Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8

Permanent contraception is the most used method of contraception among women aged 15-49 years and is one of the most straightforward surgical procedures an obstetrician-gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician-gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician-gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.

Contraception and Abortion Care for People Living With HIV: A Clinical Guide for Reproductive Health Practitioners

People capable of pregnancy are disproportionately affected by HIV. Family planning needs and services are often unmet in this population, and clinical care guidelines regarding contraceptive options and abortion care are not well elucidated. Individuals living with HIV often face unique barriers in accessing contraception and abortion services due to internalized stigma, medically complex care (eg, drug-drug interactions, adverse effects of antiretroviral therapy), and distrust of health care providers. There is also a lack of clarity among reproductive health, primary, and infectious disease care providers on best-practice contraceptive counseling and contraceptive care for individuals living with HIV, given limited opportunities to enhance expertise in reproductive infectious disease. In this review, we summarize existing and updated evidence and clinical considerations regarding contraceptive counseling and abortion care in this population.

Incidence of new outpatient long-acting reversible contraceptive insertions among a commercially insured, US population from 2010 to 2020

Objectives

Characterize new use of long-acting reversible contraceptives (LARCs), highly effective contraceptive methods, in a broad population over time.

Study Design

We constructed a retrospective cohort of commercially insured individuals aged 15 to 54 years from 2010 to 2020 and estimated monthly incidence of new LARC insertions.

Results

The monthly standardized incidence increased from 6.0 insertions per 10,000 individuals in January 2010 to 14.1 in December 2020, with a dip in insertions after March 2020. Hormonal intrauterine devices were consistently the most inserted LARC; implants were increasingly favored over time.

Conclusions

LARCs are increasingly popular forms of contraception among commercially insured individuals.

Implications

Given the increasing popularity, ensuring access to LARCs is critical.

Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007-2016, by term and preterm birth

OBJECTIVES

To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery.

STUDY DESIGN

We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC.

RESULTS

Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%-32%).

CONCLUSIONS

While postpartum LARC use increased among the privately insured 2007-2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike.

IMPLICATIONS

Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

Contraception

Contraception counseling and provision are vital components of comprehensive health care. An unplanned pregnancy can be particularly challenging for patients with chronic illness. Internal medicine physicians are uniquely positioned to assess pregnancy readiness and provide contraception, as they often intersect with pregnancy-capable patients at the moment of a new diagnosis or when providing ongoing care for a chronic medical condition. A shared decision-making counseling approach engages patients, ensures patient-centered care, and supports their choice of a contraceptive method that aligns with their reproductive plans and medical needs.

Utilization Status and Perceived Barriers Towards Long-Acting Reversible Contraceptives Among Female Youth College Students in Northern Ethiopia: A Mixed-Methods Study

Background

In Ethiopia, teenage sexual activity, unintended pregnancy, and unsafe abortions among youth college students have become the most prevalent public health problems. Contraceptive misuse, low use, and a high unmet need for long-acting reversible contraceptives are attributed to the high rate of unintended pregnancy.

Objective

To assess the utilization status of long-acting reversible contraceptives and to explore the perceived barriers among youth female college students in Mekelle City, Northern Ethiopia, in 2019.

Methods

An institutional-based, concurrent, mixed cross-sectional study with quantitative and qualitative components was conducted among four private and two public colleges in Mekelle City from March 1 to April 30, 2019. A total of 580 female youth college students were included in the quantitative study, and six in-depth and four key informant interviews were conducted for the qualitative study. The quantitative data were analyzed using descriptive statistics, frequency, and percentages. The chi-square test was done to assess the crude association between the outcome variable and independent categorical variables. A p-value of <0.05 was considered a statistically significant difference. In addition, ATLAS.ti qualitative software version 7.5 was used to code and analyze the qualitative data.

Results

With a 93.8% response rate, 544 female youth college students participated, and 177 (32.5%) were sexually active. Seventy-five (42.3%) of students had a history of pregnancy, and of these, 85% of the pregnancies were unplanned. The utilization of long-acting reversible contraceptives among sexually active college students was 7.3%. Qualitatively, the following themes emerged as perceived barriers to the utilization of long-acting reversible contraceptives: knowledge barriers, fear of side effects, misperceptions, health providers' approach, discrimination, and poor confidentiality.

Conclusion

This study revealed low utilization of long-acting reversible contraceptives among college students. The findings indicate that college students are at high risk of unintended pregnancy, unsafe abortion, and complications.

Cervically Embedded Fragment of an Intrauterine Device in a Patient with a Bicornuate Uterus: A Case Report and Review of Current Management Strategies

Intrauterine devices (IUDs) have become one of the most frequently used forms of long-acting reversible contraception (LARC) in women of childbearing age. While complications are generally considered to be minimal, they can occur during the insertion, during use, or upon removal. Uterine anomalies, such as a bicornuate uterus, can increase the risk of complications during all stages. Here, we describe a case of a patient with a bicornuate uterus who had a levonorgestrel IUD in place for five years before she experienced a dislodging of the IUD, fragmentation upon attempted removal, and ultimately required a hysteroscopy to remove an embedded fragment from the endocervical canal. Due to the limited reporting on fragmented IUDs, further studies will be required to assess the optimal management. While symptomatic patients should have the fragment removed, asymptomatic patients should have their individual history and desire for future pregnancy weighed against the risk and benefits of treatment.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Continuation Rates of the Etonogestrel Implant and Factors Associated With Early Discontinuation

BACKGROUND

The etonogestrel implant is generally considered an effective, three-year, long-acting reversible contraceptive device. Previous research, such as the landmark CHOICE study, has reported a one-year continuation rate of 72% to 84%, however, in a real-world setting these rates may be significantly lower.

OBJECTIVE

To study etonogestrel implant continuation rates and factors associated with early discontinuation in a specific clinical setting.

STUDY DESIGN

Single-center, retrospective cohort study of patients who received the etonogestrel implant between January 1, 2015, and December 31, 2017, at several practices at an academic community hospital network. Records were reviewed up to three years after implant insertion to determine continuation rates (one to three years), early discontinuation rates (≤12 months), and reasons for early discontinuation. A sample size calculation was performed to guide a subanalysis of side effects.

RESULTS

A total of 774 patients underwent etonogestrel insertion during the study period. The one-year continuation rate was lower than that of the CHOICE study (62% vs. 83%, P <0.001). A subanalysis (n=216) revealed that a majority (82%, n=177) of patients reported side effects. Side effects were more common in patients with early discontinuation compared with patients who continued use longer than one year (93% vs. 71%, P <0.001). The most common side effect, abnormal uterine bleeding, was not significantly associated with early discontinuation. A significant association (P=0.02) was found between early discontinuation and neurologic/psychiatric complaints.

CONCLUSIONS

The one-year continuation rate of the etonogestrel implant in our population is significantly lower than the value reported by CHOICE. Implant side effects are common and significantly affect rates of discontinuation. Our data suggest there is an opportunity for education and counseling for individuals opting for this method of long-acting contraception.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effects of Hormonal and Non-Hormonal Intrauterine Devices on Female Sexual Function: A Systematic Review

Objectives

The goal of this paper was to review and synthesize the extant literature exploring the impact, if any, of copper (Cu) and levonorgestrel (LNG) intrauterine devices on female sexual function.

Methods

To review the literature, Medline, PubMed, and PsychINFO, were searched for primary research articles that were available in English and measured female sexual function in Cu- and LNG-IUD users. 35 quantitative and 2 qualitative research papers met criteria for inclusion in this systematic review. The 35 quantitative articles were then rated based on the STROBE statement.

Results

The included articles indicated a positive impact of LNG-IUDs on sexual pain, and a positive-to-neutral effect of IUDs on sexual desire, however more research is warranted. This review also found IUDs to be generally non-impactful on other domains of sexual function, including arousal, lubrication, orgasm, satisfaction, and overall sexual function.

Conclusions

As this review highlights that LNG-IUDs may improve sexual pain, future research should explore this connection further. Additional RCTs should also be conducted to confirm effects on sexual function with little bias. A better understanding of the impact of both Cu- and LNG-IUDs is necessary to expand upon this field of research and uncover any other benefits or detriments from IUDs.

Retained Copper Intrauterine Device Fragment in Pregnancy: A Case Report

Copper intrauterine device (IUD) failure and fragmentation are rare, with minimal documentation on their effects in pregnancy. Recommendations from professional organizations highlight the importance of prompt identification and surgical removal, as case reports have noted various acute and chronic intra-abdominal pathologies. However, limited guidance exists around counseling patients who are pregnant with a retained IUD fragment. Here, we present a case of a normal pregnancy with a retained copper IUD fragment, while reviewing existing data on management and counseling.

Change of contraceptive preference after the free-LARC program for Thai teenagers

Background

In 2014, the Thai government launched a free-of-charge long-acting reversible contraception (LARC) program for Thai female adolescents. However, its acceptance had not been reported. Therefore, this study aimed to describe contraceptive use among women of reproductive age before and after the program was implemented.

Methods

This retrospective cross-sectional study was carried out from the medical records of 9000 women of reproductive age, who attended the Family Planning Clinic at Maharaj Nakorn Chiang Mai Hospital between 2009 and 2018. The Chi-square test was used to compare the contraceptive methods administered before and after the program was implemented, and binary logistic regression was used to find the factors associated with implant use after completion of the program.

Results

Depot medroxy progesterone acetate (DMPA) injection was the most popular contraceptive method used among 40.9% of the women. The rates of subdermal implant use were increased significantly after the program was implemented (2.3–9.3%, p < 0.001). Implant use for adolescents aged less than 20 years increased from 2.6% to 56.4%, while DMPA was the most popular method used among adult women at 36.4%. Factors associated significantly with implant use after implement of the program included age of less than 20 years (aOR = 4.17 (CI: 1.84–9.44); p = 0.001) and nulliparity (aOR = 8.55 (CI: 3.77–19.39); p < 0.001).

Conclusion

This study showed a significant increase in contraceptive implant use after the free-LARC program for adolescents had been applied.

Statement of implications

Contraceptive implant is the most effective hormonal reversible contraception. Its use rate is low among all age groups, but increased clearly after the free-of-charge program was applied for adolescents.

The Influence of Social Determinants of Health on the Provision of Postpartum Contraceptives in Medicaid

Disparities continue to exist in the timely provision of postpartum contraception. This study aimed to identify prevalence and factors associated with postpartum contraception provision among women enrolled in Medicaid. A retrospective cohort study was conducted using the 2014 National Medicaid data, linked to county-level social vulnerability index (SVI) data. Women aged 15–44 with a live birth in 2014 were included. Multivariable logistic regression was used to predict 3-day provision of long-acting reversible contraception (LARC) and 60-day provision of most effective or moderately effective contraceptives (MMEC). Overall, 3-day LARC provision was 0.2% while 60-day MMEC was 36.3%. Significantly lower odds of receiving MMEC was found among women aged 15–20 (adjusted odds ratio [aOR] = 0.87; 95% CI:0.86–0.89) compared to women 20–44 years as well as among Asian women (aOR = 0.69; 95% CI:0.66–0.72) and Hispanic women (aOR = 0.73; 95% CI:0.72–0.75) compared to White women. The provision of postpartum contraception remains low, generally, and needs attention in communities experiencing poor maternal outcomes.

Peri-abortion contraceptive counseling: A systematic review of randomized controlled trials

Objective

To assess the effects of peri-abortion contraceptive counseling interventions.

Methods

We performed a systematic review of randomized controlled trials (RCTs) that compared the effect of different types of peri-abortion contraceptive counseling interventions and were published as original papers in scientific journals. The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date. Two independent authors identified studies that met the inclusion and exclusion criteria and extracted the data. The risk of bias was assessed using the Cochrane tool, and evidence certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Whenever possible, meta-analyses were performed. The protocol was registered at PROSPERO (CRD42020187354).

Results

Eleven RCTs were eligible for inclusion (published from 2004 to 2017), from which nine compared enhanced versus standard counseling. Pooled estimates showed that, compared to standard counseling, enhanced counseling was associated with a higher incidence of effective contraceptive use (>3 months) (relative risk [RR], 1.12; 95% confidence interval [CI], 1.09–1.16), although no significant difference was found in the incidence of long-acting reversible contraceptive use (RR, 1.25; 95% CI, 0.68–2.29), contraceptive uptake (RR, 1.06; 95% CI, 0.98–1.15), and obstetric event occurrence (RR, 0.91; 95% CI, 0.57–1.47). Certainty of evidence was very low for all outcomes. In addition, two studies compared contraceptive counseling provided by physicians versus that provided by non-physicians, which did not show significant differences.

Conclusions

Enhanced contraceptive counseling may favor effective contraceptive use but may not affect the rate of obstetric event occurrence. Also, the studies did not find a difference in the effects of counseling interventions given by different providers. Since evidence certainty was very low, future well-designed RCTs are needed to make informed decisions.

Registration

The study protocol was registered at PROSPERO (CRD42020187354).

Considerations in Adolescent Use of the Etonogestrel Subdermal Implant: A Cohort Study

Objectives: To describe bleeding patterns and other side effects in adolescent implant users and characterize their impact on early discontinuation of the implant.

Study Design: This is a retrospective cohort study of female patients under 18 years who had an implant placed from 2013 to 2018. Data were collected on demographics, medical history, and side effects.

Results: Of 212 adolescents, the average age at insertion was 16 years and 84% desired placement for contraception. Common side effects included AUB (80%), mood changes (10%), and perceived weight gain (9%). Most (76%) used the implant for at least 12 months. Average time to removal was 22.1 months (SD 13.0 months) and this did not depend on presence of side effects. Twenty-seven percent of teens were able to achieve amenorrhea. Adolescents with frequent or prolonged bleeding were more likely to have implant removal prior to 12 months than those with other bleeding patterns (p = 0.003). Early removal was also more common in girls reporting weight or mood issues than those who did not (p < 0.001 and p = 0.045, respectively). BMI increased in 64% of adolescents. Average percentage change in BMI was 3.2% (0.87 kg/m²). There was no difference in baseline use of any mood-modulating medications in patients who did and did not complain of mood side effects following implant placement (p = 0.801).

Conclusion: Characterization of bleeding patterns following implant placement in adolescents have not previously been reported. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal of the implant. A relatively small number had early removal of the implant due to weight or mood complaints. Therefore, a history of obesity, depression, or other mood disorders should not be a deterrent to implant placement.

Analysis of Postpartum Uptake of Long-Acting Reversible Contraceptives Before and After Implementation of Medicaid Reimbursement Policy

OBJECTIVES

The postpartum period is a time of high unmet contraception need. Providing long-acting reversible contraception (LARC), particularly in the immediate postpartum period, is one strategy to meet contraceptive needs. This practice may also prevent unintended and short interpregnancy interval pregnancies. In recent years, state Medicaid programs have implemented reimbursement policies for LARC use in the inpatient setting. The purpose of this study was to assess the uptake of inpatient postpartum LARCs at a large urban hospital with a sizable Medicaid population, before and after policy implementation.

METHODS

Using billing records from January 2015 and December 2017, we extracted data on patient demographics and LARC uptake before Medicaid policy change (2015) and after policy change (2016 and 2017). Implant and intrauterine device insertions were classified as inpatient postpartum (0-7 days after birth), outpatient postpartum (1-8 weeks after) or interval (9+ weeks after).

RESULTS

In the 3-year study period, 2091 LARC insertions occurred, of which 700 (33.5%) were inpatient postpartum, 429 (20.5%) outpatient postpartum, and 962 (46.0%) interval. After policy implementation, inpatient postpartum LARC insertions increased from 2.6 per 100 deliveries to 16.8 per 100 deliveries. Significant differences in uptake were seen in Black and Hispanic populations. The number of outpatient postpartum LARCs remained stable and tubal sterilizations decreased.

CONCLUSIONS FOR PRACTICE

Implementation of reimbursement policies contributed to a sharp uptake of inpatient postpartum LARCs. Improved access to effective, reversible contraception could reduce the number of unplanned and short interpregnancy interval pregnancies, ultimately lowering rates of maternal morbidity and mortality.

Uterine synechiae after intrauterine device use: a case series

PURPOSE

The intrauterine device (IUD) is one of the most effective and safe contraceptive methods. Substantial literature suggests an overall return to normal fertility following IUD removal. However, there are no studies to date that evaluate endometrial function specifically in nulliparous women after levonorgestrel IUD use.

METHODS

We present three nulliparous women with a history of levonorgestrel IUD use who were evaluated for uterine dysfunction at the University of California, San Francisco Center for Reproductive Health. These patients had no other known risk factors or history of uterine manipulation, including prior uterine surgery, pelvic radiation, intrauterine infection, hypothalamic amenorrhea, or uterine anomaly.

RESULTS

Upon evaluation, these patients were found to have uterine synechiae concerning for Asherman syndrome. All three patients were eventually able to conceive through assisted reproductive technology or natural conception.

CONCLUSION

This case series is the first to suggest a possible effect of endometrial dysfunction on fertility resumption following levonorgestrel IUD removal in nulliparous patients. It is possible that a small subset of patients may be at risk for Asherman syndrome after IUD use. Larger prospective trials are needed to explore this possible association.

One-year incidence of low libido in women using levonorgestrel subdermal implant as contraception. Cohort study. Armenia, Colombia, 2014-2019

Objetivo:

Definir la incidencia de deseo sexual hipoactivo (DSH) en mujeres que planifican con el implante subdérmico de levonorgestrel (LNG) después de 12 meses, y conocer otros efectos adversos.

Materiales y métodos:

Estudio de cohorte, cuyas participantes fueron mujeres mayores de 18 años sin hijos ni embarazos previos y con pareja estable, a quienes se les había insertado el implante de LNG al menos tres meses previos en una clínica privada de carácter universitario en Armenia (Quindío), Colombia, entre 2014 y 2019. Se excluyeron mujeres con antecedentes de disfunción sexual, infecciones de transmisión sexual en los últimos 6 meses, peso mayor a 89 Kg y dificultades para el seguimiento. El muestreo fue consecutivo. Se describieron las características de la población estudiada, se estimó la incidencia acumulada de DSH y efectos adversos relacionados con el implante subdérmico de LNG

Resultados:

Participaron 238 mujeres cuya edad media fue de 24,69 (DE ± 5,82) años. Se determinó una incidencia de deseo sexual hipoactivo del 18,82%. El 60,25% de las mujeres fueron diagnosticadas con DHS en los primeros 6 meses de seguimiento. Los efectos adversos se hicieron presentes desde los primeros 3 meses de la inserción del implante, el sangrado irregular (62,34%) fue el más frecuente, seguido de la amenorrea (38,91%) y el aumento de peso (33,89%).

Conclusiones:

Es importante que los médicos y las usuarias se informen sobre la presencia del trastorno de deseo sexual hipoactivo y los efectos adversos que pueden surgir con el uso del implante subdérmico de levonorgestrel. Las futuras investigaciones deben confirmar estos hallazgos, así como su eventual base fisiológica.

Reproductive Life Goals: A Systematic Review of Pregnancy Planning Intentions, Needs, and Interventions Among Women Involved in U.S. Criminal Justice Systems

Background: Women involved in criminal justice systems (WICJ) are affected by multilevel biological and sociocultural factors that result in adverse health outcomes and health disparities. Criminal justice systems (CJS) must be appropriately resourced to address these issues. Materials and Methods: We developed a systematic review to understand the intentions and needs for pregnancy prevention and planning among WICJ to inform future reproductive health services. We conducted a systematic literature review of epidemiologic and interventional studies that addressed the pregnancy prevention and planning needs of U.S. WICJ (2000-2019). An initial screen identified 7061 articles and 3 independent reviewers determined that 28 articles (16 descriptive studies in adults, 7 descriptive studies in adolescents, and 5 interventional studies) met inclusion criteria. Results: The literature review identified high rates of contraception underutilization and negative attitudes toward pregnancy among WICJ in a wide variety of settings. WICJ described minimal access to reproductive health services, including evidence-based contraception, and experienced high rates of unplanned and undesired pregnancies. Results were interpreted in the context of the reproductive justice (RJ) framework. Conclusions: The CJS, although not designed to provide health care, should dedicate resources to address the multilevel barriers to care experienced by women. WICJ require targeted, gender-responsive, trauma-informed pregnancy prevention and planning interventions that acknowledge the history of reproductive coercion in this population and address key aspects of RJ, including the right to and to not have a child.

Are myths surrounding long-acting reversible contraception the reason for a huge unmet need for spacing pregnancies?

Background:

Long-acting reversible contraceptives (LARC), a highly effective class of contraceptives, has a limited uptake by few couples due to lack of awareness, unavailability, and myths surrounding their application and side effects.

Aims:

This study was undertaken to understand and to clear myths of LARC among patients as well as to assess the knowledge, attitudes, practices, and preference.

Materials and Methods:

A hospital-based cross-sectional study using a semistructured questionnaire was conducted in the out-patient Department of Obstetrics and Gynecology, in a tertiary level hospital in Eastern India. A total of 600 women responded to the structured validated questionnaire.

Results:

High prevalence of teenage marriages (64%), teenage pregnancies (44%), and unwanted pregnancy (41%) was noted among responders. The knowledge scores were low in 66.7%, moderate in 26.66%, and only 6.66% had high level >80% scores in the 15 questions about LARC methods. While 41% had a positive attitude to future use of LARC, a majority (59%) had a strong negative attitude due to many myths of genital tract infections, discharges, and cancer, changed menstrual bleeding patterns, delayed conception after discontinuation, and altered sexual functions. Out of those with a positive attitude, 21% of women had a preference for intrauterine devices, 19.5% of women for injectables, and only 0.5% of women preferred contraceptive implants. 24.5% of women had used LARC in their lifetime but a meager 5% were currently using them.

Conclusions:

The study shows that there is a huge unmet need for spacing contraceptive methods as childbearing spacing is not maintained. There were lack of correct knowledge and awareness, and numerous myths surrounding LARC methods.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.

Insights in Public Health: Insurance Coverage for Long-Acting Reversible Contraception Placed in Office: A Buy and Bill Demonstration Project in Hawai'i

Access to the full range of contraceptive options for all people is critical in allowing individuals to make decisions that are consistent with their reproductive goals and values, which, in turn, enables them to achieve educational, social, and economic goals. In 2010, the Patient Protection and Affordable Care Act mandated that health plans must cover contraceptive supplies and services, including drugs and devices approved by the US Food and Drug Administration without any out-of-pocket costs to patients. This federal mandate was similar to a law passed by the Hawai'i state legislature in 1999. Despite the Affordable Care Act, access barriers continue to prevent people from obtaining their preferred methods upon request. Same day access to long-acting reversible contraceptive (LARC) devices is a particular challenge in many clinical settings due to the high upfront cost of the device for providers. This Insights article describes the context of this issue in Hawai'i and information about a pilot test of a "buy and bill" program for LARC devices in an outpatient obstetrics and gynecology practice in Honolulu, Hawai'i. Ultimately, the majority of LARC devices were paid for fully by insurance, resulting in increased access to same day insertion with limited financial risk for the clinic.

Expulsion rate of intrauterine device: mediate vs. immediate puerperium period

Objective

To evaluate the rate of expulsion of intrauterine device (IUD) inserted during the immediate and mediate puerperium. To evaluate whether the type of delivery is a predictor of expulsion of the IUD when inserted in the puerperium period.

Material and Methods

This was a prospective observational study. Patients whose IUD (TCU-380 copper) was placed during the puerperal period were divided in two groups according to the time of placement: immediate and mediate puerperium. The decision regarding the time of IUD insertion was made in a non-randomized manner. Analysis was performed using chi-square, Mann-Whitney U, and Spearman’s correlation tests and logistic regression analysis.

Results

The total rate of IUD expulsions was 28.8% (49/170). There was no significant association between the occurrence of expulsion and the timing of IUD insertion (immediate vs mediate puerperium; 26.6% vs 34.78%, p=0.296). Among patients experiencing expulsion, 79.6% (39/49) underwent insertion after vaginal delivery and 20.4% (10/49) during cesarean section (CS). The type of delivery was a significant predictor for IUD expulsion (p<0.0001). Vaginal delivery was fourfold more likely to be associated with IUD expulsion inserted in the puerperal period than CS (odds ratio: 4.23, 95% confidence interval: 1.94-9.25). There was no significant correlation between the period between IUD insertion and the diagnosis of expulsion in regard to number of pregnancies (r=-0.160, p=0.271) or gestational age at delivery (r=-0.058, p=0.939).

Conclusion

Vaginal delivery was the most prevalent type of delivery in patients who underwent IUD insertion during the immediate and mediate puerperium. The risk of IUD expulsion after vaginal delivery was greater than CS.

Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE

Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography.

MATERIALS AND METHODS

Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement.

RESULTS

Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75).

CONCLUSION

IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis

OBJECTIVES

To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.

STUDY ELIGIBILITY CRITERIA

We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.

STUDY APPRAISAL AND SYNTHESIS METHODS

We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.

RESULTS

We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65).

CONCLUSION

Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.

Adherence to Recommended Practices for Provision of Long-Acting Reversible Contraception Among Providers in a Large U.S. Health Care System

Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p = 0.001; implant: 57% vs. 26%, p = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p = 0.001; implant: 65% vs. 27%, p < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.

Levonorgestrel-Releasing Intrauterine System as a Contraceptive Method in Nulliparous Women: A Systematic Review

The aim of this review was to summarize the available evidence about the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as a contraceptive method in nulliparous women. For this purpose, studies evaluating the efficacy, safety, bleeding pattern, satisfaction and discontinuation of the levonorgestrel-releasing intrauterine system in nulliparous women were analyzed. Only original research articles published in English between 1990–27th March 2020 were considered eligible. Reviews, book chapters, case studies, conference papers, opinions, editorials and letters were excluded. The systematic literature search of PubMed/MEDLINE, Scopus, Embase and Cochrane Library databases identified 816 articles, 23 of which were analyzed. The available evidence indicates that LNG-IUS is an effective and safe contraceptive method for nulliparous women that achieves high levels of satisfaction among patients. Moreover, nulliparous women seem to experience fewer expulsions than parous ones. Bleeding pattern is acceptable for the majority of patients, and bleeding disorders mainly occur in the first months after the insertion. More in-depth, long-term prospective studies are needed in this patient group to determine risk factors for the occurrence of side effects and associated discontinuations, which should not, however, delay the wider use of the method in this group, given the number of advantages.

Patterns of contraceptive use among Thai women aged ≥40 and at risk of pregnancy

OBJECTIVES

The aims of the study were to identify the patterns of contraceptive use among Thai women aged ≥40 years and the reasons for not using contraception.

METHODS

This cross-sectional study included sexually active women aged 40-49 years in Khon Kaen, Thailand. Information on contraceptive practice and reasons for not using contraception was collected through a self-reported questionnaire. The unmet need for a modern method of contraception and the unmet need for any method of contraception were calculated based on the percentage of participants who were not using contraception but who wanted to postpone or prevent pregnancy.

RESULTS

Of 400 women, 75.5% were currently using some form of contraception, with female sterilisation being the most used (35%). The main reasons for not using contraception included perceived low risk of pregnancy, health concerns, infrequent sexual intercourse and wish to become pregnant. The unmet need for a modern method of contraception was 23.3% (95% confidence interval [CI] 0.20%, 0.29%). Having children was a significant protective factor (adjusted odds ratio [OR] 0.18; 95% CI 0.08, 0.37; p = 0.000). The unmet need for any method of contraception was 12% (95% CI 0.09%, 0.16%). Previous abortion was a significant risk factor for not using any contraception (adjusted OR 2.23; 95% CI 1.12, 4.44; p = 0.022).

CONCLUSION

Although the use of contraception was common, some participants displayed a lack of knowledge and/or did not practise family planning. Our findings address the importance of improving knowledge about the risks of pregnancy and the need for effective contraception in this population.

The Teen Access and Quality Initiative: Improving Adolescent Reproductive Health Best Practices in Publicly Funded Health Centers

Quality adolescent sexual and reproductive health (ASRH) services play an important role in supporting the overall health and well-being of adolescents. Improving access to this care can help reduce unintended pregnancies, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) infection and their associated consequences, as well as promote health equity. The Centers for Disease Control and Prevention funded three grantees to implement a clinic-based ASRH quality improvement initiative complimented by activities to strengthen systems to refer and link youth to ASRH services. The purpose of this study is to describe the initiative and baseline assessment results of ASRH best practice implementation in participating health centers. The assessment found common use of the following practices: STD/HIV screening, education on abstinence and the use of dual protection, and activities to increase accessibility (e.g., offering after-school hours and walk-in and same-day appointments). The following practices were used less frequently: provider training for Long-Acting Reversible Contraception (LARC) insertion and removal, LARC availability, same-day provision of all contraceptive methods, and consistent sharing of information about confidentiality and minors' rights with adolescent clients. This study describes the types of training and technical assistance being implemented at each health center and discusses implications for future programming.

Research priorities of women at risk for preterm birth: findings and a call to action

Background

Traditional hierarchical approaches to research give privilege to small groups with decision-making power, without direct input from those with lived experience of illness who bear the burden of disease. A Research Justice framework values the expertise of patients and communities as well as their power in creating knowledge and in decisions about what research is conducted. Preterm birth has persisted at epidemic levels in the United States for decades and disproportionately affects women of color, especially Black women. Women of color have not been included in setting the agenda regarding preterm birth research.

Methods

We used the Research Priorities of Affected Communities protocol to elicit and prioritize potential research questions and topics directly from women of color living in three communities that experience disproportionately high rates of preterm birth. Women participated in two focus group sessions, first describing their healthcare experiences and generating lists of uncertainties about their health and/or healthcare during pregnancy. Women then participated in consensus activities to achieve ‘top-priority’ research questions and topic lists. The priority research questions and topics produced by each group were examined within and across the three regions for similarities and differences.

Results

Fifty-four women participated in seven groups (14 sessions) and generated 375 researchable questions, clustered within 22 topics and four overarching themes: Maternal Health and Care Before, During, and After Pregnancy; Newborn Health and Care of the Preterm Baby; Understanding Stress and Interventions to Prevent or Reduce Stress; and Interpersonal and Structural Health Inequities. The questions and topics represent a wide range of research domains, from basic science, translational, clinical, health and social care delivery to policy and economic research. There were many similarities and some unique differences in the questions, topics and priorities across the regions.

Conclusions

These findings can be used to design and fund research addressing unanswered questions that matter most to women at high risk for preterm birth. Investigators and funders are strongly encouraged to incorporate women at the front lines of the preterm birth epidemic in research design and funding decisions, and more broadly, to advance methods to deepen healthcare research partnerships with affected communities.

Quality of websites about long-acting reversible contraception: a descriptive cross-sectional study

Background

Today, there are various short- and long-acting contraceptive alternatives available for those who wish to prevent unintended pregnancy. Long-acting reversible contraception are considered effective methods with a high user satisfaction. High-quality information about contraception is essential in order to empower individuals to reach informed decisions based on sufficient knowledge. Use of the Web for information about contraception is widespread, and there is a risk that those who use it for this purpose could come in contact with sources of low quality.

Objective

The overarching aim was to investigate the quality of websites about long-acting reversible contraception.

Methods

Swedish client-oriented websites were identified through searches in Google (n = 46 included websites). Reliability and information about long-acting reversible contraceptive choices were assessed by two assessors with the DISCERN instrument, transparency was analyzed with the Journal of the American Medical Association benchmarks, completeness was assessed with inductive content analysis and readability was analyzed with Readability Index.

Results

The mean DISCERN was 44.1/80 (SD 7.7) for total score, 19.7/40 (SD 3.7) for reliability, 22.1/35 (SD 4.1) for information about long-acting reversible contraceptive choices, and 2.3/5 (SD 1.1) for overall quality. A majority of the included websites had low quality with regard to what sources were used to compile the information (n = 41/46, 89%), when the information was produced (n = 40/46, 87%), and if it provided additional sources of support and information (n = 30/46, 65%). Less than half of the websites adhered to any of the JAMA benchmarks. We identified 23 categories of comprehensiveness. The most frequent was contraceptive mechanism (n = 39/46, 85%) and the least frequent was when contraception may be initiated following an abortion (n = 3/46, 7%). The mean Readability Index was 42.5 (SD 6.3, Range 29–55) indicating moderate to difficult readability levels, corresponding to a grade level of 9.

Conclusions

The quality of client-oriented websites about long-acting reversible contraception is poor. There is an undeniable need to support and guide laypersons that intend to use web-based sources about contraceptive alternatives, so that they may reach informed decisions based on sufficient knowledge.

Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

DATA SOURCES

We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

METHODS OF STUDY SELECTION

We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

TABULATION, INTEGRATION, AND RESULTS

We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A.

CONCLUSION

Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Letters to the editor; a possible spurious correlation between human papillomavirus vaccination introduction and birth rate change in the United States

A possible spurious correlation was found between human papillomavirus (HPV) vaccination introduction and birth rate change in the United States. Thus, the effects of HPV vaccination needed to be followed carefully at an international level. The birth rate change in the US might be representative of the trend of the introduction of new contraception methods and advancing maternal age.

Patterns and trends in contraceptive use among women attending Title X clinics and a national sample of low-income women

Objectives

To describe the types of contraception used by women attending Title X-funded clinics and a comparable group of low-income reproductive-age women at risk of unintended pregnancy.

Study design

We estimated the percentage of reproductive aged (15-44 years) women using contraception, by method type and level of effectiveness in preventing pregnancy (i.e., most, moderately, and less effective), using Title X Family Planning Annual Report (2006-2016) and National Survey of Family Growth (2006-2015) data. We divided most effective methods into permanent (female and male sterilization) and reversible (long-acting reversible contraceptives [LARCs]) methods.

Results

Among Title X clients during 2006-2016, use of LARCs increased (3-14%); use of moderately effective methods decreased (64-54%); and use of sterilization (~ 2%), less effective methods (21-20%), and no method (8-7%) was unchanged. These same trends in contraceptive use were observed in a comparable group of women nationally during 2006-2015, during which LARC use increased (5-19%, p < .001); moderately effective method use decreased (60-48%, p < .001); and use of sterilization (~5%), less effective methods (19%), and no method (11-10%) was unchanged.

Conclusions

The contraceptive method mix among Title X clients differs from that of low-income women at risk of unintended pregnancy nationally, but general patterns and trends are similar in the two populations. Research is needed to understand whether method use patterns among low-income women reflect their preferences, access, or the conditions of the supply environment.

Implications

This study contributes to our understanding of patterns and trends in contraceptive use among two groups of reproductive-age women - Title X clients and low-income women nationally who are at risk of unintended pregnancy. The findings highlight areas for further research.

Utilization of Long-Acting Reversible Contraceptives in the United States After vs Before the 2016 US Presidential Election

This study examines the utilization rate of long-acting reversible contraceptives after the 2016 US presidential election compared with before the election and during the same period in 2015.

Millennials and contraception: why do they forget? An international survey exploring the impact of lifestyles and stress levels on adherence to a daily contraceptive regimen

BACKGROUND

Rates of unintended pregnancies are particularly high in young women, a finding that may be associated with their tendency not to use contraceptives correctly and/or consistently. For millennial women, busy lifestyles and associated stress may impact on daily activities including taking an oral contraceptive pill.

METHODS

Contraceptive pill users aged 21-29 years ('millennial' women; N = 4500) from nine countries in Europe and North and South America completed an online questionnaire on their daily habits and activities, disruptions to their routine and associated stress levels.

RESULTS

Thirty-nine percent of surveyed participants had forgotten to take their contraceptive pill at least once in the past month; 39% also admitted not taking it at the same time each day. On average, participants had experienced two major disruptions to their daily lives in the past year, with three quarters (74%) believing these disruptions increased their stress levels. Of those who had missed at least one pill in the past year, 40% attributed it to a busy schedule and 21% to stress, among other reasons. Over half of respondents (55%) reported they were more likely to forget their pill when preoccupied.

CONCLUSIONS

Times of stress may make it more likely for millennial women to forget to take their pill. Health care providers should be aware of typical contraceptive adherence rates among young women and ensure that contraceptive counselling sessions include discussion of lifestyle issues and potential barriers to adherence. Every woman should be counselled on all available methods, so that she can make an informed choice on what best suits her.

Placement of Levonorgestrel Intrauterine Device at the Time of Cesarean Delivery and the Effect on Breastfeeding Duration

Objectives: Studies have shown that immediate postpartum initiation of long-acting reversible contraception (LARC) methods leads to increased utilization of LARC and prevention of unintended pregnancies. It is unclear if immediate postpartum levonorgestrel-releasing intrauterine device (LNG-IUD) insertion has an effect on breastfeeding success. Study Design: This study was a secondary analysis of a randomized trial that compared intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean IUD placement with women who planned for interval IUD placement at 6 or more weeks postpartum. This parallel, 1:1, nonblinded randomized trial was conducted between March 2012 and June 2014 at the University of North Carolina Women's Hospital. We recruited pregnant women aged 18-45 years who were undergoing a cesarean delivery and desired an IUD for contraception postpartum. Results: We received breastfeeding information from 63 women who desired to use a LNG-IUD. A proportion analysis demonstrated that there was no difference in the proportion of women breastfeeding at any of the three time points, 6, 12, and 24 weeks, following placement. This remained true after adjusting for age, parity, and ethnicity. Conclusion: This study adds to the existing body of evidence that shows that most women are able to successfully breastfeed after immediate postpartum LNG-IUD placement. Women should be encouraged to breastfeed, and the desire to breastfeed should not preclude the initiation of a postplacental IUD. This study provides reassurance that immediate postpartum LNG-IUD placement does not adversely affect breastfeeding; however, more high-quality data are needed on the impact of hormonal IUDs on breastfeeding outcomes.

Use of etonogestrel implant beyond approved duration: prolonged contraceptive effectiveness

BACKGROUND

The subdermal etonogestrel contraceptive implant has a current approved duration of 3 years. There is, however, recent and strong evidence of its effectiveness for 2 additional years during which no pregnancies were documented.

CASE

We report a case of a 28-year-old woman who had an etonogestrel implant inserted 4 years earlier and wished to get pregnant. The implant was, however, deep in the triceps muscle and could not easily be removed. Her serum levels of etonogestrel remained positive even 6 years after insertion. As infertility investigation revealed endometriosis and bilateral tubal obstruction she was referred for assisted reproduction. Despite obtaining oocytes during an ovarian stimulation cycle, the endometrium was never above 4 mm, precluding embryo transfer. It was decided to remove the implant in order to improve endometrial conditions, after which the patient achieved pregnancy.

CONCLUSION

This case report suggests that the etonogestrel implant is effective for even longer than the most recent studies have shown.

Public Health Implications of Very Preterm Birth

With advanced perinatal care and technology, survival among infants born very preterm (<32 weeks gestation) has improved dramatically over the last several decades. However, adverse medical and neurodevelopmental outcomes for those born very preterm remains high, particularly at the lowest gestational ages. Public health plays a critical role in providing data to assess population-based risks associated with very preterm birth, addressing disparities, and identifying opportunities for prevention, including improving the health of reproductive-age women, before, during, and after pregnancy.

Contraceptive Use Among Women at Risk for Unintended Pregnancy in the Context of Public Health Emergencies - United States, 2016

Ensuring access to and promoting use of effective contraception have been identified as important strategies for preventing unintended pregnancy (1). The importance of ensuring resources to prevent unintended pregnancy in the context of public health emergencies was highlighted during the 2016 Zika virus outbreak when Zika virus infection during pregnancy was identified as a cause of serious birth defects (2). Accordingly, CDC outlined strategies for state, local, and territorial jurisdictions to consider implementing to ensure access to contraception (3). To update previously published contraceptive use estimates* among women at risk for unintended pregnancy^† and to estimate the number of women with ongoing or potential need for contraceptive services,^§,¶ data on contraceptive use were collected during September–December 2016 through the Behavioral Risk Factor Surveillance System (BRFSS). Results from 21 jurisdictions indicated that most women aged 18–49 years were at risk for unintended pregnancy (range across jurisdictions = 57.4%–76.8%). Estimates of the number of women with ongoing or potential need for contraceptive services ranged from 368 to 617 per 1,000 women aged 18–49 years. The percentage of women at risk for unintended pregnancy using a most or moderately effective contraceptive method** ranged from 26.1% to 65.7%. Jurisdictions can use this information to estimate the number of women who might seek contraceptive services and to plan and evaluate efforts to increase contraceptive use. This information is particularly important in the context of public health emergencies, such as the recent Zika virus outbreak, which have been associated with increased risk for adverse maternal-infant outcomes (2,4–6) and have highlighted the importance of providing women and their partners with resources to prevent unintended pregnancy.

Prenatal intent and postpartum receipt of long-acting reversible contraception among women receiving medication-assisted treatment for opioid use disorder

BACKGROUND

Many women with opioid use disorder (OUD) do not use highly effective postpartum contraception such as long-acting reversible contraception (LARC). We evaluated factors associated with prenatal intent and postpartum receipt of LARC among women receiving medication-assisted treatment (MAT) for OUD.

STUDY DESIGN

This was a retrospective cohort study of 791 pregnant women with OUD on MAT who delivered at an academic institution without immediate postpartum LARC services between 2009 and 2012. LARC intent was defined as a documented plan for postpartum LARC during pregnancy and LARC receipt was defined as documentation of LARC placement by 8 weeks postpartum. We organized contraceptive methods into five categories: LARC, female sterilization, short-acting methods, barrier methods and no documented method. Multivariable logistic regression identified characteristics predictive of prenatal LARC intent and postpartum LARC receipt.

RESULTS

Among 791 pregnant women with OUD on MAT, 275 (34.8%) intended to use postpartum LARC and only 237 (29.9%) attended the postpartum visit. Among 275 women with prenatal LARC intent, 124 (45.1%) attended their postpartum visit and 50 (18.2%) received a postpartum LARC. Prenatal contraceptive counseling (OR 6.67; 95% CI 3.21, 13.89) was positively associated with LARC intent. Conversely, older age (OR 0.95; 95% CI 0.91, 0.98) and private practice provider (OR 0.48; 95% CI 0.32, 0.72) were negatively associated with LARC intent. Although parity was not predictive of LARC intent, primiparous patients (CI 0.49; 95% CI 0.26, 0.97) were less likely to receive postpartum LARC.

CONCLUSIONS

Discrepancies exist between prenatal intent and postpartum receipt of LARC among pregnant women with OUD on MAT. Immediate postpartum LARC services may reduce LARC access barriers.

IMPLICATIONS

Despite prenatal interest in using LARC, most pregnant women with OUD on MAT did not receive postpartum LARC. The provision of immediate postpartum LARC services may reduce barriers to postpartum LARC receipt such as poor attendance at the postpartum visit.

Postpartum intrauterine device placement: a patient-friendly option

Women in the United States are increasingly choosing an intrauterine device (IUD) for contraception. Since the postpartum period is an important time to consider a patient's need for contraception, offering postpartum IUD placement is considered best practice. Effective implementation of postpartum IUD placement occurs within a context of shared decision making wherein patients are given full information about all options and guided to methods that best fit their lifestyle. Within this context, both the non-hormonal and hormonal IUDs are safe, highly effective, well tolerated, and convenient options. National guidelines support the placement of IUDs, whether immediate (within 10 min of placental delivery) or early postpartum (after 10 min and before 4 weeks after placental delivery), for breastfeeding or non-breastfeeding women. Studies have noted increased IUD expulsion rates, but equivalent IUD usage rates with immediate or early postpartum placement. Postpartum placement requires additional skills that can be easily taught. Finally, successful implementation of a postpartum IUD placement program can be accomplished in hospitals using a team-based approach.