Projections and opinions from 100 experts in long-acting reversible contraception

Society of Family Planning Research Practice Support: Strategies and considerations for addressing race and racism in quantitative family planning studies

OBJECTIVES

Family planning researchers have not critically engaged with topics of race, racism, and associated concepts like ethnicity. This lack of engagement contributes to the reproduction of research that reifies racial hierarchies rather than illuminate and interrupt the processes by which racism affects health. This Research Practice Support paper lays out considerations and best practices for addressing race and racism in quantitative family planning research.

STUDY DESIGN

We are scholars with racialized identities and expertise in racial health equity in family planning research. We draw from scholarship and guidance across disciplines to examine common shortcomings in the use and analysis of race and racism and propose practices for rigorous use of these concepts in quantitative family planning research.

RESULTS

We recommend articulating the role of race and racism in the development of the research question, authorship and positionality, study design, data collection, analytic approach, and interpretation of analyses. Definitions of relevant concepts and additional resources are provided.

CONCLUSIONS

Family planning and racism are inextricably linked. Failing to name and analyze the pathways through which structural racism affects family planning, and the people who need or want to plan if, when, or how to become pregnant or parent may reproduce harmful and incorrect beliefs about the causes of health inequities and the attributes of Black, Indigenous, and other people racialized as non-White. Family planning researchers should critically study racism and race with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

IMPLICATIONS

Family planning research can better contribute to efforts to eliminate racialized health inequities and avoid perpetuating harmful beliefs and conceptualizations of race by ensuring that they study race and racism with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

Changes in hair cortisol concentration in intrauterine device initiators: A prospective cohort study

OBJECTIVES

Prior studies found increased hair cortisol concentration (a surrogate marker for hypothalamic-pituitary-adrenal axis activation) in users of the levonorgestrel intrauterine device (LNG 52 mg IUD). We evaluated change in hair cortisol and psychometric tests in women initiating a copper (CuT380 IUD) or LNG 52 mg IUD.

STUDY DESIGN

We prospectively enrolled healthy women initiating an LNG 52 mg IUD or CuT380 IUD. Participants provided hair and blood samples and completed psychometric inventories (Patient Health Questionnaire-9, Positive and Negative Affect Schedule, and Psychological General Well-Being Index) after IUD insertion and at 6 and 12 months. We used liquid chromatography with tandem mass spectrometry to measure hair cortisol concentrations. We compared hair cortisol concentrations and psychometric test changes from baseline to 6 and 12 months using independent two-sample t tests.

RESULTS

We enrolled 39 of our targeted 86 participants (LNG 52 mg IUD 26, CuT380 IUD 13). Thirty-eight subjects (LNG 52 mg IUD 25, CuT380 IUD 13) completed 6 months of follow-up. We found no difference between cohorts in the mean change in hair cortisol concentrations at 6 months (LNG 52 mg IUD n = 21 [-0.01 pg/mg (95% CI -1.26, 1.23); CuT380 IUD n = 13 [-1.31 pg/mg (-3.36, 0.73)]). While psychometric inventory results remained within normal ranges, LNG 52 mg IUD users reported a trend toward more favorable changes over time.

CONCLUSIONS

We did not find clinically important differences in hair cortisol concentrations following initiation of a CuT380 IUD or LNG 52 mg IUD; psychometric inventories demonstrated no adverse effect of hormonal IUDs on mood.

IMPLICATIONS

Our findings of similar hair cortisol concentrations following the initiation of either the LNG 52 mg IUD or CuT380 IUD suggest that hormonal IUDs do not increase cortisol concentrations or alter stress reactivity, and favorable effects on psychometric inventories provide further reassurance that the LNG 52 mg IUD has no adverse impact on mood.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03499379.

Knowledge, beliefs and practices of nurses with long-acting reversible contraception, Cape Town

BACKGROUND

Implanon and copper intrauterine contraceptive device (IUCD) are long-acting reversible contraceptives (LARC) available in public primary health care (PHC) South Africa. These methods are the most effective forms of contraception.

AIM

To evaluate the knowledge, beliefs and practices on provision of LARC.

SETTING

Primary health care facilities within the Khayelitsha Eastern Substructure, Cape Town.

METHODS

A descriptive survey of all permanent nurses who provided contraception. Data were collected from 72/90 (80% response rate) via a validated questionnaire and evaluated using Statistical Package for Social Sciences (SPSS).

RESULTS

Knowledge of eligibility for LARC was tested. The mean knowledge scores for Implanon were 8.56/11 (s.d. 1.42) for the trained and 7.16/11 (s.d. 2.83) for the untrained (p = 0.007). The mean knowledge scores for IUCD were 10.42/12 (s.d. 1.80) for the trained and 8.03/12 (s.d. 3.70) for the untrained (p = 0.019). Participants believed that inaccessibility to training courses (29%), no skilled person available (24%) and staff shortages (35%) were barriers. Less than 50% of women were routinely counselled for LARC. Forty-one percent of nurses were trained and performed IUCD insertion, and 64% were trained and performed Implanon insertion, while 61% and 45% required further training. Confidence was low, with 32% trained and confident in IUCD and 56% trained and confident in Implanon insertion.

CONCLUSION

Lack of training, poor confidence and deficient counselling skills were barriers to effective LARC provision. The identified system-specific barriers must be addressed to improve uptake.Contribution: The first study to evaluate knowledge, beliefs and practices on LARC in providers in the Western Cape.

Factors associated with never-use of long-acting reversible contraception among adult reproductive-aged women in Ohio

BACKGROUND

The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio.

METHODS

We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use.

RESULTS

Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately.

CONCLUSIONS

Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis

Introduction:

Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care.

Materials and Methods:

Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.

Results:

Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling.

Conclusions:

A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Factors Associated With the Use of the Contraceptive Implant Among Women Attending a Primary Health Clinic in Cape Town, South Africa

Background: Long-acting reversible contraceptives (LARCs), which include the subdermal contraceptive implant and intrauterine contraception, offer women safe, highly effective, long-term pregnancy prevention, and have expanded contraceptive options. The implant greatly expands LARC options for South African women as it is available free of charge at public health facilities, but little is known about factors associated with its uptake. This study describes factors associated with the intention to use the implant, including knowledge and beliefs about the implant and perceived outcome expectancies of implant use among women in Cape Town, South Africa.

Methods: Between 2015 and 2016, the authors conducted a quantitative, cross-sectional survey among adult women attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, they measured knowledge, awareness, and attitudes, perceived outcome expectancy, and the intention to use the contraceptive implant in future among the women.

Results: The authors surveyed 481 women (mean age 29.1 years). Most of the participants (n = 364, 75.6%) had heard about the implant, 45 (9.4%) were currently using it, and 97 (20.2%) intended to use it in the future. Knowledge about the safety of the implant, beliefs about its effectiveness, and the ease of insertion and removal, and support from intimate partners were positively associated with the current use and intentions to use the implant in the future.

Conclusions: Limited knowledge of the implant, having completed secondary schooling, support from partner for women to use implant and the perceived outcome expectancies of using the implant were factors significantly associated with the intention to use the implant. Ensuring that the contraception information is available in all South African languages, regardless of education levels in women, and that comprehensive contraception education and counseling is provided during all family planning might help improve the uptake of contraceptives, including the use of the implant in the country.

Women's Use of Long-Acting Reversible Contraception for Birth Timing and Birth Stopping

The use of long-acting reversible contraceptive (LARC) methods-intrauterine devices (IUDs) and implants-has recently expanded rapidly in the United States, and these methods together approach the contraceptive pill in current prevalence. Research on LARCs has analyzed their use to reduce unintended pregnancies but not their use to enable intended pregnancies. Knowledge of both is necessary to understand LARCs' potential impacts on the reproductive life courses of U.S. women. We combine data from two nationally representative surveys to estimate women's likelihood and timing of subsequent reproductive events, including births resulting from an intended pregnancy up to nine years after discontinuing LARC use. We estimate that 62% of women will give birth, and 45% will give birth from an intended pregnancy. Additionally, 18% will have a new LARC inserted, and 13% will transition to sterilization. Most of these reproductive events occur within two years after discontinuing LARC use. Births from an intended pregnancy are especially common when no intervening switch to another contraceptive method occurs. We infer that women's motives for using LARC are varied but include the desire to postpone a birth, to postpone a decision about whether to have a(nother) birth, and to transition definitively to the completion of childbearing.

Contraceptive method type and satisfaction, confidence in use, and switching intentions

OBJECTIVE

We examined whether contraceptive method type, satisfaction with use, and confidence in correct use were independently associated with switching intentions, a precursor of switching behaviors.

STUDY DESIGN

Data were from a probability-based sample survey carried out in Delaware and Maryland in 2016 and 2017 among women ages 18 to 44. Women's current contraceptive methods were classified into 5 categories: coitally-dependent methods (barrier methods, withdrawal, and natural family planning); oral contraceptive pills, patches, and rings; injections; implants; and intrauterine contraception (IUC). Satisfaction, confidence, and switching intentions were dichotomized into being very versus less satisfied, being completely versus less confident, and having very low versus not very low switching intentions. We conducted binomial logistic regression to examine whether method type, satisfaction, and confidence were independently associated with having very low switching intentions, adjusting for a range of covariates including sociodemographics, perceived health, religious attendance frequency, sexual, contraceptive, and reproductive experiences, and state of residence (Maryland or Delaware).

RESULTS

Among 1,077 women using reversible contraception, those using IUC relative to implants, pills, patches, or rings, and coitally-dependent methods were more likely to have very low switching intentions. Among all survey respondents, those who were very satisfied and those who were completely confident in correct use were also more likely to report very low switching intentions.

CONCLUSIONS

Using IUC, being very satisfied, and being very confident in correct use were independently associated with having very low switching intentions.

IMPLICATIONS

These results suggest that those using IUC have very low intentions to switch for reasons in addition to satisfaction-level with their method. Other aspects of using IUC such as ease of use, perceived barriers to switching, or having very low switching intentions before beginning IUC may be such reasons.

The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

OBJECTIVES

To review ethical aspects of the promotion and provision of long-acting reversible contraception (LARC). Specifically, to examine (1) the tension between informational exchange and the active promotion of LARC methods to new and existing contraceptive users by healthcare professionals; and (2) the distinct ethical issues arising from the promotion of LARC methods by state-sponsored actors and healthcare professionals.

METHODS

Narrative review and ethical analysis.

FINDINGS

There is an ethical difference between raising awareness/informational provision and actively promoting or prioritising specific contraceptive methods. It matters whether the policy choice is made, or the promotional activity about contraception is undertaken, by individual healthcare professionals at a local level or by more remote state-sponsored actors, because the relationship between the promoter and the (potential) contraceptive user is of a different kind. Imposing a dual responsibility upon healthcare professionals for raising awareness/informational exchange and the active promotion of LARC creates an unnecessary tension and barrier for the delivery of patient-centred care.

CONCLUSIONS

This review highlights the need for ethical reflection on the central role of the promoting agent and the distinction between facilitating informational awareness and active promotion of LARC. LARC methods should not be prioritised in isolation and without regard to the wider implications of public promotion. A balanced narrative and information-sharing programme that respects the individual interests of each contraceptive user is called for, especially in direct professional/service user relationships. No assumption should be made that user decision-making will necessarily be determined and influenced solely by the relative effectiveness of the contraceptive method.

Contraceptive decision making among pregnancy-capable individuals with opioid use disorder at a tertiary care center in Massachusetts

OBJECTIVE

To explore contraceptive decision making among recently pregnant patients with a history of opioid use disorder.

STUDY DESIGN

We conducted semi-structured qualitative interviews, based on principles of the Ottawa Decision Support Framework, with 20 recently pregnant individuals diagnosed with opioid use disorder at a tertiary care medical center in Massachusetts. We audio-recorded the interviews and they were transcribed verbatim. We analyzed our interview data using inductive and deductive coding.

RESULTS

Participants value the availability of barrier methods as a means of preventing both sexually transmitted infections and pregnancy. For some participants, housing instability makes storing contraceptive methods and managing personal hygiene related to bleeding patterns difficult. For others, housing instability impacts their overall fertility goals. Side effects including weight gain, interactions with mood stabilizing medications, concern regarding post-operative opioids, or intrinsic aspects of a method that serve as reminders of opioid use may be unacceptable given the risk of relapse. The relapsing and remitting arc of recovery make remembering important aspects of both short- and long-acting contraceptive method use difficult, yet participants offer strategies to aid in doing so.

CONCLUSION

When choosing a contraceptive method participants in our study exhibit similarities to individuals with other chronic medical conditions as well as motivations specific to opioid use disorder. Their contraceptive decisions are grounded in integrating a method into a chaotic life, preventing relapse, and protecting future fertility.

IMPLICATIONS

Our data highlight how lived experiences at the intersection of active opioid use disorder and recovery fundamentally shape the lens through which pregnancy-capable individuals with opioid use disorder view their contraceptive decisions.

Contraceptive Method Uptake at Title X Health Centers in Utah

BACKGROUND

The Title X family planning program previously supported contraception for Utah clients with low incomes, yet its contributions may not have been sufficient to allow clients to select their preferred methods, including long-acting reversible contraceptives (LARCs). In this study, we compare the contraceptive method choices of self-paying clients with low incomes at three participating Title X health centers in Salt Lake County, Utah, before and after the removal of additional cost barriers.

METHODS

We used retrospective medical record review to assess clients' contraceptive choices during two 6-month periods: a control period with Title X-assisted sliding scale payment schedules (n = 2,776) and an intervention period offering no-cost contraceptive care (n = 2,065). We used logistic regression to identify the likelihood of selecting a LARC during the intervention period and multinomial regression to identify the selection probability of different types of available LARCs.

RESULTS

During the control period, 16% of participants chose a LARC compared with 26% in the intervention period (p ≤ .001). During the intervention period, participants were 1.8 times more likely to select LARCs (95% confidence interval, 1.65-2.13) compared with non-LARC methods, holding covariates constant. In the multinomial regression, participants were three times more likely during the intervention period to select an implant than a pill, patch, or ring, holding all other covariates constant (odds ratio, 3.08; 95% confidence interval, 2.47-3.83).

CONCLUSIONS

Title X clients offered contraceptive methods without cost more frequently selected a LARC method. Title X funding reductions may impede individuals' access to their contraceptive methods of choice.

Factors affecting men's support for the use of the contraceptive implant by their female intimate partners

Background

Family planning services have been available at no cost in the public health settings of South Africa since 1994, and now include the long-acting reversible contraceptives (LARCs) namely, the contraceptive implant and intra-uterine device (IUD). However, the uptake of LARCs has been declining in the recent years and little is known about the cause of the decline. In many relationships, men may influence their female intimate partner’s contraceptive choices. Thus, men’s involvement in reproductive health decisions and family programming may improve their support for contraceptive use, including the LARC use by their female intimate partners. This study investigated factors affecting men’s support for the use of contraceptive implant by their female intimate partners.

Methods

A quantitative, cross-sectional survey was conducted among adult men attending a public, primary health clinic in Cape Town, South Africa. Using a structured questionnaire, we measured men’s knowledge, awareness and support of, and attitudes towards use of the contraceptive implant by their female intimate partners. Data were analyzed using SPSS version 25.

Results

The sample included 65 men with a mean age of 31.2 years. Most (76.6%) believed that both men and women should be responsible for family planning. Support for general contraception use by their female intimate partners was prevalent at 80.0%, but only 33.9% reported that they would like their partners to use the implant in the future, while 35.6% were unsure and 30.5% did not support their partner’s use of the implant. Factors significantly associated with men’s support of their partner’s future use of the contraceptive implant included men’s reports that their partner wished to have another child in future, knowledge that the implant is safe for use by women who have not had children, knowledge that the implant can effectively prevent pregnancy for 3 years, and a positive attitude towards the implant’s long-lasting effectiveness.

Conclusion

Improving men’s knowledge of, and attitudes toward the contraceptive implant might increase their support for their partner’s use of the implant, which in turn might promote uptake of the implant among women. The findings of our study suggest the importance of actively engaging men in reproductive health and family planning programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40834-020-00140-7.

Telemedicine for contraceptive counseling: An exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic

OBJECTIVE

During the COVID-19 pandemic, many clinicians started offering telemedicine services. The objective of this study is to describe the experience of US family planning providers with the rapid adoption of telemedicine for contraceptive counseling during this period.

STUDY DESIGN

This is a cross-sectional web-based survey of family planning providers practicing in the United States.

RESULTS

A total of 172 providers completed the survey (34% response rate). Of these, 156 (91%) provided telemedicine services in the 2 months preceding the survey. Most (78%) were new to telemedicine. About half (54%) referred less than a quarter of contraception patients for in-person visits, and 53% stated that the most common referral reason was long-acting reversible contraceptive (LARC) insertion. A majority of providers strongly agree that telemedicine visits are an effective way to provide contraceptive counseling (80%), and that this service should be expanded after the pandemic (84%). If asked to provide telemedicine visits after the pandemic, 64% of providers would be very happy about it. Many providers used personal phones or smartphones to conduct telemedicine visits but stated that ideal devices would be work-issued computers, tablets, or phones. More than half (59%) of providers prefer video over phone visits.

CONCLUSIONS

Family planning clinicians in the United States reported a positive experience with telemedicine for contraceptive counseling during the early stage of the COVID-19 pandemic and believe that this service should be expanded. Clinicians seem to prefer using work-issued devices and conducting video rather than phone visits.

IMPLICATIONS

Telemedicine is a promising option for providing contraceptive counseling even beyond the COVID-19 pandemic. An investment in hospital or clinic-issued devices that allow for video conferencing may optimize clinicians' telemedicine experience.

[Preventive activities in women's care]

A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.

Long-Acting Reversible Contraception: Specific Issues for Adolescents

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.

Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study

BACKGROUND

The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost.

METHODS

We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC.

RESULTS

Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day.

CONCLUSIONS

This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Intrauterine Contraception: Knowledge and Prescribing Practices of Canadian Health Care Providers

OBJECTIVE

Contraception is an important issue in the lives of women, their partners, and society. Canadians and their health care providers play a critical role in contraceptive decision making that influences individuals and Canadian society. The purpose of this study was to gather data on contraception-related knowledge, counselling, and prescribing practices of Canadian health care providers.

METHODS

This project reported on the outcomes of an educational initiative, designed as a quality improvement initiative (time series level II-3), focused on Canadian health care providers' contraception-related knowledge, counselling, and prescribing practices. Outcomes were intended to inform the development of tools, resources, and educational programming. Part 1 was an online program to identify educational and knowledge gaps for health care providers. Part 2 was a practice assessment exploring and measuring health care providers' contraceptive counselling and prescribing practices.

RESULTS

A total of 4300 health care providers completed the program between July 6, 2015 and August 30, 2016. Knowledge significantly increased; post-test scores were higher than pretest scores. After completion, all participants felt more comfortable, knowledgeable, and inclined to change their practice around prescribing intrauterine contraception (IUC). The 4300 providers reported on their contraception counselling experiences with 10 patients following participation in Part 1. Forty percent of patients were using oral contraceptives, and 53% were dissatisfied with their current type of contraception. After counselling, patients reported being most comfortable with IUC (55%). Both short- and long-acting types of contraception were most often discussed or offered (74% of the time), followed by long-acting reversible contraception only (21%) and short-acting methods only (5%).

CONCLUSION

This training program filled an education need for patients and gave providers tools to change their behaviour and practice around IUC prescribing. On the basis of these data, a practice assessment model was deemed a successful way to change behaviour.

Contraception counseling for adolescents

PURPOSE OF REVIEW

In recent years, pregnancy and birth rates among adolescents in the United States have declined to all-time lows, although adolescents in the United States continue to have the highest rate of unintended pregnancy among developed countries. Contraception is a key component in the prevention of unintended pregnancy. In this review, we outline unique barriers to reproductive healthcare for adolescents and strategies to optimally address the contraceptive needs of adolescents.

RECENT FINDINGS

Adolescents face barriers such as confidentiality, cost, and access when seeking contraception. Counseling about options for contraception may involve parents or guardians when appropriate, but an adolescent's autonomy should be respected in the decision-making process. Contraceptive counseling for adolescents must not be coercive in nature. Adolescents are at an increased risk for acquisition of sexually transmitted infections, and dual use, the use of condoms and an additional method of contraception, is highly recommended. Initiatives that remove the common barriers of cost and access have demonstrated significant success in increasing the use of long-acting reversible contraceptive methods and reducing the rates of unintended pregnancy among adolescents.

SUMMARY

Counseling adolescents about contraception requires acknowledgement of the unique barriers that adolescents face and facilitating decision-making about contraceptive methods in a manner that prioritizes the adolescent's autonomy.

Not seeking yet trying long-acting reversible contraception: a 24-month randomized trial on continuation, unintended pregnancy and satisfaction

OBJECTIVES

To measure the 24-month impact on continuation, unintended pregnancy and satisfaction of trying long-acting reversible contraception (LARC) in a population seeking short-acting reversible contraception (SARC).

STUDY DESIGN

We enrolled 916 women aged 18-29 who were seeking pills or injectables in a partially randomized patient preference trial. Women with strong preferences for pills or injectables started on those products, while others opted for randomization to LARC or SARC and received their methods gratis. We estimated continuation and unintended pregnancy rates through 24months. Intent-to-treat principles were applied after method initiation for comparing incidence of unintended pregnancy. We also examined how satisfaction levels varied by cohort and how baseline negative LARC attitudes were associated with satisfaction over time.

RESULTS

Forty-three percent chose randomization, and 57% chose the preference option. Complete loss to follow-up was<2%. The 24-month LARC continuation probability was 64.3% [95% confidence interval (CI): 56.6-70.9], statistically higher than SARC groups [25.5% (randomized) and 40.0% (preference)]. The 24-month cumulative unintended pregnancy probabilities were 9.9% (95% CI: 7.2-12.6) (preference-SARC), 6.9% (95% CI: 3.3-10.6) (randomized-SARC) and 3.6% (95% CI: 1.8-6.4) (randomized-LARC). Statistical tests for comparing randomized groups on unintended pregnancy were mixed: binomial at 24-month time point (p=.02) and log-rank survival probabilities (p=.14 for first pregnancies and p=.07 when including second pregnancies). LARC satisfaction was high (80% happy/neutral, 73% would use LARC again, 81% would recommend to a friend). Baseline negative attitudes toward LARC (27%) were not clearly associated with satisfaction or early discontinuation.

CONCLUSIONS

The decision to try LARC resulted in high continuation rates and substantial protection from unintended pregnancy over 24months. Despite participants' initial desires to begin short-acting regimens, they had high satisfaction with LARC. Voluntary decisions to try LARC will benefit large proportions of typical SARC users.

IMPLICATIONS

Even women who do not necessarily view LARC as a first choice may have a highly satisfying experience and avoid unintended pregnancy if they try it.

Long-acting Reversible Contraception Among Homeless Women Veterans With Chronic Health Conditions: A Retrospective Cohort Study

BACKGROUND

US women Veterans are at increased risk of homelessness and chronic health conditions associated with unintended pregnancy. Veterans Health Administration (VHA) provision of long-acting reversible contraception (LARC) can assist in healthy pregnancy planning.

OBJECTIVES

To evaluate perinatal risk factors and LARC exposure in ever-homeless women Veterans.

RESEARCH DESIGN

A retrospective cohort study of women Veterans using VHA administrative data from fiscal years 2002-2015.

SUBJECTS

We included 41,747 ever-homeless women Veterans age 18-44 years and 46,391 housed women Veterans matched by military service period. A subgroup of 7773 ever-homeless and 8674 matched housed women Veterans deployed in Iraq and Afghanistan [Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND)] conflicts comprised a second analytic cohort.

MEASURES

Descriptive statistics compared demographic, military, health conditions, and LARC exposure in ever-homeless versus housed women Veterans. Multivariable logistic regression explored factors associated with LARC exposure in the OEF/OIF/OND subgroup.

RESULTS

All health conditions were significantly higher in ever-homeless versus housed Veterans: mental health disorder in 84.5% versus 48.7% (P<0.001), substance abuse in 35.8% versus 8.6% (P<0.001), and medical conditions in 74.7% versus 55.6% (P<0.001). LARC exposure among all VHA users was 9.3% in ever-homeless Veterans versus 5.4% in housed Veterans (P<0.001). LARC exposure in the OEF/OIF/OND cohort was 14.1% in ever-homeless Veterans versus 8.2% in housed Veterans (P<0.001). In the OEF/OIF/OND cohort, homelessness along Veterans with medical and mental health indicators were leading LARC exposure predictors.

CONCLUSIONS

The VHA is successfully engaging homeless women Veterans and providing LARC access. The prevalence of perinatal risk factors in ever-homeless women Veterans highlights a need for further programmatic enhancements to improve reproductive planning.

Knowledge of and concerns about long-acting reversible contraception among women in medication-assisted treatment for opioid use disorder

OBJECTIVES

To assess interest in, concerns about and knowledge of long-acting reversible contraceptives (LARC) among women in medication-assisted treatment (MAT) for opioid use disorder who were at risk for unintended pregnancy.

STUDY DESIGN

Women in MAT completed a survey on contraceptive use, attitudes and knowledge, including LARC methods, as part of eligibility screening for an ongoing trial evaluating family planning interventions for this population.

RESULTS

Eighty-three women at risk for unintended pregnancy completed the survey, and a subset of 51 completed supplemental questions about implants. All participants had heard of IUDs and 75/83 (90%) had heard of implants, but only 34/83 (41%) and 14/51 (27%) reported being likely to use IUDs and implants, respectively. Thirty-five women reported they were unlikely to use IUDs, with 29/35 (83%) citing unspecified "other reasons" for this position and 24/35 (69%) endorsing concerns about side effects. Seventeen women reported they were unlikely to use implants, with 8/17 (47%) citing "other reasons" and 9/17 (53%) and 10/17 (59%) reporting concerns about insertion and removal, respectively. Participants reported they knew "a little" about LARCs, but only their knowledge of implants was limited. Only 50/83 (60%) participants were aware of the superior effectiveness of IUDs and 26/51 (51%) were aware of the superior effectiveness of implants relative to other reversible methods.

CONCLUSIONS

Participants reported relatively low interest in LARCs. Many women had unspecified reasons for not using LARCs. Participants also lacked information about LARC safety and effectiveness, especially with regard to implants.

IMPLICATIONS

Women in medication-assisted treatment for opioid use disorder are at high risk of unintended pregnancy, yet contraceptive use is low and use of less effective methods is common. Women in MAT may benefit from efforts to increase knowledge about implants and assuage concerns about their insertion and removal as well as more general efforts to improve knowledge about the relative efficacy of LARCs. Many women in MAT endorsed unspecified "other reasons" for not using LARCs, which should be explored further.

Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study

BACKGROUND

Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.

OBJECTIVE

To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans.

DESIGN AND PARTICIPANTS

We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months.

MAIN MEASURES

Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG).

KEY RESULTS

Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended.

CONCLUSIONS

While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

Reassessing the importance of long-acting contraception

BACKGROUND

Several recent studies have highlighted the need for greater use of long-acting contraception. The most influential of these studies is the Contraceptive CHOICE Project, which was credited with substantially reducing participants' pregnancy risk by increasing their use of long-acting methods such as intrauterine devices and subdermal implants. However, because participants' rates of nonuse and condom use fell to zero at the outset of the intervention, it is possible that sizable pregnancy reductions could still have been achieved if enrollees had chosen shorter-acting, female-controlled methods such as oral contraception.

OBJECTIVE

The objective of the study was to estimate the proportion of the CHOICE Project's fertility impacts that could have been achieved without any increase in long-acting method use.

STUDY DESIGN

The FamilyScape 3.0 microsimulation model was used to estimate CHOICE's impact on pregnancy risk and to simulate the counterfactual effect of moving all nonusers and condom users onto shorter-acting, female-controlled methods. FamilyScape models the sexual and contraceptive behaviors of women in the United States between 2006 and 2010, which is the period when CHOICE was implemented.

RESULTS

Nearly three quarters of the CHOICE intervention's effects on pregnancy risk could have been achieved if participants had chosen shorter-acting, female-controlled methods over long-acting methods.

CONCLUSION

Prioritizing the adoption of long-acting contraception may not be the most advisable strategy for reducing unintended pregnancy. The most impactful interventions will likely be those that increase the use of female-controlled methods, long-acting or otherwise.