Three-year continuation of reversible contraception

Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid

PURPOSE

Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation.

METHODS

This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018.

RESULTS

Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001).

DISCUSSION

We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.

Could the contraceptive counselling improve contraceptive choice after abortion? A multicentric study to evaluate patients' perception

INTRODUCTION

24 % of abortion in Italy are repeated procedure. The cause of repeated abortion can be traced back to the inadequacy of the contraceptive counseling during the previous admission or to the adoption of an ineffective contraception method. This study aims to evaluate the Italian situation on the perceived quality of contraceptive counselling by patients undergoing abortion. The second aim is to verify if the chosen methods were available for immediate start.

STUDY DESIGN

Multicentric, prospective, non-interventional, non-randomized, non-pharmacological clinical observational study. We analyzed anonymous questionnaires on contraceptive counseling and LARC (Long Acting Reversable Contraceptives) availability and SARC (Short Acting Reversable Contraceptives) prescription at hospital discharge, distributed to women who requested abortion.

RESULTS

1074 participants on 15 hospitals through Italy. 82 % of the interviewees reported that they had received correct information regarding contraception. 74 % of the patients who chose LARC methods reported to have them inserted at the time of abortion. 73 % of women who had chosen a SARC method stated that they had received the prescription before discharge. After contraceptive counselling, we reported a significative reduction of "none or natural methods use" and a significant increase of SARC and LARC use compared to before the abortion.

CONCLUSION

Contraceptive counselling could allow a better contraceptive choice in patient who required abortion and we hope that future strategies will implement LARC choice. We think that a greater availability of LARC at an affordable price at the time of abortion could improve LARC choice. In case of SARC choice, we have to implement the prescription at hospital discharged.

Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review

Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.

Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians' perceived barriers and facilitators

BACKGROUND

The etonogestrel contraceptive implant is currently approved by the United States Food and Drug Administration (FDA) for the prevention of pregnancy up to 3 years. However, studies that suggest efficacy up to 5 years. There is little information on the prevalence of extended use and the factors that influence clinicians in offering extended use. We investigated clinician perspectives on the barriers and facilitators to offering extended use of the contraceptive implant.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured qualitative interviews. Participants were recruited from a nationwide survey study of reproductive health clinicians on their knowledge and perspective of extended use of the contraceptive implant. To optimize the diversity of perspectives, we purposefully sampled participants from this study. We used content analysis and consensual qualitative research methods to inform our coding and data analysis. Themes arose deductively and inductively.

RESULTS

We interviewed 20 clinicians including advance practice clinicians, family medicine physicians, obstetrician/gynecologist and complex family planning sub-specialists. Themes regarding barriers and facilitators to extended use of the contraceptive implant emerged. Barriers included the FDA approval for 3 years and clinician concern about liability in the context of off-label use of the contraceptive implant. Educational materials and a champion of extended use were facilitators.

CONCLUSIONS

There is opportunity to expand access to extended use of the contraceptive implant by developing educational materials for clinicians and patients, identifying a champion of extended use, and providing information on extended use prior to replacement appointments at 3 years.

Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Barriers and Facilitators of Extended Use of the Contraceptive Implant: A Cross-Sectional Survey of Clinicians

BACKGROUND

The U.S. Food and Drug Administration (FDA) approved the etonogestrel contraceptive implant for 3 years of use. Evidence suggests that it may be used for up to 5 years for pregnancy prevention, also known as extended use.

METHODS

We conducted a national cross-sectional survey among a group of reproductive health clinicians. We developed an online survey using the Consolidated Framework for Implementation Research (CFIR) and distributed it through e-mail listservs and social media groups from May to June 2021. We analyzed results using multivariable logistical regression.

RESULTS

Among the 300 respondents, 195 (65.0%) reported that they always offer extended use, and 50 (16.7%) reported that they sometimes offer extended use. Fifty-five respondents (18.3%) reported that they never offer extended use. After adjusting for age, gender, and clinical setting, we found that complex family planning sub-specialists (adjusted odds ratio [aOR] = 9.32; 95% confidence interval [CI] [1.81, 48.03]) and family medicine physicians (aOR = 4.37, 95% CI [1.58, 12.10]) were significantly more likely to recommend extended use compared with general obstetrics and gynecology (OBGYN) physicians. Clinicians from private practices or health maintenance organizations were significantly less likely to offer extended use than those from academic centers (aOR = 0.19, 95% CI [0.07, 0.51]; aOR = 0.06, 95% CI [0.01, 0.31]). The most common barriers to offering extended use were concerns about pregnancy risk, bleeding, and lack of FDA approval in the past 3 years. Meanwhile, clinicians identified strong published evidence supporting extended use as a key facilitator for offering it, and they perceived that prior counseling on extended use from a past clinician was a key facilitator for patients to adopt it.

CONCLUSIONS

One-third of clinicians in this study did not consistently offer extended use of the contraceptive implant. An opportunity exists to expand access to extended use by focusing on education interventions for clinicians and seeking FDA approval for 5 years of use.

Couple-Years of Protection Indicator: New Global Guidance for Updating Existing Methods and Adding New Methods

BACKGROUND

Couple-years of protection (CYP) is an indicator that allows for monitoring and evaluating of family planning (FP) program performance through simple calculations. The CYP for each contraceptive method is calculated by multiplying the number of contraceptive commodity units distributed to clients over a 1-year period by a conversion factor that quantifies the duration of contraceptive protection provided per unit distributed. CYP calculations across methods were previously updated in 2000 and 2011, resulting in changes in methodology, factor inclusion, and specific methods. Since the 2011 update, changes and additions to the modern contraceptive method mix required new CYP conversion factors for 4 methods of contraception: Levoplant implant, progestin-only pills (POPs), Caya diaphragm, and the hormonal intrauterine device.

METHODS

We conducted literature reviews of both published and gray literature and consulted with experts to identify updated data on continuation rates, duration of efficacy, and method effectiveness for the 4 methods. New CYP conversion factors were calculated for the 4 methods either by using the same calculation used previously for the method considering new data or, for new methods, using calculations for similar methods.

RESULTS

New CYP conversion factors were assigned to the 4 methods of contraception covered in this update: Levoplant, 2.5 CYP per implant inserted; POPs, 0.0833 CYP per pack (i.e., 12 cycles per CYP); Caya diaphragm, 1 CYP per device, and hormonal intrauterine device, 4.8 CYP per device inserted.

CONCLUSIONS

CYP is an important indicator for FP programs. As new methods of contraception are developed and new evidence is generated for current methods, the indicator may need to be updated. A standard process for updating and documenting future CYP updates is recommended.

Predictors of contraceptive discontinuation in Rwanda: evidence from demographic and health survey 2019-2020

BACKGROUND

Despite advancements, Rwanda continues to face challenges regarding contraceptive discontinuation. The 2019-2020 Rwanda Demographic and Health Survey (DHS) reported a 30% discontinuation rate among women within the first year of use. This study analyses predictors of discontinuation using this DHS data, with the goal of strengthening Rwanda's family planning programs.

METHODS

Data from the 2019-20 Rwanda DHS (14,634 women aged 15-49) was examined. A two-stage sampling design informed the survey. Life table methods and Cox proportional hazard models were used to analyze discontinuation rates, median usage duration across contraceptive methods, and the influence of demographic and other factors.

RESULTS

Results indicated a progressive rise in contraceptive discontinuation over different period: 16.69% at 6 months, 29.29% at 12 months, and 47.21% at 24 months. Pills and male condoms showed higher discontinuation probabilities early on. While injectables and LAM initially showed lower discontinuation, rates rose significantly by the 24th month. Health concerns and side effects were the primary reasons cited for discontinuation. The Cox proportional hazards analysis revealed significant factors influencing discontinuation: contraceptive method, desire for pregnancy, husband's disapproval, access/availability, and the desire for a more effective method.

CONCLUSION

This study highlights substantial contraceptive discontinuation rates in Rwanda, particularly for pills and injectables. Method type, health concerns, side effects, and method failure were associated with discontinuation. Interventions should focus on improving contraceptive continuation and investigating alternative methods with lower discontinuation tendencies.

Contraceptive counseling, method satisfaction, and planned method continuation among women in the U.S. southeast

OBJECTIVES

We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states.

STUDY DESIGN

We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation.

RESULTS

Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001).

CONCLUSIONS

Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction.

IMPLICATIONS

Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Selection, Initiation, Continuation, and Efficacy of Reversible Contraception Among Enlisted U.S. Service Women in Their First Term of Service From 2012 to 2020

BACKGROUND

Pregnancy is the second most common cause of limited duty days among active duty service members in the U.S. Military. Pregnancy accounts for 10% of all days on restricted duty, despite impacting a minority of active duty service members. One out of five service women will experience an unintended pregnancy every year despite the availability of no-cost contraception and reproductive healthcare. Young, single, junior enlisted service women experience the highest rate of unintentional pregnancy. Previous studies have demonstrated service branch-based variability in selection, initiation, and continuation of specific contraceptive methods related to service branch culture and access to contraception during basic training. It is unclear if these differences impact overall contraception use or fertility rates among junior enlisted service women in their first term of enlistment. This study examines rates of contraceptive selection, initiation, continuation, and efficacy among junior enlisted service women in their first 4-year enlistment period, and the service branch specific variability in these outcomes.

METHODS

This study is a secondary analysis of Military Healthcare Data Repository records from women who began basic training between 2012 and 2020 and remained on active duty for at least 12 months. We used Kaplan-Meier analyses to examine the effect of age and military branch on contraceptive continuation and efficacy. We used binomial regression for interval censored data, to assess the association of service branch with rates of contraceptive initiation, contraception use, births, and childbirth-related duty restrictions.

RESULTS

We identified 147,594 women who began basic training between 2012 and 2020. The mean age of these women at the beginning of basic training was 20.4 ± 3.1 years. Women in the marines and navy had higher contraceptive initiation rates than women in the army or air force. Among women initiating a contraceptive pill, patch, or ring (short-acting reversible contraception), 58.3% were still using some form of hormonal contraception 3 months later. Among women initiating depot-medroxyprogesterone (DMPA), 38.8% were still using any form of hormonal contraception 14 weeks later. Long-acting reversible contraceptive methods, such as intrauterine or subdermal contraceptives, had higher continuation rates and less service-based variability in continuation and failure rates than short-acting reversible contraception or depot-medroxyprogesterone. The proportion of days on any form of prescription contraception during the first 4 years on active duty varied from 23.3% in the army to 38.6% in the navy. The birth rate varied from 34.8 births/1,000 woman-years in the air force up to 62.7 births/1,000 woman-years in the army. Compared with women in the air force, women in the army experienced 2,191 additional days of postpartum leave and 13,908 days on deployment restrictions per 1,000 woman-years.

DISCUSSION

Service branch specific variability in contraceptive use is associated with differences in days of pregnancy-related duty restrictions during first 4 years on active duty among junior enlisted females. Robust implementation of best practices in contraceptive care across the military health system to improve contraceptive initiation and continuation appears to offer an opportunity to improve military readiness and promote the health and well-being of active duty service women, particularly in the army.

Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications

OBJECTIVE

This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults.

STUDY DESIGN

We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded.

RESULTS

A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication.

CONCLUSION

IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use.

IMPLICATIONS

Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.

Brief report: Influence of mandatory contraceptive education emphasizing long-acting reversible methods on continuation rates among military recruits

OBJECTIVES

Determine if the replacement of patient-initiated, individual contraceptive education with mandatory group contraceptive education, during US Navy basic training, was associated with decreased LARC continuation.

STUDY DESIGN

Secondary analysis of administrative billing data from female military recruits who began basic training between September 2012 and February 2020.

RESULTS

Servicewomen who started LARC method during rather than after basic training had higher continuation rates. Servicewomen who started training before the implementation of mandatory group education had higher IUD continuation than those trained after.

CONCLUSIONS

Implementation of mandatory group contraceptive education during basic training was not associated with a decline in LARC continuation.

The contraceptive choice at the time of a surgical and pharmacological abortion: a possible and effective option thanks to a dedicate counselling

The percentage of repeat abortion in Italy is about 25%. It is therefore important to implement the strategies that can facilitate the adoption of the most effective contraceptive methods. Long-acting reversible contraceptive methods are currently considered the most effective and with the highest rates of 12-months continuation, with a reported reduction of recurrent abortion. Our study has the aim to evaluate the contraceptive choice of women requesting abortion, when an accurate and dedicate counselling is offered and the availability of a LARC method is given immediately after pregnancy termination, both in case of surgical and medical abortion. LARC methods were chosen both in case of surgical and medical abortion, by an high percentage of patients. We reported no differences between the surgical and pharmacological groups on the choice of LARC and SARC. Our observational study shows the feasibility to perform an accurate, dedicate, and personalised counselling on contraception at time of abortion. This approach has enabled a high number of women to have a LARC method inserted at the time of abortion, as a valid strategy to prevent the risk unplanned pregnancy.

Contraceptive Implant-Associated Bleeding in Adolescent/Young Adult Clinical Practice: Associated Factors, Management, and Rates of Discontinuation

PURPOSE

To identify factors associated with bothersome implant-associated uterine bleeding, and to evaluate the impact of bleeding management on implant discontinuation.

METHODS

We analyzed a quality improvement database of implant insertions (n = 825) at three adolescent/young adult programs and described individuals with and without reported bothersome bleeding. We utilized logistic regression to assess for factors associated with bleeding.

RESULTS

Implant recipient mean age was 18.9 ± 2.6 years, and 27% reported having subsequent bothersome uterine bleeding. Recipients had increased odds of reporting such bleeding if they had previously irregular menses (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.11-1.68 irregular and infrequent, OR = 1.41; 95% CI: 1.07-1.86 irregular and frequent) or sought the implant for menstrual management purposes exclusively (OR = 1.67; 95% CI 1.42-1.96) or in combination with contraceptive need (OR 1.65; 95%: CI 1.57-1.72). Prior use of the progestin injection or implant was associated with lower odds of subsequent bleeding report (OR = 0.63; 95% CI: 0.54-0.73; OR = 0.54; 95% CI: 0.39-0.75, respectively). Medication management of bleeding was associated with the likelihood of implant discontinuation at 1 year compared to those with untreated bleeding (hazard ratio 1.98 times, 95% CI: 1.39-2.81). The implant was continued for 3 years in over 50% of recipients with ever-managed bothersome bleeding.

DISCUSSION

Individuals with historically irregular menses and those seeking the implant for menstrual management more often reported bothersome bleeding. Treating such bleeding with medication was associated with higher 1-year discontinuation rates, although many continued implant use for 3 years. Such findings may influence implant preinsertion counseling and/or postinsertion bleeding management.

Contraceptive Continuation and Experiences Obtaining Implant and IUD Removal Among Women Randomized to Use Injectable Contraception, Levonorgestrel Implant, and Copper IUD in South Africa and Zambia

Few longitudinal studies have measured contraceptive continuation past one year in sub-Saharan Africa. We surveyed 674 women who had been randomized to receive the three-month intramuscular contraceptive injectable (DMPA-IM), levonorgestrel (LNG) implant, or copper intrauterine device (IUD) during the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial in South Africa and Zambia and were subsequently followed for two additional years to explore method continuation, reasons for discontinuation, and access to implant and IUD removal services. We also conducted in-depth qualitative interviews with 39 participants. We estimated cumulative discontinuation probabilities using Kaplan-Meier estimates and assessed factors associated with discontinuation using Cox-proportional hazards models. The LNG implant continuation rate over the maximum 44-month study period was 60 percent, while rates for the copper IUD and DMPA-IM were 52 percent and 44 percent, respectively. Reasons for method discontinuation included side effects, particularly menstrual changes, and method stock-outs. Most implant and IUD users who sought removal were able to access services; however, room for improvement exists. In this cohort originally randomized to receive a contraceptive method and attend regular study visits, implants and IUDs continued to be highly acceptable over an additional two years, but facilities should continue to ensure that insertions and removals are available as requested.

One-year discontinuation among users of the contraceptive pill and injection in South East Tigray region, Ethiopia

OBJECTIVES

The aim of this study is to determine the 12 months' discontinuation rate and associated factors among family planning clients using pills and injection.

METHODS

A follow-up study was initiated to collect data from 845 family planning users between November 2017 and December 2018. An interviewer administered questionnaire was used to collect data from participants. Data were entered into EpiData version 3.1 and analyzed using SPSS version 20, where both are open-source systems. A Cox proportional-hazards model was used to estimate the hazard ratios (HR) for the rate of discontinuation among participants.

RESULT

At 12 months, 63.5% of women discontinued the use of their baseline method. For the individual methods, 84% of women that chose the pill discontinued its use and for those using the injectable, 60.7% of women discontinued its use. Using the adjusted Cox proportional-hazards model, pills users (HR = 1.77; 95%CI = [1.4-2.3]), users receiving family planning services in the same room as other maternal health clinic services (HR 1.58; 95%CI = [1.16-2.2]), users served by health officers (HR = 3.7; 95%CI = [1.66-8.2]), and users not intending to use the baseline method continuously (HR = 1.6; 95%CI = [1.16-2.24]) were significantly more likely to discontinue using the baseline method. The main reason cited for discontinuation was side effects of contraception.

CONCLUSIONS

The discontinuation rate of the baseline contraceptive method after 12 months was very high. To increase the continuity of contraceptive use, family planning services should be given in a separate room with effective counseling on potential side effects, provided by midwives or nurses who have good counseling skills.

Comparing methods of long-acting reversible contraception: A qualitative study of Delaware women's perceptions of intrauterine devices and the implant

OBJECTIVE

To distinguish Delaware women's perceptions of the intrauterine device (IUD) relative to the subdermal arm implant (implant) as well as to compare their perceptions of various IUD types.

STUDY DESIGN

In this qualitative study, we conducted in-depth interviews with 86 self-identified women between 16 and 44 years old who resided in the state of Delaware. We used quota sampling to ensure a diversity of perspectives using age, socioeconomic status, race/ethnicity, and county of residence to do so. We analyzed the data for content and themes using deductive and inductive techniques.

RESULTS

Of the 47 participants who would use long-acting reversible contraception (LARC), 36 favored IUDs over the implant, and 11 felt more comfortable with the implant. Participants' perceptions were primarily influenced by device side effects, body placement, and the removal process. Those favoring a specific IUD prioritized the presence of exogenous hormones, device size, and maximum duration of use. Thirty-nine women would not use IUDs or the implant, citing safety risks and the availability of "simpler" methods.

CONCLUSIONS

Clinicians often use tier-based descriptions when counseling patients about contraception, particularly when emphasizing the similar efficacy levels of LARC devices. Participants in our study did not perceive LARC as a homogeneous category; rather, they consistently differentiated between IUDs and implants as well as between IUD types. Such findings demonstrate the need to understand which device features inform these distinct preferences and how providers' contraceptive counseling practices can be adjusted in response.

IMPLICATIONS

Given these findings, scholars should compare and further distinguish across methods, including IUDs, whenever possible. The findings also reinforce the benefits of stocking a variety of LARC devices at clinic and practice sites and encouraging provider counseling that emphasizes method-specific concerns and features. Doing so centers users' needs and preferences.

Early Implanon discontinuation and associated factors among Implanon women users visiting public health facilities, in Kembata zone of Southern Ethiopia: An institution based cross-sectional study

Background

Contraceptive practice is the basis of fertility and plays a significant role in minimizing maternal morbidity and mortality. Implanon is one of the most effective long-acting contraceptive methods that prevents pregnancy for 3 years. Early Implanon discontinuation can lead to many negative reproductive health consequences. Therefore, this study assessed the magnitude of early Implanon discontinuation among female Implanon users visiting public health facilities to discontinue Implanon in the Kembata zone of southern Ethiopia.

Methods

An institution-based cross-sectional study design was carried out from 1 March 2020 to 30 March 2020. Simple random sampling techniques were used to select 454 women who had discontinued Implanon. The data were collected using a pretested and structured questionnaire. The collected data were entered into Epi Data version-3.1 and then exported to STATA version-16 for analysis. A descriptive analysis along with bivariate and multivariate regression was performed to identify factors associated with early Implanon discontinuation. Statistical significance was declared at a p < 0.05 along with 95% confidence intervals (CIs).

Results

In the present study, 438 women were interviewed, which corresponds to a response rate of 96.48%. The magnitude of early Implanon discontinuation was 56.4%, 95%CI (51.6, 61.2). Primary educational status [adjusted odds ratio (AOR) = 2.92, 95%CI (1.56, 5.46)], rural residency [AOR = 1.76, 95%CI (1.06, 2.92)], women with no history of modern contraceptive use [(AOR = 2.14, 95%CI (1.14, 4.03)], those who experienced service dissatisfaction [AOR = 3.05, 95%CI (1.52, 6.12)], women who experienced as Implanon side effect [AOR = 3.36, 95%CI (2.09, 5.42)], and women who were not appointed after insertion [(AOR = 2.17, 95%CI (1.18, 4.79)] have shown an association with early Implanon discontinuation.

Conclusion

The present study indicated that the magnitude of early Implanon discontinuation was high. Educational level, rural residency, women who experienced side effects, those who experienced service dissatisfaction, women with no history of contraceptive use, and those who missed follow-up appointments were associated with Implanon discontinuation. Family planning service providers should focus on Implanon side effects during pre-insertion counseling. The recommended intervention is to recognize modifiable factors like improving client satisfaction with the service, appointing for follow up after insertion, and providing quality family planning services.

Acceptability and Preference for 3-Month Versus 1-Month Vaginal Rings for HIV-1 Risk Reduction Among Participants in a Phase 1 Trial

Background: The monthly dapivirine vaginal ring provides partial protection against HIV, and a longer duration ring may reduce user burden and improve adherence. We examined acceptability and preference for 3-month versus 1-month rings for HIV-1 risk reduction in a phase 1 clinical trial. Materials and Methods: In Microbicide Trials Network-036/International Partnership for Microbicides 047, 49 HIV-negative participants aged 18-45 were randomized to one of two 3-month rings or the 1-month ring. Acceptability ratings were collected at enrollment, week 4, and study exit (week 13). At exit, ring preference was assessed quantitatively among all participants and a randomly selected subset of 24 participants completed in-depth interviews. Quantitative and qualitative findings were integrated to explore factors influencing acceptability and preference. Results: Acceptability of each ring was initially moderate and increased during the trial. Ratings were lower in the 3-month ring arms than the 1-month arm at each time point, including baseline. Most participants (34/47; 72%) preferred a 3-month ring at exit; however, this proportion was significantly lower within some subgroups characterized by site, education, race/ethnicity, and experiences with ring use. Qualitative interviews revealed reservations about hygiene and safety of the 3-month ring, including discomfort with use during menses, but these were usually outweighed by its increased convenience. Conclusions: Both ring durations were highly acceptable at study exit. Although most participants preferred a 3-month ring, preference was more divided in certain subgroups, highlighting the benefit of offering different duration options. Providing additional support to address concerns about hygiene and safety may improve acceptability of a 3-month vaginal ring.

Norethisterone Reduces Vaginal Bleeding Caused by Progesterone-Only Birth Control Pills

(1) Background: Progesterone-only pills (POP) are widely used contraceptives. About 40% of women taking these pills report vaginal bleeding/spotting; 25% find this a reason for cessation. To date, no effective remedy has been described. We aimed to examine the therapeutic approaches offered by health providers. (2) Methods: A prospective questionnaire-based study of women experiencing vaginal bleeding due to POP, comparing the effectiveness of prescribed therapies. Women were recruited through social networks, and subsequently divided into groups according to the treatment offered: (1) POP with norethisterone (n = 36); (2) double dose POP (n = 19); (3) single dose POP (continuing initial treatment, n = 57); and (4) different POP formula (n = 8). Women rated bleeding quantity and frequency at four intervals, at weeks 0, 2, 4, and 6. (3) Results: Women who added 5 mg norethisterone acetate reported a significant decrease in bleeding frequency compared to the other groups, observed after 2, 4, and 6 weeks (p-values 0.019, 0.002, and 0.002, respectively). Women also reported an overall decrease in combined bleeding quantity and frequency (p-values 0.028, 0.003, and 0.005, respectively). There was no difference in the rate of side effects among groups. (4) Conclusions: Adding 5 mg norethisterone acetate (Primolut-nor) to progesterone-only pills significantly reduces bleeding and spotting associated with POP contraception.

Sexual Functioning, Satisfaction, and Well-Being Among Contraceptive Users: A Three-Month Assessment From the HER Salt Lake Contraceptive Initiative

Few large, longitudinal studies document multiple contraceptive methods' effects on sexual functioning, satisfaction, and well-being. We leveraged data from the HER Salt Lake Contraceptive Initiative, a prospective cohort study with patient surveys at baseline, one month, and three months. Surveys assessed bleeding changes, contraceptive-related side effects, sexual functioning and satisfaction, and perceptions of methods' impact on sexual well-being. Individuals in the final sample (N = 2,157) initiated either combined oral contraceptives, levonorgestrel intrauterine devices (IUDs), copper IUDs, implants, injectables, or vaginal rings. Across methods, participants exhibited minimal changes in sexual function (Female Sexual Function Index-6 scores) or satisfaction (New Scale of Sexual Satisfaction scores) over three months. However, many perceived contraception-related changes to sexual well-being. Half (51%) reported their new method had made their sex life better; 15% reported it had made their sex life worse. Sexual improvements were associated with decreased vaginal bleeding, fewer side effects, and IUD use. Negative sexual impacts were associated with physical side effects (e.g., bloating and breast tenderness), increased bleeding, and vaginal ring use. In conclusion, contraceptive users did not experience major changes in sexual functioning or satisfaction over three months, but they did report subjective sexual changes, mostly positive, due to their method.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative

OBJECTIVE

To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative.

STUDY DESIGN

LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience.

RESULTS

Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88).

CONCLUSIONS

LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Women's Cardiovascular Health: Selecting the Best Contraception

Basic knowledge about contraceptive types, efficacy, and indications is absolutely necessary for cardiologists caring for reproductive-age women for whom pregnancy could cause significant morbidity or mortality and for those on teratogenic medications. This summary provides a comprehensive overview of contraception options.

Vaginal ring acceptability: A systematic review and meta-analysis of vaginal ring experiences from around the world

OBJECTIVE

The vaginal ring (ring) is a female-initiated, long-acting drug delivery system for different indications, including HIV prevention. Our aim was to provide evidence for acceptability of the vaginal ring across indications to support dapivirine and multipurpose prevention technology ring introduction and roll out.

STUDY DESIGN

This systematic review and meta-analysis followed PRISMA guidelines. We searched PubMed, Web of Science, Embase, and grey literature for publications reporting favorable ring acceptability and secondary outcomes involving actual ring use (comfort, ease of ring use, ring comfort during sex, expulsions, and vaginal symptoms) or hypothetical acceptability for any indication published January 1, 1970-June 15, 2021. We estimated random-effects pooled prevalence, assessing between-study variation using meta-regression.

RESULTS

Of 2,234 records, we included 123 studies with 40,434 actual and hypothetical ring users. The primary outcome assessment included 50 studies with 60 ring subgroups totaling 19,271 ring users. The favorable acceptability pooled prevalence was 85.6% (95%CI 81.3, 89.0), while hypothetical acceptability among non-ring users was 27.6% (95%CI 17.5, 40.5). In meta-regression, acceptability was higher in menopause (95.4%; 95%CI 88.4, 98.2) compared to contraceptive rings (83.7%; 95%CI 75.6, 89.5). Acceptability was lower in pharmacokinetic studies (50%; 95%CI 22.1, 77.9) compared to RCTs (89.5%; 95%CI 85.8.92.4) and in studies assessing acceptability at ≥12 months (78.5%; 95%CI 66.5, 87.1) versus studies assessing acceptability at <3 months (91.9%; 95%CI 83.7, 96.1). European (90.6%; 95%CI 83.9, 94.7), Asian (97.1%; 95%CI 92.0, 99.0), and multi-region studies (93.5%; 95%CI 84.6, 97.4) reported more favorable acceptability compared to African studies (59.4%; 95%CI 38.3, 77.5). Secondary outcomes were similarly favorable, including ring comfort (92.9%; 95%CI 89.2, 95.4), ease of use (90.9%; 95%CI 86.5, 94.0), and comfort during sex (82.7%; 95%CI 76.4, 87.6). Limitations include inconsistent outcome definitions and unmeasured factors affecting acceptability.

CONCLUSIONS

Women who used vaginal rings reported they were acceptable across indications geographic regions and indications. Policy makers should consider the ring as an important option for pregnancy and HIV prevention drug development.

IMPLICATIONS

This review found favorable acceptability among vaginal ring users across indications and geographic areas, in contrast to low hypothetical acceptability among non-users. Vaginal rings are an important drug delivery system for pregnancy and HIV preventions, and scale-up should plan to address initial hesitancy among new users.

Complications after interval postpartum intrauterine device insertion

BACKGROUND:

In the United States, up to 57% of women report resumption of sexual activity by the 6 week postpartum visit. Effective contraception should be addressed and provided at that time, to avoid unintended pregnancies and optimize interpregnancy intervals. Long-acting reversible contraceptives are the most effective forms of reversible contraception and are increasingly popular during the postpartum period. However, timing of postpartum intrauterine device (IUD) placement varies among providers and many delay insertion due to concerns for uterine perforation or expulsion of the IUD.

OBJECTIVE:

This study aimed to evaluate uterine perforation and expulsion rates with IUD insertion at 4–8 weeks postpartum vs 9–36 weeks postpartum.

STUDY DESIGN:

We performed a retrospective cohort study using the Kaiser Permanente Southern California electronic medical record from 2010 to 2016. We calculated the proportion of perforations and expulsions with IUD insertion at 4–8 weeks vs 9–36 weeks postpartum. Our primary outcome was the perforation rate. Secondarily, we evaluated the expulsion rate. For our minimum sample size calculation, to detect a difference of 0.5% in the perforation rate, with a baseline perforation rate of 0.5% for the 9–36 week postpartum IUD placement group, 80% power, and 5% alpha error rate, we would need at least 4221 participants per group, 8442 in total.

RESULTS:

A total of 24,959 patients met inclusion criteria (n=13,180 in the 4–8 week group, n=11,777 in the 9–36 week group). Of 430 patients with a confirmed complication, 157 uterine perforations and 273 IUD expulsions were identified. Perforation rates were significantly higher with placement at 4–8 weeks than at 9–36 weeks (0.78% vs 0.46%; P=.001). After adjusting for race and ethnicity, breastfeeding, IUD type, provider type, parity, most recent delivery, and body mass index, the odds of perforation remained higher with placement at 4–8 weeks than at 9–36 weeks (adjusted odds ratio, 1.92; 95% confidence interval, 1.28–2.89). Our Kaplan-Meier survival curve showed that the risk of uterine perforation remained elevated until approximately 22–23 weeks postpartum. Expulsion rates were similar between the 2 groups (1.02 vs 1.17; P=.52).

CONCLUSION:

Uterine perforation after interval postpartum IUD insertion is greater at 4–8 weeks than at 9–36 weeks, although perforation rates remain low at <1%. Expulsion rates did not differ between the groups. Because overall rates of uterine perforation are low, women can safely be offered IUDs at any interval beyond 4 weeks with minimal concern for perforation.

Increasing access to single-visit contraception in urban health care settings: Findings from a multi-site learning collaborative

OBJECTIVE(S)

Multiple barriers limit access to the full range of contraceptive options. The purpose of this quality improvement initiative was to increase single-visit access to the full range of contraceptive methods in primary care, post-abortion, and immediate postpartum settings in New York City (NYC).

STUDY DESIGN

From 2015-2018 we convened two learning collaboratives, named the Quality Improvement Network for Contraceptive Access, with 17 teams (representing 40 sites) from New York City-based hospitals and health centers using an adaptation of the Institute for Healthcare Improvement's Breakthrough Series Learning Collaborative model. Participating teams sought to implement evidence-informed recommendations to increase access. The goal was to increase the patient-centeredness of services by reducing barriers. In the absence of a way to directly measure access, we measured progress toward implementation of the four recommendations and contraceptive care utilization measures as proxies for access, and asked teams to describe facilitating factors.

RESULTS

Learning collaborative teams successfully implemented all four of the recommendations in 95% of the participating sites. Patients who chose and received a most or moderately effective method increased from 22% to 38% in primary care, and from 0% to 17% in the immediate postpartum period. Patients who chose and received a long-acting-reversible contraceptive increased from 5% to 11% in primary care, and from 0% to 3% in immediate postpartum. Facilitating factors included the involvement of interdisciplinary teams, consideration of costs, utilization of peers to demonstrate change, and champions to drive change.

CONCLUSION(S)

The application of evidence-informed recommendations using a structured quality improvement initiative increases contraceptive access.

IMPLICATIONS

This paper identifies key facilitators and factors that influenced the successful implementation of evidence-based recommendations for access to the full range of contraceptive methods in primary care, post-abortion, and immediate postpartum settings. Findings can inform future initiatives that seek to increase contraceptive access at the service delivery level, as a component of reproductive autonomy, and contraceptive equity.

Considerations in Adolescent Use of the Etonogestrel Subdermal Implant: A Cohort Study

Objectives: To describe bleeding patterns and other side effects in adolescent implant users and characterize their impact on early discontinuation of the implant.

Study Design: This is a retrospective cohort study of female patients under 18 years who had an implant placed from 2013 to 2018. Data were collected on demographics, medical history, and side effects.

Results: Of 212 adolescents, the average age at insertion was 16 years and 84% desired placement for contraception. Common side effects included AUB (80%), mood changes (10%), and perceived weight gain (9%). Most (76%) used the implant for at least 12 months. Average time to removal was 22.1 months (SD 13.0 months) and this did not depend on presence of side effects. Twenty-seven percent of teens were able to achieve amenorrhea. Adolescents with frequent or prolonged bleeding were more likely to have implant removal prior to 12 months than those with other bleeding patterns (p = 0.003). Early removal was also more common in girls reporting weight or mood issues than those who did not (p < 0.001 and p = 0.045, respectively). BMI increased in 64% of adolescents. Average percentage change in BMI was 3.2% (0.87 kg/m²). There was no difference in baseline use of any mood-modulating medications in patients who did and did not complain of mood side effects following implant placement (p = 0.801).

Conclusion: Characterization of bleeding patterns following implant placement in adolescents have not previously been reported. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal of the implant. A relatively small number had early removal of the implant due to weight or mood complaints. Therefore, a history of obesity, depression, or other mood disorders should not be a deterrent to implant placement.

The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion

STUDY OBJECTIVE

Temporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation.

DESIGN

Retrospective chart review.

SETTING

The research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents.

PARTICIPANTS

A chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding.

RESULTS

Younger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001).

CONCLUSIONS

Some patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.

Contraceptive method preference and reasons for contraceptive discontinuation among women randomized to intramuscular depot medroxyprogesterone acetate, a copper intrauterine device or a levonorgestrel implant: Findings from Durban, South Africa

OBJECTIVES

The use of intrauterine devices (IUDs) and contraceptive implants in South Africa is low with limited data on patterns of use and reasons for discontinuation. We describe contraceptive preferences and reasons for discontinuation among women enrolled in the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial from one trial site.

STUDY DESIGN

ECHO, conducted between 2015 and 2018, enrolled and randomized sexually active women, aged 16 to 35, and desiring contraception, to intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (copper-IUD) or a levonorgestrel (LNG) implant; follow-up was 12 to 18 months. We interviewed 829 women at the Durban, South Africa trial site at ECHO Trial exit to ascertain contraceptive preferences at randomization. Reasons for randomized contraceptive discontinuation were collected at ECHO Trial exit and 6 months later. Data were analyzed descriptively.

RESULTS

At the final ECHO Trial visit, among women using their randomized contraceptive method (n = 757), 21% discontinued DMPA-IM, 20% discontinued LNG implant and 22% discontinued the copper-IUD. About a quarter from each group discontinued due to problems with bleeding. Among women continuing their randomized contraceptive at trial exit (n = 597), 25% discontinued DMPA-IM within 6 months of exiting the study, 8% discontinued LNG implant and 4% discontinued copper-IUD. A third of women reported wanting to be assigned DMPA-IM at randomization, 20% wanted the LNG implant and 18% the copper-IUD.

CONCLUSIONS

Despite some women having preferences about which contraceptive they might be randomized to, discontinuation rates for all three methods at ECHO Trial exit and 6-month post-trial follow-up were low.

IMPLICATIONS

Despite limited prior use of IUDs and implants among women enrolled in this study, and a desire by some women to not receive these methods at randomization, discontinuation rates remained low. The provision of quality contraceptive counselling and support may increase uptake and continued use of implants and IUDs.

Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Expanding long-acting contraceptive options: a prospective cohort study of the hormonal intrauterine device, copper intrauterine device, and implants in Nigeria and Zambia

BACKGROUND

30 years after the introduction of the levonorgestrel-releasing intrauterine device in Europe, several sub-Saharan African countries are seeking to broaden access to this contraceptive method. In this study, we aimed to assess 12-month continuation of the hormonal intrauterine device, copper intrauterine device, and implants, as well as to assess women's experiences and satisfaction using these methods in the private sector in Nigeria and the public sector in Zambia.

METHODS

We did a prospective cohort study of long-acting reversible contraceptive users across 40 private sector clinics in Nigeria and 21 public sector clinics in Zambia. Eligible women were aged 18-49 years in Nigeria and 16-49 years in Zambia, had chosen to receive the hormonal intrauterine device, copper intrauterine device, or implant (either a 5-year levonorgestrel-releasing subdermal implant or a 3-year etonogestrel-releasing subdermal implant), and, in Nigeria only, had access to a telephone. Women were interviewed within 100 days of receiving their contraceptive method either via telephone in Nigeria or in person in Zambia, with follow-up surveys at 6 months and 12 months. The primary outcomes were method-specific, 12-month continuation rates-ie, continuation rates of the hormonal intrauterine device, copper intrauterine device, and implant across Nigeria and Zambia. We used Kaplan-Meier methods to estimate the cumulative probabilities of method-specific continuation and a log-rank test to compare contraceptive methods. We analysed self-reported satisfaction and experiences as a secondary outcome.

FINDINGS

Between June 25 and Nov 22, 2018, we enrolled a total of 1542 women (n=860 in Nigeria and n=682 in Zambia) receiving a long-acting reversible contraceptive. In total, 835 women (266 [32%] hormonal intrauterine device users, 274 [33%] copper intrauterine device users, and 295 [35%] implant users) in Nigeria and 367 (140 [38%] hormonal intrauterine device users, 149 [40%] copper intrauterine device users, and 78 [21%] implant users) in Zambia were included in the study analysis. The 12-month cumulative continuation rates were 86·8% (95% CI 82·1-90·4) for the hormonal intrauterine device, 86·9% (82·1-90·4) for the copper intrauterine device, and 85·0% (80·2-88·7) for implants in Nigeria. In Zambia, the 12-month cumulative continuation rates were 94·7% (89·2-97·4) for the hormonal intrauterine device, 89·1% (82·3-93·4) for the copper intrauterine device, and 83·1% (72·2-90·1) for implants. At least 71% of respondents across the timepoints were very satisfied with their method, and at least 55 (79%) of 70 reported having recommended their contraceptive method to someone else. Across the methods, the most commonly self-reported positive aspect of long-acting reversible contraceptive use at 12 months was effectiveness in Nigeria (range 93-94%) and long-lasting duration in Zambia (48-60%). Between 124 (50%) of 248 and 136 (59%) of 230 Nigerian participants and 26 (42%) of 62 and 66 (57%) of 117 Zambian participants reported nothing negative about their contraceptive method.

INTERPRETATION

Our study showed high continuation rates and satisfaction across long-acting reversible contraceptives, including the hormonal intrauterine device, a method that has been largely underused in sub-Saharan Africa. This finding supports the inclusion of the hormonal intrauterine device as a valuable addition to the mix of contraceptive methods in Nigeria and Zambia.

FUNDING

Bill & Melinda Gates Foundation.

Attendance of an Initial Follow-up Visit after Long-Acting Reversible Contraception Insertion and Method Continuation Among Adolescents and Young Adults: A Retrospective Study

STUDY OBJECTIVE

To assess attendance of an initial follow-up visit after long-acting reversible contraception (LARC) insertion and whether follow-up was associated with a higher likelihood of method continuation in adolescents and young adults (AYAs).

DESIGN

Retrospective chart review including patients receiving LARC (etonogestrel 68 mg implant, levonorgestrel 52 mg intrauterine device, or copper intrauterine device) between January 1, 2014, and August 1, 2017.

SETTING

An urban adolescent center providing primary care and reproductive health services.

PARTICIPANTS

A total of 331 patients 13-28 years of age.

INTERVENTIONS

Attendance of a follow-up visit 4-8 weeks after LARC insertion.

MAIN OUTCOME MEASURES

Follow-up was defined as visits addressing LARC method or routine physical examinations in the adolescent center or affiliated school-based health clinics. Continuation and discontinuation were defined as documented presence or removal, respectively, of device at various time points. Descriptive analyses, χ² test, Fisher exact test, t test, and survival analysis were used.

RESULTS

Approximately one-third (29.3%) of the patients attended a follow-up visit. Follow-up was associated with a higher likelihood of LARC removal in the first year (hazard ratio [HR] = 2.10, 95% confidence interval [CI] 1.33-3.32). At 500 days post-insertion and beyond, there was no difference in LARC continuation between AYAs who followed-up and those who did not (HR = 1.07, 95% CI 0.67-1.71).

CONCLUSION

Few AYAs attended an initial follow-up visit after LARC placement. These visits were associated with an increased likelihood of LARC removal in the first year; however, this association was not observed long term. More information is needed to determine how to approach follow-up this population.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

Subdermal Contraceptive Implant Insertion Trends and Retention in Adolescents

STUDY OBJECTIVE

There is growing advocacy for use of long-acting reversible contraception among sexually active adolescents. Our primary aims were to evaluate the etonogestrel subdermal contraceptive implant (SCI) insertion trends among adolescents, as well as SCI retention at 1, 2, and 3 years, indications for removal, and to identify pregnancies that occurred during SCI use. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective cohort study was conducted of adolescents aged 13-19 years with SCI insertions in 2008-2014 within a large integrated health care system. Demographic and clinical characteristics included age, race/ethnicity, body mass index, gravidity, parity, insertions, reinsertions, indications for removal, and pregnancy. Electronic medical record review was conducted on a randomized sample of 540 adolescents with insertions during 2008-2011 for the retention objective to validate electronically extracted variables. Analyses included descriptive statistics, survival analysis with Kaplan-Meier estimates for implant retention and Cochran-Armitage trend test for insertions according to year during 2008-2014.

RESULTS

Most adolescent SCI users were non-Hispanic white (43%), or Hispanic (34.2%) and 16 years or older (84.2%) at the time of insertion. Overall, 1-, 2-, and 3-year retention rates were 78.6%, 59.4%, and 26.2%, respectively, with retention at 44.3% at 2 years 9 months (indicative of removal of method for near expiration of 3-year device). The insertion rate trend showed statistically significant increases annually, from 0.14% in 2008 to 0.91% in 2014; P < .0001. No pregnancies were documented during implant use. The most common indication for SCI removal was device expiration.

CONCLUSION

SCI insertions increased annually among adolescents, with more than a sixfold increase over the 6-year study period, and more than half of the SCIs were retained through 2 years of use. The most common indication of SCI removal was completion of Food and Drug Administration-approved duration.

Discontinuation rates of different contraceptive methods in Thai women up to 1-year after method initiation

We assessed the discontinuation rate and the reason for discontinuation of common contraceptives used by reproductive-aged Thai women. We recruited 1880 women aged 18-45 years from the Family Planning Clinic of the Chulalongkorn Hospital in Bangkok. The participants were followed at three, six and twelve months. A Cox proportional hazards model was used to determine personal risks of discontinuing contraceptives. The incidence rate for discontinuation of combined oral contraceptive pills (COCs), depot medroxyprogesterone acetate (DMPA), copper intrauterine device (IUD), and contraceptive implant(s) were 21.3, 9.2, 4.4, and 2.3/100 person-years, respectively. Most of the women who discontinued (185/222) discontinued contraceptives due to side effects. Compared to contraceptive implant users, the adjusted hazard ratios (aHRs) [95% confidence intervals (CIs)] of discontinuing COCs, DMPA, and the copper IUD were 9.6 (4.3-21.8), 4.2 (1.8-10.0), and 2.2 (0.8-5.9), respectively. Lower income, higher parity, history of miscarriage, and history of abortion were independent predictors of contraceptive discontinuation in a multivariable model.

Women's satisfaction with and ongoing use of hormonal long-acting methods compared to the oral contraceptive pill: Findings from an Australian general practice cluster randomised trial (ACCORd)

BACKGROUND

The Australian Contraceptive ChOice pRoject (ACCORd) aimed to assess the impact of a complex general practice intervention on the uptake of long-acting reversible contraceptives (LARC).

AIMS

Using survey data from enrolled women, we aimed to compare the ongoing use and satisfaction of women who chose one of the hormonal LARC methods including the levonorgestrel intrauterine system (LNG-IUS) or levonorgestrel implant compared to the oral contraceptive pill (OCP).

MATERIALS AND METHODS

We used the data from participants' baseline, six and 12-month surveys to identify new users of implants, LNG-IUS or OCP. We included demographic information, ongoing use of the contraceptive method, reasons for dissatisfaction and discontinuation and experience of side-effects. Proportions were compared using χ² tests.

RESULTS

Of the 740 women enrolled in ACCORd, 176 started using a hormonal LARC or OCP in the study's first six months with 76 using the IUS (43%), 60 the implant (34%) and 40 (23%) the OCP. Twelve-month continuation rates for the LNG-IUS, implant and OCP were 93, 83 and 65% respectively (P < 0.001). Satisfaction was highest among the LNG-IUS users; 86% were very/somewhat satisfied compared to 75% of implant users and 61% of OCP users (P < 0.001). Main reasons for method dissatisfaction were irregular bleeding and mood changes which were similar for all methods.

CONCLUSIONS

This study provides further evidence that hormonal LARC methods have higher continuation and satisfaction rates compared to the OCP with similar side-effects. Since hormonal LARC methods have the highest contraceptive efficacy, these should be offered first-line to women.

Systemic hormonal contraception initiation after abortion: A systematic review and meta-analysis

Background

Immediate contraceptive initiation, including start of a method before abortion completion, is a convenient option for women seeking abortion care.

Objectives

To evaluate the effect of systemic hormonal contraception initiation on medical abortion effectiveness and the safety of hormonal contraceptive methods following abortion.

Data sources

PubMed, Popline, Cochrane Library, and Clinicaltrials.gov.

Study eligibility criteria

Studies that assessed medical abortion effectiveness after systemic hormonal contraception initiation and the safety of hormonal contraception initiation after abortion.

Participants

Pregnant persons undergoing or who had recently undergone an abortion.

Interventions

Initiation of systemic hormonal contraception post abortion or on the day of the first pill of the medical abortion.

Study appraisal and synthesis methods

We assessed study quality using the US Preventive Services Task Force evidence grading system. We created narrative summaries and calculated pooled relative risks when appropriate.

Results

We identified 16 studies for inclusion, 7 randomized controlled trials, and 9 cohorts. Nine studies assessed medical abortion effectiveness with hormonal contraception initiation and generally found no decreased risk of abortion success or increased risk of additional treatment. One fair-quality study reported a small increase in ongoing pregnancy rate with immediate depot medroxyprogesterone (DMPA) compared with delayed DMPA initiation (3.6% vs 0.9%, risk difference 2.7%, 90% confidence interval 0.4–5.6). We identified no bleeding-related safety concerns following hormonal contraception initiation after medical or surgical abortion. Pooled results were too imprecise to draw firm conclusions.

Limitations

Included studies were poor or fair quality and primarily in high-income or upper-middle-income settings.

Conclusions

Abortion effectiveness did not differ between immediate vs delayed initiation of most systemic hormonal contraceptive methods after a first trimester medical abortion. However, immediate DMPA initiation did show increased ongoing pregnancy. Bleeding effects with hormonal contraception initiation postabortion appeared minimal.

Implications

Initiating a hormonal contraceptive method after an abortion and as early as the same day as the first pill of the medical abortion is an option if contraception is desired. The slight increase in ongoing pregnancy with immediate DMPA initiation highlights the importance of information provision during contraceptive counseling.

Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services

STUDY OBJECTIVES

Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods.

DESIGN

Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes.

SETTING

Eleven contraceptive trainings at SBHCs across the United States from 2016-2019.

PARTICIPANTS

A total of 260 providers from 158 SBHCs serving 135,800 students.

INTERVENTIONS

On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services.

MAIN OUTCOME MEASURES

The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills.

RESULTS

At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36).

CONCLUSIONS

Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.

Long-acting contraception in adolescents and young women with type 1 and type 2 diabetes

Adolescent pregnancy is a major public health problem worldwide. Adolescents living with diabetes are not aware of the risks of unplanned pregnancy and the high rate of fetal and maternal complications when gestation occurs in women with significant hyperglycemia. These data highlight the significance of pregnancy prevention in young women with diabetes. Long-acting reversible contraceptives (LARCs), which include subdermal progestin implants and hormonal and nonhormonal intrauterine devices (IUDs), have been recommended by the American College of Obstetricians Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents and young women. This article reviews LARC options for adolescents and young women with type 1 (T1D) and type 2 (T2D) diabetes as well as the possible complications and side effects.

Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives

Background Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use.

METHODS

Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'.

RESULTS

In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04).

CONCLUSION

Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial longitudinal follow-up protocol

INTRODUCTION

Through addressing main barriers to the uptake of long-acting reversible contraceptives (LARCs) among Australian women, the Australian Contraceptive ChOice pRoject (ACCORd) trialled an educational intervention targeting general practitioners (GPs) and provided those in the intervention group with a rapid referral service for quick insertion. The cluster randomised controlled trial resulted in greater uptake of LARC in the intervention group. This protocol paper describes a longitudinal follow-up to the ACCORd Study to assess the long-term efficacy and cost-effectiveness of the intervention.

METHODS AND ANALYSIS

Women participants (patients of ACCORd GPs) completed a baseline, 6-month and 12-month survey. These participants will be invited to complete an additional follow-up survey 3 years post completion of their baseline interview. Based on the original ACCORd Study tools, the online survey will address long-term outcomes including contraceptive continuation rates and reproductive history, any unintended pregnancies, satisfaction and concerns with their current contraceptive method, and an assessment of quality of life. We will analyse data using binary regression models with generalised estimating equations and robust standard errors to account for clustering.

DISCUSSION

Demonstration of sustained use, effectiveness at reducing unwanted pregnancies and cost-effectiveness of this strategy among this cohort of Australian primary care patients, will strengthen the policy and programme urgency of addressing wider dissemination of these strategies and replicating the study elsewhere.

ETHICS AND DISSEMINATION

The ACCORd Study received approval from the Monash University Human Research Ethics Committee: CF16/188-201000080. Additionally, an amendment to conduct this 3-year longitudinal follow-up survey has been approved. The trial follow-up outcomes will be disseminated through formal academic pathways, including journal articles, national and international conferences and reports as well as using more 'mainstream' strategies such as seminars, workshops and media engagement. Additionally, outcomes will be communicated through policy briefs to Australian state and federal governments.

TRAIL REGISTRATION NUMBER

This trial is registered with the Australian and New Zealand Trials Registry ACTRN12615001346561. Recruitment and data collection have been completed for the baseline, 6-month and 12-month surveys. Data collection for the 3-year survey commenced in August 2019.

Final Program Data and Factors Associated With Long-Acting Reversible Contraception Removal: The Zika Contraception Access Network

OBJECTIVE

To describe characteristics of the full population of women who participated in the Zika Contraception Access Network program in Puerto Rico during the virus outbreak and to examine factors associated with removal of a long-acting reversible contraception (LARC) method by a Zika Contraception Access Network provider during the program's duration (May 2016-September 2017).

METHODS

We conducted an observational cohort study. The Zika Contraception Access Network program was designed to increase access to contraception services in Puerto Rico for women who chose to prevent pregnancy during the Zika virus outbreak as a primary strategy to reduce adverse Zika virus-related pregnancy and birth outcomes. Among program participants, an observational cohort of women served by the Zika Contraception Access Network Program, we describe their demographic and program-specific characteristics, including contraceptive method mix before and after the program. We also report on LARC removals by Zika Contraception Access Network providers during the program. We examined factors associated with LARC removal using multivariable logistic regression.

RESULTS

A total of 29,221 women received an initial Zika Contraception Access Network visit during the program. Ninety-six percent (27,985) of women received same-day provision of a contraceptive method and 70% (20,381) chose a LARC method. While the program was active, 719 (4%) women who chose a LARC at the initial visit had it removed. Women with a college degree or higher were more likely to have their LARC removed (adjusted prevalence ratio [aPR] 1.24); breastfeeding women (aPR 0.67) and those using a LARC method before Zika Contraception Access Network (aPR 0.55) were less likely to have their LARC removed.

CONCLUSION

The Zika Contraception Access Network program was designed as a short-term response for rapid implementation of contraceptive services in a complex emergency setting in Puerto Rico and served more than 29,000 women. The Zika Contraception Access Network program had high LARC uptake and a low proportion of removals by a Zika Contraception Access Network provider during the program. A removal-inclusive design, with access to removals well beyond the program period, maximizes women's reproductive autonomy to access LARC removal when desired. This model could be replicated in other settings where the goal is to increase contraception access.

Management of bothersome bleeding associated with progestin-based long-acting reversible contraception: a review

PURPOSE OF REVIEW

To describe common bleeding patterns and treatment strategies to minimize bothersome bleeding in users of progestin-based long-acting reversible contraception (LARC).

RECENT FINDINGS

Most levonorgestrel intrauterine device users will establish a favorable bleeding pattern within a year; NSAIDs are the most effective bridge to help with bothersome bleeding during that time period. Early follicular phase insertion and fundal placement are associated with more favorable early bleeding profiles. Recent studies exploring tranexamic acid, mifepristone, and tamoxifen's adjunct role show modest or no benefit. The progestin implant is associated with more persistent unpredictable bleeding disproportionately affecting women with higher etonogestrel serum levels; recent studies indicate that oral contraceptives, ulipristal acetate, and tamoxifen may all provide temporary relief.

SUMMARY

Women's healthcare providers can offer patients adjunct medical therapies to minimize bothersome bleeding associated with progestin LARC use, which may result in increased satisfaction and continuation rates of these effective forms of contraception.

Factors associated with early long-acting reversible contraceptives discontinuation in Ethiopia: evidence from the 2016 Ethiopian demographic and health survey

Background

Ethiopia is struggling to achieve the 2020 family planning target. But the current contraceptive prevalence uptake is low and dominated by short-acting methods. Contraceptive discontinuation rate is also high. This analysis was done to identify the reasons and factors associated with long-acting and reversible contraceptives (LARC) discontinuation in Ethiopia.

Methods

The unit of analysis was LARC-use episodes in the 5 years preceding the survey, generated from the 2016 Ethiopian Demographic and Health Survey data. A total of 1385 LARC episodes were included. Data analysis was done using STATA 15. The event file generated from the contraceptive calendar was merged to the original data set to identify factors associated with LARC discontinuation. Univariate, bivariate and inferential analyses were done for 12 months LARC discontinuation.

Result

Approximately 82% of LARC episodes were implants. About 45% of intrauterine device (IUD) and 61% of implant episodes were discontinued by 36 months. Side effects and the desire to become pregnant were the main reasons for discontinuation. Women aged 25–34 (HR = 0.26; 95% CI: 0.20–0.35) and those aged 35–49 (HR = 0.17; 95%CI: 0.11–0.26), women who participated in decision-making partially (HR = 0.53; 95%CI: 0.37–0.78), or fully (HR = 0.55; 95%CI: 0.40–0.74) and primiparous women (HR = 0.53, 95%CI: 0.33–0.86) had a lower hazard of discontinuing LARCs. On the other hand, women who had only primary education (HR = 1.32; 95%CI: 1.02–1.72) and women who were not sure about their fertility intention (HR = 2.11; 95%C: 1.28–3.46) had a higher likelihood of discontinuing these methods.

Conclusion

Majority of LARC episodes were discontinued early, mainly due to the desire for pregnancy or experience of side effects. Older women, particularly those involved in household decision-making, and primipara were less likely to discontinue LARC. Women with only primary education and those uncertain about their fertility intention had a higher likelihood of discontinuation. Family planning service providers should focus on fertility intention and side effects when counseling women for contraceptive choice. Improving women’s participation in household decision-making may decrease LARC discontinuation in Ethiopia.