Psychological distress and post-abortion contraceptive method effectiveness level chosen at an urban clinic

Mental Health Distress and Delayed Contraception Among Older Adolescents and Young Adults

Background: Symptoms of mental distress increased sharply during the COVID-19 pandemic, especially among older adolescents and young adults. Mental health distress may make it more challenging for young people to seek other needed health care, including contraception. This study explored the association of symptoms of depression, anxiety, and stress with delays in getting a contraceptive method or prescription. Materials and Methods: Data from a supplementary study (May 15, 2020-March 20, 2023) to a cluster randomized trial in 29 sites in Texas and California were used. The diverse study sample included community college students assigned female at birth of ages 18-29 years (n = 1,665 with 7,023 observations over time). We measured the association of depression (CES-D [Center for Epidemiologic Studies Depression Scale]) or anxiety and stress (DASS-21 [Depression Anxiety Stress Scales]) symptoms with delayed contraceptive care-seeking with mixed-effects multivariable regression with random effects for individual and site. We controlled for age and sociodemographic factors important for access to care. Results: Over one-third of participants (35%) reported they delayed getting the contraceptive method they needed. Multivariable regression results showed increased odds of delayed contraceptive care among participants with symptoms of depression (adjusted odds ratio [aOR] 1.58, 95% confidence interval [CI] 1.27-1.96). Likewise, delays were associated with anxiety and stress symptoms (aOR 1.46, 95% CI 1.17-1.82). Adolescents were more likely to delay seeking contraception than young adults (aOR 1.32, 95% CI 1.07-1.63). Conclusions: Results showed a strong association between mental distress and delayed contraception. Interventions are needed to increase contraceptive access for young people delaying care, along with supportive mental health care services, including for adolescents who face elevated odds of delay. ClinicalTrials.gov Identifier: NCT03519685.

Associations between contraceptive availability and rate of subsequent legal abortions in Colombia: A historical cohort analysis

OBJECTIVE

To describe factors associated with subsequent abortions in Colombia and evaluate whether high-efficacy contraceptive availability (IUD) post-index abortion was associated with higher efficacy contraceptive initiation and fewer subsequent abortions within 2 years.

METHODS

The study population comprised patients aged 15-44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2-year follow-up (2017-2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi-square and multivariate logistic regression.

RESULTS

Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017-2019). IUD availability (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.39-1.93) and insurance use (aOR, 5.03; 95% CI, 4.37-5.78) were associated with high-efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22-0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59-6.80) or moderate-efficacy (injection: aOR, 4.21 [95% CI, 3.14-5.62]; oral contraceptive pill: aOR, 4.60 [95% CI, 3.21-6.59]) methods were associated with subsequent abortion.

CONCLUSION

Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.

Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States

In the United States, about half of pregnancies are unintended, and most women of reproductive age are at risk of unintended pregnancy. Research has explored predictors of contraceptive use and unintended pregnancy, but there is a lack of research regarding access to preferred contraceptive method(s) and the complex pathways from sociodemographic factors to these family planning outcomes. This study applied Levesque et al.'s (2013) healthcare access framework to investigate pathways from sociodemographic factors and indicators of access to family planning outcomes using secondary data. Data were collected at four time points via an online survey between November 2012 and June 2014. Participants were US women of reproductive age who were seeking to avoid pregnancy (N = 1036; M_age  = 27.91, SD = 5.39; 6.9% Black, 13.6% Hispanic, 70.2% white, 9.4% other race/ethnicity). We conducted mediational path analysis, and results indicated that contraceptive knowledge (β = 0.116, p = 0.004), insurance coverage (β = 0.423, p < 0.001), and relational provider engagement (β = 0.265, p = 0.011) were significant predictors of access to preferred contraceptive method. Access to preferred contraceptive method directly predicted use of more effective contraception (β = 0.260, p < 0.001) and indirectly predicted decreased likelihood of experiencing unintended pregnancy via contraceptive method(s) effectiveness (β = -0.014, 95% confidence interval: -0.041, -0.005). This study identifies pathways to and through access to preferred contraceptive methods that may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients' needs and priorities.

Associations between use of psychotropic medications and use of hormonal contraception among girls and women aged 15-49 years in Finland: a nationwide, register-based, matched case-control study

OBJECTIVES

The relationship between the use of contraception and of psychiatric medications is understudied. We examined whether the current and past use of psychotropic medications is associated with the use and type of hormonal contraception (HC).

DESIGN

Nationwide register-based matched case-control study.

SETTINGS

All fertile-aged (15-49 years) girls and women living in Finland in 2017; data from several national registers.

PARTICIPANTS

294 356 girls and women with a redeemed prescription of HC in 2017, and their same-sized control group of non-users (n=294 356) identified through the Prescription Centre.

MAIN OUTCOME MEASURES

Associations between the use of psychotropic medications and the use of HC, and the type of HC tested in logistic regression models.

RESULTS

Altogether 19.5% of the HC users, and 18% of the HC non-users received at least one prescription for a psychotropic medication in 2017. Among HC users, the proportions of occasional and regular users of psychotropic medications in 2013-2016 were 4.5% and 14.8%, while among HC non-users the respective figures were 4.3% and 14.6%, respectively. In multivariable logistic regression models both the use of psychotropic medications in 2017, and their occasional or regular use between 2013-2016 were associated with higher odds of HC use, although with small to very small effect sizes (ORs between 1.37 and 1.06 and 95% CIs 1.22 to 1.53, and 1.03 to 1.09, respectively). After adjustment for covariates, when fixed combinations of progestogens and oestrogens for systemic use was the reference category, women using almost any class of psychotropic medications had higher odds of using other types of HC.

CONCLUSIONS

Fertile-aged girls and women with current and past use of psychotropic medications have higher odds of using HC, with a specific pattern in the type of contraceptives used. Further research is warranted to examine whether our observations indicate a reduction of unwanted pregnancies in women with psychiatric disorders.

The association between depression and contraceptive behaviors in a diverse sample of new prescription contraception users

OBJECTIVE

Among women initiating new prescription contraception, we investigated the relationship between recent depression and a range of contraceptive behaviors.

STUDY DESIGN

We used medical and pharmacy records of 52,325 women ages 19 to 29 who initiated prescription contraception (pills, patches or rings, injectables, and long-acting reversible contraceptives) in 2014-2016 at a large integrated healthcare system in Northern California. Women had continuous enrollment for a year before and after initiating, and no records of prescription contraceptive use in the year before initiating. Depression in the year prior to initiation was dichotomized into (1) no depression indicator (reference group) or (2) depression diagnosis or redeemed antidepressant. Multinomial logistic regression models examined the associations between depression and method type initiated, and contraceptive patterns, timing of discontinuation, inconsistent use, and switching methods over a year after initiating, adjusting for sociodemographics and testing for interactions between depression and having a recent birth or abortion.

RESULTS

Women with recent depression were more likely to initiate methods other than the pill, and the association was stronger for patches or rings vs pills among those with a recent birth compared to those without. Among women initiating all methods and the pill, those with depression were more likely to discontinue their method, use it inconsistently, and switch from it than use it continuously for a year.

CONCLUSION

Women with recent depression were less likely to initiate the pill; and when the pill was initiated, those with depression were more likely to discontinue use, use it inconsistently, and switch from it.

IMPLICATIONS

Women with recent depression indicators should be followed closely to ensure they have the support they need to meet their reproductive goals. Those who wish to avoid pregnancy may benefit from methods that do not require daily use.

Contraception Choice Among Those Seeking Abortion for Fetal Indication or Management of Pregnancy Loss

OBJECTIVE

To compare contraception choices of those who are undergoing abortion procedures for fetal indications or surgical management of pregnancy loss with those who are having abortions for another indication.

METHODS

We conducted a cross-sectional study at University of California, Irvine, from December 1, 2017, through December 31, 2018, and included gestational ages up to 24 0/7 weeks. We abstracted data from electronic medical records and analyzed them using descriptive statistics, χ2, Fisher exact tests, and a multivariate logistic regression model for primary outcome (whether a contraception method was chosen) and secondary outcome (whether a long-active reversible contraception was chosen).

RESULTS

Those with fetal indication were less likely to choose contraception than those with other indication (68/134, 50.7% vs 142/158, 89.9%, P<.001), and among those choosing contraception those with fetal indication were less likely to choose long-acting reversible contraception (LARC) (19/68, 27.9% vs 94/142, 66.2%, P<.001). Differences remained significant in multivariable analysis that controlled for age, gestational age in weeks, race, parity, procedure type, and comorbidities (among those with fetal indication for choosing any contraception: adjusted odds ratio [aOR] 0.11, 95% CI 0.05-0.23; choosing LARC: aOR 0.17, 95% CI 0.07-0.39).

CONCLUSION

Only half of those seeking abortion for a fetal indication or surgical management of pregnancy loss were interested in contraception.

Types of Lifetime Reproductive Coercion and Current Contraceptive Use

Background: Intimate partner violence and differential power dynamics are associated with contraceptive behaviors. This study examines the role of reproductive coercion (RC) by an intimate partner in women's decisions about contraceptive use. Materials and Methods: A self-report survey was administered to a probability sample of a diverse group of women of reproductive age in Delaware's Title X health care facilities. Currently used contraceptive methods were categorized into three effectiveness levels based on typical use failure rates: no method or low effectiveness (>10% failure), moderate effectiveness (>1% and <10% failure), and high effectiveness (<1% failure). The short-form RC scale was used to categorize RC experiences: no RC, verbal only, or behavioral. We conducted multinomial logistic regression to examine the association between types of RC and effectiveness level of current contraceptive method, taking our sampling design into account and adjusting for covariates. Results: Among 240 women (weighted n = 6529) included in the sample, 13.9% reported experiencing only verbal RC, and 16.1% reported behavioral RC. Women who reported behavioral RC were more likely to currently be using highly versus moderately (adjusted relative risk ratio [aRRR]: 26.71, 95% confidence interval [CI]: 4.59-156.0) and low effective methods (aRRR: 3.08, 95% CI: 0.97-9.82), but less likely to be using moderately (aRRR: 0.12, 95% CI: 0.02-0.77) than low effective methods. Conclusions: Using highly and low effective methods may indicate two opposing ways of managing behavioral RC experiences: controlling fertility by choosing less detectable but highly effective methods or feeling disempowered and using no or low effective partner-dependent methods.

Intimate Partner Violence and Effectiveness Level of Contraceptive Selection Post-Abortion

Background: We examined whether experiencing more types of lifetime intimate partner violence (IPV) was independently associated with the effectiveness level of the contraceptive method women chose following an abortion. Materials and Methods: Using data on 245 women who were attending an urban hospital abortion clinic, we assessed whether women had ever experienced emotional, physical, or sexual IPV. Effectiveness of women's post-abortion contraceptive method selection was categorized into high (intrauterine device [IUD] and implant), moderate (pill, patch, ring, and shot), and low (condoms, emergency contraception, and none) effectiveness. Using multinomial logistic regression, we examined the relationship between number of types of IPV experienced and post-abortion contraceptive method effectiveness, adjusting for sociodemographics, prior abortion, having children, abortion trimester, importance of avoiding pregnancy in the next year, pre-abortion psychological distress, and effectiveness level of the contraceptive method women were planning to use before contraceptive counseling. Results: Twenty-seven percent (27%) of women experienced two or three types of IPV, 35% experienced one IPV type, and 38% experienced no IPV. Compared to women with no histories of IPV, women who experienced two or more types of IPV during their lifetimes were more likely to choose contraceptive methods with moderate effectiveness (adjusted odds ratio [AOR] = 5.23, 95% confidence interval [CI]: 1.13-24.23, p = 0.035) and high effectiveness (AOR = 5.01, 95% CI: 1.12-22.39, p = 0.035) than those with low effectiveness. Conclusion: Women who experienced two or more types of lifetime IPV selected more effective contraceptive methods post-abortion. Access to contraceptives that are not partner dependent, including long-acting reversible contraceptives (LARC), may be particularly important for women who have experienced multiple types of IPV.

Current and past depressive symptoms and contraceptive effectiveness level method selected among women seeking reproductive health services

RATIONALE

More thoroughly understanding the association between elevated depressive symptoms and effectiveness level of contraceptive method selected at a reproductive health visit could help women prevent unintended pregnancy.

OBJECTIVE

This study examined how the association between both current and past depressive symptoms and effectiveness level of contraceptive method selected at a clinic visit varies by type of reproductive health visit.

METHODS

Current and past depressive symptoms and contraceptive method selected were assessed among 1215 women aged 18-25 years seeking general reproductive health or abortion services at 40 community clinics throughout the United States. Using standard categories of effectiveness based on pregnancy rates during typical use, women's contraceptive method selected was coded as a low (e.g., no method, withdrawal, condoms), moderately (pill, patch, ring, or shot), or highly effective method (IUD, sterilization, implant). Depression status was divided into four categories: 1) no elevated depressive symptoms ever, 2) current elevated depressive symptoms only, 3) past elevated depressive symptoms only, and 4) past and current elevated depressive symptoms. Visit type, general reproductive health versus abortion care, was a moderator. The interaction effect between depressive symptoms and visit type on contraceptive method effectiveness level chosen was estimated with multinomial logistic regression analyses.

RESULTS

In general reproductive health visits, having both elevated current and past depressive symptoms increased women's likelihood of choosing low versus moderately effective methods (RRR = 5.63, 95% CI = 2.31 to 13.71, p < .0005). In contrast, among abortion patients, only current elevated depressive symptoms were associated with choosing high versus moderate effectiveness methods (RRR = 1.74, 95% CI = 1.06 to 2.86, p = .029).

CONCLUSION

Results suggest that considering both women's current and past elevated depressive symptoms and the type of reproductive health visit may assist providers in helping women prevent unintended pregnancy.

Cost-effectiveness of emergency contraception options over 1 year

BACKGROUND

The copper intrauterine device is the most effective form of emergency contraception and can also provide long-term contraception. The levonorgestrel intrauterine device has also been studied in combination with oral levonorgestrel for women seeking emergency contraception. However, intrauterine devices have higher up-front costs than oral methods, such as ulipristal acetate and levonorgestrel. Health care payers and decision makers (eg, health care insurers, government programs) with financial constraints must determine if the increased effectiveness of intrauterine device emergency contraception methods are worth the additional costs.

OBJECTIVE

We sought to compare the cost-effectiveness of 4 emergency contraception strategies-ulipristal acetate, oral levonorgestrel, copper intrauterine device, and oral levonorgestrel plus same-day levonorgestrel intrauterine device-over 1 year from a US payer perspective.

STUDY DESIGN

Costs (2017 US dollars) and pregnancies were estimated over 1 year using a Markov model of 1000 women seeking emergency contraception. Every 28-day cycle, the model estimated the predicted number of pregnancy outcomes (ie, live birth, ectopic pregnancy, spontaneous abortion, or induced abortion) resulting from emergency contraception failure and subsequent contraception use. Model inputs were derived from published literature and national sources. An emergency contraception strategy was considered cost-effective if the incremental cost-effectiveness ratio (ie, the cost to prevent 1 additional pregnancy) was less than the weighted average cost of pregnancy outcomes in the United States ($5167). The incremental cost-effectiveness ratios and probability of being the most cost-effective emergency contraception strategy were calculated from 1000 probabilistic model iterations. One-way sensitivity analyses were used to examine uncertainty in the cost of emergency contraception, subsequent contraception, and pregnancy outcomes as well as the model probabilities.

RESULTS

In 1000 women seeking emergency contraception, the model estimated direct medical costs of $1,228,000 and 137 unintended pregnancies with ulipristal acetate, compared to $1,279,000 and 150 unintended pregnancies with oral levonorgestrel, $1,376,000 and 61 unintended pregnancies with copper intrauterine devices, and $1,558,000 and 63 unintended pregnancies with oral levonorgestrel plus same-day levonorgestrel intrauterine device. The copper intrauterine device was the most cost-effective emergency contraception strategy in the majority (63.9%) of model iterations and, compared to ulipristal acetate, cost $1957 per additional pregnancy prevented. Model estimates were most sensitive to changes in the cost of the copper intrauterine device (with higher copper intrauterine device costs, oral levonorgestrel plus same-day levonorgestrel intrauterine device became the most cost-effective option) and the cost of a live birth (with lower-cost births, ulipristal acetate became the most cost-effective option). When the proportion of obese women in the population increased, the copper intrauterine device became even more most cost-effective.

CONCLUSION

Over 1 year, the copper intrauterine device is currently the most cost-effective emergency contraception option. Policy makers and health care insurance companies should consider the potential for long-term savings when women seeking emergency contraception can promptly obtain whatever contraceptive best meets their personal preferences and needs; this will require removing barriers and promoting access to intrauterine devices at emergency contraception visits.

Contraceptive Use over Five Years After Receipt Or Denial of Abortion Services

CONTEXT

Nonuse and inconsistent use of contraceptives contribute to a high incidence of unintended pregnancy and abortion among U.S. women. Little is known, however, about how these outcomes shape women's subsequent contraceptive use and unintended pregnancy risk.

METHODS

Contraceptive use was examined among 880 participants in the Turnaway Study, a five-year longitudinal study of women who sought abortions at 30 U.S. facilities in 2008-2010. Multivariable mixed-effects logistic and multinomial regression models assessed differences in use by whether women received the abortion; results were used to calculate predicted percentages of women using each method. The main groups of interest were 415 women who had an abortion at a gestation near their facility's limit and 160 who were denied abortion because they were beyond the limit, and who consequently gave birth.

RESULTS

During each of the approximately five years of follow-up, the predicted percentage using any contraceptive method was 86% among women who had the abortion and 81% among those denied it. Over the entire period, the former women were more likely than the latter to use any method (odds ratio, 1.8). However, they were less likely to rely on female sterilization, rather than no method (risk ratio, 0.5), and more likely to use barrier methods (1.7) or short-acting reversible contraceptives (2.6).

CONCLUSION

Women's elevated risk of unintended pregnancy after abortion is likely due at least partly to reliance on methods with relatively low effectiveness. Factors affecting contraceptive access postabortion, as well as individual characteristics such as fecundability, require research attention.

Does the Use of Unreliable Contraceptive Methods Increase the Number of Abortions? Results from a National Survey of Women in the United States

In this study the authors assessed the association between the types contraceptive use (unreliable or traditional methods vs. modern methods) and number of abortions among a nationally representative sample of abortion patients in the United States from the Abortion Patients Survey 2008. Unadjusted and adjusted prevalence ratios were calculated to determine the association between unreliable contraceptive methods and number of abortions. Results from the unadjusted and adjusted prevalence ratios revealed that women who used modern methods of contraception were more likely to have had previous abortions compared to women who did not use contraceptives and those who used traditional methods of contraception. Implications for practice, policy, and the role of social workers are discussed.

The effects of preabortion depressive symptoms on postabortion contraceptive effectiveness level chosen among women seeking abortions

OBJECTIVE

We examined whether preabortion depressive symptoms were associated with contraceptive method effectiveness level chosen among women seeking abortions.

STUDY DESIGN

Three-hundred and forty-seven young, low-income women 18 years or older who were seeking abortions at 3 community reproductive health clinics in Northern California were recruited to participate in a study on contraceptive decision making. We classified women into choosing low-, moderate- or high-effectiveness contraceptive methods based on typical-use failure rates. We used the Center for Epidemiologic Studies Depression scale to assess depressive symptoms as a continuous and dichotomous variable. Using the standard cutoff of 20, women who scored at or above this were considered depressed for the dichotomous measure. We used multinomial logistic regression to examine the association between preabortion depressive symptoms and contraceptive effectiveness level chosen to use after an abortion, adjusting for sociodemographics, abortion characteristics, pregnancy history, future pregnancy desires, relationship characteristics and adverse experiences.

RESULTS

After adjusting for covariates, we found that a one-unit increase in depressive symptoms was associated with a higher likelihood of choosing low- versus moderate- [adjusted odd ratio (aOR)=1.05, 95% confidence interval (CI): 1.01-1.10, p<.02] and high-effectiveness methods (aOR=1.05, 95% CI: 1.002-1.10, p<.05). Furthermore, women scoring above the cutoff for depression were more likely to choose low- versus moderate-effectiveness methods (aOR=4.56, 95% CI: 1.27-16.32, p=.02).

CONCLUSIONS

More preabortion depressive symptoms were independently associated with choosing low- versus moderate- and high-effectiveness contraceptives.

IMPLICATIONS

These findings together with other findings show that preabortion depressive symptoms do not uniformly influence effectiveness level of contraceptive method selected to use after an abortion. Reproductive health care providers should consider the impact of women's psychological symptoms on their contraceptive decision making.

Social Disparities in the Relationship Between Depression and Unintended Pregnancy During Adolescence and Young Adulthood

PURPOSE

We investigated the influence of depression on subsequent risk of unintended pregnancy and social disparities within this relationship, during adolescence and young adulthood.

METHODS

Drawing upon 15-year, nationally representative data from 8,810 young U.S. women in the National Longitudinal Study of Adolescent to Adult Health, we estimated associations between depression and time to first pregnancies reported as unintended, overall and stratified by race/ethnicity, socioeconomic status, and age with Cox proportional hazard models.

RESULTS

Moderate/severe depression symptoms were associated with an increased risk of unintended first pregnancy (hazard ratio [HR], 1.21; confidence interval [CI], 1.02-1.44). In stratified models, depression increased the pregnancy risk for all minority groups (HRs, 1.36-3.25) but not white women. Depression increased the pregnancy risk for women with $0-$19,999 (HR, 1.48; CI, 1.11-1.98) and $20,000-$49,999 (HR, 1.33; CI, 1.05-1.68) income levels but not those at higher levels. Depression increased the pregnancy risk for adolescents <20 years (HR, 1.35; CI, 1.07-1.71) but decreased the risk for women >24 years (HR, .47; CI, .25-.86).

CONCLUSIONS

Findings may inform more equitable, holistic public health strategies that target depression as a modifiable risk factor for adverse reproductive outcomes during adolescence and young adulthood.

Stressful Life Events Around the Time of Unplanned Pregnancy and Women's Health: Exploratory Findings from a National Sample

Objective Little is known about how women's social context of unintended pregnancy, particularly adverse social circumstances, relates to their general health and wellbeing. We explored associations between stressful life events around the time of unintended pregnancy and physical and mental health. Methods Data are drawn from a national probability study of 1078 U.S. women aged 18-55. Our internet-based survey measured 14 different stressful life events occurring at the time of unintended pregnancy (operationalized as an additive index score), chronic disease and mental health conditions, and current health and wellbeing symptoms (standardized perceived health, depression, stress, and discrimination scales). Multivariable regression modeled relationships between stressful life events and health conditions/symptoms while controlling for sociodemographic and reproductive covariates. Results Among ever-pregnant women (N = 695), stressful life events were associated with all adverse health outcomes/symptoms in unadjusted analyses. In multivariable models, higher stressful life event scores were positively associated with chronic disease (aOR 1.21, CI 1.03-1.41) and mental health (aOR 1.42, CI 1.23-1.64) conditions, higher depression (B 0.37, CI 0.19-0.55), stress (B 0.32, CI 0.22-0.42), and discrimination (B 0.74, CI 0.45-1.04) scores, and negatively associated with ≥ very good perceived health (aOR 0.84, CI 0.73-0.97). Stressful life event effects were strongest for emotional and partner-related sub-scores. Conclusion Women with adverse social circumstances surrounding their unintended pregnancy experienced poorer health. Findings suggest that reproductive health should be considered in the broader context of women's health and wellbeing and have implications for integrated models of care that address women's family planning needs, mental and physical health, and social environments.

Psychosocial factors and pre-abortion psychological health: The significance of stigma

RATIONALE

Most research in mental health and abortion has examined factors associated with post-abortion psychological health. However, research that follows women from before to after their abortion consistently finds that depressive, anxiety, and stress symptoms are highest just before an abortion compared to any time afterwards.

OBJECTIVE

This finding suggests that studies investigating psychosocial factors related to pre-abortion mental health are warranted.

METHODS

The current study uses data from 353 women seeking abortions at three community reproductive health clinics to examine predictors of pre-abortion psychological health. Drawing from three perspectives in the abortion and mental health literature, common risks, stress and coping, and sociocultural context, we conducted multivariable analyses to examine the contribution of important factors on depressive, anxiety, and stress symptoms just before an abortion, including sociodemographics, abortion characteristics, childhood adversities, recent adversities with an intimate partner, relationship context, future pregnancy desires, and perceived abortion stigma.

RESULTS

Childhood and partner adversities, including reproductive coercion, were associated with negative mental health symptoms, as was perceived abortion stigma. Before perceived abortion stigma was entered into the model, 18.6%, 20.7%, and 16.8% of the variance in depressive, anxiety, and stress symptoms respectively, was explained. Perceived abortion stigma explained an additional 13.2%, 9.7%, and 10.7% of the variance in depressive, anxiety, and stress symptoms pre-abortion.

CONCLUSION

This study, one of the first to focus on pre-abortion mental health as an outcome, suggests that addressing stigma among women seeking abortions may significantly lower their psychological distress.

Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

OBJECTIVE

Women who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.

STUDY DESIGN

Women presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.

RESULTS

A total of 260 women, aged 18-45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.

CONCLUSION

A variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.

IMPLICATIONS

In contraceptive counseling, after screening for IPV, assessing patient's stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient's choice of method.

Contraception and mental health: a commentary on the evidence and principles for practice

Among the most prevalent and disabling chronic diseases affecting reproductive-aged women worldwide, depression and anxiety can contribute to adverse reproductive health outcomes, including an increased risk of unintended pregnancy and its health and social consequences. For women with these common mental health conditions who want to avoid an unintended pregnancy, effective contraception can be an important strategy to maintain and even improve health and well-being. Reproductive health clinicians play a critical role in providing and managing contraception to help women with mental health considerations achieve their desired fertility. In this commentary, we review the literature on relationships between mental health and contraception and describe considerations for the clinical management of contraception among women with depression and anxiety. We discuss issues related to contraceptive method effectiveness and adherence concerns, mental health-specific contraceptive method safety and drug interaction considerations, and clinical counseling and management strategies. Given important gaps in current scientific knowledge of mental health and contraception, we highlight areas for future research.

Childhood Sexual Violence and Consistent, Effective Contraception Use among Young, Sexually Active Urban Women

Unintended pregnancy (UP) is a significant public health problem. The consistent use of effective contraception is the primary method to prevent UP. We examined the role of childhood sexual and physical violence and current interpersonal violence on the risk of unintended pregnancy among young, urban, sexually active women. In particular, we were interested in examining the role of childhood violence and interpersonal violence while recognizing the psychological correlates of experiencing violence (i.e., high depressive symptoms and low self-esteem) and consistent use of contraception. For this assessment, 315 sexually active women living in Philadelphia PA were recruited from family planning clinics in 2013. A self-administered, computer-assisted interview was used to collect data on method of contraception use in the past month, consistency of use, experiences with violence, levels of depressive symptoms, self-esteem and sexual self-efficacy, substance use and health services utilization. Fifty percent of young sexually active women reported inconsistent or no contraception use in the past month. Inconsistent users were significantly more likely to report at least one prior episode of childhood sexual violence and were significantly less likely to have received a prescription for contraception from a health care provider. Inconsistent contraception users also reported significantly higher levels of depressive symptoms and significantly lower levels of self-esteem. The relation between childhood sexual violence and UP remained unchanged in the multivariate models adjusting for self-esteem or depressive symptoms. These findings highlight the long-term consequences of childhood sexual violence, independent of current depressive symptoms and low self-esteem, on consistent use of contraception.

Social discrimination, stress, and risk of unintended pregnancy among young women

PURPOSE

Prior research linking young women's mental health to family planning outcomes has often failed to consider their social circumstances and the intersecting biosocial mechanisms that shape stress and depression as well as reproductive outcomes during adolescence and young adulthood. We extend our previous work to investigate relationships between social discrimination, stress and depression symptoms, and unintended pregnancy among adolescent and young adult women.

METHODS

Data were drawn from 794 women aged 18-20 years in a longitudinal cohort study. Baseline and weekly surveys assessed psychosocial information including discrimination (Everyday Discrimination Scale), stress (Perceived Stress Scale), depression (Center for Epidemiologic Studies-Depression Scale), and reproductive outcomes. Multilevel, mixed-effects logistic regression and discrete-time hazard models estimated associations between discrimination, mental health, and pregnancy. Baron and Kenny's method was used to test mediation effects of stress and depression on discrimination and pregnancy.

RESULTS

The mean discrimination score was 19/45 points; 20% reported moderate/high discrimination. Discrimination scores were higher among women with stress and depression symptoms versus those without symptoms (21 vs. 18 points for both, p < .001). Pregnancy rates (14% overall) were higher among women with moderate/high (23%) versus low (11%) discrimination (p < .001). Discrimination was associated with stress (adjusted relative risk ratio, [aRR], 2.2; 95% confidence interval [CI], 1.4-3.4), depression (aRR, 2.4; CI, 1.5-3.7), and subsequent pregnancy (aRR, 1.8; CI, 1.1-3.0). Stress and depression symptoms did not mediate discrimination's effect on pregnancy.

CONCLUSIONS

Discrimination was associated with an increased risk of mental health symptoms and unintended pregnancy among these young women. The interactive social and biological influences on reproductive outcomes during adolescence and young adulthood warrant further study.

An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception

OBJECTIVE

We examine the association between depressive symptoms and contraceptive method choice among adolescents initiating prescription contraception.

STUDY DESIGN

This cross-sectional study analyzes baseline data of 220 urban, minority adolescent females (ages 15-19 years) presenting for prescription contraceptive initiation at a comprehensive, free-of-cost, adolescent health center in New York City. All participants met with a health care provider who provided standard contraception counseling before initiating contraception. Each participant then selected a short- or long-acting contraceptive: a 3-month supply of the pill, patch, ring or a medroxyprogesterone acetate depot injection (short-acting), or placement/referral for an intrauterine device (IUD; long-acting). We assess the independent association between contraceptive method selection and symptoms of depression [assessed by the Center for Epidemiological Studies - Depression (CES-D) scale].

RESULTS

Ten percent (n=21/220) of adolescent females selected an IUD. Bivariate analysis revealed that those with elevated levels of depressive symptoms were more likely to select an IUD as compared to those with minimal symptoms (mean CES-D score 20 vs. 13; t=3.052, p=.003). In multivariate logistic regressions, adolescent females had increased odds of selecting an IUD if they reported moderate to severe depressive symptoms (adjusted odds ratio=4.93; confidence interval, 1.53-15.83; p=.007) after controlling for ethnicity/race, education, number of lifetime partners and gravidity.

CONCLUSIONS

Inner-city, minority adolescents with elevated symptoms of depression who present for prescription contraceptive initiation may be more likely to select an IUD rather than shorter-acting methods. By recognizing adolescent females with depressive symptoms, providers can strategize their approach to effective contraception counseling.

Psychological Aspects of Contraception, Unintended Pregnancy, and Abortion

The knowledge of important biopsychosocial factors linking women's reproductive health and mental health is increasing. This review focuses on psychological aspects of contraception, unintended pregnancy, and abortion because these are common reproductive health experiences in U.S. women's lives. This review addresses the mental-health antecedents and consequences of these experiences, mostly focusing on depression and depressive symptoms before and after unintended pregnancy and contraception. As mental-health antecedents, depressive symptoms predict contraceptive behaviors that lead to unintended pregnancy, and mental-health disorders have been associated with having subsequent abortions. In examining the mental-health consequences, most sound research does not find abortion or contraceptive use to cause mental-health problems. Consequently, evidence does not support policies based on the notion that abortion harms women's mental health. Nevertheless, the abortion-care setting may be a place to integrate mental-health services. In contrast, women who have births resulting from unintended pregnancies may be at higher risk of postpartum depression. Social policies (e.g., paid maternity leave, subsidized child care) may protect women from mental-health problems and stress of unplanned children interrupting employment, education, and pre-existing family care responsibilities.

Stress symptoms and frequency of sexual intercourse among young women

INTRODUCTION

We have previously documented the relationships between stress and depression symptoms and adolescent women's nonuse and misuse of condoms and other contraceptive methods and on their unintended pregnancy rates.

AIM

Here, we examine relationships between mental health symptoms and another understudied adolescent reproductive health behavior-frequency of sexual intercourse.

MAIN OUTCOME MEASURE

Our outcome was weekly sexual intercourse activity.

METHODS

We used panel data from a longitudinal, population-based cohort study of 992 women ages 18-20. Weekly journals measured sociodemographic, relationship, reproductive, and mental health characteristics, sexual and contraceptive behaviors, and pregnancy history. We examined 27,130 surveys from 952 women during the first study year. Predictors of weekly sexual intercourse were moderate to severe stress (Perceived Stress Scale-4) and depression (Center for Epidemiologic Studies Depression Scale-5) symptoms measured at baseline. Multilevel, mixed-effects logistic regression models estimated the relationships between stress and depression symptoms and the weekly odds of sexual intercourse while adjusting for covariate fixed effects and random woman effects.

RESULTS

Nearly a quarter of the sample had moderate to severe stress (23%) and depression (24%) symptoms at baseline. Women reported sexual intercourse in 36% of weeks. Proportions of sexually active weeks were higher among women with stress (43%) and depression (40%) compared with those without symptoms (35% and 35%, respectively; P values<0.001). Controlling for covariates, women with baseline stress symptoms had 1.6 times higher weekly odds of sexual intercourse compared with women without stress (adjusted odds ratio 1.6, confidence interval [1.1, 2.5]; P=0.04). Depression symptoms were not associated with sexual intercourse frequency in adjusted models.

CONCLUSIONS

Stress symptoms were positively associated with sexual intercourse frequency among these young women. Research and practice efforts are needed to identify effective sexual health promotion and risk-reduction strategies, including contraceptive education and counseling, in the context of mental health symptoms and unintended pregnancy.

Associations of mental illness and substance use disorders with prescription contraception use among women veterans

OBJECTIVE

To investigate whether mental illness and substance use disorder (SUD) are associated with having a prescription contraceptive method among women veterans.

STUDY DESIGN

We conducted a retrospective analysis of National Veterans Administration (VA) administrative and clinical data for women veterans aged 18-45 years who made at least one primary care visit in 2008. We assessed associations between mental illness (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia and adjustment disorder) and SUD (drug/alcohol use disorder) with having a prescription contraceptive method from VA (pill, patch, ring, injection, implant and intrauterine device) using multivariable logistic regression with random effects for VA facility, adjusting for confounders.

RESULTS

Among 94,115 reproductive aged women, 36.5% had mental illness only, 0.6% had SUD only, 5.3% had both mental illness and SUD and 57.7% had neither diagnosis. In these groups, 22.1%, 14.6%, 18.2% and 17.7% (p<0.001), respectively, had documentation in 2008 of prescription contraception. After adjusting for potential confounders, women with mental illness only were as likely as women with neither diagnosis to have a prescription method and were more likely to use a highly effective prescription method (implant or intrauterine device) if using contraception [adjusted odds ratio (aOR) 1.17, 95% confidence interval (CI) = 1.08-1.27]. Women with SUD (with or without mental illness) were significantly less likely to have a prescription method than women with neither diagnosis (aOR 0.73, 95% CI = 0.57-0.95 and aOR 0.79, 95% CI = 0.73-0.86, respectively).

CONCLUSION

Women veterans with SUD are less likely to have prescription contraception compared to other women, which may increase their risk of unintended pregnancy.

The risk of unintended pregnancy among young women with mental health symptoms

Depression and stress have been linked with poor contraceptive behavior, but whether existing mental health symptoms influence women's subsequent risk of unintended pregnancy is unclear. We prospectively examined the effect of depression and stress symptoms on young women's pregnancy risk over one year. We used panel data from a longitudinal study of 992 U.S. women ages 18-20 years who reported a strong desire to avoid pregnancy. Weekly journal surveys measured relationship, contraceptive use and pregnancy outcomes. We examined 27,572 journal surveys from 940 women over the first study year. Our outcome was self-reported pregnancy. At baseline, we assessed moderate/severe depression (CESD-5) and stress (PSS-4) symptoms. We estimated the effect of baseline mental health symptoms on pregnancy risk with discrete-time, mixed-effects, proportional hazard models using logistic regression. At baseline, 24% and 23% of women reported moderate/severe depression and stress symptoms, respectively. Ten percent of young women not intending pregnancy became pregnant during the study. Rates of pregnancy were higher among women with baseline depression (14% versus 9%, p = 0.04) and stress (15% versus 9%, p = 0.03) compared to women without symptoms. In multivariable models, the risk of pregnancy was 1.6 times higher among women with stress symptoms compared to those without stress (aRR 1.6, CI 1.1,2.7). Women with co-occurring stress and depression symptoms had over twice the risk of pregnancy (aRR 2.1, CI 1.1,3.8) compared to those without symptoms. Among women without a prior pregnancy, having co-occurring stress and depression symptoms was the strongest predictor of subsequent pregnancy (aRR 2.3, CI 1.2,4.3), while stress alone was the strongest predictor among women with a prior pregnancy (aRR 3.0, CI 1.1,8.8). Depression symptoms were not independently associated with young women's pregnancy risk. In conclusion, stress, and especially co-occurring stress and depression symptoms, consistently and adversely influenced these young women's risk of unintended pregnancy over one year.