Continuation rates and reasons for removal among Implanon® users accessing two family planning clinics in Queensland, Australia

Effectiveness and continuation rates of the etonogestrel-subdermal contraceptive implant versus short-acting contraceptive methods offered at no cost in Campinas, Brazil

OBJECTIVES

To compare the efficacy, reasons for discontinuation and continuation rates of the etonogestrel (ENG)-subdermal contraceptive implant when offered at no cost, and the basis of free choice versus short-acting reversible contraceptive (SARC) methods including combined oral contraceptives (COCs), once-a-month injectables, vaginal ring, and patch.

METHODS

We conducted a prospective study at the University of Campinas, Brazil, involving women aged 18 to 40 years. They were counseled on various contraceptive methods before entering the study and followed up every 3 months for up to 24 months. Satisfaction was assessed using a Likert scale. Survival rates were estimated using the Kaplan-Meier test, and curve comparisons were performed using the log-rank test.

RESULTS

We enrolled 609 women including 358/609 women (58.8%) who chose the ENG-implant and 251/609 (41.2%) who chose SARC methods. Contraceptive failure and all other reasons for discontinuation were significantly higher in SARC users compared to the ENG-implant users (P < 0.001 and P = 0.002, respectively). The continuation rate was higher among ENG-implant users (89.9% and 75.4%) compared to SARC methods users (27.2% and 15.9%) up to 1 and 2 years after study initiation, respectively. Satisfaction was high in both groups (>82%).

CONCLUSIONS

The ENG-implant showed higher contraceptive effectiveness and higher continuation rates than SARC methods up to 2 years after study initiation. Furthermore, users from both groups were highly satisfied with their contraceptive. The main reason for discontinuing use of the ENG-implant was bothersome uterine bleeding, while for SARC methods it was for personal reasons.

Determinants of implanon discontinuation among women in Gedeo Zone, South Ethiopia: a case-control study

BACKGROUND

The main public health problem that has a significant impact on the high fertility rate, unintended pregnancies, and induced abortion is Implanon cessation. In addition to Implanon being underutilized in Ethiopia, the rate of cessation is higher among women who started using it. Nevertheless, little is known about the factors that lead to Implanon cessation.

OBJECTIVES

The study was aimed to determine the factors that led women to discontinue Implanon in Gedeo Zone, Southern Nation Nationalities and Peoples Region, southern Ethiopia, 2019.

METHOD

A community-based unmatched case-control study design was carried out. Cases and controls were selected by a multi-stage sampling with a 1:2 case-to-control ratio. Data was entered into EPi-data version 3.1 and exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. A bivariate and multivariable logistic regression was used to identify the factors affecting Implanon discontinuation. The adjusted odd ratio (AOR) with 95% Confidence Interval (CI) was used to determine the precision of estimates, and statistical significance was declared at a p-value of 0.05.

RESULT

From 516 women included in to the study, 495 (cases = 166 and controls = 329) women have responded to the questionnaires making a response rate of 96%. Monthly income 500-1000 birr [AOR: 0.3; 95% CI (0.2-0.5)], above 1000 birr [AOR: 0.2; 95% CI (0.1-0.4)], history of abortion [AOR: 2.0; 95% CI (1.0-4.1)], birth spacing [AOR: 0.6; 95% CI (0.3-0.9)], partner objection [AOR: 2.4; 95% CI (1.4-4.2)] were significantly associated factors.

CONCLUSION

This study identified that monthly income, having abortion history, birth spacing, partner objection were the factors that affect Implanon discontinuation. To reduce implanon discontinuation, reducing abortion, involving partner and increasing the birth spacing, appropriate counseling before the insertion and appropriate follow-up by a health care practitioner are highly recommended.

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

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

Early discontinuation of the IMPLANON® and associated factors in Ethiopia, systematic review and meta-analysis

Background

Implanon® is a commonly used effective long-acting reversible contraceptive method. It provides contraception for up to three years. Its early discontinuation was associated with an unwanted pregnancy, abortion, and socioeconomic burden. Thus, the main aim of this systematic review and meta-analysis is to determine the rate of early discontinuation of Implanon® and associated factors in Ethiopia.

Method

This Systematic review and meta-analysis was performed by using online databases including PubMed, Google Scholar, Cochrane, HINARI, Web of Science, and other gray and online repositories of Ethiopian Universities. The JOANNA Briggs Institute standard data extraction and appraising sheet format was used for the extraction of all included studies. To test the heterogeneity of the studies the Cochran Q test and I² statistics test were used. The Funnel plot and Egger's tests were used to detect possible publication biases of the included studies. The forest plots were used to present the finding of the overall prevalence of the early Implanon® discontinuation and the odds ratio (OR) along with a 95% CI.

Result

In this systematic review and meta-analysis seven studies with a total population of 3161 women using Implanon® were included. The overall pooled early Implanon® discontinuation rate was 31.34% (95%CI: 19.20, 43.47). Early discontinuation of Implanon® was associated with lack of counseling during service delivery 2.55times (OR: 2.55, 95%CI: 1.99, 3.25), the experienced side effect 3.25 times (OR: 3.25, 95%CI: 2.48, 4.24), absence of appointment after insertion 6.06 times (OR: 6.06, 95%CI: 2.15, 17.05), others decision on the women's choice 3.30 times (OR = 3.30, 95%CI: 2.52, 4.32), and lack the satisfaction of provided service 2.68 times (OR: 2.68, 96%CI: 1.61, 4.45).

Conclusion

About one-third of the women in Ethiopia discontinue the use of Implanon® within one year of the insertion. This is high compared to findings from other countries. Lack of counseling about the service, women's experience of the side effect, absence of the appointment following the service provision, other decisions on the method chosen, and lack of satisfaction were factors associated with the discontinuation of Implanon®. Hence, efforts should be made to reduce the rate of early discontinuation of Implanon® through drafting national guidelines and strategies accompanied by appropriate implementation, follow-up to foster adequate counseling, arrangement of appointments, helping women to decide on the choice, and increase the quality of care provision to enhance the satisfaction of the service.

Reasons for modern contraceptives choice and long-acting reversible contraceptives early removal in Amhara Region, Northwest Ethiopia; qualitative approach

BACKGROUND

Women use modern contraceptive methods, mainly either to limit or space pregnancy and both are not identical in their choices. One method may not best fit an individual's need irrespective of the time of spacing. Cognizant of this, the context with which women base in choice of contraceptives, their lived experiences in using, and factors for early removal/ discontinuation of long-acting reversible contraceptives (LARCs) are not much investigated in the study setting and our study aimed to bridge the gap through exploring the underlying reasons.

METHOD

A phenomenological study design was used to explore sampled women's reasons and experiences. Reproductive-aged women (15-49 years) who removed long-acting methods in the past 6 months were included. A criterion sampling approach was employed to recruit study participants. Data was collected using an interview guide for in-depth (IDIs) and key informant interviews and were tape-recorded with interviewees' consent. Audio data were transcribed verbatim and translated into English. The data was first saved in plain text format and imported into Atlas.ti 7.0 software to facilitate coding and categorizing. The content analysis method was used to classify, organize data, and interpret the qualitative data according to key categories.

RESULTS

Several misconceptions about contraceptives (e.g., implants are not appropriate for daily laborers, women who use contraceptives (such as injectables) can only bear girl-child, etc.) were reported by clients and health providers. These misconceptions might not have scientific merit but they are powerful enough to affect actual behaviors toward contraceptives, including early removal. The awareness, attitude, and use of contraceptives tend to be lower in rural areas. For premature removal of LARCs, side effects, and heavy menstrual bleeding, was the most commonly identified reason. The IUCD is the least preferred method and users said it is not comfortable during sex.

CONCLUSION AND RECOMMENDATION

Our study found different reasons and misconceptions for modern contraceptive methods' non-use and discontinuation. Standardized counseling approaches like the REDI (Rapport Building, Exploration, Decision Making, and Implementation) framework should be implemented in the country consistently. Some of the concrete providers' conceptions should be well-studied considering contextual factors to bring scientific evidence.

Can a 3 months treatment with oral Desogestrel prior to insertion of the etonogestrel-releasing contraceptive implant improve continuation rate at 1 year? A randomized trial

OBJECTIVE

To evaluate if daily oral 75 µg of Desogestrel (DSG) for 3 months prior to the insertion of etonogestrel-releasing contraceptive implant (ENG-IMPLANT) might help reduce its premature discontinuation.

RESULTS

A total of 66 women were randomized in the ENG-IMPLANT group (26) and in the DSG + ENG-IMPLANT group (40), respectively, in the Geneva University Hospitals and Basel University Hospital, from August 15th, 2016 through September 30th, 2019. In the DSG + ENG-IMPLANT group, patients were given a 3 months' supply of 75 µg of DSG before the insertion of the ENG-IMPLANT. All women were seen after 3 months for bleeding and satisfaction evaluation, and at 12 months post ENG-IMPLANT insertion. Higher levels of satisfaction at 12-months were found in the ENG-IMPLANT group compared to the DSG + ENG-IMPLANT group (8.5 ± 1.7 vs. 6.6 ± 2.9, p = 0.012). There were no statistically significant differences regarding tolerance (7.8 ± 2.5 vs 6.8 ± 2.6, p = 0.191) and contraceptive continuation (80% vs 72.4%, p = 0.544) between groups.

CONCLUSION

DSG prior to insertion of the ENG-IMPLANT did not improve its continuation rate neither its satisfaction at 1 year. Trial registration NCT05174195. Retrospectively registered, the 30th December 2021.

An Interpretative Study of LARCs Discontinuation in Ethiopia: The Experiences of Women Accessing Contraceptives in Selected Public Health Facilities

Background

Discontinuation of contraception for reasons other than wanting to become pregnant is a public health concern as it affects women's autonomy in sexual and reproductive health decision making as well as gender equality. Studies identified various factors, including community perception and users' dissatisfaction that limited the reach and impact of contraceptives, primarily LARCs, on women's wellbeing. In Ethiopia, however, the reasons for early discontinuation of LARCCs are not adequately explored. Against this backdrop, this study explores the main reasons for the early discontinuation of LARCs among Ethiopian women in selected public health facilities.

Methods

This study used an institution-based qualitative study design and covered selected university hospitals and health centers in Addis Ababa, Gondar, Mekelle, and Jimma. It involved in-depth interviews with 29 women aged 15-49 to gather data and explore the decision-making processes involved in the early discontinuation of LARCs. It used description, narration and thematic interpretation as data analysis procedures.

Results

Interviewees reported several reasons for early discontinuation of LARCs, including side effects (eg, weight gain/loss, heavy menses, tiredness, and reduced libido), desire to conceive, and husbands' disapproval. This study found that women were sufficiently aware of alternative contraceptives, including LARCs. Many reported experimenting before deciding on an option. Conversely, others' reports reveal the influences of gender roles and community misconceptions on women's decisions to discontinue LARCs.

Discussion and Implications

The common threads in interviewees' narratives highlight the significance of traditional values, gender roles, community perception, and experience with side effects to women's early discontinuation of LARCs. This study concludes with remarks on how to improve the effectiveness of family planning programming by adopting the gender transformative approach (GTA) in their design and implementation.

Discontinuation of long acting reversible contraceptive use and its determinants among women in Ethiopia: Systematic review and meta-analysis

Introduction

Contraception discontinuation is a major public health issue that leads to unwanted pregnancies and unsafe abortions. Therefore, this systematic review and meta-analysis aimed to estimate discontinuation of contraceptives and its determinants in Ethiopia.

Methods

PubMed, Google Scholar, Scopus, Science Direct, and Addis Ababa University online library were searched. Data were extracted using Microsoft Excel and analyzed using STATA statistical software (v. 14). Publication bias was checked by forest plot, Begg's rank test, and Egger's regression test. To look for heterogeneity, I² was computed, and an overall estimated analysis was carried out. Subgroup analysis was done by region, study setting, and publication. The pooled odds ratio for associated factors was also computed.

Results

Out of 654 studies assessed, 20 met our criteria and were included in the study. The total number of study participants was 8,780. The pooled prevalence of discontinuation of long acting reversible contraceptive use was 36.94% (95% CI: 28.547-45.326). According to sub-group analysis, Amhara region (45%) and institution-based studies (47.9%) had the highest prevalence. The most common reason for contraceptive discontinuation was negative side effect (42.3%).Women experienced side effects (AOR = 2.833:95% CI:2.005-4.003), didn't receive counseling on side effects (AOR = 2.417; 95% CI: 1.591-3.672), didn't appoint follow up (AOR = 2.820; 95% CI: 2.048-3.881), dissatisfied with the given service (AOR = 5.156; 95% CI: 3.644-7.296), and a desire to be pregnant (AOR = 2.366; 95% CI: 1.760-3.182) were predictors of discontinuation of contraceptives.

Conclusion

In Ethiopia, the pooled prevalence of long acting contraceptive discontinuation was high. Side effects, not being informed about side effects, dissatisfaction with the provided service, no insertion follow-up, and a desire to become pregnant were all associated factors. Healthcare professionals should focus on the client's reproductive goals, proper management of side effects, counseling, and post-insertion visits.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022347860, identifier CRD42022347860.

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

Background

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

Methods

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

Results

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

Conclusion

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

Determinants of early discontinuation of etonogestrel sub-dermal implant among reproductive-age women in Legambo district, Northeast Ethiopia: An unmatched case–control study

Objective:

Etonogestrel sub-dermal implant discontinuation is very common in the study area. But evidence on the determinants was limited. So, this study aimed to identify determinants of early discontinuation of etonogestrel sub-dermal implant among reproductive-age women in Legambo district, Northeast Ethiopia.

Methods:

An institution-based unmatched case–control study was conducted on 252 reproductive-age women (84 cases and 168 controls) from 1 February up to 30 April 2020. Systematic random sampling was used to select women, and the data were collected by face-to-face interview using a structured, pretested, and interviewer-administered questionnaire. The collected data were entered into Epi Data version 3.1 and analyzed by SPSS version 23. A binary logistic regression model was used to identify determinants of early discontinuation of etonogestrel sub-dermal implant. Statistical significance was declared at a p value of less than 0.05, and adjusted odds ratio with a 95% confidence interval was used to identify determinants of early discontinuation of etonogestrel sub-dermal implant in the final model.

Result:

In this study, not receiving pre-insertion counseling (adjusted odds ratio = 3.19, 95% confidence interval: (1.61, 6.30)), having a history of abortion (adjusted odds ratio = 2.89, 95% confidence interval: (1.50, 5.54)), contraceptive side effects (adjusted odds ratio = 2.45, 95% confidence interval: (1.99, 3.91)), and not receiving an appointment for a follow-up visit at the time of insertion (adjusted odds ratio = 3.45, 95% confidence interval: (1.89, 5.99)) were determinants of early discontinuation of etonogestrel sub-dermal implant.

Conclusion:

Not receiving pre-insertion counseling, having a history of abortion, contraceptive side effects, and not receiving an appointment for a follow-up visit at the time of insertion were predictors of early discontinuation of etonogestrel sub-dermal implant. Thus, healthcare professionals should give an appointment for a follow-up visit at the time of insertion and provide detailed counseling for all women, not only for those who had had an abortion and contraceptive side effects.

Incidence and predictors of first-year unplanned discontinuation of Implanon at Ayder comprehensive specialized hospital, northern Ethiopia: A retrospective follow-up study

Background

Discontinuing contraception without switching to a different type of family planning (FP) method contributes to unwanted pregnancy and unsafe abortion. Unplanned discontinuation of Implanon (which is discontinuation of Implanon without switching, but not for reasons of wanting to get pregnant) during the first year and its possible determinants have not been well investigated in Ethiopia. Therefore, this study aimed to determine the incidence and predictors of unplanned discontinuation of Implanon during the first year.

Methods

A retrospective follow-up study was conducted among 413 consecutive series of eligible women at Ayder Comprehensive Specialized Hospital in Northern Ethiopia. Data were drawn from both FP initiation and removal registration books and from contacting users by phone over a one-year period (April 2016 and March 2017). The inclusion of the categorical predictor in the final Cox model was considered if the test had a P-value of <0.25 in the log-rank test. We identified predictors of time to unplanned discontinuation using a multivariable Cox regression analysis. Adjusted hazard ratios with 95% confidence intervals (CI) were used to assess the association of covariates with the risk of discontinuation. There were no statistically significant interaction terms and proportionality assumption was fulfilled.

Results

The unplanned discontinuation rate of Implanon during the first year was 18.2%, with an incidence density of 16.3 discontinuations/1000 women-months. Compared with those under 20 years of age, women aged 20 to 24 years (AHR = 0.42; 95% CI: 0.19–0.91) had a protective effect against discontinuation. On the other hand, clients whose partner’s educational level was lower than secondary (AHR = 2.20; 95% CI: 1.08–4.49) and who had never used any modern contraception method before (AHR = 3.26; 95% CI: 1.61–6.61) had a higher risk of discontinuation.

Conclusions

Our findings have significant implications for understanding why Implanon is discontinued in an unplanned manner, and will help policy makers plan the interventions needed to improve Implanon continuity by overcoming identified barriers. Providers in similar settings should pay more attention to clients whose partners have lower educational status and who are new acceptors.

The prevalence of Implanon discontinuation and associated factors among Ethiopian women: A systematic review and meta-analysis

Background:

Implanon discontinuation before the recommended time is problematic, as it puts women at risk of unwanted pregnancies and unsafe abortions, along with negative maternal health outcomes. Although the magnitude and determinants of Implanon discontinuation have been studied in Ethiopia, the results were inconsistent, with significant variability. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of Implanon discontinuation and its determinants in Ethiopia.

Methods:

A comprehensive search of studies published before 18 February 2022 was done using electronic databases such as PubMed, Embase, Google Scholar, Scopus, Web of Science, Science Direct, and Cochrane Library. The relevant data were extracted using a Microsoft Excel 2013 and analyzed using STATA Version 16. A random-effect meta-analysis model was used to compute pooled prevalence and odds ratio. The Cochrane Q test statistics and I² tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s, and Egger’s tests were used to check for the presence of publication bias.

Results:

A total of 11 studies with 4320 study participants were included in this meta-analysis. The overall pooled prevalence of Implanon discontinuation in Ethiopia was found to be 32.62% (95% confidence interval = 24.10, 41.13). There was significant heterogeneity among the included studies (I² = 97.4%, p < 0.001). However, there was no statistical evidence of publication bias (p = 0.533). Dissatisfied with service provision at the time of insertion (odds ratio = 3.92, 95% confidence interval = 1.54, 6.29), not having pre-insertion counseling (odds ratio = 2.98, 95% confidence interval = 1.91, 5.04), the absence of post-insertion follow-up (odds ratio = 4.03, 95% confidence interval = 2.17, 5.90), and the presence of side effects (odds ratio = 2.93, 95% confidence interval = 1.87, 3.98) were found to be determinants of Implanon discontinuation.

Conclusion:

According to this systematic review and meta-analysis, one-third of Ethiopian women discontinued Implanon before the recommended time (3 years). Program managers and service providers should consider using more evidence-based and participatory counseling approaches to enhance client satisfaction. Furthermore, family planning service delivery points should be equipped to manage and reassure women who are experiencing side effects.

Subdermal Contraceptive Implant Insertion Trends and Retention in Adolescents

STUDY OBJECTIVE

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

RESULTS

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

CONCLUSION

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

Menstrual Pattern and Characteristics of One-Rod and Two-Rod Levonorgestrel Implant Users

Introduction

The maternal mortality ratio (MMR) in Indonesia reaches 359 per 100,000 live births. The long-acting reversible contraceptive (LARC) method is an effective contraceptive choice for reducing MMR. The contraceptive implant is one of the LARCs that has low usage due to lack of education about the side effects. This study aims to compare the menstrual pattern and characteristics between one-rod and two-rod levonorgestrel implant users.

Methods

A prospective cohort study was performed in patients at Cipto Mangunkusumo Hospital (RSCM) from March 2016 to May 2018. Subject recruitment was done by consecutive sampling. This study was conducted from March 2016 until May 2019. Statistical analysis was performed on the data using the chi-square test to determine the relationship between menstrual pattern and characteristics, and the use of one-rod or two-rod levonorgestrel implants.

Results

A total of 140 subjects participated in the study, comprising 70 (50%) one-rod users and 70 (50%) two-rod users. In the first month, 32.9% one-rod users experienced amenorrhea, 22.9% experienced shortened menstrual period, 30% experienced normal menstrual period, and 14,2 % experienced lengthened menstrual period. In comparison, in the first month, 41.4% two-rod users experienced amenorrhea, 15.7% experienced shortened menstrual period, 32.9% experienced normal menstrual period, and 10% experienced lengthened menstrual period. There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users.

Conclusion

There was no significant difference in menstrual patterns and characteristics between one-rod and two-rod levonorgestrel implant users. Implications. Menstrual patterns and characteristics from levonorgestrel implants user can help clinicians to reduce discontinuation rate from the acceptors. Further research should be conducted to know other side effects aside from menstrual bleeding patterns.

A systematic review on clinical effectiveness, side-effect profile and meta-analysis on continuation rate of etonogestrel contraceptive implant

BACKGROUND

Unintended pregnancies (UIP) have a significant impact on health of women and the health budget of countries. Contraception is an effective way to prevent UIPs. The study objective was to collate evidence on clinical effectiveness of etonogestrel subdermal implant (ESI), continuation rate and side effect profile among eligible women of reproductive age group, as compared to levonorgestrel intrauterine system (LNG-IUS), copper intrauterine device (Cu-IUD) and depot medroxy progesterone acetate injections; other types of contraceptive implants were excluded as comparators.

METHODS

The protocol of the systematic review was registered in Prospero (registration number: CRD42018116580). MEDLINE via PubMed, Cochrane library and web of science were the electronic databases searched. A search strategy was formulated and studies from 1998 to 2019 were included. Clinical trial registries and grey literature search was done. Critical assessment of included studies was done using appropriate tools. A qualitative synthesis of included studies was done and a meta-analysis was conducted in RevMan software for continuation rates of ESI as compared to other long acting reversible contraceptives (LARC) e.g. LNG IUS and Cu-IUD.

RESULTS

The search yielded 23,545 studies. After excluding 467 duplicates, 23,078 titles were screened and 51 studies were included for the review. Eight of the 15 studies reporting clinical effectiveness reported 100% effectiveness and overall pearl index ranged from 0 to 1.4. One-year continuation rates ranged from 57-97%; 44-95% at the end of second year and 25-78% by 3 years of use. Abnormal menstruation was the most commonly reported side effect. There was no significant difference in bone mineral density at 1 year follow-up. The meta-analyses showed that odds ratio (OR) of 1-year continuation rate was 1.55 (1.36, 1.76) for LNG-IUS vs. ESI and 1.34 (1.13, 1.58) for copper-IUD vs. ESI; showing that continuation rates at the end of one-year were higher in LNG-IUS and copper-IUD as compared to ESI.

CONCLUSION

ESI is clinically effective and safe contraceptive method to use, yet 1-year continuation rates are lower as compared to LNG-IUS and copper-IUD, mostly attributed to the disturbances in the menstruation.

Prevalence and factors associated with early discontinuation rate of Implanon utilization among women who ever used Implanon in Kucha District Gamo Gofa Zone, Southern Ethiopia

Background

The promotion of contraception in countries with high birth rates has the potential to reduce poverty, hunger, maternal, and childhood deaths. Every year in sub-Saharan Africa approximately 14 million unintended pregnancies occurred and a sizeable proportion was due to poor use of short-term hormonal methods. Contraceptive hormonal implants are highly effective and suitable for almost all women at any stage of their reproductive lives. On the other hand, early discontinuation of the Implanon contraceptive method utilization is one of the foremost problems amid the family planning program. Early discontinuation of the Implanon contraceptive method and reasons for such discontinuation lingers the most significant anxiety for family planning programs. In unindustrialized countries, contraceptive discontinuation due to health concerns is generally higher; these complaints are often related to service quality. Hence, this study aimed to assess the prevalence and factors associated with early discontinuation of Implanon among women who ever used Implanon in Kucha district, Gamo Gofa Zone, Southern Ethiopia.

Methods

Implanon contraceptive device users were selected from the Kucha district using a cross-sectional community-based survey from January to March 2018. A total of 430 women were selected and data were collected through face-to-face interviews by using a pre-tested structured questionnaire. Data were cleaned, coded, and entered into Epi-Info version 7statistical software. Factors that showed association in a bivariate analysis that has a p value of less than 0.25 were entered into multiple logistic regression models for controlling confounding factors. The strength of statistical association was measured by adjusted odds ratio, at 95% confidence intervals, and p value < 0.05 were considered as statistically significant variables.

Result

The result of this study revealed that the overall discontinuation rate of Implanon in the study was 34%. Variables having statistically significant association with Implanon discontinuation were women who never use a contraceptive method other than Implanon (AOR = 2.96, 95% CI 1.53–5.74), women who didn’t make discussion with a partner (AOR = 3.32, 95% CI 1.57–7.04), poor counseling and follow up (AOR = 9.23, 95% CI 4.7–18.13), fear of side effects (AOR = 0.12, 95% CI 0.058- 0.24) and poor satisfaction of service (AOR = 5.2, 95% CI 2.77- 9.76)

Conclusion

The overall early discontinuation rate of Implanon in the study area was high. The main factors associated with early discontinuation of Implanon were contraceptive ever use, discussion with partner, poor follow-up of counseling, fear of side effects, and un-satisfaction by the services given during the insertion rate of Implanon.

Discontinuation of implants use and associated factors among women attending health facility clinics in Hawassa City, Southern Ethiopia, 2019; cross sectional study

Background

Despite improving the availability and use of Implants, discontinuation is becoming a public health concern. A significant proportion of women discontinuing the service before its due date, which is of concern in the health system and its consequence may lead to a program failure. This might have also social and economic consequences for users. Only 8% of married women in Ethiopia use implants. Apart from its low utilization, premature removal is common for unknown reasons. However, there is paucity of information on discontinuation of implants use and associated factors in the study area.

Objective

The study was aimed to assess discontinuation of implants use and associated factors among women attending health facility clinics in Hawassa city, southern Ethiopia, from March, 01-April, 01/2019.

Methods

Facility based cross sectional study design was used. Out of 16 health facilities, 9 of them were selected for this study using simple random sampling. Total sample size of this study was determined to be 351. Data were collected from study subjects using pretested, structured questionnaire through a face-to-face interview. Data was analyzed using descriptive statistics and logistic regression. The result is presented using the Crude Odds ratio as well as Adjusted Odds Ratio with the corresponding 95% confidence level.

Result

Out of 351 study participants, the overall proportion of implants discontinuation was 49.3%(95% CI: 44.2–55.0). Lack of counseling about side effects (AOR = 2.394; 95% CI: 1.422–4.030), developing side effects (AOR = 6.325; 95% CI: 3.719–10.757) and lack of post insertion follow-up (AOR = 2.241; 95% CI: 1.186–4.234) the major factors associated with discontinuation of Implants.

Conclusion and recommendation

In this study, the overall proportion of discontinuation of Implants among women who were using Implants was high. Health professionals could give pre-insertion counseling about side effects and post insertion dates for follow-up to improve of utilization of implants.

Discontinuation of Reversible Long-Acting Contraceptive and Associated Factors among Female Users in Health Facilities of Hawassa City, Southern Ethiopia: Cross-Sectional Study

Background

Despite improvement in the availability and use of reversible long-acting contraception, discontinuation is becoming a public health concern. A significant proportion of women discontinuing the service before its due date, which is of concern in the health system with regard to its consequences, may lead to a program failure. In addition, there is a paucity of information on discontinuation of reversible long-acting contraceptives and associated factors in the study area. Therefore, this study aimed to assess discontinuation of reversible long-acting contraceptives and associated factors among female users in health facilities of Hawassa city, southern Ethiopia, 2019.

Methods

Institution-based cross-sectional design was used. Systematic sampling was used to select study participants. Women who were users of long-acting contraceptives and had come to selected health facilities for method-related reasons were included in the study. Data collectors approached and recruited participants before they contacted their care providers. Data were collected from study subjects using a pretested, structured questionnaire through face-to-face interviews after participants had contacted care providers. Results are presented using the crude and adjusted ORs with corresponding 95% CIs.

Results

The overall proportion of reversible long-acting contraceptive discontinuation was 56.6% (95% CI 52.30%, 61.10%). Maternal education at primary level (AOR 2.33, 95% CI 1.15–4.74), lack of counseling (AOR 2.50, 95% CI 1.01–6.18), side effects (AOR 2.10, 95% CI 1.31–3.34), and desire to be pregnant (AOR 2.22; 95CI 1.50–3.30) were the major factors in discontinuation.

Conclusion

In this study, the overall proportion of discontinuation of reversible long-acting contraceptives was high. Maternal education at primary level, lack of counseling, side effects, and desire to be pregnant were the key factors associated with discontinuation of the contraceptives. Health professionals should provide counseling on the side effects before insertion.

H, P. A, K. P. K, J. B. Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC

Background

Kinshasa is Africa's third largest city and one of the continent’s most rapidly growing urban areas. PMA2020 data showed that Kinshasa has a modern contraceptive prevalence of 26.5% among married women in 2018. In Kinshasa’s method mix, the contraceptive implant recently became the dominant method among contraceptive users married and in union. This study provides insight into patterns of implant use in a high-fertility setting by evaluating the 24-month continuation rate for Implanon NXT and identifying the characteristics associated with discontinuation.

Methodology

This community-based, prospective cohort study followed 531 Implanon users aged 18–49 years at 6, 12 and 24 months. The following information was collected: socio-demographic characteristics, Method Information Index (MII) and contraceptive history. The main outcome variable for this study was implant discontinuation. The incidence rate of discontinuation is presented as events per 1000 person/months (p-m), from the date of enrolment. The Cox proportional hazards modelling was used to measure predictors of discontinuation.

Results

A total of 9158.13 p-m were available for analysis, with an overall incidence rate of 9.06 (95% CI: 9.04–9.08) removals per 1000 p-m. Of nine possible co-variates tested, the likelihood of discontinuation was higher among women who lived in military camps, had less than three children, never used injectables or implants in the past, had experienced heavy/prolonged bleeding, and whose MII score was less than 3.

Conclusion

In addition to four client characteristics that predicted discontinuation, we identified one programmatic factor: quality of counseling as measured by the Method Information Index. Community providers in similar contexts should pay more attention to clients having less than three children, new adopters, and to clients living military camps as underserved population, where clients have less access to health facilities. More targeted counselling and follow-up is needed, especially on bleeding patterns.

Prevalence of early discontinuation and associated factors among a retrospective cohort of etonogestrel contraceptive implant users

Purpose: To characterise the frequency of and predictors of contraceptive implant discontinuation within 12 months of insertion in our clinical setting.Materials and methods: This retrospective cohort study included women receiving the etonogestrel contraceptive implant at our hospital between May 2007 and May 2012. We abstracted data from charts including implant removal date, bleeding complaints, reproductive and demographic characteristics, prior contraceptive use, tobacco use and implant insertion timing. Our primary outcome was implant discontinuation within 12 months following insertion. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used to generate frequencies, bivariate analyses and multivariate logistic regression models.Results: Implant discontinuation was documented in 16% of implant users prior to 12 months (89/544). Women with documented bleeding complaints in the medical record were more likely to discontinue within 12 months (OR: 4.36, CI: 2.71, 7.00). No other demographic or clinical characteristics were associated with premature discontinuation. Having less than two prior pregnancies and tobacco use were associated with documented bleeding complaints.Conclusions: Discontinuation of the implant is associated with bleeding complaints. Women with lower parity and tobacco users may be more likely to experience bleeding or to find it intolerable.

Discontinuation rate of Implanon and its associated factors among women who ever used Implanon in Dale District, Southern Ethiopia

BACKGROUND

Early discontinuation of the Implanon contraceptive method and reasons for such discontinuation remains a major concern for family planning programs. In less developed countries, contraceptive discontinuation due to health concerns is generally higher, these complaints are often related to service quality. Significant numbers of women become exposed to conception after discontinuation and accidental pregnancies that end up with abortion & stillbirth. The aim of this study was to assess the early discontinuation rate of Implanon and identify its associated factors among women who ever used Implanon in 2016 in Dale district, Southern Ethiopia.

METHODS

Community based cross-sectional study design was conducted from January to February, 2017. A total number of 711 women who ever used Implanon in 2016 were selected using multistage sampling. The data were entered and cleaned in Epi Info and analyzed using SPSS. Multivariate logistic regression analysis was used to determine the effect of factors on the outcome variables. Finally, the results were presented using adjusted odds ratio (AOR) & confidence interval of 95%.

RESULT

Early Implanon discontinuation rate in this study was 160 (23.4%) with a mean duration of Implanon use of 9.6 ± 2.5 months. The main reasons for discontinuation of Implanon were 55 (34.4%) the facing of side effects. Factors for discontinuation of Implanon were women age 20-24 years (AOR =. 44 (95% CI: 23-. 85), 25-29 years (AOR =. 52 (95% CI: 27-. 96), 35+ years, (AOR =. 08 (95% CI: 02-. 41), less likely to discontinue. Women who weren't counseled about the side effects during Implanon insertion were 1.93 times (AOR = 1.93 (95% CI: 1.27-2.93), women who didn't satisfied by the service (AOR = 2.55(CI: 95%: 1.63-3.97), women who didn't appointed for follow up (AOR = 3.13 (CI: 95%: 2.0-4.95), women who didn't choose the method by themselves (AOR = 1.83 (CI: 95%: 1.18-2.83) and women who didn't have information on family planning before Implanon insertion (AOR = 1.52 (CI: 95%: 1.1-2.28) were the predictors of Implanon discontinuation.

CONCLUSIONS

Implanon discontinuation rate in this study area was high. Appropriate counseling prior to insertion and proper follow up, autonomous choice will improve the continuation rate of Implanon.

Factors associated with first-year discontinuation of Implanon in Upper Egypt: clients' and providers' perspectives

BACKGROUND

The etonogestrel implant Implanon is a favourable and cost-effective contraceptive method for women in developing countries, and expansion of its use represents a priority for the family planning (FP) programme in Egypt. We studied the factors affecting first-year Implanon discontinuation from clients' and providers' perspectives.

METHODS

We used a mixed quantitative-qualitative methodology. We conducted a household survey of Implanon clients and three focus group discussions with FP physicians and directors.

RESULTS

We found that 13.5% of Implanon users discontinued its use in the first year. Survival analysis found that clients who had previously used Implanon (HR 0.36, 95% CI 0.15 to 0.88) and whose husbands had secondary or a higher level of education (HR 0.36,95% CI 0.19 to 0.69) were less likely to discontinue Implanon use after the first year, while clients who experienced side effects of Implanon use were more likely to discontinue it (HR 3.6,95% CI 1.60 to 8.11). Other causes of discontinuation which emerged in the qualitative analysis were the unjustified advice for Implanon removal by non-gynaecologists, due to unrelated users' complaints, and deficient pre-insertion counselling.

CONCLUSIONS

Implanon has a low first-year discontinuation rate as compared with other contraceptive methods. FP clients should be given sufficient pre-insertion counselling about side effects of Implanon and duration of protection. Physicians should offer Implanon mainly to clients seeking long-term contraception in order to decrease its discontinuation rate and increase its cost effectiveness.

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.

Early Implanon Discontinuation and Associated Factors among Implanon User Women in Debre Tabor Town, Public Health Facilities, Northwest Ethiopia, 2016

Background

Implanon discontinuation closely related to higher rates of overall fertility rate, unwanted pregnancies, and induced abortion. This might have social and economic consequences. In Ethiopia the magnitude of early Implanon discontinuation and contributing factors is not well studied.

Objective

To assess early Implanon discontinuation and associated factors among Implanon user women in Debre Tabor town, 2016.

Methods

A facility based cross-sectional study was conducted from May 1 to August 2016 through face-to-face interview. A total of 449 Implanon user women were selected by systematic random sampling technique. Epi Info version 7 and SPSS version 20 were used for data entry and analysis, respectively. Factors associated with early Implanon discontinuation were analyzed using binary and multivariable logistic regression model. Variables with p value of <0.05 and 95% confidence interval were considered as statistically significant.

Results

The overall proportion of early Implanon discontinuation among mothers was 65 % (95%, CI: 60.4%–69.5%). Having no children (AOR = 2.0, 95% CI = [1.3–4.5]), being not counseled for possible side effects (AOR = 1.50, 95% CI = [1.1–3.4]), having no appointment for follow-up (AOR = 2.6, 95% CI = [1.2–4.3]), and having developing side effects (AOR = 1.7, 95% CI = [1.5–4.4]) were found to be statistically significant factors associated with early Implanon discontinuation.

Conclusion and Recommendation

Early Implanon discontinuation among mothers was found to be high. Hence, counseling about Implanon side effects and appointment for follow-up of Implanon users should be made to increase Implanon retention.

Determinant of Implanon Discontinuation among Women Who Ever Used Implanon in Diguna Fango District, Wolayita Zone, Southern Ethiopia: A Community Based Case Control Study

Background

A significant number of women make Implanon their first choice of contraception. However, they discontinue their Implanon before its expiry date was high, but factors that contribute to discontinuing their Implanon were poorly described in Ethiopia.

Methods

A community based unmatched case control study was conducted. Then simple random sampling technique was used to select 340 women. Data was collected by nurses using face to face interview. Epi-Info version 7 and SPSS 20 software were used. Bivariate and multiple logistic regressions were performed with COR and AOR with 95% CI.

Findings

Having preinsertion counseling (AOR: 0.36, 95% CI: 0.20–0.64), having follow-up appointment (AOR: 0.35, 95% CI: 0.2–0.62), age at insertion <20 years (AOR: 3, 95% CI: 1.16–7.8), women who had no formal education (AOR: 2.8, 95% CI: 1.31–6.11), women who had ≤4 children (AOR: 1.8, 95% CI: 1.01–3.21), and women who had previous abortion history (AOR: 2.3, 95% CI: 1.10–4.63) were determinants of Implanon discontinuation.

Conclusions

Policy makers and concerned bodies should take into account future intervention and also great emphasis should be given to follow-up appointment and counseling services, especially counseling on side effects, and informed choice for clients after Implanon insertion.

Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea

BACKGROUND

Poor access to contraception contributes to persistently high maternal mortality rates in Papua New Guinea (PNG). Since 2012 contraceptive implants have been provided to women in rural areas of PNG through outreach services but follow-up data in these communities on continuation and acceptability is lacking.

OBJECTIVE

To gain insight into women's experience with contraceptive implants by assessing the acceptability, satisfaction, 12 month continuation rates and efficacy of contraceptive implants among women in rural PNG.

MATERIAL AND METHODS

We undertook a cross-sectional survey of women in two rural provinces who had received a contraceptive implant at least 12 months prior using a structured questionnaire. We sought information on device continuation rates, satisfaction scores, side effects and failure rates.

RESULTS

Of the 860 women surveyed, 97% (n = 836) still had the device in situ after 12 months and 92% (n = 793) were very happy with it. Seventy-six percent of women (n = 654) reported no side effects. Irregular bleeding was the most commonly reported side effect (n = 178, 20.6%) but only 7% (n = 13) said the bleeding was bothersome. Documented failure rates were 0.8% although pregnancy at the time of insertion could not be excluded in any of these cases.

CONCLUSION

Twelve month implant follow-up data in this study showed high continuation rates and high levels of satisfaction among a rural population in PNG. Implants have the potential to lower maternal morbidity and mortality and simultaneously address the unmet need for contraception in these communities.

Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study

OBJECTIVE

To assess the use, effectiveness and acceptance of prescribed contraception in three remote Western Australian Aboriginal communities.

PARTICIPANTS AND DESIGN

Mixed method study, including retrospective file review of contraception methods for 566 regular female Aboriginal patients, 1 November 2010 - 1 September 2014, and semi-structured interviews with 20 Aboriginal women.

SETTING

Primary care clinics in three remote Aboriginal communities.

MAIN OUTCOME MEASURES

Number of episodes of contraceptive use, effectiveness and continuation rates of prescribed contraceptive use; personal experiences, attitudes towards and beliefs about contraception options.

RESULTS

34% of women had used contraception, ranging from 15% of women aged younger than 15 years to 55% of women aged 15-19 years. The most common forms of contraception at the census date were long-acting reversible contraceptives (LARCs): 77% of women using contraception had an etonogestrel implant and 7% had depot medroxyprogesterone. Etonogestrel continuation rates at 1, 2 and 3 years were 87% (95% CI, 81-92%), 72% (95% CI, 64-78%) and 51% (95% CI, 41-60%) respectively. Medroxyprogesterone depot continuation at one year was only 14% (95% CI, 8-22%). Social acceptance of the etonogestrel implant was high; no concerns were raised about stigma or unwanted attention related to implant use.

CONCLUSION

The high uptake of LARCs in these communities is consistent with international recommendations about contraception use. High acceptability was reflected in excellent continuation rates. Service delivery models that use community engagement and capacity building are recommended for broadening the focus of sexual health beyond sexually transmitted disease detection and management, giving priority to the reproductive rights and unmet needs of Aboriginal women.

Incidence of Discontinuation of Long-Acting Reversible Contraception among Adolescent and Young Adult Women Served by an Urban Primary Care Clinic

STUDY OBJECTIVE

To estimate long-acting reversible contraception (LARC) discontinuation rates. Secondary aims were to determine risk factors for discontinuation, describe reasons for discontinuation, evaluate complications related to placement, and estimate pregnancy rates after discontinuation.

DESIGN

We conducted a retrospective cohort study of LARC method use through review of electronic medical record data.

SETTING

Our program is housed in an academic primary care pediatric and adolescent clinic in Baltimore, Maryland.

PARTICIPANTS

One hundred sixty women ages 12-24 years who received an intrauterine device or subdermal implant through our program between December 10, 2012 and December 10, 2015.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Complications from LARC insertion, device discontinuation, reason(s) for discontinuation, pregnancies resulting from device failure, and occurrence of pregnancy within 1 year of discontinuation.

RESULTS

Thirty-five women discontinued their LARC method. The 6-month discontinuation rate was 11.3% and the 12-month rate was 21.9%. Discontinuation was associated with history of sexually transmitted infection (adjusted hazard ratio, 3.21; 95% confidence interval, 1.49-6.90). The most common reason for discontinuation was bleeding for the implant and expulsion for the intrauterine device.

CONCLUSION

Our results support the safety and low discontinuation rates of LARC provision to adolescents and young adult women in a primary care setting. Discontinuation rates and reasons are consistent with those described in other studies.

Beyond the Surface

Purpose: To describe rates of and reasons for follow-up among adolescents and adults receiving contraceptive implants in a Federally Qualified Health Center (FQHC). Methods: Retrospective comparison of patient-initiated implant-related contacts during the 6 months postinsertion among adolescents (110) and adults (154) who had implants placed at a FQHC network. Results: Forty percent of adolescents and 26% of adults initiated follow-up ( P = .016). Bleeding changes and discussing removal were the most common reasons for follow-up for both groups. Adolescents (5.5%) and adults (9.0%) had similar removal rates ( P = .348). However, among patients who discussed implant removal, adults were more likely to have removals compared with adolescents ( P = .002). Conclusions: Other FQHCs may anticipate a similar experience to ours, where adolescents may be more likely than adults to initiate implant-related follow up, with removal rates of less than 10% at 6 months. Further study of physician decision making and patient autonomy regarding implantable contraception removal requests is warranted.

Twelve-month discontinuation of etonogestrel implant in an outpatient pediatric setting

OBJECTIVE

The etonogestrel (ENG) contraceptive implant is the most effective reversible contraceptive method. Uptake remains limited in adolescents, a population at high risk for unintended pregnancy. The objectives of this study were to determine the 12-month discontinuation rate of the ENG implant among adolescents in an outpatient setting and to characterize risk factors for discontinuation.

STUDY DESIGN

A retrospective chart review identified adolescent females aged 12 to 22years who received the ENG implant in one pediatric institution between January 1, 2011, and April 15, 2014. Patients were categorized into ENG discontinuers (removed prior to 12months) and ENG continuers (continued for ≥12months). Associations between demographic, clinical and postplacement characteristics with ENG discontinuation category were assessed with t tests, χ(2)/Fisher's Exact Tests and backwards stepwise logistic regression.

RESULTS

Of the 750 patients who had an ENG implant inserted, 77 (10.3%) had the device removed prior to 12months of use. The mean length of implant use for those who discontinued was 7.5months. Problematic bleeding was the most commonly cited reason for discontinuation. Older age at time of insertion, history of pregnancy and ≥1 medical visit for implant concerns (not including removal) were independently predictive (p<.01) of method discontinuation.

CONCLUSION

The vast majority of adolescents continued the ENG implant at 12months, making it an excellent contraceptive choice for adolescents within the outpatient pediatric setting. Greater efforts should be made to increase its use by pediatric providers.

IMPLICATIONS

The ENG implant is an excellent contraceptive option for adolescents in the outpatient pediatric setting.

Young Age, Nulliparity, and Continuation of Long-Acting Reversible Contraceptive Methods

OBJECTIVE

To assess the relationship among young age, nulliparity, and continuation of long-acting reversible contraceptive (LARC) methods.

METHODS

We performed a secondary analysis of the Contraceptive CHOICE Project database, an observational cohort study of 9,256 sexually active reproductive-aged females. This analysis focused on continuation of the intrauterine device and implant in nulliparous adolescent participants compared with parous, older women. We analyzed our data by age-parity groups and individual characteristics and used multivariable analysis to assess the association of age and parity on continuation.

RESULTS

There were 6,106 participants in our analytic set, including 863 aged 14-19 years. Long-acting reversible contraceptive continuation rates at 12 months were high and similar between all age-parity groups ranging from 82-86%. In the Cox proportional hazards model, nulliparous participants using the copper intrauterine device and implant were more likely to discontinue their LARC method (copper intrauterine device: adjusted hazard ratio [HR] 1.76, 95% CI 1.13-2.73, implant: adjusted HR 1.89, 95% CI 1.35-2.64) than parous participants. This effect was not observed among levonorgestrel intrauterine system users (adjusted HR 1.16, 95% CI 0.92-1.46). Age younger than 20 years was not associated with discontinuation at 12 months (adjusted HR 0.95, 95% CI 0.74-1.22).

CONCLUSION

We found that LARC continuation rates were high and similar across age and parity. Clinicians should not hesitate to recommend LARC methods to young nulliparous females owing to fear of early discontinuation.

LEVEL OF EVIDENCE

II.

Sociodemographic profiles and use-dynamics of Jadelle (levonorgestrel) implants in Jos, Nigeria

Background:

Contraceptive implants (including Jadelle) are highly effective, safe, and easy to use and have a long duration of action. They do not interfere with intercourse with immediate return to fertility after removal. However, disruption of the menstrual bleeding pattern is almost inevitable and coercive prescription may be a problem because insertion and removal of implants are provider dependent. The objective of this study was to determine the sociodemographic profiles of acceptors of Jadelle and the reasons for discontinuation in Jos, Nigeria.

Materials and Methods:

This was a 6-year retrospective chart review carried out at the Jos University Teaching Hospital.

Results:

About 1401 women accepted Jadelle with a mean (±standard deviation) of 33.4 ± 5.9 years. About 88% of the women were Christians and almost three-quarters (73.5%) had at least secondary school education. The means of parity and number of children still alive at the time of accepting Jadelle were 4.1 and 3.8, respectively. Half of the women (49.5%) were breastfeeding and over half (55.9%) had future fertility desires at the time of commencing Jadelle. About 82% had previously used other contraceptives (mostly short-acting methods such as injectables, pills, and condoms), with only 18% starting Jadelle as the first-ever contraceptive method. About 90% of the women had regular menstrual cycles. The major reason for discontinuation of Jadelle was desire for pregnancy although menstrual pattern disruption was the most common reason for removal in the first 6 months of use.

Conclusion:

The main reason for discontinuation of Jadelle was to have more children although menstrual pattern disruptions accounted for earlier discontinuation.

Long-acting reversible contraception: Findings from the Understanding Fertility Management in Contemporary Australia survey

OBJECTIVES

The aim of this research was to investigate awareness, perceived reliability and consideration of use of long-acting reversible contraception (LARC) among Australians of reproductive age.

METHODS

A sample of 18- to 50-year-old women and men (N = 2235) was randomly recruited from the Australian electoral roll in 2013. Respondents completed a self-administered, anonymous questionnaire. Data were weighted to reduce non-response bias. Factors associated with perceived reliability and consideration of use of LARC were identified in multivariable analyses.

RESULTS

Most respondents had heard of implants (76.5%) and intrauterine contraception (63.7%). However, most did not think implants (56.3%) or IUDs (63.9%) were reliable and would not consider using implants (71.6%) or IUDs (77.5%). Those significantly more likely to perceive LARC as reliable were younger, did not regard religion as important in fertility choices, had private health insurance, had been pregnant and had had an abortion; and women who had a partner. Those more likely to consider using LARC were younger and did not regard religion as important in fertility choices; women who had private health insurance, lived in an area of socioeconomic advantage and had had an abortion; and men without a partner, born in Australia and comfortable talking to a health care provider about contraceptive matters.

CONCLUSIONS

Despite high awareness of LARC among Australian adults, its perceived reliability and willingness to use it remain low in certain groups. Targeted interventions that aim to increase knowledge of the benefits and reliability of LARC and allow informed use are recommended.

Does research into contraceptive method discontinuation address women's own reasons? A critical review

OBJECTIVE

To examine the clinical and epidemiological literature addressing contraceptive method change or discontinuation and to assess whether the documented reasons reflected women's experiences.

METHODS

Major databases including Medline and PsycINFO were searched using keywords related to contraception and discontinuation, adherence and satisfaction, for articles published between January 2003 and February 2013. Studies in developed countries that focused on women of reproductive age and reasons for method change or discontinuation were included. Reasons reported were categorised and examined.

RESULTS

A total of 123 papers were reviewed in detail. Medical terminology was generally used to describe reasons for method discontinuation. The top two reported reasons were bleeding and pregnancy, but there was a lack of consensus about the categorisation of reasons. Broad categories that were not self-explanatory were included in more than half of the papers, often without further explanation. Only 12 studies expanded on categories containing 'other', 'non-medical' or 'personal' reasons. Eight papers included categories that attributed discontinuation to the participant, such as 'dissatisfied with method'.

CONCLUSIONS

Studies of reasons for discontinuation of contraceptives do not well describe women's specific reasons. Studies rely heavily on medical terms and often fail to document women's subjective experiences. Future studies should create an opportunity for women to articulate their non-medical reasons in their own words, including those related to their sexual lives. Furthermore, researchers should distinguish, if possible, between reasons for discontinuation of a method and reasons for ceasing participation in a research study.

Contraception for adolescents

Contraception is a pillar in reducing adolescent pregnancy rates. The American Academy of Pediatrics recommends that pediatricians develop a working knowledge of contraception to help adolescents reduce risks of and negative health consequences related to unintended pregnancy. Over the past 10 years, a number of new contraceptive methods have become available to adolescents, newer guidance has been issued on existing contraceptive methods, and the evidence base for contraception for special populations (adolescents who have disabilities, are obese, are recipients of solid organ transplants, or are HIV infected) has expanded. The Academy has addressed contraception since 1980, and this policy statement updates the 2007 statement on contraception and adolescents. It provides the pediatrician with a description and rationale for best practices in counseling and prescribing contraception for adolescents. It is supported by an accompanying technical report.

Contraception for adolescents

A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.

The effect of immediate postpartum compared to delayed postpartum and interval etonogestrel contraceptive implant insertion on removal rates for bleeding

OBJECTIVE

To determine whether the discontinuation rate of the etonogestrel contraceptive implant due to irregular vaginal bleeding among women with immediate postpartum insertion is increased compared to delayed postpartum and interval placement.

STUDY DESIGN

This retrospective cohort study compared women who underwent immediate postpartum etonogestrel contraceptive implant insertion (within 96 h of delivery) to delayed postpartum (6 to 12 weeks postpartum) and interval insertion between January 2008 and December 2010. Charts were reviewed for date and reason for removal. A chi-squared test was used to compare discontinuation due to bleeding between cohorts. Baseline characteristics predictive of implant removal were evaluated by simple logistic regression.

RESULTS

There were 259 women in the immediate postpartum group, 49 in the delayed postpartum group and 106 in the interval group. Average age at insertion was 22.6 (±5.5) years. Overall, 19.3% of women in the immediate postpartum group requested removal due to irregular bleeding compared to 18.4% in the delayed postpartum group [odds ratio (OR) 1.06, 95% confidence interval (CI) 0.48-2.33] and 20.8% in the interval group (OR 0.91, 95% CI 0.52-1.60). There was no difference between groups in premature removal rates for any side effect. There were no sociodemographic or clinical characteristics predictive of removal in any group.

CONCLUSION

One-fifth of etonogestrel contraceptive implant users requested premature removal due to irregular bleeding. Immediate postpartum implant insertion does not lead to increased removal rates and may help reduce unintended pregnancy. Mechanisms to help women manage irregular bleeding due to the implant are needed.

IMPLICATIONS

Immediate postpartum insertion of the etonogestrel contraceptive implant does not lead to increased removal rates due to vaginal bleeding compared to delayed postpartum or interval insertion. Immediate postpartum implant insertion may increase uptake of long-acting reversible contraception and help reduce short interpregnancy intervals and unintended pregnancy.

Twenty-four-month continuation of reversible contraception

OBJECTIVE

To estimate 24-month continuation rates of all reversible contraceptive methods for women enrolled in the Contraceptive CHOICE Project.

METHODS

We analyzed 24-month data from the 9,256 participants enrolled in the Contraceptive CHOICE Project, a prospective observational cohort study that provides no-cost contraception to women in the St. Louis region. The project promoted the use of long-acting reversible contraception (LARC) (intrauterine devices [IUDs] and implants) in an effort to reduce the rates of unintended pregnancy. This analysis includes participants who received their baseline contraceptive method within 3 months of enrollment and who completed a 24-month follow-up survey (N=6,153).

RESULTS

Twenty-four month continuation rates for long-acting reversible contraception and non-LARC methods were 77% and 41%, respectively. Continuation rates for the levonorgestrel and the copper IUDs were similar (79% compared with 77%), whereas the implant continuation rate was significantly lower (69%, P<.001) compared with IUDs at 24 months. There was no statistically significant difference in 24-month continuation rates among the four non-LARC methods (oral contraceptive pill [OCP] 43%, patch 40%, ring 41%, depot medroxyprogesterone acetate [DMPA] 38%; P=.72). Participants who chose a LARC method at enrollment were at significantly lower risk of contraceptive method discontinuation (adjusted hazard ratio 0.29, 95% confidence interval 0.26-0.32) compared with women who selected a non-LARC method.

CONCLUSION

Intrauterine devices and the implant have the highest rates of continuation at 24 months. Given their effectiveness and high continuation rates, IUDs and implants should be first-line contraceptive options and shorter-acting methods such as OCPs, patch, ring, and DMPA should be second tier.

LEVEL OF EVIDENCE

II.

Continuation rates of the subdermal contraceptive Implanon(®) and associated influencing factors

OBJECTIVES To investigate the continuation rates of the etonogestrel subdermal contraceptive implant among well-informed women, and the reasons for early discontinuation. STUDY DESIGN Retrospective consecutive cohort design. METHODS Women who had the implant inserted between 1 January 2006 and 1 January 2010 at the Atrium Medical Centre, the Netherlands were followed up for at least three years. The dates of insertion and removal were recorded, as were the reasons for removal. Statistical analysis was performed using the independent samples t-test and the Pearson alpha correlation test. RESULTS The implant was inserted in 230 women. Follow-up was possible in 214 women, with an average age of 26.7 years. Most of them were nulliparous and the majority had used a combined oral contraceptive, Implanon®, or Mirena® previously. The mean overall continuation period was 23.5 months (95% confidence interval: 21.7-25.3), with a median of 25 months. The continuation rate after 12 months was 72%; after 24 months, 53%; and after 36 months, 25%, with all women concerned having a new implant placed. The previously used contraceptive method Implanon® was associated with the highest continuation rates. An erratic bleeding pattern was the main reason for early removal. CONCLUSIONS Despite adequate counselling before insertion, the continuation rate of the etonogestrel implant was rather low compared to those reported by other investigators. The main reason for discontinuation was an irregular bleeding pattern.

Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use

OBJECTIVE

To measure discontinuation within 6 months among users of the levonorgestrel intrauterine system, copper intrauterine device (IUD), and etonogestrel implant and identify baseline characteristics associated with early discontinuation.

METHODS

This was an analysis of the Contraceptive CHOICE Project, a cohort study of 9,256 participants provided with no-cost contraception and followed with telephone interviews at 3 and 6 months. We used logistic regression to investigate characteristics associated with early discontinuation of the two IUDs and implant and described reasons for discontinuation.

RESULTS

A total of 6,167 participants were eligible for this analysis. Follow-up data were available for 5,928 participants; 5,495 (93%) were using their method at 6 months and 433 (7%) had discontinued. Discontinuation rates were 7.3%, 8.0%, and 6.9% for the levonorgestrel intrauterine system, copper IUD, and implant, respectively. After adjusting for age, race, marital status, low socioeconomic status, and history of sexually transmitted infection, we found that unmarried women were slightly more likely to discontinue compared with married women (adjusted odds ratio [OR] 1.26, 95% confidence interval [CI] 1.01-1.59 and adjusted OR 1.62, 95% CI 1.11-2.37, respectively). No other baseline characteristics, including younger age (14-19 years), were associated with early discontinuation. The most common reason given for discontinuation was cramping among IUD users and irregular or frequent bleeding among implant users.

CONCLUSION

Rates of discontinuation of long-acting reversible contraception at 6 months is low and not increased in adolescents and young women. Intrauterine devices and the implant should be considered as first-line contraceptive options among all women to reduce unintended pregnancy.

LEVEL OF EVIDENCE

: II.

A three-year comparative study of continuation rates, bleeding patterns and satisfaction in Australian women using a subdermal contraceptive implant or progestogen releasing-intrauterine system

BACKGROUND Long-acting reversible contraceptive methods (LARCs) are safe, highly effective, readily reversible, and require no action on the part of the user following insertion. Early discontinuation may put women at increased risk of unintended pregnancy. METHODS Following insertion of a progestogen-only subdermal implant or intrauterine system (IUS) at Family Planning NSW, women 18 years and older completed a questionnaire about their choice. At 6 weeks, 6, 12, 24 and 36 months by telephone or online they completed a questionnaire about bleeding patterns, side effects, satisfaction, and reasons for discontinuation. RESULTS Two hundred IUS users and 149 implant users were enrolled. The former were generally older, married or in a de-facto relationship, and had children. Forty-seven percent of implant users discontinued within three years compared to 27% of IUS users (p = 0.002). In the first two years amenorrhoea was more frequent in implant users. Frequent bleeding/spotting was more prevalent in the first year of IUS use but over time was twice as prevalent in implant users. Infrequent bleeding/spotting was more common in IUS users. CONCLUSION Both devices are highly effective and acceptable cost-effective methods. While LARCs should be promoted to women of all ages seeking contraception, early discontinuation due to unacceptable bleeding highlights the need for pre-insertion counselling.

Usefulness of progesterone-only components for contraception in patients with congenital heart disease

The objective of the study is to report the contraceptive methods used by patients with congenital heart disease (CHD) before referral to a specific preconception clinic and evaluate safety and treatment adherence of the alternative contraception method, progesterone-only component (PC), offered. Contraceptive methods in the CHD population reported included estrogen-progesterone combined contraceptives (EPCC), despite the potential risk for thromboembolism. PC has been suggested as an alternative, but, no information on its use has been reported. Retrospective analysis was performed of all patients (n = 237) referred to the preconception clinic of an adult CHD center. Thirty-three percent of patients had used EPCC in the past; 3.8% had had thromboembolic events during its use. Current contraception consisted of barrier methods in 58% of patients, EPCC in 18%, and PC in 1.3%; 21.7% of patients were not using any contraception. PC was offered as an alternative in 146 patients; 73% of patients agreed to start the treatment. At a median follow-up of 1 year, 73% of patients who started PC maintained the treatment. Gynecologic side effects were reported in 25% of patients, with no cardiovascular effects. In conclusion, a significant proportion of patients with CHD were former users of EPCC, although some had formal contraindications, and the rate of PC use before referral to the preconception clinic was low. After being offered as an alternative treatment, the use of PC in its various forms was extensive, with no thrombogenic side effects and an acceptable rate of gynecologic side effects being reported.

Impact of long-acting reversible contraception on return for repeat abortion

OBJECTIVE

The objective of the study was to determine the rate of return for repeat abortion in relation to postabortion contraceptive method choice 24 months onward from an intervention study.

STUDY DESIGN

This was a prospective cohort study involving a hospital note search for 510 women 24 months after an abortion.

RESULTS

Women using long-acting reversible contraceptive (LARC) methods (intrauterine device [IUD] and depot medroxyprogesterone acetate) had significantly lower return rates for repeat abortion (6.45%; 95% confidence interval [CI], 4.0-9.8) than non-LARC users, of whom 14.5% returned (95% CI, 9.9-20.2). A Cox proportional hazard analysis showed that the postabortion method choice was significantly related to the likelihood of returning for a repeat abortion (P = .002), controlling for major demographic factors and previous pregnancy history. Using the pill as a reference group for risk of repeat abortion, the IUD hazard ratio (HR) was 0.36 (95% CI, 0.17-0.77), the depot medroxyprogesterone acetate HR was 0.55 (95% CI, 0.21-1.45), and the HR for all other methods was 1.8 (95% CI, 0.83-3.92).

CONCLUSION

This study provides strong support for the promotion of immediate postabortion access to LARC methods (particularly intrauterine devices) to prevent repeat abortion.