Contraceptive use among Canadian women of reproductive age: results of a national survey

Regret in the Modern Contraceptive Landscape: Evaluating Regret in Patients Undergoing Tubal Ligation or Bilateral Salpingectomy for Contraception

OBJECTIVE

To estimate the prevalence of regret among Canadians undergoing tubal ligation or bilateral salpingectomy for contraception in the context of widely available, highly effective, and tolerable reversible contraceptive methods including long-acting reversible contraceptives.

METHODS

We performed an online cross-sectional survey of regret following tubal sterilization using Qualtrics software. A convenience sample was used to recruit Canadian residents between the ages of 18 and 60 years who had undergone tubal ligation or salpingectomy for contraception. The online survey was advertised on 3 social media platforms: Facebook, Twitter, and Instagram.

RESULTS

We obtained survey results for 844 Canadian residents. Regret was reported by 15.9% of respondents. Consistent with existing literature, factors associated with regret included younger age at the time of the procedure, a change in relationship status, and having the procedure performed at the time of a pregnancy. Surprisingly, 9.5% of respondents reported an element of coercion, 4.5% were unaware the procedure was considered permanent contraception, and 33.3% did not recall their provider discussing alternative forms of contraception with them prior to surgery.

CONCLUSION

We found that the prevalence of regret following tubal sterilization has not changed with the widespread availability of highly effective reversible contraceptive methods. However, most patients choosing permanent contraception will be satisfied with their decision. Shared decision-making should respect the autonomy of each patient to make their own decisions regarding the most acceptable family planning method for their circumstances.

Medication Adherence and Contraceptive Counseling

Combined oral contraceptives (COC) are a very popular form of birth control. Incorrect use and lack of adherence to treatment reduce the effectiveness of this method. Having a standard tool to identify poor-adherence profiles quickly and objectively can be helpful for midwives and potentially for COC users. The MMAS-4 adherence scale has been used in various medical fields, but there is little evidence of its potential in contraceptive consultation. This paper presents a piece of multicenter observational research based on a sample of 327 women who had attended contraceptive counselling in Spain and were COC users or had informed the midwife that they want to start to use this method. Two interviews were conducted: at the time of consultation and after one year. In our research, the MMAS-4 identified high-risk behaviors: during the 1-year follow-up period, COC users classified as poorly adherent had a significantly higher risk of missed contraceptive pills, more incidents and problems related to the method of contraception, as well as a lower degree of satisfaction with the contraceptive method. One case of unplanned pregnancy and two cases of emergency contraception were identified, all of them corresponding to poorly adherent women. The use of MMAS-4 in consultation can improve midwives' contraceptive counselling.

Can youth-engaged research facilitate equitable access to contraception in Canada? The qualitative study protocol for the Ask Us project

INTRODUCTION

There is little to no evidence in Canada on the barriers that youth face when accessing contraception. We seek to identify the contraception access, experiences, beliefs, attitudes, knowledge, and needs of youth in Canada, from the perspectives of youth and youth service providers.

METHODS AND ANALYSIS

This prospective, mixed-methods, integrated knowledge mobilisation study, the Ask Us project, will involve a national sample of youth, healthcare and social service providers, and policy makers recruited via a novel relational mapping and outreach approach led by youth. Phase I will centre the voices of youth and their service providers through in-depth one-on-one interviews. We will explore the factors influencing youth access to contraception, theoretically guided by Levesque's Access to Care framework. Phase II will focus on the cocreation and evaluation of knowledge translation products (youth stories) with youth, service providers, and policy makers.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia's Research Ethics Board (H21-01091). Full open-access publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to youth and service providers through social media, newsletters, and communities of practice, and to policy makers through invited evidence briefs and face-to-face presentations.

Factors associated with contraceptive use among women living with HIV in Canada: a controlled, cross-sectional study

BACKGROUND

Multiple contraindications to combined hormonal contraceptives (CHC) use exist. The impact of these factors on contraceptive choice, particularly among women living with HIV (WLWH), is not well understood. We measured and compared the prevalence of contraceptive use and contraindications among WLWH and women not living with HIV (controls).

METHODS

We examined cross-sectional survey and medical chart data from 83 WLWH and 62 controls, aged 16-49 and sexually active, from 2013-2017. We compared the age-adjusted prevalence and types of contraceptives used in the last month and the proportion of women with CHC contraindications, including drug interactions, medical comorbidities, and smoking at ≥ 35 years old. All WLWH received care at an interdisciplinary, women-centred HIV clinic.

RESULTS

Compared to controls, WLWH were older (median [IQR)] 39 [34-43] vs 31 [23-41] years; p = 0.003), had less post-secondary education (37% vs 73%; p < 0.001), and more often had household income < $15,000/year (49% vs 30%; p = 0.006). WLWH trended to higher contraceptive prevalence than controls (80% vs 63%; p = 0.06 adjusted for age). Overall hormonal contraceptive use was similar. However, despite controlling for age, WLWH used CHC less (4% vs 18%; p = 0.006) than controls, and had more frequently undergone tubal ligation (12% vs 2%; p = 0.03). WLWH also experienced more CHC contraindications (54% vs 13%; p = 0.0001), including smoking at ≥ 35 years old (30% vs 6%; p = 0.0003) or a CHC-related drug interaction (all antiretroviral related) (25% vs 0%; p = 0.0001).

CONCLUSIONS

WLWH attending our interdisciplinary clinic used hormonal contraception at similar rates as controls, though with different types. Differences may reflect different distributions of CHC contraindications. CHC contraindications present barriers to accessing the full range of contraceptive choices for WLWH. Guidelines and education for care providers and WLWH regarding contraceptive choices and drug interactions are needed, especially when care is provided without the benefit of an interdisciplinary women-centered healthcare team.

Women's health guidelines for the care of people with spina bifida

Women and girls with spina bifida have specific health care concerns. It is essential that they, and their health care providers have access to information to help them make healthy choices throughout their lifespan. This article aims to address key aspects of health pertinent to girls and women with spina bifida and outlines the SB Women's Health Guidelines for the Care of People with Spina Bifida. Further research into this area is needed.

Caffeine, genetic variation and anaerobic performance in male athletes: a randomized controlled trial

PURPOSE

The effect of caffeine on anaerobic performance is unclear and may differ depending on an individual's genetics. The goal of this study was to determine whether caffeine influences anaerobic performance in a 30 s Wingate test, and if 14 single nucleotide polymorphisms (SNPs) in nine genes, associated with caffeine metabolism or response, modify caffeine's effects.

METHODS

Competitive male athletes (N = 100; 25 ± 4 years) completed the Wingate under three conditions: 0, 2, or 4 mg of caffeine per kg of body mass (mg kg^-1), using a double-blinded, placebo-controlled design. Using saliva samples, participants were genotyped for the 14 SNPs. The outcomes were peak power (Watts [W]), average power (Watts [W]), and fatigue index (%).

RESULTS

There was no main effect of caffeine on Wingate outcomes. One significant caffeine-gene interaction was observed for CYP1A2 (rs762551, p = 0.004) on average power. However, post hoc analysis showed no difference in caffeine's effects within CYP1A2 genotypes for average power performance. No significant caffeine-gene interactions were observed for the remaining SNPs on peak power, average power and fatigue index.

CONCLUSION

Caffeine had no effect on anaerobic performance and variations in several genes did not modify any effects of caffeine.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov (NCT02109783).

CYP1A2 Genotype Modifies the Effects of Caffeine Compared With Placebo on Muscle Strength in Competitive Male Athletes

Caffeine is commonly used to improve athletic performance across a variety of sports. Previously, the CYP1A2 gene has been shown to modify the effects of caffeine on endurance performance. The effect of caffeine on strength and power activities is unclear and may differ depending on an individual's CYP1A2 genotype. A randomized controlled trial was used to determine whether caffeine impacts strength and power, determined by the handgrip and vertical jump tests, respectively, and whether CYP1A2 genotype modifies any effects. Competitive male athletes (age = 25 ± 4 years) completed vertical jump (n = 97), and handgrip tests (n = 102) under three conditions: 0 (placebo), 2, or 4 mg of caffeine per kilogram of body mass (in milligrams per kilogram). CYP1A2 (rs762551) genotype was determined from saliva samples. No differences between caffeine doses and placebo were observed for strength or power; however, significant Caffeine × Gene interactions were observed for all exercise tests. Individuals with the CC genotype experienced a 12.8% decrease in handgrip strength with 4 mg/kg of caffeine compared with placebo (53 ± 11 kg vs. 61 ± 17 kg, p = .02). No differences were observed in those with the AC or AA genotypes. Despite observing a significant Caffeine × Gene interaction for vertical jump performance, no differences were observed between caffeine doses and placebo for all genotypes. In summary, caffeine (4 mg/kg) worsened handgrip strength performance in those with the CC genotype, but no differences were observed in those with the AC or AA genotypes. Athletes may want to consider their CYP1A2 genotype prior to using caffeine to improve muscle strength.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

Contraception Practices Among Women on Opioid Agonist Therapy

OBJECTIVE

Despite increased public awareness and use of opioid agonist therapy (OAT), there is little published data on contraception among women on methadone or buprenorphine/naloxone. This study aimed to characterize patterns of contraception use among this population.

METHODS

We conducted a cross-sectional survey between May 2014 and October 2015 at 6 medical clinics, pharmacies, and community organizations in British Columbia. Trained surveyors used the Canadian Sexual Health Survey (CSHS) to collect information on contraceptive practices and barriers to health care access. Descriptive analysis was performed on the subset of women on OAT who were at risk for unintended pregnancy.

RESULTS

Of the 133 survey respondents, 80 (60.2%) were at risk for unintended pregnancy. Among the 46 respondents with a recent pregnancy, 44 (95.7%) reported it as unintended. Of those at risk for unintended pregnancy, the most common contraceptive methods used were "no method," male condom, and depo-medroxyprogesterone at 28.8%, 16.3%, and 12.5%, respectively. Only 5% reported dual protection with a barrier and hormonal or intrauterine method. Barriers to contraception access included difficulty booking appointments with providers and cost, although 97% of all respondents reported feeling comfortable speaking with a physician about contraception.

CONCLUSION

We found that most respondents using OAT reported prior pregnancies that were unintended, and used less effective contraceptive methods. Health care professionals who provide addiction care are uniquely positioned to address their patients' concerns about contraception. Incorporating family planning discussions into OAT services may improve understanding and use of effective contraceptive methods. Addressing unmet contraceptive needs may enable women on OAT to achieve their reproductive goals.

Contraception Use and Attitudes Among Women Seeking Pregnancy Termination: Descriptive Cross-Sectional Survey

OBJECTIVE

Unintended pregnancy has been linked to poor health and social outcomes for both mother and child. Efforts to reduce unintended pregnancies have been challenged by many financial, social, religious, and cultural factors. This study aimed to investigate how contraception use and misuse in a cohort of females seeking termination of pregnancy contribute to unintended pregnancies.

METHODS

We conducted a cross-sectional study with women presenting to a women's health clinic for pregnancy termination from April to December 2017. Consenting participants completed a self-administered, confidential questionnaire that included questions on demographic, ethnic, and social characteristics, as well as behaviours and attitudes related to contraception. Data analysis used descriptive statistics.

RESULTS

Data were collected from 334 women; about half (45%) had used contraception at the time of conception, representing a variety of different methods. Contraceptive use was associated with higher education, stable relationship status, and ethnic majority status but not with previous pregnancies or immigration status. Among contraceptive users, imperfect and inconsistent use of contraception (50% and 31%, respectively), and method failure (48%), including condom breakage, were cited as reasons for the current pregnancy. Non-users reported perceived low risk of pregnancy (55%), concerns about contraception (47%), and problems accessing contraception (27%). While the majority of participants were aware of emergency contraception, only 52% reported ever using it. Most participants (89%) planned to use contraception in the future.

CONCLUSION

Our study highlights contraceptive behaviours and patterns of individuals seeking abortion. Patient-centered contraceptive counselling in order to facilitate contraceptive choice and access can include information about the most effective contraceptives and the need for back-up contraception methods.

Salpingectomie bilatérale aux fins de contraception permanente : série de cas et facteurs limitant le changement de pratique

OBJECTIVE

The Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Society of Gynaecologic Oncology of Canada (GOC) recommend complete removal of the fallopian tubes as a permanent contraceptive method because of its association with a reduced risk of ovarian cancer. Currently, many women are not offered bilateral salpingectomy as an alternative to tubal ligation for permanent contraception.

METHOD

As part of a quality improvement initiative, we reviewed all cases of sterilization performed at our university centre between 1 January and 31 December 2018. A literature review of the clinical and ethical considerations that prevent clinicians from offering bilateral salpingectomy as permanent contraception is also presented.

RESULTS

The records of 111 women who underwent tubal sterilization were reviewed. Of these, 31.5% underwent bilateral salpingectomy; 46.8% underwent tubal fulguration; 12.6% underwent clip ligation; and 9.1% underwent tubal implant ligation (Essure). According to the information on file, only 36.3% of women were offered bilateral salpingectomy, and of these, 83.8% chose this method.

CONCLUSION

Bilateral salpingectomy should be offered to all women seeking permanent contraception. The benefits and very low risks associated with this procedure should make it a first choice option.

Can youth get the contraception they want? Results of a pilot study in the province of Quebec

Objectives

Canadian contraceptive providers report many barriers to access to contraception, and perceive youth as particularly vulnerable to these barriers. This study explores Quebec youth's experience of obtaining contraception.

Methods

A convenience sample of Quebec youth (aged 14 to 21 years) participated in an online anonymous survey of their experiences obtaining contraception. Data were collected between June 1, 2016 and December 31, 2016.

Results

One hundred and five youth were eligible to participate. Of these, 95 had used at least one form of contraception. Twelve (13%) reported not being able to obtain their preferred method of contraception, with cost being the most common barrier (N=10). Eleven participants (12%) stopped using their preferred contraceptive method: cost was a factor in four cases, and difficulty with access to the clinic/prescription in seven. Youth who required confidential access experienced more difficulty obtaining contraception (P<0.01).

Conclusion

Despite benefitting from universal pharmacare and a network of youth sexual and reproductive health clinics, Quebec youth still experience barriers to obtaining and continuing their preferred contraceptive. Youth who desire confidential care are more likely to experience difficulty obtaining contraception.

Contraception for Adolescents

Although pregnancy and abortion rates have declined in adolescents, unintended pregnancies remain unacceptably high in this age group. The use of highly effective methods of contraception is one of the pillars of unintended pregnancy prevention and requires a shared decision making process within a rights based framework. Adolescents are eligible to use any method of contraception and long-acting reversible contraceptives, which are “forgettable” and highly effective, may be particularly suited for many adolescents. Contraceptive methods may have additional non-contraceptive benefits that address other needs or concerns of the adolescent. Dual method use should be encouraged among adolescents for the prevention of both unintended pregnancies and sexually transmitted infections. Health care providers have an important role to play in ensuring that adolescents have access to high quality and non-judgmental reproductive health care services and contraceptive methods in adolescent-friendly settings that recognize the unique biopsychosocial needs of the adolescent.

Factors associated with condom use during sexual intercourse with a new partner among Scandinavian women

In this population-based, cross-sectional questionnaire study among 18-45-year-old women from Denmark, Sweden, and Norway conducted during 2011-2012 we examine factors associated with using condoms with a new partner. Condom use with a new partner was assessed among 6202 women having had a new partner in the recent six months. Odds ratios (OR) and 95% confidence intervals (CI) were estimated for the associations between sociodemographic and lifestyle factors, and sexual behavior, respectively, and condom use with a new partner using a logistic regression model. Always/almost always ("always") condom use served as the reference category in all analyses and was compared with sometimes/rarely ("sometimes") and never use in two separate analyses. Overall, respectively 36.3%, 26%, and 37.7% reported always, sometimes, or never condom use with a new partner. Married/cohabiting were more likely than single women to never (OR = 2.50, 95% CI: 2.07-3.02) or sometimes (OR = 1.30; 95% CI 1.04-1.62) use condoms with recent new partners. Increasing number of new partners in the recent six months was also associated with condom use with a new partner (never: OR for ≥3 partners = 0.56; 95% CI: 0.47-0.67; sometimes: OR for ≥3 partners = 1.64; 95% CI: 1.38-1.94). Furthermore, women reporting early age at first sexual intercourse, no contraception at first intercourse, or not being vaccinated against human papillomavirus used condoms with new partners less frequently. These findings may suggest that continued awareness about the risk of contracting sexually transmitted infections when practicing condomless sex is important.

Household income and contraceptive methods among female youth: a cross-sectional study using the Canadian Community Health Survey (2009-2010 and 2013-2014)

BACKGROUND

Low socioeconomic status is one of many barriers that may limit access to family planning services. We aimed to examine the relation between household income and contraceptive methods among female youth in Canada.

METHODS

Our study population included sexually active females aged 15-24 who were trying to avoid pregnancy. We used cross-sectional data from the 2009-2010 and 2013-2014 cycles of the Canadian Community Health Survey to compare household income and other sociodemographic covariates for those using oral contraceptives, injectable contraceptives, condoms or a dual method (condoms plus oral or injectable contraceptives).

RESULTS

Of female youth at risk for unintended pregnancy, 59.2% reported using oral contraceptives, 29.0% used dual methods, 16.8% used condoms only, 2.5% used injectable contraceptives and 13.6% did not use contraception. In multiple regression models, lower annual household income (< $80 000) was associated with decreased use of oral contraceptives (relative risk [RR] 0.85, 95% confidence interval [CI] 0.80-0.91) and dual methods (RR 0.81, 95% CI 0.71-0.91), increased use of condoms (RR 1.36, 95% CI 1.11-1.67) and injectable contraceptives (RR 1.69, 95% CI 0.98-2.92), and a greater risk of contraceptive nonuse (RR 1.19, 95% CI 0.94-1.50).

INTERPRETATION

We found that lower household income was associated with decreased use of oral contraceptives and increased reliance on injectable contraceptives and condoms only. Young, low-income females may face barriers to accessing the full range of contraceptive methods available in Canada. Easier access to affordable contraception may decrease the number of female youth at risk for unintended pregnancy due to financial barriers.

"One Blood Clot Is One Too Many": Affected Vocal Users' Negative Perspectives on Controversial Oral Contraceptives

In this article, I analyze women's negative experiences with the fourth generation of contraceptive pills: controversial drugs Yaz and Yasmin. Drawing on in-depth interviews with 24 contraceptive users residing in Canada, I highlight how women who have experienced deleterious side effects understand the risks of hormonal contraception and advocate for changes in health risk communication and prescription drug regulation. Findings show that interviewees did not feel they received adequate risk information prior to starting their new drug regimen nor did they think that pregnancy risks should be used as a comparison point for placing hormonal contraceptive risk into perspective. Patient views were generally underlined by a critique of professional risk/benefit assessment techniques and procedures. To illustrate how the modern complexities of health risk assessment extend to the realm of hormonal contraceptives, I here provide a detailed examination of women's negative experiences while on the pill.

No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception

OBJECTIVE

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

OUTCOMES

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

EVIDENCE

Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed.

VALUES

The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Universal access to no-cost contraception for youth in Canada

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

Trends and determinants of postabortion contraception use in a Canadian retrospective cohort

OBJECTIVES

We aim to describe demographic trends associated with postabortion contraceptive choice, characteristics of intrauterine device (IUD) users and relation to subsequent abortion.

STUDY DESIGN

Our retrospective chart review study included all patients obtaining an abortion from 2003 to 2010 at the primary service provider in the Interior Health Region of British Columbia, tracking each patient for 5 years to detect subsequent abortion. We used descriptive statistics to analyze demographic trends and logistic regression to examine determinants of choosing an IUD and likelihood of subsequent abortion per contraceptive method.

RESULTS

Our study cohort included 5206 patients, 1247 (24.0%) of whom chose an IUD. Patients increased IUD use from 10.14% to 45.74% of the cohort over the study period. Mean age of those choosing an IUD significantly decreased over the study period [30.9±7.3 years in 2003 to 26.2±6.5 years in 2010 (p<.001)]. In multivariable analysis, factors associated with choosing an IUD postabortion were prior delivery [aOR=2.77 (95% CI 2.40-3.20)] and being older than 20 years [20-29 years: AOR=1.87 (1.51-2.32); or 30+ years: AOR=1.96 (1.54-2.50)]. Patients choosing an IUD were less likely to have a subsequent abortion compared to those selecting oral contraceptives [aOR=1.96 (95% CI 1.54-2.52)] or depomedroxyprogesterone acetate [aOR=1.84 (95% CI 1.36-2.49)].

CONCLUSIONS

We found an increasing trend of choosing an IUD after an abortion in our population, especially among youth. Patients who chose an IUD postabortion were less likely to have a subsequent abortion over the next 5 years.

IMPLICATIONS

An important strategy for reducing subsequent abortion is to ensure that those seeking abortion have accurate information on the comparative effectiveness of postabortion contraception methods. Educational efforts, alongside removal of cost and other barriers, will contribute to the prevention of subsequent abortion and improve equitable access to IUDs among the population.

Comparing options for women seeking permanent contraception in high-resource countries: a protocol for a systematic review

BACKGROUND

For women seeking permanent contraception, there are a variety of options available including surgical techniques such as tubal ligation or bilateral salpingectomy, in-clinic procedures such as hysteroscopic techniques using micro-inserts, or the levonorgestrel-releasing intrauterine contraceptive. Despite the various methods available for women who are seeking permanent contraception, there is not a review or decision-making tool that systematically brings together outcomes related to effectiveness, tolerability, adverse effects, non-contraceptive benefits, recovery, or accessibility: all of which are important for shared decision-making between patients and health care providers.

METHODS

We registered our protocol [on Prospero: CRD42016038254] following PRISMA guidelines. A search strategy was created in collaboration with a librarian, and three databases (EMBASE, PubMed, Web of Science) will be searched along with secondary screening of relevant articles. A third reviewer will adjudicate any discrepancies. Data will be extracted independently according to population, intervention, comparison, outcomes (PICOS); length of follow-up; and funding. Articles will be assessed for bias using the Newcastle-Ottawa Scale and the Cochrane Collaboration tool. If appropriate, a network meta-analysis will be conducted to rank and analyze each method according to each objective. If heterogeneity between studies is too high or it is not possible to conduct a network meta-analysis, a narrative analysis of the study results will be provided.

DISCUSSION

Clinicians and their patients seeking permanent contraception have several options, yet we were unable to find a systematic review or decision support tool helping to facilitate shared decision-making. This systematic review can inform patients, providers, and health policy decision-makers about which options of permanent contraception will meet different reproductive goals according to various outcomes, which can lead to better health, social, economic, and mental well-being for reproductive age women. This can also aid our understanding of resulting costs to the health care system.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016038254.

Improving Physician Knowledge: A Necessary but Not Sufficient Requirement of Improving Intrauterine Contraception Access in Canada

OBJECTIVE

This study sought to identify knowledge gaps and attitudinal barriers to prescribing intrauterine contraception (IUC).

METHODS

A national, Web-based survey of Canadian gynaecology (GYN) and family medicine (FM) physicians was conducted. The survey was distributed through several channels, including physicians' databases, invitations through a commercial email aggregating service, and contacting residency programs. For knowledge-based questions, correct answers were those consistent with Canadian practice guidelines. Ethics approval was granted through Queen's Health Sciences Research Ethics Board. Project funding was through a research grant from Bayer, Inc. (Canadian Task Force Classification III).

RESULTS

A total of 600 responses were received. GYN physicians' knowledge about IUC (number correct / 40) was better than that of the FM and FM with additional women's health training (FMWH) groups (median [interquartile range] 39 [37-40], 36 [32-38], and 37 [35-39]; P < 0.0001). Factors associated with lower scores included rural practice location, lack of affiliation with medical trainees, extremes of practice duration, and self-perceived lack of knowledge about IUC. Most respondents prescribed IUC (93.7%). Among prescribers, 97.0% inserted IUC. The most common reasons for not prescribing or inserting IUC included lack of training, lack of comfort, and referral to other physicians to provide this service. Respondents indicated that they would be more likely to prescribe and/or insert IUC if cost barriers were removed, patient interest was increased, or if there was improved access to patient-centred educational materials and hands-on training modules.

CONCLUSION

This study suggests that although many GYN and FM physicians are offering IUC, misconceptions regarding contraindications still exist, and several barriers are related to deficiencies in providers' knowledge. Therefore, educational efforts should be prioritized to increase the usage of IUC.

Regulation and Resistance: Negotiation of Premarital Sexuality in the Context of Migrant and Refugee Women

Constructions of normative sexuality shape the sexual scripts that women are permitted to adopt and the manner in which such sexuality can be expressed. We explored experiences and constructions of premarital sexuality among migrant and refugee women recently resettled in Sydney, Australia, and Vancouver, Canada. A total of 78 semistructured individual interviews and 15 focus groups composed of 82 participants were undertaken with women who had migrated from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, and South America. We analyzed the data using thematic decomposition. Across all cultural groups, women's premarital sexuality was regulated through cultural and religious discourse and material practice. Such regulation occurred across three main facets of women's lives, shaping the themes presented in this article: (1) regulating premarital sex-the virginity imperative; (2) regulation of relationships with men; and (3) regulation of the sexual body. These themes capture women's reproduction of dominant discourses of premarital sexuality, as well as women's resistance and negotiation of such discourses, both prior to and following migration. Identifying migrant and refugee women's experiences and constructions of premarital sexuality is essential for culturally safe sexual health practice, health promotion, and health education.

[Natural Family Planning methods and Barrier: CNGOF Contraception Guidelines]

OBJECTIVE

To develop clinical practice recommendations for the use of natural contraception and female and male barrier methods.

MATERIALS AND METHODS

A systematic review of English and French literatures related to the safety and effectiveness of natural contraceptive methods based on PubMed, Cochrane Library, practice recommendations issued by international scientific societies and guidelines provided by the World Health Organization (WHO) as well as updates from the Center for Disease Control and Prevention (CDC).

RESULTS

Natural contraceptives methods include fertility awareness-based methods, lactational amenorrhea method (LAM) and withdrawal method. The prevalence is low (4.6% of users) and remains stable over the years. Identification of the fertile period can be symptom-based cervical mucus (Billings), two-day method, basal body temperature, symptom-thermal method or based on calendar calculation (Ogino-Knauss, standard day method). Pregnancy rate after one-year utilization varies from 0.4% to 5% in perfect use but 8% in common practice. Effectiveness increases with absence of vaginal sex and decreases when combined to barriers method inadequately implemented. Data is scarce on reliability and effectiveness of ovulation predictor kits readily available on internet. Lactational amenorrhea method (LAM) can be very effective (98%) provided three conditions are fulfilled: within 6 months after birth, amenorrhea is effective, and breastfeeding is exclusive or quasi exclusive (day/night). Withdrawal method is constraining and of limited effectiveness. Male and female condom, diaphragm, cervical cap and spermicides are mechanical and chemical barrier methods, preventing spermatozoids from passing through the cervix into the uterus and therefore preventing fecundation. Female and male condoms offer a double protection to avoid pregnancy and prevent STD's. They are effective provided strict conditions of use are fulfilled. Male condom is favored by teenagers (45.6% among 15 to 19 years old), sometimes in combination with contraceptive pill (16% of cases). Women on the pill decreases according to their age. Pregnancy rates within the first year of consistent and correct use of these methods vary between 5 to 26% and reach 20 to 32% in practical use. Diaphragm and cervical cap need to be used in combination with spermicides. Spermicides have limited effectiveness when used alone.

CONCLUSION

In common practice, natural and barrier contraceptive methods are more constraining and less effective than modern contraceptive method. They can be an alternative at given time and/or in situations where the women or the couple accept the possibility of an unexpected pregnancy which might be terminated or not. Women/couples need to be properly informed on how to use such methods, on their disadvantages and possible failures in common practice. Reminders are to be given on emergency contraceptive methods (IUD, hormonal) after unprotected sex.

Current contraceptive trends among married Egyptian women: a cross-sectional survey

OBJECTIVE

The aim of our study was to assess the knowledge and attitudes of married Egyptian women towards the different methods of contraception, examining the role of employment and education in modulating contraceptive behaviour.

METHODS

A cross-sectional survey was conducted among 2360 Egyptian women between 15 and 45 years of age who were attending outpatient clinics at a university hospital in Cairo between August 2017 and January 2018. The survey collected sociodemographic data as well as information on education, employment, knowledge about contraceptive methods, current and previous use of contraception, source of family planning advice and side effects from previous contraceptive use.

RESULTS

The response rate was 90.2%. Current use of a contraceptive method was 38.3%. The intrauterine device (IUD) was the leading contraceptive method (50.7%), followed by oral contraceptives (OCs) (23.6%). Contraceptive prevalence was significantly higher among working women (p < .001), whose primary choice was OCs, while IUD use was significantly higher among non-working women (p < .001). Contraceptive prevalence was highest among women with secondary school education or higher (41.6%).

CONCLUSION

Both employment status and educational level of the surveyed women played a significant role in their contraceptive behaviour.

Non-use of Contraception by Canadian Youth Aged 15 to 24: Findings From the 2009-2010 Canadian Community Health Survey

OBJECTIVES

Non-use of contraception is an important contributor to unintended pregnancy. This study assessed non-use of contraception and its determinants among Canadian youth aged 15 to 24.

METHODS

Data from the 2009-2010 Canadian Community Health Survey respondents aged 15 to 24 were used to identify non-users of contraception among heterosexual youth who had had intercourse within the previous 12 months, were not pregnant or sterilized, and felt it was important to avoid pregnancy. Sociodemographic, behavioural, and geographic factors were compared for non-users and users of contraception.

RESULTS

Among youth at risk for unintended pregnancy, 15.5% were non-users of contraception. There were no differences between sexes. Across regions of Canada, Quebéc had the highest proportion of at-risk youth, but at-risk Quebéc youth were the least likely to be non-users (7.4%; CI 5.7%-9.0%) compared with at-risk youth in the Territories (28.3%; CI 21.6%-35.0%). In the multivariable analysis, aside from residence outside of Quebéc, younger age, lower income, Aboriginal identification (adjusted OR [aOR] 1.67; CI 1.18-2.37), and smoking (aOR 1.55; CI 1.24-1.92) were associated with non-use. Canadian-born youth (aOR 0.61; CI 0.39-0.96) and those enrolled in school (aOR 0.63; CI 0.50-0.81) were less likely to be non-users.

CONCLUSION

The 15.5% of Canadian youth at risk for unintended pregnancy who were non-users of contraception represent an estimated 300 000 Canadian youth. Policies and programs to promote and support access to sexual health services and effective contraception with specific attention to supporting the needs of younger teens, Aboriginal youth, newcomers, low-income youth, and youth who are not in school are needed.

Video Media in Clinic Waiting Areas Increases Interest in Most Effective Contraceptive Methods

OBJECTIVE

To examine the utility of a patient-level information video as part of the contraception consultation visit. Specifically, to assess the impact of the video on women's contraception choice, and, further, to assess patient and provider acceptability of incorporating the video into the patient visit.

METHODS

A pre-post study design was used to assess the impact on patients' contraceptive choices and knowledge. Participants (n = 49) answered questions regarding contraceptive preferences and knowledge of long-acting reversible contraception (LARC), then watched a 12-minute patient-level counselling video that presented evidence-based information about contraception in descending order of effectiveness. Clinicians (n = 39) also viewed the video and completed a survey. A retrospective chart review of 100 contraception visits was completed.

RESULTS

Patient preference for IUDs increased significantly, whereas condoms decreased pre-to-post video (hormonal: 8.2% to 20.4%; copper: 0% to 16%; condoms: 32.7% to 18%, P < 0.05). Although 74.4% of clinicians believed that the hormonal IUD was the "ideal" form of contraception when no contraindications were present, 95% stated that the oral contraceptive pill was most often prescribed, and a chart review revealed that the oral contraceptive pill was discussed at 88% of contraceptive counselling visits. Both patients and clinicians found the video useful and acceptable.

CONCLUSION

A patient-level contraceptive information video improved interest in LARC. Both patients and clinicians viewed the video as an acceptable addition to the contraceptive counselling visit.

Contraceptive Choice and Use of Dual Protection Among Women Living with HIV in Canada: Priorities for Integrated Care

CONTEXT

Preventing unintended pregnancy and HIV transmission is important for women with HIV, but little is known about their contraceptive use, particularly under current antiretroviral therapy (ART) recommendations for treatment and prevention.

METHODS

The prevalence of contraceptive use and of dual protection was examined among 453 sexually active women with HIV aged 16-49 and enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study in 2013-2015; multivariable logistic regression was used to identify correlates of use. Two definitions of dual protection were assessed: the World Health Organization (WHO) definition (consistent condom use alongside another effective method) and an expanded definition (consistent condom use or a suppressed HIV viral load alongside an effective method).

RESULTS

Overall, 73% of women used effective contraceptives, primarily male condoms (45%) or tubal ligation (19%). Eighteen percent practiced WHO-defined dual protection, and 40% practiced dual protection according to the expanded definition. Characteristics positively associated with contraceptive use were younger age, having been pregnant, being heterosexual, being unaware of ART's HIV prevention benefits and having had partners of unknown HIV status (odds ratios, 1.1-6.7). Younger age and perceived inability to become pregnant were positively associated with both definitions of dual protection (1.04-3.3); additionally, WHO-defined dual protection was associated with perceiving HIV care to be women-centered and having had partners of unknown HIV status (2.0-4.1), and dual protection under the expanded definition was related to having been pregnant (2.7).

CONCLUSIONS

Future research should explore how sustained ART and broader contraceptive options can support women's sexual and reproductive health care needs.

Contraceptive preferences and unmet need for contraception in midlife women: where are the data?

This commentary discusses the limited availability of information on contraceptive preferences and unmet need for contraception among midlife women in both high and low income countries. Given that risk of pregnancy continues until women reach menopause and given the increased risk of pregnancy complications, elective abortion, and maternal mortality in women aged 45 to 54 years old, increased focus on gathering basic data on midlife women's preferences and unmet need is warranted.

Tubal Sterilization in Women Under 30: Case Series and Ethical Implications

OBJECTIVE

According to the SOGC Contraception Consensus, it is recommended that permanent contraception be offered to women regardless of age or parity. Many women who desire sterilization at a young age experience barriers from physicians who decline to facilitate the request.

METHODS

As part of a quality assurance project, we performed a review of cases where tubal sterilization was performed in women under 30 over a 42-month period (September 2013-March 2017). We also performed a literature review on the ethical and clinical considerations with respect to young women requesting permanent contraception.

RESULTS

We identified 29 women under 30 who had consented for tubal sterilization; 27.5% of women were nulliparous, and 27.5% had a medical condition for which unintended pregnancy is associated with an increased risk of adverse event. As documented in the patients' records, many women expressed prior difficulty in obtaining the procedure. Despite being informed of the risk of regret, most women proceed with the surgical procedure. Three additional women had consented and subsequently cancelled their surgical procedure.

CONCLUSION

Women who are well-informed and desire permanent contraception should be offered the procedure, regardless of age or parity. Declining such requests is a form of conscientious refusal and is not a clinical decision.

A comparison of intimate partner and other sexual assault survivors' use of different types of specialized hospital-based violence services

BACKGROUND

Little is known about the health service utilization of women sexually assaulted by their intimate partners, as compared with those sexually assaulted by other perpetrators. To address this gap, we describe the use of acute care services post-victimization, as well as a broad range of survivor and assault characteristics, across women assaulted by current or former intimate partners, other known assailants, and strangers.

METHODS

Information was gathered from individuals presenting to 30 hospital-based sexual assault and domestic violence treatment centres using a standardized data collection form. We examined the data from 619 women 16 years of age or older who were sexually assaulted by one assailant.

RESULTS

Women sexually assaulted by a current or former intimate partner were less likely than those assaulted by another known assailant or a stranger to have been administered emergency contraception (p < 0.001) or prophylaxis for sexually transmitted infections (p < 0.001), and counselled for potential use of HIV post-exposure prophylaxis (p < 0.001). However, these women were more likely than those in the other two groups to have had their injuries documented with photographs (p < 0.001), have undergone a risk assessment (p = 0.008), and/or have engaged in safety planning (p < 0.001).

CONCLUSIONS

Women sexually assaulted by current or former intimate partners utilized services offered by sexual assault and domestic violence treatment centres differently than those assaulted by other known assailants and strangers. This may reflect their different health, forensic, and social needs, as well as the importance of offering care tailored to their particular circumstances.

Influence of sex, menstrual cycle, and oral contraceptives on cerebrovascular resistance and cardiorespiratory function during Valsalva or standing

Women experience orthostatic intolerance more than men, and they experience faintness more in the early follicular [i.e., low-hormone (LH)] than luteal [i.e., high-hormone (HH)] phase of the menstrual cycle. Men (n = 13, 25.8 ± 1.8 yr old) and women in the LH (days 2-5; placebo) and HH (days 18-24; high dose) phases of the menstrual cycle with (OC; n = 14, 22.0 ± 0.8 yr old) or without (NOC; n = 12, 21.8 ± 0.5 yr old) oral contraceptive (OC) use underwent the Valsalva maneuver and a supine-sit-stand protocol. Blood pressure, normalized stroke volume [stroke volume index (SVi)], cardiac output index, heart rate, end-tidal CO₂, and middle cerebral artery (MCA) blood flow velocity were measured. When subjected to the Valsalva maneuver, all women had a greater increase in diastolic and mean MCA blood flow velocity than men (P ≤ 0.065), with no significant effect of menstrual cycle phase or OC use. When subjected to the supine-sit-stand protocol, men had lower MCA blood flow velocity (P < 0.038) than all women, and SVi was higher in men than in the NOC group in all postures (P < 0.011) and in the OC group in the LH phase of the menstrual cycle during standing (P = 0.010). Only men experienced higher resistance index (P < 0.001) and pulsatility index (P < 0.001) with standing. The OC group had lower end-tidal CO₂ (P = 0.002) than the NOC group (P = 0.030) and men (P ≤ 0.067). SVi (P = 0.004) and cardiac output index (P = 0.008) were higher in the OC than NOC group. A tendency toward a lower mean MCA blood flow velocity (P = 0.058) and higher SVi (P = 0.059) and pulsatility index (P = 0.058) was noted in the HH than LH phase. Mean arterial pressure was higher in the OC than NOC group in the LH phase (P = 0.049) and lower in the HH than LH phase (P = 0.014). Our results indicate that cycling estrogens/progestins can influence ventilatory, cardiovascular, and/or cerebrovascular physiology.NEW & NOTEWORTHY We have found sex differences in the cerebrovascular response to the Valsalva maneuver and standing. Men have greater cerebral vasoconstriction (or women have greater cerebral vasodilation) during late phase II of the Valsalva maneuver, and the cerebrovascular resistance index increases in men, but not in women, during standing. Furthermore, our findings indicate that both the menstrual cycle phase and oral contraceptive use can influence cardiovascular function both at rest and during active standing.

Levonorgestrel-releasing intrauterine systems for long-acting contraception: current perspectives, safety, and patient counseling

Unintended pregnancy is a significant global problem. In 2008, there were over 100 million unplanned pregnancies worldwide, representing approximately 41% of global conceptions. Family planning strategies in many countries are shifting from increasing the uptake of contraception among nonusers to increasing the uptake of the most effective methods among users of less effective methods. One of the most effective and acceptable methods of contraception is the levonorgestrel-releasing intrauterine system (LNG IUS); however, its uptake varies widely by country. This article reviews the currently available LNG IUSs, the rationale for increasing uptake of these methods, and evidence regarding safety, and discusses counseling strategies to best inform women about this option for contraception.

Cancer incidence attributable to the use of oral contraceptives and hormone therapy in Alberta in 2012

BACKGROUND

Hormonal contraceptives and hormone replacement therapies are classified as carcinogenic to humans (group 1) by the International Agency for Research on Cancer. We sought to estimate the proportion and total number of cancers attributable to the use of oral contraceptives and hormone therapy in Alberta in 2012.

METHODS

Population attributable risks were used to estimate the proportion of attributable cases for each associated cancer site. Relative risk estimates were obtained from the most relevant and recent epidemiologic literature. Prevalences of the use of oral contraceptives and hormone therapy in Alberta were collected from Alberta's Tomorrow Project. Specific cancer incidence data were obtained from the Alberta Cancer Registry for the year 2012.

RESULTS

Overall, 6.3% of breast cancers (n = 135) diagnosed in Alberta in 2012 were estimated to be attributable to the use of oral contraceptives, and the exposure potentially prevented about 57.3% of endometrial cancers (n = 276) and 29.1% of ovarian cancers (n = 52). About 15.5% of breast cancers (n = 258) and 8.9% of ovarian cancers (n = 13) were estimated to be attributable to the use of hormone therapy, whereas 11.3% of endometrial cancers (n = 48) were possibly prevented by the exposure.

INTERPRETATION

Based on our estimates, oral contraceptive use resulted in a net protective effect among the cancer sites studied, thus reducing the cancer burden in Alberta in 2012. The use of hormone therapy was estimated to increase the cancer burden in the province, therefore the risk and benefit of hormone therapy should be carefully considered before use.

Regulatory approval time for hormonal contraception in Canada, the United States and the United Kingdom, 2000-2015: a retrospective data analysis

BACKGROUND

Access to a wide range of contraceptive methods improves prevention of unintended pregnancy by ensuring the best method fit for each individual. We compared approval times of new hormonal contraceptives by Health Canada, the US Food and Drug Administration (FDA), and the UK Medicines and Healthcare Products Regulatory Agency (MHRA).

METHODS

We obtained dates of applications to Health Canada, the FDA and the MHRA for contraceptive methods approved from January 2000 to January 2015. We used public data sources and direct correspondence, and excluded generic versions of previously approved drugs. The primary outcome of interest was median time to approval for novel hormonal contraceptives. Secondary outcomes included the median time to approval for all hormonal contraceptives and the number of approved hormonal contraceptives comparing countries studied, as well as the median time for approval of novel compared with nonnovel hormonal contraceptives within each country.

RESULTS

During this period 16 contraceptives were approved in Canada, 26 in the US and 14 in the UK. Applications for novel contraceptives were initiated later in Canada, and time to approval was longer in Canada than in the US (p = 0.03). The median time to approval for all contraceptives in Canada was 529.5 (interquartile range [IQR] 420.8 to 784.0) days, compared with 396.0 (IQR 308.0 to 594.5) days in the US and 341.0 (IQR 244.8 to 512.2) days in the UK. No subdermal implant contraceptives are approved in Canada.

INTERPRETATION

Canadian women wait longer for novel contraceptive methods and have fewer options. Canada could improve population health by addressing the regulatory barriers associated with the unmet need for contraception. Facilitation for approval of a contraceptive implant, and improvement to prolonged novel drug approval times, could support Canadians to plan and space their pregnancies.

Can Facebook Be Used for Research? Experiences Using Facebook to Recruit Pregnant Women for a Randomized Controlled Trial

Background

Recruitment is often a difficult and costly part of any human research study. Social media and other emerging means of mass communication hold promise as means to complement traditional strategies used for recruiting participants because they can reach a large number of people in a short amount of time. With the ability to target a specified audience, paid Facebook advertisements have potential to reach future research participants of a specific demographic. This paper describes the experiences of a randomized controlled trial in Edmonton, Alberta, attempting to recruit healthy pregnant women between 8 and 20 weeks’ gestation for participation in a prenatal study. Various traditional recruitment approaches, in addition to paid Facebook advertisements were trialed.

Objective

To evaluate the effectiveness of paid advertisements on Facebook as a platform for recruiting pregnant women to a randomized controlled trial in comparison with traditional recruitment approaches.

Methods

Recruitment using traditional approaches occurred for 7 months, whereas Facebook advertisements ran for a total of 26 days. Interested women were prompted to contact the study staff for a screening call to determine study eligibility. Costs associated with each recruitment approach were recorded and used to calculate the cost to recruit eligible participants. Performance of Facebook advertisements was monitored using Facebook Ads Manager.

Results

Of the 115 women included, 39.1% (n=45) of the women who contacted study staff heard about the study through Facebook, whereas 60.9% (n=70) of them heard about it through traditional recruitment approaches. During the 215 days (~7 months) that the traditional approaches were used, the average rate of interest was 0.3 (0.2) women/day, whereas the 26 days of Facebook advertisements resulted in an average rate of interest of 2.8 (1.7) women/day. Facebook advertisements cost Can $506.91 with a cost per eligible participant of Cad $20.28. In comparison, the traditional approaches cost Cad $1087, with approximately Cad $24.15 per eligible participant. Demographic characteristics of women were similar between the 2 recruitment methods except that women recruited using Facebook were significantly earlier in their pregnancy than those recruited using traditional approaches (P<.03).

Conclusions

Paid Facebook advertisements hold promise as a platform for reaching pregnant women. The relative ease of placing an advertisement, the comparable cost per participant recruited, and the dramatically improved recruitment rates in comparison with traditional approaches highlight the importance of combining novel and traditional recruitment approaches to recruit women for pregnancy-related studies.

Trial Registration

ClinicalTrials.gov NCT02711644; https://clinicaltrials.gov/ct2/show/NCT02711644 (Archived by WebCite at http://www.webcitation.org/6kKpagpMk)

Effects of hormonal contraception on systemic metabolism: cross-sectional and longitudinal evidence

Background: Hormonal contraception is commonly used worldwide, but its systemic effects across lipoprotein subclasses, fatty acids, circulating metabolites and cytokines remain poorly understood.

Methods: A comprehensive molecular profile (75 metabolic measures and 37 cytokines) was measured for up to 5841 women (age range 24–49 years) from three population-based cohorts. Women using combined oral contraceptive pills (COCPs) or progestin-only contraceptives (POCs) were compared with those who did not use hormonal contraception. Metabolomics profiles were reassessed for 869 women after 6 years to uncover the metabolic effects of starting, stopping and persistently using hormonal contraception.

Results: The comprehensive molecular profiling allowed multiple new findings on the metabolic associations with the use of COCPs. They were positively associated with lipoprotein subclasses, including all high-density lipoprotein (HDL) subclasses. The associations with fatty acids and amino acids were strong and variable in direction. COCP use was negatively associated with albumin and positively associated with creatinine and inflammatory markers, including glycoprotein acetyls and several growth factors and interleukins. Our findings also confirmed previous results e.g. for increased circulating triglycerides and HDL cholesterol. Starting COCPs caused similar metabolic changes to those observed cross-sectionally: the changes were maintained in consistent users and normalized in those who stopped using. In contrast, POCs were only weakly associated with metabolic and inflammatory markers. Results were consistent across all cohorts and for different COCP preparations and different types of POC delivery.

Conclusions: Use of COCPs causes widespread metabolic and inflammatory effects. However, persistent use does not appear to accumulate the effects over time and the metabolic perturbations are reversed upon discontinuation. POCs have little effect on systemic metabolism and inflammation.

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

OBJECTIVE

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

OUTCOMES

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

EVIDENCE

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

VALUES

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

Exploring the relationship between socioeconomic factors, method of contraception and unintended pregnancy

BACKGROUND

It is estimated that approximately one-third of pregnancies in Canada are unintended, meaning they were either mistimed (the woman wanted to be pregnant at a different point in time) or undesired (the woman did not want to be pregnant). This study aimed to assess the impact of socioeconomic variables and method of contraception on the decision to either terminate or continue and unintended pregnancy.

METHODS

Data were obtained from two contemporaneous studies in Calgary Canada--a cross-sectional study involving women seeking abortion services (n = 577) and a longitudinal cohort study involving women with continuing pregnancies (n = 3552) between 2008 and 2012. Chi square tests and logistic regression were used to examine the association between socioeconomic variables, use of contraception and pregnancy intention.

RESULTS

96.5% of women seeking an abortion and 19.6% of women with ongoing pregnancies reported having an unintended pregnancy. Women with unintended pregnancies were significantly younger (p < 0.001), less educated (p < 0.001), had a lower household income (p < 0.001), were less likely to be in a stable relationship (p < 0.001), and less likely to speak English in the home (p < 0.002). 20.2% reported not using any form of birth control despite their desire to not get pregnant. Among women with unintended pregnancies, the only significant demographic predictor of not using any form of contraception was low educational attainment (OR = 1.7, 95% CI: 1.2-2.4).

CONCLUSIONS

Low educational attainment was associated with not using any form of contraception among women with unintended pregnancies. However, as unintended pregnancy occurs across all socio-demographic groups, care providers are encouraged to have an open discussion regarding fertility goals and contraception with all patients and refer them to appropriate resource materials.