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

Contraceptive counselling and uptake of contraception among women with cardiovascular diseases: a systematic review and meta-analysis

To address the lack of clarity regarding contraceptive counselling and uptake of contraception among women with cardiovascular disease (CVD), this study aimed to conduct a systematic review and meta-analysis on contraceptive counselling and the subsequent uptake of contraception among women with CVD. A search across six databases identified 1228 articles, with 11 studies (2580 participants) included. The pooled prevalence of contraceptive counselling was 63%, varying from 36 to 94% in individual studies. Inconsistent delivery and documentation of counselling were noted, along with a lack of knowledge about pregnancy complications and misconceptions regarding CVD severity. For contraceptive uptake (n = 5), the pooled prevalence was 64% (95% confidence interval, 45 to 82%). Women with CVD were also found to use less effective methods as well as methods not recommended for their condition (e.g., combined hormonal methods among participants with absolute or relative contraindications). Improving contraceptive counselling and choices for women with CVD can not only enhance knowledge and decision-making for women with CVD in line with their reproductive goals and preferences but reduce high-risk unintended pregnancies and adverse pregnancy outcomes.

Perceived barriers and opportunities of providing quality family planning services among Palestinian midwives, physicians and nurses in the West Bank: a qualitative study

BACKGROUND

Despite advancements in family planning (FP) services, several barriers persist in the Occupied Palestinian territory (oPt), blocking women's access to suitable, high-quality and equitable FP services. The aim of this study was to understand how healthcare providers perceive their abilities, barriers and opportunities in providing good quality FP services. Furthermore, it seeks to explore knowledge and training regarding FP among healthcare providers engaged in providing FP services.

METHODS

A qualitative study was undertaken from August to September 2022 in seven Primary Health Care (PHC) clinics distributed in three governorates and operating under the Palestinian Ministry of Health (MoH) in the West Bank. Semi-structured, in-depth face-to-face interviews were conducted with 13 health providers (Physicians, midwives and nurses), using an interview guide in Arabic language. Transcripts were subsequently analyzed using the six phases of reflexive thematic analysis.

RESULTS

FP services face various challenges, including shortages in resources such as staff, supplies, infrastructures and FP methods. Midwives possess significant potentials to offer accessible, high-quality, efficient and equitable FP services, yet, their capacities remain underutilized, representing a missed opportunity for a country like Palestine. The study provided a current overview of FP services while illustrating the need for quality FP services and the need for an updated continuous education and training, updated standardized guidelines and protocols and supportive supervision are needed across all levels of healthcare providers. Finally, providers reported a wide range of structural barriers to FP services.

CONCLUSIONS

It is crucial to meticulously address both community-related and health system factors to enhance the fulfillment of FP needs and reduce unintended and closely spaced pregnancies. Policymakers should invest in the development of laws and regulations regarding FP services, promoting a comprehensive and holistic approach to FP services. This includes formulating supportive policies, capacity building of human resources and maintaining security of FP commodities.

Emergency Contraception Knowledge, Attitudes, and Barriers Among Men: A Cross-Sectional Study

Background Emergency contraception (EC) plays a pivotal role in the prevention of unintended pregnancies following unprotected sexual intercourse. Men's awareness regarding emergency contraception is pivotal for informed decision-making and for enhancing reproductive health in this context. This study investigated Syrian men's awareness and perspectives on emergency contraception to inform diverse reproductive health initiatives. Methods We conducted a cross-sectional study in Syria, from June 2022 and April 2023. Our study included male participants aged 18 years or older who held Syrian nationality and volunteered to participate. The data collection involved administering a questionnaire comprising three sections (knowledge, attitude, and barrier assessment), encompassing a total of 30 questions. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY). Results Most participants were aged 18-25 (65.7%) and single (75.4%) and held a university degree (79.3%). The knowledge of emergency contraception was low (36.1%), with the Internet and social media (77.5%) being the primary sources of information. While 89% held positive attitudes toward emergency contraception, only 37.3% supported nonprescription availability. Age, income, and desire for children were associated with knowledge, attitudes, and the use of emergency contraception. Men aged 26-35 exhibited the highest positive attitude (8.11±1.83). Those desiring no children showed higher attitude scores (7.42±2.04). Income was positively associated with knowledge (adjusted odds ratio {AOR}=1.75 and confidence interval {CI}=1.02-2.99) and emergency contraception use (AOR=2.87 and CI=1.27-6.48). Conclusion This study underscores the knowledge gap regarding emergency contraception in Syrian men. Despite positive attitudes, awareness remains limited, particularly among those of childbearing age. Targeted education and improved accessibility to emergency contraception can enhance its use among men, particularly in those with low socioeconomic status and younger age groups.

The effect of integration of family planning education with infant vaccination visits on the uptake of postpartum family planning in Ile-Ife, Nigeria

Integration of maternal and child health services can improve service utilisation. An operations research was conducted in a Nigerian tertiary hospital. A pilot study was conducted at three family planning (FP) and vaccination sites. A formative assessment was carried out using client records and key-informant interviews. Pre- and post-integration questionnaires were administered to 715 women attending the infant vaccination clinics. Themes were developed from the qualitative data and some verbatim quotes were reported. The quantitative data were analysed using Stata, version 17. Univariate and multivariate analyses were done to compare associations between categorical independent and outcome variables where applicable, with level of significance set at <0.05 and 95% confidence interval.The health care workers were willing to integrate the two services but inadequate training and time constraint were key barriers. Significant increases in the knowledge of contraception (25.7% vs 34.7%, p = 0.001), intention to use contraception (31.2% vs 38.2%, p = 0.001), and number of new acceptors of FP (487 vs 664, p = 0.001), were recorded post-integration, even though it was difficult to determine whether the observed increase in new FP acceptors was due to increased patronage from the study participants and not from other clients who were not part of the study. Integration of FP education and infant vaccination services is a feasible and acceptable strategy for increasing contraceptive use among postpartum women, as vaccination clinic staff were willing to take on FP education along with their current duties.Impact statementWhat is already known on this subject? Few studies have reported on the outcomes related to FP and vaccination integration.What the results of this study add? A simple model of FP education and infant vaccination services integration is a feasible and acceptable strategy for increasing contraceptive use among postpartum women. However, inadequate training and time constraint were major concerns for healthcare providers.Implications of these findings for clinical practice and/or further research? Targeted family planning education and referral should be encouraged during infant vaccination visits. There is a need for further research to determine the providers' skills necessary for integration and whether integration poses a risk to either service.

Providing family planning counseling services for women with chronic medical conditions in an inpatient setting: A randomized feasibility trial

OBJECTIVES

This study aimed to evaluate the feasibility and effectiveness of providing bedside family planning services to women with chronic medical conditions in the inpatient setting.

STUDY DESIGN

We initiated a parallel randomized controlled trial of patients listed as female aged 18 to 44 years who were admitted to the hospital from February 2018 to May 2021 with at least one chronic medical condition associated with lower rates of contraception usage and no documentation of contraception. Patients who confirmed they were not using contraception were enrolled and randomized to one of the three arms. They received bedside family planning counseling and an offer of contraception prior to discharge (oral contraceptive pills, etonogestrel implant, or medroxyprogesterone injection), received a flyer recommending they talk with their outpatient physician about contraception, or received standard care. The primary outcomes were contraception use at 3 months and 12 months after discharge.

RESULTS

Altogether 76 subjects were enrolled and randomized with 22 in the counseling arm and 27 each in the other arms. In the counseling arm, five (23%; 95% CI: 8.0%-45%) elected to receive contraception prior to discharge. Inferential statistics at follow-up were not able to be calculated due to high attrition.

CONCLUSIONS

Providing counseling and offering immediate contraception initiation in the inpatient setting may be a feasible approach to improving contraception access for this population. Additional investigation into the acceptability, efficacy, and generalizability of this approach is warranted.

IMPLICATIONS

Utilizing the inpatient setting may be a feasible approach for delivering contraception counseling to women with chronic medical conditions. This approach merits further study for effectiveness and acceptability. This study highlights the need for contraceptive counseling and initiation to become a standard part of hospital care for pregnancy-capable individuals.

Contraceptive Use in Females With Advanced CKD: A Qualitative Study

Rationale & Objective

Pregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception.

Study Design

Qualitative study.

Setting & Participants

We conducted 5 focus group interviews involving 16 adult female patients with advanced chronic kidney disease (n = 3 nondialysis nontransplant chronic kidney disease, n = 9 kidney transplant, and n = 4 kidney failure receiving dialysis) in the United States, following which thematic saturation was reached.

Analytical Approach

Interview transcripts were analyzed thematically.

Results

We identified the following 5 themes: 1) variable knowledge regarding reproductive health with kidney disease, 2) inadequate counseling about contraceptive use, 3) lack of interdisciplinary coordination regarding contraceptive use, 4) insufficient educational resources available to guide the contraceptive discussion, and 5) need for research to better understand reproductive needs in females with kidney disease.

Limitations

Patients were from a single center in the United States, and the study is limited by the transferability of findings to other settings.

Conclusions

Patients with chronic kidney disease report emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Strategies to strengthen these factors may improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Plain-Language Summary

Pregnancy in females with kidney disease is common and associated with a higher risk of adverse maternal and fetal outcomes, but the use of contraception remains low. Little is known about female patients' experiences in contraceptive use that may contribute to low contraceptive use in this high-risk population. In the present study using focus group interviews, patients with chronic kidney disease reported emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Interventions are needed to strengthen these factors to improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants

ABSTRACT

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

Association of Primary Care Physicians' Individual- and Community-Level Characteristics With Contraceptive Service Provision to Medicaid Beneficiaries

Importance

Little is known about primary care physicians who provide contraceptive services to Medicaid beneficiaries. Evaluating this workforce may help explain barriers to accessing these services since contraceptive care access is critical for Medicaid beneficiaries' health.

Objective

To describe the primary care physician workforce that provides contraceptive services to Medicaid beneficiaries and explore the factors associated with their Medicaid contraceptive service provision.

Design, Setting, and Participants

This cross-sectional study, conducted from August 1 to October 10, 2022, used data from the Transformed Medicaid Statistical Information System from 2016 for primary care physicians from 4 specialties (family medicine, internal medicine, obstetrics and gynecology [OBGYN], and pediatrics).

Main Outcomes and Measures

The main outcomes were providing intrauterine devices (IUDs) or contraceptive implants to at least 1 Medicaid beneficiary, prescribing hormonal birth control methods (including a pill, patch, or ring) to at least 1 Medicaid beneficiary, the total number of Medicaid beneficiaries provided IUDs or implants, and the total number Medicaid beneficiaries prescribed hormonal birth control methods in 2016. Physician- and community-level factors associated with contraceptive care provision were assessed using multivariate regression methods.

Results

In the sample of 251 017 physicians (54% male; mean [SD] age, 49.17 [12.58] years), 28% were international medical graduates (IMGs) and 70% practiced in a state that had expanded Medicaid in 2016. Of the total physicians, 48% prescribed hormonal birth control methods while 10% provided IUDs or implants. For OBGYN physicians, compared with physicians younger than 35 years, being aged 35 to 44 years (odds ratio [OR], 3.51; 95% CI, 2.93-4.21), 45 to 54 years (OR, 3.01; 95% CI, 2.43-3.72), or 55 to 64 years (OR, 2.27; 95% CI, 1.82-2.83) was associated with higher odds of providing IUDs and implants. However, among family medicine physicians, age groups associated with lower odds of providing IUDs or implants were 45 to 54 years (OR, 0.66; 95% CI, 0.55-0.80), 55 to 64 years (OR, 0.51; 95% CI, 0.39-0.65), and 65 years or older (OR, 0.29; 95% CI, 0.19-0.44). Except for those specializing in OBGYN, being an IMG was associated with lower odds of providing hormonal contraceptive service (family medicine IMGs: OR, 0.80 [95% CI, 0.73-0.88]; internal medicine IMGs: OR, 0.85 [95% CI, 0.77-0.93]; and pediatric IMGs: OR, 0.85 [95% CI, 0.78-0.93]). Practicing in a state that expanded Medicaid by 2016 was associated with higher odds of prescribing hormonal contraception for family medicine (OR 1.50; 95% CI, 1.06-2.12) and internal medicine (OR, 1.71; 95% CI, 1.18-2.48) physicians but not for physicians from other specialties.

Conclusions and Relevance

In this cross-sectional study of primary care physicians, physician- and community-level factors, such as specialty, age, and the Medicaid expansion status of their state, were significantly associated with how they provided contraceptive services to Medicaid beneficiaries. However, the existence of associations varied across clinical specialties. Ensuring access to contraception among Medicaid beneficiaries may therefore require policy and program approaches tailored for different physician types.

Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data

OBJECTIVES

To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy.

DESIGN

A retrospective analysis of US claims data.

SETTING

Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database.

PARTICIPANTS

We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy.

PRIMARY OUTCOMES

Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims.

RESULTS

The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70).

CONCLUSION

Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.

Providers' approaches to contraceptive provision in Cape Town

Background

Health care providers can play a significant role in empowering women to make informed decisions when selecting suitable contraceptive methods during contraceptive counseling. This study explores primary care providers' perspectives and approaches to contraceptive service provision for women attending public sector clinics in South Africa, with the intention of ascertaining established practices and training needs.

Methods

Ten in-depth interviews were conducted at five primary health care facilities in urban areas in Cape Town, South Africa. Eligible participants included nurses providing contraceptive services and willing to participate in the study. The qualitative software package NVivo was used to sort and manage data. Data was analyzed using a thematic analysis approach.

Results

Overall, providers emphasized supporting women in contraceptive decision-making. Sexual and reproductive health training increased providers confidence to deliver appropriate contraceptive services. Contraceptive prescribing practices were influenced by women's medical history and preferred bleeding patterns. Providers' concerns about adherence to methods for younger women and suspected adverse events for older women impacted on prescribing. Challenges experienced when providing contraceptive services included: contraceptive stockouts; time constraints of employed women accessing the service; and their work pressure due to providing other health services.

Discussion

Health care providers play a critical role in facilitating women's right to access high quality contraceptive services. Providers saw themselves as negotiators during contraceptive counseling. They considered both women's preferences and their own recommendations for contraception, to provide information that would enable women to make informed contraceptive decisions. By reinforcing this approach to contraceptive counseling and focusing on shared decision-making, should encourage autonomy in method selection and limit the influence of provider's contraceptive method selection.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Pregnancy Intention Screening in Patients With Systemic Rheumatic Diseases: Pilot Testing a Standardized Assessment Tool

OBJECTIVE

Systemic rheumatic conditions affect reproductive-aged patients and often require potentially teratogenic medications. We assessed the feasibility and impact of a standardized pregnancy intention screening question (One Key Question [OKQ]) in a large academic rheumatology practice.

METHODS

This 6-month pilot quality improvement initiative prompted rheumatologists to ask female patients aged 18 to 49 years about their pregnancy intentions using OKQ. We administered surveys to assess rheumatologists' barriers to and comfort with reproductive health issues. We performed chart reviews to assess uptake and impact on documentation, comparing charts with OKQ documented with 100 randomly selected charts eligible for pregnancy intention screening but without OKQ documented.

RESULTS

When we compared 32 of 43 preimplementation responses with 29 of 41 postimplementation responses, the proportion of rheumatologists who reported they were very comfortable with assessing their patients' reproductive goals increased (31%-38%) and the proportion reporting obstetrics and gynecology (OB/GYN) referral challenges as barriers to discussing reproductive goals decreased (41%-21%). During the implementation period, 83 of 957 (9%) eligible patients had OKQ documented in their chart. Female providers were more likely to screen than male providers (odds ratio 2.42, 95% confidence interval 1.21-4.85). Screened patients were more likely to have their contraceptive method documented (P < 0.001) and more likely to have been referred to OB/GYN for follow-up (P = 0.003) compared with patients who were not screened with OKQ.

CONCLUSION

Although uptake was low, this tool improved provider comfort with assessing reproductive goals, the quality of documentation, and the likelihood of OB/GYN referral. Future studies should examine whether automated medical record alerts to prompt screening increase uptake.

Who is providing contraception care in the United States? An observational study of the contraception workforce

BACKGROUND

Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States.

OBJECTIVE

This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation.

STUDY DESIGN

We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau's American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons.

RESULTS

Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15-44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty.

CONCLUSION

This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

"Did I Choose a Birth Control Method Yet?": Health Care and Women's Contraceptive Decision-Making

In the United States, unintended pregnancy is medicalized, having been labeled a health problem and "treated" with contraception. Scholars find women's access to contraception is simultaneously facilitated and constrained by health care system actors and its structure. Yet, beyond naming these barriers, less research centers women's experiences making contraceptive decisions as they encounter such barriers. Through in-depth, semi-structured interviews with 86 diverse, self-identified women, this study explores how the medicalization of unintended pregnancy has influenced women's contraceptive access and decision-making. We highlight the breadth of such influence across multiple contraceptive types and health care contexts; namely, we find the two most salient forces shaping women's contraceptive decisions to be their insurance coverage and providers' contraceptive counseling. Within these two categories, we offer crucial nuance to demonstrate how these oft-cited barriers implicitly and explicitly influence women's decisions. Paradoxically, it is the health care system, itself, that both offers yet constrains women's contraceptive decisions.

Barriers to Contraceptive Use Among Urban Adolescents and Youth in Conakry, in 2019, Guinea

Background: Despite efforts to improve access to family planning, contraceptive prevalence remains relatively low among adolescents and youth in Guinea. The objective of this study was to understand the barriers to the use of modern contraceptive methods among urban adolescents and youth (15–24 years) in Conakry, Guinea.

Methods: This was a qualitative study using an exploratory design. It was conducted in the capital city of Guinea, Conakry in 2019. Respondents included adolescents and youth aged 15–24 years, health care providers, and parents of adolescents and youth. In-depth individual interviews (IDIs) and focus group discussions (FGDs) were used to collect the data. Sixty IDIs and ten FGDs were planned in Conakry. These data were recorded and transcribed, when applicable, from the local languages into French in an anonymous manner. The data were analyzed using a mixed (inductive and deductive) thematic approach following the elements of the socio-ecological model.

Results: Overall, 56 IDIs and 10 FGDs were conducted with 136 participants and included in this analysis. Respondents were adolescents (16%), youth (30%), and key informants (54%) who were health care providers (public and private), decision-makers, parents of adolescents and youth, and neighbors. Among adolescent respondents, 75% were female, and of the youth, 61% were female. Our analysis indicates various and interrelated barriers that limit the access and use of contraceptives by adolescents and youth. These included the individual (fear of side effects, cost, and rumor-related misinformation), interpersonal or family (spouse perception and sexuality taboo and perception of sexual activity before marriage), sociocultural (religious prohibitions and ethnicity), and health care system (breakdown of contraceptive methods in public health facilities, perception of service delivery, provider attitudes, visiting hours, geographic proximity of services, and quality of training received by health care providers) barriers.

Conclusion: In our context, the use of modern contraceptive methods by adolescents and youth is influenced by an interaction of various barriers, including individual, interpersonal, sociocultural, and health care system factors. Strengthening contraceptive uptake interventions by involving different stakeholders, including adolescents, parents, religious, and community leaders, and improving the quality of sexual and reproductive health services would help in reducing barriers to contraceptive use among adolescents and youth.

Determining the impact of the Zika pandemic on primary care providers' contraceptive counseling of non-pregnant patients in the US: a mixed methods study

BACKGROUND

Global pandemics like Zika (ZIKV) factor into pregnancy planning and avoidance, yet little is known about how primary care providers (PCPs) incorporate public health guidance into contraceptive counseling. Study objectives include: 1) determining the impact of the ZIKV pandemic on contraceptive counseling changes; and 2) assessing PCP knowledge and practice regarding contraception, ZIKV, and CDC ZIKV guidelines.

METHODS

Study components included: (1) a retrospective review of electronic health records of non-pregnant, reproductive age women presenting for preventive health visits between 2014 and 2017 assessed using interrupted time series analyses (ITSA) to identify changes in documentation of ZIKV risk assessment and contraceptive counseling; and (2) a sequential, cross-sectional study with quantitative surveys and qualitative, semi-structured interviews of PCPs providing preventive care to non-pregnant patients at eight federally qualified health centers in Utah. We performed descriptive analyses on survey data and analyzed qualitative data for dominant themes using a modified Health Belief Model.

RESULTS

We conducted 6634 chart reviews yielding 9840 visits. The ITSA did not reveal changes in ZIKV risk assessment or contraceptive counseling. Twenty-two out of 40 (55%) eligible providers participated in the provider component. Participants averaged 69 and 81% correct on contraceptive and ZIKV knowledge questions, respectively. Sixty-five percent reported counseling consistent with CDC ZIKV guidelines. Qualitative analysis found providers unlikely to prioritize ZIKV risk assessment in contraceptive counseling for non-pregnant patients.

CONCLUSIONS

PCPs who care for non-pregnant women are knowledgeable about contraception and ZIKV; however, there was no change in ZIKV risk assessment or contraceptive counseling. This stresses the importance of developing strategies to improve guideline uptake.

Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers

The unmet need for modern contraception remains high around the world, particularly for youth. While some of this unmet need is driven by limited health infrastructure and method mix availability, many adolescents who visit family planning providers still do not receive methods that fit their needs. This suggests that providers may be biased against youth and that interventions to change provider behavior could help close this gap. However, it is unclear if this bias is a result of age or other characteristics common among young women such as not being married and not having children. We use a discrete choice experiment in Burkina Faso, Pakistan, and Tanzania to disentangle the effects of age on providers' decisions to provide contraception from the effects of other potential confounding factors. We find that, although young women may experience the most bias, age is not the main driver. Rather, marital status and parity seem to influence provider decisions to offer services or counsel on modern methods. These findings suggest that interventions to reduce provider bias should focus on changing behavior towards unmarried and nulliparous women, regardless of their age.

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

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

Determinant of unmeet need family planning in Indonesia (PMA 2015)

OBJECTIVE

This study was made to describe the effectiveness of family planning needs in married women in Indonesia and the factors that influence them.

METHODS

This research is descriptive analytic study using the Cross-Sectional Study design. This research uses Performance Monitoring and Accountability (PMA2015/Indonesia-R1) data. The research subjects were 7672 women (married). Data were analyzed using SPSS.

RESULTS

The results showed that married women who unmet need is 16% in Indonesia. On the sociodemographic characteristics of age, education and number of children significantly associated with the unmet need (p=0.000). This study recommended expected that policy makers of family planning programs and related agencies need to improve socialization of program implementation and ideal number of children planning and also require a comprehensive and systematic way to improve efforts and coverage of family planning acceptors, one of which is by making a renewal in the use of media.

From training to implementation: Improving contraceptive practices in South Carolina

OBJECTIVE

Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice.

STUDY DESIGN

Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses.

RESULTS

Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision.

CONCLUSION

The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care.

IMPLICATIONS

In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

Physician awareness regarding contraceptive counselling in women with chronic disease

INTRODUCTION

Contraceptive counselling is essential in women with chronic disease, though it is frequently overlooked. We aimed to assess practices and awareness in contraceptive counselling in hospital physicians caring for reproductive age women with chronic disease.

METHODS

A questionnaire was distributed in April 2017 to physicians from 16 medical specialties in a tertiary care hospital in Portugal. Statistical analysis performed using Microsoft Office Excel^® and IBM SPSS-Statistics^®.

RESULTS

Two-hundred physicians participated in the survey: 59.5% were female, 55% under 35 years-old and 48.5% were residents. Only 26.5% practiced in surgical specialties. Two-thirds consistently inquired about the use of contraception. Most referred patients to Family Planning services or performed contraceptive counselling when pregnancy posed significant health risks (89.0%), when prescribing teratogenic medication (79.5%) or drugs with potential interaction with contraceptives (75.0%). Lack of training in contraception was the main reason for not referring patients to Family Planning services. While 83% considered counselling very important, only 5% had recently undergone training and 12.5% felt knowledgeable enough to perform it. Only 12.5% were aware of the institution's Family Planning resources. Female gender, non-surgical specialty, age over 35 years-old and over 10 years since specialisation were positively associated with awareness.

CONCLUSION

Most physicians addressed contraceptive management in women with comorbidities, but adequate training is lacking. Our results highlight the importance of communication between health care providers to achieve an adequate and multidisciplinary approach to reproductive and general health goals.

Healthcare providers' knowledge and perceptions regarding the use of modern contraceptives among adolescent girls in Umlazi Township, KwaZulu-Natal province, South Africa

INTRODUCTION

the phenomenon of unintended adolescent pregnancy continues to be a reproductive and public health concern in sub-Saharan Africa. Healthcare providers play an important role in influencing the use of contraceptives among adolescent girls. This study assessed knowledge and perceptions of healthcare providers regarding the use of modern contraceptives among adolescent girls in Umlazi township, KwaZulu-Natal province, South Africa.

METHODS

this was a descriptive study involving 35 healthcare providers covering all 10 primary healthcare clinics in Umlazi township. Data collected through a structured questionnaire were coded, entered into Epi data manager (version 4.6) and exported to STATA (version 15.0) for analysis.

RESULTS

of the thirty-five healthcare providers that participated in this study, professional nurses (54.3%) and enrolled nurses (17.1%) constituted the majority. The mean age of the participants was 42.11 years, with 88.6% being females. More than a third (37.1%) of healthcare providers did not know whether or not modern contraceptives make users promiscuous, while more than half (57%) had negative attitudes towards adolescents exploring contraceptive methods. Healthcare providers viewed health systems challenges, such as poor working conditions, long queues, and contraceptives stock-outs, as deterrents towards the provision of quality sexual behaviour counselling and modern contraceptive education to users.

CONCLUSION

poor health systems and negative behaviours by healthcare providers influences the delivery of family planning services in primary healthcare clinics and serve as barriers to quality family planning services provided to younger women.

A Novel Contraception Counseling and Shared Decision-Making Curriculum for Internal Medicine Residents

INTRODUCTION

Many women of reproductive age with complex medical conditions receive primary care through an internal medicine (IM) physician rather than an obstetrician/gynecologist. Long-acting reversible contraception methods are the most effective form of contraception; however, IM residents are not routinely trained in them. Infrequent training in, inadequate knowledge of, and discomfort with contraception counseling limit the counseling performed by IM residents. Shared decision-making (SDM) is a method of patient-centered communication that can improve communication about patient preferences and increase patient satisfaction with and adherence to contraception. We developed a curriculum to teach contraception counseling under the framework of SDM for IM residents.

METHODS

The curriculum focused on contraception counseling through the lens of SDM designed for IM and medicine/pediatrics residents (PGY 2-PGY 4). We adapted an existing seven-step model of SDM to fit elements of contraception counseling. The curriculum consisted of a didactic teaching session with integration of an instructional video and structured interactive discussion. The session lasted 60 minutes.

RESULTS

Fifty-eight residents participated in the curriculum. On pre- and postcurriculum surveys, residents reported improvement in contraception knowledge (overall mean precurriculum = 57%, postcurriculum = 70%, p < .001) and comfort with contraception counseling (overall mean precurriculum = 3.2, postcurriculum = 3.6, p < .01). Residents expressed strong support for SDM before and after the curriculum.

DISCUSSION

Based on the survey results, the curriculum successfully addressed gaps in residents' comfort with contraception counseling and knowledge of contraception side effects and efficacy.

Decisional conflict associated with clinicians discouraging particular contraceptive methods

RATIONALE, AIMS, AND OBJECTIVES

Approximately 45% of pregnancies in the United States are unintended. The use of contraception reduces the risk of unintended pregnancy. The initiation of several contraceptive methods requires seeing a clinician. This study explored how clinicians' expressed preferences against particular contraceptive methods impacted participants' confidence in their method choice and perception of shared contraceptive decision making.

METHODS

Eligible individuals were 18 to 45 years of age, assigned female sex at birth, English speaking, and either using or had previously used contraception. Participants completed an anonymous survey via web link on Amazon Mechanical Turk. Primary self-reported outcomes were (a) proportion of participants being discouraged from a particular contraceptive method, (b) decisional conflict, and (c) extent of shared decision making. Secondary self-reported outcomes were (a) importance of contraceptive attributes and (b) self-reported quality of care.

RESULTS

Six hundred sixty-nine participants completed the survey. Most were white (74.0%), non-Hispanic (84.5%), married or cohabitating (69.4%), and nulliparous (47.2%). A total of 33.8% reported that a clinician had discouraged them from using a particular contraceptive method, most commonly because of side effects, usability, and/or method effectiveness. Effectiveness, affordability, and side effects were the self-reported most important contraceptive features. Those who were discouraged from using a method (versus those who were not) were more likely to report decisional conflict (41.2% vs 30.0%, P = .004), yet reported a higher extent of shared decision making (median: 76 vs 71; P = .03). Adjusting for age and nulliparity did not impact results, except nulliparity made the relationship between being discouraged from using a method and shared decision making no longer significant (P = .06).

CONCLUSIONS

Decisional conflict might arise when clinicians discourage individuals using particular contraceptive methods. Clinicians' reasons for discouraging methods might not always align with patients' preferences. More research is needed to examine how to reduce decisional conflict and support contraceptive method selection.

Translating policy to practice: theory-based formative research to improve messaging and over-the-counter access to emergency contraception in Florence, Italy

OBJECTIVES

Italy's 2015 emergency contraception (EC) policy made EC available without prescription for individuals aged 18 years and older; however, women living in Italy continue to face barriers to accessing EC. The purposes of this study were to understand EC knowledge, attitudes and behaviours among women living in Italy and explore the impact of the 2015 policy.

METHODS

Researchers conducted 30 interviews with women living in Florence, Italy, aged 18-50 years and using the Italian health care system. Researchers used an expanded grounded theory approach to understand women's EC experiences, with diffusion of innovations (DOI) serving as a conceptual lens. Researchers completed open and axial coding to identify emerging themes.

RESULTS

Participants had low awareness of the 2015 EC policy and suggested increased messaging in strategic locations to overcome this barrier. They held positive and negative attitudes towards EC: while some perceived the advantage of EC compared with unintended pregnancy, others expressed concerns about irresponsible behaviour and safety. Finally, conscientious objection impacted access, despite women's desire for autonomous EC decision making.

CONCLUSION

The findings offer practical recommendations to guide EC messaging in Italy to increase women's access to EC. Recommendations include using theory- and audience-based methods to overcome gaps in policy knowledge and real and perceived barriers to EC access. Incorporating DOI as a theoretical framework with women's voices presents a novel opportunity to enhance policy and EC dissemination.

Perceived Barriers to Accessing Pregnancy-Related Health Information Among Married Adolescent Women: A Qualitative Study in Iran

STUDY OBJECTIVE

To date, no study has reported barriers to accessing pregnancy-related health information among married women younger than the age of 19 years. Indeed, the voice of the girls being married is absent in the literature. We sought to explore the barriers to accessing pregnancy-related health information from the perspective of Iranian married adolescent women.

DESIGN

Qualitative study.

SETTING

The research was conducted in Mashhad city (health care centers) and Shahrood County (a maternity teaching hospital, and urban/rural health care centers) in Iran.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

Twenty-four married adolescent women aged 14-19 years were recruited through purposive sampling. Individual in-depth interviews were tape-recorded, transcribed verbatim, and analyzed using conventional content analysis. Prolonged engagement with participants, maximum-variation sampling, member checking, peer deferring, and external audit were used to enhance the rigor of the study.

RESULTS

The results showed 3 categories: "structural barriers," "individual barriers," and "sociocultural barriers." The structural barriers category consisted of 2 subcategories, namely, poor quality of education and counseling in the health care centers, and transportation barriers. The 2 subcategories of the individual barriers category consisted of affective barriers and cognitive barriers. The sociocultural barriers category included the following 2 subcategories: husband's decision-making power and fear of being labeled infertile.

CONCLUSION

The barriers identified in this study should be considered when designing educational interventions for married adolescent women. Moreover, further research is needed to enhance current knowledge on this topic.

Misconceptions and Beliefs Regarding the Use of Intrauterine Devices for Nulliparous Women Among Chinese Health Care Providers

STUDY OBJECTIVE

To investigate the knowledge and beliefs regarding the use of intrauterine devices (IUDs) for nulliparous women among Chinese health care providers and assess the potential factors related to their misconceptions and conservative beliefs. DESIGN, SETTING, PARTICIPANT, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A self-administered survey was conducted at 2 Chinese national academic conferences in 2015. The questionnaire data obtained from 103 health care providers were analyzed to examine the providers' knowledge regarding the safety and effectiveness of IUDs and the complications associated with IUD use, as well as their beliefs regarding the suitability of IUDs for nulliparous women. An ordinal logistic regression model was used to evaluate the potential factors related to their beliefs.

RESULTS

Misconceptions about the complications associated with IUD use were common among our respondents, and they were least likely to know that IUDs do not increase the risk of developing pelvic inflammatory disease (26/97) or ectopic pregnancy (23/102) (22.5%-26.8%). Only approximately 10% of the providers believed that adolescents (9/94) or unmarried nulliparas (10/95) could be candidates for IUDs. In contrast, they were more likely (37/96, 38.5%) to consider married nulliparous women as appropriate candidates (P < .001). Misconceptions about the complications of IUD use were associated with more conservative beliefs regarding IUD use for nulliparous women (adjusted odds ratio, 1.34; 95% confidence interval, 1.00-1.79).

CONCLUSION

The health care providers' insufficient knowledge regarding IUDs contributed to their outdated and conservative beliefs about the suitability of IUDs for nulliparous women. In addition, the difference in the providers' beliefs regarding IUD use for married and unmarried nulliparous women might reflect the stigma associated with premarital sex in Chinese traditional culture.

Informed choice in modern contraceptive method use: pattern and predictors among young women in India

Research on informed choice in modern contraceptive method acceptance by young married women is pertinent in the broader context of individual freedom and reproductive rights, especially in countries where women continue to have limited control over their reproductive and contraceptive choices. This study in India asked: (1) is young married women's acceptance of specific modern contraceptive methods an informed choice? and (2) what are the enablers and barriers to informed choice? The study used data for currently married women aged 15-24 (N = 20,752) from the fourth round of the National Family Health Survey (NFHS-4) conducted in 2015-16. A Method Information Index (MII) was calculated as a measure of informed choice from the percentage of users who responded 'yes' to all three questions on: whether they were informed about methods other than the one they received, told about the method-specific side-effects, and advised what to do if they experienced side-effects. Binary logistic regression analysis was carried out to examine the adjusted effect of factors associated with the MII separately for female sterilization, the intrauterine device and the oral contraceptive pill, and a combined MII including all three methods plus injectables. One-fifth of the study women used any modern contraceptive method at the time of survey, of which only 36% had fully informed choice. The likelihood of being informed about the methods was significantly higher among those using the oral contraceptive pill (OR: 1.75, CI 1.58-1.94), IUD (OR: 2.23, CI 1.97-2.52) and injectables (OR: 1.37, CI 0.97-1.94) compared with those who were sterilized. Informed choice varied by region and the socioeconomic profile of the users. Inadequately informed choice violates the reproductive rights of young women and might result in higher post-use health problems, discontinuation of and unmet need for contraceptives, unintended pregnancies, induced abortions and regret, adversely affecting women's health. Training of health/family planning workers in India about the importance of reproductive rights is urgently required to enhance informed contraceptive choice and improve the health of young married women.

A multidimensional approach to inform family planning needs, preferences and behaviours amongst women in South Africa through body mapping

Background

In recent decades there have been great improvements in the reproductive health of women in low- and middle-income countries and increases in the use of modern contraceptive methods. Nonetheless, many women are not able to access information, contraceptive technologies and services that could facilitate preventing unintended pregnancies and planning the number and timing of desired pregnancies.

In South Africa, the contraceptive prevalence rate is 64.6%. However, this relatively high contraceptive prevalence rate masks problems with quality contraceptive service delivery, equitable access, and women’s ability to correctly and consistently, use contraceptive methods of their choice. This study set out to understand the specific family planning and contraceptive needs and behaviours of women of reproductive age in South Africa, through a lived experience, multisensory approach.

Methods

Participatory qualitative research methods were used including body mapping workshops amongst reproductive aged women recruited from urban and peri urban areas in the Western Cape South Africa. Data including body map images were analysed using a thematic analysis approach.

Results

Women had limited biomedical knowledge of the female reproductive anatomy, conception, fertility and how contraceptives worked, compounded by a lack of contraceptive counseling and support from health care providers. Women’s preferences for different contraceptive methods were not based on a single, sensory or experiential factor. Rather, they were made up of a composite of sensory, physical, social and emotional experiences underscored by potential for threats to bodily harm.

Conclusions

This study highlighted the need to address communication and knowledge gaps around the female reproductive anatomy, different contraceptive methods and how contraception works to prevent a pregnancy. Women, including younger women, identified sexual and reproductive health knowledge gaps themselves and identified these gaps as important factors that influenced uptake and effective contraceptive use. These knowledge gaps were overwhelmingly linked to poor or absent communication and counseling provided by health care providers. Body mapping techniques could be used in education and communication strategies around sexual and reproductive health programmes in diverse settings.

The effectiveness of a digital shared decision-making tool in hormonal contraception during clinical assessment: study protocol of a randomized controlled trial in Spain

Background

Decision-making tools represent a paradigm shift in the relationship between the clinician and the user/patient. Some of their advantages include patient commitment, the promotion of preferences and values, and increased treatment adherence.

This study protocol aims to assess the effectiveness of a decision-making tool in contraception (SHARECONTRACEPT) concerning: a) Improvement in counselling on hormonal contraception at the medical consultation, measured in terms of decreasing decisional conflict and improving knowledge of available contraceptive options; b) Improvement in adherence to treatment measured in terms of: persistence in the chosen treatment, compliance with dose or procedure of use, and ability to deal with incidents related to the use of the contraceptive method; and decreasing unwanted pregnancies and voluntary interruption of pregnancy.

The SHARECONTRACEPT tool, developed by previous phases of this project, is available at: http://decisionscompartides.gencat.cat/en/decidir-sobre/anticoncepcio_hormonal/

Methods/design

A longitudinal, prospective-type, randomized, controlled community clinical trial, carried out in the clinical contraceptive counselling units of 6 autonomous regions in Spain, with an experimental group and a control group. Description of the intervention: The health professionals participating will be randomly assigned to one of the two groups. Clinicians assigned to the experimental group will perform contraceptive counselling assisted by SHARECONTRACEPT, and those of the control group will follow the conventional contraceptive counselling provided in their clinical unit.

It is planned to study 1708 users (control group n = 854 and intervention group n = 854), recruited from women who attend the consultations of the health professionals. The selected users will be followed up for one year. The data will be collected through ad-hoc questionnaires, and validated instruments for measuring decisional conflict and adherence to treatment.

Discussion

The results of this study protocol will offer evidence of the effectiveness of a shared decision-making tool, SHARECONTRACEPT, which may prove a useful tool for users and professionals to promote adherence to contraceptive methods.

Trial registration

Clinical Register number ISRCTN5827994. Date: 15/04/2019 (Retrospectively registered)

Integration of a Comprehensive Contraception Education Program Into Clinical Practice in a Family Planning Clinic

OBJECTIVE

To improve rates of contraception adherence by implementing a comprehensive contraception educational program for women receiving care at a family planning clinic.

DESIGN

Quasi-experimental cohort study in which we evaluated women presenting before (control group) and after program implementation (intervention group) and compared the proportion of women returning for contraceptive method change and/or for unintended pregnancy.

SETTING

Family planning clinic of a large academic medical center.

PARTICIPANTS

English-speaking women ages 12 to 50 years who presented to the clinic for pregnancy termination or initiation of a new contraceptive method from May 2012 to May 2014.

INTERVENTION

A provider-facilitated, patient-centered educational intervention was implemented to foster patient knowledge and choice about contraception.

RESULTS

We conducted chart review to identify any clinic visit that occurred in the 12 months after the index visit. Pearson's chi-square test was used to compare results for women in both groups. The intervention group included 201 women, and the control group included 162 women. In the control group, 28% (n = 46/162) returned within the year for unintended pregnancy and/or contraceptive method change, whereas only 17% (n = 35/201) returned in the study group. This difference was statistically significant (p < .05).

CONCLUSION

Initiation of a comprehensive contraception educational program was associated with a decrease in rates of return visits for unintended pregnancy and contraceptive method changes. This implies an improvement in adherence to the initially chosen contraceptive method. Such interventions hold promise for improving contraceptive adherence and decreasing unintended pregnancy. Improving contraceptive adherence is a critical first step to decreasing unintended pregnancies.

Opportunities lost: Barriers to increasing the use of effective contraception in the Philippines

Background

In the Philippines, one in four pregnancies are unintended and 610 000 unsafe abortions are performed each year. This study explored the association between missed opportunities to provide family planning counseling, quality of counseling and its impact on utilization of effective contraception in the Philippines.

Methods

One-hundred-one nationally representative health facilities were randomly selected from five levels of the health system. Sexually-active women 18–49 years old, wanting to delay or limit childbearing, attending primary care clinics between April 24 and August 8, 2017 were included. Data on contraceptive use, counseling and availability were collected using interviews and facility assessments. Effective contraceptive methods were defined as those with rates of unintended pregnancy of less than 10 per 100 women in first year of typical use.

Findings

849 women were recruited of whom 51.1% currently used effective contraceptive methods, 20.6% were former effective method users and 28.3% had never used an effective method. Of 1664 cumulative clinic visits reported by women in the previous year, 72.6% had a missed opportunity to receive family planning counseling at any visit regardless of level of facility, with 83.7% having a missed counseling opportunity on the day of the interview. Most women (55.9%) reported health concerns about modern contraception, with 2.9% receiving counseling addressing their concerns. Only 0.6% of former users and 2.1% never-users said they would consider starting a modern contraceptive in the future. Short and long acting reversible contraceptive methods were available in 93% and 68% of facilities respectively.

Conclusions

Missed opportunities to provide family planning counseling are widespread in the Philippines. Delivery of effective contraceptive methods requires that wider legal, policy, social, cultural, and structural barriers are addressed, coupled with systems approaches for improving availability and quality of counseling at all primary health care contacts.

"It is a thing that depends on God": barriers to delaying first birth and pursuing alternative futures among newly married adolescent girls in Niger

Background

Pregnancy among adolescent girls in Niger contributes to 34% of all deaths among females ages 15–19, but there is a dearth of research as to the specific contextual causes. In Zinder region, an area that is especially impoverished and where girls are at heightened risk, there is very little information on the main obstacles to improving adolescents’ health and well-being. This qualitative study examines the underlying social, individual and structural factors influencing married girls’ early first birth and participation in alternative opportunities (such as education or economic pursuits) in Niger.

Methodology

In July of 2017, researchers conducted in-depth interviews with a non-probability sample of community members in three communes of Zinder Region, Niger. Participants (n = 107) included adolescent girls, husbands of adolescent girls, influential adults, community leaders, health providers, and positive deviants. All interviews were transcribed, coded and analyzed using Dedoose software.

Results

Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, desire for children, and belief that childbirth is “God’s will” interfere with a girl’s ability to delay. Girls’ social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue. Participants favor adolescents’ pursuit of increased economic opportunities or education, but would not support delaying birth to do so.

Conclusions

Findings indicate the need for a holistic approach to delaying early birth and stimulating girls’ participation in economic and educational pursuits. Potential interventions include mitigating barriers to reproductive health care; training adolescent girls on viable economic activities; and providing educational opportunities for girls. Effective programs should also include or target immediate members of the girls’ families (husbands, parents, in-laws), influential local leaders and members of the community at large.

Health-related quality of life in undergraduate women using any contraceptive

OBJECTIVE

The aim of this research was to assess university students' health-related quality of life whether they use some contraceptive method or not.

METHODS

This research is a cross-sectional study. Female participants who studied a degree in health at the University of Seville (Spain) were recruited. Respondents completed a demographic questionnaire and health-related quality of life was measured with validated instrument SEC-QoL (Sociedad Española de Contracepción- Quality of Life) in Spanish that measured five dimensions: sexual, social, breast, menstrual and psychosocial.

RESULTS

A total of 992 women aged 21.37 (3.6) years old participated in this study. Women who used a contraceptive method reached higher scores at the SEC-QoL questionnaire 47.09 (17.04) and 46.91 (18.73) than those that didn't. Likewise, women who chose a hormonal method showed a better overall health-related quality of life, compared to those who used a non-hormonal method. Participants who used hormonal contraceptives obtained higher scores in all health-related quality of life domains (social, menstrual, breast and sexual), except psychological domain when compared to those who used a non hormonal method or none. Furthermore, a moderated mediation model showed that the effect of the current contraceptive method on health-related quality of life was partially explained by the moderated mediation of the time using this method, the reason for using it and the existence of a partner.

CONCLUSION

The usage of hormonal contraceptives increases health-related quality of life in young women. Several variables regarding the experience with contraceptive methods should be considered in order to examine the effect on health-related quality of life in undergraduate women.

Attitudes and practices related to intrauterine devices for nulliparous women among Chinese health care providers

BACKGROUND

Unintended pregnancy and induced abortion among young (unmarried or nulliparous) women have become serious social and health issues in China, which are thought to partly result from low use of long-acting reversible contraception, such as intrauterine devices (IUDs). Considering that providers may play an especially important role in increasing use of this particular method, we investigated Chinese health care providers' attitudes and practices regarding IUDs use for nulliparous women, and further examine the potential factors and reasons contributing to their attitudes and practices.

METHODS

We recruited health care providers at two Chinese national academic conferences and surveyed them about knowledge of IUDs, willingness to recommend IUDs to nulliparous women, and their related practices. Modified Poisson regression was used to examine the potential factors related to their attitudes and practices.

RESULTS

Approximately a half of respondents reported unwillingness to recommend IUDs to nulliparous women. Providers with more misperceptions about the safety and contraindications were more likely to be unwilling to recommend IUDs to nulliparous women. Moreover, 71.0% of respondents rarely or never recommended or provided IUDs to nulliparous women. Providers' unwillingness to recommend IUDs to nulliparous women was associated with their infrequent practices (aPR=1.43; 95% CI: 1.04, 1.96). In addition to concerns about the side effects or complications, traditional sexual concept against premarital sex was often cited as a reason by Chinese health providers for their negative attitudes towards IUDs use for nulliparous women, a large proportion of whom are unmarried.

CONCLUSIONS

Our findings suggest that negative attitudes and infrequent practices regarding IUDs use for nulliparous women are common in Chinese health care providers. Moreover, misperceptions about IUDs, as well as traditional sexual concept, contribute to Chinese health care providers' negative attitudes towards IUDs use for nulliparous women, and may further reduce their provision. Educational interventions are needed to improve providers' accurate knowledge of IUDs and fill the gap between traditional sexual concept and young women's needs of contraceptive services.

Adolescent Reproductive Health Care: Views and Practices of Pediatric Hospitalists

BACKGROUND AND OBJECTIVES

Many hospitalized adolescents are at increased risk for pregnancy complications due to an underlying medical condition, however sexual risk assessment is not consistently performed in this setting. While adolescents and their parents are supportive of sexual health discussion in the inpatient setting, a thorough understanding of factors that influence provision of this care among pediatric hospital physicians is lacking. This formative information is needed to facilitate efforts to improve and standardize clinical care provision. Our objective is to assess the frequency and factors that influence the provision of adolescent sexual and reproductive care by pediatric hospitalists.

METHODS

We performed a cross-sectional computerized survey of hospitalists at 5 pediatric hospitals who cared for ≥1 adolescent (14-21 years old) in the past year. Sexual and reproductive care practices were assessed by using a 76-item novel survey informed by the theory of planned behavior. We used descriptive statistics to summarize the data.

RESULTS

Sixty-eight pediatric hospitalists participated (49% response rate): 78% were women and 65% were aged <40 years. Most (69%) reported treating >46 adolescents annually, including many who are at an increased risk for pregnancy complications due to teratogenic medication use or a comorbid condition. A majority felt that sexual and reproductive services are appropriate, although many endorsed barriers, including concern about follow-up after emergency contraception (63%) and time constraints (53%). Most reported insufficient knowledge regarding contraception (59%), desired contraception education (57%), and were likely to increase contraceptive provision if provided education (63%). Hospitalists rarely provided condoms or referral for an intrauterine device.

CONCLUSIONS

Pediatric hospitalists frequently care for adolescents who are at risk for pregnancy complications and generally agree that reproductive care is appropriate in the inpatient setting. With these findings, we highlight the critical need for effective comprehensive reproductive health service interventions that are tailored to address the numerous actionable barriers identified in this study.

Medicaid Claims for Contraception Among Women With Medical Conditions After Release of the US Medical Eligibility Criteria for Contraceptive Use

INTRODUCTION

The US Medical Eligibility Criteria for Contraceptive Use (MEC) identified 20 medical conditions that increase a woman's risk for adverse outcomes in pregnancy. MEC recommends that women with these conditions use long-acting, highly effective contraceptive methods. The objective of our study was to examine provision of contraception to women enrolled in Medicaid who had 1 or more of these 20 medical conditions METHODS: We used Medicaid Analytic Extract claims data to study Medicaid-enrolled women who were of reproductive age in the 2-year period before MEC's release (2008 and 2009) (N = 442,424) and the 2-year period after its release (2011 and 2012) (N = 533,619) for 14 states. We assessed 2 outcomes: provision of family planning management (FPM) and provision of highest efficacy methods (HEMs) for the entire study population and by health condition. The ratio of the after-MEC rate to the before-MEC rate was used to determine significance in MEC's uptake.

RESULTS

Outcomes increased significantly from the before-MEC period to the after-MEC period for both FPM (1.06; lower bound confidence interval [CI], 1.05) and HEM (1.37; lower bound CI, 1.36) for a 1-sided hypothesis test. For the 19 of 20 conditions we were able to test for FPM, contraceptive use increased significantly for 12 conditions, with ratios ranging from 1.05 to 2.14. For the 16 of 20 conditions tested for HEM, contraception use increased significantly for all conditions, with ratios ranging from 1.19 to 2.80.

CONCLUSION

Provision of both FPM and HEM increased significantly among women with high-risk health conditions from the before-MEC period (2008 and 2009) to the after-MEC period (2011 and 2012). Health policy makers and clinicians need to continue promotion of effective family planning management for women with high-risk conditions.

Low-Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit

CONTEXT

Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use.

METHODS

In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum.

RESULTS

Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum.

CONCLUSION

Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.

Use of hormonal contraceptives among immigrant women and their daughters in Norway: Data from the Norwegian Prescription Database

INTRODUCTION

Immigrants and their offspring constitute 16.3% of the population in Norway. Knowledge about their contraceptive use is important in order to inform adequate family planning services. Prior research has shown less use of contraception among first-generation immigrants than among non-immigrant women. Our aim is to compare the use of hormonal contraceptives between immigrants and their adult daughters.

MATERIAL AND METHODS

Information from the Norwegian Prescription Database on all hormonal contraceptives dispensed at all pharmacies in Norway in 2008 was merged with demographic, socioeconomic and immigration data from the National Population Register and information from the Regular General Practitioner Database and the Medical Birth Registry Norway. A total of 10 451 women aged 16-30 from five countries with relatively large numbers of immigrants and adult daughters living in Norway in 2008 were included in the study. Descriptive statistics and logistic regression analyses were conducted. The main outcome measure was use of any hormonal contraceptive.

RESULTS

More daughters of immigrants from Vietnam compared with immigrant women from these countries (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8-2.8) and Poland (OR 2.3, 95% CI: 1.6-3.3) used hormonal contraceptives. However, no adjusted differences between generations were detected for immigrants from Pakistan (OR 1.2, 95% CI 1.0-1.4), Morocco (OR 1.0, 95% CI 0.7-1.4) or Chile (OR 1.3, 95% CI 0.8-1.9).

CONCLUSIONS

Further research should explore the reasons for heterogeneity in use of contraception among daughters of immigrants from different origins and explore whether daughters of immigrant mothers from some areas have unmet needs of contraception.

Practices and knowledge of female gynecologists regarding contraceptive use: a real-world Chinese survey

Background

There is no evidence of the practices of obstetricians and gynecologists (OB/GYNs) regarding contraceptive use and determinants influencing contraceptive choices, including emergency methods such as combined oral contraceptives (COCs) and levonorgestrel intrauterine system (LNGIUS). This survey determines the practices and knowledge among Chinese female OB/GYNs regarding modern contraceptive methods.

Methods

A multicenter questionnaire was completed by 2000 female OB/GYNs participating in training courses organized by the gynecological endocrinology training committee of the Chinese Medical Doctor Association from February to May 2013.

Results

This survey achieved a response rate of 51.4%. The rate of induced abortion among this group was 56.3%; this may be attributable to unreliable contraceptive methods (55.5%) and failure of reliable contraceptive methods (18.9%). Intrauterine devices (IUDs) were more commonly used by parous women than nulliparous women (42.6% vs 1.7%; p < 0.0001), followed by condom and rhythm method (24.2% vs 20.8%). However, nulliparous women commonly used rhythm method (48.3% vs 3.3%; p < 0.0001) and condoms (19.2% vs 10.5%; p = 0.008). OB/GYNs demonstrated misconceptions of OB/GYNs about COCs, such as the risk of breast cancer, amenorrhea and premature ovarian failure, and decreased fertility as reported by 37.10, 10.6, and 7.5% of the respondents, respectively.

Conclusions

IUDs were commonly used by parous Chinese OB/GYNs. Unreliable contraceptive methods and misconceptions about the side effects of COCs may result in the high rate of unintended pregnancies. Hence, awareness of safe and effective contraceptive methods should be strengthened among OB/GYNs in China.

Providers perspective and geographic and institutional factors associated with family planning counseling

OBJECTIVES

Family planning (FP) counseling is an essential activity to prevent unplanned pregnancies and allow a fulfilling sex life. We defined adequate counseling in FP as the counseling given to women and men of reproductive age that provided complete information about use, application, effectiveness, side effects, and contraindications. Two objectives are proposed in this study. First, we seek to analyze geographic and institutional factors associated with FP counseling in primary and secondary healthcare facilities in Mexico. Second, we seek to identify the cultural barriers that providers perceive as a limitation of the clients so that they can come to request information related to FP and that are associated with FP counseling.

METHODS

This cross-sectional study uses a complex, probabilistic, stratified sampling design representative at national level by institution, region and rural-urban areas. We collected 16,829 provider questionnaires at healthcare facilities. Bivariate and logistic regression analyses were performed.

RESULTS

Providers in rural areas had a greater possibility of offering adequate counseling (OR = 2.98; 95%CI 1.18-7.53). Providers in the northern region of the country were more likely to provide adequate counseling (OR = 5.37; 95% CI 1.91-15.12). Providers whom perceive religion as a limitation for clients to come to request information about FP are less likely to provide adequate counseling (OR = 0.37; 95% CI 0.15-0.88).

CONCLUSIONS

Physical space exclusively for the provision of FP counseling and the availability of manuals were not associated with adequate counseling. There is a need to address the social and cultural influences on the quality of counseling in these healthcare facilities.

A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study

BACKGROUND

Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling.

OBJECTIVE

The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool.

METHODS

This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention.

RESULTS

We are currently enrolling practices and anticipate study completion in 15 months.

CONCLUSIONS

This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

Provider-based barriers to provision of intrauterine contraception in general practice

OBJECTIVES

Intrauterine contraception (IUC) is highly effective, safe and long-lasting, but is not a popular method of contraception among British women. This study examined barriers to the uptake of IUC in general practice in England.

METHOD

A sequential mixed-method approach to explore the views of practitioners regarding the provision of IUC. We e-surveyed 208 practitioners from 69 practices in a region of England and subsequently interviewed 14 practitioners from eight practices.

RESULTS

Just under half of general practitioners (GPs) (46.8%; 58/124), and only 8.2% (4/49) of nurses reported being trained to fit IUC. Lack of knowledge of IUC was a barrier to fitting, and also to recommending IUC, especially by practitioners who were not trained to fit. There was discordance between reported knowledge of eligibility for IUC and the likelihood of recommending IUC. Respondents were less likely to recommend IUC to young, nulliparous women, women who had experienced a previous ectopic pregnancy, a recent sexually transmitted infection (STI), or an abnormal cervical smear. The qualitative data indicate that risk aversion and limited training, together with practitioners' assessments that women are uninterested, may lead to IUC being precluded as a suitable method.

CONCLUSIONS

Increased practitioner education, for those not trained to fit IUC, may remove a barrier to the uptake of IUC in general practice. More research is required on the discordance between the practitioners' views on the characteristics of women considered suitable for IUC, and the criteria set out in the UK Medical Eligibility Criteria (UKMEC) guidelines.

Perceptions of adolescent 'simulated clients' on barriers to seeking contraceptive services in health centers and pharmacies in Mexico

OBJECTIVE

To examine adolescent simulated clients' perceived barriers to quality care as they sought information on contraceptives in public-sector healthcare facilities and pharmacies in Mexico.

STUDY DESIGN

We used a qualitative research design and conducted semi-structured interviews with eight young women who posed as simulated clients at health centers and pharmacies in Mexico City. Grounded Theory was used to analyze the transcripts.

RESULTS

Barriers to receiving information about contraceptives included healthcare professionals who gave administrative pretexts to avoid providing services. Simulated clients also felt judged by healthcare professionals and reported a lack of simple, understandable and pertinent information. Healthcare professionals did not ensure clients understood and had no further questions about using contraceptives, which resulted in clients' poor perceived self-efficacy, as well as a lack of confidence in the healthcare system to help them.

CONCLUSIONS

When healthcare professionals fail to provide services according to the World Health Organization's five basic criteria of adolescent friendly care, adolescents perceive important barriers in their access to contraceptive methods. Quality of sexual health care in Mexico would benefit from efforts to improve healthcare professionals' knowledge, attitudes and skills related to adolescent friendly service delivery.