Long-acting reversible contraception for adolescents

Why-UD? Assessing the requirement to trial an intrauterine device as a condition for elective sterilisation in female patients

Some National Health Service healthcare boards in the UK will approve a request for female sterilisation only if the patient first accepts a trial period of 1 year with an intrauterine device (IUD), a form of long-acting reversible contraception. In this article, I argue that this requirement is not justified by appeal to any of (or any combination of) promotion of informed consent, paternalistic concerns regarding patient regret in later life and health service budgetary considerations. Informed consent and patient autonomy may be promoted by a mandatory waiting period, but the concomitant imposition of an IUD trial during this period cannot be justified on these grounds. As long as elective vasectomy is offered by the healthcare system, elective female sterilisation should be accessible under reasonably similar-even if not identical-conditions.

Factors associated with long-acting reversible contraceptives usage among sexually active adolescent girls and young women in Zimbabwe

Despite the benefits of long-acting reversible contraceptives (LARCs), they are not being utilized in Zimbabwe as much as the short-acting reversible contraceptives (SARCs). The aim of the study was to explore factors associated with LARC usage among Zimbabwean adolescent girls and young women, using data from the 2015 Zimbabwe Demographic and Health Survey. Cross tabulations and chi-square tests were used initially to describe associations. Odd ratios were then used to measure the strength of association between LARCs usage and the independent variables using stepwise multinomial logistic regression. From the 2132 sexually active females included in the study 9.1% were LARCs users and 42% were SARCs users at the time of the survey. Secondary and primary education had increased odds of not using any method (OR: 5.032, 95% CI: 2.136-11.8512 and OR: 5.799, 95% CI: 2.327-14.453 respectively) compared to tertiary education. Women with no living children had increased odds of not using any method (OR 66.543, 95% CI: 25.784-171.7381). Being not married was associated with decreased odds of SARCs usage (OR 0.399, 95% CI: 0.285-0.558). Desire for no more children was associated with reduced odds of SARCs usage (OR: 0.448, 95% CI: 0.304-0.66). Being a member of the Apostolic Faith church was associated with increased odds of not using any method (OR 1.423517, 95% CI: 1.018-1.990309). In conclusion, acquiring a tertiary education, having children, a desire to cease bearing children altogether, being unmarried and belonging to the highest wealth class were generally associated with an increased likelihood of using LARCs. Being a member of the Apostolic Faith church was associated with a decreased likelihood of LARCs usage. Findings from the study are relevant in the Zimbabwean context and highlights the relevant factors essential to focus on, when carrying out interventions aimed at increasing LARCs uptake in the country.

Factors associated with unintended pregnancy and contraceptive practices in justice-involved adolescent girls in Australia

INTRODUCTION

Despite a decline in unintended teenage pregnancy in Australia, rates remain higher amongst justice-involved adolescent girls, who are more likely to be from disadvantaged socio-economic backgrounds, have histories of abuse, substance use and/or mental health issues. Furthermore, exposure to the criminal justice system may alter access to education and employment and opportunities, potentially resulting in distinct risk-factor profiles. We examine factors associated with unintended pregnancy, non-contraceptive use and Long-Acting Reversible Contraception (LARC) in a sample of sexually active, justice-involved adolescent girls from Western Australia and Queensland.

METHODS

Data from the Mental Health, Sexual Health and Reproductive Health of Young People in Contact with the Criminal Justice System (MeH-JOSH) Study was analysed on 118 sexually active adolescent girls. Participants were aged between 14 and 17 years, purposefully sampled based on justice-system involvement and completed an anonymous telephone survey. We constructed two multivariate models taking reproductive outcomes as the dependent variables.

RESULTS

Over one quarter (26%, 30/118) reported a past unintended pregnancy, 54 did not use any contraception at their last sexual encounter, and 17 reported LARC use. Following adjustments in the multivariate analysis, lifetime ecstasy use was associated with both unintended pregnancy (aOR 3.795, p = 0.022) and non-contraception use (aOR 4.562, p = 0.004). A history of physical abuse was also associated with both any contraception (aOR 3.024, p = 0.041) and LARC use (aOR 4.892, p = 0.050). Identifying as Aboriginal & Torres Strait Islander, education/employment status and geographic location appeared to have no association.

CONCLUSION

Our findings suggest that justice-involved adolescent girls have distinct risk factors associated with unplanned pregnancy and contraception use compared to the general population, but more research is required to understand the mechanisms and contexts underlying these risk factors. How exposure to physical violence may encourage contraception and LARC use, in particular, warrants further attention as does the association with ecstasy use.

Attitudes about the Provision of Sexual Health Services in an Inpatient Setting

OBJECTIVE

To examine the relationship between clinicians' attitudes about the appropriateness of providing sexual health services in the inpatient setting and confidence in providing services METHODS: An online survey was emailed to pediatric hospitalists, adolescent medicine, and pediatric and adolescent gynecology societies and directors. Confidence in managing 8 sexual health situations was measured on a 4-point Likert scale, summed, averaged, and dichotomized into confident and not so confident. Participants were asked to rate on a 5-point Likert scale their belief that providing sexual health services in the inpatient setting would be appropriate. An adjusted, multivariate logistic regression identified associations between participant demographic characteristics, professional characteristics, and confidence and attitudes about the appropriateness of providing inpatient sexual health services.

RESULTS

Among the 610 participants, the mean age was 40 years. Most were females (79%), non-Hispanic White (71%), and practiced pediatric hospital/general medicine (73%). Most (73%) were not so confident across all 8 confidence items. Overall, 61% "strongly agreed" that providing sexual health services in the inpatient setting was appropriate. Participants who reported younger age, being female, and confidence in providing services were significantly associated with strong agreement that it was appropriate to provide sexual health services in the inpatient setting. Those who identified as Christian non-Catholic were significantly less likely to report strong agreement.

CONCLUSION

Most providers strongly agreed that providing sexual health services in the inpatient setting was appropriate, yet most were not so confident in managing sexual health situations. Future studies should focus on addressing concerns and barriers to providing sexual health services.

Negative Perceptions and Long-Acting Reversible Contraceptive Choice in Adolescents and Young Adults: A Cross-Sectional Study

OBJECTIVE

Long-acting reversible contraceptives (LARCs) have high rates of safety, satisfaction, and continuation in adolescents and young adults (AYAs). Despite this, utilization of these methods by AYAs is low. The purpose of this study was to evaluate the negative personal perceptions or beliefs about birth control and LARCs and their association with contraceptive use in AYAs.

METHODS

We surveyed young people (14-24 years old) seeking care at a Title X-supported adolescent reproductive and sexual health clinic to assess negative perceptions of birth control methods, with an emphasis on LARCs. We used appropriate bivariate statistics to compare those endorsing 3 or fewer negative perceptions with those who had more than 3 and logistic regression to identify predictors of contraceptive choice.

RESULTS

We recruited 345 participants; 337 (97.7%) completed the survey. Among respondents, the median age was 20 (range 14-24) years, and 7.04% of participants had ever been pregnant. The most commonly held negative perceptions were fear of device migration or breakage causing adverse health effects and concern about effect on future fertility. The number of negative perceptions endorsed did not differ significantly by age. However, a greater number of negative perceptions and younger age were clinical predictors of LARC nonuse.

CONCLUSION

AYAs have negative perceptions about LARCs that are often inaccurate and may limit contraceptive acceptability and perceived options. Engaged and respectful dialogue with AYAs about their concerns and fears is essential to provide accurate and patient-centered contraceptive counseling and to ensure that young people can make informed contraceptive choices.

[Long-Term Reversible Contraception in Adolescence: The Reality of a Tertiary Pediatric Hospital in Portugal]

INTRODUCTION

Contraception in adolescence is essential to prevent unwanted pregnancies, abortion and sexually transmitted diseases. The use of longacting reversible contraceptive methods (LARCs) has been highly recommended due to their efficacy since they are user independent methods. The aim of this study was to evaluate the use of LARCs in adolescence in the population of a Childhood and Adolescence Gynecology clinic, and to describe the sociodemographic characteristics of the adolescents as well as previous contraceptive practices.

MATERIAL AND METHODS

Retrospective analysis that included adolescents using LARCs, monitored in a Childhood and Adolescence Gynecology clinic of a Portuguese tertiary pediatric hospital, between June 2012 and June 2021.

RESULTS

A total of 122 adolescents were included, with a median age of 16 (11 - 18) years and 62.3% (n = 76) were sexually active. The preferred method was the subcutaneous implant, placed in 82.3% (n = 101), followed by the Levonorgestrel-Intrauterine System in 16.4% (n = 20) and the copper intrauterine device in 1.3% (n = 1). The main indications for LARCs were contraceptive needs 90.2% (n = 110), abnormal uterine bleeding during puberty in 14.8% (n = 18), dysmenorrhea in 10.7% (n = 13) and need for amenorrhea in 0.8% (n = 1). The median time of implant use was 20 (1 - 48) months and of the LNG-IUS it was 20 (1 - 36) months. The 12-month adherence rate for both was 76.2% (n = 93). The removal rate for reasons besides the expiration date was 9.8% (n = 12) in adolescents who had implants, and no LNG-IUS or copper intrauterine devices were removed. There were no pregnancies after insertion of LARCs.

CONCLUSION

Contraceptive needs were the main reason for choosing LARCs, followed by abnormal uterine bleeding during puberty management and dysmenorrhea. All these factors may contribute to the high rate of satisfaction and continuity of these methods.

Impact of polymer crosslinking on release mechanisms from long-acting levonorgestrel intrauterine systems

Polydimethylsiloxane (PDMS) crosslinking density is a critical material attribute of levonorgestrel intrauterine systems (LNG-IUSs) that affects drug release and may have a significant influence on product performance and safety. Accordingly, the objective of the present work was to investigate the impact of PDMS crosslinking on the release mechanisms of LNG-IUSs and thereby achieve better product understanding. To investigate the effect of PDMS crosslinking, LNG-IUSs with varying prepolymer ratios and different mixing conditions were prepared. Accelerated and real-time in vitro release of the LNG-IUSs were conducted for up to 80 days and 7 months, respectively. Contrary to conventional understanding, formulations with higher crosslinking density showed faster drug release rates. To further understand this anomalous release behavior, the microstructure and molecular properties (using scanning electron microscopy, mercury intrusion porosimetry, polymer swelling studies, solid-state silicon NMR, and wide-angle X-ray diffraction) were investigated. Interestingly, it was revealed that high PDMS crosslinking forms a solid-state porous branched network with amorphous polymer domains facilitating fast solvent uptake (in organic solvents) and easy access to the drug particles leading to rapid mass transport of the drug molecules. Furthermore, formulations processed using planetary mixing showed higher crosslinking densities and faster drug release rates than those prepared using manual mixing. Model fitting of all LNG-IUSs were carried out using first order, two-phase (zero order plus Higuchi), and Korsmeyer-Peppas models. The first order model (which showed the best fitting for the full release profile) was used to establish correlations between the drug release rates and the PDMS crosslinking densities of LNG-IUSs. This is the first comprehensive report providing novel insights into crosslinking-induced microstructural changes and physicochemical properties that dictate drug release from LNG-IUSs.

Factors influencing contraceptive decision making and use among young adolescents in urban Lilongwe, Malawi: a qualitative study

BACKGROUND

The prevalence of teenage pregnancies in Malawi is 29%. About 25% of those are married while 30% are unmarried adolescents (15-19 years old) who use contraceptives. Data on contraceptive use has focused on older adolescents (15-19 years old) leaving out the young adolescents (10-14 years old). This study assessed factors that influence contraceptive decision-making and use among young adolescents aged 10-14 years.

METHODS

This was a qualitative study that used the Theory of Reasoned Action (TRA) model to understand the processes that influence contraceptive decision-making among young adolescents (10-14 years old) in urban Lilongwe. The study was conducted in six youth health-friendly service centers and 12 youth clubs. Two focus group discussions and 26 in-depth interviews were conducted among sexually active in and out of school young adolescents and key informants. The results are organized into themes identified during the analysis.

RESULTS

Results showed that contraceptive decision-making is influenced by social factors (individual, interpersonal, society) and adolescents' perceptions regarding hormonal contraceptives. There is also a disconnect between Education and Adolescent Sexual and Reproductive Health policies.

CONCLUSION

The findings suggest that interventions that scale up contraceptive use need male and female involvement in decision making. Addressing myths around contraceptives, and harmonization of Education and Sexual and Reproductive Health policies in the country would motivate adolescents to use contraceptives.

Lessons Learned from Longer Acting Reversible Contraception Applied to Longer Acting HIV Prevention Technologies

PURPOSE OF REVIEW

This review describes lessons learned from longer acting contraception and employs a reproductive justice lens to inform expansion of emerging HIV prevention technologies.

RECENT FINDINGS

Reproductive justice is a framework that advocates for the promotion of universal sexual and reproductive freedoms, particularly among historically marginalized communities. This framework takes a holistic view of individuals and sees the interconnections between sexual health, reproductive health, and overall health. Employing a sexual and reproductive justice perspective is essential to understanding and helping to mitigate the role intersecting structural, sexual, and reproductive oppressions, including those demonstrated through promotion of longer acting contraception, and can critically inform rollout of future prevention technologies, such as longer acting HIV pre-exposure prophylaxis. This review highlights the need for researchers, clinicians, and policymakers to apply lessons learned from contraception and specifically focuses on principles of reproductive justice to offer expanding HIV prevention options.

Use of nonpreferred contraceptive methods among women in Ohio

OBJECTIVES

We describe the prevalence and correlates of nonuse of preferred contraceptive method among women 18-44 years of age in Ohio using contraception.

STUDY DESIGN

The population-representative Ohio Survey of Women had 2529 participants in 2018-2019, with a response rate of 33.5%. We examined prevalence of preferred method nonuse, reasons for nonuse, and satisfaction with current method among current contraception users (n = 1390). We evaluated associations between demographic and healthcare factors and preferred method nonuse.

RESULTS

About 25% of women reported not using their preferred contraceptive method. The most common barrier to obtaining preferred method was affordability (13%). Those not using their preferred method identified long-acting methods (49%), oral contraception (33%), or condoms (21%) as their preferred methods. The proportion using their preferred method was highest among intrauterine device (IUD) users (86%) and lowest among emergency contraception users (64%). About 16% of women using permanent contraception reported it was not their preferred method. Having the lowest socioeconomic status (versus highest) (prevalence ratio [PR]: 1.47, 95% CI: 1.11-1.96), Hispanic ethnicity (versus non-Hispanic white) (PR: 1.83, 95% CI: 1.15-2.90), reporting poor provider satisfaction related to contraceptive care (PR: 2.33, 95% CI: 1.02-5.29), and not having a yearly women's checkup (PR: 1.31, 95% CI: 1.01-1.68) were significantly associated with nonuse of preferred method. Compared to preferred-method nonusers, higher proportions of preferred-method users reported consistent contraceptive use (89% vs. 73%, p < 0.001) and intent to continue use (79% vs. 58%, p < 0.001).

CONCLUSIONS

Affordability and poor provider satisfaction related to contraceptive care were associated with nonuse of preferred contraceptive method. Those using their preferred method reported more consistent use.

IMPLICATIONS

Cost is an important barrier for women in obtaining their preferred contraceptive methods. Low quality birth control care may also be a barrier to preferred-method use. Removal of cost barriers and improvement in contraceptive counseling strategies may increase access to preferred contraceptive methods.

The Impact of Progestin-only Contraception on Adolescents with Macromastia

Progestin-only contraception has become increasingly popular among adolescents. However, patients, parents, and providers share concerns regarding the potential impact that progestin-only contraception may have on breast growth. We sought to explore the impact of progestin-only contraception on breast hypertrophy and symptomatology in adolescents with macromastia.

METHODS

Patients between the ages of 12 and 21 years undergoing reduction mammaplasty were prospectively assessed for baseline and postoperative breast symptomatology and medication use. The medical records of female controls within the same age range were retrospectively reviewed.

RESULTS

A total of 378 participants with macromastia and 378 controls were included in analyses. A higher proportion of controls used progestin-only methods compared with participants with macromastia (28.0% versus 5.3%, P < 0.001). The most commonly prescribed methods were the depot medroxyprogesterone acetate injection (31.0%), levonorgestrel-containing intrauterine device (31.0%), and subdermal implant (26.2%). Patients with macromastia who used progestin-only contraception had a greater amount of breast tissue resected during reduction mammaplasty (P = 0.04), reported greater musculoskeletal pain (P = 0.008), and were roughly 500% more likely to experience breast pain (odds ratio, 4.94; 95% confidence interval, 1.58-15.47; P = 0.005) than those with macromastia who never used hormonal contraception.

CONCLUSIONS

Adolescents with macromastia who use progestin-only contraception may have greater breast hypertrophy and worse breast and musculoskeletal pain. When appropriate, providers may wish to consider other contraception methods for patients who are at-risk for breast hypertrophy or those who suffer from macromastia-related symptoms.

Long-acting contraception in adolescents and young women with type 1 and type 2 diabetes

Adolescent pregnancy is a major public health problem worldwide. Adolescents living with diabetes are not aware of the risks of unplanned pregnancy and the high rate of fetal and maternal complications when gestation occurs in women with significant hyperglycemia. These data highlight the significance of pregnancy prevention in young women with diabetes. Long-acting reversible contraceptives (LARCs), which include subdermal progestin implants and hormonal and nonhormonal intrauterine devices (IUDs), have been recommended by the American College of Obstetricians Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents and young women. This article reviews LARC options for adolescents and young women with type 1 (T1D) and type 2 (T2D) diabetes as well as the possible complications and side effects.

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

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

Factors associated with sexual and reproductive health behaviour of street-involved young people: findings from a baseline survey in Southwest Nigeria

BACKGROUND

To achieve the Sustainable Development Goal 3, which is to ensure healthy lives and promote well-being for all persons of all ages, street-involved young people (SIYP) must be assured of universal access to sexual and reproductive healthcare. This study aims to determine the factors associated with age- and sex-specific differences in the sexual and reproductive health (SRH) behaviour of SIYP in southwest Nigeria.

METHODS

This was a cross-sectional study that recruited 1505 SIYP aged 10-24 years by use of respondent-driven and time-location sampling. Data were collected through interviewer-administered questionnaires on socioeconomic characteristics; access to SRH information; contraceptive knowledge and use; sexual behavior; and sexual practice. The outcome variables were inconsistent condom use, multiple sexual partners, and transactional sex. Binomial regression analysis models were developed to determine risk indicators for outcome variables.

RESULTS

Although 968 (64.3%) participants were sexually active and 1089 (72.4%) knew about modern contraception, only 300 (31.0%) sexually active respondents used modern contraceptives. Knowledge of modern contraception (AOR: 0.11; 95% C.I: 0.01-0.82, p = 0.03) and being employed (AOR: 0.38; 95% C.I: 0.15-0.95, p = 0.04) reduced the odds for inconsistent condom use among male SIYPs. For female SIYPs, knowledge of modern contraception reduced the odds for inconsistent condom use (AOR: 0.26; 95% C.I: 0.08-0.90, p = 0.03), whereas access to SRH information significantly increased the odds for inconsistent condom use (AOR: 5.06; 95% C.I: 1.67-15.37, p = 0.004).

CONCLUSION

Age- and sex- related factors associated with risky sexual behaviors vary among SIYP. Addressing these differences in the delivery of targeted interventions to reduce sexual health risk of SIYP may be required.

Medical Options for Care of Gender Diverse and Transgender Youth

Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.

A Package of Sexual and Reproductive Health and Rights Interventions-What Does It Mean for Adolescents?

This article analyzes the relevance of the comprehensive definition of sexual and reproductive health and rights (SRHR) to adolescents and identifies adolescent-specific implications for the implementation of an essential package of SRHR interventions. The delivery of a comprehensive approach to SRHR targeting adolescents is underpinned by five principles-equity, quality, accountability, multisectorality, and meaningful engagement. All SRHR interventions included in the package are relevant to adolescents, given the diversity of adolescents' SRHR needs and considering their specific attributes, circumstances, and experiences. Ensuring that this package is available, accessible, and acceptable to adolescents requires an approach that looks at adolescents as being biologically and socially distinct from other age groups and acknowledges that they face some specific barriers when accessing SRHR services. This article provides cross-cutting strategies for the implementation of a comprehensive approach to SRHR for adolescents and specific considerations in delivering each intervention in the package of essential SRHR interventions. To further implement the International Conference on Population and Development Programme of Action, a prerequisite for achieving the Sustainable Development Goals, SRHR interventions must be adolescent responsive, delivered through multiple platforms, leveraging multisectoral collaboration, and strengthening accountability and participation.

Long-acting reversible contraceptives for adolescent females: a review of current best practices

PURPOSE OF REVIEW

This review will address the need for adolescent contraception, compare the benefits of long-acting reversible contraceptives (LARC) with non-LARC methods, discuss unique barriers to LARC for adolescents, and provide physicians with latest recommendations for counseling adolescents on contraception.

RECENT FINDINGS

The United States has the highest adolescent birth rate of any developed country at 18.8 births per 1000 females aged 15-19 years. This rate is more than double the rate in France (9/1000) and Spain (9/1000), and nearly 1.6× the rate in the United Kingdom (12/1000). As the most effective and user-independent methods of contraception, LARC have the potential to notably lower the adolescent birth rate. However, despite higher rates of patient satisfaction and continuation with LARC, adolescent LARC usage remains low. Just 4.3% of all American females aged 15-19 years who reported using some form of contraception between 2006 and 2010 used an intrauterine device (IUD) or subdermal implant, compared with 96% who used the male condom and 56% who used the oral contraceptive pill (OCP). Barriers to adolescent LARC usage include patient and provider misinformation, high upfront costs, and issues of confidentiality and consent.

SUMMARY

LARC methods are recommended by most reproductive and adolescent healthcare organizations as the most effective contraceptive options for adolescent females. Pediatricians should provide their adolescent patients with up-to-date information on all options for contraception, including risks and benefits. It is important for them to remove their own personal biases when counseling patients and work to reduce barriers to LARC for adolescent females.

Development of a Mobile App on Contraceptive Options for Young African American and Latina Women

Young African American and Latina women aged 15 to 24 are more likely to adopt short-acting forms of contraception over long-acting reversible contraception. Mobile applications and other forms of digital media may be useful for providing adolescents with information about sexual and reproductive health both inside and outside of the health care setting. The miPlan app was designed in accordance with principles of user experience design, and its content was informed by the theory of planned behavior and the transtheoretical model of behavior change. A university-based design team engaged young African American and Latina women to inform app development and provide input on app design, conducting multiple rounds of usability testing. Researchers then evaluated the acceptability of the miPlan app in family planning clinics among African American and Latina women aged 15 to 24. Participants rated the app highly acceptable, finding it both easy to use and highly informative. We demonstrate that mobile applications designed in conjunction with user populations may be effective at providing health information due to users' ability to identify with them and their accessibility.

MyLARC: A Theory-Based Interactive Smartphone App to Support Adolescents' Use of Long-Acting Reversible Contraception

STUDY OBJECTIVE

Develop and test the feasibility of a Health Belief Model theory-based interactive smartphone application (app) aimed at providing information and support to adolescents with long-acting reversible contraception (LARC).

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Using a mixed-method design, we conducted 30 in-person interviews with adolescent LARC users who were enrolled in school-based health centers in New York City. Interviews were conducted in 2 phases: during phase 1, 12 participants viewed a pilot version of the app (MyLARC); during phase 2, 18 additional participants interacted with an expanded version of the app. Phase 2 participants downloaded MyLARC onto their smartphone and app usage was tracked.

MAIN OUTCOME MEASURES

Participants' responses to the in-person interviews and data usage of MyLARC from phase 2 determined the feasibility and acceptability of using MyLARC to support young women's satisfaction and continuation of LARC methods.

RESULTS

Noneducational games were recommended as an approach to provide information to adolescents in an engaging way, as well as educational graphics and visually appealing content. Data tracking of MyLARC usage among phase 2 participants revealed a total of 67 unique logins to the app with 18 average page visits per unique login. The total amount of times MyLARC was opened was 1197. The most frequented features were 'Info about LARC' (95 unique visits) and 'Games' (80 unique plays).

CONCLUSION

A theory-based interactive smartphone app with LARC-specific information and support is an appropriate and appealing medium to provide information and support to adolescents using LARC. Games represented a novel opportunity to engage adolescents with health information.

"It's Pretty Hard to Tell Your Mom and Dad That You're on a Method": Exploring How an App Could Promote Adolescents' Communication with Partners and Parent(s) to Increase Self-Efficacy in Long-Acting Reversible Contraception Use

STUDY OBJECTIVE

Youth-friendly information and support are integral components to promote adolescents' successful use of long-acting reversible contraception (LARC), and smartphone apps offer a promising medium. To inform content development for an app guided by the Health Belief Model, we conducted interviews with adolescent LARC users to assess self-efficacy and experiences with LARC, their communication with partners and parent(s) about LARC, and how apps could support this communication.

DESIGN, SETTING, AND PARTICIPANTS

We conducted semistructured, in-depth interviews with 30 female adolescent LARC users enrolled in urban school-based health centers.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Descriptive analyses were used to assess demographic characteristics, experience and comfort communicating with current and future partners and parent(s) about LARC, self-efficacy around LARC, and how app elements could support LARC use.

RESULTS

Participants (mean age, 16 years; range, 14-19 years) were predominately Hispanic (77%; n = 23) and black (20%; n = 6). Almost all (97%; n = 29) had told their current partner about their LARC, but of these, only 15 (50%) would feel comfortable talking with a new sexual partner. Most participants (73%; n = 22) had not told their parent(s) about getting a LARC, but many reported they were likely to share app information with their parent(s). Of the few participants who did tell their parent(s), 38% (n = 3) reported that it was difficult to do so. Adolescents described ways in which app use could help initiate conversations with new partners and parent(s).

CONCLUSION

These findings suggest the potential of a theory-based smartphone app to meet adolescent LARC users' information and support needs. The app should include information on strategies for communicating with future partners and parent(s).

Promoting Teen Contraceptive Use by Intervention With Their Mothers

INTRODUCTION

The purpose of this pilot study was to test a community outreach model designed to help mothers in a rural, medically underserved area navigate their teen daughters to health department services for long-acting reversible contraception (LARC) or alternative contraception.

METHODS

The pilot study used a single-group, post-test only design. Mothers of teen daughters (N=142) received a 1-hour, one-to-one intervention session (in outreach settings) from Community Liaisons. Mothers received training on how to communicate with their daughters about LARC and other contraceptive methods. Data were collected from June through October 2014, and analyzed in September 2015.

RESULTS

The authors re-contacted 104 of 142 mothers enrolled in the study, achieving a 73.2% retention rate. Of these, 12.5% had daughters receiving LARC. An additional 11.0% had daughters with health department-verified initiation of birth control pills. Only one correlate-whether a mother believed her daughter was having sex-was associated with receiving either LARC or birth control pills. Among those indicating they knew their daughters were having sex, 31.7% of the daughters received LARC/birth control pills. By contrast, among mothers not indicating they knew their daughters were having sex, only 2.9% had daughters receiving LARC or birth control pills.

CONCLUSIONS

Findings suggest that an outreach-based program delivered directly to mothers of teen daughters may be a highly effective method for enhancing service utilization of LARC and the initiation of birth control pill use in a rural, medically underserved area.

Effects of Obstetric Complications on Adolescent Postpartum Contraception and Rapid Repeat Pregnancy

STUDY OBJECTIVE

To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with χ² and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables.

RESULTS

Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion (P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity (P = .002), parity (P = .003), number of previous spontaneous or therapeutic abortions (P = .026); they were also more like to have nonlive birth as a complication (P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups.

CONCLUSION

Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy.

Use of and access to oral and injectable contraceptives in Brazil

OBJECTIVE

To analyze the prevalence of current use of oral and injectable contraceptives by Brazilian women, according to demographic and socioeconomic variables and issues related to access to those medicines.

METHODS

A cross-sectional, population-based analytical study with probability sampling based on data from the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), carried out between September 2013 and February 2014 in 20,404 Brazilian urban households. Prevalence was calculated based on reports from non-pregnant women aged 15-49 on the use of oral or injectable contraceptives. The independent variables were gender, age, level of education, socioeconomic class, Brazilian region and marital status. Also analyzed were access, means of payment, sources, and reported medicines. Statistical analyses considered 95% confidence intervals (95%CI) and Pearson Chi-square test to evaluate the statistical significance of differences between groups, considering a 5% significance level.

RESULTS

Prevalence of use was 28.2% for oral contraceptives (OC) and 4.5% for injectable contraceptives (IC). The highest prevalence of oral contraceptives was in the South region (37.5%) and the lowest in the North region (15.7%). For injectable contraceptives there was no difference between regions. Access was higher for oral contraceptive users (90.7%) than injectable contraceptives users (81.2%), as was direct payment (OC 78.1%, IC 58.0%). Users who paid for contraceptives acquired them at retail pharmacies (OC 95.0% and IC 86.6%) and at Farmácia Popular (Popular Pharmacy Program) (OC 4.8% and IC 12.7%). Free of charge contraceptives were mostly obtained from the Brazilian Unified Health System - SUS (OC 86.7%; IC 96.0%). Free samples were reported by 10.4% of users who did not pay for oral contraceptives. Most of paying users did not try to obtain contraceptives from SUS. Monophasic combined oral contraceptives were the most frequently reported (71.6%) and low-level levonorgestrel + ethinylestradiol combination accounted for 38.7% of them. The most frequently reported medicines are included in the Relação Nacional de Medicamentos Essenciais (RENAME - National List of Essential Medicines.

CONCLUSIONS

Most women aged 15 to 49 who reported using contraceptives had access to the medicine and use monophasic combined oral contraceptives of appropriate efficiency and safety purchased by direct payment, mainly from retail pharmacies.

OBJETIVO

Analisar a prevalência do uso atual de contraceptivos orais e injetáveis por mulheres brasileiras, segundo variáveis demográficas, socioeconômicas e aspectos relacionados ao acesso a esses medicamentos.

MÉTODOS

Estudo transversal, analítico, baseado nos dados da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM), de base populacional e amostra probabilística, realizada entre setembro/2013 e fevereiro/2014, em 20.404 domicílios urbanos brasileiros. A prevalência foi calculada a partir do relato das mulheres de 15 a 49 anos, não grávidas, sobre o uso de contraceptivos orais ou contraceptivos injetáveis. As variáveis independentes foram sexo, idade, escolaridade, nível socioeconômico, região geográfica e situação conjugal. Também foram analisados acesso, fontes de financiamento, fontes de obtenção e medicamentos citados. As análises estatísticas consideraram intervalos de confiança de 95% (IC95%) e teste Qui-quadrado de Pearson para avaliação da significância estatística das diferenças entre os grupos, considerando o nível de significância de 5%.

RESULTADOS

A prevalência de uso de contraceptivos orais (CO) foi 28,2% e de contraceptivos injetáveis (CI), 4,5%. A prevalência de contraceptivos orais foi maior no Sul (37,5%) e menor no Norte (15,7%). Para contraceptivos injetáveis não houve diferença entre as regiões. O acesso foi maior para as usuárias de contraceptivos orais (90,7%) do que de contraceptivos injetáveis (81,2%), assim como o pagamento por desembolso direto (CO 78,1%; CI 58,0%). As usuárias que pagaram pelo contraceptivo compraram na farmácia comercial (CO 95,0% e CI 86,6%) e na Farmácia Popular (CO 4,8% e CI 12,7%). A principal fonte de obtenção gratuita foi o SUS (CO 86,7%; CI 96,0%). Amostra grátis foi citada por 10,4% das usuárias que não pagaram pelos contraceptivos orais. A maioria das usuárias que pagaram, não tentou obter no SUS. Contraceptivos orais combinados monofásico foram os mais citados (71,6%) e a combinação levonorgestrel+etinilestradiol de baixa concentração representou 38,7% destes. Os medicamentos mais citados constam na Relação Nacional de medicamentos Essenciais.

CONCLUSÕES

A maioria das mulheres entre 15 e 49 anos que referiram usar contraceptivos obteve acesso ao medicamento, usa contraceptivos orais combinados monofásico, de eficácia e segurança adequada, obtido com pagamento do próprio bolso, principalmente, nas farmácias comerciais.

Contraception for adolescents with chronic rheumatic diseases

Contraception is an important issue and should be a matter of concern in every medical visit of adolescent and young patients with chronic rheumatic diseases. This narrative review discusses contraception methods in adolescents with juvenile systemic lupus erythematosus (JSLE), antiphospholipid syndrome (APS), juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). Barrier methods are safe and their use should be encouraged for all adolescents with chronic rheumatic diseases. Combined oral contraceptives (COC) are strictly prohibited for JSLE and APS patients with positive antiphospholipid antibodies. Reversible long-acting contraception can be encouraged and offered routinely to the JSLE adolescent patient and other rheumatic diseases. Progestin-only pills are safe in the majority of rheumatic diseases, although the main concern related to its use by adolescents is poor adherence due to menstrual irregularity. Depot medroxyprogesterone acetate injections every three months is a highly effective contraception strategy, although its long-term use is associated with decreased bone mineral density. COC or other combined hormonal contraceptive may be options for JIA and JDM patients. Oral levonorgestrel should be considered as an emergency contraception method for all adolescents with chronic rheumatic diseases, including patients with contraindication to COC.

Leading With LARCs in Nigeria: The Stars Are Aligned to Expand Effective Family Planning Services Decisively

Despite years of family planning effort in Nigeria, the modern contraceptive prevalence (mCPR) has reached only 10%. Yet a few recent seminal, well-executed programs have been outstandingly successful providing long-acting reversible contraceptives (LARCs)—both in the public and private sector, and in the North and South. Remarkably, the LARCs they provided were equivalent to 2% mCPR in 2015 alone.

Accordingly, we advocate markedly increased support for: (1) private-sector approaches such as social franchising, particularly in the South, (2) mobile outreach, and (3) support to public clinical facilities, including expanding access through community health extension workers (CHEWs), particularly in the North. Success will require system support, quality, and concerted engagement from a variety of partners including the Government of Nigeria.

Without significant progress in Nigeria, the global FP2020 goal appears unattainable. Fortunately, leading with LARCs along with wide choice of other methods provides a clear avenue for success.

The Enigma of Rapid Repeat Pregnancy: A Qualitative Study of Teen Mothers

STUDY OBJECTIVE

Rapid repeat pregnancy accounts for 18% of teen pregnancies and leads to adverse health, economic, and developmental outcomes for teen mothers and their children. Few interventions have been successful in reducing rapid repeat pregnancy. In this qualitative study we examined adolescent mothers' perceptions of their decision-making and behaviors that helped prevent or promote a rapid repeat pregnancy. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Semistructured interviews were conducted with 31 adolescent mothers, aged 16-21 years; 15 of these subjects experienced a repeat pregnancy within a year of their first child's birth and 16 had not. Two researchers used a grounded, inductive technique to identify emergent themes; interviews were subsequently coded accordingly. Counts were tabulated of the number of times themes were endorsed among those with or without a repeat pregnancy.

RESULTS

Four overarching themes emerged from the interviews: intentionality regarding pregnancy planning, patients' degree of independence in making contraceptive choices, sense of control over life experience, and barriers to follow-through on contraceptive planning. Teens who had not experienced a rapid repeat pregnancy more often endorsed themes of intentionality in preventing or promoting a pregnancy, independence in decision-making, and feelings of control over their experience. Ambivalence and lack of decision-making about seeking another pregnancy were frequently endorsed by mothers who had experienced a second pregnancy.

CONCLUSION

Decision-making regarding seeking or preventing a rapid repeat pregnancy is complex for teen mothers; techniques to help support decision-making or to delay pregnancy until decision-repeat making is complete might be important in reducing rapid pregnancy.

Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers

Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.

Understanding the low uptake of long-acting reversible contraception by young women in Australia: a qualitative study

Background

Australia has high rates of teenage pregnancy compared with many Western countries. Long-acting reversible contraception (LARC) offers an effective method to help decrease unintended pregnancies; however, current uptake remains low. The aim of this study was to investigate barriers to LARC use by young women in Australia.

Methods

Healthcare professionals were recruited through publicly available sources and snowball sampling to complete an interview about young women’s access to and use of LARC. The sample consisted of general practitioners, nurses, medical directors of reproductive and sexual health organisations, a sexual health educator, and health advocates. In addition, four focus groups about LARC were conducted with young women (aged 17–25 years) recruited via health organisations and a university. The data were analysed thematically.

Results

Fifteen healthcare professionals were interviewed and four focus groups were conducted with 27 young women. Shared barriers identified included norms, misconceptions, bodily consequences, and LARC access issues. An additional barrier identified by young women was a perceived lack of control over hormones entering the body from LARC devices. Healthcare professionals also raised as a barrier limited confidence and support in LARC insertions. Strategies identified to increase contraceptive knowledge and access included increasing nurses’ role in contraceptive provision and education, improving sex education in schools, and educating parents.

Conclusions

Challenges remain for young women to be able to make informed choices about contraception and easily access services. More research is needed around innovative approaches to increase LARC knowledge and access, including examining the role of nurses in enhancing young women’s reproductive health.

Using the hospital as a venue for reproductive health interventions: a survey of hospitalized adolescents

BACKGROUND AND OBJECTIVES

Less than one-half of sexually active adolescents have received counseling regarding contraception and sexually transmitted disease (STD) from their health care provider. We hypothesized that hospitalized adolescents would be interested in receiving reproductive health education and/or STD testing. In addition, we assessed the opinion of female adolescents on initiation of contraception during hospitalization.

METHODS

A convenience sample of 13- to 18-year-old male and female adolescent patients hospitalized at a tertiary pediatric hospital were approached for inclusion. Consenting patients completed a self-administered anonymous questionnaire.

RESULTS

Questionnaires from 49 female adolescents and from 51 male adolescents were collected. Based on their answers, 37% of female adolescents and 44% of male adolescents want to learn more about contraception and/or abstinence in the hospital independent of sexual activity. Thirty percent of respondents reported a desire for STD testing in the hospital. Fifty-seven percent of female subjects answered that adolescents should be offered contraception while in the hospital.

CONCLUSIONS

Among hospitalized adolescents in this study, there was an interest in reproductive health education and contraception even among those with a primary care provider and without sexual experience. Thus, hospital-based pediatricians can play a pivotal role in expanding critical sexual health services by discussing and offering sexual health care to hospitalized adolescents. We recommend that hospitals make a brochure available to all admitted adolescents, with opportunity for follow-up discussions with their hospitalist.

'Organisation of contraceptive care' and attitudes among healthcare providers in two Swedish cities with different socio-demographic profiles

OBJECTIVE To compare contraceptive services provided by family planning clinics in Linköping and Norrköping in Östergötland County, Sweden. The two cities are of similar size but have different socio-demographic profiles. The abortion rate in Linköping (15.3 per 1000) is substantially lower than in Norrköping (21.1 per 1000). METHODS The study was performed in two steps. First, the clinics providing contraceptive services in the two cities were studied using ten pre-defined quality indicators. Thereafter, 11 healthcare providers were interviewed: six in Linköping and five in Norrköping. The interviews were analysed using qualitative content analysis. RESULTS No differences were found in the organisation of contraceptive care in the two cities. Neither city met the criteria for five of the ten quality indicators. The analysis of the interviews generated four themes: 'Guidelines and electronic record template', 'Criteria for good contraceptive counselling', 'Availability of contraception', and 'Sexual health'. The interviews revealed that the clinical leadership in Norrköping was insufficient. CONCLUSION Clinics in the two cities are organised in the same way so that differences in abortion rates cannot be related to differences in organisation. The reasons for the differences in abortion rates in the two cities have yet to be determined.

Predicting painful or difficult intrauterine device insertion in nulligravid women

OBJECTIVE

To assess the relationship of preinsertion vaginal ultrasound assessment and menstrual and gynecologic history as predictors of difficult or painful intrauterine device insertion in nulligravid women.

METHODS

Nulligravid women seeking contraception were invited to participate in this nonrandomized study and given the choice between the levonorgestrel-releasing intrauterine system or a copper-releasing intrauterine device. All 165 enrolled women were interviewed and a pelvic examination, including vaginal ultrasonography, was performed before insertion. Insertion difficulties and pain intensity were recorded and assessed against uterine measurements and background characteristics.

RESULTS

Most insertions were assessed as easy (n=144 [89.4%]) and only two (1.2%) failed. Most women had uterine measurements smaller than the studied devices. Odds for difficulties at insertion decreased with every increasing millimeter in total uterine length (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.78-0.96, P=.006) and cervical length (OR 0.85, 95% CI 0.74-0.97, P=.02) and similarly with every decreasing degree of (straighter) flexion angle (OR 0.96, 95% CI 0.94-0.99, P=.005). No absolute threshold measurements could be determined. Still, the majority of insertions in small and flexed uteri were uneventful. Severe insertion pain was common (n=94 [58.4%]). Severe dysmenorrhea was the only predictor of insertion pain (OR 8.16 95% CI 2.56-26.02, P<.001).

CONCLUSION

Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure. Although smaller uterine length measurements and steeper flexion angle more often predicted difficulties, the majority of insertions were uneventful in women with small measures. Dysmenorrhea was the only predictor of pain.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01685164.

LEVEL OF EVIDENCE

II.

Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women

CONTEXT

Long-acting reversible contraceptive (LARC) methods are recommended for young women, but access is limited by cost and lack of knowledge among providers and consumers. The Colorado Family Planning Initiative (CFPI) sought to address these barriers by training providers, financing LARC method provision at Title X-funded clinics and increasing patient caseload.

METHODS

Beginning in 2009, 28 Title X-funded agencies in Colorado received private funding to support CFPI. Caseloads and clients' LARC use were assessed over the following two years. Fertility rates among low-income women aged 15-24 were compared with expected trends. Abortion rates and births among high-risk women were tracked, and the numbers of infants receiving services through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were examined.

RESULTS

By 2011, caseloads had increased by 23%, and LARC use among 15-24-year-olds had grown from 5% to 19%. Cumulatively, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008. Compared with expected fertility rates in 2011, observed rates were 29% lower among low-income 15-19-year-olds and 14% lower among similar 20-24-year-olds. In CFPI counties, the proportion of births that were high-risk declined by 24% between 2009 and 2011; abortion rates fell 34% and 18%, respectively, among women aged 15-19 and 20-24. Statewide, infant enrollment in WIC declined 23% between 2010 and 2013.

CONCLUSIONS

Programs that increase LARC use among young, low-income women may contribute to declines in fertility rates, abortion rates and births among high-risk women.

Contraceptive needs of the adolescent

The provision of contraception to adolescents requires specific attention. Adolescents require contraceptive methods which are safe, effective and simple to use. While long-acting reversible contraceptive methods are preferable, they should have a choice and not be forced or mandated especially in situations where this may compromise safety. After counselling they should have the ability to choose any method of contraception. Under the appropriate circumstances, each method of contraception may have a place. This chapter will be devoted to evaluating the most current scientific rationale for the indication for use of each method of contraception in adolescents.

Pregnancy intention and use of contraception among Hispanic women in the United States: data from the National Survey of Family Growth, 2006-2010

BACKGROUND

Both unintended and adolescent childbearing disproportionately impact the Hispanic population of the United States.

METHODS

We used the 2006-2010 National Survey of Family Growth (NSFG) to provide the most recent, nationally representative description of pregnancy, childbearing, and contraception for Hispanic females aged 15-44. We determined baseline fertility data for self-identified Hispanic female respondents. Among those reporting a pregnancy history, we calculated the proportion of pregnancies identified as unintended and their association with sociodemographic variables. We also assessed outcomes and estimates of relative risk for unintended pregnancy. Finally, we examined contraceptive use prior to self-reported unintended pregnancies.

RESULTS

Approximately 70% of Hispanic women reported ever being pregnant, including 18% of teenagers. Over half (51%) of those pregnancies were unintended, including 81% among teenagers. The adjusted risk of unintended pregnancy was highest in women 15 to 19 years old and those with three or more pregnancies (incidence rate ratio [IRR] 1.64, 95% confidence interval [CI]: 1.44-1.88 and IRR 1.77, 95% CI: 1.53-2.06, respectively). Half of unintended pregnancies were preceded by no contraception. The most common reason for unintended pregnancy preceded by contraception was "improper use" (45%) and among pregnancies without use, the most common response (37%) was "I did not think I could get pregnant."

CONCLUSIONS

There is a high frequency of unintended pregnancy and lack of contraceptive use among Hispanic women. These findings highlight the need for improved reproductive education and contraceptive counseling in this population.