Menstrual irregularity from hormonal contraception: a cause of reproductive health concerns in minority adolescent young women

Perceived and Objective Fertility Risk Among Female Survivors of Adolescent and Young Adult Cancer

Importance

Fertility is important to many survivors of adolescent and young adult (AYA) cancer, yet data on this population's fertility perceptions and their alignment with objective infertility risk are scant.

Objective

To assess whether estimated treatment gonadotoxicity and posttreatment menstrual pattern are associated with higher infertility risk perception.

Design, Setting, and Participants

This retrospective cohort study included female young adult survivors of cancer diagnosed between ages 15 and 39 years were recruited between March 25, 2015, and September 24, 2018, from 2 state cancer registries, social media, and clinician referrals to participate in a study of posttreatment ovarian function. Data analysis occurred between March 1 and September 1, 2022.

Exposures

Participants reported their menstrual pattern. Estimated treatment gonadotoxicity was ascertained through medical record review.

Main Outcomes and Measures

Participants reported infertility risk perception and were categorized as increased risk (feeling less fertile or unable to become pregnant) or no increased risk (feeling more or as fertile) compared with female individuals their age. Objective infertility risk was determined by estimated gonadotoxicity, menstrual pattern, and ovarian reserve testing of self-collected dried blood spots. Multivariable logistic regression identified factors associated with perceived infertility and underestimation or overestimation of infertility risk.

Results

This study included 785 female participants with a mean (SD) age of 33.2 (4.8) years at enrollment and 25.9 (5.7) years at diagnosis. Most participants self-identified their race and ethnicity as White (585 [74.5%]) and non-Hispanic (628 [78.7%]). Most participants (483 [61.5%]) perceived a higher risk of infertility compared with female participants their age. Prior exposure to moderate- or high-gonadotoxicity treatments was associated with higher odds of perceiving increased infertility risk compared with exposure to low-gonadotoxicity treatments (adjusted odds ratio [AOR], 2.73 [95% CI, 1.87-3.97] and 15.39 [95% CI, 5.52-42.96], respectively). Amenorrhea and irregular cycles were associated with higher odds of perceiving increased infertility risk (AOR, 3.98 [95% CI, 2.13-7.41] and 1.69 [95% CI, 1.19-2.40], respectively). Perceived infertility risk had minimal agreement with objective risk (κ = 0.19). Multiparity (AOR, 4.17 [95% CI, 2.61-6.64]) was associated with increased odds of underestimation, while older age (AOR, 0.94 [95% CI, 0.89-0.98]), endocrine comorbidity (AOR, 0.35 [95% CI, 0.18-0.69]), and prior infertility (AOR, 0.16 [95% CI, 0.07-0.38]) were associated with lower odds of underestimation. Multiparity (AOR, 0.48 [95% CI, 0.27-0.86]), breast cancer (AOR, 0.38 [95% CI, 0.20-0.73]), and skin cancer (AOR, 0.24 [95% CI, 0.11-0.51]) were associated with lower odds of overestimation.

Conclusions and Relevance

In this cohort study, survivors of AYA cancer had high rates of perceiving increased infertility risk but frequently overestimated or underestimated their risk. These findings suggest that counseling on infertility risk throughout survivorship may reduce misalignment between perceptions and actual risk, decrease fertility-related psychological distress, and inform family planning decisions.

Negative Perceptions and Long-Acting Reversible Contraceptive Choice in Adolescents and Young Adults: A Cross-Sectional Study

OBJECTIVE

Long-acting reversible contraceptives (LARCs) have high rates of safety, satisfaction, and continuation in adolescents and young adults (AYAs). Despite this, utilization of these methods by AYAs is low. The purpose of this study was to evaluate the negative personal perceptions or beliefs about birth control and LARCs and their association with contraceptive use in AYAs.

METHODS

We surveyed young people (14-24 years old) seeking care at a Title X-supported adolescent reproductive and sexual health clinic to assess negative perceptions of birth control methods, with an emphasis on LARCs. We used appropriate bivariate statistics to compare those endorsing 3 or fewer negative perceptions with those who had more than 3 and logistic regression to identify predictors of contraceptive choice.

RESULTS

We recruited 345 participants; 337 (97.7%) completed the survey. Among respondents, the median age was 20 (range 14-24) years, and 7.04% of participants had ever been pregnant. The most commonly held negative perceptions were fear of device migration or breakage causing adverse health effects and concern about effect on future fertility. The number of negative perceptions endorsed did not differ significantly by age. However, a greater number of negative perceptions and younger age were clinical predictors of LARC nonuse.

CONCLUSION

AYAs have negative perceptions about LARCs that are often inaccurate and may limit contraceptive acceptability and perceived options. Engaged and respectful dialogue with AYAs about their concerns and fears is essential to provide accurate and patient-centered contraceptive counseling and to ensure that young people can make informed contraceptive choices.

Recent Intimate Partner Violence and Oral Contraceptive Pill Adherence in a Cohort of Reproductive-Aged Women

Objective: Intimate partner violence (IPV) is an important public health problem that impacts reproductive decision-making. Although previous literature has reported a negative impact on contraceptive adherence overall, this study specifically aims to investigate the association between IPV and oral contraceptive pill (OCP) adherence. Methods: We analyzed baseline survey data from 373 OCP users participating in the MyNewOptions study. Recent IPV was defined as any positive response to HARK, a 4-question tool assessing emotional, sexual, and physical abuse in the past year, or self-report of sexual coercion in the past 6 months. High OCP adherence was defined by self-report of missing ≤1 pill per month, which was then corroborated by pharmacy claims data. Multivariable regression analyses were performed to assess the influence of recent IPV history and patient-level variables on OCP adherence. Results: Just over half of our participants were highly adherent to OCPs (53.6%), and approximately one-quarter reported recent IPV exposure (25.2%). Women with recent IPV were significantly less likely to be OCP adherent than those without IPV (adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI): 0.32-0.92). Protestant religion was also associated with high OCP adherence (AOR 2.41, 95% CI: 1.24-4.65, compared with no religious affiliation), while younger age groups (18-25 and 26-33 years) were less likely to have high OCP adherence compared with the 34-40 age group (AOR 0.45, 95% CI: 0.20-1.00 and AOR 0.40, 95% CI: 0.18-0.91, respectively). Conclusion: Recent IPV exposure is associated with low OCP adherence among women of reproductive age. ClinicalTrials.gov identifier: NCT02100124.

A comparison of contraceptive services for adolescents at school-based versus community health centers in Oregon

OBJECTIVE

To compare Oregon school-based health centers (SBHCs) with community health centers (CHCs) as sources of adolescent contraceptive services.

DATA SOURCES

Oregon electronic health record data, 2012-2016.

STUDY DESIGN

We compared clinic-level counseling rates and long-acting reversible contraception (LARC) provision, adolescent populations served, and visit-level LARC provision time trends. We evaluated adjusted associations between LARC provision and Title X participation by clinic type.

DATA COLLECTION/EXTRACTION METHODS

We used diagnosis and procedure codes to identify contraceptive counseling and provision visits, excluding visits for adolescents not at risk of pregnancy.

PRINCIPAL FINDINGS

CHCs were more likely to provide LARC on-site than SBHCs (67.2% vs. 36.4%, respectively). LARC provision increased more at SBHCs (5.8-fold) than CHCs (2-fold) over time. SBHCs provided more counseling visits per clinic (255 vs. 142) and served more young and non-White adolescents than CHCs. The adjusted probability of LARC provision at Title X SBHCs was higher than non-Title X SBHCs (4.4% [3.9-4.9] vs. 1.7% [1.4-2.0]), but there was no significant association at CHCs.

CONCLUSIONS

In Oregon, CHCs and SBHCs are both important sources of adolescent contraceptive services, and Title X plays a crucial role in SBHCs. Compared with CHCs, SBHCs provided more counseling, showed a larger increase in LARC provision over time, and served more younger and non-White adolescents.

Adherence to Oral Contraception in Young Women: Beliefs, Locus of Control, and Psychological Reactance

Background: There is a high dropout rate of oral contraceptive pills (OCP), mainly due to a lack of adherence to treatment. The aim of this study was to identify the psychological processes and attitudes toward medication involved in adherence to OCP, depending on the prescription, to avoid unintended pregnancies (AUP) or gynecological problems (GP). Methods: This cross-sectional study was conducted by asking 689 young women in the fertile period, mean age 23.41 (SD = 5.90), to complete questionnaires related to attitudes, beliefs, psychological reactance, locus of control, and adherence to contraceptive medication. Descriptive analyses and a binary logistic regression were performed. Results: The results confirmed that different beliefs and psychological processes were involved in adherence to oral contraception, based on women’s reasons for taking contraceptive medication. More psychological processes were involved in non-adherence in the AUP group than in the GP group. Psychological reactance contributed most to explaining non-adherence in women who used the OCP to prevent unintended pregnancies. Conversely, women with gynecological problems reported difficulties in adherence, mainly due to their beliefs about contraceptive pills. Conclusions: These findings indicate that attitudes toward medication and psychological processes can play an important role in adherence to OCP, including reasons for using the pill. Identifying the psychological factors and beliefs linked with contraception could guide health professionals to provide counseling to women, thus increasing their adherence to medication and maximizing their health and well-being.

Digital Medical Device Companion (MyIUS) for New Users of Intrauterine Systems: App Development Study

Background

Women choosing a levonorgestrel-releasing intrauterine system may experience changes in their menstrual bleeding pattern during the first months following placement.

Objective

Although health care professionals (HCPs) can provide counseling, no method of providing individualized information on the expected bleeding pattern or continued support is currently available for women experiencing postplacement bleeding changes. We aim to develop a mobile phone–based medical app (MyIUS) to meet this need and provide a digital companion to women after the placement of the intrauterine system.

Methods

The MyIUS app is classified as a medical device and uses an artificial intelligence–based bleeding pattern prediction algorithm to estimate a woman’s future bleeding pattern in terms of intensity and regularity. We developed the app with the help of a multidisciplinary team by using a robust and high-quality design process in the context of a constantly evolving regulatory landscape. The development framework consisted of a phased approach including ideation, feasibility and concept finalization, product development, and product deployment or localization stages.

Results

The MyIUS app was considered useful by HCPs and easy to use by women who were consulted during the development process. Following the launch of the sustainable app in selected pilot countries, performance metrics will be gathered to facilitate further technical and feature updates and enhancements. A real-world performance study will also be conducted to allow us to upgrade the app in accordance with the new European Commission Medical Device legislation and to validate the bleeding pattern prediction algorithm in a real-world setting.

Conclusions

By providing a meaningful estimation of bleeding patterns and allowing an individualized approach to counseling and discussions about contraceptive method choice, the MyIUS app offers a useful tool that may benefit both women and HCPs. Further work is needed to validate the performance of the prediction algorithm and MyIUS app in a real-world setting.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

STUDY OBJECTIVE

To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.

DESIGN

In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.

SETTING

Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.

PARTICIPANTS

Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.

RESULTS

Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.

CONCLUSION

Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

Hormonal contraceptive use in Ghana: The role of method attributes and side effects in method choice and continuation

OBJECTIVE

To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy.

STUDY DESIGN

We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation.

RESULTS

Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided.

CONCLUSIONS

Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate.

IMPLICATIONS

Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

Predicting menstrual bleeding patterns with levonorgestrel-releasing intrauterine systems

PURPOSE

To develop a bleeding-pattern prediction model to inform counselling on amount and regularity of bleeding after levonorgestrel-releasing intrauterine system (LNG-IUS) placement.

MATERIALS AND METHODS

Fixed-cluster and regression-tree models were developed using bleeding data pooled from two clinical trials of LNG-IUSs. Models were trained and cross-validated on LNG-IUS 12 data, then applied to LNG-IUS 20 and LNG-IUS 8 data. Three clusters were generated for the fixed-cluster model: predominantly amenorrhoea; predominantly spotting; and predominantly bleeding. A random-forest model predicted the future-bleeding cluster, then the probability of cycle regularity was calculated. In the regression-tree model, women were assigned by the model to less- or more-bleeding groups.

RESULTS

With LNG-IUS 12 (n = 1351) in the fixed-cluster model, 70.4% of women were correctly classified. The correct classification rates for LNG-IUS 20 (n = 216) and LNG-IUS 8 (n = 1300) were 72.2% and 69.0%. The probability distribution for cycle regularity showed regular and irregular bleeding were best separated with LNG-IUS 12 data, and less well with LNG-IUS 20 and LNG-IUS 8 data. In the regression-tree model there was high variability in the more- and less-bleeding group distributions with LNG-IUS 12 data.

CONCLUSIONS

A fixed-cluster model predicted bleeding patterns better than a regression-tree model in women using LNG-IUS, yielding understandable, informative output.

The relationship between the use of combined hormonal contraception with a predominance of gestagens and the selected types of female body in young women from the region of Lower Silesia

Oral contraceptive agents are currently the most popular and one of the most effective methods for preventing pregnancy. The data shows that over 300 million women in the world use contraceptive drugs containing synthetic hormones to avoid an unwanted pregnancy. Their effects may affect other systems, leading to the occurrence of various problems associated with the use of the drug. The aim of the study is to estimate the frequency of prevalence of subjective effects associated with the use of combined hormonal contraception with a predominance of gestagens by young women Surveys were conducted among female students of Wrocław universities from December 2010 to January 2011. They covered 257 women aged statistically 23.58 (SD=2.95). They were divided into three age classes: 19-22, 23-24, 25- 28. The individual age of menarche and the hormonal type of body were determined. Only persons with a gestagenic or estrogenic type of body were qualified for the study. Results: 64.6% of all respondents declared the use of hormonal contraception. Combined agents with a predominance of gestagens constituted 87% in this group. Their use brings both positive (90%) and negative (65%) aspects. The most common positive effects include high contraceptive effectiveness, regulation of menstruation and minimisation of skin problems. The most frequent negative effects include: weight gain, spotting, breast swelling and decreased libido. Surprisingly, the study did not show any correlation between the hormonal type and the occurrence of side effects. There was no significant statistical relationship between the type of hormonal contraception used and the hormonal type.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes

INTRODUCTION

Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review.

METHODS

We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers.

RESULTS

We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains.

CONCLUSIONS

Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

"Just Wear Dark Underpants Mainly": Learning from Adolescents' and Young Adults' Experiences with Early Discontinuation of the Contraceptive Implant

STUDY OBJECTIVE

Long-acting reversible contraception, including the contraceptive implant, is recommended for teens and young women. However, some young women discontinue the implant early, and we seek to better understand their experiences.

DESIGN, SETTING, AND PARTICIPANTS

We conducted interviews with 16 young women ages 14 to 24 who presented for removal of the contraceptive implant within 6 months after placement at outpatient adolescent, family medicine, and obstetrics and gynecology clinics. We coded and analyzed transcripts to identify themes and develop a thematic framework.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We explored decision-making regarding placement and removal of the implant, differences between anticipated and experienced side effects, and recommendations for counseling.

RESULTS

The participants reported experiencing significant side effects that led to removal, most often frequent or heavy bleeding or mood changes. These healthy young women were unprepared for these symptoms, despite remembering being told about possible side effects. Participants wanted more concrete examples of possible side effects, and personal stories of side effects experienced by others, rather than general terms such as irregular bleeding or mood changes. Few discussed problems with their providers; instead, they relied on the Internet or friends to help decide when to remove the implant. Nearly half of the participants did not start new contraception after removal, although they voiced a continued desire to avoid pregnancy.

CONCLUSION

We identified a need for more descriptive counseling about side effects experienced by individuals, and guidance on what to do about problems encountered after placement.

Providing Contraception to Adolescents

Adolescents have high rates of unintended pregnancy and face unique reproductive health challenges. Providing confidential contraceptive services to adolescents is important in reducing the rate of unintended pregnancy. Long-acting contraception such as the intrauterine device and contraceptive implant are recommended as first-line contraceptives for adolescents because they are highly effective with few side effects. The use of barrier methods to prevent sexually transmitted infections should be encouraged. Adolescents have limited knowledge of reproductive health and contraceptive options, and their sources of information are often unreliable. Access to contraception is available through a variety of resources that continue to expand.

What influences adolescents' contraceptive decision-making? A meta-ethnography

Increased access to and use of contraception has contributed significantly to the decline in teen birth rates since 1991, yet many teens use contraception inconsistently or not at all. This meta-ethnography was conducted to identify the factors that influence adolescents' contraceptive decision-making. Fourteen qualitative studies were examined using G. W. Noblit and R. D. Hare's (1988) meta-ethnographic approach. Three themes of self, partner and family were found to influence contraceptive decision-making in both positive and negative ways. Assisting adolescents to maximize positive and reduce negative influences regarding contraceptive decision-making has the potential to assist teens to more effectively avoid unintended pregnancy and sexually transmitted infections.

A survey on Swiss women's preferred menstrual/withdrawal bleeding pattern over different phases of reproductive life and with use of hormonal contraception

BACKGROUND

Today, options for bleeding-free lifestyle are actively promoted by the media, the pharmaceutical industry and health specialists. With regard to contraceptive counselling it is important to find out what women really want.

METHODS

In the present study we collected information on women's attitudes towards monthly bleeding and preferences, if they could have the option to modify their individual bleeding pattern. Furthermore we evaluated the preferences with use of combined hormonal contraceptives (CHCs). Switzerland has never been surveyed before with regard to these issues. Questionnaires were distributed in our family planning clinic and two outdoor offices to clients aged 15 to 19 years, 25 to 34 years, and 45 to 49 years.

RESULTS

Of 530 questionnaires, 292 were eligible for analysis. Around 50 of the participants would appreciate having fewer menstrual period-related symptoms. Some 37% preferred experiencing a monthly bleeding; 32% opted for every 2 to 6 months; and 29%, for no bleeding at all. This heterogeneous distribution did not differ between clients with and without menstrual symptoms. With regard to CHC use, predictable bleeding was rated as very positive and breakthrough bleeding as negative.

CONCLUSION

Contraceptive counsellors should be aware that women's wishes differ widely. Predictability of bleeding seems to be more important to them than postponing it.

Dual contraceptive use among adolescents and young adults: correlates and implications for condom use and sexually transmitted infection outcomes

BACKGROUND

Simultaneous condom and hormonal contraception usage ('dual method use') maximises protection against pregnancy and sexually transmitted infection (STI), although there is concern that promotion of this strategy could result in diminished condom use and inadvertently increase STI risk. In this study, we (1) assessed how the use of dual methods, versus condoms alone, related to STI and consistency of condom use and (2) described the correlates of dual use.

METHODS

A sample of 1450 young people aged 12-25 years were surveyed and screened for chlamydia and gonorrhoea at non-clinical sites in two high morbidity Californian counties in 2002-2003. Differences in STI prevalence and reported consistency of condom use were assessed for 'condom only' and 'dual method' users. Correlates of dual use were analysed via multivariate polytomous logistic regression.

RESULTS

Condom only and dual method users did not significantly differ in terms of STI prevalence or reported consistency of condom use. Sex, age, race and relationship tenure were significant correlates of dual use.

DISCUSSION

In these observational data, dual method use did not detrimentally affect STI risk. If interpreted alongside each subgroups' risk patterns for STI and unplanned pregnancy, the correlates of dual use can inform STI and pregnancy prevention interventions.

Disparities in abortion rates: a public health approach

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities. As efforts to restrict abortion will have no effect on these underlying factors, and instead will only result in more women experiencing later abortions or having an unintended childbirth, they are likely to result in worsening health disparities. We provide a review of the causes of abortion disparities and argue for a multifaceted public health approach to address them.

Do racial and ethnic differences in contraceptive attitudes and knowledge explain disparities in method use?

CONTEXT

Sustained efforts have not attenuated racial and ethnic disparities in unintended pregnancy and effective contraceptive use in the United States. The roles of attitudes toward contraception, pregnancy and fertility remain relatively unexplored.

METHODS

Knowledge of contraceptive methods and attitudes about contraception, pregnancy, childbearing and fertility were assessed among 602 unmarried women aged 18-29 at risk for unintended pregnancy who participated in the 2009 National Survey of Reproductive and Contraceptive Knowledge. The contribution of attitudes to racial and ethnic disparities in effective method use was assessed via mediation analysis, using a series of regression models.

RESULTS

Blacks and Latinas were more likely than whites to believe that the government encourages contraceptive use to limit minority populations (odds ratio, 2.5 for each). Compared with white women, Latinas held more favorable attitudes toward pregnancy (2.5) and childbearing (coefficient, 0.3) and were more fatalistic about the timing of pregnancy (odds ratio, 2.3); blacks were more fatalistic about life in general (2.0). Only one attitude, skepticism that the government ensures contraceptive safety, was associated with contraceptive use (0.7), but this belief did not differ by race or ethnicity. Although blacks and Latinas used less effective methods than whites (0.3 and 0.4, respectively), attitudes did not explain disparities. Lower contraceptive knowledge partially explained Latinas' use of less effective methods.

CONCLUSIONS

Providing basic information about effective methods might help to decrease ethnic disparities in use. Research should examine other variables that might account for these disparities, including health system characteristics and provider behavior.

Clinical practice: Contraception in adolescents

In affluent societies, median age at menarche has dropped to below 13 years. Younger age at menarche is associated with earlier sexual activity. To avoid unintended teenage pregnancies, barriers to contraception provision must be kept low, i.e. availability without prescription or through a low-threshold prescription system, low-cost options and long-term prescriptions or easy refills. Since many adolescents are (over)concerned about side effects, these should be addressed. A gynaecological examination prior to prescription is no longer recommended. All effective reversible contraceptive methods are available to adolescents: user-based hormonal contraceptives, trimonthly depot medroxyprogesterone acetate (DMPA), and long-acting reversible contraception (LARC). User-based hormonal contraceptives carry a small absolute risk of venous thromboembolism (~4 per 10,000 patient-years), but the risk is more than tenfold higher among young women with an inherited clotting defect. DMPA reduces bone mineral accumulation, but this is a reversible effect; the metabolic risks, including weight gain and insulin resistance, appear to be greater. LARC, including intrauterine contraceptive devices and the progestogen-containing implant, is gaining popularity among teenagers; abnormal bleeding is the main side effect. Any effective contraceptive should preferably be combined with consistent condom use to prevent sexually transmitted infections ("the double Dutch").

Race, ethnicity and differences in contraception among low-income women: methods received by Family PACT Clients, California, 2001-2007

CONTEXT

The extent to which racial and ethnic differences in method choice are associated with financial barriers is unclear. Understanding these associations may provide insight into how to address racial and ethnic disparities in unintended pregnancy.

METHODS

Claims data from the California Family PACT program, which provides free family planning services to low-income residents, were used to determine the proportions of women receiving each type of contraceptive method in 2001-2007. Bivariate and multivariate analyses were performed to identify associations between women's race and ethnicity and the primary contraceptive method they received in 2007.

RESULTS

Compared with white women, blacks and Latinas were less likely to receive oral contraceptives (odds ratios, 0.4 and 0.6, respectively) and the contraceptive ring (0.7 and 0.5), and more likely to receive the injectable (1.6 and 1.4) and the patch (1.6 and 2.3). Black women were less likely than whites to receive the IUD (0.5), but more likely to receive barrier methods and emergency contraceptive pills (2.6); associations were similar, though weaker, for Latinas. Racial and ethnic disparities in receipt of effective methods declined between 2001 and 2005, largely because receipt of the patch (which was introduced in 2002) was higher among minority than white women.

CONCLUSION

Although Family PACT eliminates financial barriers to method choice, the methods women received differed substantially by race and ethnicity in this low-income population. The reduction in racial and ethnic disparities following introduction of the patch suggests that methods with novel characteristics may increase acceptability of contraceptives among minority women.

Disparities in family planning

Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider 3 factors that contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider-related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility.

Experience with side effects among users of injectables, the IUD, and oral contraceptive pills in four urban areas of Honduras

Contraceptive side effects are often the most commonly reported reason for method discontinuation, particularly of modern methods. We use data from eight focus groups and 800 exit interviews to examine women's experiences with contraceptive side effects in four urban areas of Honduras. Ease of treatment and differences in motivation to avoid pregnancy are suggested explanations for why side effects cause some women to continue and others to discontinue. Although side effects are a common reason for discontinuation in this population, less than half of the surveyed women were informed about potential side effects by a health worker on the day of the interview.

Contraceptive attitudes among inner-city African American female adolescents: Barriers to effective hormonal contraceptive use

STUDY OBJECTIVE

To better understand the contraceptive attitudes of low-income, inner-city African American female adolescents.

DESIGN

We conducted four focus group sessions with African American female adolescents.

SETTING

An urban, community health clinic serving low-income patients on Chicago's south side.

PARTICIPANTS

African American female adolescents (n = 15) between 14 and 19 years of age.

INTERVENTIONS

Focus group sessions lasting approximately 90 minutes in length were conducted using a pre-determined script with set probes and open-ended questions.

MAIN OUTCOME MEASURES

Qualitative analysis was conducted to identify major themes related to adolescents' contraceptive attitudes.

RESULTS

Six themes related to the contraceptive attitudes of these adolescents emerged: Concerns About Hormones, Concerns About Privacy, Concerns About Compliance, Limited Awareness of New Methods of Hormonal Contraception (HC), Preference for Condoms, and Acceptability of Emergency Contraception (EC). Overall, adolescents in these sessions expressed skepticism and unwillingness to use continuous methods of HC. For some adolescents, concerns about hormones, privacy, and compliance outweighed their concerns about pregnancy.

CONCLUSION

Concerns about perceived side effects and long-term health risks associated HC and privacy in obtaining contraception and reproductive health care, as well as concerns about ability to comply with daily and weekly HC regimens are common among African American female adolescents and may deter consistent HC use. Although condoms and EC appear to be highly acceptable among this group, adolescents also report a number of barriers to their consistent use. Efforts to reduce early, unintended pregnancy among African American youth should focus on addressing adolescents' HC-related concerns, improving access to EC, and helping female adolescents effectively negotiate condom use.