis was used to estimate the number of unintentional pregnancies in active duty women which could be prevented. A secondary cost analysis was performed to analyze the direct cost savings to the U.S. Government. The total number of Armed Services members is estimated to be over 1.3 million, with an estimated 208,146 being women. Assuming an age-standardized unintended pregnancy rate of 78 per 1,000 women, 16,235 unintended pregnancies occur each year. Using a combined LNG-IUS failure and expulsion rate of 2.2%, a decrease of 794, 1588, and 3970 unintended pregnancies was estimated to occur with 5%, 10% and 25% usage, respectively. Annual cost savings from LNG-IUS use range from $3,387,107 to $47,352,295 with 5% to 25% intrauterine device usage. One-way sensitivity analysis demonstrated LNG-IUS to be cost-effective when the cost associated with pregnancy and delivery exceeded $11,000. Use of LNG-IUS could result in significant reductions in unintended pregnancy among active duty women, resulting in substantial cost savings to the government health care system.

Different Pearl Indices in studies of hormonal contraceptives in the United States: impact of study population

OBJECTIVE

To examine the impact of subject characteristics on efficacy as measured by the Pearl Index (PI) in clinical trials and to make study populations similar by matching.

METHODS

Our analysis used US data from four large Phase III studies. We compared results from one fertility control patch study with pooled data from three studies with virtually identical design on oral hormonal contraceptives. First, we identified three characteristics that had the most impact on the PI. Second, we used these three variables and matched subjects from the patch study with those from the oral contraceptive (OC) studies. Finally, we calculated the PIs for matched and unmatched subjects from both the patch study and the OC studies.

RESULTS

A total of 3706 subjects were included in our analysis. The variables 'Hispanic ethnicity', 'previous pregnancy' and 'previous use of hormonal contraceptives' had the most impact on the PI. The PIs for the matched patch cohort and the matched OC cohort were 2.97 and 2.48, respectively. Those for the unmatched patch cohort and the unmatched OC cohort were 10.17 and 0.90, respectively.

CONCLUSION

Subject characteristics strongly influence the PI in clinical studies of hormonal contraceptives. In particular, Hispanic ethnicity, previous pregnancies and no previous use of hormonal contraceptives result in a higher PI.

IMPLICATIONS

PIs from different clinical trials cannot be meaningfully compared unless subject characteristics that have most impact on the PI are similar or are made to be similar statistically as we did here by matching.

Unintended pregnancies among young women living in urban slums: evidence from a prospective study in Nairobi city, Kenya

BACKGROUND

Despite the significant proportion of young people residing in slum communities, little attention has been paid to the sexual and reproductive health (SRH) challenges they face during their transition to adulthood within this harsh environment. Little is known about the extent to which living in extreme environments, like slums, impact SRH outcomes, especially during this key developmental period. This paper aims to fill this research gap by examining the levels of and factors associated with unintended pregnancies among young women aged 15-22 in two informal settlements in Nairobi, Kenya.

METHODS

We use data from two waves of a 3-year prospective survey that collected information from adolescents living in the two slums in 2007-2010. In total, 849 young women aged 15-22 were considered for analysis. We employed Cox and logistic regression models to investigate factors associated with timing of pregnancy experience and unintended pregnancy among adolescents who were sexually active by Wave 1 or Wave 2.

FINDINGS

About two thirds of sexually experienced young women (69%) have ever been pregnant by Wave 2. For 41% of adolescents, the pregnancies were unintended, with 26% being mistimed and 15% unwanted. Multivariate analysis shows a significant association between a set of factors including age at first sex, schooling status, living arrangements and timing of pregnancy experience. In addition, marital status, schooling status, age at first sex and living arrangements are the only factors that are significantly associated with unintended pregnancy among the young women.

CONCLUSIONS

Overall, this study underscores the importance of looking at reproductive outcomes of early sexual initiation, the serious health risks early fertility entail, especially among out-of school girls, and sexual activity in general among young women living in slum settlements. This provides greater impetus for addressing reproductive behaviors among young women living in resource-poor settings such as slums.

Characteristics of Abortion Care Seekers in Western Nigeria

BACKGROUND

Induced abortion remains a major challenge in Nigeria and indeed the developing world because of its contribution to maternal morbidity and mortality. In Nigeria, abortion law is restrictive, and therefore abortion is provided clandestinely. Information on characteristics of abortion care seekers is available but requires updating. Hence, the need to carry out this study in order to suggest effective and proper intervention strategies to combat the problem of unwanted pregnancy and unsafe abortion.

STUDY DESIGN

This was a prospective hospital-based study. Data collection was done by making use of a pretested standardized questionnaire.

RESULTS

About two-fifths (42.8%) of the respondents were between the ages of 15 and 24 years, of which the adolescents between the ages of 15 and 19 years constituted 11.7%. Slightly less than half (48.4%) of the respondents were unmarried, while married women constituted 51%. Students were the single highest group (32.4%), closely followed by trading, which was the predominant economic activity (32.3%). Respondents terminated their pregnancies mainly because they were unmarried, students or did not desire to have children. Most of the respondents (43.4%) obtained abortion service from health facility they had used previously as a family clinic, while 38.6% of the women were introduced to providers by friends. Average contraceptive prevalence among the abortion care seekers was 29.9%.

CONCLUSION

Abortion needs cut across all reproductive age groups. Reproductive health services including sexuality education and contraception should be provided for women while major governmental policy changes should be made to make abortion care accessible and safe.

Unsafe abortion: a cruel way of birth control

BACKGROUND

Unsafe abortion refers to a procedure for terminating an unintended pregnancy performed either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

OBJECTIVES

The objectives of the study are to assess the factors attributing to practice of unsafe abortion and to suggest feasible and cost-effective measures to counter the same.

METHODS

An extensive search of all materials related to the topic was made using library sources including Pubmed, Medline and World Health Organization. Keywords used in the search include unsafe abortion and unintended pregnancy.

RESULTS

Multiple socio-demographic determinants and barriers such as illiterate women, poor socio-economic status, poor awareness about abortion services, associated stigma, and untrained health professionals have been identified resulting in restricted utilization/access of women to safe abortion services. Consequences of unsafe abortion have been alarming, seriously questioning the quality of health care delivery system.

CONCLUSION

Concerted and dedicated efforts of government in collaboration with the private sector, community members and non-governmental organizations are needed to ensure that women have a better access to contraceptives, abortion services, and post-abortion care that are safe, affordable, and free from stigma.

Effects of maternal pregnancy intention, depressive symptoms and social support on risk of low birth weight: a prospective study from southwestern Ethiopia

BACKGROUND

Low birth weight (LBW) is the principal risk factor for neonatal and infant mortality in developing countries. This study examines the effects of unwanted pregnancy, prenatal depression and social support on the risk of low birth weight in rural southwestern Ethiopia. We hypothesized that unwanted pregnancy and prenatal depression increase the risk of low birth weight, while social support mediates this association.

METHODS

Data for the study comes from a prospective study in which women were followed from pregnancy through to delivery. Six hundred twenty two women were followed and 537 birth weights were measured within 72 hours. Multivariable log binomial regression was used to model the risk of low birth weight.

RESULTS

The mean birth weight was 2989 grams (SD ± 504 grams), and the incidence of LBW was 17.88%. The mean birth weight of babies after unwanted pregnancy was 114 g lower compared to births from intended pregnancy. Similarly, mean birth weight for babies among women with symptoms of antenatal depression was 116 grams lower. Results of unadjusted log-binomial regression showed that unwanted pregnancy, prenatal depression and social support were associated with LBW. The relationship between antenatal depressive symptoms and LBW was mediated by the presence of social support, while the association between LBW and unwanted pregnancy remained after multivariable adjustment.

CONCLUSION

The incidence of low birth weight is high in the study area. Poverty, nonuse of antenatal care, low social support and unwanted pregnancy contribute to this high incidence of low birth weight. Hence, identifying women's pregnancy intention during antenatal care visits, and providing appropriate counseling and social support will help improve birth outcomes.

Effect of a low-dose contraceptive patch on efficacy, bleeding pattern, and safety: a 1-year, multicenter, open-label, uncontrolled study

This Phase III, uncontrolled, open-label, multicenter study was conducted to investigate the contraceptive efficacy, bleeding pattern, and cycle control of a novel once-a-week contraceptive patch, delivering low-dose ethinyl estradiol (EE) and gestodene (GSD) at the same systemic exposure seen after oral administration of a combined oral contraceptive containing 0.02 mg EE/0.06 mg GSD. Participants were women aged 18 to 35 years, all of whom received the EE/GSD patch for 13 cycles each of 21 treatment days (one patch per week for 3 weeks) followed by a 7-day, patch-free interval. The primary efficacy variable was the occurrence of unintended pregnancies during the study period as assessed by life table analysis and the Pearl Index. Secondary efficacy variables were days with bleeding during four 90-day reference periods and during 1 treatment year, bleeding pattern, and cycle control. The Kaplan-Meier probability of contraceptive protection after 364 treatment days was 98.8% and the adjusted Pearl Index was 0.81. The percentage of participants with intracyclic bleeding/spotting decreased over time, from 11.4% to 6.8% in cycles 1 and 12, respectively. Almost all participants (range: 90.8%-97.6%) experienced withdrawal bleeding across the study period. Compliance was very high (mean: 97.9%; median: 100%). The most frequent adverse events were headache (9.5%) and application site reaction (8.5%); no clinically significant safety concerns were observed. Results suggest the EE/GSD patch is highly effective in preventing pregnancy. Menstrual bleeding pattern was favorable and within the ranges expected of a healthy female population. The patch was well tolerated and treatment compliance was high.

The possibility of compensation for damages in cases of wrongful conception, wrongful birth and wrongful life. An Estonian perspective

While case law in cases of wrongful conception, wrongful birth and wrongful life is completely missing in Estonia, this article is aimed at providing possible solutions under Estonian law to some of the legally complex problems that these cases contain. Through the analysis of Estonian, German and U.S. legal literature and case law, the article is mainly focused on proposing some solutions to the legal problems concerning compensable damage, but also explains the Estonian legal framework of the contractual and delictual basis for compensation for the damages. The application of several grounds for the possibility of limiting the compensation in the afore-mentioned cases are analysed.

Effectiveness of family planning policies: the abortion paradox

OBJECTIVE

The relation between levels of contraceptive use and the incidence of induced abortion remains a topic of heated debate. Many of the contradictions are likely due to the fact that abortion is the end point of a process that starts with sexual activity, contraceptive use (or non-use), followed by unwanted pregnancy, a decision to terminate, and access to abortion. Trends in abortion rates reflect changes in each step of this process, and opposing trends may cancel each other out. This paper aims to investigate the roles played by the dissemination of contraception and the evolving norms of motherhood on changes in abortion rates.

METHODS

Drawing data from six national probability surveys that explored contraception and pregnancy wantedness in France from 1978 through 2010, we used multivariate linear regression to explore the associations between trends in contraceptive rates and trends in (i) abortion rates, (ii) unwanted pregnancy rates, (iii) and unwanted birth rates, and to determine which of these 3 associations was strongest.

FINDINGS

The association between contraceptive rates and abortion rates over time was weaker than that between contraception rates and unwanted pregnancy rates (p = 0.003). Similarly, the association between contraceptive rates and unwanted birth rates over time was weaker than that between contraceptive rates and unwanted pregnancy rates (p = 0.000).

Engineering a segmented dual-reservoir polyurethane intravaginal ring for simultaneous prevention of HIV transmission and unwanted pregnancy

The HIV/AIDS pandemic and its impact on women prompt the investigation of prevention strategies to interrupt sexual transmission of HIV. Long-acting drug delivery systems that simultaneously protect womenfrom sexual transmission of HIV and unwanted pregnancy could be important tools in combating the pandemic. We describe the design, in silico, in vitro and in vivo evaluation of a dual-reservoir intravaginal ring that delivers the HIV-1 reverse transcriptase inhibitor tenofovir and the contraceptive levonorgestrel for 90 days. Two polyether urethanes with two different hard segment volume fractions were used to make coaxial extruded reservoir segments with a 100 µm thick rate controlling membrane and a diameter of 5.5 mm that contain 1.3 wt% levonorgestrel. A new mechanistic diffusion model accurately described the levonorgestrel burst release in early time points and pseudo-steady state behavior at later time points. As previously described, tenofovir was formulated as a glycerol paste and filled into a hydrophilic polyurethane, hollow tube reservoir that was melt-sealed by induction welding. These tenofovir-eluting segments and 2 cm long coaxially extruded levonorgestrel eluting segments were joined by induction welding to form rings that released an average of 7.5 mg tenofovir and 21 µg levonorgestrel per day in vitro for 90 days. Levonorgestrel segments placed intravaginally in rabbits resulted in sustained, dose-dependent levels of levonorgestrel in plasma and cervical tissue for 90 days. Polyurethane caps placed between segments successfully prevented diffusion of levonorgestrel into the tenofovir-releasing segment during storage.Hydrated rings endured between 152 N and 354 N tensile load before failure during uniaxial extension testing. In summary, this system represents a significant advance in vaginal drug delivery technology, and is the first in a new class of long-acting multipurpose prevention drug delivery systems.

Dead infants and unmarried women--from forensic pathology reports 1910-12

The lack of access to contraceptives and poor control over their own pregnancies represented a major problem for women 100 years ago. An unwanted pregnancy could lead to social exclusion and loss of paid work, and clandestine births and infanticide thus posed a social problem. A review of the archives of the Norwegian Board of Forensic Medicine in the period 1910 to 1912 shows that one-fifth of all expert opinions were related to infants and pregnancy. Autopsies performed on children constituted over one-third of all forensic autopsies during this period. Although the reports provide a timely reminder of the value of hard-earned rights in Norway, the lack of control over their own sexuality and unwanted pregnancies are unfortunately still the reality for a large proportion of the world's women.

Contraceptive use among women seeking repeat abortion in Addis Ababa, Ethiopia

Limited access to modern contraceptives in populations that desire smaller families can lead to repeat unintended pregnancy and repeat abortions. We conducted an analysis of the medical records of 1,200 women seeking abortion-related services in public and private facilities in Addis Ababa, Ethiopia from October 2008 to February 2009. We examined the characteristics of initial and repeat abortion clients including prior contraceptive use and subsequent method selection. The incidence of repeat abortion was 30%. Compared with women seeking their first abortion, significantly more repeat abortion clients had ever used contraceptives and they were nearly twice as likely to leave the facility with a method. However, repeat abortion clients were significantly more likely to have ever used short-term reversible methods and to choose short-term methods post-abortion. Contraceptive counseling services for repeat abortion clients' should address reasons for previous contraceptive failure, discontinuation, or non-use. Post-abortion family planning services should be strengthened to help decrease repeat abortion.

Situation analysis of patients attending TU Teaching Hospital after medical abortion with problems and complications

INTRODUCTION

In Nepal medical abortion has been approved for use since 2009. There were many cases coming to Tribhuvan University Teaching Hospital coming with problems and complications following medical abortion. Thus the objective of this study was to analyze the cases that came to TUTH following medical abortion with problems and complications.

METHODS

This is a prospective study conducted in the Department of Obstetrics and Gynecology of TUTH. Study was carried from 1st August 2011 to 30th November 2012. Women who came to TUTH with any complaints following medical abortion were interviewed, examined and treatment provided. Relevant clinical finding were noted.

RESULTS

There were a total of 57 cases during the study. Most (66.6%) of the women were in age group 20-29 years age. There were 45 (79%) women who had abortion up to 9 weeks. Medical shop was the main place where most of the women (45.6%) directly come to know about medical abortion. More than 34 (77.2%) received the service from medical shops without any supervision. Most 31 (54.4%) presented with incomplete abortion. There were three cases of continuing pregnancy and four presented with ectopic pregnancy. Eighteen (31.6%) cases needed admission. Fifty six percent of the cases were treated with manual vacuum aspiration, six cases underwent laparotomy and there was one maternal mortality.

CONCLUSIONS

There is a need for proper dissemination and implementation of guideline for management of these women and adequate supervision to reduce the problems and complications.

Long-acting reversible contraception: a practical solution to reduce unintended pregnancy

Unintended pregnancy remains a significant global public health problem; 41% of all pregnancies worldwide in 2008 were unintended. The unintended pregnancy rate is greater in less developed regions (57 per 1000 women aged 15-44 years) than in more developed regions (42 per 1000), with the United States a notable exception at a rate of 52 per 1000 women. Among US women, nearly half of unintended pregnancies are due to incorrect or inconsistent use of a contraceptive method. Long-acting reversible contraception (LARC) includes the intrauterine device and subdermal implant and offers the potential to address the problem of unintended pregnancy. LARC is extremely safe and over 99% effective at preventing pregnancy. In real-world tests LARC methods were over 20 times more effective at preventing unintended pregnancy (HRadj=21.8, 95% confidence interval, 13.7 to 34.9) compared to the contraceptive pill, patch, or ring. Despite their level of effectiveness, less than 15% of contracepting women worldwide use LARC. LARC are only infrequently contraindicated, even among younger and nulliparous women. Instead education, access, and cost are the primary barriers. In a US study of nearly 10000 women aged 14-45 years, when the three barriers were removed 75% of study participants chose a LARC method. As a result, the study reported an 80% reduction in teen births and 75% reduction in abortions among women in the cohort compared to national statistics. If we are serious about reducing unintended pregnancy, we need to be serious about increasing the use of methods that we know work. Greater LARC use and continuation has been proven to effectively reduce unintended pregnancy, including abortion and teen pregnancy.

Use of emergency contraception among women aged 15-44: United States, 2006-2010

Emergency contraception can be used by women after sexual intercourse in an effort to prevent an unintended pregnancy. Roughly one-half of all pregnancies in the United States are unintended (1,2). The FDA first approved emergency contraceptive pills in 1998, but there is evidence of limited use of hormonal contraceptives for emergency contraception since the 1960s (3,4). Now, there are at least four brands of emergency contraceptive pills; most are available over the counter for women aged 17 and over (5). Although insertion of a copper intrauterine device can be used for emergency contraception (1,4), this report focuses only on emergency contraceptive pills. This report describes trends and variation in the use of emergency contraception and reasons for use among sexually experienced women aged 15-44 using the 2006-2010 National Survey of Family Growth.

[Post-rape pregnancy]

A rape is a traumatizing circumstance for the victim. This aggression often has, regrettably, immediate repercussions, and then medium and long-term ones. Its complications are psychological, but also sometimes somatic, like pregnancy. Through an international literature review, and the study of the national legislation, we will summarize the main essential elements of the medical and forensic care of a pregnancy arising after a rape.

It is time to integrate abortion into primary care

The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women. The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care. To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.

Looking beyond legality: understanding the context of female sex workers in greater Cairo, Egypt

Data on demographic, social and behavioural characteristics of female sex workers in greater Cairo are very scarce. A cross-sectional study was conducted with 431 randomly selected sex workers after mapping of sites where they gather. Data collection was performed by direct interviewing using a questionnaire sheet covering sociodemographic data and sexual history with paying and non-paying partners. More than one half of participants (52.7%) were aged < 30 years. Only 39.3% were exclusively working as sex workers while the rest had other jobs beside sex work. Almost 70% were responsible for deperidants. The age of first selling sex was < 15 years for 4.7% of the women and 15-25 years for 58.7%. Unwanted pregnancies were experienced by 36.2% and 34.8% had had an abortion. Many participants had ever been arrested by the police (71.2%). The study has provided some useful background data for further studies in this very sensitive area of research.

Unintended pregnancy and abortion in Uganda

Unintended pregnancy is common in Uganda, leading to high levels of unplanned births, unsafe abortions, and maternal injury and death. Because most pregnancies that end in abortion are unwanted, nearly all ill health and mortality resulting from unsafe abortion is preventable. This report summarizes evidence on the context and consequences of unintended pregnancy and unsafe abortion in Uganda, points out gaps in knowledge, and highlights steps that can be taken to reduce levels of unintended pregnancy and unsafe abortion, and, in turn, the high level of maternal mortality.