Effectiveness of the non-spermicidal fit-free diaphragm

Digital support for first time self-injectable contraceptive users in Nairobi, Kenya: A design evaluation

BACKGROUND

Women in Kenya have an unmet need for contraception, and self-injectable contraceptives offer a new, self-managed fertility control option. Self-injection reduces the need to travel to a facility for ongoing care, but the initial, in-person, consultation may be a barrier. Training in self-injection administration could be delivered via WhatsApp on a mobile phone.

METHODS

This study aimed to observe and document the design process of a WhatsApp delivered self-injectable contraceptive service. This design evaluation employs a mixed methods approach using; observation of design meetings, analysis of design documents (process maps, prototypes) and interviews with the design team. Participants who tested the remote training element of the final service design were interviewed about their experiences.

RESULTS

Four tasks, delivered by the digital service, were explored in further detail: provide information on self-injectables; ensure the technical and privacy requirements of the video call are met; obtain information from the user to check eligibility; and observe the users first self-injection. The challenges, assumptions, iterations, and learning associated with these key tasks were documented and 3 case studies emerged. These case studies explore how the digital service altered the timing and medium of a clinical interaction, the construction of the user's physical space when interacting with the service and the challenge of performing legitimacy via WhatsApp.

CONCLUSION

By examining self-care facilitated by digital technologies, there are opportunities to learn about self-care, digital care and face-to-face care. Through examining the design process, we discovered ways in which digital services can change the rhythm of health care interactions, namely by stretching the time, space and medium of clinical interaction. When interactions are altered in this way, clinical legitimacy must be negotiated in new ways.

Spermicidal and antifertility effects of an imbibing and soluble nonoxynol-9 diaphragm (ISND) in rabbits

OBJECTIVE

To determine the minimum effective concentration (MEC) of an imbibing and soluble nonoxynol-9 (N-9) diaphragm (ISND) required for immobilisation of all spermatozoa in vitro and in vivo. The speed of semen absorbance, time of ISND to dissolution, and the antifertility effects were also investigated in rabbits.

METHODS

In vitro spermicidal tests with ISND were conducted using fresh semen from humans and rabbits. Spermicidal and antifertility effects were observed in vivo after the ISND was placed directly into the vagina of rabbits.

RESULTS

The MEC of N-9 required in the ISND to totally immobilise sperm within 20 seconds was 0.15 mg/ml for human sperm, and 0.5 mg/ml for rabbit sperm. The human semen was absorbed into the ISND in 45 minutes; the diaphragm dissolved in the vagina 3.5 hours later. In vivo, in rabbits, the MEC of N-9 required to immobilise sperm within five minutes of mating was 1 mg/kg in the ISND, and 10 mg/kg for the nonoxynol-9 film. The median effective dose of N-9 in the ISND was 1.07 mg/kg, whereas for the film it was 3.30 mg/kg.

CONCLUSION

The spermicidal and antifertility activities of a low dose N-9 in the ISND were high, with properties of imbibition and solubility confirmed.

Contraception use and effectiveness among women in a trial of the diaphragm for HIV prevention

BACKGROUND

There is little data on contraceptive effectiveness or use patterns from sub-Saharan Africa.

STUDY DESIGN

We analyzed data from women at risk of pregnancy (n=4905) in the Methods for Improving Reproductive Health in Africa trial of the diaphragm for HIV prevention. We described reported contraceptive method use and calculated rates of pregnancy by contraceptive method. We compared time to first pregnancy by study arm (condoms or condoms plus diaphragm), and estimated a Cox proportional hazards model to identify predictors of pregnancy.

RESULTS

Condoms (25.8%), injectables (25.4%) and OC (21.6%) were the most commonly used methods; long-acting method use was rare. During the trial, 51.6% of women used the same method, 27.4% switched to a more effective method and 20.9% switched to a less effective method; 21.4% of women became pregnant. Pregnancy rates by contraceptive group mirrored published estimates; frequency of study product use was not associated with pregnancy.

CONCLUSION

Long-acting methods of contraception should be made available in HIV prevention trials and to women in Southern Africa.

Comparison of diaphragm and combined oral contraceptive pill users in the Australian family planning setting

OBJECTIVES

To determine the number of women fitted with a diaphragm or cervical cap at family planning clinics across the Australian State of New South Wales (NSW) from 2000 to 2005. To compare the demographic characteristics of women fitted with this form of contraceptive with women prescribed the combined oral contraceptive pill (COCP).

METHOD

An audit of women presenting for contraceptive services between 2000 and 2005 was undertaken. The demographic characteristics of women fitted with a barrier method or prescribed the COCP between 1st April, 2002, and 31st October, 2004, were obtained from the Family Planning NSW Activity Data Set (FADS).

RESULTS

The proportion of women fitted with a diaphragm or cap remained constant between 2001 and 2005 at approximately 5%. During the 31 months that the study period lasted, 793 women were fitted with a diaphragm or cervical cap compared with 8047 women prescribed the COCP during the same time frame (including 76 women who received both a diaphragm and COCP prescription during this period). Women fitted with the barrier contraceptive were significantly more likely to be older, to have received a tertiary level education and to have private health insurance than their counterparts prescribed the COCP. They were less likely to come from a non-English speaking background.

DISCUSSION

The diaphragm and cervical cap are viable contraceptive methods for a specific group of older, well-educated women. The possible benefits of female-controlled barrier devices in the prevention of sexually transmissible infections may result in a wider demographic use in the future.

SILCS diaphragm: postcoital testing of a new single-size contraceptive device

BACKGROUND

This study was conducted to compare the effectiveness of a new, single-size silicone contraceptive diaphragm used with either spermicide [2% nonoxynol-9 (N-9)] or lubricant in preventing sperm from penetrating midcycle cervical mucus.

STUDY DESIGN

A crossover postcoital test (PCT) in healthy, sexually active women not at risk for pregnancy due to tubal occlusion was conducted. Couples had a baseline PCT without a device to verify normal fertility parameters. Qualified couples underwent up to two test cycles using the SILCS diaphragm with a metal spring. A subgroup of couples underwent a third test cycle with the SILCS polymer spring diaphragm used with N-9 gel.

RESULTS

Fifteen couples completed a baseline cycle and were randomized to order of study gel. Of these, 14 couples completed a baseline cycle and at least one test cycle, 12 couples completed a baseline cycle and two test cycles and 8 couples completed a third test cycle with the polymer spring prototype. Sperm was detected in the vaginal pool in all completed test cycles. The SILCS metal spring diaphragms used with N-9 gel reduced the average number of progressively motile sperm per high power field in the cervical mucus from a baseline of 12.5 to 0, while use of this device with lubricant reduced the number to 0.5. The SILCS polymer spring diaphragm used with N-9 performed the same as the metal spring used with N-9.

CONCLUSION

The SILCS diaphragm used with N-9 gel performed well. It is likely that the SILCS diaphragm will give acceptable results in a contraceptive effectiveness study but that adjunctive use of a chemical barrier such as N-9 gel will be necessary for it to be most effective.

Delivery of microbicides to the vagina: difficulties reported with the use of three devices, adherence to use and preferences

PURPOSE

A crossover study was carried out in 405 couples to compare women's difficulties with three different devices that could be used to administer a microbicide and to evaluate adherence to use and preference for any one of the devices.

METHODS

Couples used a single size diaphragm, a vaginal ring or disposable applicators for 1 month each in a randomly assigned order.

RESULTS

Few women reported difficulty using the applicators or the ring; however, almost two-thirds reported difficulty using the diaphragm. Approximately 5%, 10% and 40% of the women and a similar but slightly lower percentage of their partners reported incorrect use of the applicator, vaginal ring and diaphragm, respectively. About half the women preferred the vaginal ring, while around half the men preferred the applicator.

CONCLUSION

The release of microbicides from a vaginal ring is a lead worth pursuing. The diaphragm is the only one of the three devices that also offers mechanical protection, but it requires greater investment in patient education to ensure adherence to use.

Barriers to contraceptive use in product labeling and practice guidelines

Many contraceptives are encumbered with potentially unnecessary restrictions on their use. Indeed, fear of side effects, fostered by alarmist labeling, is a leading reason that women do not use contraceptives. In the United States, hormonal methods currently require a prescription, although research suggests that women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate initiation date, leaving little need for routine direct physician involvement. Sizing, spermicidal use, and length-of-wear limits burden users of cervical barriers and may be unnecessary. Despite recent changes in the labeling of intrauterine devices, clinicians commonly restrict use of this method and in some countries may limit the types of providers authorized to insert them. Although in some cases additional research is necessary, existing data indicate that evidence-based demedicalization of contraceptive provision could reduce costs and improve access.

Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe

BACKGROUND

Women who are the most vulnerable to sexually transmitted diseases/HIV are often unable to consistently use condoms. One potential alternative method currently under investigation is the diaphragm.

GOALS

The goals of this study were to assess diaphragm uptake and use over time in Zimbabwe and to identify factors associated with self-reported consistent diaphragm use.

STUDY

Women attending family planning clinics who were inconsistent condom users received a diaphragm intervention and were followed for 6 months.

RESULTS

Of the 186 participants, 99% ever reported using the diaphragm, and, at study exit, 96% had used it in the previous 2 months. Consistent diaphragm use since the previous visit was reported by 13% to 16% of the women, and in multivariate regression analysis, it was significantly associated with never using condoms (adjusted odds ratio, 24.08; 95% confidence interval, 6.71-86.34). Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence, and contraception.

CONCLUSION

Diaphragms were well accepted among women at risk for sexually transmitted diseases/HIV.

Canadian Contraception Consensus

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Diaphragms in clinical trials: is clinician fitting necessary?

BACKGROUND

The need for fitting a contraceptive diaphragm has recently been questioned in the context of upcoming trials in which the ability of the diaphragm to prevent sexually transmitted infections will be tested. Being able to provide the same size device to all women would greatly simplify supplying the device and training the clinicians, provided that it does not compromise effectiveness.

METHODS

Data from studies of Lea's Shield and FemCap, in which all women were sized for a standard diaphragm and half were randomized to use it during the studies, were reanalyzed to determine if it was feasible to give all women in a barrier study the same size diaphragm or, alternatively, to determine if diaphragm size could be predicted using an algorithm of one or more parameters.

RESULTS

If all women received a size 70 diaphragm, rather than being fitted by a clinician, 33.2% would receive the same size that they would have received if they had been fitted by a clinician. If the definition of a "correct" fit were broadened to include one size larger or smaller than what the clinician would have prescribed, 78.0% would be "correctly" fitted. Using an algorithm that considered parity, body weight and other factors did not improve results.

CONCLUSION

It would be acceptable to conduct a trial in which all women receive a size 70 diaphragm, provided that all women are sized; that safety, effectiveness and acceptability are closely monitored and that study results are stratified by the diaphragm size determined by clinician fitting. It would also be informative to use sized diaphragms as the comparator in studies of new single-size devices.

Diaphragm versus diaphragm with spermicides for contraception

BACKGROUND

The diaphragm is usually used with a spermicide. However, some practitioners have suggested that spermicides offer no additional contraceptive protection and have advocated alternative guidelines for the use of diaphragms.

OBJECTIVES

The objective of this review was to compare the effectiveness, safety and acceptability of the diaphragm with and without spermicide.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, POPLINE, CINAHL, the Cochrane Controlled Trials Register, and reference lists of relevant articles. In addition, we contacted experts in the field to identify unpublished studies.

SELECTION CRITERIA

Randomized controlled trials comparing women of reproductive age using the diaphragm with and without spermicide as the sole contraceptive method that reported clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data on outcomes and trial characteristics and any discrepancies were resolved by consensus or by consultation with the third reviewer. The results of the one identified study are presented descriptively.

MAIN RESULTS

We identified only one study. No significant difference was found in the pregnancy rates (with typical use or consistent use) or discontinuation rates between the diaphragm-with-spermicide and diaphragm-without-spermicide groups. There was a trend towards higher pregnancy rates in the diaphragm-without-spermicide group. However, this study failed to recruit the planned number of participants and was consequently underpowered.

REVIEWER'S CONCLUSIONS

As only one underpowered study was identified, we cannot distinguish between the contraceptive effectiveness of the diaphragm with and without spermicide. We cannot draw any conclusion at this point, further research is needed.

Barrier methods of contraception

Despite the problems associated with coitus-dependent methods of contraception, barrier methods have an important role. The fact that they work as contraceptives without systemic effects makes them particularly appropriate for women with medical conditions that prevent the use of hormonal contraception. In addition, condoms and perhaps all barrier methods provide protection from sexually transmitted infections, making them essential for sexually active women at risk for STDs. Their continued importance is evidenced by the ongoing research to develop and improve barrier methods of contraception.