Medical contraindications to estrogen and contraceptive use among women veterans

Abortion After Pregnancy Occurrence with Contraceptive Use Among Veterans

Objective: Many people report becoming pregnant while using contraception. Understanding more about this phenomenon may provide insight into pregnant people's responses to and healthcare needs for these pregnancies. This study explores the outcome (e.g., birth, miscarriage, abortion) of pregnancies among Veterans in which conception occurred in the month of contraceptive use. Study Design: We used data from the Examining Contraceptive Use and Unmet Need Study, a telephone-based survey conducted in 2014-2016 of women Veterans (n = 2302) ages 18-44 receiving primary care from the Veterans Health Administration. For each pregnancy, we estimated the relationship between occurrence in the month of contraceptive use and the outcome of the pregnancy using multinomial logistic regression, controlling for relevant demographic, clinical, and military factors and clustering of pregnancies from the same Veteran. Results: The study included 4436 pregnancies from 1689 Veterans. Most participants were ≥30 years of age (n = 1445, 85.6%), identified as non-Hispanic white (n = 824, 51.6%), and lived in the Southern United States (n = 994, 55.6%). Nearly 60% (n = 1007) of Veterans who had ever been pregnant reported experiencing a pregnancy in the month of contraceptive use; a majority of those pregnancies (n = 1354, 80.9%) were described as unintended. In adjusted models, pregnancies occurring in the month of contraceptive use were significantly more likely to end in abortion (aOR: 1.76, 95% CI: 1.42-2.18) than live birth. Conclusions: Pregnancy while using contraception is common among Veterans; these pregnancies are more likely to end in abortion than live birth. Given widespread restrictions to reproductive health services across much of the United States, ensuring Veterans' access to comprehensive care, including abortion, is critical to supporting reproductive autonomy and whole health.

Contraindicated use of modern contraceptives among mothers from a Pelotas Birth Cohort

OBJECTIVE

To describe the prevalence of contraindicated use of combined hormonal contraceptives, progesterone-only contraceptives, and intrauterine devices in mothers participating in the 2015 Pelotas Birth Cohort according to the WHO medical eligibility criteria.

METHODS

The biological mothers of children belonging to the 2015 Pelotas birth cohort who attended the 48-month follow-up were studied. The 48-month follow-up data were collected from January 1, 2019, to December 31, 2019. Contraindicated use of modern contraceptives was considered to occur when these women presented at least one of the contraindications for the use of modern contraceptives and were using these methods. The prevalence of contraindicated use was calculated according to each independent variable and their respective 95% confidence intervals (95%CI).

RESULTS

The analyzed sample consisted of 3,053 women who used any modern contraceptive method. The prevalence of contraindicated use of modern contraceptives totaled 25.9% (95%CI: 24.4-27.5). Combined hormonal contraceptives showed the highest prevalence of contraindicated use (52.1%; 95%CI: 49.3-54.8). The prevalence of contraindicated use of modern contraceptives methods was greater in women with family income between one and three minimum wages, a 25-30 kg/m2 body mass index, indication by a gynecologist for the used method, and purchasing the contraceptive method at a pharmacy. The higher the women's education, the lower the prevalence of inappropriate use of modern contraceptives.

CONCLUSION

In total, one in four women used modern contraceptives despite showing at least one contraindication. Policies regarding women's reproductive health should be strengthened.

Prevalence of non-preferred family planning methods among reproductive-aged women in Burkina Faso: results from a cross-sectional, population-based study

Family planning researchers have traditionally focused efforts on understanding contraceptive non-use and promoting contraceptive uptake. Recently, however, more scholars have been exploring method dissatisfaction, questioning the assumption that contraceptive users necessarily have their needs met. Here, we introduce the concept of "non-preferred method use", which we define as the use of one contraceptive method while having the desire to use a different method. Non-preferred method use reflects barriers to contraceptive autonomy and may contribute to method discontinuation. We use survey data collected from 2017 to 2018 to better understand non-preferred contraceptive method use among 1210 reproductive-aged family planning users in Burkina Faso. We operationalise non-preferred method use as both (1) use of a method that was not the user's original preference and (2) use of a method while reporting preference for another method. Using these two approaches, we describe the prevalence of non-preferred method use, reasons for using non-preferred methods, and patterns in non-preferred method use by current and preferred methods. We find that 7% of respondents reported using a method they did not desire at the time of adoption, 33% would use a different method if they could and 37% report at least one form of non-preferred method use. Many women cite facility-level barriers, such as providers refusing to give them their preferred method, as reasons for non-preferred method use. The high prevalence of non-preferred method use reflects the obstacles that women face when attempting to fulfil their contraceptive desires. Further research on reasons for use of non-preferred methods is necessary to promote contraceptive autonomy.

Physician Dispositions Toward Noninvasive Non-Hormonal Contraception

Introduction

Evidence-based, nonbiased, counseling on contraceptive options, followed by shared decision-making, is key in facilitating reproductive justice in a diverse population. An estimated 3% of contraceptive users in the United States use fertility awareness-based methods (FABMs) for contraception, and demand for these methods is increasing. FABMs can be a highly effective form of family planning when used in accordance with evidence-based protocols. They are preferred by some patients due to medical contraindications to hormonal contraceptives, lack of side effects, religious convictions, preference to avoid hormones or contraceptive devices, improved body literacy, or a combination of the above. FABMs are infrequently covered in medical school curricula and are often perceived by physicians to be of low efficacy. There is an opportunity for improvement of physicians' evidence-based knowledge of FABMs, which has the potential to improve patient understanding of and access to the full menu of family planning options.

Methods

A self-administered, cross-sectional survey was distributed to assess physician knowledge and opinions of FABMs by key university contacts. Univariate and bivariate statistics were calculated for close-ended questions and responses to open-ended questions were analyzed for common themes.

Results

A total of 79 participants completed the entire survey. Another 11 submitted partially completed surveys. For completed surveys, questions assessing knowledge of key concepts underlying FABMs, performance by specialty was 55% correct for OB/GYN (n = 16), 55% (n = 47) correct for family medicine, 36% (n = 10) correct for internal medicine, and 35% (n = 6) correct for pediatrics. Negative, neutral, mixed, and positive opinions related to FABMs were represented.

Conclusions

There are opportunities to improve physicians' evidence-based knowledge of FABMs; this may improve patient-centered contraceptive care.

Contraceptive Use Among Women in the United States Aged 18-44 Years with Selected Medical Contraindications to Estrogen

Objective: Medical contraindications to estrogen limit women's contraceptive options. This study assessed the association between selected medical contraindications to estrogen on contraceptive use and examined whether contraindications serve as a barrier to the prevention of unintended pregnancy. Materials and Methods: We analyzed women aged 18-44 at risk of unintended pregnancy participating in the 2017 Behavioral Risk Factor Surveillance System. Survey questions queried women regarding contraceptive use and contraindications to estrogen use. We assessed the most recently used contraceptive method and compared the odds of women using each category of contraception (no methods, less effective methods, pill/patch/ring, injection, intrauterine device, implant, permanent contraception) between those with and without potential contraindications to estrogen using multinomial logistic regression models. Results: This study included 32,098 women, of whom 16% had one or more potential contraindications to estrogen. There were significant differences in contraceptive choice by potential contraindication status (p < 0.01). Fifteen percent of women with potential contraindications reported using estrogen-containing methods (pill, patch, or ring) compared with 20% of women with no potential contraindication. Women with potential contraindications to estrogen more frequently used permanent contraception (odds ratio [OR] vs. pill/patch/ring: 1.48 95% confidence interval [CI]: 1.17-1.88) or no contraceptive method (OR vs. pill/patch/ring: 1.37 95% CI: 1.07-1.75) after adjustment for race, age, marital status, and income. Conclusions: Potential medical contraindications to estrogen are associated with permanent contraception and the use of no contraception. These results portray a complicated relationship but could suggest a lack of access to other contraceptive options.

Combined hormonal contraceptives use among women with contraindications according to the WHO criteria: A systematic review

INTRODUCTION

Combined hormonal contraceptives (CHC), containing estrogen, remain the most popular choice of contraceptive among women. While the method offers many benefits, the use of CHC involves potential health risks. The aim of this study was to analyze the available evidence on the prevalence of CHC use among women with contraindications to their use according to the WHO recommendations (2015).

METHODS

Pubmed, Lilacs, and Web of Sciences databases were searched. Selection was based on articles that described the use of combined hormonal contraceptives according to the characteristics that are listed as contraindications in WHO medical eligibility criteria for contraceptive use.

RESULTS

A total of 4363 articles were identified and 18 articles were selected for the review. The most prevalent contraindications against use of CHC were systemic arterial hypertension, migraine, and smoking (in women aged 35 years or older). Prevalence rates of contraindications against use of CHC ranged from 5.9% to 41.9%.

CONCLUSIONS

A high proportion of women still use CHC when contraindicated to do so according to the WHO criteria. Health policies should focus on highlighting the importance of a detailed health evaluation on CHC candidates, to reduce the proportion of inappropriate prescriptions.

A 1-year prospective, open-label, single-arm, multicenter, phase 3 trial of the contraceptive efficacy and safety of the oral progestin-only pill drospirenone 4 mg using a 24/4-day regimen

Objectives

To evaluate contraceptive effectiveness and safety of oral drospirenone 4 mg 24/4-day regimen in the United States.

Study design

We performed a prospective, single-arm, multicenter phase 3 trial in sexually active women for up to thirteen 28-day treatment cycles. Primary outcome was the Pearl index, calculated using confirmed on-drug pregnancies and evaluable cycles in nonbreastfeeding women aged ≤ 35 years. We assessed adverse events (AEs), including hyperkalemia and venous thromboembolism.

Results

Of 1006 women who received at least one dose of drospirenone, 352 women (35.0%) completed the trial and 654 (65.0%) women discontinued before trial end. Most participants (92.2%) were ≤ 35 years; one third had a body mass index (BMI) ≥ 30 kg/m². Among nonbreastfeeding women aged ≤ 35 years, there were 17 pregnancies (Pearl index: 4.0; 95% confidence interval [CI], 2.3-6.4; n = 953), of which three were unconfirmed and two were from sites excluded from the main analysis for major breaches of Food and Drug Administration regulations. The Pearl index was 2.9 (95% CI: 1.5-5.1) for confirmed pregnancies among 915 nonbreastfeeding women aged ≤ 35 years from sites with no protocol violations. Nearly all (95.4%) treatment-emergent AEs were mild or moderate in intensity. No cases of venous thromboembolism were reported. The frequency of hyperkalemia was 0.5%. Women with baseline systolic/diastolic blood pressure ≥ 130/85 mmHg had a mean reduction from baseline in blood pressure at exit visit (- 8.5/- 4.9 mmHg; n = 119). No other clinically relevant changes were observed. Participant satisfaction was high.

Conclusion

Drospirenone 4 mg 24/4 regimen provides effective contraception with a good safety/tolerability profile in a broad group of women, including overweight or obese women.

Implications

This new progestin-only contraceptive, drospirenone 4 mg in a 24/4 regimen, provides a contraceptive option for the majority of women regardless of blood pressure or BMI.

Perceived Barriers and Facilitators to Contraceptive Use Among Women Veterans Accessing the Veterans Affairs Healthcare System

BACKGROUND

Although many studies evaluate factors influencing contraceptive use, little is known about barriers and facilitators that may be specific to or prevalent among women veterans using the Veterans Affairs Healthcare System (VA).

DESIGN

Semistructured telephone interviews with a national sample of 189 women veterans at risk for unintended pregnancy who receive care in the VA were used to explore barriers and facilitators to contraceptive use as well as elicit suggestions for improving VA contraceptive care. The sample consisted primarily of women with risk factors for adverse reproductive health outcomes, including belonging to ethnic/racial minority groups, having a medical or mental health condition(s), and/or reporting a history of military sexual trauma. Transcript narratives were analyzed using content analysis and the constant comparison method.

RESULTS

Five distinct themes emerged as barriers or facilitators to contraceptive use depending on participants' VA facility and provider, and women offered concrete suggestions to address each barrier. Most participants (56%) noted poor efficiency as a barrier; others (39%) felt hindered by limited contraceptive counseling and patient education. Approximately one-third (34%) noted that low patient awareness of services impeded care and another one-third (32%) stressed poor interaction with providers as a barrier. Finally, 31% noted feeling ostracized at VA, and emphasized fostering a woman-friendly environment to remove discomfort associated with seeking contraceptive care.

CONCLUSIONS

These findings suggest that, despite widespread access to low-cost contraception, many women veterans experience barriers to accessing high-quality contraceptive care. These barriers are system and provider specific and warrant further internal evaluation.

Contraceptive Care in the Veterans Health Administration

In recent years, the number of women Veterans obtaining care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. Women Veterans are a diverse group of women with complex sociodemographic and medical backgrounds, and meeting their needs presents a unique challenge for VA. Efforts including the establishment of comprehensive women's health clinics and training practitioners in women's health have greatly improved healthcare services for women Veterans over the last few decades. Recent data from a large cross-sectional survey study suggest that contraceptive use in VA is similar to the general population and that rates of unintended pregnancy, while still significant, are not higher than that in the general population. Subgroup analyses of this survey data, however, suggest that ongoing efforts are needed to improve outcomes in vulnerable subpopulations of women Veterans, particularly ethnic/racial minorities and Veterans with complex medical backgrounds. Policy changes such as the elimination of copayments for contraceptive prescriptions and the dispensing of more months of contraceptive supply are evidence-based starting points for improvements, in addition to leveraging VA's integrated system and research infrastructure to improve patient-centered counseling and contraceptive access.