Preventing unintended pregnancy among young women in Kenya: prospective cohort study to offer contraceptive implants

Adolescent girls and young women's (AGYW) access to and use of contraception services in Cape Town: perspectives from AGYW and health care providers

BACKGROUND

Access and use of contraception services by adolescent girls and young women (AGYW) remains suboptimal, exposing AGYW to early and often unexpected pregnancy. Unexpected pregnancies are a public health concern, associated with poor neonatal and maternal health outcomes, as well as school dropout, which may result in economic hardships. This study aimed to explore (a) AGYW perceptions and experiences of receiving contraception services from health care providers and (b) health care providers' perceptions and experiences of providing contraception services to AGYW.

METHODS

Data were collected through semi-structured individual interviews with AGYW aged 15-24 years old and health care providers working in eight health care facilities around the Cape Town metropolitan area, in South Africa's Western Cape Province. Thematic analysis was used to analyse the data.

RESULTS

AGYW and health care providers voiced varying, and often contrasting, perceptions of some of the barriers that hinder AGYW's access to contraception services. AGYW indicated that provider-imposed rules about when to access contraceptive services hindered access, while health care providers felt that these rules were necessary for coordinating their work. In addition, AGYW highlighted health care providers' hostile attitudes towards them as an important factor discouraging access. On the contrary, health care providers did not think that their attitudes hampered AGYW's access to and use of contraception services, instead they emphasised that challenges at the health system level were a major issue, which they feel they have little control over. Such challenges made health care providers' work unpleasant and frustrating, impacting on their work approach and how they receive and offer services to AGYW.

CONCLUSION

The expectation of negative attitudes from health care providers continues to be at the centre of AGYW discouragement towards accessing contraception services. System challenges are among some of the key drivers of health care provider's hostile attitudes, posing challenges to the efficient provision of services. In order to improve AGYW's access to and use of contraception services, and subsequently achieve the country's SDGs, conscious efforts need to be directed towards improving the workload and working conditions of health care providers.

Unintended pregnancy and contraception use among African women living with HIV: Baseline analysis of the multi-country US PEPFAR PROMOTE cohort

BACKGROUND

About 90% of unintended pregnancies are attributed to non-use of effective contraception-tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine contraceptive device (IUCD), and implant. We assessed the prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs)-implants and IUCDs, among women living with HIV (WLHIV) receiving antiretroviral therapy (ART).

METHODS

We conducted cross-sectional analyses of the US-PEPFAR PROMOTE study WLHIV on ART at enrollment. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI).

RESULTS

Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with a potential to become pregnant reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR = 0.97 (95% CI: 0.90-1.04), p = 0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with education attained, primary versus higher education, aPRR = 1.10 (95% CI: 1.02-1.18), p = 0.013; marriage/stable union, aPRR = 1.10 (95% CI: 1.01-1.21), p = 0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p = 0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; and controlled HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p = 0.014. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p = 0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p = 0.386; HIV load (≤ 1000 copies/ml copies/ml), aPRR=1.73 (95% CI: 1.26-2.37), p<0.001; and formal/self-employment, aPRR = 1.37 (95% CI: 1.02-1.91), p = 0.027.

CONCLUSIONS

Unintended pregnancy was common while use of effective contraception methods particularly LARCs was low among these African WLHIV. HIV viral load, education, sexual-activity, fertility desires, and economic independence are pertinent individual-level factors integral to the multi-level barriers to utilization of effective contraception among African WLHIV. National programs should prioritize strategies for effective integration of HIV and reproductive health care in the respective African countries.

Task-shifting and family planning continuation: contraceptive trajectories of women who received their method at a community-based event in Kinshasa, DRC

While community-based interventions are a proven high-impact strategy to increase contraceptive uptake in low-income countries, their capacity to support women's contraceptive choices (including continued use, switching and discontinuation) in the long run remains insufficiently discussed. This cohort study follows 883 women 3 and 6 months after they received a modern method during community campaigns organized in Kinshasa (D.R. Congo), to analyze their contraceptive trajectories and the factors associated with ever discontinuing contraceptive use in the first 6 months following a campaign. In the community-based distribution (CBD) model currently institutionalized in DRC, campaign clients are not provided with additional doses or support, besides baseline counseling, to (dis-)continue using the method they received, but must rely on Family Planning resources within the existing local health system. Almost a third (28.9%) of all women discontinued modern contraception during the study period, with much higher discontinuation rates for short-acting methods (38.7% for pills and up to 68.9% for DMPA-SC). Variables previously associated with high discontinuation (marital status, fertility intentions and side-effects) led to higher odds of "ever discontinuing". However, these variables became non-significant when controlling for resupply issues. Women's self-reported reasons for discontinuation confirmed the multivariate regression results. Detailed sub-analysis of resupply issues for pills, injectables and Cyclebeads pointed to the role of cost, unreliable campaign schedules and weak integration of community-based strategies into the formal health system. Extremely low rates of implants removal suggest similar access to FP services issues. The study highlights the need to identify CBD strategies best suited to support women's choices and preferences towards successful contraceptive trajectories in fragile health systems.

Prevalence of and factors associated with contraceptive discontinuation in Kenya

BACKGROUND

 The overwhelming uptake of contraception in Kenya at 58% suggests huge potential for a continued increase, but discontinuation threatens efforts to achieve new targets. Further increases in contraceptive prevalence will depend more on continuation and re-adoption amongst past users because unintended pregnancies would increasingly result from discontinuation. Eliminating discontinuations from side effects and method failure could increase continuation rates by 10%.

AIM

 To establish the prevalence and factors associated with contraceptive discontinuation.

SETTING

 Kenya, with a successful family planning programme, but also the challenge of discontinuation rates of 31%.

METHODS

 Contraceptive calendar data from the 2014 Kenya Demographic and Health Survey were used in the survival analysis approach.

RESULTS

 Overall discontinuation rates were 37% (24 months) and 74% at (36 months), whilst discontinuation in need was 36%. Side effects accounted for 40% of discontinuations, whilst injection and pill recorded the highest rates. Current method emerged as a predictor of discontinuation at 24 months with the following hazard ratio (HR) at 95% confidence interval [CI]; intrauterine device (IUD) (HR = 0.466, CI = 0.254-0.857), injection (HR = 0.801, 95% CI = 0.690-0.930), implants (HR = 0.580, 95% CI = 0.429-0.784) and at 36 months, injection (HR = 0.808, 95% CI = 0.722-0.904) and implants (HR = 0.585, 95% CI = 0.468-0.730). Age (15-24 years) displayed influence only at 36 months (HR = 1.219, 95% CI = 1.044-1.424).

CONCLUSION

 The study showed a close link between contraceptive method used and discontinuation and thus the need to address method-related issues in an attempt to minimise discontinuation in Kenya. Expanding contraceptive options and improving the quality of service can scale up switching and thus help reduce discontinuation and unintended births.

Level and Timing of Implanon Discontinuation and Associated Factors among Women Who Used Implanon in Andabet District, Public Health Facilities, North-West Ethiopia

Background

Implanon discontinuation is unacceptably high in developing countries, including Ethiopia. Furthermore, there is an observed problem of high unintended pregnancy after method discontinuation that strides to program failure. Therefore, the purpose of this study was to assess the level and determinants of Implanon discontinuation among women who used Implanon in Andabet district, public health facilities, North-West Ethiopia, 2017.

Methods

Facility-based cross-sectional study design was employed among 537 women from Feb. 03 to April 28, 2017. Study participants were selected using a systematic random sampling technique. A face-to-face interview was employed to collect data. Epi-Info version 7 was used for data entry and SPSS version 20 for analysis. Both descriptive and analytical statistical analysis was computed. On multivariable binary logistic regression, a p value of less than 0.05 was used to declare statistical significance.

Results

About 37% of Implanon users have discontinued the method before the intended time. About 86% of them discontinued Implanon before two years of insertion. Women who had no live child (AOR = 2.17, 95% CI: 1.25-3.77), women who did not receive preinsertion counseling (AOR = 1.85, 95% CI: 1.15-2.97), women who developed Implanon-related side effect (AOR = 5.17, 95% CI: 3.18-8.40), and women who did not satisfy by the service provided (AOR = 5.40, 95% CI: 3.04-9.57) had higher odds of Implanon discontinuation. On the other hand, women who received appointment follow-up (AOR = 0.23, 95% CI: 0.13-0.41) had lower odds of Implanon discontinuation.

Conclusions

The level of Implanon discontinuation before its intended time was high in the district. Hence, strengthening preinsertion counseling and appointment follow-up as well as improving the clients' level of service satisfaction could increase Implanon's continuation.

Slowing progress: the US Global Gag Rule undermines access to contraception in Madagascar

Madagascar's health system is highly dependent on donor funding, especially from the United States (US), and relies on a few nongovernmental organisations (NGOs) to provide contraceptive services in remote areas of the country. The Trump administration reinstated and expanded the Global Gag Rule (GGR) in 2017; this policy requires non-US NGOs receiving US global health funding to certify that neither they nor their sub-grantees will provide, counsel or refer for abortion as a method of family planning. Evidence of the impact of the GGR in a country with restrictive abortion laws, like Madagascar - which has no explicit exception to save the woman's life - is limited. Researchers conducted semi-structured interviews with 259 representatives of the Ministry of Health and NGOs, public and private health providers, community health workers and contraceptive clients in Antananarivo and eight districts between May 2019 and March 2020. Interviews highlighted the impact of the GGR on NGOs that did not certify the policy and lost their US funding. This reduction in funding led to fewer contraceptive service delivery points, including mobile outreach services, a critical component of care in rural areas. Public and private health providers reported increased contraceptive stockouts and fees charged to clients. Although the GGR is ostensibly about abortion, it has reduced access to contraception for the Malagasy population. This is one of few studies to directly document the impact on women who themselves described their increased difficulties obtaining contraception ultimately resulting in discontinuation of contraceptive use, unintended pregnancies and unsafe abortions.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ ² p .009; I ² = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ ² p .004; I ² = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ ² p .36; I ² = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ ² p < .0001; I ² = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Use of long-acting reversible contraception among adolescents and young women in Kenya

The Kenya Demographic and Health Survey (KDHS 2014) revealed changing patterns in the contraceptive use of young women aged 15-24, shifting from injectable methods to implants. Long-acting reversible contraception (LARC) is user friendly, long-term, and more effective than other modern methods. It could be a game-changer in dealing with unintended pregnancies and herald a new chapter in the reproductive health and rights of young women. This study determined the factors associated with LARC use among adolescent girls and young women to expand the evidence of its potential as the most effective method of reducing unwanted pregnancies among the cohort. This study analysed secondary data from KDHS 2014 using binary logistic regression. The findings showed a rise in LARC use (18%), with identified predictors of reduced odds being aged 15-19 [OR = 0.735, 95% CI = 0.549-0.984], residence (rural) [OR = 0.674, CI = 0.525-0.865], religion (Protestant/other Christian) [OR = 0.377, CI = 0.168-0.842], married, [OR = 0.746, CI = 0.592-0.940], and region (high contraception) [OR = 0.773, CI = 0.626-0.955], while the number of living children showed increased odds for 1-2 children [OR = 17.624, CI = 9.482-32.756] and 3+ children [OR = 23.531, CI = 11.751-47.119]. This study established the rising popularity of LARC and identified factors that can be addressed to promote it. Its increased uptake could help Kenya achieve the International Conference on Population and Development 25's first and second commitments on teenage pregnancies and maternal and new-born health, thus promoting the health, wellbeing, educational goals, and rights of this critical cohort. This study can guide the accelerated efforts needed in Kenya's march towards the five zeros of unmet need for contraception, teenage pregnancies, unsafe abortions, preventable maternal deaths, and preventable neonatal/infant deaths.

Determinants of Implant Utilization among Married Women of Childbearing Age in Chencha Town, Southern Ethiopia, 2017: A Case-Control Study

Globally, 53% of women in reproductive age group use modern methods of contraception, with less than one percent of which using implants. In Ethiopia and other parts of sub-Saharan Africa, short-term contraceptive methods have been more utilized than long-acting methods like implants. Despite their effectiveness, implants have been underutilized due to various reasons. There is a dearth of stronger evidences on those factors in the country in general and the study area in particular. Therefore, this study aimed to identify determinants of implant utilization among married women of reproductive age at Chencha town, Gamo Gofa Zone, Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia. A community-based case-control study design was conducted among 324 women of reproductive age, 90 cases (users of implants) and 234 controls (users of short-acting contraceptives) from July to August 2017. Data were collected using a pretested, structured questionnaire through face-to-face interview. The data were entered and coded using Epi info 3.5.1 and then exported to Statistical Package for Social Sciences (SPSS) version 20 for cleaning and analysis. Descriptive analysis was done to quantify proportions, means, and standard deviations of variables. Bivariate and multivariable logistic regressions were done to identify the determinants of implant utilization. A total of 324 married women of reproductive age group were interviewed with response rate of 98%. In this study, the major determinants for implant utilization were desire to have 3-4 children {AOR = 0.104, 95% CI (0.03, 0.4)}, husband disproval {AOR = 0.11, 95% CI (0.038, 0.314)}, joint decision {AOR = 3.11, 95% CI (1.02, 9.48)}, and decision by other persons {AOR = 0.065, 95% CI (0.012, 0.352)}. This study found out that desire to have more children, husband disapproval, joint decision making, and decision by other persons were determinants of implant utilization among the target women. Implant utilization would improve through strengthening existing interventions targeting women with high fertility desire, transformation of gender norms in household decisions, and counseling for informed decisions.

Access to public transportation and health facilities offering long-acting reversible contraceptives among residents of formal and informal settlements in two cities in Kenya

BACKGROUND

Despite improved health facility access relative to rural areas, distance and transportation remain barriers in some urban areas. Using household and facility data linked to residential and transportation geographic information we describe availability of health facilities offering long-acting reversible contraceptive (LARC) methods and measure access via matatus (privately owned mid-size vehicles providing public transport) in urban Kenya.

METHODS

Study data were collected by the Measurement, Learning and Evaluation (MLE) Project. Location information for clusters (2010) representative of city-level population were used to identify formal and informal settlement residents. We measured straight-line distances between clusters and facilities that participated in facility audits (2014) and offered LARCs. In Kisumu, we created a geographic database of matatu routes using Google Earth. In Nairobi, matatu route data were publicly available via the Digital Matatus Project. We measured straight-line distance between clusters and matatu stops on 'direct' routes (matatu routes with stop(s) ≤1 km from health facility offering LARCs). Facility and matatu access were compared by settlement status using descriptive statistics. We then used client exit interview data from a subset of facilities in Nairobi (N = 56) and Kisumu (N = 37) Kenya (2014) to examine the frequency of matatu use for facility visits.

RESULTS

There were 141 (Informal = 71; Formal = 70) study clusters in Nairoibi and 73 (Informal = 37; Formal = 36) in Kisumu. On average, residential clusters in both cities were located ≤1 km from a facility offering LARCs and ≤ 1 km from approximately three or more matatu stops on direct routes regardless of settlement status. Client exit interview data in Nairobi (N = 1602) and Kisumu (N = 1158) suggest that about 25% of women use matatus to visit health facilities. On average, women who utilized matatus travelled 30 min to the facility, with 5% travelling more than 1 hour. Matatu use increased with greater household wealth.

CONCLUSIONS

Overall, formal and informal settlement clusters were within walking distance of a facility offering LARCs, and multiple matatu stops were accessible to get to further away facilities. This level of access will be beneficial as efforts to increase LARC use expand, but the role of wealth and transportation costs on access should be considered, especially among urban poor.

Motherhood increases support for family planning among Kenyan adolescents

OBJECTIVE

Adolescent fertility rates are high in Kenya, and increase the risks of unintended repeat pregnancies and maternal and infant morbidity and mortality. Our objective was to examine knowledge, practices, and influences surrounding contraceptive access and use among Kenyan postpartum adolescents.

STUDY DESIGN

We conducted a mixed methods study (surveys and focus group discussions) with postpartum adolescents and family planning (FP) providers at two maternal and child health clinics in Kenya.

MAIN OUTCOME MEASURES

Four focus group discussions (FGDs) were conducted with postpartum adolescents (stratified by age and site), and two FGDs were conducted with FP providers (stratified by site). Transcripts were analyzed for prevalent themes. The participants also completed individual surveys that were analyzed for contraceptive knowledge.

RESULTS

Adolescent contraceptive decision-making and use were shaped by social norms of adolescent sexual behaviour. Lack of FP knowledge, community misinformation, and insufficient counselling and time with providers all contributed to adolescent concerns about FP. However, as adolescents transitioned to motherhood, they felt more encouraged to use FP and had increased awareness of FP benefits.

CONCLUSION

Both postpartum adolescents and providers felt delivery of FP services could be improved if providers had better training and counselling tools.

Timing of abortion among adolescent and young women presenting for post-abortion care in Kenya: a cross-sectional analysis of nationally-representative data

Background

Complications of unsafe abortion are a leading cause of maternal mortality in sub-Saharan Africa. Adolescents and young women are disproportionately represented among those at risk of these complications. Currently, we know little about the factors associated with young women’s timing of abortion. This study examined the timing of abortion as well as factors influencing it among adolescents and young women aged 12–24 years who sought post-abortion care (PAC) in health facilities in Kenya.

Methods

We draw on data from a cross-sectional study on the magnitude and incidence of induced abortion in Kenya conducted in 2012. The study surveyed women presenting with a diagnosis of incomplete, inevitable, missed, complete, or septic abortion over a one-month data collection period in 328 health facilities (levels 2–6). Survey data, specifically, from adolescents and young women were analyzed to examine their characteristics, the timing of abortion, and the factors associated with the timing of abortion.

Results

One thousand one hundred forty-five adolescents and young women presented for PAC during the data collection period. Eight percent of the women reported a previous induced abortion and 78% were not using a modern method of contraception about the time of conception. Thirty-nine percent of the index abortions occurred after 12 weeks of gestation. A greater proportion of women presenting with late abortions (more than 12 weeks gestational age) (46%) than those presenting with early abortions (33%) presented with severe complications. Controlling for socio-demographic and reproductive history, timing of abortion was significantly associated with place of residence (marginal), education, parity, clinical stage of abortion and level of severity.

Conclusions

Late-term abortions were substantial, and may have contributed substantially to the high proportion of women with post-abortion complications. Efforts to reduce the severity of abortion-related morbidities and mortality must target young women, particularly those living in rural and other remote areas. Interventions to reduce unintended pregnancies in this population are also urgently needed to improve early pregnancy detection and timely care seeking.

Factors associated with nonadherence to instructions for using the Nestorone®/ethinyl estradiol contraceptive vaginal ring

OBJECTIVES

We sought to identify factors associated with nonadherence to instructions for using a novel contraceptive providing 1 year of protection.

STUDY DESIGN

Data from a multicountry Phase 3 trial of the Nestorone® (segesterone acetate)/ethinyl estradiol (NES/EE) contraceptive vaginal ring (CVR) were analyzed. Participants were instructed to use the CVR over 13 cycles and follow a 21/7 regimen. Their reports of CVR removals >2 h outside scheduled removal periods served as a proxy for nonadherence. We used multivariate logistic regression to determine factors associated with such use.

RESULTS

Of 905 participants, 120 (13%) reported CVR removals >2 h. Removals for washing [odds ratio (OR) 3.96, 95% confidence interval (CI) 2.50-6.27] or sexual intercourse (OR 3.19, 95% CI 2.03-4.99), and finding CVR insertion difficult (OR 2.80, 95% CI 1.36-5.80) were factors associated with removals >2 h. Lower educational attainment also predicted ring removal >2 h (OR 3.23, 95% CI 1.55-6.75). Women residing in Europe or Australia were less likely to remove the ring for >2 h compared with women in the United States (OR 0.44, 95% CI 0.24-0.83 and OR 0.13, 95% CI 0.02-0.98, respectively). Participants who reported removals >2 h were more likely to discontinue CVR use (OR 1.93, 95% CI 1.24-2.95), report dissatisfaction (OR 2.20, 95% CI 1.32-3.69) and become pregnant during the study (OR 4.07, 95% CI 1.58-10.50).

CONCLUSIONS

Removing the CVR for washing and removing it before intercourse are factors associated with nonadherence to ring use. These are important topics for counseling women who are considering or using vaginal rings, including the NES/EE CVR.

IMPLICATIONS

Findings from this study may be useful in guiding counseling for current and prospective vaginal ring users. Anticipatory guidance should focus on how the ring feels in the vagina and during sex. Asking about ring removals may help identify women who are at increased risk for having an unplanned pregnancy.

A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it

Background

Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a “never-before” opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights.

Main body

In this commentary, we call for action in several key areas to address adolescents’ persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a ‘condoms-only’ mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents.

Conclusion

This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

Making good on a call to expand method choice for young people - Turning rhetoric into reality for addressing Sustainable Development Goal Three

Background

Investments in the nearly two billion young people, aged 10–24 years, in the world today are necessary to meet global development commitments, specifically the Sustainable Development Goals and Ending Preventable Child and Maternal Deaths. More than 12 million married and unmarried adolescents (aged 15–19) will give birth in 2016. Complications of pregnancy and childbirth are the second leading cause of death among 15–19 year-old women and early childbearing can significantly curtail social and economic prospects for young women. Facilitating the ability of sexually active young people to choose and effectively use a satisfactory contraceptive method will ensure they can exercise their right to prevent, delay or space pregnancy.

The Global Consensus Statement, “Expanding Contraceptive Choice for Adolescents and Youth to Include Long Acting and Reversible Contraception” provides evidence on the safety and effectiveness of LARCs for young people. Three inter-dependent actions linking advocacy and policy (advocating for policy and guideline revisions); supply (improving quality and accessibility of an expanded method choice) and an enabling environment (social norms and comprehensive reproductive health information) are suggested as vital to achieving full access and full choice for all sexually active young people. Identified approaches include national advocacy addressing policy guidelines and standard operating procedures that guide providers in the provision of age and developmentally appropriate contraceptive services; pre-service and in-service training for health care providers to be able to effectively communicate and counsel young people, including dispelling myths and misconceptions around LARCs; and partnering with young people to design appropriate, contextually-relevant, and effective strategies to increase their self-efficacy and, at the community level, address broader social norms to dispel stigma and discrimination.

Conclusion

An immediate call to action for collaborative and coordinated global, regional and national efforts that enable full access and full choice for all young people is paramount to achieve their reproductive health intentions and the Sustainable Development Goal targets.

Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature

Adolescent pregnancy, particularly unintended pregnancy, can have lasting social, economic, and health outcomes. The objective of this review is to identify high-quality interventions and evaluations to decrease unintended and repeat pregnancy among young people in low- and middle-income countries. PubMed, Embase, PsycInfo, Cinahl Plus, Popline, and the Cochrane Databases were searched for all languages for articles published through November 2015. Gray literature was searched by hand. Reference tracing was utilized, as well as unpacking systematic reviews. Selected articles were those that were evaluated as having high-quality interventions and evaluations using standardized scoring. Twenty-one high-quality interventions and evaluations were abstracted. Nine reported statistically significant declines in pregnancy rates (five cash transfer programs, one education curriculum, two life-skills curricula, and a provision of contraception intervention), seven reported increases in contraceptive use (three provision of contraception interventions, two life-skills curricula, a peer education program, and a mass media campaign), two reported decreases in sexual activity (a cash transfer program and an education and life-skills curriculum), and two reported an increase in age of sexual debut (both cash transfer programs). The selected high quality, effective interventions included in this review can inform researchers, donors, and policy makers about where to make strategic investments to decrease unintended pregnancy during young adulthood. Additionally, this review can assist with avoiding investments in interventions that failed to produce significant impact on the intended outcomes. The diversity of successful high-quality interventions, implemented in a range of venues, with a diversity of young people, suggests that there are multiple strategies that can work to prevent unintended pregnancy.

Previous induced abortion among young women seeking abortion-related care in Kenya: a cross-sectional analysis

Background

Unsafe abortion is a leading cause of death among young women aged 10–24 years in sub-Saharan Africa. Although having multiple induced abortions may exacerbate the risk for poor health outcomes, there has been minimal research on young women in this region who have multiple induced abortions. The objective of this study was therefore to assess the prevalence and correlates of reporting a previous induced abortion among young females aged 12–24 years seeking abortion-related care in Kenya.

Methods

We used data on 1,378 young women aged 12–24 years who presented for abortion-related care in 246 health facilities in a nationwide survey conducted in 2012. Socio-demographic characteristics, reproductive and clinical histories, and physical examination assessment data were collected from women during a one-month data collection period using an abortion case capture form.

Results

Nine percent (n = 98) of young women reported a previous induced abortion prior to the index pregnancy for which they were receiving care. Statistically significant differences by previous history of induced abortion were observed for area of residence, religion and occupation at bivariate level. Urban dwellers and unemployed/other young women were more likely to report a previous induced abortion. A greater proportion of young women reporting a previous induced abortion stated that they were using a contraceptive method at the time of the index pregnancy (47 %) compared with those reporting no previous induced abortion (23 %). Not surprisingly, a greater proportion of young women reporting a previous induced abortion (82 %) reported their index pregnancy as unintended (not wanted at all or mistimed) compared with women reporting no previous induced abortion (64 %).

Conclusions

Our study results show that about one in every ten young women seeking abortion-related care in Kenya reports a previous induced abortion. Comprehensive post-abortion care services targeting young women are needed. In particular, post-abortion care service providers must ensure that young clients receive contraceptive counseling and effective pregnancy prevention methods before discharge from the health care facility to prevent unintended pregnancies that may result in subsequent induced abortions.

Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Progestin-Only Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 8: PROGESTIN-ONLY CONTRACEPTION: Summary Statements Recommendations.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

WHO Tiered-Effectiveness Counseling Is Rights-Based Family Planning

Contraceptive effectiveness is the leading characteristic for most women when choosing a method, but they often are not well informed about effectiveness of methods. Because of the serious consequences of “misinformed choice,” counseling should proactively discuss the most effective methods—long-acting reversible contraceptives and permanent methods—using the WHO tiered-effectiveness model.

Depot Medroxyprogesterone Acetate Use Is Associated With Elevated Innate Immune Effector Molecules in Cervicovaginal Secretions of HIV-1-Uninfected Women

OBJECTIVE

The effects of sex hormones on the immune defenses of the female genital mucosa and its susceptibility to infections are poorly understood. The injectable hormonal contraceptive depot medroxyprogesterone acetate (DMPA) may increase the risk for HIV-1 acquisition. We assessed the local concentration in the female genital mucosa of cationic polypeptides with reported antiviral activity in relation to DMPA use.

METHODS

HIV-1-uninfected women were recruited from among couples testing for HIV in Nairobi, Kenya. Cervicovaginal secretion samples were collected, and the concentrations of HNP1-3, LL-37, lactoferrin, HBD-2, and SLPI were measured by enzyme-linked immunosorbent assays. Levels of cationic polypeptides in cervicovaginal secretions were compared between women who were not using hormonal contraception and those using DMPA, oral, or implantable contraception.

RESULTS

Among 228 women, 165 (72%) reported not using hormonal contraception at enrollment, 41 (18%) used DMPA, 16 (7%) used an oral contraceptive, and 6 (3%) used a contraceptive implant. Compared with nonusers of hormonal contraception, DMPA users had significantly higher mean levels of HNP1-3 (2.38 vs. 2.04 log₁₀ ng/mL; P = 0.024), LL-37 (0.81 vs. 0.40 log10 ng/mL; P = 0.027), and lactoferrin (3.03 vs. 2.60 log₁₀ ng/mL; P = 0.002), whereas SLPI and HBD-2 were similar.

CONCLUSIONS

Although all analyzed cationic polypeptides have intrinsic antiviral capacity, their interaction and cumulative effect on female genital mucosa susceptibility to infections in vivo has yet to be unraveled. This study suggests a potential mechanism underlying the effect of DMPA on the innate immune defenses, providing a rationale to investigate its effect on HIV-1 acquisition risk.

Interventions to improve adolescents' contraceptive behaviors in low- and middle-income countries: a review of the evidence base

OBJECTIVE(S)

Many adolescents in developing countries have an unmet need for contraception, which can contribute to poor reproductive health outcomes. Recent literature reviews have not adequately captured effective contraceptive services and interventions for adolescents in low- and middle-income countries (LMICs). This study aims to identify and evaluate the existing evidence base on contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes.

STUDY DESIGN

Structured literature review of published and unpublished papers about contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes.

RESULTS

We identify common elements used by programs that measured an impact on adolescent contraceptive behaviors and summarize outcomes from 15 studies that met inclusion criteria. Effective programs generally combined numerous program approaches and addressed both user and service provision issues. Overall, few rigorous studies have been conducted in LMICs that measure contraceptive behaviors. Few interventions reach the young, the out of school and other vulnerable groups of adolescents.

CONCLUSION(S)

Though the evidence base is weak, there are promising foundations for adolescent contraceptive interventions in nearly every region of the world. We offer recommendations for programmers and identify gaps in the evidence base to guide future research.

Characteristics of Kenyan women in a prospective cohort study who continue using subdermal contraceptive implants at 12 months

OBJECTIVE

Subdermal contraceptive implant continuation has not been well studied in Africa. We conducted a secondary data analysis to compare baseline characteristics of Kenyan women who continued to use the subdermal implant at 12 months to those who did not.

STUDY DESIGN

Kenyan women aged 18-24 years who presented to a family planning clinic for short-acting hormonal contraception were offered a two-rod subdermal implant instead. Participants were followed for 12 months after initiation of their contraceptive method. Statistical analysis included Pearson's chi-square or Fisher's exact tests for comparisons of proportions. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to determine factors associated with continuation.

RESULTS

Eighty-six (89%) of the 97 women who chose the implant were followed for 12 months. Of these women, 68 (79%) continued to use the implant. None of the factors we examined had a statistically significant association with continued use of the implant. Duration of intended use was the only strong factor; 83% of women with 3+ years of need continued using the implant, compared to 56% of those with shorter needs (Risk ratio = 1.48, 95% CI = 0.94-2.31). No substantive continuation differences were found when comparing other participant characteristics including months with their current partner, personal desire and partner preference for future children, previous use of modern birth control and other factors.

CONCLUSION

High implant continuation rates were noted regardless of previous use of modern birth control, partner preference for children or baseline concern for menstrual change.

IMPLICATIONS

Contraceptive use in Africa continues to focus on short-acting contraceptives despite the proven superior efficacy of long-acting reversible contraceptives in other settings. The high subdermal implant continuation among Kenyan women in this prospective study, regardless of baseline characteristics, supports the need for increasing access and future research in this population.

Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia

OBJECTIVE

To describe predictors of contraceptive method discontinuation and switching behaviours among HIV-positive couples receiving couples' voluntary HIV counselling and testing services in Lusaka, Zambia.

DESIGN

Couples were randomized in a factorial design to two-family planning educational intervention videos, received comprehensive family planning services and were assessed every 3 months for contraceptive initiation, discontinuation and switching.

METHODS

We modelled factors associated with contraceptive method upgrading and downgrading via multivariate Andersen-Gill models.

RESULTS

Most women continued the initial method selected after randomization. The highest rates of discontinuation/switching were observed for injectable contraceptive and intrauterine device users. Time to discontinuing the more effective contraceptive methods or downgrading to oral contraceptives or condoms was associated with the women's younger age, desire for more children within the next year, heavy menstrual bleeding, bleeding between periods and cystitis/dysuria. Health concerns among women about contraceptive implants and male partners not wanting more children were associated with upgrading from oral contraceptives or condoms. HIV status of the woman or the couple was not predictive of switching or stopping.

CONCLUSION

We found complicated patterns of contraceptive use. The predictors of contraception switching indicate that interventions targeted to younger couples that address common contraception-related misconceptions could improve effective family planning utilization. We recommend these findings be used to increase the uptake and continuation of contraception, especially long-acting reversible contraceptive (LARC) methods, and that fertility goal based, LARC-focused family planning be offered as an integral part of HIV prevention services.

There are some questions you may not ask in a clinic: providing contraception information to young people in Kenya using SMS

OBJECTIVE

To evaluate the acceptability, information access, and potential behavioral impact of providing contraception information via text message on mobile phones to young people in Kenya.

METHODS

Three methods of data collection were implemented during the 17-month pilot period for the Mobile for Reproductive Health (m4RH) program in Kenya: automatic logging of all queries to the m4RH system; demographic and behavior change questions sent via short message service protocol (SMS) to everyone who used m4RH during the pilot period; and telephone interviews with a subset of m4RH users.

RESULTS

During the pilot period, 4817 unique users accessed m4RH in Kenya. Of these, 82% were 29 years of age and younger, and 36% were male. Condom and natural family-planning information was accessed most frequently, although users queried all methods. One in 5 used the m4RH system to locate nearby clinics. Respondents liked the simple language and confidentiality of receiving health information via mobile phone, and reported increased contraceptive knowledge and use after using m4RH.

CONCLUSION

Providing contraception information via mobile phone is an effective strategy for reaching young people. More research is needed to learn how to link young people to youth-friendly services effectively.