Eliminating health disparities in unintended pregnancy with long-acting reversible contraception (LARC)

Social Determinants of Health and Patient-Reported Difficult Discontinuation of Long-Acting Reversible Contraception

Background: Some individuals who receive long-acting reversible contraception (LARC) face barriers to discontinuation. The inability to discontinue a contraceptive method when desired negatively impacts a person's reproductive autonomy. Persons impacted by social determinants of health (SDH) may be disproportionately affected. The objective of this study is to evaluate the association of SDH with patient-reported difficult LARC discontinuation. Methods: A retrospective cross-sectional analysis of data from the 2017-2019 cycle of the National Survey of Family Growth was conducted. The main outcome was patient-reported difficulty discontinuing a LARC method (intrauterine device or implant) in the last 10 years. Descriptive statistics were used to identify demographic characteristics and SDH domains. Multivariable logistic regression models were used to estimate associations across SDH domains with difficult LARC removal. Results: A total of 754 respondents reported wanting to have their LARC removed, and 105 (11%) reported difficulty discontinuing LARC methods. One-third of respondents experienced one or more SDH, notably food insecurity (26%) or transportation barriers (30%). After adjusting for age, race, education, geographic location, parity, and body mass index (BMI), persons with one or more SDH had an increased adjusted odds ratio (aOR) for difficultly discontinuing LARCs compared with respondents without any SDH (2.11; 95% confidence interval [CI]: 1.21, 3.69). Transportation barriers demonstrated the largest aOR of 2.90 (95% CI: 1.07, 7.87). Conclusions: SDH are associated with challenges to LARC discontinuation. SDH are unique risk factors that can impact one's entire contraceptive experience. A nuanced discussion of SDH at the time of contraceptive counseling may be a critical step in addressing the intersectionality of method selection and reproductive agency.

Health literacy needs and preferences for a technology-based intervention to improve college students' sexual and reproductive health

Objective: To explore health literacy needs and preferences for a technology-based intervention (app) to improve sexual and reproductive health (SRH) among college students. Participants: In Spring 2019, in-depth interviews were conducted with 20 participants (10 male, 10 female) from a large, public university. Methods: Interview guide was developed based on Integrated Model of Health Literacy domains and Diffusion of Innovation constructs. Data were analyzed in MaxQDA using applied thematic analysis. Results: Dominant themes included accessing health information and services, evaluating options to make decisions, intervention utility and characteristics, and the emergent theme of credibility. Specific topics included accessing STI testing, contraceptive decision making, information on human papillomavirus (HPV) and the HPV vaccine, patient-provider communication, app design and function elements, and modifying the app to meet the SRH needs of diverse college students. Conclusions: Findings identified areas where an app could address college students' SRH literacy, ultimately improving SRH outcomes among this population.

Contraception in patients with liver disease and liver transplant

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Acceptability and continuation of use of the subdermal contraceptive implant among adolescents and young women in Argentina: a retrospective cohort study

A new public policy was instituted in Argentina for free distribution of subdermal contraceptive implants to women aged 15-24 years old in the public healthcare system. The objective of this study is to determine the extent to which this population adhered to the implant, as well as predictors of continuation. The retrospective cohort study was based on a telephone survey of a random sample of 1101 Ministry of Health-registered implant users concerning the continuation of use, satisfaction with the method and side-effects, and reasons for removal. Descriptive statistics and multivariate regression analysis were used to explore the association between adherence and having received contraceptive counselling, satisfaction, and side effects. We found high levels of adherence (87%) and satisfaction (94%). Common reported side effects were amenorrhoea or infrequent bleeding, perceived weight gain, increased menstrual bleeding and headaches. Multivariate regression analysis indicates that, among adolescents, having received contraceptive counselling increased comfort, while frequent bleeding at six months hindered trust. Participants who had a history of a prior delivery or who had themselves primarily chosen the method were less likely to request the removal of the implant. Our results support the public policy of free implant distribution in the public health sector. This is a sustainable public policy that contributes to equity and access to effective contraception. It is appropriate for adolescents and young women and will also reduce unintended pregnancies. Our results suggest that counselling patients is key prior to insertion of the implant, as it improves acceptability and continuation.

Abortion Surveillance - United States, 2021

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2021.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2021, a total of 48 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 47 reporting areas provided data each year during 2012-2021. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2020 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 625,978 abortions for 2021 were reported to CDC from 48 reporting areas. Among 47 reporting areas with data each year during 2012-2021, in 2021, a total of 622,108 abortions were reported, the abortion rate was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 204 abortions per 1,000 live births. From 2020 to 2021, the total number of abortions increased 5% (from 592,939 total abortions), the abortion rate increased 5% (from 11.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 4% (from 197 abortions per 1,000 live births). From 2012 to 2021, the total number of reported abortions decreased 8% (from 673,634), the abortion rate decreased 11% (from 13.1 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 207 abortions per 1,000 live births).In 2021, women in their 20s accounted for more than half of abortions (57.0%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (28.3% and 28.7%, respectively) and had the highest abortion rates (19.7 and 19.4 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.5 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 30-39 years.From 2020 to 2021, abortion rates increased among women aged 20-39 years, decreased among adolescents aged 15-19 years, and did not change among adolescents aged <15 years and women aged ≥40 years. Abortion rates decreased from 2012 to 2021 among all age groups, except women aged 30-34 years for whom it increased. The decrease in the abortion rate from 2012 to 2021 was highest among adolescents compared with any other age group. From 2020 to 2021, abortion ratios increased for women aged 15-24 years, decreased among adolescents aged <15 years and women aged ≥35 years and did not change for women aged 25-34 years. From 2012 to 2021, abortion ratios increased among women aged 15-29 years and decreased among adolescents aged <15 years and women aged ≥30 years. The decrease in abortion ratio from 2012 to 2021 was highest among women aged ≥40 years compared with any other age group.In 2021, the majority (80.8%) of abortions were performed at ≤9 weeks' gestation, and nearly all (93.5%) were performed at ≤13 weeks' gestation. During 2012-2021, the percentage of abortions performed at >13 weeks' gestation remained ≤8.7%. In 2021, the highest percentage of abortions were performed by early medication abortion at ≤9 weeks' gestation (53.0%), followed by surgical abortion at ≤13 weeks' gestation (37.6%), surgical abortion at >13 weeks' gestation (6.4%), and medication abortion at >9 weeks' gestation (3.0%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 66.6% of abortions were early medication abortions. In 2020, the most recent year for which PMSS data were reviewed for pregnancy-related deaths; six women died as a result of complications from legal induced abortion.

Interpretation

Among the 47 areas that reported data continuously during 2012-2021, overall decreases were observed during 2012-2021 in the total number, rate, and ratio of reported abortions; however, from 2020 to 2021, increases were observed across all measures.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Levonorgestrel Emergency Contraception Information Accuracy From West Virginia Community Pharmacies: A Mystery Caller Approach

BACKGROUND

To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies.

METHODS

A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC.

RESULTS

Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies).

CONCLUSIONS

Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes

BACKGROUND

Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis.

OBJECTIVE

This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device.

STUDY DESIGN

This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device.

RESULTS

A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44).

CONCLUSION

This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.

Reproductive Planning and the Choice of Long-acting Reversible Contraceptive Primary to Health: A Cross-Sectional Study

OBJECTIVE

 Evaluate the different perspectives that involve the choice of long-acting reversible contraceptives (LARCs), the issues related to this process and the consequences of deciding one method in the women's in the primary health care (PHC) center in Sousas, a district in Campinas, SP (Brazil).

METHODS

 This is an analytical cross-sectional study, it was performed at the PHC in Sousas. Data were collected through the analysis of medical records and interviews with women who live in Sousas and had the insertion of the copper intrauterine device (IUD) (D) from April 2021 to April 2022 or the etonogestrel implant (I) from May to December 2022. The study was approved by the Research Ethics Committee of the Medical Science School at the State University of Campinas (UNICAMP).

RESULTS

 Reason for choosing this LARC: medical (D: 52%; I: 100%), easy adhesion (D: 71%; I: 67%), effectiveness (D: 55%; I: 100%). Indication by health professionals (D: 65%; I: 100%). And improvement of clinical characteristics: mood (D: 77%; I: 67%), body mass index (BMI; D: 52%; I: 33%), and libido (D: 84%; I: 67%).

CONCLUSION

 It is suggested that women tend to decide between LARCs when guided by their doctor or PHC health professionals, and they select LARCs because of the ease of use and low failure rates. Therefore, this study highlights how LARCs can positively interfere in the aspects that pervade contraception, such as BMI, libido, and mood.

Determinants and prevalence of modern contraceptive use among sexually active female youth in the Berekum East Municipality, Ghana

INTRODUCTION

Contraceptive use among sexually active women in Ghana remains low despite the efforts by the Ghana Health Service. This development has negative consequences on reproductive health care, particularly among adolescents. This study assessed the prevalence and factors influencing contraceptive use among sexually active young women in the Berekum Municipality, Ghana.

METHOD

A community-based cross-sectional analytical study was carried out in Berekum East Municipality among young women between the ages of 15 to 24 years. Using a probabilistic sampling technique, we recruited 277 young women from the four selected communities in the Berekum Municipality based on data available from the Municipal Health Administration. We applied a univariate and multivariate logistic regression analysis to test the associations between the dependent and independent variables at a 95% Confidence interval (CI) and 5% significance (p value = 0.005).

RESULTS

The modern contraceptive prevalence rate among the study participants was 211 (76%). Contraceptives ever used were emergency contraceptive pills 88 (41.7%) condoms 84 (39.8%), injectables 80 (37.9%) and the rest used the Calendar method 16 (7.58%), withdrawal 15 (7.11%), and implants 11 (5.21%). In the adjusted multivariate logistic regression, Age (AOR = 2.93; 95% CI; 1.29-7.50) p = 0.023, marital status (AOR = 0.08; 95%CI; 0.01-0.91) p = 0.041 and religion (AOR = 0.17; 95% CI; 0.05-0.64) p = 0.009 were significantly associated with contraceptive use. Other determinants such as hearing about contraceptives (AOR = 9.44; 95%CI; 1.95-45.77) p = 0.005, partner opposition (AOR = 33.61; 95%CI; 1.15-985.39) p = 0.041, side effects (AOR = 4.86; 95%CI; 1.83-12.91) p = 0.001, lack of knowledge (AOR = 5.41; 95%CI; 1.15-25.42) p = 0.032, and respondents receiving counselling on family planning were significantly associated with contraceptive use (AOR = 4.02; 95% CI;1.29-12.42), p = 0.016.

CONCLUSION

Contraceptive use among sexually active women in the Berekum Municipality is higher than the national conceptive prevalence rate. However, factors such as knowledge about the side effects of contraceptive influences contraceptive use among women. Healthcare providers must explore avenues to enhance partner involvement, intensify health education and detailed counselling about contraceptive use to address misconceptions and myths surrounding the side effects of contraceptives.

Knowledge, beliefs and practices of nurses with long-acting reversible contraception, Cape Town

BACKGROUND

Implanon and copper intrauterine contraceptive device (IUCD) are long-acting reversible contraceptives (LARC) available in public primary health care (PHC) South Africa. These methods are the most effective forms of contraception.

AIM

To evaluate the knowledge, beliefs and practices on provision of LARC.

SETTING

Primary health care facilities within the Khayelitsha Eastern Substructure, Cape Town.

METHODS

A descriptive survey of all permanent nurses who provided contraception. Data were collected from 72/90 (80% response rate) via a validated questionnaire and evaluated using Statistical Package for Social Sciences (SPSS).

RESULTS

Knowledge of eligibility for LARC was tested. The mean knowledge scores for Implanon were 8.56/11 (s.d. 1.42) for the trained and 7.16/11 (s.d. 2.83) for the untrained (p = 0.007). The mean knowledge scores for IUCD were 10.42/12 (s.d. 1.80) for the trained and 8.03/12 (s.d. 3.70) for the untrained (p = 0.019). Participants believed that inaccessibility to training courses (29%), no skilled person available (24%) and staff shortages (35%) were barriers. Less than 50% of women were routinely counselled for LARC. Forty-one percent of nurses were trained and performed IUCD insertion, and 64% were trained and performed Implanon insertion, while 61% and 45% required further training. Confidence was low, with 32% trained and confident in IUCD and 56% trained and confident in Implanon insertion.

CONCLUSION

Lack of training, poor confidence and deficient counselling skills were barriers to effective LARC provision. The identified system-specific barriers must be addressed to improve uptake.Contribution: The first study to evaluate knowledge, beliefs and practices on LARC in providers in the Western Cape.

Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine

OBJECTIVE

Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine.

METHODS

We used the Maine Health Data Organization's All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020-September 2020, April 2020-March 2021) as compared with the reference period (October 2015-March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs.

RESULTS

The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated.

CONCLUSION

Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.

Factors associated with long-acting reversible contraception usage: Results from the National Survey of Family Growth

OBJECTIVE

The authors aimed to identify factors associated with long-acting reversible contraception (LARC) usage.

METHODS

The current cross-sectional study used data from the National Survey of Family Growth from 2011 to 2019. Respondents aged 15 to 44 years were included. Those with previous sterilization, infertility, or pregnant were excluded. The outcome evaluated was use of a LARC.

RESULTS

Of 61 543 814 women, 44 287 911 (72.0%) met inclusion criteria. The rate of LARC use was 13.4%. Factors associated with an increased likelihood of LARC usage were married/living with a partner (adjusted relative risk [aRR], 1.18 [95% CI, 1.02-1.37]), perceived good health (aRR, 1.44 [95% CI, 1.13-1.84]), year of survey 2017 to 2019 (aRR, 1.53, [95% CI, 1.28-1.83]), one or two past pregnancies (aRR, 1.62 [95% CI, 1.24-2.12]) or three or more past pregnancies (aRR, 1.67 [95% CI, 1.22-2.28]), age at first live birth <20 years (aRR, 1.58 [95% CI, 1.20-2.08]) or 20 to 24 years (aRR, 1.45 [95% CI, 1.13-1.87]), age at onset of sexual activity 13-19 years (aRR, 1.50 [95% CI, 1.26-1.78]), and a 0- to 5-month period of nonintercourse in the past year (aRR, 1.63 [95% CI, 1.40-1.90]). Factors associated with decreased LARC usage were age ≥ 35 years (aRR, 0.74 [95% CI, 0.65-0.85]), being non-Hispanic Black (aRR, 0.75 [95% CI, 0.62-0.89]) or non-Hispanic other (aRR, 0.72 [95% CI, 0.59-0.88]), intending to have children (aRR, 0.65 [95% CI, 0.57-0.74]), and never being sexually active (aRR, 0.10 [95% CI, 0.06-0.16]).

CONCLUSIONS

Using a nationally representative sample of women in the United States, the authors identified modifiable factors associated with LARC use. Results may be used to plan interventional trials to increase LARC usage.

Achieving Equity in Postpartum Contraception Access

Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.

Contraception knowledge and practices among students in Lebanese universities

This study aimed to evaluate the proportion of contraception users among Lebanese youth, and the extent of knowledge and perception on birth control; and to raise awareness and sensitise young adults to sexual health, which remains taboo in Lebanon. The 30-item questionnaire was broadcasted to students in private and public universities in Lebanon, through social media and it collected information on contraception use and student knowledge. Over 30% of responders were medical students, and 41% have ever used contraceptives (mostly women); among which, 52.1% for contraception versus 47.9% for medical reasons. According to responders, the pill ranked high in terms of effectiveness (72.4% of responders perceive the pill as effective), followed by the male condom (69.1%) and the hormonal intrauterine device (29.6%). Some would not use contraception in the future, for religious reasons (30.8%) or for fear of complications (46.2%); indeed, around a third of contraceptive users (all female) have experienced adverse effects. Finally, students expressed concern about long-term complications of contraceptive use (pulmonary embolism/phlebitis, breast/endometrial/ovarian cancer, stroke, depression and myocardial infarction). Though less frequent than in the Western world, contraception use in Lebanon is non-negligible and gaps in university students' knowledge on contraception were identified; which should prompt sexual education and family planning initiatives in Lebanon.

Patient and provider perspectives on barriers and facilitators to reproductive healthcare access for women experiencing homelessness with substance use disorders in San Francisco

BACKGROUND

Women experiencing homelessness with substance use disorders face unique and intersecting barriers to realizing their reproductive goals.

OBJECTIVE

This study explored the reproductive aspirations of this population, as well as the barriers to accessing reproductive services from the perspectives of affected individuals, and the healthcare providers who serve them.

DESIGN

This mixed-methods study included surveys and interviews with women experiencing homelessness with substance use disorders and healthcare providers.

METHODS

We conducted surveys and semi-structured interviews with women recruited from opiate treatment programs and homeless encampments in San Francisco, California in 2018. We also conducted interviews and focus groups with healthcare providers in reproductive health and substance use treatment settings. Interviews were recorded, transcribed, and coded. Descriptive statistics of survey results were performed.

RESULTS

Twenty-eight women completed surveys, 96% of whom reported current substance use. Ten women participated in interviews. One-third (9/28) reported desiring pregnancy in the next year; over half (16/28) reported they would be somewhat or very happy to learn they were pregnant. A majority used no contraception at last intercourse (14/28). Twenty-six healthcare providers participated in interviews (n = 15) and focus groups (n = 2). Patients and providers identified similar barriers to care access, including discrimination, logistical and financial challenges, and delayed pregnancy awareness. While providers proposed solutions focused on overcoming logistical challenges, patients emphasized the importance of transforming the healthcare environment to treat patients affected by substance use and homelessness with dignity and respect.

CONCLUSION

Women experiencing homelessness with substance use disorders face intersecting and compounding barriers to accessing reproductive health services. For patients, the impact of stigma and bias on treatment experiences are particularly salient, in contrast to logistical barriers emphasized by providers. Improving access will require structural and individual-level solutions to address stigma and create person-centered, trauma-informed, and respectful care environments.

Some key questions: Pregnancy intention screening by community health workers

BACKGROUND

Unintended pregnancy contributes to a high burden of maternal and fetal morbidity in the United States, and pregnancy intention screening offers a key strategy to improve preconception health and reproductive health equity. The One Key Question© is a pregnancy intention screening tool that asks a single question, "Would you like to become pregnant in the next year?" to all reproductive-age women. This study explored the perspectives of community health workers on using One Key Question in community-based settings.

OBJECTIVES

This study aimed to identify barriers and facilitators to the use of the One Key Question pregnancy intention screening tool by community health workers who serve reproductive-age women in Salt Lake City, Utah.

DESIGN

Using reproductive justice as a guiding conceptual framework, this study employed a qualitative descriptive design. Participants were asked to identify barriers and facilitators to the One Key Question, with open-ended discussion to explore community health workers' knowledge and perceptions about pregnancy intention screening.

METHODS

We conducted focus groups with 43 community health workers in Salt Lake City, Utah, from December 2017 through January 2018. Participants were trained on the One Key Question algorithm and asked to identify barriers and facilitators to implementation. All focus groups occurred face-to-face in community settings and used a semi-structured facilitation guide developed by the study Principal Investigator with input from community partners.

RESULTS

Pregnancy intention screening is perceived positively by community health workers. Barriers identified include traditional cultural beliefs about modesty and sex, lack of trust in health care providers, and female bias in the One Key Question algorithm. Facilitators include the simplicity of the One Key Question algorithm and the flexibility of One Key Question responses.

CONCLUSION

One Key Question is an effective pregnancy intention screening tool in primary care settings but is limited in its capacity to reach those outside the health system. Community-based pregnancy intention screening offers an alternative avenue for implementation of One Key Question that could address many of these barriers and reduce disparities for underserved populations.

A Path Towards Reproductive Justice: Incorporating a RJ Framework into North Carolina's Improving Community Outcomes for Maternal and Child Health Initiative

PURPOSE

Long-acting reversible contraception (LARC) is encouraged as a strategy to address racial disparities in birth outcomes. Black woman-led organizations and stakeholders recommend a thoughtful integration of Reproductive Justice for any LARC programs. This paper will describe how one state-funded maternal and child health program reconceptualized an evidence-based strategy (EBS) focused on increasing access to LARC, to a broader strategy that incorporated principles of Reproductive Justice to improve birth outcomes.

DESCRIPTION

In 2016, North Carolina established the Improving Community Outcomes for Maternal and Child Health (ICO4MCH) program. As part of this program, five county health departments were awarded funding to "increase access to LARC". Noting community partners' concerns with this strategy, ICO4MCH leadership revised the strategy to focus on using the Reproductive Justice framework to improve utilization of reproductive life planning and access to LARC. Leaders modified the strategy by changing performance measures and scope of work/deliverables required by grantees.

ASSESSMENT

Using quarterly reports and focus group data from ICO4MCH grantees, we identified key steps communities have taken to prioritize Reproductive Justice. Key findings include that sites hosted Reproductive Justice trainings for team members and changed language describing family planning services. These activities were tailored to fit community context and existing perceptions about reproductive health services.

CONCLUSION

The ICO4MCH program was able to modify a LARC EBS to better emphasize Reproductive Justice. Local agencies desiring to shift their LARC programs should include and value feedback from those with lived experience and partner with organizations committed to Reproductive Justice.

Long-acting reversible contraception: Targeting those judged to be unfit for parenthood in the United States and the United Kingdom

There is a long history of regarding marginalised groups as unfit to parent and of eugenic policies targeting those with 'undesirable' bodily conditions or behaviours. This is part of a broader pattern of stratified reproduction - structural conditions that enable or discourage certain groups from reproducing - that often brings about and exacerbates injustices. This paper critically assesses the US and UK social and medical literature on applying pressure to marginalised groups, or those who have behaved 'irresponsibly', to use long-acting reversible contraception (LARC). Targeting young people for LARC fails to recognise that social inequality is the context for teenage pregnancy, not the result of it. Provider pressure on women of colour to use LARC is linked to institutional racism, whilst policy for those with physical and intellectual disabilities is shaped by disability discrimination. Other groups to be targeted include so-called 'welfare mothers', substance users, those who have had children put into care and offenders. Particularly controversial are cases in which LARC has been ordered by courts. LARC policy incorporating these kind of discriminatory practices needs to stop; future policy should focus on person-centred care that bolsters reproductive justice.

Measurement and Operationalization of the Social Determinants of Health and Long-Acting Reversible Contraception Use in the U.S.: A Systematic Scoping Review

Introduction

The objective of this review was to conduct a systematic evaluation of the measurement and operationalization of the social determinants of health in research on long-acting reversible contraception use in the U.S. To contribute to the ongoing refinement of the quality of social determinants of health and long-acting reversible contraception use research, this systematic scoping review examines how social determinants of health are measured and operationalized in studies that examine long-acting reversible contraception initiation and usage at the patient level.

Methods

A detailed search of 5 electronic databases (PubMed, Embase, Web of Science, CINAHL, and PsycINFO) was conducted between December 2020 and January 2021 according to PRISMA guidelines. Determinants were assessed using the Dahlgren and Whitehead model. The protocol and data extraction template were developed a priori.

Results

A total of 27 articles representing 26 studies were included in our study. A total of 12 studies were retrospective and cross-sectional in design; the remaining studies were a combination of designs. Healthcare services and health insurance were identified as the most frequently researched categories of determinants. There was wide variation in reported operationalization of race and ethnicity, limited engagement with sexuality, and uneven geographic representation across studies.

Discussion

This systematic scoping review is the first, to the best of our knowledge, to focus on the measurement and operationalization of social determinants of health and on current long-acting reversible contraception use research. Future research on the impact of social determinants of health on long-acting reversible contraception use must explore the full range of factors shaping contraceptive decision making and use and focus on equity-informed data collection methods and reporting.

Determinants of the use of contraceptive methods by adolescents in the Democratic Republic of the Congo: results of a cross-sectional survey

Background

Family planning (FP) is an effective strategy to prevent unintended pregnancies of adolescents. We aimed at identifying the socio-demographic factors underlying the low use of contraceptive methods by teenage girls in the Democratic Republic of the Congo (DRC).

Methods

A secondary analysis targeting teenage girls aged 15–19 was carried out on the Performance, Monitoring and Accountability project 2020 (PMA 2020) round 7 data, collected in Kinshasa and Kongo Central provinces. The dependent variable was the “use of contraceptive methods by sexually active teenage girls”, calculated as the proportion of teenagers using modern, traditional or any contraceptive methods. Independent variables were: level of education, age, province, religion, marital status, number of children, knowledge of contraceptive methods and household income. Pearson's chi-square and logistic regression tests helped to measure the relationship between variables at the alpha significance cut point of 0.05.

Results

A total of 943 teenagers were interviewed; of which 22.6, 18.1 and 19.9% ​​used any contraceptive method respectively in Kinshasa, Kongo Central and overall. The use of modern contraceptive methods was estimated at 9.9, 13.4 and 12.0% respectively in Kinshasa, Kongo Central and overall. However, the use of traditional methods estimated at 8.0% overall, was higher in Kinshasa (12.7%) and lower (4.7%) in Kongo Central (p < .001). Some factors such as poor knowledge of contraceptive methods (aOR = 8.868; 95% CI, 2.997–26.240; p < .001); belonging to low-income households (aOR = 1.797; 95% CI, 1.099–2.940; p = .020); and living in Kongo central (aOR = 3.170; 95% CI, 1.974–5.091; p < .001) made teenagers more likely not to use any contraceptive method.

Conclusion

The progress in the use of contraceptive methods by adolescent girls is not yet sufficient in the DRC. Socio-demographic factors, such as living in rural areas, poor knowledge of FP, and low-income are preventing teenagers from using FP methods. These findings highlight the need to fight against such barriers; and to make contraceptive services available, accessible, and affordable for teenagers.

Abortion Surveillance - United States, 2020

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2020.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Opportunities for Increasing Access to Effective Contraception in Australia

Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Are LARC Users Less Likely to Use Condoms? An Analysis of U.S. Women Initiating LARC in 2008-2018

INTRODUCTION

Public health professionals have raised concern that increased use of long-acting reversible contraceptives (LARC) could raise women's risk for sexually transmitted infections (STIs), because LARC's superior pregnancy protection may decrease women's motivation to use a barrier method for supplemental pregnancy prevention. This study uses population-based data to examine whether condom use is lower, particularly among young women who are at increased STI risk, after initiating LARC versus moderately effective methods.

METHODS

With the 2011-2019 data files of the National Survey of Family Growth, we examine the percent of sexually active months with condom use in the year after LARC or moderately effective method initiation for a nationally representative sample of 2,018 women aged 15-44 years. Multinomial logistic models regressed condom use on method type and age group, as well as their interaction, while adjusting for key confounders.

RESULTS

The unadjusted likelihood of any condom use is substantially lower among women who initiated LARC versus moderately effective methods (12% vs. 37%), and this difference is greater among younger versus older women. After accounting for differences in women's reproductive and sociodemographic profiles, however, a statistically significant difference in condom use by method initiated remains only for those aged 20-34 years.

CONCLUSIONS

Crude estimates suggest that condom use is lower after initiating LARC versus moderately effective methods, especially among young women. After accounting for the confounding effects of LARC users' distinct profiles-particularly in terms of parity and teenage childbearing-the difference is decreased overall and no longer significant for adolescent women. Overall results indicate a need for new STI prevention strategies and policies that emphasize the importance of dual prevention for LARC users at risk of STIs.

The impact of caller characteristics on levonorgestrel emergency contraception access in West Virginia community pharmacies

OBJECTIVE

Access to levonorgestrel (LNG) emergency contraception (EC) has increased since the FDA removed age restrictions on over-the-counter (OTC) LNG EC in 2013, but availability is highly variable and numerous barriers to access remain. The purpose of this study was to assess availability and accessibility of LNG EC at community pharmacies in West Virginia (WV).

METHODS

A mystery caller cross-sectional study was conducted to assess availability and accessibility of LNG EC. Inquiries were made by identified 'research' staff and by staff presenting as a 16 y/o.

RESULTS

Nearly half of community pharmacies reported having LNG EC in stock. Pharmacy staff were significantly more likely to tell research callers LNG EC was in stock (53%) and more likely to report willingness to order it (50%) than 'teen' callers (45% and 34%, respectively). There was no significant difference between caller types on the five barriers assessed.

CONCLUSION

Lack of availability may contribute to teen and unintended pregnancies.

Factors associated with discontinuation among long-acting reversible contraceptive users: a multisite prospective cohort study in urban public health facilities in Ethiopia

OBJECTIVE

The study aims to determine discontinuation among long-acting reversible contraceptive users at 3, 6, 9 and 12 months after initiation and its associated factors among new long-acting reversible contraceptive (LARC) users.

DESIGN

A facility-based multicentre prospective cohort study was conducted with a sample size of 1766 women.

SETTING

The study was conducted in five large cities of Ethiopia (Addis Ababa, Gondar, Mekelle, Jimma and Harar) between March 2017 and December 2018. Various referral hospitals and health centres that are found in those cities are included in the study.

PARTICIPANTS

The study population was all women who were new users of LARCs and initiated LARCs in our selected public health facilities during the enrolment period.

INTERVENTIONS

A pretested structured questionnaire was administered at enrolment and at 6 and 12 months to determine discontinuation proportion and factors associated with discontinuation.

RESULT

From the total of 1766 women sampled for the study only 1596 (90.4%) participants completed all the questionnaires including the 12-month follow-up study. The overall proportion of discontinuation of LARCs at 12 months was 21.8% (95% CI 19.8 to 23.9). The overall discontinuation proportions at 3, 6, 9 and 12 months were 2.94%, 8.53%, 3.94% and 6.36%, respectively. Location of method initiation (adjusted HR (aHR)=5.77; (95% CI 1.16 to 28.69)) and dissatisfaction with the method (aHR=0.09; (95% CI 0.03 to 0.21)) were found to be the predictors of discontinuation among intrauterine contraceptive device users. Being satisfied with the method (aHR=0.21; (95% CI 0.15 to 0.27)), initiation after post abortion (aHR=0.48; (95% CI: 0.26, 0.89)) and joint decision with partner for method initiation (aHR=0.67; (95% CI: 0.50, 0.90)) were inversely associated with implant discontinuation.

CONCLUSION

The majority of LARC users discontinue the method in the first 6 months after insertion and dissatisfaction with the method increased the likelihood of removal during the first year of LARC use.

Contraceptive use among cisgender women with bacterial sexually transmitted infections: A cross-sectional study

BACKGROUND

Data on contraceptive use among women with bacterial sexually transmitted infections (STIs) are sparse, despite this population's high risk for unplanned pregnancy.

METHODS

This cross-sectional study included 1623 cisgender women recently diagnosed with a bacterial STI who completed a public health Partner Services interview between January 2017 and December 2019 in King County, WA, USA. Contraceptive methods were categorized as: (1) highly or moderately effective and (2) least effective or no method. Poisson regression models were used to assess associations between individual characteristics and contraceptive method.

RESULTS

Almost two thirds of the women (62.6%) reported using highly or moderately effective contraception, with 30.3% of women using long-acting contraception (LARC). More than one in three women (37.4%) reported using least effective methods or no method. Black women were less likely to report using a highly or moderately effective method compared to White women (aRR 0.58, 95% CI 0.43-0.80) and women with private insurance were more likely to report using a highly or moderately effective method compared to those with public insurance (aRR 1.67, 95% CI 1.28-2.19).

CONCLUSIONS

Given that many women with bacterial STIs are not desiring pregnancy, this study highlights the need for additional reproductive health services for women with recent STI diagnoses.

The impact of awareness and attitudes towards long-action reversible contraceptives on the intention to use: a survey among youth with unintended pregnancies

PURPOSE

To understand the associations between awareness, attitudes, and intentions to use long-acting reversible contraceptives (LARCs) among youth seeking induced abortion services in Shanghai, China.

MATERIALS AND METHODS

A cross-sectional survey was carried out among 1,215 nulliparous youth with unintented pregnancies in 41 hospitals of Shanghai, China, through a stratified sampling process between January and May 2019. Multivariable logistic regression was used to test the associations between awareness, attitudes and intentions to use LARCs.

RESULTS

Around 70% of youth had heard of at least one method of LARCs. About 38% of youth perceived that the copper-bearing intrauterine contraceptive device (Cu-IUD) was safe; the rate was 8% and 7%, respectively, for levonorgestrel-releasing intrauterine system (LNG-IUS) and subdermal implants. Less than 40% of youth thought Cu-IUD was effective in contraception, and it was around 6% for LNG-IUS and subdermal implants. Overall, less than 8% of youth expressed intentions to use LARCs. Positive attitudes towards LARCs were highly associated with the intentions to use LARCs [adjusted Odds Ratio (OR) 3.22, 95% confidence interval (CI) 1.96-5.42, p < 0.001].

CONCLUSIONS

Low awareness and negative attitudes towards LARCs were found in this study, and the negative attitudes towards LARCs could contribute to low intentions to use LARCs among youth who had already experienced unintended pregnancies.

Assessing the cost-effectiveness of contraceptive methods from a health provider perspective: case study of Kiambu County Hospital, Kenya

BACKGROUND

Kenya's contraceptive prevalence rate at 53% is low, with wide disparity among the 47 counties that make up the country (2-76%). Significant financial investment is required to maintain this level of contraceptive use and increase it to levels seen in more developed countries. This is in the context of a growing population, declining donor funding, limited fiscal space and competing health challenges. Studies have shown that long-term contraceptive methods are more cost-effective than short-term methods. However, it is unclear if this applies in Sub-Saharan Africa; with limited financial resources, lower social economic status among users, and publicly managed commodity supply chains, in vertical programs largely dependent on donor funding. This study assessed the cost-effectiveness of contraceptive methods used in Kenya.

METHODS

A cross-sectional study was undertaken in a county referral hospital in mid-2018. Purposive sampling of 5 family planning clinic providers and systematic sampling of 15 service delivery sessions per method was done. Questionnaire aided interviews were done to determine inputs required to provide services and direct observation to measure time taken to provide each method. Cost per method was determined using activity based costing, effectiveness via couple year protection conversion factors, and cost-effectiveness was expressed as cost per couple year protection.

RESULTS

The intra-uterine copper device was most cost-effective at 4.87 US dollars per couple year protection followed by the 2-Rod Implant at 6.36, the 1-Rod Implant at 9.50, DMPA at 23.68, while the combined oral contraceptive pills were least cost-effective at 38.60 US dollars per couple year protection. Long-term methods attracted a higher initial cost of service delivery when compared to short-term methods.

CONCLUSION

Long-term contraceptive methods are more cost-effective. As such, investing in long-term contraceptives would save costs despite higher initial cost of service delivery. It is recommended, therefore, that Sub-Saharan Africa countries allocate more domestic financial resources towards availability of contraceptive services, preferably with multi-year planning and budget commitment. The resources should be invested in a wide range of interventions shown to increase uptake of long-term methods, including reduction of cost barriers for the younger population, thereby increasing contraceptive prevalence rates.

Abortion Surveillance - United States, 2019

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2019.

Description of System

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010–2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010–2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15–44 years), and 13% (from 225 abortions per 1,000 live births), respectively.

In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25–39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years.

In 2019, 79.3% of abortions were performed at ≤9 weeks’ gestation, and nearly all (92.7%) were performed at ≤13 weeks’ gestation. During 2010–2019, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks’ gestation (49.0%), followed by early medical abortion at ≤9 weeks’ gestation (42.3%), surgical abortion at >13 weeks’ gestation (7.2%), and medical abortion at >9 weeks’ gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2010–2019, overall decreases were observed during 2010–2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%–3% increases were observed across all measures.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Untangling the roots of the West Virginia opioid crisis: relationships in adolescent pregnancy, drug misuse, and future outcomes

Context

West Virginia (WV) is afflicted by high rates of teenage pregnancy and births, opioid usage during pregnancy, and Neonatal Abstinence Syndrome births. Current efforts are ineffective at reducing teenage pregnancy and opioid misuse. While pregnancy and opioid usage may appear to be separate issues, a number of associations suggest adolescent pregnancy, opioid use, and other health-related outcomes are part of a cluster of negative health conditions that should be addressed holistically.

Objective

To determine whether there is an association between teenage pregnancy and negative health outcomes, including opioid misuse, among WV adolescent girls.

Methods

This study was conducted from July 2018 to March 2019. We obtained the most recently-available aggregate data at the county level for each of the 55 WV counties from the WV Department of Health and Human Resources (WVDHHR) on July 30, 2018, and we analyzed it during the fall of 2018. Raw data regarding pregnancy-related outcomes included WV girls between the ages of 15 and 19, was acquired between 2014 and 2017 by county, and was provided by the WVDHHR as a mean taken across all four years. Raw data regarding opioid misuse outcomes and heart-health variables included WV girls and women of all ages, was collected between 2014 and 2017 by county, and was provided by the WVDHHR as a mean taken across all four years, unless stated otherwise. Pearson correlation analysis was utilized to examine the associations between the teenage pregnancy and birth rates, opioid misuse, pregnancy, and heart-health-related statistics, as well as environmental variables.

Results

Teenage pregnancy and birth rates were positively associated with fetal death rates (r=0.308, p<0.05 and r=0.261, p<0.10, respectively). The rate of fetal death among mothers aged 15-19 years was higher in counties with higher teenage pregnancy and birth rates. As the pregnancy and birth rates increased, the rate of abortion increased even more (r=0.434 and r=0.304 respectively, both p<0.05). Teenage pregnancy and birth rates were associated with opioid overdose death rates for all WV girls and women (Pearson correlations, r=0.444 and 0.418 respectively, both p<0.01). WV counties with higher pregnancy and birth rates among girls aged 15-19 years had a greater proportion of women dying from opioid overdose. Teenage pregnancy and birth rates were both positively correlated with obesity, physical inactivity, high cholesterol, and high blood pressure (all r>0.39, all p<0.05). Neither the high-school dropout rate nor the number of WVDHHR listed clinics were associated with teenage pregnancy or birth rates (p>0.10).

Conclusion

Reduction of unintended teenage pregnancy may be viewed as a nontraditional, holistic, method of ameliorating the opioid misuse crisis in the state of WV. This recommendation should be part of a multi-pronged approach to mitigating the opioid epidemic in WV and all of Appalachia.

Prevalence and predictors of long-acting reversible contraceptive use among sexually active women in 26 sub-Saharan African countries

Background

Long-acting reversible contraceptives (LARCs) are associated with high efficacy rates and continuity of use. Based on the foregoing, we sought to examine the prevalence and factors associated with LARC use among sexually active women in 26 countries in sub-Saharan Africa(SSA).

Methods

Secondary data from Demographic and Health Surveys conducted in 26 countries in SSA between January 2010 and December 2019 were pooled and analysed. A total of 56 067 sexually active women 15–49 y of age met the inclusion criteria. Bivariate and multivariate regression analyses were performed to examine the association between selected factors and the use of LARCs in SSA. Results were presented as crude odds ratios and adjusted odds ratios (aORs) with statistical precision at <0.05.

Results

The prevalence of LARC use was 21.73%, ranging from 1.94% in Namibia to 54.96% in Benin. Sexually active women with secondary or higher education (aOR 1.19 [95% confidence interval {CI} 1.08 to 1.32]), those cohabiting (aOR 1.25 [95% CI 1.06 to 1.47]) and those with four or more children (aOR 2.22 [95% CI 1.78 to 2.78]) were more likely to use LARCs compared with those without education, never married and with no biological child.

Conclusions

The use of LARCs in the 26 countries in SSA was relatively low. Hence, the identified contributory factors of LARC use should be tackled with appropriate interventions. These include continuous campaigns on the efficacy of LARCs in reducing unintended pregnancy, maternal mortality and morbidity.

Women's Use of Long-Acting Reversible Contraception for Birth Timing and Birth Stopping

The use of long-acting reversible contraceptive (LARC) methods-intrauterine devices (IUDs) and implants-has recently expanded rapidly in the United States, and these methods together approach the contraceptive pill in current prevalence. Research on LARCs has analyzed their use to reduce unintended pregnancies but not their use to enable intended pregnancies. Knowledge of both is necessary to understand LARCs' potential impacts on the reproductive life courses of U.S. women. We combine data from two nationally representative surveys to estimate women's likelihood and timing of subsequent reproductive events, including births resulting from an intended pregnancy up to nine years after discontinuing LARC use. We estimate that 62% of women will give birth, and 45% will give birth from an intended pregnancy. Additionally, 18% will have a new LARC inserted, and 13% will transition to sterilization. Most of these reproductive events occur within two years after discontinuing LARC use. Births from an intended pregnancy are especially common when no intervening switch to another contraceptive method occurs. We infer that women's motives for using LARC are varied but include the desire to postpone a birth, to postpone a decision about whether to have a(nother) birth, and to transition definitively to the completion of childbearing.

Providing universal access to modern contraceptive methods: An extended cost-effectiveness analysis of meeting the demand for modern contraception in Ethiopia

Despite recent advances in access to and use of modern contraception in Ethiopia, further improvement is needed, particularly among poorer women. This extended cost-effectiveness analysis investigated the health outcomes, their distribution, and financial risk protection associated with meeting the demand for modern contraception for all Ethiopian women. We developed five Markov models with wealth quintile-specific input data to investigate the effects of meeting this demand and followed a hypothetical cohort of 1,252,000 women through their reproductive lives from ages 15-49 years. The health outcomes are reported in quality-adjusted life years (QALYs) gained and in intermediate health outcomes, such as the total number of induced abortions, unintended pregnancies, and pregnancy-related deaths averted. The economic effect of meeting the demand for modern contraception was assessed by estimating the financial risk protection benefits in terms of averted out-of-pocket payments and the reduction in the number of cases of catastrophic health expenditure by quintile. Meeting the demand for modern contraception was deemed highly cost effective, with an incremental cost-effectiveness ratio of $96.60/QALY gained per woman. A total of 676,300 QALYs were gained, and approximately 1,900,000 unintended pregnancies, 250,000 induced abortions, and 9000 pregnancy-related deaths were averted over the 35-year period. Most of these gains were achieved among low-income groups. When the demand for modern contraception was met, almost 40,000 cases of catastrophic health expenditure were averted in the poorest quintile. The total governmental cost was higher in all quintiles when the demand for modern contraception was met compared to the baseline scenario, with the largest percentage increase in governmental spending in the poorest quintiles. Meeting the demand for modern contraception fulfills the priority-setting criteria established by the Ethiopian Ministry of Health and makes the Ethiopian health care system more equitable.

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population

OBJECTIVE

To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type.

STUDY DESIGN

We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status.

RESULTS

Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI.

CONCLUSIONS

In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth.

IMPLICATIONS

Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.

Trends in subdermal contraceptive implant use in Mexico 2009-2018: A population-based study

OBJECTIVE

To describe subdermal implant use in Mexico over time, by state and by age.

METHODS

We conducted a repeated cross-sectional study using the 2009, 2014, and 2018 waves of the National Survey of Demographic Dynamics (Encuesta Nacional de la Dinámica Demográfica [ENADID]). Our outcome was current use of contraception, by type, with a focus on the implant. We used visualizations, descriptive and bivariate statistics, and multinomial models to assess change over time, geographic patterns, method mix, and factors associated with implant use (vs intrauterine device [IUD] or other hormonal methods).

RESULTS

Implant use is increasing over time in Mexico, from 1.1% of women who have ever used a method in 2009 to 4.5% in 2018 (P < 0.001); the change is greatest among adolescents (2.5% in 2009 to 12.2% in 2018; P < 0.001). Change in implant use as a fraction of modern method use was heterogeneous across Mexican states. The adjusted relative likelihood of using an implant compared with IUD was 34% higher for adolescents compared with women aged 20-29 years (relative risk ratio 1.34, 95% confidence interval 1.16-1.55, P < 0.001), controlling for other variables in the model.

CONCLUSION

Use of subdermal implants is increasing over time in Mexico and is concentrated among adolescents. Implants have the potential to expand access to highly effective contraception in Mexico.

Barriers to post-placental intrauterine device receipt among expectant minority women

PURPOSE

We aimed to identify barriers to breastfeeding-compatible post-placental intrauterine devices (IUDs) for expectant predominantly non-Hispanic African-American women.

MATERIALS AND METHODS

This cross-sectional survey study, conducted at 3 Cleveland community partner locations, enrolled 119 expectant predominantly unmarried but partnered non-Hispanic African-American women. The survey assessed contraceptive, IUD-specific and breastfeeding attitudes and intentions. Survey responses were described with percentages and frequencies, and compared by feeding intention using 2-sided Chi-Square tests. Factor analysis with Varimax rotation identified 2 potential measures of reluctance to post-placental IUD acceptance. The relationship of factors scores to maternal characteristics was assessed.

RESULTS

Feeding intention (breastfeeding versus not) was not related to perceived barriers to post-placental IUD receipt among expectant minority women. A "Personal Risks Reluctance" factor included low risk IUD events (migration and expulsion), misconceptions (delayed fertility return), menstrual changes and partner preference: a higher score was significantly associated with younger age group but no other maternal characteristics. A "Not Me Reasons" factor included provider and insurance barriers, and was not related to any maternal characteristics.

CONCLUSIONS

Expectant minority women's perceived barriers to post-placental IUDs are not related to prenatal feeding intentions. We identified two clinically relevant factors that appear to measure barriers to post-placental IUD acceptance.

Clinic factors associated with utilization of a pregnancy-intention screening tool in community health centers

OBJECTIVE

Routine pregnancy-intention screening in the primary care setting is a promising practice to help patients achieve their reproductive goals. We aim to describe the utilization of a pregnancy-intention screening tool integrated in the electronic health record (EHR) of a national network of community health centers (CHCs) and identify clinic-level factors associated with tool use.

STUDY DESIGN

We conducted a clinic-level retrospective observational study to assess tool utilization during the first 3 years after the tool was made available in the EHR (November 2015 to October 2018). We describe characteristics of clinics with higher tool utilization (≥90th percentile) versus lower utilization (<90th percentile) and the types of providers who used the tool. We then employ negative binomial regression to identify independent clinic-level factors associated with tool utilization.

RESULTS

Across 194 clinics in our study sample which served 289,754 eligible female patients, the tool was used for 113,116 (39%). Medical assistants performed 60.3% of screenings and clinicians performed 11.2%. CHCs with higher tool utilization rates were more likely to be located in rural settings (RR 1.75, 95% CI 1.07-2.87) and serve patient populations with higher proportions of women (RR 1.32, 95% CI 1.24-1.41) and lower proportions of patients with non-English language preference (RR 0.92, 95% CI 0.89-0.95).

CONCLUSIONS

Many health centers utilized pregnancy-intention screening after an EHR-based tool was made available, though overall screening rates were low.

IMPLICATIONS

Additional study of implementation strategies and effectiveness of pregnancy-intention screening tools is needed. Implementation of future pregnancy-intention screening interventions must be tailored to address clinic-level barriers and facilitators to screening.

[Adolescents and teachers´ knowledge, attitude and practice towards contraception: results from a qualitative study conducted in the Democratic Republic of the Congo]

Introduction

the purpose of this study was to assess adolescents and teachers´ knowledge, attitude and practices towards family planning (FP).

Methods

in 2018, a qualitative study was conducted among seven teachers and 62 teenagers aged 15-19 years based on the Theory of Reasoned Action published by Fishbein and Ajzen in 2011. Data were collected from six focus group (FG) with adolescents and seven semi-structured interviews of teachers. They were analyzed using Atlas Ti software on the basis of a deductive approach.

Results

periodic abstinence, male condoms and pills were the only contraceptive methods reported. Adolescents and teachers were apprehensive about using artificial contraceptive methods other than irregularly used male condom. Girls prefer natural methods fearing side effects. The majority of adolescents wanted to be informed about FP in school; however, they felt that the content of the Life Education Course (EVIE) was insufficient and that teachers lacked of openness. Peers, brothers, sisters and internet were the main sources of information. Mothers were an important source of information especially for girls, unlike fathers who were generally less appreciated.

Conclusion

knowledge about FP is weak. Misconceptions about contraception lead to the use of ineffective practices to prevent unintended pregnancies. Training programs to improve teachers´ knowledge should be developed and the content of the EVIE course should be formalized and regulated.

Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder

Maternal opioid use disorder increased > 4-fold from 1999 to 2014 and is associated with poor maternal and fetal outcomes. Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population and may face additional barriers to accessing and effectively using contraception compared to women without opioid use disorder, particularly highly effective long-acting reversible contraception. Additionally, women with opioid use disorder tend to use less effective forms of contraception such as condoms alone. Barriers to contraceptive access include patient misconceptions or knowledge gaps regarding reproductive health and family planning, cost, intimate partner violence, fear of criminalization, difficulty accessing care, comorbid health conditions, and health care provider misconceptions or practice limitations. Strategies that may assist women with opioid use disorder in achieving their family planning goals include colocation of family planning services within opioid treatment facilities, optimization of patient care services to minimize the need for costly and/or time consuming follow-up, increasing provider education and awareness of best practices in family planning and opioid use disorder treatment, and providing patient-centered family planning education and counseling. Additional research is needed to identify and develop strategies that empower women who use opioids to effectively access and use their preferred contraceptive method.

Contraceptive selection and practice: Associations with self-identified race and socioeconomic disadvantage

Many researchers and policymakers have linked contraceptive programs to improvements in women's and children's socioeconomic outcomes. However, these studies have overlooked how socioeconomic status may be an initial driver of contraceptive choice and behavior. Here, I examine the relationship between a comprehensive measure of socioeconomic disadvantage, self-identified race, and contraceptive method selection at enrollment in a unique longitudinal study of contraceptive clients who received a new type of method at no cost. I then examine whether socioeconomic disadvantage has an association with contraceptive switching or discontinuation. I demonstrate that socioeconomic disadvantage decreases the chance of selecting any IUD, while Black racial membership increases the chance of selecting the 3-month injectable and Multiracial membership increases the chance of selecting the Vaginal Ring. I then demonstrate that socioeconomic disadvantage and self-identified race have intersectional and variable associations with switching, and, to a lesser extent, discontinuing methods. These findings offer an important insight for implementation in contraceptive programs: eliminating financial barriers to access contraceptive services does not eliminate the socioeconomic contexts that influence method selection and use that occur as part of everyday lived experiences. Taken cumulatively, these results suggest that contraceptive services should be offered to women in ways that ensure access to reproductive justice without obscuring the need for social changes in the institutions that create disadvantage and shape contraceptive use itself.

Abortion Surveillance - United States, 2018

PROBLEM/CONDITION

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

PERIOD COVERED

2018.

DESCRIPTION OF SYSTEM

Each year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2018, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2009-2018. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2017 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

RESULTS

A total of 619,591 abortions for 2018 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2009-2018, in 2018, a total of 614,820 abortions were reported, the abortion rate was 11.3 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 189 abortions per 1,000 live births. From 2017 to 2018, the total number of abortions and abortion rate increased 1% (from 609,095 total abortions and from 11.2 abortions per 1,000 women aged 15-44 years, respectively), and the abortion ratio increased 2% (from 185 abortions per 1,000 live births). From 2009 to 2018, the total number of reported abortions, abortion rate, and abortion ratio decreased 22% (from 786,621), 24% (from 14.9 abortions per 1,000 women aged 15-44 years), and 16% (from 224 abortions per 1,000 live births), respectively. In 2018, women in their 20s accounted for more than half of abortions (57.7%). In 2018 and during 2009-2018, women aged 20-24 and 25-29 years accounted for the highest percentages of abortions; in 2018, they accounted for 28.3% and 29.4% of abortions, respectively, and had the highest abortion rates (19.1 and 18.5 per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.6%, respectively) and had the lowest abortion rates (0.4 and 2.6 per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2018 and throughout 2009-2018 were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years. Abortion rates decreased from 2009 to 2018 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with women in any other age group. From 2009 to 2013, the abortion rates decreased for all age groups and from 2014 to 2018, the abortion rates decreased for all age groups, except for women aged 30-34 years and those aged ≥40 years. In addition, from 2017 to 2018, abortion rates did not change or decreased among women aged ≤24 and ≥40 years; however, the abortion rate increased among women aged 25-39 years. Abortion ratios also decreased from 2009 to 2018 among all women, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with women in any other age group. The abortion ratio decreased for all age groups from 2009 to 2013; however, from 2014 to 2018, abortion ratios only decreased for women aged ≥35 years. From 2017 to 2018, abortion ratios increased for all age groups, except women aged ≥40 years. In 2018, approximately three fourths (77.7%) of abortions were performed at ≤9 weeks' gestation, and nearly all (92.2%) were performed at ≤13 weeks' gestation. In 2018, and during 2009-2018, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.0%). In 2018, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks' gestation (52.1%), followed by early medical abortion at ≤9 weeks' gestation (38.6%), surgical abortion at >13 weeks' gestation (7.8%), and medical abortion at >9 weeks' gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 50.0% of abortions were early medical abortions. In 2017, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women were identified to have died as a result of complications from legal induced abortion.

INTERPRETATION

Among the 48 areas that reported data continuously during 2009-2018, decreases were observed during 2009-2017 in the total number, rate, and ratio of reported abortions, and these decreases resulted in historic lows for this period for all three measures. These decreases were followed by 1%-2% increases across all measures from 2017 to 2018.

PUBLIC HEALTH ACTION

The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is a major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.

Insights in Public Health: Insurance Coverage for Long-Acting Reversible Contraception Placed in Office: A Buy and Bill Demonstration Project in Hawai'i

Access to the full range of contraceptive options for all people is critical in allowing individuals to make decisions that are consistent with their reproductive goals and values, which, in turn, enables them to achieve educational, social, and economic goals. In 2010, the Patient Protection and Affordable Care Act mandated that health plans must cover contraceptive supplies and services, including drugs and devices approved by the US Food and Drug Administration without any out-of-pocket costs to patients. This federal mandate was similar to a law passed by the Hawai'i state legislature in 1999. Despite the Affordable Care Act, access barriers continue to prevent people from obtaining their preferred methods upon request. Same day access to long-acting reversible contraceptive (LARC) devices is a particular challenge in many clinical settings due to the high upfront cost of the device for providers. This Insights article describes the context of this issue in Hawai'i and information about a pilot test of a "buy and bill" program for LARC devices in an outpatient obstetrics and gynecology practice in Honolulu, Hawai'i. Ultimately, the majority of LARC devices were paid for fully by insurance, resulting in increased access to same day insertion with limited financial risk for the clinic.

Are higher unintended pregnancy rates among minorities a result of disparate access to contraception?

Abstract

Unintended pregnancy is a major global issue. Women who experience an unintended pregnancy have a significant risk of morbidity and mortality. Additionally, these women also experience substantial financial hardships. Many women, particularly women of color, do not have adequate access to reliable and affordable contraception resulting in major health disparities among this group. This review explores the relationship between unintended pregnancy and inadequate access to contraception and is divided into 5 sections: addressing problems associated with unintended pregnancies, unintended pregnancy rate in the US, disparities of unintended pregnancy rates and access to care, addressing potential solutions, and finally conclusions.

Keyterms

unintended pregnancy, healthcare disparities, contraception, access to care.

Long-acting reversible contraception utilization and associated factors among women in extended postpartum period in Hossana town, southern Ethiopia: cross sectional study

Background

In low and middle-income countries, 95% of postpartum women want to avoid a pregnancy for 2 years, but 70% are not using contraception. Delay in use of contraception by couples during postpartum period can result in many unwanted pregnancies. Long-acting reversible contraception (LARC) is ideal for postpartum women. Therefore this study aimed at assessing the prevalence and factors associated with LARC use among postpartum women.

Methods

Facility based cross sectional study was conducted from July 23-Aug 25, 2018. Systematic random sampling technique was employed to recruit a total of 381 women in extended postpartum period visiting Child Immunization service in hosanna health institutions. Pretested structured questionnaire was used for data collection. Data was analyzed by SPSS version 20. Binary and multiple logistic regression analysis was done. The presence and strength of association was determined using AOR with its 95% CI. Variables with P value less than 0.05 were considered as statistical significant.

Results

The prevalence of LARC use was 36.5% (95%CI (33.05–39.95)). The main reason for not using LARC was fear of side effect and false information. Previous use of LARC (AOR = 3.3, 95%CI (1.7–6.5)) and have ever discussed with health providers on LARC (AOR = 2.5, 95%CI (1.1–5.74)) were found to be significantly associated with LARC use.

Conclusions

The utilization of LARC among postpartum women was found to be higher than other studies in Ethiopia. Provision of effective contraceptive counseling during Antenatal, delivery and postnatal care services with emphasis on LARC/Postpartum Intra-Uterine Device is important.

Long-Acting Reversible Contraception: Specific Issues for Adolescents

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.