Continuation of copper-containing intrauterine devices at 6 months

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION AND RECOMMENDATION

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

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

Background

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

Methods

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

Results

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

Discussion and Implications

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

Switching and discontinuation of participant-masked randomization to a copper or levonorgestrel intrauterine device when presenting for emergency contraception

OBJECTIVES

Examine intrauterine device (IUD) switching or discontinuation up to 6 months after participant-masked randomization to different IUDs.

STUDY DESIGN

Participants were randomized 1:1 to the copper T380A or levonorgestrel 52 mg IUD for emergency contraception and informed they could switch IUD type without cost at any time.

RESULTS

Of the 327 subjects allocated to the levonorgestrel IUD, 7 (2.1%) switched their IUD type by 6 months versus 18 (5.5%) of the 328 copper IUD users (RR: 0.4 [95% CI: 0.2, 0.9], p = 0.03). Six-month IUD discontinuation occurred in 34 (10.4%) levonorgestrel and 35 (10.7%) copper IUD users.

CONCLUSION

Individuals randomly assigned to IUD type at presentation for emergency contraception continue their assigned IUDs at high rates over 6 months.

IMPLICATIONS

While many recruited individuals declined enrollment, those who accepted randomization had high continuation rates; the high continuation and low cross-over supports using IUD randomization as a tool for future investigation. Participants' similar rates of and reasons for switching and discontinuation by IUD type over the study period may impact clinical counseling.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Systematic review registration

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

Systematic review of copper intrauterine contraception continuation in young nulliparous women based on intrauterine device type

OBJECTIVES

No copper intrauterine device (IUD) type is known to better suit young nulliparous women who tend to experience higher rates of IUD discontinuation compared with their older parous counterparts. A systematic review to determine which IUDs have higher continuation rates in young nulliparous women was undertaken.

DESIGN

Systematic review and meta-analyses of available evidence based on IUD type.

DATA SOURCES

AMED, BNI, CINAHL, DARE, EMBASE, EMCARE, HMIC, MEDLINE, PsycINFO, PubMed, TRIP, and the Cochrane Library electronic databases were searched from inception to 11 May 2022; as well as the Bandolier, Medicines and Healthcare products Regulatory Agency, Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Department of Health, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines, WHO and Google Scholar websites.

ELIGIBILITY CRITERIA

All studies on IUDs currently available in the UK or comparable (same design and size) to those available in the UK, involving nulliparous women of any age including those aged under 30.

DATA EXTRACTION AND SYNTHESIS

Independently extracted data were assessed as low risk of bias using the Mixed Methods Appraisal Tool. Random effects meta-analyses of proportions were performed where data, including subgroups, were amenable to quantitative synthesis. Heterogeneity was reported using tau² and I² statistics, and sensitivity analyses were also performed.

RESULTS

Nineteen studies involving 13 045 nulliparous women were included but the heterogeneity of participant ages, parity and IUD types made quantitative synthesis of outcome data in totality inappropriate. The highest continuation rate obtained was 91.02% (95% CI 88.01% to 93.64%) for the smaller TCu 380A at 12 months post insertion.

CONCLUSIONS

Evidence for IUD use in young nulliparous women based on IUD type remains limited. Smaller sized IUD types appear better suited to this group of IUD users, however, more research is needed.

PROSPERO REGISTRATION NUMBER

CRD42019120969.

Factors associated with discontinuation among long-acting reversible contraceptive users: a multisite prospective cohort study in urban public health facilities in Ethiopia

OBJECTIVE

The study aims to determine discontinuation among long-acting reversible contraceptive users at 3, 6, 9 and 12 months after initiation and its associated factors among new long-acting reversible contraceptive (LARC) users.

DESIGN

A facility-based multicentre prospective cohort study was conducted with a sample size of 1766 women.

SETTING

The study was conducted in five large cities of Ethiopia (Addis Ababa, Gondar, Mekelle, Jimma and Harar) between March 2017 and December 2018. Various referral hospitals and health centres that are found in those cities are included in the study.

PARTICIPANTS

The study population was all women who were new users of LARCs and initiated LARCs in our selected public health facilities during the enrolment period.

INTERVENTIONS

A pretested structured questionnaire was administered at enrolment and at 6 and 12 months to determine discontinuation proportion and factors associated with discontinuation.

RESULT

From the total of 1766 women sampled for the study only 1596 (90.4%) participants completed all the questionnaires including the 12-month follow-up study. The overall proportion of discontinuation of LARCs at 12 months was 21.8% (95% CI 19.8 to 23.9). The overall discontinuation proportions at 3, 6, 9 and 12 months were 2.94%, 8.53%, 3.94% and 6.36%, respectively. Location of method initiation (adjusted HR (aHR)=5.77; (95% CI 1.16 to 28.69)) and dissatisfaction with the method (aHR=0.09; (95% CI 0.03 to 0.21)) were found to be the predictors of discontinuation among intrauterine contraceptive device users. Being satisfied with the method (aHR=0.21; (95% CI 0.15 to 0.27)), initiation after post abortion (aHR=0.48; (95% CI: 0.26, 0.89)) and joint decision with partner for method initiation (aHR=0.67; (95% CI: 0.50, 0.90)) were inversely associated with implant discontinuation.

CONCLUSION

The majority of LARC users discontinue the method in the first 6 months after insertion and dissatisfaction with the method increased the likelihood of removal during the first year of LARC use.

Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review

OBJECTIVE

Levonorgestrel-releasing intrauterine devices (LNG-IUDs) and copper intrauterine devices (Cu-IUDs) offer long-acting contraception; however, some women may discontinue use within the first year due to bleeding pattern changes, limiting their potential. This systematic literature review investigated whether differences in bleeding profiles influence continuation rates in women in America, Europe and Australia.

METHODS

Searches performed in PubMed and Embase were screened to identify publications describing bleeding patterns and rates of early IUC removal/discontinuation or continuation, descriptions of bleeding patterns, reasons for discontinuation, and patient satisfaction, acceptability and tolerability for LNG-IUDs and Cu-IUDs published between January 2010 and December 2019. The results were further restricted to capture citations related to 'Humans' and 'Females'. The review was limited to studies published from 2010 onwards, as changing attitudes over time mean that results of studies performed before this date may not be generalizable to current practice.

RESULTS

Forty-eight publications describing 41 studies performed principally in the USA (n = 17) and Europe (n = 13) were identified. Publications describing bleeding patterns in LNG-IUD users (n = 11) consistently observed a reduction in bleeding in most women, whereas two of three studies in Cu-IUD users reported heavy bleeding in approximately 40% of patients. Rates of discontinuation for both devices ranged widely and may be as high as 50% but were lower for LNG-IUDs versus Cu-IUDs. Discontinuation rates due to bleeding were consistently higher for Cu-IUDs versus LNG-IUDs.

CONCLUSIONS

Bleeding is a common reason for discontinuation of Cu-IUDs and LNG-IUDs. The more favourable bleeding pattern observed in LNG-IUD users may be associated with a lower rate of early discontinuation of LNG-IUDs versus Cu-IUDs.

Continuation of Copper T in Immediate Postplacental, Immediate Postabortal and Interval Period of Insertion

AIM

Copper containing IUCDs are one of most effective mode of contraception for birth spacing. We conducted this prospective observational study to suggest a possible better period of insertion of IUCDs with cost-saving benefits.

METHODS

All married women in the reproductive age group desirous of Copper-T 375 IUD insertion in either immediate postplacental (PP), immediate postabortal (PA) or interval (INT) period were recruited. The women were asked to return for scheduled follow-up visits at 6 weeks, 6 months and 12 months. They were advised to visit family planning clinic any time if they experienced pelvic pain, discharge per vaginum, unusual bleeding or missed periods. At each visit, women were interviewed for any side effects they have experienced and were asked to elaborate. Pelvic pain was assessed from visual analogue scale. Continuation rate was measured at the end of one year.

RESULTS

Women in INT group (90.14%) had the highest continuation rate followed by PP (83.18%) and PA (80%) groups. Women in PP (AOR = 3.37, 95% CI 1.17-9.72) and PA (AOR = 4.53, 95% CI 1.33-14.04) groups had higher odds of discontinuation compared to INT group after adjusting for age, parity, working and education status. There was a significant difference between the groups when cumulative expulsion was considered (p = 0.045), but none when cumulative removal (p = 0.107) was taken into account.

CONCLUSION

The continuation rate remained high in women who had insertion in the interval period compared to immediate postplacental and postabortal periods.

[Copper-containing intrauterine device (cIUD): Comparison of tolerance and efficacy in nulliparous and parous women over 6 months]

INTRODUCTION

The copper-containing intra-uterine device IUD (cIUD) is a non-hormonal, effective, long-acting method of contraception, which is not widely used in nulliparous patients in France. The objectives of the study are to compare the safety of the cIUD by the rate of continuation at 6 months between nulliparous and parous patients, and to assess the complications and side effects at insertion and during follow-up. Material and method This is a multicenter prospective epidemiological study with follow-up for 6 months. The adult patients were included in Nantes from February 2019 to October 2019 during the insertion of a IUD in different centers: the student health service (SUMPPS) (Nantes), the Clotilde de Vautier center in the Clinic Jules Verne (Nantes) and in the gynecological offices of the city of Nantes.

RESULTS

A total of 94 patients were included during the insertion of the cIUD. At 6 months, 77 patients answered the second questionnaire, 49 patients were nulliparous and 28 were parous. The pain on insertion was greater in nulliparous patients with a VAS of 6.5±2.4 (0-10) versus 3.9±2.2 (0-8) for multiparous patients (P<10^-4). The 6-month continuation rate for the cIUD was 92.8% for 83.4% for nulliparous patients, and parous patients with no significant difference (P=0.25). Expulsion was the only complication found with 12.2% in nulliparous and 3.5% in parous (P=0.40). Otherwise, 64% of the patients observed heavy bleeding than before without difference with the parity, and 72% of the nulliparous declared to have dysmenorrhea requiring the use of analgesics, against 47% of the parous (P=0.025). The nulliparous were very satisfied or satisfied for 89% in daily life and 96% of them in sex life, without difference compared to parous (97% and 100% respectively).

CONCLUSION

There is no difference in the rate of continuation at 6 months between nulliparous and parous. Nulliparous complained more often of dysmenorrhea in comparison to the period before the cIUD. The satisfaction rates were comparable.

A 1-year comparison of TCu380Ag versus TCu380A intrauterine contraceptive devices in India

OBJECTIVE

To compare TCu380Ag and TCu380A intrauterine contraceptive devices after 1 year of use.

METHODS

A prospective randomized controlled trial was conducted among healthy married women aged 20-35 years who attended the family planning clinics of three tertiary centers in India between August 1, 2015, to March 31, 2018. The TCu380Ag group (n=300) received one of three sizes of this device depending on uterocervical length: maxi (8.0-9.0 cm), normal (7.0-8.5 cm), or mini (6.0-7.5 cm). The remaining 300 participants received TCu380A. Follow-up was conducted at 3-monthly intervals to assess continuation rate, acceptability, efficacy, adverse effects, and complications.

RESULTS

The TCu380Ag group had a higher continuation rate than the TCu380A group at 1 year (84.0% vs 75.8%; P=0.01), with an efficacy of 99.6% versus 100.0% (P>0.05). Overall estimated continuation rates were 94.5% (95% confidence interval [CI] 91.7%-96.4%) and 88.4% (95% CI 83.2%-91.5%), respectively (P=0.026). Use of TCu380Ag was associated with fewer adverse effects (heavy menstrual bleeding, abdominal pain, or expulsion) when compared with TCu380A (P>0.05 for all comparisons). Discontinuation rates owing to adverse effects were 6.59% for TCu380Ag versus 13.26% for TCu380A (P=0.01).

CONCLUSIONS

Varying sizes of TCu380Ag could provide an alternative to TCu380A.

One-year continuation of postpartum intrauterine contraceptive device: findings from a retrospective cohort study in India

Objective

To evaluate outcomes of a national postpartum (within 48 h of delivery) copper intrauterine device placement (PPCuIUD) program in six “high-focus states” with high unmet family planning need in India.

Study design

We identified high-volume district hospitals that provided PPCuIUD in six (Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Chhattisgarh) Indian states (two per state). Each selected hospital maintained a list of PPCuIUD acceptors with contact phone numbers. We randomly selected 100 women at each site for inclusion in a telephone survey of IUD outcomes at 1 year. Questions regarded IUD expulsion, discontinuation because of symptoms (e.g., pain, bleeding, discharge), discontinuation for other reasons and use of alternative contraception if discontinuation reported.

Results

We could contact 844 of the 1200 randomly selected women, of whom 673 (79.7%) had postplacental insertion (within 10 min of delivery), while 171 (20.3%) had an early postpartum insertion (between 10 min to 48 h after delivery). Of those contacted, 530 women (62.8%) reported continuing with the method beyond 1 year, 63 (7.5%) reported having an expulsion, 163 (19.3%) reported having removals for associated side effects (bleeding, pain and discharge), and 88 (10.4%) reported having removals for other reasons. After removal or expulsion, almost half of the women (46.5%) did not switch to any other modern contraceptive method.

Conclusion

PPCuIUD continuation rate at 1 year was 62.8%. Most removals within 1 year were due to associated side effects. Almost half of the women discontinuing PPCuIUD did not switch to an alternative modern contraceptive method.

Implications

The 1-year continuation rate of PPCuIUD achieved through a large-scale national program in India is satisfactory. The program though needs to address the low uptake of other modern contraceptive methods after discontinuation.

[The contraception consultation: CNGOF Contraception Guidelines]

OBJECTIVE

Determine the most accurate information to give to women, the most efficient way of doing it, the physical examination during a contraceptive visit and the most appropriate follow-up.

METHODS

A systematic review of French-speaking or English-speaking evidence-based literature about contraception and its visit was performed using Pubmed, Cochrane and international recommendations.

RESULTS

Showing a contraceptive preference decreases women's satisfaction (EL1) and may decrease contraceptive persistence (EL4). A GATHER's like structured consultation is recommended (Grade A). It allows a contraceptive choice improvement (EL2). Contraceptive knowledge improvement associated with a structured consultation allows a decrease in unplanned pregnancies (EL1) compared to a traditional non-personalized consultation. The main expectations of women are slightly different from what is expected by practitioners (EL2). The main topics to be addressed are efficiency, risks, cost, duration of action and practicality (EL2). The quality of interpersonal communication could allow greater contraceptive persistence (EL2). A careful behavior at the beginning of the consultation and facilitating the expression of the woman's point of view could increase the persistence of the initially prescribed contraception (EL2). Explaining the chosen contraception's adverse effect is recommended because it could allow a better persistence (Grade B). Decision aids has shown interest in the therapeutic choice (EL1). Computerized modules or slide shows in the waiting room before consultation could make the contraceptive choice easier (EL2). The presentation of contraception by effectiveness categories is better than pregnancy numbers for comparing the methods (EL1). Performing a blood pressure measurement prior to an estroprogestative contraception prescription is recommended (Grade C). In women without risk factors, literature data do not allow specific recommendations regarding breast, pelvic examination, laboratory screening and follow-up (Professional agreement).

Impact of Contraceptive Education on Knowledge and Decision Making: An Updated Systematic Review

CONTEXT

Educational interventions can help individuals increase their knowledge of available contraceptive methods, enabling them to make informed decisions and use contraception correctly. This review updates a previous review of contraceptive education.

EVIDENCE ACQUISITION

Multiple databases were searched for articles published March 2011-November 2016. Primary outcomes were knowledge, participation in and satisfaction/comfort with decision making, attitudes toward contraception, and selection of more effective methods. Secondary outcomes included contraceptive behaviors and pregnancy. Excluded articles described interventions that had no comparison group, could not be conducted feasibly in a clinic setting, or were conducted outside the U.S. or similar country.

EVIDENCE SYNTHESIS

A total of 24,953 articles were identified. Combined with the original review, 37 articles met inclusion criteria and described 31 studies implementing a range of educational approaches (interactive tools, written materials, audio/videotapes, and text messages), with and without healthcare provider feedback, for a total of 36 independent interventions. Of the 31 interventions for which knowledge was assessed, 28 had a positive effect. Fewer were assessed for their effect on attitudes toward contraception, selection of more effective methods, contraceptive behaviors, or pregnancy-although increased knowledge was found to mediate additional outcomes (positive attitudes toward contraception and contraceptive continuation).

CONCLUSIONS

This systematic review is consistent with evidence from the broader healthcare field in suggesting that a range of interventions can increase knowledge. Future studies should assess what aspects are most effective, the benefits of including provider feedback, and the extent to which educational interventions can facilitate behavior change and attainment of reproductive health goals.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Continuation of copper and levonorgestrel intrauterine devices: a retrospective cohort study

BACKGROUND

Studies conflict on whether the duration of use of the copper intrauterine device is longer than that of the levonorgestrel intrauterine device, and whether women who continue using intrauterine devices differ from those who discontinue.

OBJECTIVE

We sought to assess continuation rates and performance of levonorgestrel intrauterine devices compared with copper intrauterine devices over a 5-year period.

STUDY DESIGN

We performed a retrospective cohort study of 1164 individuals who underwent intrauterine device placement at an urban academic medical center. The analysis focused on a comparison of continuation rates between those using levonorgestrel intrauterine device and copper intrauterine device, factors associated with discontinuation, and intrauterine device performance. We assessed the differences in continuation at discrete time points, pregnancy, and expulsion rates using χ² tests and calculated hazard ratios using a multivariable Cox model.

RESULTS

Of 1164 women who underwent contraceptive intrauterine device insertion, 956 had follow-up data available. At 2 years, 64.9% of levonorgestrel intrauterine device users continued their device, compared with 57.7% of copper intrauterine device users (P = .11). At 4 years, continuation rates were 45.1% for levonorgestrel intrauterine device and 32.6% for copper intrauterine device (P < .01), and at 5 years continuation rates were 28.1% for levonorgestrel intrauterine device and 23.8% for copper intrauterine device (P = .33). Black race, primiparity, and age were positively associated with discontinuation; education was not. The hazard ratio for discontinuation of levonorgestrel intrauterine device compared with copper intrauterine device >4 years was 0.71 (95% confidence interval, 0.55-0.93) and >5 years was 0.82 (95% confidence interval, 0.64-1.05) after adjusting for race, age, parity, and education. Copper intrauterine device users were more likely to experience expulsion (10.2% copper intrauterine device vs 4.9% levonorgestrel intrauterine device, P < .01) over the study period and to become pregnant in the first year of use (1.6% copper intrauterine device vs 0.1% levonorgestrel intrauterine device, P < .01).

CONCLUSION

We found a difference in continuation rates between levonorgestrel and copper intrauterine device users at 4 years but not at 5 years. Copper intrauterine device users were more likely to experience expulsion and pregnancy.

Long-acting reversible contraception in adolescents: a systematic review and meta-analysis

BACKGROUND

Among adolescent pregnancies, 75% are unintended. Greater use of highly-effective contraception can reduce unintended pregnancy. Although multiple studies discuss adolescent contraceptive use, there is no consensus regarding the use of long-acting reversible contraception as a first-line contraception option.

OBJECTIVE

We performed a systematic review of the medical literature to assess the continuation of long-acting reversible contraceptives among adolescents.

STUDY DESIGN

Ovid-MEDLINE, Cochrane databases, and Embase databases were searched using key words relevant to the provision of long-acting contraception to adolescents. Articles published from January 2002 through August 2016 were selected for inclusion based on specific key word searches and detailed review of bibliographies. For inclusion, articles must have provided data on method continuation, effectiveness, or satisfaction of at least 1 long-acting reversible contraceptive method in participants <25 years of age. Duration of follow-up had to be ≥6 months. Long-acting reversible contraceptive methods included intrauterine devices and the etonogestrel implant. Only studies in the English language were included. Guidelines, systematic reviews, and clinical reviews were examined for additional citations and relevant points for discussion. Of 1677 articles initially identified, 90 were selected for full review. Of these, 12 articles met criteria for inclusion. All studies selected for full review were extracted by multiple reviewers; inclusion was determined by consensus among authors. For studies with similar outcomes, forest plots of combined effect estimates were created using the random effects model. The meta-analysis of observational studies in epidemiology guidelines were followed. Primary outcomes measured were continuation of method at 12 months, and expulsion rates for intrauterine devices.

RESULTS

This review included 12 studies, including 6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial. The 12 studies included 4886 women age <25 years: 4131 intrauterine device users and 755 implant users. The 12-month continuation of any long-acting reversible contraceptive device was 84.0% (95% confidence interval, 79.0-89.0%). Intrauterine device continuation was 74.0% (95% confidence interval, 61.0-87.0%) and implant continuation was 84% (95% confidence interval, 77.0-91.0%). Among postpartum adolescents, the 12-month long-acting reversible contraceptive continuation rate was 84.0% (95% confidence interval, 71.0-97.0%). The pooled intrauterine device expulsion rate was 8.0% (95% confidence interval, 4.0-11.0%).

CONCLUSION

Adolescents and young women have high 12-month continuation of long-acting reversible contraceptive methods. Intrauterine devices and implants should be offered to all adolescents as first-line contraceptive options.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II.

Impact of Contraceptive Education on Contraceptive Knowledge and Decision Making: A Systematic Review

CONTEXT

Educational interventions can help increase knowledge of available contraceptive methods, enabling individuals to make informed decisions and use contraception more effectively. This systematic review evaluated contraceptive education interventions to guide national recommendations on quality family planning services.

EVIDENCE ACQUISITION

Three databases (CINAHL, PubMed, and PsycINFO) were searched from 1985 through 2012 for peer-reviewed articles on educational interventions, with supplemental searches conducted through 2015. Primary outcomes were knowledge, participation in and comfort with decision making, and attitudes toward contraception. Secondary outcomes included contraceptive use behaviors and unintended pregnancy.

EVIDENCE SYNTHESIS

Database searches in 2011 identified 5,830 articles; 17 met inclusion criteria and were abstracted into evidence tables. Searches in 2012 and 2015 identified four additional studies. Studies used a wide range of tools (decision aids, written materials, audio/videotapes, and interactive games), with and without input from a healthcare provider or educator. Of 15 studies that examined the impact of educational interventions on knowledge, 14 found significant improvement using a range of tools, with and without input from a healthcare provider or educator. Fewer studies evaluated outcomes related to decision making, attitudes toward contraception, contraceptive use behaviors, or unintended pregnancy.

CONCLUSIONS

Results from this systematic review are consistent with evidence from the broader healthcare field suggesting that a range of educational interventions can increase knowledge. Future studies should assess what aspects of educational interventions are most effective, the extent to which it is necessary to include a healthcare provider or educator, and the extent to which educational interventions can impact behaviors.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Intrauterine devices at six months: does patient age matter? Results from an urban family medicine federally qualified health center (FQHC) network

BACKGROUND

Federally qualified health centers (FQHCs) can address high rates of unintended pregnancy among adolescents in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing adolescent use of IUDs, some physicians remain concerned about IUD tolerance and safety in adolescents. Therefore we compared adolescents and adults in a family physician staffed FQHC network with regard to (1) IUD postinsertion experience, (2) device discontinuation, and (3) sexually transmitted infection (STI) rates.

METHODS

We conducted a retrospective cohort study among women <36 years old who had an IUD inserted in 2011 at a New York City FQHC staffed by family physicians.

RESULTS

We included 684 women (27% adolescents, 73% adults). During the 6-month postinsertion period, 59% of adolescents and 43% of adults initiated IUD-related clinical contact after insertion, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion or removal or STI rates.

CONCLUSIONS

Urban FQHC providers may anticipate that, compared with their adult IUD users, adolescents will initiate more clinical follow-up visits after insertion. Both groups will, however, have similar clinical concerns about, reasons for, and rate of device discontinuation and low STI rates.

Use of frameless intrauterine devices and systems in young nulliparous and adolescent women: results of a multicenter study

BACKGROUND

The purpose of this study was to provide additional data on the experience with frameless copper and levonorgestrel (LNG) intrauterine devices (IUDs) in nulliparous and adolescent women.

METHODS

Nulliparous and adolescent women, 25 years of age or younger, using the frameless copper IUD or the frameless LNG-releasing intrauterine system (IUS), were selected from previous studies and a current multicenter post-marketing study with the frameless copper IUD. The small copper-releasing GyneFix(®) 200 IUD consists of four copper cylinders, each 5 mm long and only 2.2 mm wide. The frameless FibroPlant(®) LNG-IUS consists of a fibrous delivery system releasing the hormone levonorgestrel (LNG-IUS). The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus.

RESULTS

One hundred and fifty-four nulliparous and adolescent women participated in the combined study. One pregnancy occurred with the GyneFix 200 IUD after unnoticed early expulsion of the device (cumulative pregnancy rate 1.1 at one year). Two further expulsions were reported, one with the GyneFix 200 IUD and the other with the FibroPlant LNG-IUS. The cumulative expulsion rate at one year was 1.1 with the copper IUD and 2.2 with the LNG-IUS. The total discontinuation rate at one year was low (3.3 and 4.3 with the copper IUD and LNG-IUS, respectively) and resulted in a high rate of continuation of use at one year (96.7 with the copper IUD and 95.7 with the LNG-IUS, respectively). Continuation rates for both frameless copper IUD and frameless LNG-IUS remained high at 3 years (>90%). There were no cases of perforations or pelvic inflammatory disease reported during or following insertion.

CONCLUSION

This report confirms earlier studies with frameless devices and suggests that the high user continuation rate is attributable to the optimal relationship between the IUD and the uterine cavity. IUD studies have shown that an IUD that does not fit well will often lead to side effects (ie, pain, bleeding, embedment, expulsion) and subsequent removal of the IUD. Early discontinuation is not the aim of long-acting reversible contraception.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

: II.

The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception

Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper intrauterine device (IUD), the most effective method of EC, continues to provide contraception as effective as sterilization for up to 12 years, and it should be offered as the first-line method of EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an important role in reducing rates of unintended pregnancy. The EC visit should include access to the copper IUD as optimal care but should ideally include access to all highly effective methods of contraception.