Miscommunication between healthcare providers and patients may result in unplanned pregnancies

Do women with a previous unintended birth subsequently experience missed opportunities for postpartum family planning counseling? A multilevel mixed effects analysis

Client-provider communication about family planning (FP) remains an important strategy for preventing unintended pregnancy. Yet, the literature lacks empirical studies examining whether and how women's intendedness of a recent pregnancy may impact subsequent receipt of FP counseling. We investigated whether the intendedness of a recent pregnancy is associated with subsequent missed opportunities (MOs) for FP counseling, taking into account compositional and contextual factors. We performed a secondary analysis using pooled data from the 2016, 2017 and 2018 Performance Monitoring and Accountability 2020 cross-sectional surveys conducted in Nigeria, adjusting for complex design effects. Weighted multilevel logistic regression modeling was used to examine the relationships between pregnancy intention and MOs, overall and at the health facility, using two-level random intercept models. In the analytic sample of women within 24 months postpartum (N = 6479), nearly 60% experienced MOs for FP counseling overall and even 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs. In the multivariable models adjusted for individual-/household- and community-level factors, women whose recent birth was either mistimed or unwanted were just as likely to have MOs for FP counseling as their counterparts whose pregnancy was intended (p > 0.05). Factors independently associated with a MOs include individual/household level factors such as level of education, exposure to FP media, household wealth index and contextual-level variables (geographic region). While evidence that pregnancy intendedness is associated with MOs for FP counseling remains inconclusive, efforts to mitigate these MOs requires prioritizing women's prior pregnancy intentions as well as equipping healthcare providers with the capacity need to provide high-quality client-centered FP counseling, particularly for women whose recent birth was unintended.

Perceptions and Knowledge of Women Regarding Contraception and Current Trends in Contraceptive Use in Korea

PURPOSE

This study aimed to investigate the perceptions and behaviors of Korean women of reproductive age in regards to contraception counseling.

MATERIALS AND METHODS

The study sample was collected in Korea and comprised 1011 women aged 20-44 years and 150 obstetrics and gynecology (OB/GYN) doctors. Participants completed online questionnaires assessing their current methods of contraception, knowledge of and satisfaction with contraceptive methods, and willingness to learn about and use other contraceptive methods.

RESULTS

Women used condoms (74.2%), natural methods (cycle control or withdrawal, 52.4%), and combined oral contraceptives (COCs) (36.9%) more frequently than long-acting reversible contraception (LARC) methods, such as hormone-releasing intrauterine system (IUS) (4.5%), copper-intrauterine devices (3.3%), and subdermal implants (1.4%). Although the proportion of women who used LARC was low, those who used hormone-releasing IUS or subdermal implants reported high levels of satisfaction. The findings revealed discordant results between women and OB/GYN doctors regarding the initiation and quality of information provided by doctors about contraception and overall satisfaction with counseling. Most women (83.1%) expressed a desire to have more information about various contraceptive methods. More than 60% of women reported a willingness to use LARC, such as hormone-releasing IUS or subdermal implants, when provided with detailed information in counseling.

CONCLUSION

The majority of Korean women are familiar with condoms and natural methods, but lack knowledge about alternative contraceptive methods, including LARC. Women who used LARC reported higher levels of satisfaction than those who used other methods.

Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care

BACKGROUND

Poor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) -which is associated with satisfaction and continued contraceptive use among various populations.

OBJECTIVE

To examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas.

PATIENT INVOLVEMENT

Formative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition.

METHODS

Cross-sectional surveys were administered to Latinas ages 15-29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations.

RESULTS

103 Latinas (mean age = 21.4) participated. 33% of participants<21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants< 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively).

DISCUSSION

Patient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those<21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population.

PRACTICAL VALUE

Results from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.

Predictions of Miscommunication in Verbal Communication During Collaborative Joint Action

Purpose The purpose of the current study was to examine the lexical and pragmatic factors that may contribute to turn-by-turn failures in communication (i.e., miscommunication) that arise regularly in interactive communication. Method Using a corpus from a collaborative dyadic building task, we investigated what differentiated successful from unsuccessful communication and potential factors associated with the choice to provide greater lexical information to a conversation partner. Results We found that more successful dyads' language tended to be associated with greater lexical density, lower ambiguity, and fewer questions. We also found participants were more lexically dense when accepting and integrating a partner's information (i.e., grounding) but were less lexically dense when responding to a question. Finally, an exploratory analysis suggested that dyads tended to spend more lexical effort when responding to an inquiry and used assent language accurately-that is, only when communication was successful. Conclusion Together, the results suggest that miscommunication both emerges and benefits from ambiguous and lexically dense utterances.

Cognitive Processing of Miscommunication in Interactive Listening: An Evaluation of Listener Indecision and Cognitive Effort

Purpose The purpose of the current study was to evaluate the social and cognitive underpinnings of miscommunication during an interactive listening task. Method An eye and computer mouse-tracking visual-world paradigm was used to investigate how a listener's cognitive effort (local and global) and decision-making processes were affected by a speaker's use of ambiguity that led to a miscommunication. Results Experiments 1 and 2 found that an environmental cue that made a miscommunication more or less salient impacted listener language processing effort (eye-tracking). Experiment 2 also indicated that listeners may develop different processing heuristics dependent upon the speaker's use of ambiguity that led to a miscommunication, exerting a significant impact on cognition and decision making. We also found that perspective-taking effort and decision-making complexity metrics (computer mouse tracking) predict language processing effort, indicating that instances of miscommunication produced cognitive consequences of indecision, thinking, and cognitive pull. Conclusion Together, these results indicate that listeners behave both reciprocally and adaptively when miscommunications occur, but the way they respond is largely dependent upon the type of ambiguity and how often it is produced by the speaker.

Contraceptive Decision Making Among Latina Immigrants: Developing Theory-Based Survey Items

BACKGROUND

Contraception is important for reproductive autonomy, yet many Latinas do not use contraception consistently despite research reporting a desire to do so. Factors varying in priority and value come into play during contraceptive decision making. When measuring these, relevant survey items may vary by populations.

AIM

This study focused on developing an ethnically responsive, patient-centered, content-valid survey for measuring factors that influence contraceptive decision making among immigrant Latinas.

METHOD

Nonpregnant self-identified Latinas ages 15 to 24 years in Baltimore, MD, were recruited from a family planning facility. Using the theory of planned behavior as a theoretical framework and prior formative research, initial survey items were drafted (Step 1). Content validation and cognitive interviewing procedures (Step 2 and Step 3) were used to develop final items.

RESULTS

Final items (27) were content-validated by the target population; items reflect important factors and relevant contexts affecting contraceptive decision making among Latinas in Baltimore.

DISCUSSION

These theory-based items provide an important contribution to the literature because they measure and explore factors related to contraceptive decision making in an understudied population. Providers might consider these factors during counseling to build patient-centered communication. These items might serve to measure responses to theory of planned behavior-based interventions designed to improve the contraceptive counseling of Latinas.

Contraception: what is the resistance all about?

PURPOSE

The aim of this study is to identify the aspects associated with resistance to contraception, providing healthcare workers with the necessary tools to increase compliance with contraception and, ultimately, reduce the rate of voluntary abortions.

MATERIAL AND METHODS

We performed a review of the literature published in Medline between 1st January 2000 and 31st July 2020. We included studies based on qualitative analyses, describing women's perception and attitudes towards contraception, including a population aged 15 years or older and conducted in either Europe or North America.

RESULTS

A total of 23 articles were included in the study. Resistance to contraceptive uptake was most frequently due to ambivalence about pregnancy, with up to 54% of ambivalent women reporting not using any means of contraception, and communication issues with the partner and/or health care provider, with a positive association found between communication with the partner and contraceptive use (OR 1.07; p < .050). Additional barriers to contraceptive use were the quality of the relationship with the partner, the perception of the risk of becoming pregnant after unprotected sexual intercourse, and unfamiliarity with contraception.

CONCLUSIONS

Family planning consultations should acknowledge the aspects that influence contraceptive uptake and address them as part of their consultations.

Advanced Prescription of Emergency Contraceptive Pills Among Adolescents and Young Adults

OBJECTIVE

To examine healthcare providers' adherence to professional recommendations for advanced prescription of emergency contraceptive pills (ECPs).

METHODS

We conducted a retrospective chart review of 432 visits by 282 unique nonpregnant women 14 to 25 years of age seen at an obstetrics and gynecology teaching clinic to determine the percentage of visits during which advanced prescriptions of ECPs were provided when indicated. A logistic regression model, which accounted for nonindependent observations through generalized estimating equations, was used to identify factors associated with the provision of ECP advanced prescriptions.

RESULTS

Approximately one-fifth of eligible visits (19.9%) and eligible patients (19.1%) had documentation of an ECP advanced prescription when indicated. Healthcare providers in this clinical setting were more likely to prescribe ECPs to adolescents and women whose primary contraceptive methods were associated with higher failure rates in typical use, such as condoms. Compared with women aged 20 to 25 years, the adjusted odds ratio of receiving an advanced prescription for ECPs was 5.94 (95% confidence interval [CI] 2.85-12.41) for adolescents. Compared with users of depot medroxyprogesterone acetate, the adjusted odds ratio was 4.25 (95% CI 1.62-11.15) for condom users, and 3.90 (95% CI 1.54-9.86) for users of other short-term hormonal contraceptives.

CONCLUSIONS

Despite clear professional recommendations for ECP advanced prescriptions for all women at risk for unintended pregnancy, a substantial gap exists between this standard of care and routine clinical service provision in an obstetrics and gynecology teaching clinic.

Use of the Levonorgestrel Intrauterine Device in Women With Type 2 Diabetes

IN BRIEF Women with type 2 diabetes are less likely to receive prescriptions for contraceptives despite the fact that diabetes is associated with an increased risk of maternal and fetal complications. In the largest case series to date examining use of the levonorgestrel-releasing intrauterine device (LNG-IUD) in women with type 2 diabetes, we demonstrate that the LNG-IUD is safe and effective and does not affect glycemic control in women with type 2 diabetes. In this study of 115 women under the age of 55 years with type 2 diabetes who had an LNG-IUD placed between 2007 and 2012, we found low rates of pregnancies, expulsions, and other complications in every age category and disease stratification. Thirty-nine patients had A1C data before and up to 2 years after placement, and there was no significant change in A1C (mean A1C decrease of 0.17, 95% CI -0.76 to 0.43). This study will enable evidence-based contraceptive counseling for women with type 2 diabetes.

Effects of family planning factors on the awareness of sexual and reproductive healthcare rights among married women of reproductive age in China: a cross sectional study

OBJECTIVES

Although family planning in China has changed gradually since 1994, there are few studies about family planning and women's reproductive rights. The main objective of this study was to examine awareness of sexual and reproductive healthcare rights (SRHCRs), and learn how factors related to family planning influence awareness of SRHCRs among married women of reproductive age in China.

METHODS AND PARTICIPANTS

Inner Mongolia, Chongqing, Guangdong and Henan were selected for the study, and a total of 2504 married women of reproductive age were recruited. A self-administered anonymous questionnaire was used to collect information on participants' awareness of SRHCRs.

RESULTS

There were a total of 10 843 (≤6×2504) responses, with a response rate of 72.17% (10 843/15 024) on average among participants regarding SRHCRs (a multiple response set). The highest response rate was for choice (Right 3) (90.64%, 95% CI 89.47%, 91.81%), followed by privacy (Right 5) (86.11%, 95% CI 84.72%, 87.50%) and information (Right 1) (84.47%, 95% CI 83.02%, 85.93%). Only 43.39% (95% CI 41.40%, 45.38%) of participants gave responses to safety (Right 4). Participants without children showed more interest in Right 1, in access (Right 2) and in Right 4. Those who utilised tests for fetal sex determination paid more attention to Rights 2 and 4. Women who accepted informed choice were more likely to be aware of all six rights except for Right 3 and dignity (Right 6). Those individuals who were satisfied or very satisfied with comprehensive sexual and reproductive health counselling services were more likely to show interest in all six rights.

CONCLUSIONS

Awareness of SRHCRs among reproductive aged women in China is still inadequate. Family planning service providers might strengthen the service awareness of sex and reproductive health rights according to the different needs of women.

Practice Bulletin No. 152: Emergency Contraception

Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.

Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review

The Contraceptive CHOICE Project (CHOICE) sought to reduce unintended pregnancies in the St. Louis Region by removing cost, education, and access barriers to highly effective contraception. CHOICE was a prospective cohort study of over 9,000 women 14-45 years of age who received tiered contraceptive counseling to increase awareness of all reversible methods available, particularly long-acting reversible contraceptive (LARC) methods. Participants were provided with contraception of their choice at no cost for 2-3 years. We studied contraceptive method choice, continuation, and population outcomes of repeat abortion and teen pregnancy. Seventy-five percent of study participants chose one of the three LARC methods (46% levonorgestrel intrauterine system, 12% copper intrauterine device, and 17% subdermal implant). LARC users reported greater continuation than non-LARC users at 12 months (87% versus 57%) and 24 months (77% versus 41%). In our cohort, LARC methods were 20 times more effective than non-LARC methods. As a result, we observed a reduction in the percent of repeat abortions from 2006 to 2010 in St. Louis compared with Kansas City and nonmetropolitan Missouri and found substantial reductions in teen pregnancy, birth, and abortion (34.0, 19.4, and 9.7 per 1000 teens, respectively) compared with national rates among sexually experienced teens (158.5, 94.0, and 41.5 per 1000, respectively). Improved access to LARC methods can result in fewer unintended pregnancies and abortions and considerable cost savings to the health care system.

Providers' perspectives on male involvement in family planning in the context of a cluster-randomized controlled trial evaluating integrating family planning into HIV care in Nyanza Province, Kenya

Integration of family planning (FP) services into HIV care and increasing male partner involvement in FP are being explored as strategies to reduce unmet need for contraception. Providers' views can give valuable insight into current FP care. We evaluated the perspectives of HIV care providers working at HIV clinics in Nyanza Province, Kenya, on male partner involvement in FP. This qualitative study was part of a cluster-randomized controlled trial evaluating the impact of integrating FP into HIV services on contraceptive prevalence among HIV-positive patients in Nyanza Province, Kenya. Thirty individual interviews were conducted among health-care workers at 11 HIV care facilities in Nyanza Province, Kenya. Interviews were conducted from integrated and control sites one year after implementation of FP/HIV integration. Data were transcribed and analyzed using grounded theory methods and ATLAS-ti. Providers supported male partner inclusion when choosing FP and emphasized that decisions should be made collaboratively. Providers believed that men have traditionally played a prohibitive role in FP but identified several benefits to partner involvement in FP decision-making including: reducing relationship conflicts, improving FP knowledge and contraceptive continuation, and increasing partner cohesion. Providers suggested that integrated FP/HIV services facilitate male partner involvement in FP decision-making since HIV-positive men are already established patients in HIV clinics. Some providers stated that women had a right to choose and start FP alone if their partners did not agree with using FP. Integrated FP services may be a useful strategy to help increase male participation to reduce the unmet FP need in sub-Saharan Africa. It is important to determine effective ways to engage male partners in FP, without impinging upon women's autonomy and reproductive rights.

Counseling about medication-induced birth defects with clinical decision support in primary care

BACKGROUND

We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.

METHODS

Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.

RESULTS

Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.

CONCLUSIONS

Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Adolescent users of an online contraception selection tool: how user preferences and characteristics differ from those of adults

STUDY OBJECTIVE

The objective of this study was to report user statistics of an online contraception selection tool over a 6-month period, comparing preferences and characteristics of adolescents to those of adults.

SETTING

Choosing Wisely, available on the website www.SexualityandU.ca, is an interactive program that helps women select an ideal birth control method.

DESIGN

Answers to the online questionnaire were logged for a 6-month period. Answers of adolescent users were retrospectively reviewed for responses to questions regarding personal preferences and compared with those of adults.

PARTICIPANTS

Participants of the study included users who self-identified as first-time users of Choosing Wisely.

RESULTS

3178 adolescents (age ≤19) and 4206 adults self-identified as new users and completed the software module. Adolescents less commonly reported weighing over 198 pounds or to be smokers. 61% of adolescents would prefer to avoid menses (vs 52% of adults) and 83% of adolescent would find a pregnancy devastating (vs 64% of adults). 1720 (54%) of the adolescents had menstrual complaints; of these 500 (29%) did not believe they could reliably take a pill daily. The majority of both adolescents (73%) and adults (71%) claimed to be willing to use a contraceptive method that required interruption of intercourse.

CONCLUSIONS

Choosing Wisely is attracting large numbers of teens and adults, whose responses provide insight into the characteristics of those seeking contraception. Our data corroborate the need for contraceptive options such as combined contraceptives that do not require daily pill-taking and contraceptives that offer menstrual management. However, the magnitude of these statistically significant differences was not always as impressive clinically.

The impact of contraceptive counseling in primary care on contraceptive use

BACKGROUND

Whether contraceptive counseling improves contraceptive use is unknown.

OBJECTIVE

To evaluate the association between contraceptive counseling provided by primary care physicians and patients' contraceptive use.

DESIGN/PARTICIPANTS

All women aged 18-50 who visited one of four primary care clinics between October 2008 and April 2010 were invited to complete surveys about their visit. Seven to 30 days post visit, participants completed a survey assessing pregnancy intentions, receipt of contraceptive counseling, and use of contraception at last sexual intercourse. Survey data were linked to medical record data regarding contraceptive prescriptions prior to and during the clinic visit. Women were classified as in need of contraceptive counseling if they were sexually active, were not pregnant or trying to get pregnant, and had no evidence of contraceptive use prior to their index clinic visit.

KEY RESULTS

Fifty percent (n = 386) of women were in need of contraceptive counseling at the time of their visit. Those who received contraceptive counseling from a primary care provider were more likely to report use of hormonal contraception when they last had sex (unadjusted OR: 3.83, CI: 2.25-6.52), even after adjusting for age, race, education, income, marital status, pregnancy intentions, and prior pregnancy (adjusted OR: 2.68, CI: 1.48-4.87). Counseling regarding specific types of contraception was associated with an increased use of those methods. For example, counseling regarding hormonal contraceptives was associated with a greater likelihood of use of hormonal methods (adjusted OR: 4.78, CI: 2.51-9.12) and counseling regarding highly effective reversible methods was highly associated with use of those methods (adjusted OR: 18.45, CI: 4.88-69.84). These same relationships were observed for women with prior evidence of contraceptive use.

CONCLUSIONS

Contraceptive counseling in primary care settings is associated with increased hormonal contraceptive use at last intercourse. Increasing provision of contraceptive counseling in primary care may reduce unintended pregnancy.

Patient decision-making preference and physician decision-making style for contraceptive method choice in an Asian culture: does concordance matter?

This study investigates preferences for patient-physician decision-making in an emerging economy with an Asian culture. A survey of 445 randomly sampled women, aged 20-40 in Hanoi, Vietnam, revealed that pre-consultation attitudes were most positive toward a "shared" decision-making approach with the physician for contraceptive method choice. However, following random assignment to one of three vignettes (passive, shared or autonomous) featuring a young Vietnamese woman reaching a contraceptive method decision with her physician, preference was highest for the "autonomous" approach. Furthermore, discordance between pre-consultation preference for decision-making style and the physician's decision-making style negatively impacted evaluations under some but not all circumstances. This study demonstrates that, despite living in a hierarchic Asian culture, active participation in contraceptive method choice is desired by many urban Vietnamese women. However, there is variation on this dimension and adjusting the physician's style to be concordant with patient preference appears important to maximizing patient satisfaction.

Characteristics and concerns of women choosing an online contraception selection tool ("choosing wisely")

BACKGROUND

Choosing Wisely, a user-friendly and interactive application developed and tested at Queen's University, is a self-administered computer-based questionnaire that aims to assist women, their partners, and their health care providers in deciding among contraceptive options. The application asks specific, direct questions regarding a patient's preferences, health, and lifestyle, and it then generates three lists: (1) indicated contraceptive methods, (2) options that may be suitable, and (3) contraindicated methods.

OBJECTIVE

To report statistics on the users of Choosing Wisely in the first 13 months since the launch of the program on the award-winning SOGC website Sexualityandu.ca in June, 2007.

METHODS

At the end of the program module, each user's answers were logged anonymously in a Microsoft Excel spreadsheet along with the time and date of completion. Descriptive statistics were generated in SPSS version 16.0.

RESULTS

Between June 21, 2007, and July 25, 2008, 9775 users completed the Choosing Wisely program. Of these users, 8942 (91.5%) were female, and 8745 (89.5%) were under 35. At least one concern regarding contraceptive options was reported by 7359 users (75.3%), and the most common of these was weight gain, selected by 4806 (65.3%).

CONCLUSION

Choosing Wisely has attracted an average of 24 users per day seeking more information on birth control methods. The responses gathered from the program will likely allow for both a better understanding of the characteristics of women who desire birth control and refinement of the program, with the aim of better serving those who are seeking contraceptive advice.

Why do women experience untimed pregnancies? A review of contraceptive failure rates

Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. A number of socio-demographic factors seem to impact on the risk of a woman experiencing contraceptive failure. Many of the issues exist across cultural boundaries and are complex to address. In discussing the failure rates for individual contraceptive methods, this article will highlight the advantage of improving uptake of long-acting reversible methods of contraception which have a high efficacy and are less user-dependent than many of the other available methods.

Health care providers' knowledge about contraceptive evidence: a barrier to quality family planning care?

BACKGROUND

The underuse of effective contraceptive methods by women at risk for unintended pregnancy is a major factor contributing to the high rate of unintended pregnancy in the United States. As health care providers are important contributors to women's contraceptive use, this study was conducted to assess provider knowledge about contraception.

STUDY DESIGN

Bivariate and multivariate analyses were performed using data collected from a convenience sample of health care providers (physicians, nurse practitioners and physician assistants) at meetings of the professional societies of family medicine and obstetrics and gynecology.

RESULTS

Younger providers were more knowledgeable, as were obstetrician/gynecologists, female providers and providers who provide intrauterine contraception in their practice.

CONCLUSIONS

The lack of consistent and accurate knowledge about contraception among providers has the potential to dramatically affect providers' ability to provide quality contraceptive care for their patients, which could have an impact on their ability to prevent unintended pregnancies.

Barriers to emergency contraception (EC): does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS?

OBJECTIVE

The aim of this study was to focus on barriers, controversy and perceived risk associated with use of emergency contraception (EC) after unprotected sexual intercourse.

DESIGN AND METHOD

Data were extracted from the literature of the MEDLINE database service. Original articles, surveys, clinical trials and investigations are considered for this review.

RESULTS

After the introduction of over-the-counter and advance prescription provisions for easy access to EC, the rural-urban disparity in availability of EC poses a barrier to use of EC for rural dwellers. The socio-economically weaker section of the population is unable to purchase EC because of low or no income, although there is mounting pressure by the State for prevention of unintended pregnancy by use of EC. Some healthcare providers have objected to provide EC to the patient on the grounds of their conscience and morality. Some providers and users have also expressed concerns about the possibility of increase in irresponsible sexual behaviour because of easy access to EC. There may be some truth in their apprehension because nearly 3.2 million unintended pregnancies occur annually despite various contraceptive options available in USA and the extensive use of EC is directly proportional to the volume of unprotected sexual intercourse, which is too directly proportional to the quantum of risk for contacting sexually transmitted infections (STIs)/AIDS.

CONCLUSIONS

Emergency contraception is a one-off postcoital procedure and not to be opted after every sexual intercourse. Controversy about EC may be resolved if it is used within this limit. Extensive use of EC may increase risk for contacting STIs/AIDS.

Contraceptive counseling by gynecologists--which issues are discussed and does gender play a role?

OBJECTIVES

Explorative pilot study with the aim of gaining insight into the contraceptive counseling practices and possible gender differences of a selected group of male and female gynecologists.

DESIGN

Semi-structured telephone-interviews of 48 gynecologists concerning the content and strategies of their contraceptive counseling with special focus on aspects relevant to patient adherence.

RESULTS

Male and female gynecologists inform equally frequently about various methods and reproductive health aspects such as risks, the advantages and disadvantages of the methods and side effects. Male physicians speak more often about the efficiency and benefits of the methods, while their female colleagues emphasize STI and emergency contraception. Sexual health aspects were seldom mentioned as issues of discussion. For the choice of a contraceptive method efficiency was considered very important by 100%, reversibility by 83%, side effects by 85% and convenience by 79%. Naturalness and costs were more often quoted as important by female, and benefits by male gynecologists. Side effects are considered the most important factor for patient adherence by 60%, counseling and information is predominantly cited by female, and patient's character and personality by male doctors.

CONCLUSIONS

While contraceptive counseling by practising gynecologists includes basic information about available methods and their efficiency, as well as some reproductive health issues, sexual health issues are often neglected. Gender differences occasionally influence the choice of the topics as well as the attitude towards the patient.

Women's experiences with emergency contraception in an internal medicine practice

BACKGROUND

Emergency contraceptive pills (ECPs) are effective for preventing unintended pregnancy. Whether patients in primary care settings receive physician counseling regarding ECPs has not been evaluated.

METHODS

We conducted a cross-sectional telephone survey of reproductive-age women who sought care at a university-based general internal medicine clinic regarding receipt of physician counseling about ECPs, knowledge and experiences with ECPs, and attitudes toward using ECPs.

RESULTS

One hundred forty-nine women aged 18-45 completed the survey. Eighty percent of respondents (n = 119) were at risk for unintended pregnancy. Although all women in the sample had seen an internist in the previous 12 months, only 10% had received physician counseling about ECPs. There was little difference in the proportion of women who received counseling about ECPs comparing those who received care from an obstetrician/gynecologist and an internist with women who received care from an internist alone (13% vs. 8%, p = 0.529). Receipt of ECP counseling was not associated with the consistency of current contraceptive use. No women who were married or over the age of 40 were counseled about ECPs. The majority of participants (92%) had heard of ECPs, although most (54%) had learned about them through the media. Fifty-four percent of women would be likely to use ECPs to prevent unintended pregnancy.

CONCLUSIONS

Only a fraction of women seeing internists for their primary care are receiving counseling about ECPs, irrespective of receiving care from an obstetrician/gynecologist. As primary care physicians, internists should determine risk for unintended pregnancy, assess patients' knowledge and attitudes toward ECPs, and provide counseling about this effective therapy.

Contraceptive failures and determinants of emergency contraception use

OBJECTIVES

Two years after emergency contraceptive pills (ECPs) were made available without prescription in France, we investigated the determinants of ECP use in a representative sample of women at risk for unintended pregnancy.

STUDY DESIGN

This study is based on data collected from a population-based cohort exploring contraceptive practices and abortion (N=2863).

RESULTS

Among the 706 women at risk for unintended pregnancy during the first year of follow-up (2001), only 11.1% used ECPs. Women in stable relationships or using the same contraceptive method during the year were less likely to use ECPs than other women. The study also demonstrates that detailed knowledge of ECPs increases the probability of its subsequent use.

CONCLUSIONS

Given the low frequency of ECP use in cases of unintended pregnancy risk, these results suggest that information campaigns should be targeted not only at women with irregular contraceptive practices but also at women who experience errors in the use of their regular contraceptive method.

Surgical Termination of Pregnancy: Evaluation of 14,903 Cases

OBJECTIVE

To evaluate the demographic and clinical characteristics of patients who underwent surgical termination of pregnancy and to assess the efficacy of the termination methods.

MATERIALS AND METHODS

This retrospective study was carried out on 14,903 healthy women who had intrauterine pregnancy of <or= 10 weeks of gestation as determined by transvaginal ultrasonography. All patients underwent either suction curettage (SC) with dilatation or SC only. Family planning counseling was given to all patients before the procedure and subjects were evaluated for any complications after the procedure.

RESULTS

SC with dilatation was performed in 43.2% of patients and SC only was performed in 56.8%. Mean age was 31 +/- 4.3 years. Only 5% of cases were primigravidas and 87% had formal education; 91% had one or more surgical abortions for previous pregnancies. Before the procedure, 67% were using coitus interruptus, 10% condom, 6% intrauterine device, 5% vaginal lavage, and 3% oral contraceptives as the contraceptive method, and 9% did not use any contraception. Infection, excessive bleeding, retention of fetoplacental material and uterine perforation were reported as complications of the procedure. After the procedure and following family planning counseling, 92% began to use an efficient, modern contraceptive method.

CONCLUSION

This study points out that surgical abortion is not a contraceptive method. Most surgical abortions can be prevented by effective usage of modern contraceptive methods. The importance of well-planned contraceptive counseling and education is emphasized. Better family planning counseling and education, and the availability of modern contraceptive methods can easily decrease the incidence of surgical abortions.

Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents

PURPOSE

Little is known about how physicians' attitudes and knowledge of contraception could impact the unintended pregnancy rate in the United States. The objective of this study was to analyze survey data from physicians in primary care training programs in Pittsburgh, PA.

METHODS

A cross-sectional survey was administered to primary care medical residents in Allegheny County, PA. Descriptive statistics were used to illustrate training, attitudes and knowledge regarding contraceptive management. A multivariable analysis was performed to elucidate associations between training, attitudes and behavior.

RESULTS

Of 143 residents surveyed, 74 (52%) responded. The mean score on contraceptive knowledge assessment was 54%. Obstetrics/gynecology residents performed consistently better on the knowledge index (p<.01). Among nonobstetrics/gynecology residents, formal training in contraception, female gender, ability to insert an intrauterine device and not being a family practitioner were independently associated with improved knowledge (p<.05).

CONCLUSIONS

Most of the responding graduating residents view contraception as an important component of primary care. However, young physicians have a contraceptive knowledge base that is inconsistent across primary care specialties. Improvement in this area might improve the unintended pregnancy rate in the United States.

New recommendations for the periodic well-woman visit: impact on counseling

Since 2000, the recommendations for women's health care have undergone considerable changes that have prompted a modification in terminology from the "annual examination" to the "periodic well-woman visit." A pelvic examination is not required before prescribing hormonal contraception, selected women 30 years or older may receive less frequent cytological testing and teaching breast self-examination is no longer recommended unless the patient requests it. Counseling will be needed to reassure women that these changes are based on sound scientific evidence. The periodic well-woman visit provides an opportunity for ongoing contraceptive counseling. The expanding array of contraceptive choices necessitates counseling that focuses on methods that are most appropriate for the individual. In addition to the changes in screening recommendations, increased utilization of ancillary staff, self-administered questionnaires and other time-saving strategies to gather information before the patient sees the health care provider can increase the time available for counseling within the time constraints of an office visit.

Focus on Women: Linking HIV Care and Treatment with Reproductive Health Services in the MTCT-Plus Initiative

Despite important advances in expanding access to antiretroviral therapy in the countries most heavily affected by HIV/AIDS, there has been little consideration of the connections between HIV prevention, care and treatment programmes and reproductive health services. In this paper, we explore the integration of reproductive health services into HIV care and treatment programmes. We review the design and progress of the MTCT-Plus Initiative, which provides HIV care and treatment services to HIV positive women as well as their HIV positive children and partners. By emphasising the long-term follow-up of families and the provision of comprehensive care across the spectrum of HIV disease, MTCT-Plus highlights the potential synergies in linking reproductive health services to HIV care and treatment programmes. While HIV care and treatment programmes in resource-limited settings may not be able to integrate all reproductive health services into a single service delivery model, there is a clear need to include basic reproductive health services, such as access to appropriate contraception and counselling and management of unplanned pregnancies. The integration of these services would be facilitated by greater insight into the reproductive choices of HIV positive women and men, and into how health care providers influence access to reproductive health services of people with HIV and AIDS.