Family planning knowledge, attitudes and practices among bariatric healthcare providers

Evaluation of telemedicine for contraceptive counseling given to pregnant women during the COVID-19 pandemic: A randomized controlled trial

In this study, we aimed to evaluate the impact of telemedicine for contraceptive counseling on knowledge levels and satisfaction with Family Planning Services. We collected data from 77 third-trimester pregnant women using a personal information form, Family Planning Knowledge Questionnaire, and the Satisfaction with Family Planning Services Scale and compared the data using chi-square test, Fisher's exact chi-square test, t-test for independent and dependent groups and Mann-Whitney U analysis. The experimental group participants (n = 37) received two informative video visits for contraceptive counseling, while the women in the control group (n = 40) received routine face-to-face Family Planning Services at their primary health care center. Participants in the experimental group showed a greater increase in knowledge levels and higher satisfaction with Family Planning Services than those in the control group (p < 0.05). In conclusion, we determined that telemedicine for contraceptive counseling is a promising option even beyond the pandemic.

A Scoping Review: Bariatric Providers' Knowledge and Behaviors Related to Contraceptive Counseling

Bariatric surgery is a common treatment for obesity, and about half of patients undergoing these procedures are patients of reproductive age. Following bariatric procedures, rapid weight loss and an increase in fertility occur. Guidelines recommend pregnancy delay for 12-24 months postoperatively. It is important that patients capable of pregnancy undergoing bariatric procedures receive preoperative contraceptive counseling. Studies surveying bariatric providers demonstrate that most providers understand the importance of delaying pregnancy and contraceptive counseling. However, deficiencies in bariatric provider knowledge, comfort, and practice with contraceptive counseling were identified. These gaps highlight opportunities for improvement in preoperative care to ensure patients are receiving appropriate contraception.

Gynecologic counseling for patients undergoing bariatric surgery: a scoping review

PURPOSE OF REVIEW

Obesity is associated with several gynecologic conditions. While bariatric surgery is regarded as the most effective treatment option for obesity, gynecologic counseling for patients planning bariatric surgery is limited and often focused on fertility. The goal of this scoping review is to investigate the current recommendations for gynecologic counseling prior to bariatric surgery.

RECENT FINDINGS

A comprehensive search was conducted to find peer reviewed studies written in English discussing a gynecologic issue of patients who were planning or previously had bariatric surgery. All the included studies identified a gap in preoperative gynecologic counseling. The majority of the articles made specific recommendations for a multidisciplinary approach to preoperative gynecologic counseling with a call to involve gynecologists or primary care providers.

SUMMARY

Patients deserve to receive appropriate counseling about how obesity and bariatric surgery impact their overall gynecologic health. We advocate that the scope of gynecologic counseling includes more than pregnancy and contraception counseling. We propose a gynecologic counseling checklist for female patients undergoing bariatric surgery. Offering patients a referral to a gynecologist from the patient's first entry to a bariatric clinic is imperative to facilitate appropriate counseling.

Contraceptive counselling in 3 Canadian bariatric surgery clinics: a multicentre qualitative study of the experiences of patients and health care providers

BACKGROUND

Evidence suggests an increase in fertility and unintended pregnancy after bariatric surgery; contraceptive counselling, traditionally defined as a discussion of contraception options, is therefore an important facet of surgical planning. Our aim was to investigate patient experiences of contraceptive counselling, the attitudes of health care providers (HCPs) toward contraceptive counselling, and their perceptions of the facilitators and barriers to contraceptive counselling in bariatric surgery clinics.

METHODS

We conducted a qualitative study using semistructured interviews with patients and HCPs at publicly funded Canadian bariatric surgery clinics from May 2018 to February 2019. We recruited bariatric HCPs from across Canada using snowball sampling, and recruited patient participants from 3 Canadian bariatric surgery programs. Patient participants had to be at risk of pregnancy in the postoperative period, aged 18-45 years old and have completed all preoperative counselling. We included HCPs who delivered care in a publicly funded, hospital-affiliated bariatric surgery clinic in Canada. Team members analyzed transcripts thematically.

RESULTS

We completed 27 interviews (patient n = 16, HCP n = 11). Our analysis identified 3 separate themes: missing information in contraception counselling, making assumptions about who would benefit from counselling and strategies for improving contraception counselling. We found patients and HCPs wanted more resources on the safety and efficacy of contraceptive methods.

INTERPRETATION

Our study showed a need for structured contraceptive counselling in bariatric surgery clinics. Information resources that support patients and HCPs who provide counselling are needed.

Extremely early pregnancy (<6 mo) after sleeve gastrectomy: maternal and perinatal outcomes

BACKGROUND

Data are scarce regarding outcomes of pregnancies occurring very early after bariatric surgery.

OBJECTIVES

We compared outcomes of pregnancies occurring extremely early (surgery-to-conception interval <6 mos) after laparoscopic sleeve gastrectomy (LSG) with those occurring later (≥6 mos postsurgery).

SETTING

A university hospital.

METHODS

We reviewed the records of all women who underwent LSG and delivered during 2006-2019.

RESULTS

Of 196 women, 23 (11.7%) became pregnant within 6 months of surgery. For these women, the median surgery-to-conception interval was 116 [interquartile range 76-161] days, compared with 903 [465-1377] days for the remaining cohort. Three (13.0%) women turned out postoperatively to be pregnant at the time of LSG. Compared with women who conceived later, the extremely early pregnancy group had lower gestational weight gain (median 4 versus 10 kg, P < .001), including negative gestational weight gain in 9 (39.1%) women. The proportion of small for gestational age (SGA) infants was higher among women who conceived within 6 months after surgery rather than later (26.1% versus 10.4%, P = .04). Other maternal and perinatal outcomes were similar between the groups. In multivariate analysis, conceiving within 6 months after LSG was the only independent factor associated with delivering a SGA infant (odds ratio [95% confidence interval]: 3.35 (1.12, 10.01), P = .03).

CONCLUSIONS

Pregnancy occurring in the first 6 months after LSG was independently associated with a higher rate of SGA infants. Delaying conception during the very early postoperative period is recommended. Providing adequate contraception and excluding the presence of early pregnancy at the time of surgery are of utmost importance.

Optimizing contraceptive access for women undergoing bariatric surgery

With the dramatic increase in the prevalence of obesity, there is a corresponding increase in surgical procedures to treat obesity. Reproductive aged women (18-45 years old) undergo half of the bariatric surgical procedures performed in the United States each year. These women experience profound physiologic changes in response to bariatric surgery, including dramatic changes in reproductive function. Current guidelines recommend delaying attempts at conception for 12-24 months after bariatric surgery during the time of most profound weight loss. Despite these recommendations, many women report unprotected intercourse during this time, and many use less efficacious contraceptive options. Herein, we address contraceptive considerations in women of reproductive age who undergo bariatric surgery and opportunities to maximize a multidisciplinary surgical approach to optimize their overall health.

Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper.

Contraception, Menstruation, and Sexuality after Bariatric Surgery: a Prospective Cohort Study

BACKGROUND

Women with a history of bariatric surgery are recommended to avoid pregnancy at least 12 months after surgery. Evidence on the impact of bariatric surgery on contraception, menstrual cycle, and sexuality in the first year postoperative is therefore indispensable.

OBJECTIVES

The objective of this paper is to prospectively study changes in contraception, menstrual cycle and sexuality in women of reproductive age following bariatric surgery.

SETTING

The study was conducted in two secondary medical centers and a tertiary academic medical center.

METHODS

Women attending for bariatric surgery or who recently underwent bariatric surgery completed online questionnaires about contraception, menstrual cycle, and sexual behavior before surgery and 6 and 12 months after surgery.

RESULTS

The study included data from 71 women, including 70 and 47 women at 6 and 12 months after bariatric surgery, respectively. Preoperatively, 43.6% (n = 31/71) used a short-acting hormonal contraceptive, the usage of which decreased significantly to, respectively, 32.8% (n = 23/70; p = .031) and 27.7% (n = 13/47; p = .022) 6 and 12 months post-surgery. Usage of long-acting contraceptive methods increased from 26.7% (n = 19/71) preoperatively to 38.6% (n = 27/70; p = .021) and 42.6% (n = 20/47; p = .004) at 6 and 12 months. Combined oral contraceptives (COC) remained used (39.4% preoperatively, 27.1 and 14.9% at 6 and 12 months postoperatively). Menstrual cycle (frequency, pattern, duration of the cycle, and the menstruation itself) and sexual behavior (intimate relationship, frequency of intercourse, and satisfaction) did not differ significantly before and after surgery.

CONCLUSIONS

Women undergoing bariatric surgery appear to switch their type of contraceptive from oral, short-acting hormonal contraceptives to non-oral, long-acting contraceptives. No changes in menstrual cycle and sexual behavior were shown.

Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive procedures

BACKGROUND

Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness.

OBJECTIVES

To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness.

SETTING

United States.

METHODS

We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness.

RESULTS

Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as "other" (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics.

CONCLUSIONS

Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

Perioperative pregnancy interval, contraceptive counseling experiences, and contraceptive use in women undergoing bariatric surgery

BACKGROUND

Reproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women's experience with perioperative counseling and postoperative contraceptive use is limited.

OBJECTIVE

We sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population.

STUDY DESIGN

We performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months.

RESULTS

We enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was "very important" to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5-4.3, P < .001).

CONCLUSION

A substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.

Safety of hormonal contraception for obese women

INTRODUCTION

Obese women have special safety requirements for contraceptive choice, but the evidence supporting such decision is dispersed and sometimes conflicting. Despite being effective, well tolerated and safe for most women, hormonal contraceptives are underused by obese women due to fear of contraceptive failure, weight gain and venous thrombosis. Areas covered: We performed a comprehensive literature search to identify studies about hormonal contraception in overweight and obese women, including safety concerns. We considered the safety of hormonal contraceptives for otherwise healthy obese women and for those with comorbidities such as hypertension, diabetes, vascular disease, or a history of deep venous thrombosis. Expert opinion: Over time there is no convincing evidence that obesity increases the risk of contraceptive failure. Hormonal contraceptive users may have a modest weight gain that is comparable to that of non-users. Current evidence supports the safe use of combined hormonal contraceptives by obese women after detailed clinical screening to exclude comorbidities that may contraindicate the use of estrogens. Progestin-only methods are generally safe, and long-acting reversible contraceptives hold the best combination of efficacy, safety and convenience for this group, although individualization is advisable.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

BACKGROUND

Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.

PARTIAL SOLUTION

Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.

CONCLUSION

Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.

New developments in long-acting reversible contraception: the promise of intrauterine devices and implants to improve family planning services

After decades of having the developed world's highest rates of unintended pregnancy, the United States finally shows signs of improvement. This progress is likely due in large part to increased use of highly effective long-acting reversible methods of contraception. These methods can be placed and do not require any maintenance to provide years of contraception as effective as sterilization. Upon removal, fertility returns to baseline rates. This article addresses advances in both software-improved use and elimination of barriers to provide these methods; and hardware-novel delivery systems and devices.