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Shankar M, Hooker L, Edvardsson K, Norman WV, Taft AJ. The prevalence and variations in unintended pregnancy by socio-demographic and health-related factors in a population-based cohort of young Australian women. Aust N Z J Public Health 2023:100046. [PMID: 37085430 DOI: 10.1016/j.anzjph.2023.100046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/26/2023] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVE The aim of this study is toestimate the prevalence of unintended pregnancy and associated socio-demographic and health-related factors among a national cohort of young Australian women. METHODS Secondary analysis of three waves (2013-2015) of the Australian Longitudinal Study on Women's Health new young cohort. Women born between 1989 and 1995 were recruited through internet and traditional media, and peer referral. Respondents completed a baseline web-based survey in 2013 (n=17,010) on their health and healthcare use and were followed up annually. This analysis uses data from women reporting ever having vaginal sex in waves 2 (n=9,726/11,344) and 3 (n=6,848/8,961). We assessed correlates of lifetime and recent unintended pregnancy using multivariable regression models. RESULTS At wave 2, among women aged 19-24, lifetime prevalence of unintended pregnancy was 12.6%, rising to 81.0% among ever pregnant women. Pregnancy outcomes among women with a history of unintended pregnancy differed by geographical residence. Disparities in odds of unintended pregnancy were seen by relationship and educational status, contraceptive use, sexual coercion and risky alcohol use. CONCLUSIONS Unintended pregnancy among young Australians is disproportionally experienced by women with structural disadvantages and exposure to sexual coercion. PUBLIC HEALTH IMPLICATIONS Service improvements to achieve equitable distribution of contraception and abortion services must be integrated with initiatives responding to sexual coercion.
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Affiliation(s)
- Mridula Shankar
- Gender and Women's Health Unit, Centre for Health Equity, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia.
| | - Leesa Hooker
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia; La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Kristina Edvardsson
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angela J Taft
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia
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Guleria S, Thomsen LT, Munk C, Nygård M, Hansen BT, Elfström KM, Arnheim-Dahlström L, Liaw KL, Frederiksen K, Kjær SK. Contraceptive use at first intercourse is associated with subsequent sexual behaviors. Contraception 2019; 99:217-221. [DOI: 10.1016/j.contraception.2018.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/28/2018] [Accepted: 12/19/2018] [Indexed: 11/30/2022]
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Biggs MA, Kimport K, Mays A, Kaller S, Berglas NF. Young Women's Perspectives About the Contraceptive Counseling Received During Their Emergency Contraception Visit. Womens Health Issues 2018; 29:170-175. [PMID: 30890252 DOI: 10.1016/j.whi.2018.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Research aimed at understanding women's experiences accessing emergency contraception (EC) services and the extent to which providers support women's autonomous contraceptive decision making is limited. This study explores young women's experiences with contraceptive counseling when accessing EC at family planning specialty clinics that serve young adult and adolescent patients. METHODS We conducted 22 in-depth telephone interviews with women ages 15-25 years who had recently accessed EC at two San Francisco Bay Area youth-serving clinics about their thoughts and experiences using and accessing contraception. We analyzed transcripts thematically, using inductive qualitative analytic methods to identify patterns across the interviews. RESULTS Most respondents described their recent clinic visit to access EC positively. Specifically, they expressed appreciation about receiving comprehensive information about other methods of contraception without pressure, judgment, or the expectation that they adopt a particular method. They also pointed to the influence of prior health care experiences in which they felt pressured or judged, leading them to avoid accessing future reproductive health services. CONCLUSIONS We found that young women seeking EC appreciated learning about other contraceptive methods, but do not want to feel pressured to adopt a method in addition to EC. Findings highlight the importance of respecting young women's contraceptive decisions for building and maintaining provider trust and suggest that contraceptive counseling approaches that prioritize specific methods may reduce some young women's trust in providers and use of reproductive health services.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, California.
| | - Katrina Kimport
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, California
| | - Aisha Mays
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, California
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, California
| | - Nancy F Berglas
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco, Oakland, California
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Guleria S, Juul KE, Munk C, Hansen BT, Arnheim-Dahlström L, Liaw KL, Nygård M, Kjaer SK. Contraceptive non-use and emergency contraceptive use at first sexual intercourse among nearly 12 000 Scandinavian women. Acta Obstet Gynecol Scand 2017; 96:286-294. [PMID: 28029175 DOI: 10.1111/aogs.13088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/22/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of this study was to describe recent patterns of contraceptive use at first sexual intercourse and to examine whether selected factors are associated with non-use and emergency contraceptive pill use at first sexual intercourse, among 18- to 26-year-old women from Denmark, Norway and Sweden. MATERIAL AND METHODS This was a population-based, questionnaire study of randomly chosen 18- to 26-year-old Scandinavian women. The prevalence of contraception methods used at first sexual intercourse was calculated. Factors associated with contraceptive non-use and emergency contraceptive pill use at first sexual intercourse were determined using log binomial models. RESULTS The prevalence of contraceptive non-use and emergency contraceptive pill use was lowest in Denmark (9.6 and 2.1%, respectively) compared with Norway (14.1 and 4.4%) and Sweden (16.6 and 4.5%). The risk of contraceptive non-use increased in women who had first sexual intercourse at or before 14 years of age (13-14 years: prevalence ratio 1.40; 95% confidence interval 1.24-1.58). The risk of both non-use and emergency contraceptive pill use increased when the partner at first sexual intercourse was 20 years or older, and with increasing age difference between the partner and the woman at her first sexual intercourse. Smoking initiation prior to first sexual intercourse increased risk of contraceptive non-use (prevalence ratio 1.70; 95% confidence interval 1.50-1.92), and alcohol initiation prior to first sexual intercourse increased risk of emergency contraceptive pill use at first sexual intercourse (prevalence ratio 1.95; 95% confidence interval 1.49-2.54). CONCLUSIONS Contraceptive non-use at first sexual intercourse was strongly associated with early age at first sexual intercourse. Emergency contraceptive pill and contraceptive non-use at first sexual intercourse were both strongly associated with increasing partner age and an increasing difference in age between the woman and her partner. Hence, young women should be educated to negotiate contraceptive use with their partners.
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Affiliation(s)
- Sonia Guleria
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Kirsten E Juul
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Christian Munk
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Bo T Hansen
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Lisen Arnheim-Dahlström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Kai-Li Liaw
- Epidemiology, Merck Research Laboratories, Kenilworth, NJ, USA
| | - Mari Nygård
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Susanne K Kjaer
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Gynecology, Rigshospitalet University Hospital, University of Copenhagen, Copenhagen, Denmark
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Safety data for levonorgestrel, ulipristal acetate and Yuzpe regimens for emergency contraception. Contraception 2015; 93:93-112. [PMID: 26546020 DOI: 10.1016/j.contraception.2015.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/23/2015] [Accepted: 11/01/2015] [Indexed: 12/30/2022]
Abstract
UNLABELLED The World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) provide recommendations for use of emergency contraceptive pills (ECPs), including levonorgestrel (LNG) and combined oral contraceptives (COCs). A new ECP formulation, ulipristal acetate (UPA), is now available worldwide. To determine whether LNG, UPA or COC (Yuzpe) ECPs are safe for women with certain characteristics or medical conditions, we searched the PubMed and Cochrane databases for articles published from date of inception until May 2015 pertaining to the safety of LNG, UPA or Yuzpe ECP use. For direct evidence, we considered studies that looked at safety outcomes among women with certain medical conditions or characteristics taking ECPs compared with women not taking ECPs. For indirect evidence, we considered studies that reported pharmacokinetic (PK) data for ECP use among women with certain medical conditions or characteristics and studies that reported safety outcomes among healthy women taking ECPs. Five studies provided direct evidence; of these five studies, four examined LNG or Yuzpe use among pregnant or breastfeeding women, and one reported risk of ectopic pregnancy among women repeatedly using LNG ECPs. Poor pregnancy outcomes were rare among pregnant women who used LNG or Yuzpe ECPs during the conception cycle or early pregnancy. Breastfeeding outcomes did not differ between women exposed to LNG ECP and those unexposed, and there was no increased risk of ectopic pregnancy versus intrauterine pregnancy after repeated use of LNG ECPs compared with nonuse. Forty-five studies provided indirect evidence. One PK study demonstrated that LNG passes into breastmilk but in minimal quantities. In addition, nine studies examined pregnancy outcomes following ECP failure among healthy women, and 35 articles reported adverse events. Studies suggest that serious adverse events are rare among women taking any of these ECP formulations. IMPLICATIONS Evidence on safety of ECPs among women with characteristics or medical conditions listed within WHO and CDC family planning guidance is limited. However, both direct and indirect evidence for our study question did not suggest any special safety concerns for the use of ECPs among women with particular medical conditions or personal characteristics, such as pregnancy, lactation or frequent ECP use.
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Schwarz EB, Papic M, Parisi SM, Baldauf E, Rapkin R, Updike G. Routine counseling about intrauterine contraception for women seeking emergency contraception. Contraception 2014; 90:66-71. [PMID: 24674042 DOI: 10.1016/j.contraception.2014.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/07/2014] [Accepted: 02/13/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. STUDY DESIGN For 8 months before and 21 months after this change in clinic policy, women aged 15-45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n=328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. RESULTS Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. CONCLUSIONS Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. IMPLICATIONS Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.
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Affiliation(s)
- E Bimla Schwarz
- University of Pittsburgh, Department of Medicine; University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology; University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences.
| | | | - Sara M Parisi
- University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology
| | - Erin Baldauf
- University of Pittsburgh, Department of Medicine
| | - Rachel Rapkin
- University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Glenn Updike
- University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences
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Ekstrand M, Tydén T, Darj E, Larsson M. Twelve-month follow-up of advance provision of emergency contraception among teenage girls in Sweden-a randomized controlled trial. Ups J Med Sci 2013; 118:271-5. [PMID: 24102148 PMCID: PMC4190889 DOI: 10.3109/03009734.2013.841308] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the effect of an intervention with advance provision of emergency contraceptive pills (ECP), condoms, and extended information to a targeted group of teenage girls, compared with a control group, 12 months after intervention. MATERIAL AND METHODS A randomized controlled trial among 420 girls, 15-19 years old, requesting emergency contraception at a youth clinic in Sweden was carried out. Data were collected by a questionnaire at the initial visit and structured telephone interviews 12 months after enrolment. Differences between the intervention group and the control group regarding ECP use, time interval from unprotected intercourse to ECP intake, contraceptive use, and sexual risk-taking were analysed. RESULTS One year after the intervention 62% of the girls could be reached for follow-up. The girls in the intervention group reported a shorter time interval (mean 15.3 hours) from unprotected intercourse to ECP intake compared to the control group (mean 25.8 hours) (p = 0.019), without any evidence of decreased use of contraceptives or increased sexual risk-taking. CONCLUSION Even up to 12 months following the intervention, advance provision of ECP at one single occasion, to a specific target group of adolescent girls, shortens the time interval from unprotected intercourse to pill intake, without jeopardizing contraceptive use or increasing sexual risk-taking. Considering the clinical relevance of these results, we suggest that advance provision of ECP could be implemented as a routine preventive measure for this target group.
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Affiliation(s)
- Maria Ekstrand
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
- Department of Care Science, Malmö University, Malmö, Sweden
| | - Tanja Tydén
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Darj
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Margareta Larsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Moosazadeh M, Nekoei-Moghadam M, Emrani Z, Amiresmaili M. Prevalence of unwanted pregnancy in Iran: a systematic review and meta-analysis. Int J Health Plann Manage 2013; 29:e277-90. [PMID: 23630092 DOI: 10.1002/hpm.2184] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 03/12/2013] [Accepted: 03/13/2013] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Different studies show that a considerable number of pregnancies are unwanted and can have side effects on mothers'' children's and finally society's health. Accordingly, this meta-analysis study has been carried out to estimate a relatively accurate level of unwanted pregnancies in Iran. METHODS Present studies and published documents were retrieved from Persian and English electronic databases. To increase sensitivity and to select more studies, the reference list of the published studies was checked. After studying the titles and texts of documents, repeated and irrelevant ones were excluded. Data was analyzed using STATA V.11. RESULTS Forty-nine qualified papers were selected with a 43,061 sample size. The meta-analysis of unwanted pregnancy prevalence in Iran equals 30.6% (CI = 28.1-33.1). Also' according to the present meta-analysis' the most common contraceptive methods used by couples prior to unwanted pregnancies are as follows: pills 27.1%' withdrawal 38.6%' IUD 11.4%' injection contraceptives 2.8%' vasectomy 0.28% and no method 24.5%. DISCUSSION AND CONCLUSION The results of meta-analysis showed that about one-third of pregnancies in Iran are unwanted and a high percent of them are among women who had used contraceptives. Therefore' it is necessary to adopt more appropriate policies on the following: education, proper pregnancy age, using contraceptive methods, men's role in family planning programs and quality promotion in family planning services.
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Affiliation(s)
- Mahmood Moosazadeh
- Research Center for Modeling in Health, Institute of Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Samartzis EP, Merki-Feld GS, Seifert B, Kut E, Imthurn B. Six years after deregulation of emergency contraception in Switzerland: Has free access induced changes in the profile of clients attending an emergency pharmacy in Zürich? EUR J CONTRACEP REPR 2012; 17:197-204. [DOI: 10.3109/13625187.2012.661108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Leung VWY, Soon JA, Levine M. Measuring and Reporting of the Treatment Effect of Hormonal Emergency Contraceptives. Pharmacotherapy 2012; 32:210-21. [DOI: 10.1002/j.1875-9114.2012.01041.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Vivian W. Y. Leung
- Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver; British Columbia; Canada
| | - Judith A. Soon
- Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver; British Columbia; Canada
| | - Marc Levine
- Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver; British Columbia; Canada
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Piascik P, Lowe FH, Moore GR, Wallace DL, Steinke DT. Drug-utilization evaluation of emergency contraception in a major public university student population. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2010. [DOI: 10.1111/j.1759-8893.2010.00016.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kenyon DB, Sieving RE, Jerstad SJ, Pettingell SL, Skay CL. Individual, interpersonal, and relationship factors predicting hormonal and condom use consistency among adolescent girls. J Pediatr Health Care 2010; 24:241-9. [PMID: 20620850 DOI: 10.1016/j.pedhc.2009.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 06/29/2009] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Few existing studies have considered influences of adolescents' sexual partners on contraceptive consistency. This study examines the influence of personal characteristics, partner characteristics, and relationship factors on consistency of contraceptive use among an ethnically diverse sample of adolescent girls at high risk for pregnancy and sexually transmitted diseases. METHOD Data are from 110 sexually active 13- to 17-year-old girls participating in a clinic-based intervention study aimed at reducing sexual risk behaviors. Personal characteristics were assessed at baseline (T1), and partner and relationship characteristics were assessed at 12 months (T2). RESULTS Multivariate analyses revealed that T2 hormonal contraceptive consistency was predicted by T1 hormonal consistency, girls' desire to use birth control, having the same sexual partner at T1 and T2, perceived partner support for birth control, and communication with partner about sexual risk. T2 condom use consistency was negatively predicted by emergency contraceptive use history and perceived partner support for birth control. DISCUSSION Findings underscore the importance of nurses addressing both personal and relationship factors in their efforts to promote consistent contraceptive use among sexually active adolescent girls.
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Affiliation(s)
- DenYelle Baete Kenyon
- Health Disparities Research Center, Sanford Research/University of South Dakota, Sioux Falls, SD, USA.
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McAloney K, Mccrystal P, Percy A. Sex, drugs and STDs: Preliminary findings from the Belfast Youth Development Study. DRUGS-EDUCATION PREVENTION AND POLICY 2010. [DOI: 10.3109/09687630903074826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sander PM, Raymond EG, Weaver MA. Emergency contraceptive use as a marker of future risky sex, pregnancy, and sexually transmitted infection. Am J Obstet Gynecol 2009; 201:146.e1-6. [PMID: 19646565 DOI: 10.1016/j.ajog.2009.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 04/03/2009] [Accepted: 05/12/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the study was to examine whether emergency contraceptive use predicts future sex at risk for pregnancy, pregnancy, or sexually transmitted infection among young women. STUDY DESIGN A secondary analysis of control group participants (n = 718) from a recent trial of advanced provision of emergency contraception was conducted. RESULTS We found no association between use of emergency contraception and either pregnancy or infection. Recent use predicted decreased occurrence of subsequent sex at risk for pregnancy among women with a history of sexually transmitted infection (relative risk [RR], 0.39; 95% confidence interval [CI], 0.15-0.97), whereas ever having used predicted increased occurrence among women who either were highly effective method users (RR, 1.45; 95% CI, 1.05-2.01) or had no history of sexually transmitted infection (RR, 1.31; 95% CI, 1.04-1.65). CONCLUSION Information about prior emergency contraceptive use was not a useful predictor of subsequent pregnancy, infection, or sex at risk for pregnancy among these young women.
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Affiliation(s)
- Petra M Sander
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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15
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16
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Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009; 113:833-839. [PMID: 19305327 DOI: 10.1097/aog.0b013e31819c856c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To estimate the interest in using intrauterine contraception among women and adolescent girls seeking emergency contraception or walk-in pregnancy testing. METHODS We surveyed 412 women and adolescent girls who requested emergency contraception or pregnancy testing at four family planning clinics in Pittsburgh, Pennsylvania. The 41-item survey assessed knowledge of, attitudes toward, and interest in using an intrauterine device (IUD). Data were analyzed using chi2 and Fisher exact tests and multivariable logistic regression methods. RESULTS The response rate was 85%. Twelve percent (95% confidence interval [CI] 9-15) of women and adolescent girls surveyed expressed interest in same-day insertion of an IUD, and 22% (95% CI 18-26) wanted more information about IUDs. Interest in same-day IUD insertion increased with higher education level, prior unwanted pregnancy, and experience with barriers to use of contraception. CONCLUSION Same-day IUD insertion may be a reasonable way to increase the use of highly-effective contraception among women and adolescent girls seeking emergency contraception or walk-in pregnancy testing. LEVEL OF EVIDENCE II.
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Byamugisha JK, Mirembe FM, Faxelid E, Gemzell-Danielsson K. Emergency contraception and fertility awareness among university students in Kampala, Uganda. Afr Health Sci 2008; 6:194-200. [PMID: 17604507 PMCID: PMC1832063 DOI: 10.5555/afhs.2006.6.4.194] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Uganda has a high maternal mortality ratio with unsafe abortions being one of the major causes. Young people are particularly vulnerable to unsafe induced abortion with its sequelae. Emergency contraception (EC) may reduce unsafe abortions if easily accessible and acceptable. OBJECTIVE To determine knowledge about, ever use and attitudes towards EC among resident and non-resident female first year university students in Kampala. METHODS This Cross sectional study was carried out at Makerere University from January to March 2005.Out of 5971 females admitted in the academic year 2004/2005,379 answered a self administered questionnaire. The students were approached individually and given the questionnaire if they consented. RESULTS The mean age of the participants was 21 years. Less than half (45.1%) had ever heard about emergency contraceptive pills (ECPs). The most common sources of information about EC were friends (34%),media (24.8%) and schools (19.4%). The ever pregnancy rate was 3.4 percent and 42 percent were in a steady relationship of three or more months. The contraceptive ever-use rate was 14.5 percent. Among the users the most common methods were condoms (48.9%) and withdrawal (23.4%). Emergency contraceptive pills had been used by seven students. Forty two percent did not know the time interval within which ECPs can work and one third thought it would interrupt an ongoing pregnancy. Thirty five percent did not know when in the menstrual cycle they were likely to conceive. The majority of the students were against over the counter (OTC) availability of EC because of fear of misuse. CONCLUSIONS Knowledge about Emergency contraception and fertility awareness is low among the female first year university students. Friends and the media are an important source of EC information. Awareness and knowledge of EC should be increased.
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Affiliation(s)
- Josaphat K Byamugisha
- Dept of Obstetrics and Gynecology, Faculty of Medicine, Makerere University, Kampala, Uganda.
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Phipps MG, Matteson KA, Fernandez GE, Chiaverini L, Weitzen S. Characteristics of women who seek emergency contraception and family planning services. Am J Obstet Gynecol 2008; 199:111.e1-5. [PMID: 18355784 DOI: 10.1016/j.ajog.2008.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 11/12/2007] [Accepted: 02/08/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the demographic characteristics and sexual risk behaviors of women who seek emergency contraception (EC) and general family planning (FP) services. STUDY DESIGN This cross-sectional study included 227 women aged 17-43 years who were being evaluated for either EC or FP in an outpatient setting from 2003-2004. Descriptive statistics and odds ratios were included. RESULTS The EC group, compared with the FP group, had higher proportions of women with education beyond high school (62% vs 52%; P = .02), and not married (79% vs 42%; P < .01). The groups also differed by age, race, and income. The EC group was more likely to have been unprotected at their last intercourse (odds ratio, 5.56; 95% CI, 2.22, 14.29) and less likely to have a previous sexually transmitted infection (odds ratio, 0.41; 95% CI, 0.17, 0.96). CONCLUSION The development of EC education programs for women is important for increasing awareness for diverse groups of women and their healthcare providers.
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Affiliation(s)
- Maureen G Phipps
- Department of Obstetrics & Gynecology, Women & Infants Hospital of Rhode Island, Providence, RI 02905, USA.
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Peremans L, Verhoeven V, Philips H, Denekens J, Van Royen P. How does a Belgian health care provider deal with a request for emergency contraception? EUR J CONTRACEP REPR 2008; 12:317-25. [PMID: 17853170 DOI: 10.1080/13625180701502377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate how Belgian health care providers deal with a request for emergency contraception. METHOD In 2002-2003 we conducted 12 focus groups with pharmacists, general practitioners and school physicians. A skilled moderator accompanied by an observer conducted the focus groups using a semi-structured screenplay. RESULTS All these health care providers agree with the free access to emergency contraception (EC), but experience considerable frustration with regard to the practical aspects and the legal framework. General practitioners (GPs) claim to spend a lot of time on requests for EC and they are concerned about the quality of the counselling provided in pharmacies. Pharmacists are creative when giving counselling in the pharmacy, but there is, nevertheless, a problem with a lack of privacy. School physicians are frustrated that there is no legal possibility to respond to a request for EC when they feel they are ideally placed to advise adolescents. CONCLUSION The over-the-counter sale of EC offers women better access, but many barriers still interfere with optimal care. Pharmacists experience a lack of skills to communicate with adolescents and a lack of privacy to give counselling. GPs have good intentions, but are confronted with a lack of willingness on the part of the patients and also financial barriers. School physicians want more possibilities to help adolescents.
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Affiliation(s)
- Lieve Peremans
- University of Antwerp, Department of General Practice, Antwerp, Belgium.
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Sidebottom A, Harrison PA, Donna A, Finnegan K. The varied circumstances prompting requests for emergency contraception at school-based clinics. THE JOURNAL OF SCHOOL HEALTH 2008; 78:258-263. [PMID: 18387025 DOI: 10.1111/j.1746-1561.2008.00298.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Little is known about the circumstances that prompt teenagers to request emergency contraception (EC). This evaluation was designed to refine the EC clinical protocol and improve pregnancy prevention efforts in high school-based clinics by analyzing information on EC use and subsequent contraception use of EC patients. METHODS Sites included 5 clinics located at mainstream, racially diverse, and urban high schools. Nursing staff documented all EC-related visits during the 2002-2003 school year on a standardized form. These forms and additional information were collected from chart reviews. RESULTS EC was requested in 113 instances involving 91 students and dispensed in all but 4 instances. The most frequently reported circumstance prompting an EC request was the use of no protection (37.2%), followed by a condom mishap (27.4%) and questionable protection from a hormonal method (23.9%). Anxiety despite adequate protection from a hormonal method (9.7%) or a condom (1.8%) accounted for the remaining cases. Although the clinical protocol included a follow-up appointment 2 weeks after receipt of EC, 39.5% of EC users failed to keep this appointment. The chart review revealed that hormonal contraception was eventually initiated following two thirds (68.0%) of the EC instances that involved either no protection or only a condom. CONCLUSIONS Because young EC seekers vary considerably in terms of sexual experience, contraceptive use consistency, and pregnancy risk, individualized risk assessment and counseling are essential. The EC visit may be an optimal time to encourage initiation or reinstitution of hormonal methods of birth control.
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Affiliation(s)
- Abbey Sidebottom
- Minneapolis Department of Health and Family Support, Minneapolis, MN 55415-1384, USA.
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Giacaman R, Abu-Rmeileh NME, Mataria A, Wick L. Palestinian women's pregnancy intentions: Analysis and critique of the Demographic and Health Survey 2004. Health Policy 2008; 85:83-93. [PMID: 17698239 DOI: 10.1016/j.healthpol.2007.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2007] [Revised: 06/23/2007] [Accepted: 06/29/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The Palestinian DHS2004 reports on pregnancy intentions and their determinants are analyzed for the first time. Through this analysis, the survey instrument limitations are also highlighted. METHODS Data on 15-49 years old ever married, non-pregnant women reporting on their last pregnancy were selected from a nationally representative cross sectional survey dataset. RESULTS Older women were more likely not to desire the pregnancy at all, and younger women more likely to have desired to wait; with higher reports of not desiring the pregnancy at all or desiring to wait among those with a higher number of children; with higher reports of not desiring the pregnancy at all, or desiring to wait, among women who reported ever using family planning methods. Women who experienced prenatal and postnatal complications reported higher levels of having desired to wait or not having wanted the pregnancy at all, calling for the inclusion of process measures in pregnancy intention studies. CONCLUSIONS While some of our findings are comparable to those cited in the international literature, the analysis was limited to the type of questions asked in the Palestinian DHS survey. There is a need to further develop the survey instrument in order to address women's needs from a public health policy perspective. We call for the inclusion of additional social measures to identify some of the contextual factors that influence pregnancy intentions.
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Affiliation(s)
- Rita Giacaman
- Institute of Community and Public Health, Birzeit University, Box 154, Ramallah, West Bank, Occupied Palestinian Territory
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Verhoeven V, Peremans L, Avonts D, Van Royen P. The profile of emergency contraception users in a chlamydia prevalence study in primary care in Belgium. EUR J CONTRACEP REPR 2007; 11:175-80. [PMID: 17056447 DOI: 10.1080/13625180600766289] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We describe the use of emergency contraception (EC) and its association with sociodemographic, contraceptive and behavioural characteristics in a sample of family practice attendants in Belgium. METHODS The study was part of a large Chlamydia trachomatis (CT) prevalence study in general practice. Sexually active women under 40 who consulted their general practitioner for routine gynaecological care were enrolled in the study. Participants completed a questionnaire on sociodemographic variables, urogenital symptoms, sexual history and sexual behaviour, and delivered a sample for CT testing. Logistic regression analysis was performed to identify determinants of a history of EC use in women in this sample. RESULTS Of 815 questioned women, 23.5% had ever used EC. EC users were a heterogeneous group with respect to educational level, age and ethnicity. The use of emergency contraception was associated with the level of urbanisation, condom use, not having children yet, young age of first sexual intercourse, having had multiple partners in the past year, a history of unintended pregnancy, and current or previous STI. DISCUSSION Information on availability and correct use of EC, and on the need for additional testing for STI, are necessary to help primary care attendees to preserve their future reproductive health.
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Bakhru A, Stanwood N. Performance of Contraceptive Patch Compared With Oral Contraceptive Pill in a High-Risk Population. Obstet Gynecol 2006; 108:378-86. [PMID: 16880309 DOI: 10.1097/01.aog.0000228850.85346.e2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the potential benefit of the transdermal contraceptive patch compared with the oral contraceptive pill for its acceptability and compliance in a population at high risk for future unintended pregnancies and abortions. METHODS Assessment of the contraceptive patch and pill was prospective. We gathered information on women undergoing contraceptive counseling at three Planned Parenthood clinics. Discontinuation, adverse effects, and pregnancy outcomes were catalogued. The primary outcome was time to discontinuation of the patch or pill. Survival analyses with life tables and Cox proportional hazards were used to assess acceptability and compliance. Pearl indices were calculated for both the pill and patch. RESULTS A total of 1,230 contraceptive-naïve women were identified. Subjects were a racially diverse group of primarily single women. Eighty-nine percent of the study population met our definition of being at high risk for a future unintended pregnancy or pregnancy termination. Loss to follow-up was higher among patch users (45.2% versus 29.5%, P<.001). Verified continued use beyond the first three cycles was lower with a patch (67% versus 89%, P<.001). Skin irritation and site reactions were the treatment-limiting factor for 3.3% of patch users. The 3,206 cycles captured in this study resulted in a Pearl index of 3.62 for the pill and 14.84 for the patch. Differences in the baseline demographic and contraceptive practices may account for this discrepancy although, in multivariate analysis, patch users continued to do worse. CONCLUSION In this high-risk population, we found the contraceptive patch to have lower continuation and effectiveness rates. Further research should investigate factors contributing to poorer real-world performance by the patch.
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MESH Headings
- Administration, Cutaneous
- Administration, Oral
- Adolescent
- Adult
- Child
- Cohort Studies
- Contraception Behavior
- Contraceptive Agents, Female/administration & dosage
- Contraceptive Agents, Female/adverse effects
- Contraceptive Agents, Female/therapeutic use
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Combined/therapeutic use
- Female
- Humans
- New York
- Proportional Hazards Models
- Prospective Studies
- Treatment Refusal
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Affiliation(s)
- Arvind Bakhru
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland, Baltimore, 21201, USA.
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Sarkar NN. Emergency contraception: a contraceptive intervention approaching target despite controversy and opposition. J Public Health (Oxf) 2006. [DOI: 10.1007/s10389-006-0036-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
The objective was to describe the demographic and sexual characteristics of clients attending a Sexual Health Clinic for emergency contraception (EC). Information about women attending the Parramatta Sexual Health Clinic (PSHC) who received EC between January 1999 and July 2002 was derived from the clinic database. Age-matched controls were randomly selected. Univariate and logistic regression analysis was performed to establish which factors were associated with use of EC. Two hundred and sixty-seven women requesting EC, and an equal number of controls, were studied. Factors that were independently associated with EC use were being a student, (OR=1.7 [95% CI 1.02-2.69]) and having a regular sexual partner (OR=2.3 [95% CI 1.14-4.73]). Women requiring EC were significantly less likely to have had a sexually transmitted infection (STI) (OR=0.3 [95% CI 0.16-0.60]) or a previous pregnancy (OR=0.2 [95% CI 0.09-0.67]) than controls. We concluded that users of EC are at low-risk for STIs, but need counselling about safer sex.
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Affiliation(s)
- J Fox
- Sexually Transmitted Infections Research Centre, The University of Sydney, Marian Villa, Westmead Hospital, Westmead, NSW 2145, Australia
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Camp SL, Wilkerson DS, Raine TR. The benefits and risks of over-the-counter availability of levonorgestrel emergency contraception. Contraception 2004; 68:309-17. [PMID: 14636933 DOI: 10.1016/j.contraception.2003.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Removing the prescription requirement for Plan B will help ensure that the product plays a larger role nationally in the reduction of unintended pregnancy and abortion-important public health goals. Over-the-counter (OTC) sale of Plan B should present no serious safety issues. OTC consumers are able to understand and follow the instructions for proper use of Plan B. Efficacy of the OTC product is likely to be the same as, or better than, the prescription product, given more timely access to treatment. Based on the results of a growing body of literature and foreign marketing experience, the risk of unintended health consequences also appears to be minimal. There is no evidence to suggest that American women will abuse Plan B as an OTC product.
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Affiliation(s)
- S L Camp
- Women's Capital Corporation, 1990 M Street NW, Suite 250, Washington, DC 20036, USA
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Abstract
Unintended pregnancy and abortion rates among US adolescents remain high although hormonal contraception is safe and effective in this population. Controversies affecting the provision of hormonal contraception for adolescents include the side effects of oral contraceptives, the possibility that progestin-only injectables lead to decreased bone health, and debate as to whether emergency contraception should be available to teens without a prescription. Each of these issues is addressed with a review of relevant literature.
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Affiliation(s)
- Anne R Davis
- Department of Obstetrics and Gynecology, Division of Prevention and Ambulatory Care, New York Presbyterian Hospital, PH-16, 630 West 168th Street, New York, NY 10032, USA.
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Gainer E, Sollet C, Ulmann M, Lévy D, Ulmann A. Surfing on the morning after: analysis of an emergency contraception website. Contraception 2003; 67:195-9. [PMID: 12618253 DOI: 10.1016/s0010-7824(02)00491-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The introduction of widespread nonprescription delivery of hormonal emergency contraception (EC) calls for development of innovative tools to provide information to and gather feedback from EC users. Individuals seeking confidential information on sexual health and contraception are increasingly turning to the Internet as the resource of choice. This study employed analytical software and manual content analysis to examine the use of a website dedicated to an EC product (www.norlevo.com) over the course of 2 years. Frequency of visits to and pageviews of the site increased consistently over the 2-year time period, and the bulk of the visitors to the site were EC users seeking responses to frequently asked questions. The most common concern raised by users was the occurrence of spotting and menstrual bleeding following EC use. This analysis reveals that within the context of nonprescription access to hormonal EC, a website can constitute a potent educational tool for health professionals and EC users and provide a valuable source of post-marketing feedback on product use.
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Affiliation(s)
- Erin Gainer
- Laboratoire HRA Pharma, 19 rue Frédérick Lemaître, 75020 Paris, France.
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Ugocsai G, Rózsa M, Ugocsai P. Scanning electron microscopic (SEM) changes of the endometrium in women taking high doses of levonorgestrel as emergency postcoital contraception. Contraception 2002; 66:433-7. [PMID: 12499036 DOI: 10.1016/s0010-7824(02)00431-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Endometrial surface changes by scanning electron microscope were studied in three women who intentionally took high doses of levonorgestrel as an emergency postcoital contraceptive. Based upon findings of a close link between endometrial receptivity and surface integrity, significant alterations of the uterine lining structure may represent a drug effect accomplishing endometrial contraception. High doses of levonorgestrel (4-6 times more than recommended) caused detectable changes on the surface regardless of the menstrual cycle phase when the medication was taken. Cycle classification was based on estradiol and progesterone hormone levels, which corresponded to the menstrual diary. Comparison to control specimens displayed marked restructuralization of the endometrium. As a main feature, the number of ciliated cells were reduced, and cilia disappeared in the proliferative and periovulatory phase. In the secretory phase, pinopodia disappeared and the endometrial integrity broke down. The contraceptive effect of levonorgestrel seems to be accomplished by alteration of the endometrial surface and, therefore, receptivity.
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Affiliation(s)
- G Ugocsai
- Department of Obstetrics and Gynecology, Academic Teaching Hospital, H-5900 Orosháza, Könd 59, Hungary
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Aneblom G, Larsson M, von Essen L, Tydén T. Women's voices about emergency contraceptive pills "over-the-counter": a Swedish perspective. Contraception 2002; 66:339-43. [PMID: 12443964 DOI: 10.1016/s0010-7824(02)00367-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study aimed to describe women's experiences with the emergency contraceptive pill (ECP) as a prescription-free over-the-counter (OTC) product. Women (median age 24) who had bought ECP as an OTC product were interviewed in focus groups. Data were analyzed by content analysis. All participants appreciated the OTC availability. Timesaving aspects were seen as important benefits and pharmacies were seen as the right place to sell ECP. The media was the main source of information about OTC, probably due to the debates of the introduction of ECP as an OTC product in Sweden. All women discussed the mechanism of action. The women's experiences of interacting with the pharmacists were both positive and negative. Inconsistencies in routines with regard to providing ECP and different attitudes toward use of ECP among the pharmacists, were identified. The women expected up-to-date information about ECP and the OTC availability from gynecologists and other health professionals.
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Affiliation(s)
- Gunilla Aneblom
- Department of Women's and Children's Health, Uppsala University, S-751 85, Uppsala, Sweden.
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Kettle H, Cay S, Brown A, Glasier A. Screening for Chlamydia trachomatis infection is indicated for women under 30 using emergency contraception. Contraception 2002; 66:251-3. [PMID: 12413621 DOI: 10.1016/s0010-7824(02)00387-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A total of 838 women attending a large family planning clinic in Scotland for emergency contraception were offered screening for Chlamydia trachomatis infection. 569 were screened using ligase chain reaction test in first void urine at the time of presenting for emergency contraception and were retested 1 or 2 weeks later. Women aged under 20 and over 30 years were significantly more likely to decline to be tested than women aged 20 to 30. The prevalence of chlamydia was 7.6% in woman aged 24 or less, 5.3% in women aged 25 to 29, and 1.2% in women aged 30 or more. Only two women (< 1%) who tested negative at the time of using EC were positive 1 or 2 weeks later. Women under age 30 who use EC should be offered screening for chlamydia infection and testing at the time they attend for EC is adequate to detect the great majority of infected women.
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Affiliation(s)
- Helen Kettle
- Lothian Primary Care NHS Trust Family Planning and Well Woman Services, Lothian, Scotland, UK
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