The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review

Adoption of contraception following a pregnancy loss in India

OBJECTIVE

The present study was carried out to describe contraceptive adoption following pregnancy terminations that resulted in outcomes other than live birth.

METHOD

Retrospective calendar data on 31486 women who had experienced a pregnancy loss within the last 60 months prior to the survey date were drawn from a nationally representative dataset. Logistic regression was employed to model the associated factors with contraceptive uptake.

RESULTS

Overall, 57.8% reported not adopting any method following the end of the recent pregnancy. There was a significant association between the choice of contraceptive method and timing of adoption. Women with living children were significantly more likely to adopt contraception as compared to women without any child.

CONCLUSION

Contraceptive uptake following a non-live birth is considerably low in India. Interventions in reproductive health should focus on provision of different contraceptive methods and counseling emphasizing on effectiveness and correct use of the methods at the end of any pregnancy.

Unintended pregnancy and contraception use among African women living with HIV: Baseline analysis of the multi-country US PEPFAR PROMOTE cohort

BACKGROUND

About 90% of unintended pregnancies are attributed to non-use of effective contraception-tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine contraceptive device (IUCD), and implant. We assessed the prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs)-implants and IUCDs, among women living with HIV (WLHIV) receiving antiretroviral therapy (ART).

METHODS

We conducted cross-sectional analyses of the US-PEPFAR PROMOTE study WLHIV on ART at enrollment. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI).

RESULTS

Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with a potential to become pregnant reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR = 0.97 (95% CI: 0.90-1.04), p = 0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with education attained, primary versus higher education, aPRR = 1.10 (95% CI: 1.02-1.18), p = 0.013; marriage/stable union, aPRR = 1.10 (95% CI: 1.01-1.21), p = 0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p = 0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; and controlled HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p = 0.014. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p = 0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p = 0.386; HIV load (≤ 1000 copies/ml copies/ml), aPRR=1.73 (95% CI: 1.26-2.37), p<0.001; and formal/self-employment, aPRR = 1.37 (95% CI: 1.02-1.91), p = 0.027.

CONCLUSIONS

Unintended pregnancy was common while use of effective contraception methods particularly LARCs was low among these African WLHIV. HIV viral load, education, sexual-activity, fertility desires, and economic independence are pertinent individual-level factors integral to the multi-level barriers to utilization of effective contraception among African WLHIV. National programs should prioritize strategies for effective integration of HIV and reproductive health care in the respective African countries.

A Decision Aid for Postpartum Adolescent Family Planning: A Quasi-Experimental Study in Tanzania

BACKGROUND

We evaluated the effects of our postpartum Green Star family planning decision aid on the decisional conflict, knowledge, satisfaction, and uptake of long-acting reversible contraception among pregnant adolescents in Tanzania.

METHODS

We used a facility-based pre-post quasi-experimental design. The intervention arm received routine family planning counseling and the decision aid. The control received only routine family planning counseling. The primary outcome was the change in decisional conflict measured using the validated decision conflict scale (DCS). The secondary outcomes were knowledge, satisfaction, and contraception uptake.

RESULTS

We recruited 66 pregnant adolescents, and 62 completed this study. The intervention group had a lower mean score difference in the DCS than in the control (intervention: -24.7 vs. control: -11.6, p < 0.001). The mean score difference in knowledge was significantly higher in the intervention than in the control (intervention: 4.53 vs. control: 2.0, p < 0.001). The mean score of satisfaction was significantly higher in the intervention than in the control (intervention: 100 vs. control: 55.8, p < 0.001). Contraceptive uptake was significantly higher in the intervention [29 (45.3%)] than in the control [13 (20.3%)] (p < 0.001).

CONCLUSION

The decision aid demonstrated positive applicability and affordability for pregnant adolescents in Tanzania.

Relationship of Age at Menarche, Coitarche and First Gestation: A Retrospective Cohort Analysis

Introduction

Teenage pregnancy is defined as a pregnancy occurring between ages 10 and 19 (Loredo-Abdlá et al., 2017; Belitzky, 1985; Kaplanoglu et al., 2015), and is associated with increased morbidity and mortality for both mother and child. Several factors have been identified with increased risk of a teenage pregnancy, including incomplete sexual education awareness and increased exposure at a young age. In addition, an earlier onset of sexual intercourse, or coitarche, has been linked to a higher risk of teenage pregnancy. Early menarche, defined as first menstruation before the age of 12 has been previously identified as a risk factor for an earlier coitarche, possibly linking an early menarche with a higher incidence of teenage pregnancy. This study aims to compare and determine the relationship between the incidence of teenage pregnancy with early menarche and coitarche in a low income setting.

Design Setting Participants Interventions Main Outcome Measures

A cross sectional review of electronic records of women admitted for delivery in a second level center in northeastern Mexico, being a low-income setting, where 814 teenage and 1474 adult mothers were included.

Results

Primigravid teenagers had earlier menarche and coitarche than adult counterparts and opted for postpartum contraception more frequently. Linear regression analysis revealed significant unadjusted beta coefficients between age at first pregnancy and coitarche (0.839) and menarche (0.362). Menarche and coitarche had a significant linear regression association of 0.395.

Conclusion

We found amongst primigravid patients that teenagers had earlier menarche and coitarche than adults, which in turn correlated to their age at their first pregnancy.

Placement of long-acting reversible contraception for minors who are mothers should not require parental consent

Decreasing unintended teenage pregnancy, especially repeat teenage pregnancy, is an important public health goal. Unfortunately, legal barriers in the USA impede this goal as all minors are unable to consent for birth control in 24 states, and only 10 of those states allow consent after the minor has given birth according to state statutory law. Placement of long-acting reversible contraception (LARC) is one of the most effective methods of preventing rapid repeat pregnancies. However, restrictions are placed on adolescents who may not have the option of parental consent if the parents are unwilling, or not present, to give consent. A predicament arises when healthcare professionals are willing to place the contraceptive for the patient, but cannot due to the restrictions and guidelines outlined by each state. Even though these adolescents are legally viewed as minors, adolescent mothers should be able to consent to the placement of LARC. Notably, adolescents have the legal ability to give consent for the healthcare of their child starting in the prenatal period. I argue that this ability should be extended to include adolescent consent for their own healthcare. Additionally, the procedure to place LARC is relatively low risk and highly effective, which is an opportune situation to allow minors to consent. Allowing adolescents to consent to LARC after delivery is a simple and effective way to decrease rapid repeat pregnancy rates in the USA.

Postpartum Contraceptive Decision-Making of Parous Teens-A Qualitative Study

STUDY OBJECTIVE

Approximately 25% of teens in the United States will become pregnant before the age of 18, and within 2 years, more than 31% will have a repeat pregnancy. Acknowledging that some adolescents might seek or be ambivalent toward rapid repeat pregnancy, compared with their counterparts, not using a long-acting reversible contraception method increases a teen's risk of another pregnancy in 2 years by more than 35 times. We seek to better understand the influences and factors surrounding adolescent postpartum contraceptive decision-making following the index delivery.

DESIGN

We completed a qualitative study via focused, semistructured interviews during an inpatient postpartum course. The interview guide was modeled after those used in other studies of adolescent contraceptive decision-making, beta tested, and developed iteratively. Interviews were completed, transcribed, coded, and analyzed with the assistance of Dedoose.

SETTING

The study was conducted at MetroHealth Medical Center in Cleveland, Ohio.

PARTICIPANTS

Parous adolescents aged 13-19 RESULTS: We performed 12 interviews prior to reaching theoretical saturation. Themes were identified related to the participants' prior experiences with contraception and prior and current pregnancies. The participants' contraceptive choices were influenced by personal relationships, varying levels of autonomy, misperceptions, and changing contraceptive needs.

CONCLUSIONS

We found that adolescents' contraceptive decision-making was influenced by their social networks and community, including their parents and friends. Mothers played a key role as adolescents transitioned to gaining more autonomy over their reproductive decisions. Providers should consistently present adolescents with comprehensive contraceptive options as a component of preventive health care.

The Impact of a Home Visiting Program Enhanced to Address Repeat Adolescent Pregnancy-A Randomized Controlled Trial of Steps to Success

INTRODUCTION

A small but growing body of evidence suggests individualized support services and improved access to contraception can promote healthy birth spacing among adolescent mothers. This study examines the effectiveness of Steps to Success, a 2-year home visiting program in San Angelo, Texas, enhanced with content designed to reduce rapid repeat pregnancy among young mothers, increase fathers' involvement, and support mothers' education and career aspirations.

METHODS

The study used a randomized controlled trial, with 594 young mothers ages 14-20 randomly assigned to either a program group that received Steps to Success or a control group that received an existing home visiting program focused only on parenting and child development. Women in both research groups completed a baseline survey upon enrolling in the study and 1- and 2-year follow-up surveys.

RESULTS

After 2 years, participants in the Steps to Success and existing home visiting groups had similar rates of repeat pregnancy. However, women in the Steps to Success group were more likely to use long-acting reversible contraceptives (effect size = 0.18, p = 0.066), particularly younger adolescent mothers ages 14-18 (effect size = 0.34, p = 0.010). Steps to Success also decreased the incidence of unprotected sex for younger adolescent mothers (effect size = -0.25, p = 0.035). Steps to Success did not improve outcomes in other domains.

DISCUSSION

Steps to Success improved some outcomes related to healthy birth spacing among younger adolescent mothers. Communities interested in similar programming may want to consider focusing their services on this age group.

Assessment of a Novel Fixation Method of a Frameless Intrauterine Contraceptive Device Inserted during Cesarean Delivery as a Means of Preventing Displacements and Expulsions: A Prospective Observational Study

The primary objective of this study was to assess the novel fixation method of a frameless copper-releasing intrauterine device inserted following placental delivery during cesarean section and analyze its impact in reducing device displacement and expulsion during and after uterine involution. We hypothesized that the dual-anchoring technique could reduce the risk of intrauterine device displacement and expulsion during and after the uterine involution. The study was conducted at the Gazi University Medicine Faculty Hospital in Ankara, Turkey. Twenty-one pregnant women were enrolled. Insertion was performed following placental removal. To confirm the proper placement and good retention of the device, the distance between the fundal serosa (S) and device anchor knot (A) was measured (S–A) during follow-ups, by ultrasound. There were significant differences in the S–A, as observed by ultrasound at discharge and at 6 weeks post-delivery, which is consistent with the tissue contractions associated with uterine involution. Notwithstanding the uterine involution, no device displacements or expulsions occurred, which indicated a good retention of the frameless device. This innovative retention method of the frameless intrauterine device ensures a well-tolerated, long-term contraception, allowing for immediate contraception and proper pregnancy spacing for cesarean scar healing, and overcomes the issue of expulsion encountered with conventional intrauterine systems.

Continuum of care for maternal, newborn and child health: Evidence from a national survey in Mexico

OBJECTIVE

To compare coverage of maternal, newborn and child health (MNCH) continuum of care between women who had experienced adolescent maternity (AM) and those who had not.

METHODS

Using a Mexican probabilistic survey representative at the national level (ENSANUT 2018-19), we developed a cross-sectional analysis of 1,768 women aged 12 to 49 years who had a child within five years before the interview. We used modified Poisson models to estimate prevalence ratios (PRs) and independent and conditional coverage levels based on the probability estimates yielded by these models at different stages of maternal-newborn care process.

RESULTS

PRs for the MNCH continuum of care were approximately 40% lower for women who had experienced AM compared to those who had not (95%CI:0.35, 1.14). The coverage for the MNCH continuum of care was only 7.4% [95%CI: 3.5, 11.2] and 11.7% [95%CI: 9.3, 14.1] in women who had/not experienced AM, respectively.

CONCLUSIONS

The provision of a continuum of care for mothers and their children can be achieved through a combination of well-defined policies and strategies that improve health care practices and services throughout the life cycle. It is necessary to expand the coverage and quality of care, which will provide the opportunity to shift the focus from vertical programs to integrated continuous care. Policy makers must implement interventions that are consistent with specific problems of population and health-care providers. Our analysis highlights the deficiencies in the care process, making this study a useful reference for countries with similar characteristics.

Postpartum Green Star family planning decision aid for pregnant adolescents in Tanzania: a qualitative feasibility study

BACKGROUND

The use of a decision aid in clinical settings has been beneficial. It informs and educates patients about the available treatment options that can help them reduce decision-making conflicts related to feeling uninformed compared with routine care. There is a scarcity of published data about using a decision aid during family planning counseling with postpartum women focusing on long-acting reversible contraception in Tanzania. Therefore, we developed a "postpartum Green Star family planning decision aid" and assessed its feasibility. The study outcomes were practicality, usefulness, and acceptability perceived by pregnant adolescents and nurses/midwives.

METHODS

We used an exploratory qualitative in-depth interview involving six nurses/midwives with three or more years of experience in family planning services and 12 pregnant adolescents aged 15-19 years. Purposive sampling was used to select the participants, and selection relied on the saturation principle of data collection. We used a semi-structured interview guide translated into the Kiswahili language. Data were transcribed and analyzed following inductive content analysis.

RESULTS

The amount of information presented was just right, with the time of reading the data ranging from 20 min to 1 h. The study participants perceived the flow of information to be good, with small significant changes suggested. Kiswahili language was used and reported to be appropriate and well elaborated. However, a few words were told to be rephrased to reduce ambiguity. The nurses/midwives said that the decision aid included most of the vital information the participants wanted to know during their family planning counseling. Pregnant adolescents stated that the decision aid improved their knowledge and provided new details on the long-acting reversible contraception methods (intrauterine copper devices and implants) offered immediately after childbirth. The participants stated that the decision aid addressed long-acting reversible contraception methods' benefits and side effects and dispelled myths and misconceptions. The study participants considered the decision aid helpful in complementing the family planning counseling offered and improving pregnant adolescents' knowledge.

CONCLUSION

The postpartum Green Star family planning decision aid was practical, useful, and acceptable in enhancing the objectivity of counseling about long-acting reversible contraception methods. It improved the knowledge of pregnant adolescents in Tanzania about the available contraception methods (i.e., the use of intrauterine copper devices and implants), which can be immediately used postpartum. Further research is needed to assess the effects of the decision aid on long-acting reversible contraception postpartum uptake among pregnant adolescents in Tanzania.

Contraceptive priorities among women seeking family planning services in Finland in 2017-2019

OBJECTIVE

To assess how women's reproductive history, contraceptive experience and need of abortion care are associated with priorities for contraception.

STUDY DESIGN

In this cross-sectional survey study, we gathered information on women's history of births and abortions, previous use and satisfaction with contraceptive methods, and features of contraceptive methods they value most. Women were recruited at public family planning and outpatient abortion clinics in the capital region of Helsinki, Finland.

RESULTS

Of the 1006 women responding, 502 were recruited during visits for abortion care and 504 for contraceptive counseling. Women seeking abortion care more often had a history of abortion than women seeking contraceptive counseling (44% vs 11%), presented with a higher mean number of different contraceptive methods used (69% vs 55% with more than 2 previous methods), and were less often satisfied with the methods used (36% vs 60% satisfied with 2 out of 3 methods), p < 0.001 for all. In addition, women seeking abortion care had lower odds of prioritizing effectiveness (aOR 0.3, 95% CI 0.2-0.5), and higher odds of prioritizing lower hormonal levels or non-hormonal alternatives (aOR 2.0, 95% CI 1.3-3.2). There was no difference between the groups regarding priorities of lesser pelvic pain (aOR 0.7, 95% CI 0.5-1.1), regular period (aOR 01.2, 95% CI 0.8-1.9), or the method being easy to use (aOR 1.2, 95% CI 0.8-1.8).

CONCLUSIONS

There is a contrast between guidelines emphasizing effectiveness in postabortion contraception, and many women's contraceptive priorities.

IMPLICATION STATEMENT

Clinicians providing contraceptive counseling must be mindful of each individual's personal contraceptive priorities.

Trends in subdermal contraceptive implant use in Mexico 2009-2018: A population-based study

OBJECTIVE

To describe subdermal implant use in Mexico over time, by state and by age.

METHODS

We conducted a repeated cross-sectional study using the 2009, 2014, and 2018 waves of the National Survey of Demographic Dynamics (Encuesta Nacional de la Dinámica Demográfica [ENADID]). Our outcome was current use of contraception, by type, with a focus on the implant. We used visualizations, descriptive and bivariate statistics, and multinomial models to assess change over time, geographic patterns, method mix, and factors associated with implant use (vs intrauterine device [IUD] or other hormonal methods).

RESULTS

Implant use is increasing over time in Mexico, from 1.1% of women who have ever used a method in 2009 to 4.5% in 2018 (P < 0.001); the change is greatest among adolescents (2.5% in 2009 to 12.2% in 2018; P < 0.001). Change in implant use as a fraction of modern method use was heterogeneous across Mexican states. The adjusted relative likelihood of using an implant compared with IUD was 34% higher for adolescents compared with women aged 20-29 years (relative risk ratio 1.34, 95% confidence interval 1.16-1.55, P < 0.001), controlling for other variables in the model.

CONCLUSION

Use of subdermal implants is increasing over time in Mexico and is concentrated among adolescents. Implants have the potential to expand access to highly effective contraception in Mexico.

Evaluating teen options for preventing pregnancy: Impacts and mechanisms

This paper presents findings from an experimental evaluation of the Teen Options to Prevent Pregnancy (TOPP) program, an 18-month intervention that consists of a unique combination of personalized contraceptive counseling, facilitated access to contraceptive services, and referrals to social services. We find that TOPP led to large and statistically significant increases in the use of long-acting reversible contraceptives (LARCs), accompanied by substantial reductions in repeat and unintended pregnancy among adolescent mothers. We provide an exploratory analysis of the channels through which TOPP achieved its impacts on contraceptive behavior and pregnancy outcomes. A back-of-the-envelope decomposition implies that the increase in LARC use can explain at most one-third of the reduction in repeat pregnancy. We provide suggestive evidence that direct access to contraceptive services was important for increasing LARC use and reducing repeat pregnancy. We did not find any spillover effects on non-targeted outcomes, such as educational attainment and benefit receipt.

Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review

INTRODUCTION

Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC.

MATERIAL AND METHODS

In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively.

RESULTS

We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do.

CONCLUSIONS

Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.

Use of long-acting reversible contraception among adolescents and young women in Kenya

The Kenya Demographic and Health Survey (KDHS 2014) revealed changing patterns in the contraceptive use of young women aged 15-24, shifting from injectable methods to implants. Long-acting reversible contraception (LARC) is user friendly, long-term, and more effective than other modern methods. It could be a game-changer in dealing with unintended pregnancies and herald a new chapter in the reproductive health and rights of young women. This study determined the factors associated with LARC use among adolescent girls and young women to expand the evidence of its potential as the most effective method of reducing unwanted pregnancies among the cohort. This study analysed secondary data from KDHS 2014 using binary logistic regression. The findings showed a rise in LARC use (18%), with identified predictors of reduced odds being aged 15-19 [OR = 0.735, 95% CI = 0.549-0.984], residence (rural) [OR = 0.674, CI = 0.525-0.865], religion (Protestant/other Christian) [OR = 0.377, CI = 0.168-0.842], married, [OR = 0.746, CI = 0.592-0.940], and region (high contraception) [OR = 0.773, CI = 0.626-0.955], while the number of living children showed increased odds for 1-2 children [OR = 17.624, CI = 9.482-32.756] and 3+ children [OR = 23.531, CI = 11.751-47.119]. This study established the rising popularity of LARC and identified factors that can be addressed to promote it. Its increased uptake could help Kenya achieve the International Conference on Population and Development 25's first and second commitments on teenage pregnancies and maternal and new-born health, thus promoting the health, wellbeing, educational goals, and rights of this critical cohort. This study can guide the accelerated efforts needed in Kenya's march towards the five zeros of unmet need for contraception, teenage pregnancies, unsafe abortions, preventable maternal deaths, and preventable neonatal/infant deaths.

The role of pregnancy intendedness and prenatal contraceptive counseling on postpartum contraceptive use

Background

The study was conducted to prospectively examine how pregnancy intendedness and prenatal provider counseling about postpartum contraceptive options are associated with lack of contraception use at 6 months post-birth (e.g., increased risk for a short interpregnancy interval).

Methods

Logistic regression models were used to examine risk for no postpartum contraception use among a sample of low-income and racially/ethnically diverse women recruited from two metropolitan perinatal clinics in Tulsa, OK.

Results

Women who reported that they were trying to get pregnant or “okay either way” about getting pregnant had significantly lower odds of using contraception at 6 months post childbirth than those who had unintended pregnancies. Having providers who discussed postpartum contraceptive options during pregnancy significantly increased the odds of contraceptive uptake among those who were planning or ambivalent about their pregnancies.

Conclusions

Intentions of a current pregnancy and provider contraceptive counseling matter for postpartum contraceptive use and the associated risk for a short interval subsequent pregnancy. Provider contraceptive counseling that accounts for the intendedness of a current pregnancy may offer a more targeted approach to prevent a short interval subsequent pregnancy.

Determinants of Long-acting Reversible Contraception (LARC) Initial and Continued Use among Adolescents in the United States

Long-acting reversible contraception (LARC) has gained attention as a promising strategy for preventing unintended adolescent pregnancies in the United States. However, LARC use among adolescents at risk for pregnancy remains low compared to women in their 20s. The purpose of the current study was to synthesize the empirical literature published between 2010 and 2018 identifying the facilitators of and barriers to adolescents' (< age 20) LARC use in the United States. Thirty quantitative and qualitative studies were included in the current systematic review. The facilitators of and barriers to adolescent LARC use fell within five themes: LARC method characteristics, individual characteristics, social networks, healthcare systems, and historical time and geographical region. Barriers to adolescent LARC use largely echoed those identified in previous research noting the barriers to LARC use among young adult women (e.g., provider concerns with placing IUDs for nulliparous women, common adverse side effects associated with some LARC methods). However, qualitative studies identified adolescents' mothers as central figures in helping adolescents successfully obtain the LARC methods they desired. Conversely, adolescents' partners seemed to only play a minor role in adolescents' contraceptive decisions. Findings within the reviewed studies also suggested some subpopulations of adolescents may be experiencing pressure to initiate LARC use or have less ability to have their LARC device removed if they wish to discontinue use. Adolescent health practitioners and clinicians should consider the unique social-environmental influences of adolescents' contraceptive access and behaviors to best meet adolescents' contraceptive needs and desires.

Impacts of a Home Visiting Program Enhanced with Content on Healthy Birth Spacing

OBJECTIVES

This study sought to determine the impact of Healthy Families Healthy Futures (HFHF) enhanced with Steps to Success (STS). HFHF is a structured home visiting program for teen parents in Houston that focuses on improving parenting skills and preventing child abuse. HFHF enhanced with STS includes content and activities aimed to reduce repeat pregnancies within 24 months after the first child's birth.

METHODS

The study team recruited 248 young mothers for the study, primarily through local health clinics and schools, and then randomly assigned them to either a treatment group that was eligible to participate in HFHF enhanced with STS or to a control group. The control group was not offered any other program through the study. Outcomes were measured by a survey administered 12 months after program intake, in five domains aligned with the program's logic model: (1) exposure to information related to program content, (2) contraception knowledge, (3) contraception use, (4) enhanced family functioning, and (5) child health and development. To estimate program impacts, we used ordinary least squares regression, controlling for demographics and baseline measures of the outcome variables, if available. We use both frequentist approaches (calculations of statistical significance) and Bayesian posterior probabilities to interpret the findings.

RESULTS

HFHF enhanced with STS significantly (p < .05) impacted exposure to information on parenting and birth control, with effects of 20.8 and 15.4 percentage points, respectively. Using Bayesian posterior probabilities, there is an 85% chance that the program had a favorable effect on these outcomes. We also calculate a probability of 77% that the program had a favorable impact on long-acting reversible contraceptive (LARC) use, but a probability of 89% that the program reduced knowledge of birth control pills; these two results were not statistically significant (p = .17 and .10, respectively).

CONCLUSIONS FOR PRACTICE

These findings are primarily favorable and consistent with the program content and goals. Smaller than anticipated sample sizes due to recruitment challenges increased the chances for random error to affect the ability to detect statistically significant differences on many of our other outcomes; Bayesian posterior probabilities can therefore aid in interpreting the impact estimates. More research of this promising model is warranted.

Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care

OBJECTIVE

To identify characteristics of women who have consistent plans in terms of contraceptive effectiveness from antepartum to postpartum care.

STUDY DESIGN

This is a secondary analysis of a retrospective chart review of women who delivered at a single tertiary care center from 2012 to 2014. Preferred postpartum contraceptive plan was abstracted at three time points (prenatal care, hospital discharge, and outpatient postpartum care) and categorized into three tiers of effectiveness. We then examined consistency between the first two time points for the effectiveness in postpartum contraceptive method planned.

RESULTS

Of the 8,394 women in the study cohort, 2,642 (31.5%) had a consistent postpartum contraceptive plan. Women who had a consistent plan were more likely to have higher parity (aOR 2.36, 95% CI 2.06-2.70 for parity 2+), choose highly effective methods of contraception (p < 0.001), achieve their contraception plan (adjusted odds ratio [aOR] 2.16, 95% confidence interval [95% CI] 1.85-2.52), but not more likely to have a subsequent pregnancy within 365 days of delivery (aOR 0.92, 95% CI 0.81-1.05).

CONCLUSION

Better understanding contraceptive decision-making as a journey and removing external barriers during that process is a necessary component of pregnancy care.

IMPLICATIONS

Counseling and documentation of contraceptive preferences throughout antepartum and postpartum care can help improve contraceptive outcomes.

Increased Vulnerability to Pregnancy and Sexual Violence in Adolescents with Precocious Menstruation

This cross-sectional, observational, and descriptive study was conducted to evaluate the association between age at menarche in the adolescent population and the age at sexual initiation, age at first pregnancy, and experience of sexual violence in the adolescent population visiting a primary health unit in Brazil. We recruited 201 female adolescents who visited the gynecology outpatient clinic of a Basic Health Unit in the Federal District of Brazil. These adolescents answered a questionnaire with regard to sexual and reproductive health during doctor's appointments. To calculate the association, we recorded data for age at menarche, age at first sexual intercourse, age at first pregnancy, and experience of sexual violence. Pearson and Mann–Whitney correlation coefficient statistical tests were performed to evaluate the association between these variables. Mean age at menarche was lower among adolescents who became pregnant (p = 0.0004) and those who experienced sexual violence (p = 0.0008). Further, there was a strong association between age at menarche and age at first sexual intercourse (p < 0.0001). This study also demonstrated that the earlier the age at menarche, the earlier was the age at sexual initiation and age at first unintended pregnancy and the greater was the risk of experiencing sexual violence. Early menarche may be considered a vulnerability factor during adolescence.

Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception

Background: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods (p = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.

Retos en la prevención del embarazo adolescente subsiguiente, un estudio desde la perspectiva de madres adolescentes

Resumen El presente artículo expone el resultado de una evaluación cualitativa sobre las acciones que los servicios públicos de salud desarrollan para la prevención de embarazos subsiguientes en adolescentes, en un estado en el centro-norte de México. El objetivo fue documentar los obstáculos percibidos para prevenir embarazos subsiguientes en madres adolescentes. La información se obtuvo entre 2016-2018, mediante entrevistas individuales en los domicilios de jóvenes usuarias de servicios públicos de salud. El análisis de la información se hizo a partir de la propuesta de Strauss y Corbin para teoría fundamentada. Las experiencias compartidas por las jóvenes madres fueron analizadas y clasificadas en dos categorías, obstáculos asociados a: (1) competencias profesionales, y (2) a imaginarios morales. Se concluye que las limitaciones más importantes tienen que ver con el hecho de que la estrategia de servicios amigables para adolescentes deja de implementarse en aquellas que han sido madres, sin considerar el impacto biológico y psicosocial que tienen los embarazos subsiguientes en la adolescencia y la necesidad de postergar la reproducción hasta la edad adulta.

Unique Needs of the Adolescent

Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

Association Between Women's Use of Long-Acting Reversible Contraception and Declining Abortion Rates in New Zealand

Background: To investigate the hypothesis that increased uptake of long-acting reversible contraception (LARC) by women played a role in the declining abortion rates observed in New Zealand between 2008 and 2014. Materials and Methods: This quantitative ecological study analyzed routinely collected national data pertaining to abortion numbers, contraceptive prescriptions, and census population estimates for the period 2004-2014. Annual prescription and prevalence rates (per 1000 women) were calculated for short- and long-acting methods to investigate changes over time. Poisson's regression was used to (1) test whether the abortion rate changed by year; (2) whether 2010 (when the contraceptive implant became subsidized) was a significant point of change; and (3) test the relationship between declining abortions and patterns of contraceptive use. Results: Estimated LARC prevalence increased from 2009 to 2014, with a corresponding decrease observed in prescription of short-acting methods. The declining abortion rate accelerated each year from 2008 to 2014 (with a faster decline from 2010 to 2014), but 2010 was not a significant point of change. Three factors had statistically significant associations with declining abortion rates (p < 0.01): year (acting as a surrogate for all social changes), women's use of the levonorgestrel (LNG)-implant, and the combined model: use of the LNG-implant and copper intrauterine device (CuIUD) had the best fit (using Akaike's Information Criterion), indicating that this variable explained more of the year-to-year variability in abortion rates. Conclusions: The shift toward women's increased use of the two publically funded LARC methods (LNG-implants and CuIUD) was significantly associated with the declining abortion rates in New Zealand.

Antenatal contraception counselling and provision of contraception after delivery for first-time young mothers enrolled with a Family Nurse Partnership programme

OBJECTIVE

To evaluate antenatal contraceptive counselling and provision of postpartum contraception on contraceptive choices of first-time teenage mothers enrolled with a Family Nurse Partnership (FNP) programme.

DESIGN

Health service research evaluation.

POPULATION

Cohort of FNP clients (n=195), Scotland, UK.

METHODS

Antenatal contraceptive counselling and provision of chosen method from the hospital. Evaluation consisted of (i) self-administered questionnaires of FNP clients and (ii) interviews with FNP clients and FNP nurses.

MAIN OUTCOME MEASURES

FNP client views on intervention. Secondary outcomes included: contraceptive choice antenatally, at day 10 postpartum, 3 and 12 months after delivery, and views of FNP nurses on the intervention.

RESULTS

Antenatal questionnaires were completed by 118/195 (61%) clients. 96/118 (81%) agreed that it was very or quite helpful to receive antenatal contraceptive counselling and 80/118 (68%) were planning to use a long-acting reversible method of contraception (LARC). 97/121 (80%) wished to receive contraception before leaving the hospital. 104/195 (53%) completed a questionnaire at day 10 postpartum, of which 33 (32%) indicated that they had received contraception from the hospital. FNP nurses expressed frustration when contraception was not provided; this was usually attributed to the busy workload of the maternity department.

CONCLUSIONS

Antenatal contraceptive counselling was appreciated by FNP clients and they expressed a preference for contraception provision following delivery. Over two-thirds planned to use a LARC method but many did not receive this from the hospital. Further interventions are required to ensure that the provision of postpartum contraception is prioritised for this group of young women.

Repeat pregnancies in teenage mothers: An exploratory study

AIM

To explore young mothers' experience of rapid repeat pregnancy.

BACKGROUND

Despite a reduction in teenage pregnancies in England over the last two decades, the number of repeat pregnancies remains high, accounting for around 25% of teenage pregnancies. There is a lack of qualitative evidence of teenage perspectives making planning appropriate interventions challenging.

DESIGN

Exploratory design.

METHODS

Six young women were purposively sampled from a Family Nurse Partnership programme in the South London. Semi-structured interviews conducted in spring 2017 elicited experiences of repeat pregnancy.

FINDINGS

Each repeat pregnancy was unplanned and accounted for by participants' rejection of Long Acting Reversible Contraceptives and inconsistent use of non- Long Acting Reversible Contraceptives. Misinformation about Long Acting Reversible Contraceptives contributed to their rejection and staff delivery of contraceptive advice was influential. Motherhood was initially prioritised over other life goals to make sense of second pregnancy. Discharge from the Family Nurse Partnership may lead to fractured service contacts. Peer support and health professional contact through social media were proposed as "stepping stones" out of the service.

CONCLUSIONS

Practice developments working in partnership with young mothers to reduce the risk of a repeat teenage pregnancy are highlighted. Further research is recommended.

IMPACT

Understanding the experiences of teenage mothers who are at risk of rapid repeat pregnancy can assist nurses to provide preventative care and support. Structured advice through social media platforms can provide "stepping stones" that bridge gaps in provision as young mothers transition through services. Further research and development into the role of social media and contraceptive counselling are necessary.

Factors associated with the resumption of sexual intercourse before the scheduled six-week postpartum visit

This retrospective cohort study was aimed at evaluating the factors associated with the resumption of sexual intercourse (SI) before the six-week postpartum visit and was carried out between 1 January and 15 February 2014. The main variables studied included maternal age, number of living children, mode of delivery, complications observed at delivery and resumption or not of SI. Data from women who resumed SI were compared to those of women who did not. Fisher's exact test and t-test were used for comparison. We recruited 120 women, among whom 95 (79.1%) resumed SI. Of these, 65/95 (68.4%) did not attend the postpartum visit while 30 (31.6%) did (P = 0.321). The factors associated with early resumption of SI were maternal age of 20-34 years (P < 0.001), women with one child (P < 0.004) and who had had an uncomplicated vaginal delivery (P < 0.001). Our conclusion is that nursing mothers should receive postpartum contraception before leaving the hospital.

Women's and healthcare professionals' views on immediate postnatal contraception provision: a literature review

OBJECTIVES

Provision of immediate postnatal contraception, including long-acting reversible contraceptive (LARC) methods, is increasingly identified and endorsed as a key strategy for reducing unplanned and rapid repeat pregnancies. This literature review aims to evaluatethe views of women and healthcare professionals regarding the receipt, initiation or delivery of these services.

METHODS

Databases (Embase, Medline, CINAHL, HMIC) were searched for relevant English language studies, from January2003 to December 2017. In addition, Evidence Search, Google Scholar and Scopus (citation search) were used to identify further literature. Other relevant websites were accessed for policies, guidance and supplementary grey literature.

RESULTS

There is clear guidance on how to deliver good-quality postnatal contraception to women, but the reality of service delivery in the UK does not currently meet these aspirations, and guidance on implementation is lacking. The available evidence on the provision of immediate postnatal contraception focuses more on clinical rather than patient-centred outcomes. Research on postnatal women's views is limited to receptivity to LARC and contraception counselling rather than what influences their decision-making process at this time. Research on views of healthcare professionals highlights a range of key systemic barriers to implementation.

CONCLUSIONS

While views of postnatal women and healthcare professionals are largely in support of immediate postnatal contraception provision, important challenges have been raised and present a need for national sharing of service commissioning and delivery models, resources and evaluation data. Provider attitudes and training needs across multidisciplinary groups also need to be assessed and addressed as collaborative working across a motivated, skilled and up-to-date network of healthcare professionals is viewed as key to successful service implementation.

Long acting reversible contraception use and associated factors among married women of reproductive age in Nepal

Modern contraceptives are highly effective and proven means of preventing unintended pregnancy and reducing maternal mortality. Social and economic characteristics are some of the key determinants of health and utilization family planning. However, studies examining the factors associated with utilization of long acting reversible contraception (LARC) are limited in Nepal. This study assessed the factors associated with utilization of LARC methods among married women of reproductive age in Nepal. Secondary data analysis was conducted using the 2016 Nepal Demographic and Health Survey (NDHS). A logistic regression model examined the association of socioeconomic, demographic, or fertility related characteristics with the use of LARCs among 9875 ever married women of reproductive age. The overall utilization rate of LARC in this study was 4.7%. Women in the age group of <25 years (AOR: 0.65, 95% CI: 0.45-0.92) and 25-35 years (AOR: 0.70, 95% CI: 0.56-0.89), having husbands with primary education (AOR:0.71; 95%CI: 0.64-0.84) and no education (AOR: 0.54; 95%CI: 0.38-0.73), belonging to Janajatis (AOR: 0.55; 95%CI: 0.42-0.71) and Newars (AOR: 0.29; 95%CI: 0.19-42), poor wealth quintile (AOR: 0.60; 95% CI: 0.45-0.86) had negative association with LARC use. On the other hand, women having their husband as a skilled worker (AOR: 1.49; 95%CI: 1.10-2), having two or less than two children (AOR: 1.46; 95% CI: 1.15-1.186), and having desire for children in future (AOR: 3.24; 95% CI: 2.29-4.57) had positive association with the use of LARC. In this study, younger women's age, low or no husband's education, from indigenous community such as Janajati and Newer, being in lowest wealth quintile negatively influenced the use of LARC. Conversely, women having her husband as skilled worker, parity less than two, and desire of having future children, positively influenced the use of LARC. The study highlights the need to reach women who were in the lower socioeconomic background to improve LARC use.

Fertility intentions and the adoption of long-acting and permanent contraception (LAPM) among women: evidence from Western Kenya

Background

The use of long-acting and permanent method (LAPM) for family planning (FP) is of importance to the FP movement. A better understanding of how fertility-related intentions shape the usage of LAPM is important for programming. This paper explored the interaction of fertility intentions with LAPM use in rural western Kenya.

Methods

We draw on monitoring data from 28,515 women aged 15–49 years who received FP services between 2013 and 2015 as part of a community-based FP project. We assessed the association between the use of LAPM and fertility intentions, adjusting for age, parity, education, service delivery model, FP counseling and year of data collection.

Results

Of the 28,515 women who accessed FP services during the period (2013–2015), about two-thirds (57%) reported using LAPM, much higher than the national rates, and around 46% wanted another child within or after two years. In a multivariable regression model, women who desired no more children tended to use LAPM more than those wanting a child within or after some years as well as those uncertain about their future intentions.

Conclusion

The significant rates of utilization of LAPM between both women who desired no more children and the fair proportion of use among women spacing births underscore the benefits of sustained community level interventions that address both the demand and supply barriers of contraceptive adoption and use.

Clinic-Based Programs to Prevent Repeat Teen Pregnancy: A Systematic Review

CONTEXT

The purpose of this paper is to synthesize and evaluate the evidence on the effectiveness of repeat teen pregnancy prevention programs offered in clinical settings.

EVIDENCE ACQUISITION

Multiple databases were searched for peer-reviewed articles published from January 1985 to April 2016 that included key terms related to adolescent reproductive health services. Analysis of these studies occurred in 2017. Studies were excluded if they focused solely on sexually transmitted disease/HIV prevention services, or occurred outside of a clinic setting or the U.S., Canada, Europe, Australia, or New Zealand. Inclusion and exclusion criteria further narrowed the studies to those that included information on at least one short-term (e.g., increased knowledge); medium-term (e.g., increased contraceptive use); or long-term (e.g., decreased repeat teen pregnancy) outcome, or identified contextual barriers or facilitators for providing adolescent-focused family planning services. Standardized abstraction methods and tools were used to synthesize the evidence and assess its quality. Only studies of clinic-based programs focused on repeat teen pregnancy prevention were included in this review.

EVIDENCE SYNTHESIS

The search strategy identified 27,104 citations, 940 underwent full-text review, and 120 met the adolescent-focused family planning services inclusion criteria. Only five papers described clinic-based programs focused on repeat teen pregnancy prevention. Four studies found positive (n=2) or null (n=2) effects on repeat teen pregnancy prevention; an additional study described facilitators for helping teen mothers remain linked to services.

CONCLUSIONS

This review identified clinic-based repeat teen pregnancy prevention programs and few positively affect factors that may reduce repeat teen pregnancy. Access to immediate postpartum contraception or home visiting programs may be opportunities to meet adolescents where they are and reduce repeat teen pregnancy.

THEME INFORMATION

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

Abortion among Adolescents in Israel: Intervention and Health Behavior Outcomes

The current study investigated the post-abortion health behaviors of adolescents. Authors assessed the association between pre-abortion interventions and receiving post-abortion checkups and uptake of effective contraceptives. Participants were 172 adolescents under 19 years of age who were recruited pre-abortion at 10 hospitals in Israel and followed up by phone one and two months post-abortion. Results indicate that a quarter of participants did not receive a post-abortion checkup. The reported reasons for this were mostly personal, with very few cases attributed to accessibility issues. Rates of effective contraceptive use increased from the pre- to post-abortion periods but were still not high. Longer duration of pre-abortion counseling with a social worker, having the checkup where the abortion took place, and parental involvement increased the odds of having a post-abortion checkup. Getting a prescription for oral contraceptive pills at the time of abortion increased the odds of uptake one month post-abortion. Nonadherence to post-abortion recommendations is a problem with the potential to cause health risks and more unintended pregnancies. Effective social work interventions to promote behavioral change are needed, especially those based on theory and evidence.

Postpartum contraceptive use and interpregnancy interval among women with opioid use disorder

OBJECTIVE

The purpose of this study was to describe postpartum contraceptive utilization patterns among women with OUD and evaluate the relationship between postpartum contraceptive method choice and interpregnancy interval.

METHODS

A retrospective cohort study was conducted with women in Pennsylvania Medicaid with a diagnosis of OUD between 2008 and 2013. Postpartum contraceptive use within 90 days after delivery was identified through claims data and categorized by effectiveness (highly-effective, effective, and no method observed). Kaplan-Meier time-to-event analyses and multivariable-adjusted marginal Cox regression models were used to evaluate the relationship between postpartum contraceptive method choice and interpregnancy interval. Multivariable logistic regression analyses were used to identify risk factors predictive of a short interpregnancy interval (≤18 months).

RESULTS

We identified 7805 women (9260 pregnancies) who had a diagnosis of OUD. Nearly three-quarters (74.5%) had no contraceptive method observed, 18.1% received an effective method, and only 7.4% received a highly-effective method (LARC or female sterilization) during the postpartum period. In Kaplan-Meier analyses, no significant differences were found in the time-to-next pregnancy interval when an effective contraceptive method vs. no contraceptive method was used. In multivariable analysis, predictors of a significantly longer interpregnancy interval were LARC use (HR 0.43, 95% CI 0.26-0.69), gestational hypertension (HR 0.80, 95% CI 0.65-0.97), and age (HR 0.95, 95% CI 0.94-0.96). Approximately 20% of women with OUD had a short interpregnancy interval.

CONCLUSION

Few women with OUD use highly-effective postpartum contraception, which is protective against short interpregnancy intervals.

Frequency of 6-week follow-up appointment scheduling after intrauterine device insertion

INTRODUCTION

Long-acting reversible contraception (LARC) is widely recommended to reduce unintended pregnancy in the USA. As intrauterine device (IUD) use increases, evaluating the role of post-insertion follow-up is important.

METHODS

A retrospective patient record review was conducted to assess the follow-up experience of women who had an IUD placed at the University of Kansas Medical Center from 1 January to 30 June 2015. Data were collected on patient demographics, IUD placement, follow-up visit attendance, and outcomes in the 12 months following placement. The primary outcome of interest was the proportion of patients who attended a 6-week follow-up visit. Secondary outcomes included adverse events detected at the 6-week visit and IUD removal within a year of placement.

RESULTS

Among 380 women who had an IUD inserted, physician documentation of a recommended 6-week follow-up visit was present in 91.3% of patient medical records. Two-thirds (66.6%) of patients receiving a recommendation returned for a follow-up visit. Of the 380 women who had an IUD placed, 66 (17.4%) had their IUD removed within 1 year of placement. Of those, 50 women attended the 6-week follow-up visit and 16 did not (19.8% vs 12.6%, p=0.08). Of the IUD removals, 14 occurred at the 6-week visit. After excluding IUD removals which occurred at the 6-week visit, attending a 6-week follow-up visit was not associated with IUD removal or retention (p=0.52).

CONCLUSION

Despite recommendations to forgo the 6-week follow-up visit, visits were still common, with no demonstrated value added.

Assessment of utilization of long acting reversible contraceptive and associated factors among women of reproductive age in Harar City, Ethiopia

Introduction

World health organization report indicated that, in 2013 alone, over 289,000 maternal death that resulted from pregnancy and delivery related complication were reported worldwide indicating a decline of 45% from 1990. The sub-Saharan Africa region alone accounted for 62% of maternal death followed by southern Asian country (24%). Provision of family planning is one of the effective intervention that prevent unwanted and ill spaced pregnancy there by reducing maternal mortality and morbidity. Given that its effectiveness and, associated fewer visits to health facilities, LARC are very important in tackling maternal mortality and morbidity. However, little is known regarding its prevalence in eastern Ethiopia. Thus, this study aimed to assess utilization of long acting reversible contraceptives and associated factors among women of reproductive age groups.

Methods

A facility based cross-sectional study conducted in Harar city among 402 study participants. The study participants selected by using systematic random sampling method. The quantitative data collected using structured interviewer administered questionnaires. All variables with p-value of ≤ 0.25 in bivariate logistic regression were taken into multivariable model. Variables having p value ≤ 0.05 in the multivariate analysis were taken as significant predictors. Crude and adjusted odds ratios with their 95% confidence intervals were calculated.

Results

The study identified that the utilization of long acting reversible contraceptive among mother of reproductive age was 38%. Study participants whose occupation was daily laborer were less likely to utilize long acting reversible contraceptive compared to those whose occupation was house wife (adjusted OR = 0.3; 95% CI 0.01 to 0.8). Moreover, those mothers who were unable to read and write utilize long acting reversible contraceptive 5 times more likely compared to those who were above grade 12 (adjusted OR = 4.9; 95% CI 1.2 to 19.6).

Conclusion

The prevalence of long acting reversible contraceptive was found to be low. Maternal education and occupation were factors found to have a significant association with utilization of long acting reversible contraceptive. Community and facility level awareness creation should be reinforced to improve utilization of long acting reversible contraceptives.

Factors influencing repeated teenage pregnancy: a review and meta-analysis

OBJECTIVE

Existing evidence of predictors of repeated teenage pregnancy has not been assessed rigorously. This systematic review provides a comprehensive evaluation of protective and risk factors that are associated with repeated teenage pregnancy through a metaanalytical consensus.

DATA SOURCES

We used PubMed, EMBASE, CINAHL, ProQuest, PsychINFO, ScienceDirect, Scopus, and Web of Science databases from 1997-2015 and the reference list of other relevant research papers and related reviews.

STUDY ELIGIBILITY CRITERIA

Eligibility criteria included (1) epidemiologic studies that analyzed factors associated with repeated pregnancy or birth among adolescents <20 years of age who were nulliparous or experienced at least 1 pregnancy, and (2) experimental studies with an observational component that was adjusted for the intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

We performed narrative synthesis of study characteristics, participant characteristics, study results, and quality assessment. We also conducted random-effects and quality-effects metaanalyses with meta-regression to obtain pooled odds ratios of identified factors and to determine sources of between-study heterogeneity.

RESULTS

Twenty-six eligible epidemiologic studies, most from the United States (n=24), showed >47 factors with no evidence of publication bias for each metaanalysis. Use of contraception (pooled odds ratio, 0.60; 95% confidence interval, 0.35-1.02), particularly long-acting reversible contraceptives (pooled odds ratio, 0.19; 95% confidence interval, 0.08-0.45), considerably reduced repeated teenage pregnancy risk. Among studies about contraception, the number of follow-up visits (adjusted coefficient, 0.72; P=.102) and country of study (unadjusted coefficient, 2.57; permuted P=.071) explained between-study heterogeneity. Education-related factors, which included higher level of education (pooled odds ratio, 0.74; 95% confidence interval, 0.60-0.91) and school continuation (pooled odds ratio, 0.53; 95% confidence interval, 0.33-0.84), were found to be protective. Conversely, depression (pooled odds ratio, 1.46; 95% confidence interval, 1.14-1.87), history of abortion (pooled odds ratio, 1.66; 95% confidence interval, 1.08-2.54), and relationship factors, such as partner support, increased the repeated teenage pregnancy risk.

CONCLUSION

Contraceptive use, educational factors, depression, and a history of abortion are the highly influential predictors of repeated teenage pregnancy. However, there is a lack of epidemiologic studies in low- and middle-income countries to measure the extent and characteristics of repeated teenage pregnancy across more varied settings.

Which Abortion Patients Have Had a Prior Abortion? Findings from the 2014 U.S. Abortion Patient Survey

Background: Updated information about abortion patients who have had a prior abortion could inform patient-centered practices that help women avoid unintended pregnancies in the future.

Materials and Methods: Data come from a national sample of 8,380 nonhospital U.S. abortion patients accessing services at 87 facilities. The dependent variable was a self-reported measure of prior abortion. Bivariate and multivariable analyses were used to assess associations between a range of demographic and circumstantial characteristics and reports of obtaining a prior abortion.

Results: We found that 45% of patients reported having one or more prior abortions. Age was most strongly associated with this outcome, and patients aged 30 and older had more than two times the odds of having had a prior abortion compared with those aged 20–24. Other characteristics associated with an increased likelihood of prior abortion included having one or more children, being black, relying on insurance or financial assistance to pay for the procedure, and exposure to disruptive events in the last 12 months. Characteristics associated with a decreased likelihood of having a prior abortion included having a college degree and living 25 or more miles from the facility where the current abortion was obtained.

Conclusions: Age is the biggest risk factor for having had a prior abortion; the longer a woman has been alive, the longer she is at risk of unintended pregnancy. Some characteristics associated with prior abortion were beyond the control of the individuals experiencing them.

Intervention Now to Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement

BACKGROUND

Unintended repeat conceptions can result in emotional, psychological and educational harm to young women, often with enduring implications for their life chances. This study aimed to identify which young women are at the greatest risk of repeat unintended pregnancies; which interventions are effective and cost-effective; and what are the barriers to and facilitators for the uptake of these interventions.

METHODS

We conducted a mixed-methods systematic review which included meta-analysis, framework synthesis and application of realist principles, with stakeholder input and service user feedback to address this. We searched 20 electronic databases, including MEDLINE, Excerpta Medica database, Applied Social Sciences Index and Abstracts and Research Papers in Economics, to cover a broad range of health, social science, health economics and grey literature sources. Searches were conducted between May 2013 and June 2014 and updated in August 2015.

RESULTS

Twelve randomised controlled trials (RCTs), two quasi-RCTs, 10 qualitative studies and 53 other quantitative studies were identified. The RCTs evaluated psychosocial interventions and an emergency contraception programme. The primary outcome was repeat conception rate: the event rate was 132 of 308 (43%) in the intervention group versus 140 of 289 (48%) for the control group, with a non-significant risk ratio (RR) of 0.92 [95% confidence interval (CI) 0.78-1.08]. Four studies reported subsequent birth rates: 29 of 237 (12%) events for the intervention arm versus 46 out of 224 (21%) for the control arm, with an RR of 0.60 (95% CI 0.39-0.93). Many repeat conceptions occurred in the context of poverty, low expectations and aspirations and negligible opportunities. Qualitative and realist evidence highlighted the importance of context, motivation, future planning and giving young women a central and active role in the development of new interventions.

CONCLUSIONS

Little or no evidence for the effectiveness or cost-effectiveness of any of the interventions to reduce repeat pregnancy in young women was found. Qualitative and realist evidence helped to explain gaps in intervention design that should be addressed. More theory-based, rigorously evaluated programmes need to be developed to reduce unintended repeat pregnancy in young women.

TRIAL REGISTRATION

PROSPERO, CRD42012003168 . Cochrane registration number: i = fertility/0068.

Racial and ethnic disparities in postpartum care and contraception in California's Medicaid program

BACKGROUND

Considerable racial and ethnic disparities have been identified in maternal and infant health in the United States, and access to postpartum care likely contributes to these disparities. Contraception is an important component of postpartum care that helps women and their families achieve optimal interpregnancy intervals and avoid rapid repeat pregnancies and preterm births. National quality measurements to assess postpartum contraception are being developed and piloted.

OBJECTIVE

To assess racial/ethnic variation in receipt of postpartum care and contraception among low-income women in California.

STUDY DESIGN

We conducted a prospective cohort study of 199,860 Californian women aged 15-44 with a Medicaid-funded delivery in 2012. We examined racial/ethnic variation of postpartum care and contraception using multivariable logistic regression to control for maternal age, language, cesarean delivery, Medicaid program, and residence in a primary care shortage area (PCSA).

RESULTS

Only one-half of mothers attended a postpartum visit (49.4%) or received contraception (47.5%). Compared with white women, black women attended postpartum visits less often (adjusted odds ratio [aOR], 0.73; 95% confidence interval [CI], 0.71-0.76), were less likely to receive any contraception (aOR, 0.83; 95% CI, 0.78-0.89) and were less likely to receive highly effective contraception (aOR, 0.64; 95% CI, 0.58-0.71). Women with Spanish as their primary language were more likely to get any contraception (aOR, 1.15; 95% CI, 1.11-1.19) but had significantly lower odds of receiving a highly effective method (aOR, 0.94; 95% CI, 0.90-0.99) compared with women with English as their primary language. Similarly, women in PCSAs had a greater odds of getting any contraception (aOR, 1.06; 95% CI, 1.03-1.09), but 24% lower odds of getting highly effective contraception than women not living in PCSAs (aOR, 0.76; 95% CI, 0.73-0.79).

CONCLUSION

Significant racial/ethnic disparities exist among low-income Californian mothers' likelihood of attending postpartum visits and receiving postpartum contraception as well as receiving highly effective contraception.

Postpartum contraception: initiation and effectiveness in a large universal healthcare system

BACKGROUND

Repeat pregnancies after a short interpregnancy interval are common and are associated with negative maternal and infant health outcomes. Few studies have examined the relative effectiveness of postpartum contraceptive choices.

OBJECTIVE

We aimed to determine the initiation trends and relative effectiveness of postpartum contraceptive methods, with typical use, on prevention of short delivery intervals (≤27 months) among women with access to universal healthcare, including coverage that entails no co-payments and allows unlimited contraceptive method switching.

STUDY DESIGN

This retrospective cohort study included women who were enrolled in the United States military healthcare system who were admitted for childbirth between October 2010 and March 2015, with ≥6 months postpartum enrollment. With the use of insurance records, we determined the most effective contraceptive method initiated during the first 6 months after delivery, even if subsequently discontinued. Rates of interdelivery intervals of ≤27 months, as proxies for interpregnancy intervals ≤18 months, were determined with the use of the Kaplan-Meier estimator. Women who were disenrolled, who reached 27 months after delivery without another delivery, or who reached the end of the study period were censored. The influence of sociodemographic variables and contraceptive choices on time to subsequent delivery was evaluated by Cox regression analysis, which accounted for a possible correlation among multiple deliveries by an individual woman.

RESULTS

During the study timeframe, 373,840 women experienced a total of 450,875 postpartum intervals. Women averaged 27 (standard deviation, 5.3) years of age at the time of delivery; 33.9% of them were <25 years old; 15.5% of them were active duty service members, and 31.6% of them had insurance sponsors of junior enlisted rank (which suggests lower income). Postpartum contraceptive methods that were initiated included self or partner sterilization (7%), intrauterine device (13.5%), etonogestrel implant (3.4%), depot medroxyprogesterone acetate (2.5%), and pill, patch, or ring (36.8%). Furthermore, 36.7% of them did not initiate a prescription method. Etonogestrel implant initiation increased from 1.7% of postpartum women in the first year of our study to 5.3% in the final year. The estimated short interdelivery interval rate was 17.4%, but rates varied with contraceptive method: 1% with sterilization, 6% with long-acting reversible contraception, 12% with depot medroxyprogesterone, 21% with pill, patch, or ring, and 23% with no prescription method. In a multivariable analysis, the adjusted hazard of a short interdelivery interval was highest among women who were younger, on active duty, or with officer insurance sponsors. Compared with nonuse of any prescription contraceptive, the use of an intrauterine device reduced the hazard of a subsequent delivery (adjusted hazard ratio, 0.19; 95% confidence interval, 0.18-0.20), as did etonogestrel implant (adjusted hazard ratio, 0.21; 95% confidence interval, 0.19-0.23); the pill, patch, or ring had less effect (adjusted hazard ratio, 0.80; 95% confidence interval, 0.78-0.81).

CONCLUSION

Postpartum initiation of long-acting reversible contraception is highly effective at the prevention of short interdelivery intervals, whereas pill, patch, or ring methods are associated with rates of short interdelivery intervals similar to users of no prescription contraception. This study supports long-acting reversible contraception as first-line recommendations for postpartum women who wish to retain fertility but avoid early repeat pregnancy.

An umbrella review of meta-analyses of interventions to improve maternal outcomes for teen mothers

The purpose of this study was to perform an umbrella review of meta-analyses of intervention studies designed to improve outcomes of pregnant or parenting teenagers. An extensive search retrieved nine reports which provided 21 meta-analyses analyses. Data were extracted by two reviewers. Methodological quality was assessed using the AMSTAR Instrument. Most effect sizes were small but high quality studies showed significant outcomes for reduced low birth weight (RR = 0.60), repeat pregnancies/births (OR = 0.47-0.62), maternal education (OR = 1.21-1.83), and maternal employment (OR = 1.26). Several parenting outcomes (parent-child teaching interaction post-intervention [SMD = -0.91] and at follow-up [SMD = -1.07], and parent-child relationship post-intervention [SMD = -0.71] and at follow-up [SMD = -0.90]) were significant, but sample sizes were very small. Many reports did not include moderator analyses. Behavioral interventions offer limited resources and occur too late to mitigate the educational and social disparities that precede teen pregnancy. Future intervention research and policies that redress the social determinants of early childbearing are recommended.

Motivational Interviewing to Promote Long-Acting Reversible Contraception in Postpartum Teenagers

STUDY OBJECTIVE

To determine if teenage patients receiving prenatal care in an adolescent-focused clinic, emphasizing long-acting reversible contraception (LARC) using motivational interviewing techniques, had higher rates of uptake of postpartum LARC than a control group.

DESIGN AND SETTING

Retrospective cohort study comparing young women who received prenatal care in an adolescent-focused setting with those enrolled in standard prenatal care.

PARTICIPANTS

Adolescents between the ages of 13 and 17 years receiving prenatal care within the Maricopa Integrated Health safety-net system between 2007 and 2014.

INTERVENTIONS

Motivational interviewing within the context of adolescent-focused prenatal care.

MAIN OUTCOME MEASURES

Rates of uptake of LARC within 13 postpartum weeks.

RESULTS

The adjusted rate of LARC for adolescent-focused prenatal care participants by 13 weeks postpartum was 38% (95% confidence interval [CI], 29%-47%) compared with 18% (95% CI, 11%-28%) for standard care participants, with an adjusted odds ratio of LARC use of 2.8 (95% CI, 1.5-5.2). Among patients who received adolescent-focused prenatal care, most (27% vs 12.7%) were using an intrauterine device as opposed to an implantable contraceptive device.

CONCLUSION

Participation in an adolescent-focused antepartum setting using motivational interviewing to emphasize postpartum LARC resulted in nearly 3 times higher rates of uptake compared with standard prenatal care.

Risk factors for child physical abuse and neglect among Chinese young mothers

Although studies have reported a linkage between young pregnancy and child maltreatment risk, it is still unclear about what factors place young mothers at greater risk of maltreating their child in Chinese context. Based on the socio-ecological model, risk factors in 4 domains: family background/structure, maternal stressors, mother-child interaction, and child behavioral issue in relation to physical assault, neglect, both physical assault and neglect, and either physical assault or neglect among Chinese young mothers in Hong Kong were assessed. 392 young mothers were recruited from an integrated supportive program for young mothers. The mean age of mothers at delivery was 21.8 (SD=3.0) and 52.3% were married. Individual risk factors and cumulative risk domains related to different child maltreatment groups were examined. Our results show both overlapping and unique risk factors across the domains associated with physical assault and neglect. Further, young families exposed to higher number of risk domains show higher rates for physical assault and neglect, co-occurrence of physical assault and neglect, and either form of maltreatment. In addition, various risk domains were found to be particularly important for different forms of maltreatment: family background/structure domain was found to be an important risk domain for neglect; mother-child interaction domain for both physical assault and neglect; family background/structure and maternal stressors domains for either physical assault or neglect. Closer examination of a subgroup of adolescent mothers aged 18 and below shows that family background/structure was an important risk domain for this group.

Immediate versus delayed postpartum insertion of contraceptive implant for contraception

BACKGROUND

The spacing of pregnancies has a positive impact on maternal and newborn health. The progestin contraceptive implant, which is a long-acting, reversible method of contraception, has a well-established low failure rate that is compatible with tubal sterilization. The standard provision of contraceptive methods on the first postpartum visit may put some women at risk of unintended pregnancy, either due to loss to follow-up or having sexual intercourse prior to receiving contraception. Therefore, the immediate administration of contraception prior to discharge from the hospital that has high efficacy may improve contraceptive prevalence and prevent unintended pregnancy.

OBJECTIVES

To compare the initiation rate, effectiveness, and side effects of immediate versus delayed postpartum insertion of implant for contraception.

SEARCH METHODS

We searched for eligible studies up to 28 October 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE. We examined review articles and contacted investigators. We also checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant for contraception.

DATA COLLECTION AND ANALYSIS

Two review authors (JS, YW) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL or SK). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

Three studies that included 410 participants met the inclusion criteria of the review. We did not identify any ongoing trials. Two included studies were at low risk of selection, attrition, and reporting biases, but were at high risk of performance and detection biases due to the inability to blind participants to the intervention. One included study was at high risk of attrition bias. The overall quality of the evidence for each comparison ranged from very low to moderate; the main limitations were risk of bias and imprecision.Initiation rate of contraceptive implants at the first postpartum check-up visit was significantly higher in the immediate insertion group than in the delayed insertion group (RR 1.41, 95% CI 1.28 to 1.55; three studies, 410 participants; moderate quality evidence).There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant used at six months after insertion (RR 1.02, 95% CI 0.93 to 1.11; two studies, 125 participants; low quality evidence) or at 12 months after insertion (RR 1.04; 95% CI 0.81 to 1.34; one study, 64 participants;very low quality evidence)Women who received an immediate postpartum contraceptive implant insertion had a higher mean number of days of abnormal vaginal bleeding within six weeks postpartum (MD 5.80 days, 95% CI 3.79 to 7.81; one study, 215 participants; low quality evidence) and a higher rate of other side effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; one study, 215 participants; low quality evidence) than those who received a delayed postpartum insertion. There appeared to be little or no difference between the groups in heavy, irregular vaginal bleeding or associated severe cramping within 12 months (RR 1.01, 95% CI 0.72 to 1.44, one study, 64 participants;very low quality evidence).It was unclear whether there was any difference between the groups in scores for participant satisfaction on a 0-10 scale (MD -0.40, 95% CI -1.26 to 0.46, low quality evidence), or in rates of unintended pregnancy (RR 1.82, 95% CI 0.38 to 8.71, 1 RCT, 64 women, very low quality evidence) at 12 months, or in rate of breastfeeding rate at six months (RR 2.01, 95% CI 0.72 ro 5.63, 1 RCT, 64 women, very low quality evidence) rate did not differ significantly between the groups.

AUTHORS' CONCLUSIONS

Evidence from this review indicates that the rate of initiation of contraceptive implant at the first postpartum check-up visit was higher with immediate postpartum insertion than with delayed insertion. There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant use at 6 months. It was unclear whether there was any difference between the groups in continuation of contraceptive use at 12 months or in the unintended pregnancy rate at 12 months.

Adolescent Pregnancy

Adolescent pregnancy, although on the decline, represents a significant public health concern. Often adolescents present late to prenatal care, either from lack of knowledge, fear of consequences, limited access, stigma, or all of the above. Although multifaceted, there are many risks both to mother and child that are increased in adolescent pregnancy. Many are unintended and are at risk for repeat adolescent pregnancy, especially within the first 2 years. Risks include but are not limited to: low birth weight, preterm delivery, stillbirth, and preeclampsia, as well as feelings of social isolation, delayed or neglected educational goals, and maternal depression.