Fear of intrauterine contraception among adolescents in New York City

Low Acceptability of Certain Contraceptive Methods among Young Women

STUDY OBJECTIVE

To examine what predicts low personal acceptability of 4 different contraceptive methods among young women.

DESIGN

Cross-sectional survey.

SETTING

Urban adolescent contraception clinic in Colorado.

PARTICIPANTS

Female clinic patients ages 13-24 initiating contraception from August 2011 to April 2012.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Survey participants reported their personal acceptability for oral contraceptive pills, depot medroxyprogesterone, contraceptive implants, and intrauterine devices on a scale from 0 (low) to 10 (high). Responses of 0-4 were categorized as low personal acceptability. Demographic characteristics, reproductive history, and perceived contraceptive satisfaction of friends and family members were incorporated into multivariable and hierarchical logistic regression models to determine distinct predictors of low personal acceptability for each method.

RESULTS

Surveys were completed by 1067 women. Participants' mean age was 20 (±2.6) years. Half (552/1067) were white, 26% (277/1067) Hispanic, and 8.5% (91/1067) black. Of participants who were aware of oral contraceptive pills 52% (535/1037) reported low acceptability of this method compared with 74% (645/876) of those aware of depot medroxyprogesterone. Fewer reported low acceptability of intrauterine devices (37% or 303/825) or implant (43% or 356/839), although fewer overall participants had heard of these methods. Each method had unique predictors of low personal acceptability, however, for all method models, significant predictors included knowing someone who had become pregnant while using that method or having a friend who dislikes that method.

CONCLUSION

Young women in this study with low personal acceptability of the 4 most common contraceptive methods had distinct demographic and reproductive health characteristics. Perceived negative experiences of friends and family members using contraception appeared most influential.

Long-acting reversible contraceptive use in the post-abortion period among women seeking abortion in mainland China: intentions and barriers

Background

This study aimed to describe the intentions of and barriers to the use of long-acting reversible contraceptives (LARCs) in the post-abortion period among women seeking abortion in mainland China.

Methods

A cross-sectional study was conducted from July 2015 to December 2015 using a waiting room questionnaire. A total of 381 women seeking abortions were recruited at a public hospital abortion clinic. The outcome variable was an ‘intention-to-use’ LARCs in the immediate post-abortion period. Chi-square tests were used to assess associations between categorical variables. Statistically significant variables (p ≤ 0.05) were then further analyzed by logistic regression.

Results

Among 381 respondents, 42.5% intended to use LARCs in the immediate post-abortion period; 35.2% intended to use intra-uterine devices (IUDs); and 13.9% intended to use implants. Previous use of LARC was a predictor for an intention to use LARCs (odds ratio [OR] = 2.41; 95% confidence interval [CI]: 1.06–5.47). Participants with one or no child had reduced odds for an intention to use LARC (OR = 0.32, 95% CI: 0.15–0.47 and OR = 0.29, 95% CI: 0.13–0.68, respectively). Women with a higher sex frequency (at least once per week) showed increased odds for LARC use (OR = 3.34; 95% CI: 1.03–10.78) and married women were more likely to use LARC than single women (OR = 1.57; 95% CI:1.00–2.47). Women who planned to have another baby within two years were more likely not to use LARCs in the immediate post-abortion period (OR = 0.97; 95% CI: 0.43–2.12). Barriers to the use of LARCs were anxiety relating to impaired future fertility (56.2%), LARCs being harmful to health (45.2%), irregular bleeding (44.3%), risk of IUD failure (41.6%) and lack of awareness with respect to LARCs (36.1%).

Conclusions

Intention to use LARCs was predicted by marital status, frequency of sexual activity, number of children, planned timing of next pregnancy, and previous LARC use. Impaired future fertility, being harmful to health, irregular bleeding, risk of complications, and lack of awareness with regards to LARCs were the main barriers in their potential use.

"I think maybe 10 years seems a bit long." Beliefs and attitudes of women who had never used intrauterine contraception

AIM

To explore, in a general practice setting, the concerns, beliefs and attitudes about intrauterine contraception (IUC) reported by women, who had never used the methods.

METHODS

We used a sequential mixed-method (QUAL/quant) approach. A pragmatic, self-selecting sample of 30 women, aged 18-46 years, who had never used IUC), was recruited through seven general practices in South East England. Themes arising from qualitative interviews were used to construct a quantitative survey, completed by a pragmatic sample of 1195 women, aged 18-49 years, attending 32 general practices in the same region, between February and August 2015.

RESULTS

Qualitative themes were concerns about the long-acting nature of IUC, concerns about body boundaries, and informal knowledge of IUC, especially 'friend of a friend' stories. Women were not sure if the devices can be removed before their full 5- or 10-year duration of use, and felt that these timeframes did not fit with their reproductive intentions. Quantitative survey data showed that the most commonly endorsed concerns among never-users were painful fitting (55.8%), unpleasant removal of the device (60.1%), and concern about having a device 'inside me' (60.2%).

CONCLUSIONS

To facilitate fully informed contraceptive choice, information provided to women considering IUC should be tailored to more fully address the concerns expressed by never-users, particularly around the details of insertion and removal, and concerns about the adverse, long-term effects of the device. Women need to be reassured that IUC can be removed and fertility restored at any time following insertion.

TRIAL REGISTRATION

Trial registration NIHR CRN portfolio; 15912.

Provider and Health System Factors Associated with Usage of Long-Acting Reversible Contraception in Adolescents

STUDY OBJECTIVE

Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents. Surveys of primary care providers suggest that physician and clinic factors might influence LARC counseling, but their effect on usage is unknown. Our objective was to explore provider and clinic characteristics associated with LARC usage in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional study of 5363 women ages 15-21 years receiving primary care within a large health system in Massachusetts in 2015. We used data abstracted from electronic medical records to characterize rates of LARC usage. We analyzed the association of provider (specialty, degree, gender, resident status, LARC credentialing) and clinic (Title X funding, onsite LARC provision, onsite obstetrician-gynecologist) factors with adolescents' LARC usage using multivariate logistic regression.

RESULTS

Overall, 3.4% (95% confidence interval [CI], 2.9-3.9) of adolescents were documented as currently using a LARC method. Older adolescents were significantly more likely to use a LARC method (adjusted odds ratio, 2.41; 95% CI, 1.62-3.58 for women ages 20-21 years compared with ages 15-17 years). Adolescents whose primary care provider was a resident were significantly more likely to use a LARC method (adjusted odds ratio, 1.65; 95% CI, 1.02-2.68). Provider specialty, degree, gender, onsite LARC provision, and onsite obstetrician-gynecologist were not significantly associated with LARC usage in adolescents.

CONCLUSION

Being older and having a primary care provider early in their training increased the odds of LARC usage among adolescents in a large Massachusetts health system. Across primary care specialties, educating providers about the appropriate uses of LARC methods in nulliparous adolescents might facilitate LARC usage.

Provider and lay perspectives on intra-uterine contraception: a global review

BACKGROUND

Intra-uterine contraception (IUC) involves the use of an intra-uterine device (IUD), a highly effective, long-acting, reversible contraceptive method. Historically, the popularity of IUC has waxed and waned across different world regions, due to policy choices and shifts in public opinion. However, despite its advantages and cost-effectiveness for programmes, IUC's contribution to contraceptive prevalence is currently negligible in many countries. This paper presents the results of a systematic review of the global literature on provider and lay perspectives on IUC. It aims to shed light on the reasons for low use of IUC and reflect on potential opportunities for the method's promotion.

METHODS

A systematic search of the literature was conducted in four peer-reviewed journals and four electronic databases (MEDLINE, EMBASE, POPLINE, and Global Health). Screening resulted in the inclusion of 68 relevant publications.

RESULTS

Most included studies were conducted in areas where IUD use is moderate or low. Findings are similar across these areas. Many providers have low or uneven levels of knowledge on IUC and limited training. Many wrongly believe that IUC entails serious side effects such as pelvic inflammatory disease (PID), and are reluctant to provide it to entire eligible categories, such as HIV-positive women. There is particular resistance to providing IUC to teenagers and nulliparae. Provider opinions may be more favourable towards the hormonal IUD. Some health-care providers choose IUC for themselves. Many members of the public have low knowledge and unfounded misconceptions about IUC, such as the fear of infertility. Some are concerned about the insertion and removal processes, and about its effect on menses. However, users of IUC are generally satisfied and report a number of benefits. Peers and providers exert a strong influence on women's attitudes.

CONCLUSION

Both providers and lay people have inaccurate knowledge and misconceptions about IUC, which contribute to explaining its low use. However, many reported concerns and fears could be alleviated through correct information. Concerted efforts to train providers, combined with demand creation initiatives, could therefore boost the method's popularity. Further research is needed on provider and lay perspectives on IUDs in low- and middle-income countries.

A Qualitative Application of Diffusion of Innovations to Adolescents' Perceptions of Long-Acting Reversible Contraception's Attributes

STUDY OBJECTIVE

Long-acting reversible contraceptive (LARC) methods are the most effective forms of reversible contraception but adolescents often opt for other, less effective methods. In this study we explored how adolescents viewed LARC as an innovation to be adopted or rejected, and how their assessment of innovation attributes affected their decisions about LARC. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Sexually active adolescents between 15 and 22 years old (n = 22) participated in semistructured qualitative interviews. The data underwent a content analysis informed by constructs of the diffusion of innovations and emergent interview themes.

RESULTS

Data analysis indicated 3 subgroups of participants on the basis of their inclination to use LARC and the mutability of that position: positive/persuaded (n = 7), negative/low knowledge (n = 10), and negative/adamant (n = 5). Participants' perceptions of the relative advantage, compatibility, complexity, trialability, and observability of LARC cohered around subgroup membership. Perceived complexity entailed in obtaining LARC and fears about LARC were observed across all participants. All participants believed that one has to try LARC to know how it will work for her, personally. This led the positive/persuaded group to be undeterred by others' negative experiences with LARC and the negative/low knowledge and negative/adamant groups to decide LARC was too risky to try.

CONCLUSION

Adolescents engage in nuanced evaluations of LARC, weighing competing information about LARC while receiving anecdotal and empirical information about LARC from various valid sources. To reduce the uncertainty about LARC that prohibits trying these methods, adolescents require straightforward information about LARC that directly addresses the advantages of LARC over other methods coupled with candid acknowledgement of the potential disadvantages of LARC.

A Snapshot of Urban Adolescent Women's Contraceptive Knowledge at the Onset of a Community Long-Acting Reversible Contraceptive Promotion Initiative

STUDY OBJECTIVE

To contextualize young women's knowledge and attitudes regarding contraception at the outset of an intervention promoting long-acting reversible contraceptive (LARC) use for teen pregnancy prevention.

DESIGN AND SETTING

Our intervention was on the basis of diffusion of innovation theory, and at the outset we were interested in likely early adopters' existing knowledge and attitudes toward contraception. This mixed methods study consisted of focus groups within positive youth development programs in Rochester, New York; we discussed young women's knowledge and sources of information for all US Food and Drug Administration-approved contraceptive methods.

PARTICIPANTS

Seven focus groups and 24 female adolescent participants aged 15-19 years.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Quantitative ranking of all contraceptive methods; qualitative themes from focus group discussions.

RESULTS

Our findings showed a high level of knowledge about a select group of methods, which included LARC methods, and that participants received contraceptive information from peers and family. Participants had more concerns than positive impressions regarding the effectiveness, safety, practicality, and partner reception of the contraceptive methods, with the exception of the condom. Quantitatively, the condom received the highest average rating.

CONCLUSION

The importance of personal anecdotes in our findings supports the use of outreach and information campaigns; providing medically accurate information and spreading positive personal anecdotes will be key to improving young women's impressions of the safety and acceptability of LARC use. This snapshot of contraceptive knowledge indicates that young women can be mature, informed consumers of sexual and reproductive health care, and through diffusion of innovation could be key players in promoting the most effective means of pregnancy prevention.

Bone Mineral Density and Weight Changes in Adolescents Randomized to 3 Doses of Depot Medroxyprogesterone Acetate

STUDY OBJECTIVE

To assess the association between medroxyprogesterone acetate exposure and bone mineral density (BMD) loss and weight change in adolescents.

DESIGN

Forty-eight-week prospective, randomized trial conducted May 2012-April 2014.

SETTING

Recruitment occurred in the general community and outpatient clinics in central Ohio.

PARTICIPANTS

Self-referred sample of 34 female adolescents aged 12-21 years initiating depot medroxyprogesterone acetate (DMPA).

INTERVENTIONS

Randomization to 1 of 3 DMPA doses (150, 104, or 75 mg) given intramuscularly every 12 weeks for 48 weeks.

MAIN OUTCOME MEASURES

Absolute and percent change in BMD from 0-48 weeks at the L1-L4 lumbar spine, total hip, and femoral neck; absolute and percent change in weight at 48 weeks.

RESULTS

DMPA dose was associated with medroxyprogesterone acetate exposure as evidenced by a direct relationship (P < .001) between dose group and area under the concentration time curve. At 48 weeks, no significant BMD decreases were seen in the 75 mg dose group. The 104 and 150 mg dose groups experienced significant (P < .01) decreases in L1-L4 lumbar spine BMD (3.1% and 4.0%, respectively). The 150 mg group also had significant (P < .05) decreases in total hip (3.0%) and femoral neck (4.0%) BMD. No group differences in weight change were observed. No pregnancies occurred in any DMPA dose group.

CONCLUSIONS

Our data provide evidence of a dose-response relationship between DMPA and BMD loss. Intramuscular DMPA doses less than 150 mg can decrease risk of BMD loss in adolescents. The risk/benefit ratio of lower-dose DMPA should be further investigated in larger and more diverse adolescent populations.

2016 Updates to US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use: Highlights for Adolescent Patients

The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.

What do young Australian women want (when talking to doctors about contraception)?

Background

Access to most contraceptives in Australia requires a prescription from a doctor, and it has been shown that doctors can influence women’s decision-making with respect to contraception. However, little research has documented how women experience their interactions with doctors within the context of a contraceptive consultation. Understanding such experiences may contribute to our knowledge of factors that may influence women’s contraceptive decisions more broadly.

Methods

We report on findings from the Contraceptive Use, Pregnancy Intentions and Decisions (CUPID) survey of young Australian women, a large-scale longitudinal study of 3,795 women aged 18–23 years. We performed a computer-assisted search for occurrences of words that indicated an interaction within the 1,038 responses to an open-ended question about contraception and pregnancy. We then applied a combination of conventional and summative content analysis techniques to the 158 comments where women mentioned an interaction about contraception with a doctor.

Results

Our analysis showed that women desire consistent and accurate contraception information from doctors, in addition to information about options other than the oral contraceptive pill. Some young women reported frustrations about the choice limitations imposed by doctors, perceived by these women to be due to their young age. Several women expressed disappointment that their doctor did not fully discuss the potential side-effects of contraceptives with them, and that doctors made assumptions about the woman’s reasons for seeking contraception. Some women described discomfort in having contraception-related discussions, and some perceived their doctor to be unsupportive or judgmental.

Conclusions

Both the content and the process of a contraceptive consultation are important to young Australian women, and may be relevant contributors to their choice and ongoing use of a contraceptive method. These findings provide useful insights into aspects of the patient-provider interaction that will enhance the efficacy of the contraceptive consultation. It is recommended that doctors adopt patient-centred, shared decision-making strategies to support women in making choices about contraception that suit their individual circumstances. We also acknowledge the need to involve other health care providers, other than doctors, in educating, informing, and assisting women to make the best contraceptive choice for themselves.

Barriers and Facilitators to Adolescents' Use of Long-Acting Reversible Contraceptives

Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse. The etonogestrel implant and intrauterine devices, referred to as long-acting reversible contraceptives, or LARCs, are the most effective reversible contraceptive methods. These methods are safe for use by adolescents, yet the number of LARC users remains low among adolescents in the United States. In this review we examine recent literature about barriers and facilitators to LARC use among adolescent women. Factors that influence decision-making and provision are organized into 4 categories: (1) cost and clinical operations; (2) adolescent awareness and attitudes; (3) confidentiality, consent, and parental attitudes; and (4) health care provider knowledge, attitudes, and counseling. Knowledge deficits and misconceptions among adolescents and their health care providers are key barriers to adolescent LARC use.

Important considerations in adolescent health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding

PURPOSE OF REVIEW

The present article addresses recent research related to three key facets of adolescent preventive care and health maintenance: long-acting reversible contraception, human papillomavirus vaccination, and heavy menstrual bleeding.

RECENT FINDINGS

Recent studies suggest that long-acting reversible contraception use results in significantly lower rates of unintended pregnancies, and is well tolerated by nulliparous adolescent females. Additionally, a strong recommendation from a pediatric primary care provider is extremely effective in ensuring human papillomavirus vaccination prior to sexual debut. Finally, heavy menstrual bleeding is often under-recognized in adolescents, and evaluation and treatment of these patients are variable.

SUMMARY

Based on the recent literature findings, the pediatric primary care provider should be encouraged to, first, recommend long-acting reversible contraception for prevention of unintended pregnancy in adolescent patients; second, strongly endorse vaccination to protect against human papillomavirus in all patients prior to sexual debut; and, third, screen adolescent females for signs and symptoms of heavy menstrual bleeding.

Medications to ease intrauterine device insertion: a systematic review

BACKGROUND

Potential barriers to intrauterine device (IUD) use include provider concern about difficult insertion, particularly for nulliparous women.

OBJECTIVE

This study aims to evaluate the evidence on the effectiveness of medications to ease IUD insertion on provider outcomes (i.e., ease of insertion, need for adjunctive insertion measures, insertion success).

SEARCH STRATEGY

We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that examined medications to ease interval insertion of levonorgestrel-releasing IUDs and copper T IUDs.

RESULTS

From 1855 articles, we identified 15 RCTs that met our inclusion criteria. Most evidence suggested that misoprostol did not improve provider ease of insertion, reduce the need for adjunctive insertion measures or improve insertion success among general samples of women seeking an IUD (evidence Level I, good to fair). However, one RCT found significantly higher insertion success among women receiving misoprostol prior to a second IUD insertion attempt after failed attempt versus placebo (evidence Level I, good). Two RCTs on 2% intracervical lidocaine as a topical gel or injection suggested no positive effect on provider ease of insertion (evidence Level I, good to poor), and one RCT on diclofenac plus 2% intracervical lidocaine as a topical gel suggested no positive effect on provider ease of insertion (evidence Level I, good). Limited evidence from two RCTs on nitric oxide donors, specifically nitroprusside or nitroglycerin gel, suggested no positive effect on provider ease of insertion or need for adjunctive insertion measures (evidence Level I, fair).

CONCLUSIONS

Overall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls. Among women with a recent failed insertion who underwent a second insertion attempt, one RCT found improved insertion success among women using misoprostol versus placebo.

Long-Acting Reversible Contraception Counseling and Use for Older Adolescents and Nulliparous Women

PURPOSE

The majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention.

METHODS

Sexually active women aged 18-25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering.

RESULTS

Women in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR = .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42-.79) and to select LARC (aOR = .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41-.85).

CONCLUSIONS

Continued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.

Interdependent Barriers to Providing Adolescents with Long-Acting Reversible Contraception: Qualitative Insights from Providers

STUDY OBJECTIVE

Long-acting reversible contraceptive (LARC) methods are the most effective form of reversible contraception but are underutilized by adolescents. The purpose of this study was to identify the context-specific barriers to providing adolescents with LARC that are experienced by pediatricians, family medicine physicians, and advanced practice nurses (APNs).

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Pediatricians, family medicine providers, and APNs (n = 16) who care for adolescents participated in semistructured qualitative interviews. Interview data were analyzed using a modified grounded theory approach.

MAIN OUTCOME MEASURES

Pediatricians, family medicine physicians, and APNs self-reported attitudes and practices regarding LARC provision to adolescents.

RESULTS

Provider confidence in LARC, patient-centered counseling on LARC, and instrumental supports for LARC all work interdependently either in support of or in opposition to provision of LARC to adolescents. Low provider confidence in LARC for adolescents was characterized by confusion about LARC eligibility criteria and perceptions of LARC insertion as traumatic for adolescents. Patient-centered counseling on LARC required providers' ability to elicit patient priorities, highlight the advantages of LARC over other methods, and address patients' concerns about these methods. Instrumental support for LARC included provider training on LARC, access to and financial support for LARC devices, and opportunity to practice LARC insertion and counseling skills.

CONCLUSION

Although none of the identified essential components of LARC provision to adolescents exist in isolation, instrumental support like provider training on LARC and access to LARC devices have the most fundamental effect on the other components and on providers' attitudes and practices regarding LARC for adolescents.

Trends in Long-Acting Reversible Contraception Use in Adolescents and Young Adults: New Estimates Accounting for Sexual Experience

PURPOSE

The purposes of the analysis were to compare long-acting reversible contraception (LARC) use estimates that include all reproductive age women with estimates that are limited to women at risk for unintended pregnancy and to examine trends for adolescents (15-19 years) and young adults (20-24 years).

METHODS

Using the 2006-2010 and 2011-2013 National Surveys of Family Growth, we compared LARC estimates for all women with estimates limited to women at risk for unintended pregnancy (those who were sexually experienced, and neither pregnant, seeking pregnancy, postpartum or infecund). We used t tests to detect differences according to the population included and to evaluate trends for adolescents and young adults.

RESULTS

Among adolescents and young adults, 56% and 14%, respectively, have never had vaginal intercourse, versus 1%-4% for women aged 25-44 years. Given the high percentage of adolescents and young adults who never had vaginal intercourse, LARC estimates were higher for these age groups (p < .05), but not for women aged 25-44 years, when limited to those at risk for unintended pregnancy. Among adolescents at risk, the increase in LARC use from 2006-2008 (1.1%) to 2008-2010 (3.6%) was not significant (p = .07), and no further increase occurred from 2008-2010 to 2011-2013 (3.2%); by contrast, among young adults at risk, LARC use increased from 2006-2008 (3.2%) to 2008-2010 (6.9%) and from 2008-2010 to 2011-2013 (11.1%).

CONCLUSIONS

Because many adolescents and young adult women have never had vaginal intercourse, for these groups, including all women underestimates LARC use for pregnancy prevention. Among young adults, use of LARC for pregnancy prevention has increased but remains low among adolescents.

New developments in intrauterine device use: focus on the US

Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.

Urban Adolescents' and Young Adults' Decision-Making Process around Selection of Intrauterine Contraception

STUDY OBJECTIVE

To examine adolescent and young adults' priorities, values, and preferences affecting the choice to use an intrauterine contraceptive device (IUD).

DESIGN

Qualitative exploratory study with analysis done using a modified grounded theory approach.

SETTING

Outpatient adolescent medicine clinic located within an academic children's hospital in the Bronx, New York.

PARTICIPANTS

Twenty-seven women aged 16 to 25 years of age on the day of their IUD insertion.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We conducted semistructured interviews exploring participant's decision making process around selecting an IUD. We were specifically interested in elucidating factors that could potentially improve IUD counseling.

RESULTS

We identified 4 broad factors affecting choice: (1) personal; (2) IUD device-specific; (3) health care provider; and (4) social network. Most of the participants perceived an ease with a user-independent method and were attracted by the high efficacy of IUDs, potential longevity of use, and the option to remove the device before its expiration. Participants described their health care provider as being the most influential individual during the IUD decision-making process via provision of reliable, accurate contraceptive information and demonstration of an actual device. Of all people in their social network, mothers played the biggest role.

CONCLUSION

Adolescents and young women who choose an IUD appear to value the IUDs' efficacy and convenience, their relationship with and elements of clinicians' contraceptive counseling, and their mother's support. Our results suggest that during IUD counseling, clinicians should discuss these device-specific benefits, elicit patient questions and concerns, and use visual aids including the device itself. Incorporating the factors we found most salient into routine IUD counseling might increase the number of adolescents and young women who choose an IUD as a good fit for them.

A Qualitative Study of Factors That Influence Contraceptive Choice among Adolescent School-Based Health Center Patients

STUDY OBJECTIVE

Long-acting reversible contraceptive (LARC) methods can prevent teen pregnancy yet remain underutilized by adolescents in the United States. Pediatric providers are well positioned to discuss LARCs with adolescents, but little is known about how counseling should occur in pediatric primary care settings. We explored adolescent womens' attitudes and experiences with LARCs to inform the development of adolescent-centered LARC counseling strategies.

DESIGN

Qualitative analysis of one-on-one interviews.

SETTING

Participants were recruited from 2 urban school-based, primary care centers.

PARTICIPANTS

Thirty adolescent women aged 14-18 years, diverse in race/ethnicity, and sexual experience.

INTERVENTIONS

Interviews were audio-recorded, transcribed, and coded using inductive and deductive coding.

MAIN OUTCOME MEASURE

Major themes were identified to integrate LARC-specific adolescent preferences into existing counseling approaches.

RESULTS

Participants (mean age, 16.2 years; range, 14-18 years) represented a diverse range of racial and/or ethnic identities. Half (15/30) were sexually active and 17% (5/30) reported current or past LARC use. Five themes emerged regarding key factors that influence LARC choice, including: (1) strong preferences about device-specific characteristics; (2) previous exposure to information about LARCs from peers, family members, or health counseling sessions; (3) knowledge gaps about LARC methods that affect informed decision-making; (4) personal circumstances or experiences that motivate a desire for effective and/or long-acting contraception; and (5) environmental constraints and supports that might influence adolescent access to LARCs.

CONCLUSION

We identified 5 factors that influence LARC choice among adolescent women and propose a framework for incorporating these factors into contraceptive counseling services in pediatric primary care settings.

Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial

BACKGROUND

Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting.

OBJECTIVE

We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion.

STUDY DESIGN

This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year.

RESULTS

Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43).

CONCLUSIONS

The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.

Knowledge and Acceptability of Long-Acting Reversible Contraception Among Adolescent Women Receiving School-Based Primary Care Services

BACKGROUND

A key strategy to reduce unintended adolescent pregnancies is to expand access to long-acting reversible contraceptive (LARC) methods, including intrauterine devices and subdermal contraceptive implants. LARC services can be provided to adolescents in school-based health and other primary care settings, yet limited knowledge and negative attitudes about LARC methods may influence adolescents' utilization of these methods. This study aimed to evaluate correlates of knowledge and acceptability of LARC methods among adolescent women at a school-based health center (SBHC).

METHODS

In this cross-sectional study, female patients receiving care at 2 SBHCs in Seattle, Washington completed an electronic survey about sexual and reproductive health. Primary outcomes were (1) LARC knowledge as measured by percentage correct of 10 true-false questions and (2) LARC acceptability as measured by participants reporting either liking the idea of having an intrauterine device (IUD)/subdermal implant or currently using one.

RESULTS

A total of 102 students diverse in race/ethnicity and socioeconomic backgrounds completed the survey (mean age 16.2 years, range 14.4-19.1 years). Approximately half reported a lifetime history of vaginal sex. Greater LARC knowledge was associated with white race (regression coefficient [coef] = 26.8; 95% CI 13.3-40.4; P < .001), history of vaginal intercourse (coef = 29.9; 95% CI 17.1-42.7; P < .001), and current/prior LARC use (coef = 22.8; 95% CI 6.5-40.0; P = .007). Older age was associated with lower IUD acceptability (odds ratio = 0.53, 95% CI 0.30-0.94; P = .029) while history of intercourse was associated with greater implant acceptability (odds ratio 5.66, 95% CI 1.46-22.0; P = .012).

DISCUSSION

Adolescent women in this SBHC setting had variable knowledge and acceptability of LARC. A history of vaginal intercourse was the strongest predictor of LARC acceptability. Our findings suggest a need for LARC counseling and education strategies, particularly for young women from diverse cultural backgrounds and those with less sexual experience.

Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers

Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion

OBJECTIVE

Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking.

STUDY DESIGN

Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared.

RESULTS

Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27).

CONCLUSION

This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention.

An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception

OBJECTIVE

We examine the association between depressive symptoms and contraceptive method choice among adolescents initiating prescription contraception.

STUDY DESIGN

This cross-sectional study analyzes baseline data of 220 urban, minority adolescent females (ages 15-19 years) presenting for prescription contraceptive initiation at a comprehensive, free-of-cost, adolescent health center in New York City. All participants met with a health care provider who provided standard contraception counseling before initiating contraception. Each participant then selected a short- or long-acting contraceptive: a 3-month supply of the pill, patch, ring or a medroxyprogesterone acetate depot injection (short-acting), or placement/referral for an intrauterine device (IUD; long-acting). We assess the independent association between contraceptive method selection and symptoms of depression [assessed by the Center for Epidemiological Studies - Depression (CES-D) scale].

RESULTS

Ten percent (n=21/220) of adolescent females selected an IUD. Bivariate analysis revealed that those with elevated levels of depressive symptoms were more likely to select an IUD as compared to those with minimal symptoms (mean CES-D score 20 vs. 13; t=3.052, p=.003). In multivariate logistic regressions, adolescent females had increased odds of selecting an IUD if they reported moderate to severe depressive symptoms (adjusted odds ratio=4.93; confidence interval, 1.53-15.83; p=.007) after controlling for ethnicity/race, education, number of lifetime partners and gravidity.

CONCLUSIONS

Inner-city, minority adolescents with elevated symptoms of depression who present for prescription contraceptive initiation may be more likely to select an IUD rather than shorter-acting methods. By recognizing adolescent females with depressive symptoms, providers can strategize their approach to effective contraception counseling.

The relationship between contraceptive features preferred by young women and interest in IUDs: an exploratory analysis

CONTEXT

Little research has examined the relationship between women's preferences of contraceptive features and their interest in IUD use. Given high levels of contraceptive discontinuation and dissatisfaction, a better understanding of contraceptive preferences may support women in finding their optimal method and meeting their family planning goals.

METHODS

Data from 382 heterosexual women aged 18-29 were collected via a 2012 Internet survey. Chi-square tests and multivariate, multinomial logistic regression models were used to examine relationships between contraceptive features preferred by women and their interest in IUD use.

RESULTS

Forty-eight percent of women reported being unsure whether they would ever use an IUD; 20% were interested in using one, and 32% were not. In multivariate analyses, characteristics of a contraceptive method found positively associated with IUD interest were the method's not interfering with sexual pleasure (relative risk ratio, 3.4), being 99% effective without user action (2.5) and being effective for up to five years without any user action (3.8). Women who preferred a method that they could see or that would allow them to resume fertility immediately after discontinuation were less likely than those who did not to be interested in using rather than not using an IUD (0.4-0.5).

CONCLUSIONS

The findings of this exploratory analysis indicate that women value a multitude of contraceptive features, which may have implications for their interest in using an IUD. Future research should consider the ways that women's contraceptive preferences can be incorporated into contraceptive counseling.