Depo Now: preventing unintended pregnancies among adolescents and young adults

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

What's Known and What's Next: Contraceptive Counseling and Support for Adolescents and Young Adult Women

The low rates of actual contraceptive failure and high rates of contraceptive use among young women highlight that choice of contraceptive method and patterns of contraceptive use greatly influence unintended pregnancy risk. Promoting contraceptive use among adolescent and young adult women requires supportive health systems and health providers who understand this population's evolving developmental needs. It also requires an awareness of effective tools for counseling patients, while being mindful of the power dynamics operational during clinical encounters to avoid inadvertently coercive interpersonal dynamics. Missed opportunities to provide such patient-centered care can lead to unplanned pregnancies and suboptimal health and social consequences for young women. Unfortunately, health providers often lack the tools and resources to appropriately identify and meet individual young women's contraceptive needs. This article summarizes the evidence supporting contraceptive counseling strategies linked with contraceptive initiation among young women, and evidence-based approaches for supporting contraceptive adherence and continuation after method initiation. It also orients readers to the unique neurodevelopmental factors that influence the shared decision-making process during contraception counseling sessions with young women. New and emerging approaches for supporting contraceptive initiation, adherence, and continuation are reviewed.

The potential for intramuscular depot medroxyprogesterone acetate as a self-bridging emergency contraceptive

Objective

To examine the rate of ovulatory disruption when intramuscular depot medroxyprogesterone acetate (DMPA) is administered across graded stages of dominant follicle development.

Study design

We assigned enrolled participants to one of three preassigned dominant follicle size groups: 12-14 mm, 15–17 mm and ≥ 18 mm. We followed dominant follicles via serial transvaginal ultrasound (TVUS) until the follicles reached their assigned size, at which time we administered DMPA. For 5 consecutive days thereafter, we followed the follicles via TVUS to observe follicle rupture and obtained serum luteinizing hormone (LH), estradiol, and progesterone concentrations. In the following 2 weeks, we collected serum progesterone concentrations twice weekly to detect possible ovulatory delay or dysfunction. We also collected serum medroxyprogesterone acetate (MPA) concentrations at 1 and 24 h after DMPA administration to examine against ovulatory outcomes.

Results

Twenty-six of 29 enrolled women completed the study. DMPA suppressed ovulation in 17/26 (65%) and caused ovulatory dysfunction in 1/26 (4%) participants. Larger follicles were more likely to rupture despite DMPA (12–14 mm: 0/10 (0%); 15–17 mm: 3/10 (30%); ≥ 18 mm: 6/6 (100%); p < .01). Pre-DMPA LH concentrations ranged from 13.8 to 93.7 IU/L (mean 49.0 IU/L) in cases of follicle rupture. We observed no cases of follicle rupture when DMPA was administered through cycle day 12. All 24-h MPA concentrations exceeded those needed for ovulation suppression.

Conclusion

DMPA suppressed and additionally disrupted ovulation in 65% and 4% of observed cycles, respectively. DMPA may provide effective emergency contraception as well as ongoing contraception if administered prior to an expected ovulation and specifically before the LH surge.

Implications

DMPA may be an alternative form of emergency contraception that can also self-bridge to ongoing contraception. As ovulation was not observed among any follicles when DMPA was given through cycle day 12, women who initiate DMPA up through cycle day 12 may not require backup contraception.

Universal access to no-cost contraception for youth in Canada

Timely access to effective contraception reduces the incidence of unintended pregnancy. Cost is a significant barrier to using contraception for youth in Canada. Many must pay out-of-pocket because they have no pharmaceutical insurance, their insurance does not cover the contraceptives they desire, or they wish to obtain contraceptives without their parents' knowledge. To address these barriers and reduce rates of unintended pregnancy, this statement recommends that all youth should have confidential access to contraception, at no cost, until the age of 25. The statement also recommends measures to help achieve this goal across Canada.

Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents

PURPOSE

Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents.

METHODS

We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year.

RESULTS

The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20).

CONCLUSIONS

While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.

Contraceptive care for Canadian youth

Sexual and reproductive health is an important component of comprehensive health care for youth. This statement provides guidance for selecting and prescribing contraceptives for youth, including commonly prescribed hormonal contraceptives-the pill, patch, ring and injectable progestin-and long-acting reversible contraceptives (LARCs). LARCs, including subdermal implants (which are not available in Canada) and intrauterine contraceptives (IUCs), are substantially more effective during typical use than hormonal contraceptives. This statement endorses LARCs as the first-line option for contraception for Canadian youth, while emphasizing that providers must collaborate with youth to select a contraceptive method that is acceptable, safe, effective and practical for them. Strategies that eliminate obstacles to initiating and continuing contraception are provided.

Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions

Adolescents have special sexual and reproductive health needs (whether or not they are sexually active or married). This review assesses the impact of interventions to improve adolescent sexual and reproductive health (including the interventions to prevent female genital mutilation/cutting [FGM/C]) and to prevent intimate violence. Our review findings suggest that sexual and reproductive health education, counseling, and contraceptive provision are effective in increasing sexual knowledge, contraceptive use, and decreasing adolescent pregnancy. Among interventions to prevent FGM/C, community mobilization and female empowerment strategies have the potential to raise awareness of the adverse health consequences of FGM/C and reduce its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. There was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence. Further studies with rigorous designs, longer term follow-up, and standardized and validated measurement instruments are required to maximize comparability of results. Future efforts should be directed toward scaling-up evidence-based interventions to improve adolescent sexual and reproductive health in low- and middle-income countries, sustain the impacts over time, and ensure equitable outcomes.

Self-administration of injectable contraceptives: a systematic review

Background

The contraceptive injectable is a safe and effective method that is used worldwide. With the variety of injectable delivery systems, there is potential for administration by the woman herself. Self‐administration of the contraceptive injectable is the subject of this systematic review.

Objectives

To assess how effective and safe the contraceptive injectable method is when women themselves perform/administer it, compared with when the usual healthcare providers administer it.

Search strategy

We searched PubMed, Popline, Cochrane, CINAHL, and Embase for articles with subject headings or text words related to ‘self‐administration’ and ‘contraception’.

Selection criteria

Studies that compared the administration of the contraceptive injectable by the woman herself versus administration by the healthcare provider were included. Outcomes of interest were continuation rates, safety, and the women's overall satisfaction with the contraceptive provider and method.

Data collection and analysis

We undertook data extraction, descriptive analysis, and assessment of risk of bias.

Main results

Three studies met the inclusion criteria. The best available evidence shows that there may be little or no difference in continuation rates when women self‐administer contraceptive injections (326 per 1000 women; 95% CI 192–554 per 1000 women) compared with administration by healthcare providers (304 per 1000 women). Safety was not estimable as no serious adverse events were reported in any of the studies. With regards to overall satisfaction towards the provider and the method, the effect of the intervention was uncertain.

Authors’ conclusions

Findings suggest that with appropriate information and training the provision of contraceptive injectables for the woman to self‐administer at home can be an option in some contexts.

Tweetable abstract

This review assessed the continuation rates and safety of self‐administration of the contraceptive injection.

This review assessed the continuation rates and safety of self‐administration of the contraceptive injection.

Predictors of Early Discontinuation of Effective Contraception by Teens at High Risk of Pregnancy

STUDY OBJECTIVE

In the United States, teen pregnancy rates are declining. However, the United States still has the highest teen pregnancy rate among high-income countries. Understanding factors that predict discontinuation of effective contraception might help to further decrease teen pregnancy. We aimed to assess predictors of early discontinuation of effective contraception during typical use by high-risk teens. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We recruited 145 women aged 13-20 years (mean, 17.7 ± 1.8 years); 68% (99/145) Hispanic; 26% (38/145) black; 14% (20/145) ever pregnant; and 4% (6/145) high school dropouts who chose an effective contraceptive method during a health care visit and we prospectively assessed use of the method after 6 months. Contraceptive choices of the 130 participants who were reassessed at 6 months (90% retention) were: intrauterine device (IUD), 26% (34/130); depot medroxyprogesterone acetate (DMPA), 8% (10/130); combined oral contraceptives (COCs), 48% (62/130); transdermal patch (Patch), 13% (17/130); and intravaginal ring (Ring), 5% (7/130).

RESULTS

After 6 months, only 49 of 130 (38%) continued their chosen method; 28 of 130 (22%) never initiated the method; and 53 of 130 (40%) discontinued. Users and nonusers at 6 months did not differ according to cultural and/or social characteristics (age, ethnicity, acculturation, education, health literacy) but differed according to contraceptive method type. For the 102 of 130 who initiated a method, 88% continued use of the IUD, 20% DMPA, 43% COC, 17% Patch and Ring (P < .001). Using Cox proportional hazards multivariable analysis, compared with IUDs, all other methods predicted discontinuation: DMPA (hazard ratio [HR], 5.6; 95% confidence interval [CI], 1.2-26.7; P < .05); COCs (HR, 6.6; 95% CI, 1.8-25; P < .01); Patch and Ring (HR, 12; 95% CI, 3.0-48; P < .001). Discontinuation was also predicted by past use of hormonal contraceptives (HR, 1.9; 95% CI, 1.0-3.6; P < .05) and high school dropout (HR, 8.2; 95% CI, 1.6-41; P < .01).

CONCLUSION

Contraceptive method type is the strongest predictor of early discontinuation; compared with IUDs, all other methods are 6-12 times more likely to be discontinued. Cultural and/or social characteristics, with the exception of school dropout, are of little predictive value. Increasing the use of IUDs by high-risk teens could decrease discontinuation rates and possibly teen pregnancy rates.

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

OBJECTIVE

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

OUTCOMES

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

EVIDENCE

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

VALUES

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

Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study

OBJECTIVES

We assessed intrauterine device (IUD) preference among women presenting for emergency contraception (EC) and the probability of pregnancy among concurrent oral levonorgestrel (LNG) plus LNG 52 mg IUD EC users.

METHODS

We offered women presenting for EC at a single family planning clinic the CuT380A IUD (copper IUD) or oral LNG 1.5 mg plus the LNG 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion.

RESULTS

One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse. Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral LNG plus the LNG IUD. The probability of pregnancy two weeks after oral LNG plus LNG IUD EC use was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral LNG plus the LNG IUD and who had reported multiple episodes of unprotected intercourse including an episode more than 5 days prior to treatment.

CONCLUSIONS

Study participants seeking EC who desired an IUD preferentially chose oral LNG 1.5 mg with the LNG 52 mg IUD over the copper IUD. Neither group had EC treatment failures. Including the option of oral LNG 1.5 mg with concomitant insertion of the LNG 52 mg IUD in EC counseling may increase the number of EC users who opt to initiate highly effective reversible contraception.

IMPLICATIONS

Consideration should be given to LNG IUD insertion with concomitant use of oral LNG 1.5 mg for EC. Use of this combination may increase the number of women initiating highly effective contraception at the time of their EC visit.

Injectable agents for pre-exposure prophylaxis: lessons learned from contraception to inform HIV prevention

PURPOSE OF REVIEW

Long-acting injectable (LAI) forms of preexposure prophylaxis (PrEP) are in clinical trials, generating much hope for HIV prevention. But this is not the first time that an injectable form of preventive medication has emerged: the contraceptive agent depomedroxyprogesterone acetate (DMPA) has an important precedent. DMPA's long journey, its initial reception, and ongoing implementation challenges can help inform the field of HIV prevention as we plan for approval, acceptance, and scale-up of LAI-PrEP.

RECENT FINDINGS

DMPA faced a long regulatory journey in the USA, with a lag of 25 years from initial application (1967) to approval (1992). Acceptance after introduction was rapid, but challenges hampered scale-up. Specific lessons learned include that extensive acceptability work is needed in parallel to product development. Also, low continuation rates, challenges with timing of initiation, and difficulty ensuring access for the most vulnerable populations have limited DMPA's impact. A new subcutaneous formulation presents opportunities for administration outside of clinical settings and for self-administration.

SUMMARY

Those involved in LAI-PrEP development and those who plan to be involved in its future implementation must consider these lessons and possible solutions from DMPA to ensure a successful future for this new HIV prevention modality.

Interventions for preventing unintended pregnancies among adolescents

BACKGROUND

Unintended pregnancy among adolescents represents an important public health challenge in high-income countries, as well as middle- and low-income countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these interventions, hence the need to review the evidence-base.

OBJECTIVES

To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

SEARCH METHODS

We searched all relevant studies regardless of language or publication status up to November 2015. We searched the Cochrane Fertility Regulation Group Specialised trial register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 11), MEDLINE, EMBASE, LILACS, Social Science Citation Index and Science Citation Index, Dissertations Abstracts Online, The Gray Literature Network, HealthStar, PsycINFO, CINAHL and POPLINE and the reference lists of articles.

SELECTION CRITERIA

We included both individual and cluster randomised controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10 years to 19 years.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias, and extracted data. Where appropriate, binary outcomes were pooled using a random-effects model with a 95% confidence interval (Cl). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 53 RCTs that enrolled 105,368 adolescents. Participants were ethnically diverse. Eighteen studies randomised individuals, 32 randomised clusters (schools (20), classrooms (6), and communities/neighbourhoods (6). Three studies were mixed (individually and cluster randomised). The length of follow up varied from three months to seven years with more than 12 months being the most common duration. Four trials were conducted in low- and middle- income countries, and all others were conducted in high-income countries. Multiple interventionsResults showed that multiple interventions (combination of educational and contraceptive-promoting interventions) lowered the risk of unintended pregnancy among adolescents significantly (RR 0.66, 95% CI 0.50 to 0.87; 4 individual RCTs, 1905 participants, moderate quality evidence. However, this reduction was not statistically significant from cluster RCTs. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) was not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomisation and the use of different statistical tests in reporting outcomes. Educational interventionsEducational interventions were unlikely to significantly delay the initiation of sexual intercourse among adolescents compared to controls (RR 0.95, 95% CI 0.71 to 1.27; 2 studies, 672 participants, low quality evidence).Educational interventions significantly increased reported condom use at last sex in adolescents compared to controls who did not receive the intervention (RR 1.18, 95% CI 1.06 to 1.32; 2 studies, 1431 participants, moderate quality evidence).However, it is not clear if the educational interventions had any effect on unintended pregnancy as this was not reported by any of the included studies. Contraceptive-promoting interventionsFor adolescents who received contraceptive-promoting interventions, there was little or no difference in the risk of unintended first pregnancy compared to controls (RR 1.01, 95% CI 0.81 to 1.26; 2 studies, 3,440 participants, moderate quality evidence).The use of hormonal contraceptives was significantly higher in adolescents in the intervention group compared to those in the control group (RR 2.22, 95% CI 1.07 to 4.62; 2 studies, 3,091 participants, high quality evidence)

AUTHORS' CONCLUSIONS

A combination of educational and contraceptive-promoting interventions appears to reduce unintended pregnancy among adolescents.  Evidence for programme effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

Hormonal and intrauterine methods for contraception for women aged 25 years and younger

BACKGROUND

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods.

OBJECTIVES

To compare the contraceptive failure (pregnancy) rates and to examine the continuation rates for hormonal and intrauterine contraception among young women aged 25 years and younger.

SEARCH METHODS

We searched until 4 August 2015 for randomized controlled trials (RCTs) that compared hormonal or intrauterine methods of contraception in women aged 25 years and younger. Computerized databases included the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS. We also searched for current trials via ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We considered RCTs in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared with another contraceptive method, for women aged 25 years and younger. The other contraceptive method could have been another intrauterine contraceptive, another hormonal contraceptive or different dose of the same method, or a non-hormonal contraceptive. Treatment duration must have been at least three months. Eligible trials had to include the primary outcome of contraceptive failure rate (pregnancy). The secondary outcome was contraceptive continuation rate.

DATA COLLECTION AND ANALYSIS

One author conducted the primary data extraction and entered the information into Review Manager. Another author performed an independent data extraction and verified the initial entry. For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Because of disparate interventions and outcome measures, we did not conduct meta-analysis.

MAIN RESULTS

Five trials met the inclusion criteria. The studies included a total of 1503 women, with a mean of 301 participants. The trials compared the following contraceptives: combined oral contraceptive (COC) versus transdermal contraceptive patch, vaginal contraceptive ring, or levonorgestrel intrauterine system 20 µg/day (LNG-IUS 20); LNG-IUS 12 µg/day (LNG-IUS 12) versus LNG-IUS 16 µg/day (LNG-IUS 16); and LNG-IUS 20 versus the copper T380A intrauterine device (IUD). In the trials comparing two different types of methods, the study arms did not differ significantly for contraceptive efficacy or continuation. The sample sizes were small for two of those studies. The only significant outcome was that a COC group had a higher proportion of women who discontinued for 'other personal reasons' compared with the group assigned to the LNG-IUS 20 (OR 0.27, 95% CI 0.09 to 0.85), which may have little clinic relevance. The trial comparing LNG-IUS 12 versus LNG-IUS 16 showed similar efficacy over one and three years. In three trials that examined different LNG-IUS, continuation was at least 75% at 6 to 36 months.

AUTHORS' CONCLUSIONS

We considered the overall quality of evidence to be moderate to low. Limitations were due to trial design or limited reporting. Different doses in the LNG-IUS did not appear to influence efficacy over three years. In another study, continuation of the LNG-IUS appeared at least as high as that for the COC. The current evidence was insufficient to compare efficacy and continuation rates for hormonal and intrauterine contraceptive methods in women aged 25 years and younger.

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.

Does research into contraceptive method discontinuation address women's own reasons? A critical review

OBJECTIVE

To examine the clinical and epidemiological literature addressing contraceptive method change or discontinuation and to assess whether the documented reasons reflected women's experiences.

METHODS

Major databases including Medline and PsycINFO were searched using keywords related to contraception and discontinuation, adherence and satisfaction, for articles published between January 2003 and February 2013. Studies in developed countries that focused on women of reproductive age and reasons for method change or discontinuation were included. Reasons reported were categorised and examined.

RESULTS

A total of 123 papers were reviewed in detail. Medical terminology was generally used to describe reasons for method discontinuation. The top two reported reasons were bleeding and pregnancy, but there was a lack of consensus about the categorisation of reasons. Broad categories that were not self-explanatory were included in more than half of the papers, often without further explanation. Only 12 studies expanded on categories containing 'other', 'non-medical' or 'personal' reasons. Eight papers included categories that attributed discontinuation to the participant, such as 'dissatisfied with method'.

CONCLUSIONS

Studies of reasons for discontinuation of contraceptives do not well describe women's specific reasons. Studies rely heavily on medical terms and often fail to document women's subjective experiences. Future studies should create an opportunity for women to articulate their non-medical reasons in their own words, including those related to their sexual lives. Furthermore, researchers should distinguish, if possible, between reasons for discontinuation of a method and reasons for ceasing participation in a research study.

Emergency contraception review: evidence-based recommendations for clinicians

Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile, and availability. The most effective emergency contraceptive is the copper intrauterine device (IUD), followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, whereas ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.

Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate

OBJECTIVES

To evaluate feasibility, acceptability, continuation, and trough serum levels following self-administration of subcutaneous (sc) depot medroxyprogesterone acetate (DMPA).

STUDY DESIGN

Women presenting to a family planning clinic to initiate, restart or continue DMPA were offered study entry. Participants were randomized in a 2:1 ratio to self- or clinician administered sc DMPA 104 mg. Those randomized to self-administration were taught to self-inject and were supervised in performing the initial injection; they received printed instructions and a supply of contraceptive injections for home use. Participants randomized to clinician administration received usual care. Continued DMPA use was assessed by self-report and trough medroxyprogesterone acetate levels at 6 and 12 months.

RESULTS

Two hundred fifty women were invited to participate, and 137 (55%) enrolled. Of these, 91 were allocated to self-administration, and 90/91 were able to correctly self-administer sc DMPA. Eighty-seven percent completed follow-up. DMPA use at 1 year was 71% for the self-administration group and 63% for the clinic group (p=0.47). Uninterrupted DMPA use was 47% and 48% for the self and clinic administration groups at 1 year (p=0.70), respectively. Serum analyses confirmed similar mean DMPA levels in both groups and therapeutic trough levels in all participants.

CONCLUSIONS

Sixty-three percent of women approached were interested in trying self-administration of DMPA, even in the context of a randomized trial, and nearly all eligible for enrollment were successful at doing so. Self-administration and clinic administration resulted in similar continuation rates and similar DMPA serum levels. Self-administration of sc DMPA is feasible and may be an attractive alternative for many women.

IMPLICATIONS

Self-administration of sc DMPA is a feasible and attractive option for many women. Benefits include increased control over contraceptive measures and less time spent on contracepting behaviors. Globally, self-administration has the potential to revolutionize contraceptive uptake by increasing the number of women with access to DMPA.

Immediate versus delayed initiation of the contraceptive patch after abortion: a randomized trial

BACKGROUND

Immediate start of the contraceptive patch has not been studied in women after surgical abortion.

STUDY DESIGN

Women presenting for surgical abortion who had chosen the transdermal patch for contraception were randomized to either delayed start of the patch (beginning the Sunday after their abortion) or immediate start (directly observed application of the patch in the clinic). Subjects were contacted at 2 and 6 months to assess contraceptive use.

RESULTS

Two hundred ninety-eight women were randomized, and the follow-up rate was 71% at 2 months and 53% at 6 months. Method continuation did not differ by timing of initiation. At 2 months, 71% in the delayed-start group and 74% in the immediate-start group were using the patch [p=.6, with a difference of 3.1%, 95% confidence interval (CI)=-17.2% to +11.2%]. At 6 months, 55% in the delayed-start group and 43% in the immediate-start group were using the patch (p=.13, with a difference of 11.9%, 95% CI=-19.2% to +34%).

CONCLUSION

Immediate initiation of the contraceptive patch after surgical abortion was not associated with increased use of patch at 2 or 6 months.

Adolescent gynecology: special considerations for special patients

Developments in the field of adolescent gynecology highlight the specific expertise and care required by this population. Given the ability to shape their future health choices, adolescents are a critical target for preventative health care. The approach to the evaluation and management of this unique population rests not only on the practitioner's adept ability to recognize the unique clinical challenges that may occur, but also rests on his/her understanding of these problems. Here, we review recent guidelines and practice patterns in the evaluation and management of issues in adolescent gynecology.

Immediate start of hormonal contraceptives for contraception

BACKGROUND

Health care providers often tell women to wait until the next menses to begin hormonal contraception. The intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. At the time of the initial review, how immediate start compared to conventional menses-dependent start was unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception.

OBJECTIVES

This review examined randomized controlled trials (RCTs) of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

SEARCH METHODS

In August 2012, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies. Earlier searches also included EMBASE.

SELECTION CRITERIA

We included RCTs that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated.

MAIN RESULTS

Five studies were included. No new eligible studies have been found since the review was initially conducted. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77). A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. Also, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22).

AUTHORS' CONCLUSIONS

We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, i.e., immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Hormonal and intrauterine methods for contraception for women aged 25 years and younger

BACKGROUND

Women between the ages of 15 and 24 years have high rates of unintended pregnancy; over half of women in this age group want to avoid pregnancy. However, women under age 25 years have been found to have higher typical contraceptive failure rates within the first 12 months of use than older women. High discontinuation rates may also be a problem in this population. Concern that adolescents and young women will not find hormonal or intrauterine contraceptives acceptable or effective might deter healthcare providers from recommending these contraceptive methods. 

OBJECTIVES

This review examined randomized controlled trials of hormonal or intrauterine methods used for contraception in women aged 25 years and younger.

SEARCH METHODS

In February 2012, we searched the computerized databases Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS for randomized controlled trials that compared hormonal or intrauterine methods used for contraception in women aged 25 years and younger. We also searched for current trials via ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

We considered all randomized controlled trials in any language that reported the contraceptive failure rates for hormonal or intrauterine contraceptive methods, when compared to another contraceptive method, for women aged 25 years and younger. The other contraceptive method could be another intrauterine method, another hormonal method, or a non-hormonal method. Treatment duration must have been at least three months.

DATA COLLECTION AND ANALYSIS

The first author extracted the data and entered the information into RevMan. Another author performed an independent data extraction and verified the initial entry. Because of disparate contraceptive exposures, we were not able to combine the studies in meta-analysis.

MAIN RESULTS

Four trials met the inclusion criteria. The trials compared the combined oral contraceptive versus the transdermal contraceptive patch, the combined oral contraceptive versus the vaginal contraceptive ring, the combined oral contraceptive versus the levonorgestrel intrauterine system, and the levonorgestrel intrauterine system versus the copper T380A intrauterine device. Because of small numbers of participants, the trials were not informative regarding contraceptive efficacy. Data on continuation rates were also limited. In one of these trials, the levonorgestrel intrauterine system was found to have a similar 12-month continuation rate as the combined oral contraceptive (odds ratio (OR) 1.48; 95% CI 0.76 to 2.89). In that trial, a higher proportion of women discontinued the levonorgestrel intrauterine system because of pain (OR 14.62; 95% CI 0.81 to 263.16), whereas a higher proportion of women discontinued the combined oral contraceptive for personal reasons (OR 0.27; 95% CI 0.09 to 0.85).

AUTHORS' CONCLUSIONS

Current evidence is insufficient to compare contraceptive efficacy and continuation rates for hormonal and intrauterine methods in women aged 25 years and younger. Limited data suggests that the levonorgestrel intrauterine system may be an acceptable alternative to the combined oral contraceptive in this population.

The Quick Start Contraception Initiation Method during the 6-week postpartum visit: an efficacious way to improve contraception in Federally Qualified Health Centers

BACKGROUND

About half of all pregnancies in the United States are unplanned, and many start soon after a previous delivery. Our aim was to determine if the implementation of the Quick Start Contraception Initiation Method during the 6-week postpartum evaluation could improve the delivery of contraception.

STUDY DESIGN

The medical records of 979 patients seen for their 6-week postpartum visit at our urban Federally Qualified Health Center (FQHC) between July 2004 and June 2006 were reviewed. The patients were distributed into two groups defined by evaluations performed prior to or after the implementation of the new contraception initiation method. Summary statistics and differences in the proportions were calculated. A probability of <.05 was considered significant.

RESULTS

The Quick Start Contraception Initiation Method was implemented in July 2005. Five-hundred and sixteen patients were in Group 1, and 463 patients were in Group 2. Demographic variables were similar among groups. Contraception delivery rate was 50% in Group 1 and 72% in Group 2 (p<.05). Eighty percent of patients in Group 1 and 76% of those in Group 2 requested contraception, and 26% of Group 1 and 3% of Group 2 did not receive it. The improvement in dispensing contraception was most noticeable among teenagers.

CONCLUSION

These findings suggest that the Quick Start Contraception Initiation Method at the time of the 6-week postpartum evaluation improves the delivery of contraception in FQHCs.

Initiation of progestogen-only injectables on different days of the menstrual cycle and its effect on contraceptive effectiveness and compliance: a systematic review

BACKGROUND

Initiation of contraceptive progestogen-only injections conventionally require that women delay starting them until menses begin, during which time interval a woman may be at risk of unintended pregnancy. Our objective was to determine from the literature when a woman can initiate progestogen-only injectables for contraception.

STUDY DESIGN

We searched MEDLINE and Cochrane databases for all articles (in all languages) published in peer-reviewed journals between database inception to February 2012, for evidence relevant to starting injectables on different days of the menstrual cycle and its impact upon contraceptive effectiveness or those that examined different strategies for initiation and their effects on compliance and continuation.

RESULTS

Eight articles met our criteria for inclusion. All studies examined initiation of depot medroxyprogesterone (DMPA); no studies of norethisterone enantate were identified. Three articles, reported that when DMPA was initiated later than Cycle Day 7, ovulation occurred in some women. Approximately 90% of women had poor quality cervical mucus within 24 h after they received an injection. Five studies of compliance and continuation demonstrated that the use of another contraceptive method as a "bridging option" was not successful in helping women initiate DMPA. When DMPA was given throughout the menstrual cycle, more women were eligible to receive their first injection but only about half returned on time for their subsequent injection and some pregnancies occurred.

CONCLUSION

Ovulation is rare when DMPA is provided within the first 7 days of the menstrual cycle. Use of another contraceptive as a "bridging option" until DMPA can be initiated has been unsuccessful in helping women initiate DMPA and is associated with higher rates of pregnancy.

Self-administration of subcutaneous depot medroxyprogesterone acetate for contraception: feasibility and acceptability

BACKGROUND

The objectives of the study were to assess feasibility, continuation rates and patient satisfaction with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC).

MATERIALS AND METHODS

The study included 50 DMPA-seeking women between the ages of 18 and 49 years enrolled at two Florida Planned Parenthood health centers. Participants were taught self-injection during their initial study visit and, upon proficiency, self-injected one dose in clinic. Participants then injected a series of three more doses outside the health center over 9 months. Continuation rates, feasibility and acceptability were determined by analysis of four postinjection surveys.

RESULTS

Continuation of DMPA-SC at injection 4 was 74% (95% confidence interval 62%-86%). Overall, survey responses from the three at-home injections indicated the method to be convenient (95%), easy (87%) and recommendable to others (94%). Twenty percent of injections were met with difficulty, most commonly cited as plunger resistance. No pregnancies occurred in study.

CONCLUSIONS

Continuation was high with DMPA-SC self-injection. Participants reported injection to be easy and convenient and are likely to recommend self-administration to other women. Device issues are one potential deterrent.

Use of the Copper T380A intrauterine device by adolescent mothers: continuation and method failure

STUDY OBJECTIVE

This report contributes to limited empirical data regarding use of the Copper T380A intrauterine device among adolescent mothers.

DESIGN

We conducted a retrospective case series of adolescent mothers aged 15 to 21 years whose index delivery occurred before age 18 and met study inclusion criteria.

SETTING

All adolescent mothers received obstetrics and gynecology care at one urban clinical site in Washington, DC.

PARTICIPANTS

All participated in a teen secondary pregnancy prevention program from April 2002 to November 2008 and used the Copper T380A intrauterine device.

MAIN OUTCOME MEASURES

We abstracted data to evaluate intrauterine device utilization, expulsion, removal, and pregnancy diagnosis.

RESULTS

Thirty-nine adolescent mothers met inclusion criteria. Six patients had partial or complete expulsion (15%; 95% CI, 6-29), and 10 requested removal (26%; 95% CI, 14-41) within 24 months of placement. Four users (10%; 95% CI, 3-23) became pregnant. Three had an intrauterine device in place at time of conception, while one became pregnant due to unrecognized device expulsion.

CONCLUSIONS

In this case series, many adolescent mothers discontinued Copper T380A use within two years of placement. The numbers of patients were too limited to provide stable estimates of contraceptive effectiveness. Larger comparative studies will further evaluate both effectiveness and acceptability of this device among teen mothers.

Vaginal estrogen supplementation during Depo-Provera initiation: a randomized controlled trial

BACKGROUND

Irregular bleeding is often cited as the reason for discontinuation of depot-medroxyprogesterone acetate (DMPA) after the first injection. Estrogen supplementation during DMPA initiation may decrease bleeding and improve continuation.

STUDY DESIGN

This prospective, randomized, controlled trial evaluated estrogen supplementation during DMPA initiation. Women initiating DMPA were randomized to receive an estradiol vaginal ring for 3 months versus DMPA alone. Bleeding diaries and questionnaires at three and 6 months assessed bleeding, continuation and ring acceptability.

RESULTS

Seventy-one participants enrolled; 49 completed the first follow-up period. The median number of bleeding or spotting days was 16 in the estrogen ring group (n=26) versus 28 in the DMPA alone group (n=23) (p=.19). Seventy-seven percent of the intervention group received a second injection compared with 70% in the DMPA alone group (p=.56). For each additional day of bleeding and/or spotting reported, women were 3% less likely to receive a second injection (OR 0.97, 95% CI 0.94-0.99). Acceptability of the vaginal ring was high among those in the intervention group.

CONCLUSIONS

Vaginal estrogen supplementation during DMPA initiation is acceptable to women and may decrease total bleeding.

Interventions for preventing unintended pregnancies among adolescents

BACKGROUND

Unintended pregnancy among adolescents represent an important public health challenge in developed and developing countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these intervention, and hence the need to review their evidence-base

OBJECTIVES

To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

SEARCH STRATEGY

We searched electronic databases (CENTRAL, PubMed, EMBASE) ending December 2008. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

SELECTION CRITERIA

We included both individual and cluster randomized controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10-19 years.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and risk of bias in studies that met the inclusion criteria. Where appropriate, binary outcomes were pooled using random effects model with a 95% confidence interval (Cl).

MAIN RESULTS

Forty one RCTs that enrolled 95,662 adolescents were included. Participants were ethnically diverse. Eleven studies randomized individuals, twenty seven randomized clusters (schools (19), classrooms (5), and communities/neighbourhoods (3). Three studies were mixed (individually and cluster randomized). The length of follow up varied from 3 months to 4.5 years. Data could only be pooled for a number of studies (15) because of variations in the reporting of outcomes. Results showed that multiple interventions (combination of educational and contraceptive interventions) lowered the rate of unintended pregnancy among adolescents. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) is not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomization and the use of different statistical test in reporting outcomes.

AUTHORS' CONCLUSIONS

Combination of educational and contraceptive interventions appears to reduce unintended pregnancy among adolescents. Evidence for program effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

Missed hormonal contraceptives: new recommendations

OBJECTIVE

To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy.

EVIDENCE

Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

Initiation of oral contraceptives--start now!

PURPOSE

Conventional practice for initiating oral contraceptive (OC) pills involves waiting to start the pills with the next menstrual period. We investigated whether immediate initiation of OCs would lead to improved continuation rates and therefore decreased pregnancy rates in adolescents aged 12-17 years.

METHODS

Study subjects were recruited from adolescent women presenting to 2 inner city clinics requesting OCs. A total of 539 adolescents between 12 and 17 years old were randomized to conventional initiation of the OC pill (Conventional Start [CS]) versus immediate, directly observed OC pill ingestion in the clinic (Quick Start [QS]). At 3 and 6 months the participants completed interviews that questioned them about their OC continuation and pregnancies.

RESULTS

In all, 86% of our adolescents completed follow-up interviews at 3 months, and 77% at 6 months. There were 45 pregnancies during the study period. QS was associated with continuing OCs to a second pack (adjusted OR 1.8, 95% CI 1.1-3.3). There was no difference in OC continuation rates at 3 or 6 months. Only 26% of adolescents continued OCs at 6 months and we identified 45 pregnancies during follow-up.

CONCLUSION

We conclude that directly observed, immediate initiation of oral contraceptives (QS) with adolescents briefly improves continuation although overall continuation rates are discouraging low. Health care providers could use this simple strategy to start adolescents on OCs at the initial visit. The low 6-month OC continuation rates highlight the need to seek novel ways to provide adolescents with the necessary tools to be successful at contraception.

Public and private providers' involvement in improving their patients' contraceptive use

BACKGROUND

This study measured differences in the provision of care between public and private providers of contraceptive services, what problems using contraception these providers perceived their patients to have and providers' views on how to improve their patients' method use.

STUDY DESIGN

A nationally representative mixed-mode survey (mail, Internet and fax) of private family practice and obstetrician/gynecologist physicians who provided contraceptive care in 2005 was conducted. A parallel survey was administered to public contraceptive care providers in community health centers, hospitals, Planned Parenthood clinics and other sites during the same period. Descriptive and multivariate analyses were conducted across both surveys.

RESULTS

A total of 1256 questionnaires were completed for a response rate of 62%. A majority of providers surveyed believed that over 10% of their contraceptive clients experienced ambivalence about avoiding pregnancy, underestimated the risk of pregnancy and failed to use contraception for one or more months when at risk for unintended pregnancy. Implementation of protocols to promote contraceptive use ranged widely among provider types: a full 78% of Panned Parenthood clinics offered quick-start pill initiation, as did 47% of public health departments. However, 38% of obstetrician-gynecologists, 27% of "other public" clinics and only 13% of family physicians did so. Both public and private providers reported that one of the most important things they could do to improve patients' contraceptive method use was to provide more and better counseling. At least 46% of private providers and at least 21% of public providers reported that changing insurance reimbursement to allow more time for counseling was very important.

CONCLUSIONS

Strategies to improve contraceptive use for all persons in need in the United States have the potential to be more effective if the challenges contraceptive providers face and the differences between public and private providers are taken into account.

Immediate start of hormonal contraceptives for contraception

BACKGROUND

Health care providers often tell women to wait until the next menses to begin hormonal contraception. The main intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was first introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. How immediate start compares to conventional menses-dependent start is unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception.

OBJECTIVES

This review examined randomized controlled trials of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

SEARCH STRATEGY

We searched MEDLINE, CENTRAL, POPLINE, EMBASE, and LILACS for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies.

SELECTION CRITERIA

We included randomized controlled trials that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated.

MAIN RESULTS

Five studies were included. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a 'bridge' method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a 'bridge' method (OR 1.99; 95% CI 1.05 to 3.77).A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. For satisfaction, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22).

AUTHORS' CONCLUSIONS

We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, that is, immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Injectable contraception: what should the longest interval be for reinjections?

BACKGROUND

Progestin-only injectable contraceptives continue to gain in popularity, but uncertainty remains about pregnancy risk among women late for reinjection. The World Health Organization (WHO) recommends a "grace period" of 2 weeks after the scheduled 13-week reinjection. Beyond 2 weeks, however, many providers send late clients home to await menses.

STUDY DESIGN

A prospective cohort study in Uganda, Zimbabwe and Thailand followed users of depot-medroxyprogesterone acetate (DMPA) for up to 24 months. Users were tested for pregnancy at every reinjection, allowing analysis of pregnancy risk among late comers.

RESULTS

The analysis consists of 2290 participants contributing 13,608 DMPA intervals. The pregnancy risks per 100 women-years for "on time" [0.6; 95% confidence interval (CI), 0.33-0.92], "2-week grace" (0.0; 95% CI, 0.0-1.88) and "4-week grace" (0.4; 95% CI, 0.01-2.29) injections were low and virtually identical.

CONCLUSION

Extending the current WHO grace period for DMPA reinjection from 2 to 4 weeks does not increase pregnancy risk and could increase contraceptive continuation.

Self pregnancy testing in an urban family planning clinic: promising results for a new approach to contraceptive follow-up

BACKGROUND

Immediate initiation of depo-medroxyprogesterone acetate (DMPA) increases continuation and decreases pregnancies compared to conventional (next menstrual period) initiation. A drawback is the need to return in 4 weeks for a repeat pregnancy test to identify any pregnancy that was too early to diagnose on the day of injection. If women can perform home pregnancy tests (HPTs) to detect human chorionic gonadotropin (hCG) in urine, the need for this follow-up visit may be eliminated. This study assesses whether women can perform their own HPT.

STUDY DESIGN

This is a single-visit observational trial of an HPT kit. Subjects recruited from a waiting room in an urban family planning clinic received an HPT kit with standard instructions to use immediately. Subjects and a research assistant each interpreted the test. Their results were then compared to a standard cassette type test for detection of hCG performed by clinic staff. kappa was calculated to assess the level of agreement.

RESULTS

Three hundred ten subjects enrolled. They were young (mean age, 25.2 years), mostly Hispanic (91%) women. A change in the font and explicitness of the instructions decreased the incidence of invalid tests from 12.7% to 4.8%. The subject and research assistant's interpretation of the test had a high level of agreement, kappa=0.95 [95% confidence interval (CI), 0.92-0.99]. There was also a high level of agreement between the subjects' results and the standard test, kappa=0.88 (95% CI, 0.82-0.95).

CONCLUSIONS

Women presenting for pregnancy testing at an urban clinic are able to perform HPTs with a high level of accuracy. The appearance of the instructions influenced the incidence of false-negative and invalid tests. Home pregnancy tests may be useful in follow-up protocols when immediate initiation of DMPA is employed.

Long-acting contraceptives in adolescents

PURPOSE OF REVIEW

To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed.

RECENT FINDINGS

The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits.

SUMMARY

The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.