Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3627 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures appear to be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Global trends in use of long-acting reversible and permanent methods of contraception: Seeking a balance

The global trend shows that the use of permanent contraception to prevent unintended pregnancy is high. Although the trend also shows a rise in the use of long-acting reversible methods, these are still underutilized despite having contraceptive as well as non-contraceptive benefits. Lack of knowledge among women, dependence on the provider for information, and provider bias for permanent contraception are cited as reasons for this reduced uptake. Training of healthcare providers and increased patient awareness about the effectiveness of long-acting reversible contraceptive methods will increase their uptake and help prevent unintended pregnancies.

Trends of contraception among ladies of local population in Pakistan; why, how, when and what?

Objective:

To analyze trends of use of methods of contraception along with study of impact of various demographic and social factors on contraception in Peshawar, Pakistan.

Methods:

A cross-sectional descriptive study with random purposive sampling was conducted at Combined Military Hospital Peshawar, from Mar 2015-Nov 2015. Self-designed questionnaire with demographic details and questions pertinent to contraceptive practices was utilized as study instrument. Females reporting to concerned hospital for contraceptive advice and prescription were distributed with questionnaire and written informed consent form. Formal approval was taken from ethical committee of hospital. Data was analyzed via descriptive analysis (SPSS-21), qualitative data was expressed as frequencies and percentages; quantitative as mean±standard deviation (SD). Main outcome variable i-e contraceptive device used; was cross-tabulated with independent variables.

Results:

Response rate was 53.2% (n-426). Usage of contraceptive device was as follows; 51.2% Nil, 9.4% barriers, 22.3% oral/injectable hormones, 13.4% IUCDs, 3.8% sterilization. There was a strong relationship between type of contraceptives used and age (p<0.001), client’s education (p<0.001), husband’s education (p<0.001), number of children (p<0.001), religion (p0.013), socioeconomic class (p<0.001), and religious beliefs about use of contraceptives (p<0.001). More Muslims considered contraception irreligious than non-Muslims (p 0.02). There was no significant impact of husbands’ pressure to not to use contraceptives on type of contraception practised (p 0.114).

Conclusion:

Contraceptive devices are under-utilized in the study participants. Multidisciplinary approach should be applied to enhance client education, awareness and counseling to utilize these devices more appropriately and regularly.

Evaluating the impact of social franchising on family planning use in Kenya

BACKGROUND

In Kenya, as in many low-income countries, the private sector is an important component of health service delivery and of providing access to preventive and curative health services. The Tunza Social Franchise Network, operated by Population Services Kenya, is Kenya's largest network of private providers, comprising 329 clinics. Franchised clinics are only one source of family planning (FP), and this study seeks to understand whether access to a franchise increases the overall use or provides another alternative for women who would have found FP services in the public sector.

METHODS

A quasi-experimental study compared 50 catchment areas where there is a Tunza franchise and no other franchised provider with 50 purposively matched control areas within 20 km of each selected Tunza area, with a health facility, but no franchised facility. Data from 5609 women of reproductive age were collected on demographic and socioeconomic status, FP use, and care-seeking behavior. Multivariate logistic regression, with intervention and control respondents matched using coarsened exact matching, was conducted.

RESULTS

Overall modern contraceptive use in this population was 53 %, with 24.8 % of women using a long-acting or permanent method (LAPM). There was no significant difference in odds of current or new FP use by group, adjusted for age. However, respondents in Tunza catchment areas are significantly more likely to be LAPM users (adj. OR = 1.49, p = 0.015). Further, women aged 18-24 and 41-49 in Tunza catchment areas have a significantly higher marginal probability of LAPM use than those in control areas.

CONCLUSIONS

This study indicates that access to a franchise is correlated with access to and increased use of LAPMs, which are more effective, and cost-effective, methods of FP. While franchised facilities may provide additional points of access for FP and other services, the presence of the franchise does not, in and of itself, increase the use of FP in Kenya.

Trends and determinants of IUD use in the USA, 2002-2012

STUDY QUESTION

What factors and subgroups have propelled the recent increase in intrauterine device (IUD) use in the USA?

SUMMARY ANSWER

The increase in IUD use, from 1.8 to 9.5% in the USA between 2002 and 2012, was driven primarily by a marked uptake among parous women who intended to have more children.

WHAT IS KNOWN ALREADY

Recent data suggest an unprecedented increase in IUD use among women in the USA, yet less is known about how this increase has affected the overall proportion of women, at risk of unintended pregnancy, who are using contraception and which social and economic groups are involved.

STUDY DESIGN, SIZE, DURATION

Data are drawn from the 2002 and 2011-2013 National Surveys of Family Growth. The surveys were based on cross-sectional, national samples of women of 15-44 years of age in the USA. Women responded to in-person interviews, which lasted an average of 80 min. The response rate was 80% in 2002 and 73% in 2011-2013. The sample included 7643 completed interviews in 2002 and 5601 interviews in 2011-2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study was limited to women at risk of unintended pregnancy, i.e. women who were sexually active in the previous 3 months (using contraception or not); it excludes women who were sterile, currently pregnant or trying to conceive. Altogether, 5181 women were at risk in the 2002 sample and 3681 were at risk in the 2012 sample. We used descriptive statistics to investigate trends in contraceptive use patterns by women's sociodemographic characteristics between 2002 and 2012 and used logistic regression to identify current predictors of IUD use in 2012.

MAIN RESULTS AND THE ROLE OF CHANCE

IUD use increased from 1.8% in 2002 to 9.5% in 2012 (P < 0.001). The surge was especially marked among parous women who intended to have more children (4.2% in 2002 to 19.3% in 2012; P < 0.001); it occurred to a lesser extent among parous women who did not intend to have more children (2.0-9.7% P < 0.001), suggesting that IUDs are more often used for spacing than for ending childbearing in the USA. The most important predictors of IUD use in 2012 were age, parity and intent to have children. Dissatisfaction with a previous method was also associated with IUD use (adjusted odds ratio = 1.89, P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

As with all cross-sectional studies, causal inference is limited. Data are self-reported, but the survey had a high response rate and rigorous quality controls.

WIDER IMPLICATION OF THE FINDINGS

This study shows promising trends in the use of highly effective contraceptive methods in the USA, which may help to explain recently reported declines in unintended pregnancy in the USA.

STUDY FUNDING/COMPETING INTERESTS

Caroline Moreau was supported by the William Robertson endowment funds. The work of Hannah Lantos and William Mosher on this analysis was supported by the Department of Population Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health. The authors declare that no conflict of interest exists.

The risk of using intrauterine devices to benign reproductive system conditions in postmenopausal women: A case control study

Background:

To investigate the effect of using intrauterine devices (IUDs) during the fertile window on women's reproductive system health.

Materials and Methods:

2,744 postmenopausal women in the Minhang District, Shanghai, China were enrolled. In the IUDs group there were 2,253 women; in the tubal ligation group there were 202 women and there were 289 women in the control group. We selected subjects according to the cases number in different hospital by using step sampling, and, in addition, collected the sociological data and information of the previously used contraceptives by the subjects, which included whether the contraceptives were used appropriately and the effect they had. Kolmogorov-Smirnov test, Levene's test, and logistic regression analysis were used to analyze the data.

Results:

The prevalence rate of benign reproductive system conditions was significantly different among them (P < 0.05). Further comparison revealed, the rate in Group 1 was significantly lower than that in Group 2 and Group 3 (P < 0.05, respectively). Results of logistic regression analysis show that the risk factors for development of such conditions lie in the women's pregnancy history [odds ratio (OR) = 3.85], reproductive history (OR = 0.5), the use of IUD in fertile window (OR = 0.4), tubal ligation (OR = 1.74), birth control time (OR = 0.9), contraceptive failure history (OR = 1.7), and history of family planning procedures (OR = 1.73).

Conclusion:

IUDs, maybe, can effectively reduce the risk of getting benign reproductive conditions in postmenopausal females.

Contraception for women with diabetes: challenges and solutions

Diabetes mellitus (DM), the most common of metabolic disorders, is a global public health concern. Numbers are rising with 383 million adults currently diagnosed with DM and another 175 million as yet undiagnosed. The rise in cases includes increasing numbers of women of a reproductive age whose reproductive health and contraception need careful consideration. Unintended pregnancy with poor glycemic control at the time of conception increases the chance of adverse pregnancy outcomes including stillbirth, congenital abnormalities, and perinatal mortality. In order to minimize complications, safe and effective contraception is paramount for all women with DM. This is a challenge as women have been found to be reticent to ask for advice, appear to lack understanding of risks, and are less likely to be using contraception than women without DM. The World Health Organization has developed Medical Eligibility Criteria to guide contraceptive choice. Women with DM without complications can choose from the full range of contraceptive methods including hormonal contraception as the advantages of use outweigh any risk. Women with diabetic complications may need specialist advice to assess the risk–benefit equation, particularly in respect of hormonal contraception. Women should be aware that there is no restriction to the use of oral and copper intrauterine emergency contraception methods. There is a need for an integrated approach to diabetes and reproductive health with improved communication between women with DM and their health care providers. Women need to be aware of advice and services and should make their own choice of contraception based on their needs and associated risk factors. Practitioners can offer nonjudgmental guidance working in partnership with women. This will enable discussion of risks and benefits of contraceptive methods and provision of advice dedicated to improving overall health and well-being.

US family physicians' intrauterine and implantable contraception provision: results from a national survey

OBJECTIVE

Establish a current cross-sectional national picture of intrauterine device (IUD) and implant provision by US family physicians and ascertain individual, clinical site and scope of practice level associations with provision.

STUDY DESIGN

Secondary analysis of data from 2329 family physicians recertifying with the American Board of Family Medicine in 2014.

RESULTS

Overall, 19.7% of respondents regularly inserted IUDs, and 11.3% regularly inserted and/or removed implants. Family physicians provided these services in a wide range of clinical settings. In bivariate analysis, almost all of the individual, clinical site and scope of practice characteristics we examined were associated with provision of both methods. In multivariate analysis, the scope of practice characteristics showed the strongest association with both IUD and implant provision. For IUDs, this included providing prenatal care with [adjusted odds ratio (aOR) 3.26, 95% confidence interval (95% CI)=1.93-5.49] or without (aOR=3.38, 95% CI=1.88-6.06) delivery, performance of endometrial biopsies (aOR=16.51, 95% CI=11.97-22.79) and implant insertion and removal (aOR=8.78, 95% CI=5.79-13.33). For implants, it was providing prenatal care and delivery (aOR=1.77, 95% CI=1.15-2.74), office skin procedures (aOR=3.07, 95% CI=1.47-6.42), endometrial biopsies (aOR=3.67, 95% CI=2.41-5.59) and IUD insertion (aOR=8.58, 95% CI=5.70-12.91).

CONCLUSIONS

While a minority of family physicians regularly provided IUDs and/or implants, those who provided did so in a broad range of outpatient settings. Individual and clinical site characteristics were not largely predictive of provision. This connotes potential for family physicians to increase IUD and implant access in a variety of settings. Provision of both methods was strongly associated with scope of practice variables including performance of certain office procedures as well as prenatal and/or obstetrical care.

IMPLICATIONS

These data provide a baseline from which to analyze change in IUD and implant provision in family medicine, identify gaps in care and ascertain potential leverage points for interventions to increase long-acting reversible contraceptive provision by family physicians. Interventions may be more successful if they first focus on sites and/or family physicians who already provide prenatal care, obstetrical care, skin procedures and/or endometrial biopsies.

Intrauterine contraception

Intrauterine devices (IUDs) are effective, reversible forms of contraception with high patient satisfaction and continuation. IUDs can be safely used by most women and should be considered the first-line method of contraception for all women. This descriptive review will discuss the clinical issues associated with IUDs - including management of side effects, noncontraceptive uses and insertion and removal. When the burdens of cost are removed, women are more likely to select and IUDs. Health policy changes that increase insurance coverage for contraception will improve access to IUDs. IUDs remain an underutilized form of contraception in USA and efforts to improve availability and access to long-acting reversible contraception methods is needed to optimize their use.

Effects of initiating a contraceptive implant on subsequent condom use: A randomized controlled trial

OBJECTIVE

To evaluate whether initiation of a contraceptive implant, a method of long-acting reversible contraception, reduces condom use, as measured by a biomarker of recent semen exposure [prostate-specific antigen (PSA)].

STUDY DESIGN

We conducted a randomized controlled clinical trial in which 414 Jamaican women at high risk for sexually transmitted infections (STIs) attending family planning clinics received the contraceptive implant at baseline ("immediate" insertion arm, N=208) or at the end ("delayed" insertion arm, N=206) of a 3-month study period. Participants were tested for PSA at baseline and two follow-up study visits and were asked about their sexual activity and condom use.

RESULTS

At baseline, 24.9% of women tested positive for PSA. At both follow-up visits, the prevalence of PSA detection did not significantly differ between the immediate versus delayed insertion arm [1-month: 26.1% vs. 20.2%, prevalence ratio (PR)=1.3, 95% confidence interval (CI)=0.9-1.9; 3-month: 25.6% vs. 23.1%, PR= 1.1, 95% CI=0.8-1.6]. The change in PSA positivity over the three study visits was not significantly larger in the immediate arm compared to the delayed arm (1-sided p-value of .15).

CONCLUSIONS

Contraceptive implants can be successfully introduced into a population at high risk of unintended pregnancy and STIs without a biologically detectable difference in unprotected sex in the short term. This information strengthens the evidence to support promotion of implants in such populations and can help refine counseling for promoting and maintaining use of condoms among women who choose to use implants.

IMPLICATIONS

Sex unprotected by a condom was not higher over 3 months in women receiving a contraceptive implant, compared with those not receiving the implant.

Projections and opinions from 100 experts in long-acting reversible contraception

OBJECTIVE

This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods.

STUDY DESIGN

We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions.

RESULTS

The most commonly identified barrier was the cost of the device (63%), followed by women's knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25-29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion.

CONCLUSIONS

Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women's contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women's individual needs.

IMPLICATIONS

Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women's reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.

Task Shifting Provision of Contraceptive Implants to Community Health Extension Workers: Results of Operations Research in Northern Nigeria

BACKGROUND

Contraceptive use remains low in Nigeria, with only 11% of women reporting use of any modern method. Access to long-acting reversible contraceptives (LARCs) is constrained by a severe shortage of human resources. To assess feasibility of task shifting provision of implants, we trained community health extension workers (CHEWs) to insert and remove contraceptive implants in rural communities of Bauchi and Sokoto states in northern Nigeria.

METHODS

We conducted 2- to 3-week training sessions for 166 selected CHEWs from 82 facilities in Sokoto state (September 2013) and 84 health facilities in Bauchi state (December 2013). To assess feasibility of the task shifting approach, we conducted operations research using a pretest-posttest design using multiple sources of information, including surveys with 151 trained CHEWs (9% were lost to follow-up) and with 150 family planning clients; facility observations using supply checklists (N = 149); direct observation of counseling provided by CHEWs (N = 144) and of their clinical (N = 113) skills; as well as a review of service statistics (N = 151 health facilities). The endline assessment was conducted 6 months after the training in each state.

RESULTS

CHEWs inserted a total of 3,588 implants in 151 health facilities over a period of 6 months, generating 10,088 couple-years of protection (CYP). After practicing on anatomic arm models, most CHEWs achieved competency in implant insertions after insertions with 4-5 actual clients. Clinical observations revealed that CHEWs performed implant insertion tasks correctly 90% of the time or more for nearly all checklist items. The amount of information that CHEWs provided clients increased between baseline and endline, and over 95% of surveyed clients reported being satisfied with CHEWs' services in both surveys. The study found that supervisors not only observed and corrected insertion skills, as needed, during supervisory visits but also encouraged CHEWs to conduct more community mobilization to generate client demand, thereby promoting access to quality services. CHEWs identified a lack of demand in the communities as the major barrier for providing services.

CONCLUSION

With adequate training and supportive supervision, CHEWs in northern Nigeria can provide high-quality implant insertion services. If more CHEWs are trained to provide implants and greater community outreach is conducted to generate demand, uptake of LARCs in Nigeria may increase.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3827 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was statistically significantly higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures may be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Knowledge and attitudes of Latin American obstetricians and gynecologists regarding intrauterine contraceptives

Background

Intrauterine contraceptives (IUCs), including the copper intrauterine device and the levonorgestrel-releasing intrauterine system (LNG-IUS), are among the reversible contraceptive methods with high effectiveness. However, use is low in many settings, including some Latin American countries, mainly due to the influences of myths, fears, and negative attitudes, not only of users and potential users, but also of different cadres of health care professionals. The purpose of this study was to assess the knowledge and attitudes of a group of Latin American obstetricians and gynecologists regarding IUCs.

Methods

A survey was conducted during a scientific meeting organized in Chile in 2014 to present and discuss updated information about contraception. Obstetricians and gynecologists from 12 Latin American countries, who reported that they provide daily contraception services in both the public and private sectors, participated in the meeting. Participants who agreed to take part in the survey responded to a multiple-choice questionnaire on issues regarding knowledge, use, and attitudes about IUCs.

Results

Of the 210 obstetricians and gynecologists participating in the meeting, the respondents to each question varied from 168 (80.0%) to 205 (97.6%). Almost 50% recognized that the failure rate of combined oral contraceptives, patches, and vaginal rings is 8%–10%. Furthermore, 10% of the participants did not recognize the high contraceptive effectiveness of long-acting reversible contraceptive methods. Additionally, almost 80% of the respondents answered that they did not offer IUCs to nulligravidas and almost 10% did not offer IUCs to adolescents, albeit almost 90% of the respondents reported that nulligravidas are candidates for an LNG-IUS.

Conclusion

Some deficiencies and contradictions in terms of knowledge and attitudes were identified from the answers of the Latin American obstetricians and gynecologists who participated in the survey. The knowledge and attitudes of health care professionals about IUCs are important in order to provide adequate counseling and to expand the use of IUCs.

Planning ahead for implementation of long-acting HIV prevention: challenges and opportunities

PURPOSE OF REVIEW

Broad-based access, uptake, and dissemination of daily oral HIV preexposure prophylaxis (PrEP) have been slow, despite strong evidence for efficacy. Effective and efficient implementation of long-acting HIV prevention products will require both analysis of the dynamics and determinants of daily oral PrEP implementation and identification of the distinct challenges and opportunities inherent in emerging technologies.

RECENT FINDINGS

Evidence suggests the importance of addressing implementation issues at three levels: patient, provider, and system. Patient-level factors include targeted education and messaging, tailored supports to enhance acceptability and uptake, and effective strategies for promoting adherence/persistence and retention in care. Provider-level factors include engaging a broad mix of providers, while ensuring adequate training and support for patient assessment, counseling, and follow-up. Systems-level factors include optimal delivery modalities, resource allocation, and ensuring access to populations most in need of new prevention options.

SUMMARY

Formative social/behavioral research must be undertaken proactively to prepare for and address future implementation challenges and reduce the gap between proving efficacy in clinical trials and assuring real-world effectiveness. Conceptualizing new HIV prevention technologies as behavioral interventions at the level of the patient, provider, and system will be paramount to effective and efficient implementation.

Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana

Background

Understanding what factors influence the receipt of postabortion contraception can help improve comprehensive abortion care services. The abortion visit is an ideal time to reach women at the highest risk of unintended pregnancy with the most effective contraceptive methods. The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors’ likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method.

Methods

We used retrospective cohort data collected from 64 health facilities in three regions of Ghana. The dataset includes information on all abortion procedures conducted between 1 January 2008 and 31 December 2010 at each health facility. We used fixed effect Poisson regression to model the associations of interest.

Results

More than half (65 %) of the 29,056 abortion clients received some form of contraception. When midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers (RR: 1.18; 95 % CI: 1.13, 1.24) or physicians (RR: 1.21; 95 % CI: 1.18, 1.25), after controlling for facility-level variation and client-level factors. Compared to women seen by house officers, abortion clients seen by midwives and physicians were more likely to receive a long-acting and permanent rather than a short-acting contraceptive method (RR: 1.46; 95 % CI: 1.23, 1.73; RR: 1.58; 95 % CI: 1.37, 1.83, respectively). Younger women were less likely to receive contraception than older women irrespective of provider type and indication for the abortion (induced or PAC).

Conclusions

When comparing consultant physicians, house officers, and midwives, the type of abortion provider is associated with whether women receive postabortion contraception and with whether abortion clients receive a long-acting and permanent or a short-acting method. New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1875-2) contains supplementary material, which is available to authorized users.

Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the U.S. Food and Drug Administration-approved duration

OBJECTIVE

To evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device (IUD) in women using the method beyond the current U.S. Food and Drug Administration (FDA)-approved duration of 3 and 5 years, respectively.

METHODS

Women willing to continue using their implant or 52-mg levonorgestrel IUD beyond the FDA-approved duration were followed prospectively for contraceptive effectiveness. Unintended pregnancy rate per 100 women-years was calculated. Implant users are offered periodic venipuncture for analysis of serum etonogestrel levels. The Kruskal-Wallis test was used to compare the etonogestrel levels across body mass index (BMI) groups.

RESULTS

Implant users (n=237) have contributed 229.4 women-years of follow-up, with 123 using the etonogestrel implant for 4 years and 34 using it for 5 years. Zero pregnancies have been documented, for a failure rate of 0 (one-sided 97.5% confidence interval [CI] 0-1.61) per 100 women-years. Among 263 levonorgestrel IUD users, 197.7 women-years of follow-up have been completed. One pregnancy was confirmed, for a failure rate of 0.51 (95% CI 0.01-2.82) per 100 women-years. Among implant users with serum etonogestrel results, the median and range of etonogestrel level at 3 years of use was 188.8 pg/mL (range 63.8-802.6 pg/mL) and 177.0 pg/mL (67.9-470.5 pg/mL) at 4 years of use. Etonogestrel levels did not differ by BMI at either time point (3 years: P=.79; 4 years: P=.47).

CONCLUSION

Preliminary findings indicate the contraceptive implant and 52-mg hormonal IUD continue to be highly effective for an additional year beyond the FDA-approved 3 and 5 years. Serum etonogestrel levels indicate the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use.

LEVEL OF EVIDENCE

II.

Long-acting reversible contraception: Findings from the Understanding Fertility Management in Contemporary Australia survey

OBJECTIVES

The aim of this research was to investigate awareness, perceived reliability and consideration of use of long-acting reversible contraception (LARC) among Australians of reproductive age.

METHODS

A sample of 18- to 50-year-old women and men (N = 2235) was randomly recruited from the Australian electoral roll in 2013. Respondents completed a self-administered, anonymous questionnaire. Data were weighted to reduce non-response bias. Factors associated with perceived reliability and consideration of use of LARC were identified in multivariable analyses.

RESULTS

Most respondents had heard of implants (76.5%) and intrauterine contraception (63.7%). However, most did not think implants (56.3%) or IUDs (63.9%) were reliable and would not consider using implants (71.6%) or IUDs (77.5%). Those significantly more likely to perceive LARC as reliable were younger, did not regard religion as important in fertility choices, had private health insurance, had been pregnant and had had an abortion; and women who had a partner. Those more likely to consider using LARC were younger and did not regard religion as important in fertility choices; women who had private health insurance, lived in an area of socioeconomic advantage and had had an abortion; and men without a partner, born in Australia and comfortable talking to a health care provider about contraceptive matters.

CONCLUSIONS

Despite high awareness of LARC among Australian adults, its perceived reliability and willingness to use it remain low in certain groups. Targeted interventions that aim to increase knowledge of the benefits and reliability of LARC and allow informed use are recommended.

Happiness about unintended pregnancy and its relationship to contraceptive desires among a predominantly Latina cohort

CONTEXT

Women frequently profess happiness about unintended pregnancies; such incongruence is associated with use of less effective contraceptive methods and inconsistent or incorrect method use. Yet, the methods women use may differ from those they desire.

METHODS

Data on 578 women were drawn from a prospective survey of postpartum women aged 18-44 recruited from three hospitals in Texas between 2012 and 2014. Jonckheere-Terpstra tests were used to compare women's feelings about a future pregnancy with their childbearing intentions. Fisher-Freeman-Halton tests compared distributions of contraceptive methods currently used and desired by women who professed happiness about a future unintended pregnancy, as well as distributions of desired methods by women's reported feelings.

RESULTS

The proportion of women who reported happiness about a future pregnancy was 59% among those intending to wait two or three years for another child, 46% among those intending to wait four or more years, and 36% among those intending to have no more children. Among women who professed happiness, a greater proportion desired to use a highly effective contraceptive method than were currently using one (72% vs. 15% among those intending no more children; 55% vs. 23% among those intending to wait at least four years; and 36% vs. 10% among those intending to wait two or three years). Across intention categories, the types of methods desired did not differ by whether women professed happiness or unhappiness.

CONCLUSIONS

Women who profess happiness about a future unintended pregnancy may nonetheless desire highly effective contraceptive methods.

IUD String Perforation Through Anterior Cervix: A Case Report

BACKGROUND

Intrauterine devices are increasingly the preferred method of contraception chosen by Canadian women. IUD strings are commonly not visible at follow-up, but rarely are visible yet not located within the endocervical canal. We report a case of IUD strings perforating the ectocervix.

CASE

An asymptomatic, 26-year-old woman presented for removal of her levonorgestrel-releasing intrauterine system, over a year following insertion of the device. Upon examination the IUD strings were found to be emerging from within the cervical tissue, 10 mm above the external os.

CONCLUSION

We discuss removal techniques, review the literature, and examine possible reasons for this presentation. These techniques may interest a range of practitioners managing contraceptive care for women.

Knowledge and attitudes of Latin American gynecologists regarding unplanned pregnancy and use of combined oral contraceptives

Background

Unintended pregnancy is a public health problem and unmet medical need worldwide. It is estimated that in the year 2012, almost 213 million pregnancies occurred, and the global pregnancy rate decreased only slightly from 2008 to 2012. It was also estimated that 85 million pregnancies (40% of all pregnancies) were unintended and that 38% ended in an unintended birth.

Objectives

To assess knowledge and attitudes of Latin American (LA) obstetricians and gynecologists (OBGYNs) regarding unintended pregnancies and aspects of combined oral contraceptive (COC) use.

Methods

A survey was conducted during a scientific meeting about contraception in 2014, in which OBGYNs from 12 LA countries who provide attention in contraception were invited to respond to a multiple-choice questionnaire to assess their knowledge and attitudes regarding unplanned pregnancy and some aspects regarding COC use.

Results

A total of 210 OBGYNs participated in the study. Their knowledge regarding COC failure was low. The participants reported they believed that their patients habitually forgot to take a pill and that their patients did not know what to do in these situations. They were aware of the benefits of COC use; however, they were less prone to prescribe COCs for the purpose of protecting against ovarian and endometrial cancer, and one-quarter of them had doubts about the association between COC use and cancer risk.

Conclusion

The interviewed LA OBGYNs showed some flaws in terms of knowledge of COC failure rates and the non-contraceptive benefits and risks of COCs. To adequately counsel their patients regarding COC intake, OBGYNs must be updated regarding all aspects of COC use.

Shared Decision Aids: Increasing Patient Acceptance of Long-Acting Reversible Contraception

Unintended pregnancies are an important public health issue. Long-acting reversible contraceptive methods (LARCs) are reliable, safe, highly effective methods for most women; however they are underutilized in the United States. Shared decision aids were added to usual care in five public health family planning clinics in the Southeastern United States, staffed by advance practice nurses and registered nurses. All five sites showed an increase in the use of LARCs during the time period that shared decision aids were used (results statistically significant to p < 0.001). It is important for women to make informed choices about contraception, and shared decision aids can be utilized to support this decision making. This resource has been adopted for statewide use in all public health clinics, and implications for practice suggest that the use of shared decision aids is an effective method to support informed patient decision making and acceptance of LARC methods of contraception.

Long-acting reversible contraception in the pediatric emergency department: clinical implications and common challenges

Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents and young adults. As the use of LARC increases, pediatric emergency medicine clinicians should be able to recognize different types of LARC and address their common adverse effects, adverse reactions, and complications. This continuing medical education activity provides an overview of LARC and will assist clinicians in the evaluation and management of patients with LARC-associated complaints.

The impact of reproductive health legislation on family planning clinic services in Texas

We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state's family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding. Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012-2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women's access to family planning services.

Contraceptive continuation in Hispanic women

OBJECTIVE

The purpose of this study was to examine the effect of Hispanic ethnicity on the continuation and satisfaction of reversible contraceptive methods.

STUDY DESIGN

We analyzed 12 months of data that were collected from 7913 participants in the Contraceptive CHOICE Project. Kaplan-Meier survival curves were used to estimate continuation, and Cox proportional hazard models were used to estimate the risk of discontinuation.

RESULTS

Hispanic women were more likely to choose a long-acting reversible contraceptive (LARC) method compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75%, respectively; P < .05). The 12-month continuation rates were higher for LARC methods than combined hormonal methods for all race/ethnicity (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%). There was no statistical difference in discontinuation of LARC methods at 12 months. Eighty percent of LARC users reported high satisfaction levels at 12 months, regardless of race/ethnicity.

CONCLUSION

Hispanic women in the Contraceptive CHOICE Project experienced high continuation and satisfaction for LARC methods, similar to women of other ethnicities.

Prevalence and associated factors of contraceptive discontinuation and switching among Bangladeshi married women of reproductive age

Introduction

Contraceptive discontinuation is a worldwide incident that may be connected with low incentive to avoid pregnancy. Contraceptive discontinuation highly contributes to unplanned pregnancy and unwanted births.

Objectives

The objective of this study was to observe the prevalence of discontinuation and switching of contraceptive methods among Bangladeshi married women. In addition, the sociodemographic factors associated with contraceptive discontinuation and switching were assessed.

Methods

Secondary cross-sectional data was used in this study. A total of 16,273 married Bangladeshi women of reproductive age (15–49 years) were considered in the present study, from the Bangladesh Demographic and Health Survey, 2011. Logistic regression models were used to determine the relationships between key sociodemographic factors and user status.

Results

The prevalence of discontinuation and switching of contraceptive method among women were 38.4% and 15.4%, respectively. The logistic regression model demonstrated that women in early reproductive years (25–29 years and 30–34 years) significantly more often (odds ratio [OR] =0.84 and 0.71, respectively) discontinued use of contraceptives. Significantly higher rates of discontinuation were pronounced among women who used the pill (OR =0.72) and injectable contraception users (OR =0.60), had small family size (OR =0.49), lived in a rural community (OR =1.65), and who were less educated (OR =1.55).

Conclusion

Contraceptive discontinuation may reflect an association among less education, currently married, and smaller family size. Awareness of contraceptive methods can decrease the burden of unplanned pregnancies and thus progresses the family planning program.

Knowledge and perceptions of the intrauterine device among family planning providers in Nepal: a cross-sectional analysis by cadre and sector

Background

Nepal has high unmet need for family planning and low use of intrauterine devices (IUDs). While clients’ attitudes toward the IUD are known in a variety of contexts, little is known about providers’ knowledge and perceptions of the IUD in developing countries. Nepal’s liberal IUD service provision policies allow the opportunity to explore provider knowledge and perceptions across cadres and sectors. This research contributes to an understanding of providers’ IUD perceptions in low-resource environments, and increases evidence for IUD task-sharing and private sector involvement.

Methods

A questionnaire was administered to 345 nurses and auxiliary nurse midwives (ANMs) affiliated with the private Mahila Swastha Sewa (MSS) franchise, public sector, or private non-franchise sector. All providers had been trained in TCu 380A IUD insertion and removal. The questionnaire captured providers’ IUD experience, knowledge, and perceived barriers to recommendation. Descriptive, multivariate linear, and multinomial logistic regression was conducted, comparing providers between cadre and sector.

Results

On average, providers answered 21.5 of 35 questions correctly, for a score of 61.4%. Providers scored the lowest on IUD medical eligibility, answering 5.9 of 14 questions correctly. Over 50% of providers were able to name the four side effects most frequently associated with the IUD; however, one-third of all providers found at least one of these side effects unacceptable. Adjusted results show that cadre does not significantly impact provider’s IUD knowledge scores or side effect perceptions. Public sector affiliation was associated with higher knowledge scores regarding personal characteristic eligibility and more negative perceptions of two normal IUD side effects. IUD knowledge is significantly associated with provider’s recent training and employment at multiple facilities, and side effect perceptions are significantly associated with client volume, range of family planning methods, and region.

Conclusions

Provider knowledge and attitudes towards IUD provision are similar across cadre and sector, supporting WHO task-sharing guidelines and validating Nepal’s family planning policies. However, overall provider knowledge is low. We recommend that providers need to receive further training and support to improve knowledge, manage side effects, and recognize women in periods of high unmet need - such as post-partum or post-abortion women - as suitable candidates for IUDs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0701-y) contains supplementary material, which is available to authorized users.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Worldwide research productivity in emergency contraception: a bibliometric analysis

BACKGROUND

The main goal of this study was to assess worldwide research activity in emergency contraception (EC) using bibliometric indicators.

METHODS

Data in SciVerse Scopus were searched for documents pertaining to emergency contraception. Data obtained were then exported to Microsoft Excel and analyzed using Statistical Package for Social Sciences.

RESULTS

A total of 2142 documents were published about EC worldwide. Documents were written in 27 different languages and were published from 78 countries. Publications in EC started on late 1960s. Total number of citations for published EC documents was 30154 while median citation per document was six. The h-index of the retrieved documents was 58. The leading country in EC research was United States of America with a total of 559 documents (26.10%). One hundred and ninety five (9.10%) documents were published in Contraception journal. The leading institution in EC research and publications was Princeton University (50; 2.33%) followed by University of California, San Francisco (34; 1.59%).

CONCLUSIONS

The present data revealed that there is a worldwide increasing interest in EC research. Willingness of health policy makers to make EC accessible to the public will determine the future of EC research activity and future of EC as a contraceptive method.

Emergency contraception review: evidence-based recommendations for clinicians

Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile, and availability. The most effective emergency contraceptive is the copper intrauterine device (IUD), followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, whereas ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.

'Organisation of contraceptive care' and attitudes among healthcare providers in two Swedish cities with different socio-demographic profiles

OBJECTIVE To compare contraceptive services provided by family planning clinics in Linköping and Norrköping in Östergötland County, Sweden. The two cities are of similar size but have different socio-demographic profiles. The abortion rate in Linköping (15.3 per 1000) is substantially lower than in Norrköping (21.1 per 1000). METHODS The study was performed in two steps. First, the clinics providing contraceptive services in the two cities were studied using ten pre-defined quality indicators. Thereafter, 11 healthcare providers were interviewed: six in Linköping and five in Norrköping. The interviews were analysed using qualitative content analysis. RESULTS No differences were found in the organisation of contraceptive care in the two cities. Neither city met the criteria for five of the ten quality indicators. The analysis of the interviews generated four themes: 'Guidelines and electronic record template', 'Criteria for good contraceptive counselling', 'Availability of contraception', and 'Sexual health'. The interviews revealed that the clinical leadership in Norrköping was insufficient. CONCLUSION Clinics in the two cities are organised in the same way so that differences in abortion rates cannot be related to differences in organisation. The reasons for the differences in abortion rates in the two cities have yet to be determined.

Unmet demand for highly effective postpartum contraception in Texas

OBJECTIVES

We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth.

METHODS

We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery.

RESULTS

At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC).

CONCLUSIONS

This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between women's method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception.

IMPLICATIONS

In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Women's contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women

CONTEXT

Long-acting reversible contraceptive (LARC) methods are recommended for young women, but access is limited by cost and lack of knowledge among providers and consumers. The Colorado Family Planning Initiative (CFPI) sought to address these barriers by training providers, financing LARC method provision at Title X-funded clinics and increasing patient caseload.

METHODS

Beginning in 2009, 28 Title X-funded agencies in Colorado received private funding to support CFPI. Caseloads and clients' LARC use were assessed over the following two years. Fertility rates among low-income women aged 15-24 were compared with expected trends. Abortion rates and births among high-risk women were tracked, and the numbers of infants receiving services through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were examined.

RESULTS

By 2011, caseloads had increased by 23%, and LARC use among 15-24-year-olds had grown from 5% to 19%. Cumulatively, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008. Compared with expected fertility rates in 2011, observed rates were 29% lower among low-income 15-19-year-olds and 14% lower among similar 20-24-year-olds. In CFPI counties, the proportion of births that were high-risk declined by 24% between 2009 and 2011; abortion rates fell 34% and 18%, respectively, among women aged 15-19 and 20-24. Statewide, infant enrollment in WIC declined 23% between 2010 and 2013.

CONCLUSIONS

Programs that increase LARC use among young, low-income women may contribute to declines in fertility rates, abortion rates and births among high-risk women.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic

STUDY QUESTION

What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago.

SUMMARY ANSWER

Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted.

WHAT IS KNOWN ALREADY

LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce.

STUDY DESIGN, SIZE AND DURATION

We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted.

MAIN RESULTS AND THE ROLE OF CHANCE

We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted.

LIMITATIONS, REASONS FOR CAUTION

The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world.

WIDER IMPLICATIONS OF THE FINDINGS

LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

Adolescent substance use and unplanned pregnancy: strategies for risk reduction

Substance use among adolescents increases the risk of unplanned pregnancies, which then increases the risk of fetal exposure to addictive, teratogenic substances. Specific interventions are necessary to target pregnancy planning and contraception among reproductive-age substance users. Screening for substance use using the CRAFFT is recommended in all health care settings treating adolescent patients. Screening for tobacco and nicotine use is also recommended along with the provision of smoking cessation interventions. Using motivational interviewing style and strategies is recommended to engage adolescents in discussions related to reducing substance use, risky sexual behavior, and probability of unplanned pregnancy or late-detection pregnancy.