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Qureshey EJ, Chen HY, Wagner SM, Chauhan SP, Fishel Bartal M. Factors associated with long-acting reversible contraception usage: Results from the National Survey of Family Growth. Int J Gynaecol Obstet 2023; 161:71-78. [PMID: 36181291 DOI: 10.1002/ijgo.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to identify factors associated with long-acting reversible contraception (LARC) usage. METHODS The current cross-sectional study used data from the National Survey of Family Growth from 2011 to 2019. Respondents aged 15 to 44 years were included. Those with previous sterilization, infertility, or pregnant were excluded. The outcome evaluated was use of a LARC. RESULTS Of 61 543 814 women, 44 287 911 (72.0%) met inclusion criteria. The rate of LARC use was 13.4%. Factors associated with an increased likelihood of LARC usage were married/living with a partner (adjusted relative risk [aRR], 1.18 [95% CI, 1.02-1.37]), perceived good health (aRR, 1.44 [95% CI, 1.13-1.84]), year of survey 2017 to 2019 (aRR, 1.53, [95% CI, 1.28-1.83]), one or two past pregnancies (aRR, 1.62 [95% CI, 1.24-2.12]) or three or more past pregnancies (aRR, 1.67 [95% CI, 1.22-2.28]), age at first live birth <20 years (aRR, 1.58 [95% CI, 1.20-2.08]) or 20 to 24 years (aRR, 1.45 [95% CI, 1.13-1.87]), age at onset of sexual activity 13-19 years (aRR, 1.50 [95% CI, 1.26-1.78]), and a 0- to 5-month period of nonintercourse in the past year (aRR, 1.63 [95% CI, 1.40-1.90]). Factors associated with decreased LARC usage were age ≥ 35 years (aRR, 0.74 [95% CI, 0.65-0.85]), being non-Hispanic Black (aRR, 0.75 [95% CI, 0.62-0.89]) or non-Hispanic other (aRR, 0.72 [95% CI, 0.59-0.88]), intending to have children (aRR, 0.65 [95% CI, 0.57-0.74]), and never being sexually active (aRR, 0.10 [95% CI, 0.06-0.16]). CONCLUSIONS Using a nationally representative sample of women in the United States, the authors identified modifiable factors associated with LARC use. Results may be used to plan interventional trials to increase LARC usage.
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Affiliation(s)
- Emma J Qureshey
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Han-Yang Chen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Stephen M Wagner
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Ventura LM, Beatty KE, Khoury AJ, Smith MG, Ariyo O, Slawson DL, Weber AJ. Contraceptive Access at Federally Qualified Health Centers During the South Carolina Choose Well Initiative: A Qualitative Analysis of Staff Perceptions and Experiences. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 2:608-620. [PMID: 35141709 PMCID: PMC8820399 DOI: 10.1089/whr.2021.0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/20/2022]
Abstract
Introduction: Federally qualified health centers (FQHCs) provide essential contraceptive services to low-income individuals; yet, access to all method options, notably intrauterine devices (IUDs) and implants, may be limited at non-Title X FQHCs. The South Carolina (SC) Choose Well initiative is a statewide contraceptive access initiative that was launched in 2017 and extends into 2022. Choose Well established a collaborative network between training and clinical partners and is aimed at facilitating implementation of contraceptive care best practices through capacity-building and training of clinical and administrative staff in partner organizations. The initiative provided funding for workforce expansion and contraceptive methods. We examined perceptions of staff from Choose Well-participating FQHCs regarding contraceptive access during the first 2 years of the initiative, including factors that facilitated or posed access challenges as well as sustaining factors. This study informs the process evaluation of Choose Well while providing data critical for uncovering and scaling up contraceptive access initiatives. Materials and Methods: Interviews were conducted with FQHC staff (n = 34) in 2018 and 2019 to assess Choose Well implementation and were recorded, transcribed, and double-coded via at least 80% interrater reliability or consensus coding. Data were analyzed according to clinical and administrative factors influencing contraceptive access. Results: Increased capacity for contraceptive counseling and provision through training and external funding for IUDs and implants were the most noted clinical factors facilitating access. Streamlining workflow processes was also a facilitator. Buy-in and engagement among staff and leadership emerged as a facilitator at some clinics and as a barrier at others. Policy/structural factors related to costs of devices and insurance coverage were identified as threats to sustainability. Conclusions: The Choose Well initiative contributed to the perception of an increase in contraceptive access at participating FQHCs in SC. Statewide contraceptive access initiatives have the potential to support FQHCs in meeting their clients' contraceptive needs. Organizational buy-in, sustainability of funding, and training are key to realizing the full potential of these initiatives.
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Affiliation(s)
- Liane M Ventura
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Kate E Beatty
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Amal J Khoury
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Michael G Smith
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Oluwatosin Ariyo
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Deborah L Slawson
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Amy J Weber
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
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Matsushita T, Hasegawa T, Noma H, Ota E, Chou VB, Okada Y. Interventions to increase access to long-acting reversible contraceptives. Hippokratia 2021. [DOI: 10.1002/14651858.cd014987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomomi Matsushita
- Department of Obstetrics and Gynaecology; Showa University School of Medicine; Tokyo Japan
| | - Takeshi Hasegawa
- Showa University Research Administration Center (SURAC); Showa University; Tokyo Japan
| | - Hisashi Noma
- Department of Data Science; The Institute of Statistical Mathematics; Tokyo Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science; St. Luke's International University; Chuo-ku Japan
| | - Victoria B Chou
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland USA
| | - Yoshiyuki Okada
- Department of Obstetrics and Gynecology; Showa University Northern Yokohama Hospital; Kanagawa Japan
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4
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Chakraborty P, Gallo MF, Nawaz S, Smith MH, Hood RB, Chettri S, Bessett D, Norris AH, Casterline J, Turner AN. Use of nonpreferred contraceptive methods among women in Ohio. Contraception 2021; 103:328-335. [PMID: 33607120 PMCID: PMC10104247 DOI: 10.1016/j.contraception.2021.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 02/06/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Payal Chakraborty
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States.
| | - Maria F Gallo
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States
| | - Saira Nawaz
- The Ohio State University, College of Public Health, Center for Health Outcomes, Policy, and Evaluation Studies, Columbus, OH, United States
| | - Mikaela H Smith
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States
| | - Robert B Hood
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States
| | - Shibani Chettri
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States
| | - Danielle Bessett
- University of Cincinnati, Department of Sociology, Cincinnati, OH, United States
| | - Alison H Norris
- The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, United States
| | - John Casterline
- The Ohio State University, College of Arts and Sciences, Department of Sociology, Columbus, OH, United States
| | - Abigail Norris Turner
- The Ohio State University, College of Medicine, Division of Infectious Diseases, Columbus, OH, United States
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Biggs MA, Tome L, Mays A, Kaller S, Harper CC, Freedman L. The Fine Line Between Informing and Coercing: Community Health Center Clinicians' Approaches to Counseling Young People About IUDs. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2020; 52:245-252. [PMID: 33289277 DOI: 10.1363/psrh.12161] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 06/12/2023]
Abstract
CONTEXT While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care. METHODS As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians' contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects. RESULTS Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher-efficacy methods and respecting patients' choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects. CONCLUSIONS Providers try to promote their young patients' autonomous decision making, but their support for high-efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient-centered counseling approaches, including honoring patient requests for removals.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Lucia Tome
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aisha Mays
- Department of Family and Community Medicine, University of California, San Francisco
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco
| | - Lori Freedman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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Edwards S, Mercier R, Perriera L. Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter? J Obstet Gynaecol Res 2020; 47:501-507. [PMID: 33145878 DOI: 10.1111/jog.14552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/16/2020] [Accepted: 10/16/2020] [Indexed: 11/27/2022]
Abstract
AIM The intrauterine device (IUD) is highly effective birth control, but US IUD usage lags. Barriers to usage, including patient attitudes and lack of knowledge, are not well-characterized. This study sought to investigate how attitudes and knowledge about IUD vary by age and race. METHODS A survey was distributed to all women in the outpatient obstetrics and gynecology office of a large, urban, academic medical center in Philadelphia. Exclusion criteria included inability to read English or age less than 14 years. Surveys queried participant demographics, knowledge about and opinions of IUD. The authors performed exploratory bi-variable analysis using t tests and chi-square testing to determine which outcomes differed by age and race. For those differing significantly, the authors performed regression analysis to assess for confounding by other factors. RESULTS Of 1366 women approached, 521 completed the survey (38% response rate). After controlling for confounding, only responses to the statement 'Hormonal birth control is safe and effective' differed significantly by age. Knowledge about IUD did not differ significantly by race, but black women were significantly more likely to perceive that they had insufficient knowledge about IUD compared to white women (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.06-3.46). Black women had a more negative opinion of IUD safety (OR: 5.0; 95% CI: 2.35-10.66) and reliability (OR: 5.5; 95% CI: 2.20-14.13) than white women. CONCLUSION Attitudes and knowledge about IUD do not differ significantly by age. While knowledge about IUD is similar between races, black women may have more negative opinions of IUD.
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Affiliation(s)
- Sara Edwards
- Thomas Jefferson Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, USA
| | - Rebecca Mercier
- Thomas Jefferson Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, USA
| | - Lisa Perriera
- Thomas Jefferson Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania, USA
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Davis CMA, Kaneshiro B, Tschann M. Insights in Public Health: Insurance Coverage for Long-Acting Reversible Contraception Placed in Office: A Buy and Bill Demonstration Project in Hawai'i. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2020; 79:312-316. [PMID: 33047106 PMCID: PMC7547176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Chevelle M A Davis
- Office of Public Health Studies, University of Hawai'i at Mānoa, Honolulu, HI (CMAD)
| | - Bliss Kaneshiro
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, HI (BK, MT)
| | - Mary Tschann
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, HI (BK, MT)
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Harrison MS, Zucker R, Scarbro S, Sevick C, Sheeder J, Davidson AJ. Postpartum Contraceptive Use Among Denver-Based Adolescents and Young Adults: Association with Subsequent Repeat Delivery. J Pediatr Adolesc Gynecol 2020; 33:393-397.e1. [PMID: 32251837 PMCID: PMC7650863 DOI: 10.1016/j.jpag.2020.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/27/2020] [Accepted: 03/29/2020] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To determine the association of postpartum contraceptive use with repeat deliveries among adolescents and youth. DESIGN Retrospective, observational analysis of electronic health record data. SETTING Single, urban facility in Denver, Colorado, United States. PARTICIPANTS Women aged 10-24 years who gave birth between January 1, 2011 and December 31, 2015. INTERVENTIONS AND MAIN OUTCOME MEASURES Postpartum contraceptive use and time to subsequent delivery. RESULTS Among 4068 women, 1735 (43%) used postpartum contraception. In adjusted analyses, characteristics associated with contraceptive use included Hispanic ethnicity (relative risk [RR], 1.1; P = .03), incremental prenatal visits (RR, 1.01; P = .047), and attendance at postpartum care (RR, 1.60; P < .001). Long-acting reversible contraceptive (LARC) use was higher among women younger than 15 years (reference: 20-24 years; RR, 1.12; P < .001) and lower among women aged 18-19 years (RR, 0.93; P = .009). Hispanic women had higher rates of LARC use than non-Hispanic women (RR, 1.07; P = .02). Compared with inpatient LARC placement, outpatient placement (1-4 weeks and 5 or more weeks) rates were lower (RR, 0.77 and RR, 0.89, respectively; P < .001). Time to subsequent delivery was shorter in non-LARC users (median, 659 days) and contraception nonusers (median, 624 days) compared with LARC users (median, 790 days; P < .001); non-LARC postpartum contraceptive use did not significantly alter time to repeat delivery compared with that in women who used no method (P = .24). CONCLUSION Postpartum LARC use reduced the risk of repeat pregnancy with a significant increase in time to the next delivery. Non-LARC use was not different from no contraceptive use in terms of time to repeat delivery.
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Affiliation(s)
- Margo S Harrison
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Aurora, Colorado.
| | - Rachel Zucker
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Sharon Scarbro
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Carter Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeanelle Sheeder
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Aurora, Colorado
| | - Arthur J Davidson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado; Denver Public Health, Denver Health, Denver, Colorado
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The effect of an educational video on long-acting reversible contraception (LARC) utilization at 6-8 weeks postpartum period: a randomized controlled trial. Arch Gynecol Obstet 2020; 302:1503-1509. [PMID: 32734413 DOI: 10.1007/s00404-020-05710-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/25/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Long-acting reversible contraception is highly effective in preventing unintended pregnancy and unsafe abortion. An educational video administered during early postpartum period might be an effective tool to improve postpartum LARC use. The objectives were to evaluate whether a postpartum educational video about LARC could increase postpartum LARC utilization at 6-8 weeks postpartum and to assess why postpartum women did not receive LARC. METHODS This randomized-controlled trial was conducted at the postpartum unit of a university Hospital between August 2016 and February 2017. Postpartum women who were aged > 20 years and willing to participate were recruited. Participants allocated to the study group watched the 7-min educational video on LARC methods while the control group did not. To assess LARC utilization, data were collected at 6-8 weeks postpartum using telephone calls and/or medical record review to determine postpartum contraception use and reasons for not using LARC. RESULTS Two-hundred and seventy participants were enrolled, and the video (135) and non-video (135) groups had similar baseline characteristics. In the video group, 57.8% (95% CI 49.0-66.2) reported using a LARC method, compared to 25.9% (95% CI 18.8-34.2) in the non-video group (p < 0.05). The reasons for not using LARC in both groups were inconvenience of access (42.0-43.8%) and uncertainty about methods (17.0-24.6%). CONCLUSION The educational video introduced at immediate postpartum period was efficacious in increasing the utilization of LARC at 6-8 weeks postpartum. Inconvenience of access was the most common reason cited for not using LARC. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.in.th TCTR20171225001 "retrospectively registered".
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Kaller S, Mays A, Freedman L, Harper CC, Biggs MA. Exploring young women's reasons for adopting intrauterine or oral emergency contraception in the United States: a qualitative study. BMC Womens Health 2020; 20:15. [PMID: 31992295 PMCID: PMC6986082 DOI: 10.1186/s12905-020-0886-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recent focus on increasing access to long-acting reversible contraceptive methods has often overlooked the diverse reasons why women may choose less effective methods even when significant access barriers have been removed. While the copper intrauterine device (IUD) is considered an acceptable alternative to emergency contraception pills (ECPs), it is unclear to what extent low rates of provision and use are due to patient preferences versus structural access barriers. This study explores factors that influence patients' choice between ECPs and the copper IUD as EC, including prior experiences with contraception and attitudes toward EC methods, in settings where both options are available at no cost. METHODS We telephone-interviewed 17 patients seeking EC from three San Francisco Bay Area youth-serving clinics that offered the IUD as EC and ECPs as standard practice, regarding their experiences choosing an EC method. We thematically coded all interview transcripts, then summarized the themes related to reasons for choosing ECPs or the IUD as EC. RESULTS Ten participants left their EC visit with ECPs and seven with the IUD as EC option. Women chose ECPs because they were familiar and easily accessible. Reasons for not adopting the copper IUD included having had prior negative experiences with the IUD, concerns about its side effects and the placement procedure, and lack of awareness about the copper IUD. Women who chose the IUD as EC did so primarily because of its long-term efficacy, invisibility, lack of hormones, longer window of post-coital utility, and a desire to not rely on ECPs. Women who chose the IUD as EC had not had prior negative experiences with the IUD, had already been interested in the IUD, and were ready and able to have it placed that day. CONCLUSIONS This study highlights that women have varied and well-considered reasons for choosing each EC method. Both ECPs and the copper IUD are important and acceptable EC options, each with their own features offering benefits to patients. Efforts to destigmatize repeated use of ECPs and validate women's choice of either EC method are needed to support women in their EC method decision-making.
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Affiliation(s)
- Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Aisha Mays
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Lori Freedman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 3333 California St, Suite 335, San Francisco, CA 94143 USA
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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Immediate Postpartum Long-Acting Reversible Contraception Programs in Texas Hospitals Following Changes to Medicaid Reimbursement Policy. Matern Child Health J 2019; 23:1595-1603. [PMID: 31363887 DOI: 10.1007/s10995-019-02763-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption. METHODS Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services. RESULTS Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs. CONCLUSIONS FOR PRACTICE We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.
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Krishnaswami J, del C. Colon-Gonzalez M. Reforming Women's Health Care: A Call to Action for Lifestyle Medicine Practitioners to Save Lives of Mothers and Infants. Am J Lifestyle Med 2019; 13:495-504. [PMID: 31523215 PMCID: PMC6732876 DOI: 10.1177/1559827619838461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/21/2019] [Indexed: 12/16/2022] Open
Abstract
Maternal and infant mortality are fundamental indicators of a society's health and wellness. These measures depict a health crisis in the United States. Compared with other rich countries, women in the United States more frequently die from pregnancy or childbirth, and infants are less likely to survive to their first birthday. Most of these deaths are preventable; disproportionately affect diverse, low-income groups; and are perpetuated by social and health care inequities and subpar preventive care. Lifestyle medicine (LM) is uniquely positioned to ameliorate this growing crisis. The article presents key prescriptions for LM practitioners to build health and health equity for women. These prescriptions, summarized by the acronym PURER, include action in the areas of (1) practice, (2) understanding/empathy, (3) reform, (4) empowerment, and (5) relationship health. The PURER approach focuses on partnering with diverse female patients to promote resilience, promoting social connection and engagement, facilitating optimal family planning and advocating for culturally responsive, equitable health care systems. Through PURER, LM practitioners can help women and partners resiliently overcome the harmful challenges of discrimination and stress characterizing present-day American life. Over time, the equitable and collective practice of LM can help ameliorate the health care barriers undermining the health of women, families, and society.
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Affiliation(s)
- Janani Krishnaswami
- Internal Medicine / Preventive Medicine, University
of Texas Rio Grande Valley. Texas (MDCCG)
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Pfitzer A, Hyjazi Y, Arnold B, Aribot J, Hobson RD, Pleah TG, Turke S, O'Colmain B, Arscott-Mills S. Findings and Lessons Learned From Strengthening the Provision of Voluntary Long-Acting Reversible Contraceptives With Postabortion Care in Guinea. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S271-S284. [PMID: 31455624 PMCID: PMC6711623 DOI: 10.9745/ghsp-d-18-00344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 02/18/2019] [Indexed: 11/20/2022]
Abstract
Integrating voluntary long-acting reversible contraceptive (LARC) methods within postabortion care (PAC) in Guinea has increased LARC uptake among PAC clients, compared with non-PAC clients. With aid from government champions and leveraging of resources, Guinea has incorporated PAC into national policies and guidelines and trained providers on PAC and LARCs to expand service provision. Integrating voluntary family planning into postabortion care (PAC) presents a critical opportunity to reduce future unintended pregnancies. Although Guinea has low contraceptive prevalence overall, acceptance of long-acting reversible contraceptives (LARCs) among PAC clients is higher than among interval LARC users and higher than the national average. In 2014, we assessed the extent of LARC provision within PAC services and the factors influencing integration. Primary and secondary data collected from 143 interviews, 75 provider assessments, and facility inventories and service statistics from all 38 public facilities providing PAC in Guinea allowed exploration of voluntary family planning uptake in the context of PAC. Study findings showed that 38 of 456 (8.3%) public health facilities or 38 of 122 (31.1%) facilities with a mandate to manage obstetric complications provided PAC services. Service statistics from 4,544 PAC clients in 2013 indicate that 95.2% received counseling and 73.0% voluntarily left the facility with contraception, with 29.6% of acceptors choosing a LARC. Family planning within PAC was emphasized in advocacy, policy and guidelines, quality improvement, and supervision, and the range of contraceptive options for postabortion clients was expanded to enable them to avoid a second unintended pregnancy. Factors that influenced provision of family planning within PAC included (1) the ability of champions both within and outside the Ministry of Public Health to advocate for PAC and leverage donor resources, (2) the incorporation of PAC with postabortion family planning into national policies, standards, and guidelines, (3) training of large numbers of providers in PAC and LARCs, and (4) integration of LARCs within PAC into quality improvement and supervision tools and performance standards. Guinea has gradually scaled up provision of PAC services nationwide and its experience may offer learning opportunities for other countries; however, continued advocacy for further expansion to more rural areas of the country and among private health facilities is necessary.
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Affiliation(s)
| | | | | | | | | | | | - Shani Turke
- Bill & Melinda Gates Institute for Population and Reproductive Health, Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Abidjan, Côte d'Ivoire
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Onyewuchi UF, Tomaszewski K, Upadhya KK, Gupta PS, Whaley N, Burke AE, Trent ME. Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting. Clin Pediatr (Phila) 2019; 58:24-33. [PMID: 30318927 PMCID: PMC6261697 DOI: 10.1177/0009922818805234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.
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Affiliation(s)
| | | | | | - Priya S. Gupta
- Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Anne E. Burke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria E. Trent
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kroelinger CD, Morgan IA, DeSisto CL, Estrich C, Waddell LF, Mackie C, Pliska E, Goodman DA, Cox S, Velonis A, Rankin KM. State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies. J Womens Health (Larchmt) 2018; 28:346-356. [PMID: 30388052 DOI: 10.1089/jwh.2018.7083] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation. MATERIALS AND METHODS Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified. RESULTS The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities. CONCLUSIONS Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.
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Affiliation(s)
- Charlan D Kroelinger
- 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion , CDC, Atlanta, Georgia
| | - Isabel A Morgan
- 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion , CDC, Atlanta, Georgia .,2 Association of Schools and Programs of Public Health , Washington, District of Columbia
| | - Carla L DeSisto
- 3 Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | - Cameron Estrich
- 4 Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | - Lisa F Waddell
- 5 Association of State and Territorial Health Officials , Arlington, Virginia
| | - Christine Mackie
- 5 Association of State and Territorial Health Officials , Arlington, Virginia
| | - Ellen Pliska
- 5 Association of State and Territorial Health Officials , Arlington, Virginia
| | - David A Goodman
- 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion , CDC, Atlanta, Georgia
| | - Shanna Cox
- 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion , CDC, Atlanta, Georgia
| | - Alisa Velonis
- 3 Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | - Kristin M Rankin
- 3 Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago , Chicago, Illinois
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Monteiro I, Guazzelli CF, Bahamondes L. Advances in contraceptive vaginal rings: what does the future hold? Expert Opin Pharmacother 2018; 19:1685-1691. [PMID: 30286682 DOI: 10.1080/14656566.2018.1519549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Contraceptive vaginal rings (CVRs) are good contraceptive options because they do not require skilled providers, are self-administered, and show a higher stability of drug diffusion. AREAS COVERED This article provides a review of the developments made with CVRs over the past number of years, while giving focus to the latest CVRs that have gone through clinical development. The author of the article also provides an expert perspective on the future of these useful therapeutic options. EXPERT OPINION Pharmacokinetic studies have shown that segesterone, an absorbable progestin that is used alone or in combination with ethinyl estradiol (EE) or E2, is the CVR of choice at this present time. Indeed, segesterone has demonstrated safety and efficacy as a CVR and is also an appropriate option for lactating women, as they are not absorbed orally. However, good cycle control is important for improved CVR adherence. CVRs that allow the combination of more than one drug may unravel another multi-purpose use when combined with microbicides and could provide combined protection to women who wish to protect themselves from pregnancy and sexually transmitted infection.
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Affiliation(s)
- Ilza Monteiro
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
| | - Cristina Falbo Guazzelli
- b Family Planning clinic, Department of Obstetrics and Gynecology , University of Campinas Medical School , São Paulo , Brazil
| | - Luis Bahamondes
- a Family Planning clinic, Department of Obstetrics and Gynecology , Federal University of Medical School , São Paulo, Campinas , Brazil
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Jacovetty EL, Clare CA, Squire MB, Kubal KP, Liou S, Inchiosa MA. Clinical oversight and the avoidance of repeat induced abortion. Int J Gynaecol Obstet 2018; 142:349-353. [PMID: 29862496 DOI: 10.1002/ijgo.12543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/19/2018] [Accepted: 06/01/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the impact of patient counseling, demographics, and contraceptive methods on repeat induced abortion in women attending family planning clinics. METHODS A retrospective chart review of repeat induced abortions was performed. The analysis included patients with an initial induced abortion obtained between January 1, 2001, and March 31, 2014, at New York City Health + Hospitals/Metropolitan. The duration of involvement in the family planning program, the use of contraceptive interventions, and 18 patient factors were analyzed for their correlation with the incidence of repeat induced abortions per year of follow-up. RESULTS A decreased rate of repeat induced abortions was associated with a longer duration of clinical oversight (r2 =0.449, P<0.001), a higher contraceptive efficacy score (r=0.280, P=0.025), and a larger number of clinic visits for contraception (r=0.333, P=0.007). CONCLUSION A continuum of contact with all of the services of a family planning clinic demonstrated a strong efficacy to limit repeat induced abortions. By determining the patient characteristics that most influence repeat induced abortion rates, providers can best choose the most efficacious method of contraception available.
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Affiliation(s)
- Erica L Jacovetty
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, USA
| | - Camille A Clare
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, USA
| | - Mary-Beatrice Squire
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, USA
| | - Keshar P Kubal
- Department of Anesthesiology, New York Medical College, Valhalla, NY, USA
| | - Sherry Liou
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Mario A Inchiosa
- Department of Anesthesiology, New York Medical College, Valhalla, NY, USA.,Department of Pharmacology, New York Medical College, Valhalla, NY, USA
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Fischbein RL, Lanese BG, Falletta L, Hamilton K, King JA, Kenne DR. Pregnant or recently pregnant opioid users: contraception decisions, perceptions and preferences. Contracept Reprod Med 2018; 3:4. [PMID: 29610676 PMCID: PMC5870942 DOI: 10.1186/s40834-018-0056-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 03/14/2018] [Indexed: 12/25/2022] Open
Abstract
Background Multiple factors are linked to extremely high unintended pregnancy rates among women who use opioids, including various barriers to contraception adherence. These include patient level barriers such as lack of knowledge and education about highly effective contraception, and potential provider barriers. Using a mixed-methods framework to examine the contraception-related perceptions and preferences of opioid using women is a necessary next step to understanding this phenomenon. Methods A mixed-method study was conducted which included both self-report questionnaires along with a semi-structured qualitative interview of opioid-using pregnant or recently pregnant women in two drug treatment facilities in Ohio. Results Forty-two women completed the study. The majority of recent (75%) and total pregnancies were unintended. Male condoms were reported as the highest form of lifetime contraception used within the present sample (69%). Participants reported low lifetime use of long acting reversible contraception (LARC) (ranging from 5 to 12%). Participants preferred hormonal injections first (40%), followed by IUDs (17%). Reasons for preferences of injections and LARC were similar: not needing to remember, side effects, and long-term effectiveness. Conclusions Most of the study population participants stated they would utilize contraception, particularly Tier 1 LARC methods, if freely available; however, high rates of unintended pregnancy were observed in this sample. This indicates the need for contraception education, and addressing the procedural, logistical and economic barriers that may be preventing the use of LARC among this population.
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Affiliation(s)
- Rebecca L Fischbein
- 1Department of Family and Community Medicine, Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, OH 44272 USA
| | - Bethany G Lanese
- 2College of Public Health, Department of Health Policy and Management, Kent State University, 750 Hilltop Drive, 322 Lowry Hall, P.O. Box 5190, Kent, OH 44242 USA
| | - Lynn Falletta
- 2College of Public Health, Department of Health Policy and Management, Kent State University, 750 Hilltop Drive, 322 Lowry Hall, P.O. Box 5190, Kent, OH 44242 USA
| | - Kelsey Hamilton
- 2College of Public Health, Department of Health Policy and Management, Kent State University, 750 Hilltop Drive, 322 Lowry Hall, P.O. Box 5190, Kent, OH 44242 USA
| | - Jennifer A King
- Old Brooklyn Community Development Corporation, Cleveland, OH USA
| | - Deric R Kenne
- 2College of Public Health, Department of Health Policy and Management, Kent State University, 750 Hilltop Drive, 322 Lowry Hall, P.O. Box 5190, Kent, OH 44242 USA
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Vanya M, Devosa I, Barabás K, Bártfai G, Kozinszky Z. Choice of contraception at 6-8 weeks postpartum in south-eastern Hungary. EUR J CONTRACEP REPR 2018; 23:52-57. [PMID: 29393708 DOI: 10.1080/13625187.2017.1422238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aims of the study were to describe the sociodemographic determinants, breastfeeding- and sexual life-related predictive factors of contraceptive use at 6-8 weeks postpartum. METHODS A prospective, web-based questionnaire survey was carried out by distributing an access code to women immediately after delivery at the Department of Obstetrics and Gynaecology, the University of Szeged, Szeged, Hungary, between 1 September 2013 and 1 May 2015. RESULTS In total, 1875 women were invited to participate in the study, 632 of whom refused or were excluded and 644 were not sexually active. The remaining sexually active women (n = 599) completed the questionnaire. At 6-8 weeks postpartum, 22.5% were using an effective contraceptive method and 40.2% were relying on lactational amenorrhoea (LAM). We found a significant direct association between the educational level of a woman's partner and her use of an effective contraceptive method (p < .001) (adjusted odds ratio [AOR]: 1.9) or LAM (AOR: 1.49). Use of an effective contraceptive method before pregnancy increased the likelihood of using the same method after delivery (AOR: 3.16) and decreased the likelihood of LAM use at weeks 6-8 (AOR: 0.31). The AOR for effective contraceptive use was 2.23 times higher in women who had sexual intercourse once or more a week compared with those who had sexual intercourse less frequently. CONCLUSIONS Concerted efforts to promote the use of long-acting reversible contraception (LARC) are required, particularly among women who would like future childbearing. Further research is needed on the factors contributing to the low uptake of LARC in this population.
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Affiliation(s)
- Melinda Vanya
- a Health Research and Health Promotion Research Group, Teacher Training Faculty , Pallas Athena University , Kecskemét , Hungary.,b MEDITEAM Szeged Co. Ltd. , Szeged , Hungary.,c Department of Obstetrics and Gynaecology , Pándy Kálmán Hospital , Gyula , Hungary
| | - Iván Devosa
- a Health Research and Health Promotion Research Group, Teacher Training Faculty , Pallas Athena University , Kecskemét , Hungary.,d Hungarian Academy of Sciences , Academic Committee of Szeged, Education Committee on Theoretical Education , Szeged , Hungary
| | - Katalin Barabás
- e Department of Behavioural Sciences, Faculty of General Medicine , Albert Szent-Györgyi Health Centre, University of Szeged , Szeged , Hungary
| | - György Bártfai
- f Department of Obstetrics and Gynaecology, Faculty of General Medicine , Albert Szent-Györgyi Health Centre, University of Szeged , Szeged , Hungary
| | - Zoltan Kozinszky
- a Health Research and Health Promotion Research Group, Teacher Training Faculty , Pallas Athena University , Kecskemét , Hungary.,g Department of Obstetrics and Gynaecology , Blekinge Hospital , Karlskrona , Sweden
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Abstract
PURPOSE OF REVIEW Injectable contraception is a highly effective form of birth control that is globally popular. Recent research has focused on ways to make injectables such as depot medroxyprogesterone acetate (DMPA) more accessible and to improve the side-effect profile of injectables. This review will focus on new directions and approaches to the use of injectable contraception. RECENT FINDINGS Research in the area of injectable contraception has focused on improving access for women through home or self-injection, and also task-shifting and community-based distribution in low-resource areas. Specific to DMPA, studies have focused on lowering the overall dose of medication while maintaining efficacy, and improving drug-delivery systems. More research into the association between DMPA and HIV is needed, and also the effects of administration of DMPA at the time of medication abortion. SUMMARY Injectable contraceptives are an important part of the global method mix of highly effective birth control. Improving the accessibility and side effect profile of commodities such as DMPA will make injectables even more valuable for women seeking effective contraception.
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Understanding Factors Associated with Postpartum Visit Attendance and Contraception Choices: Listening to Low-Income Postpartum Women and Health Care Providers. Matern Child Health J 2017; 20:132-143. [PMID: 27342600 PMCID: PMC5290059 DOI: 10.1007/s10995-016-2044-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.
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Usinger KM, Gola SB, Weis M, Smaldone A. Intrauterine Contraception Continuation in Adolescents and Young Women: A Systematic Review. J Pediatr Adolesc Gynecol 2016; 29:659-667. [PMID: 27386754 DOI: 10.1016/j.jpag.2016.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/07/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Adolescents are at high risk for unintended pregnancies. Although intrauterine devices (IUDs), long-acting reversible contraceptives (LARCs), are known to be highly effective in preventing pregnancy, little is known about IUD adherence in adolescents. In this systematic review (SR) we examined IUD continuation rates compared with other forms of contraception in young women aged 25 years and younger. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A systematic search of Ovid Medline, Cochrane Library, and Embase was conducted for the years 1946-2015. Included studies examined IUD use in women 25 years of age and younger, compared IUD use with another form of contraception, and measured continuation rates at 12 months. The quality of each study was appraised using the Downs and Black criteria, and 12-month continuation rates among studies were pooled and analyzed according to contraceptive type. RESULTS Of 3597 articles retrieved, 9 studies met criteria for SR. Synthesized across studies, 12-month continuation was significantly higher for IUD users (86.5%, 12,761/14,747) compared with oral contraceptives (39.6%, 1931/4873), Depo-Provera (Pfizer Inc, New York, NY) hormonal injection (39.8%, 510/1282), vaginal ring (48.9%, 196/401), and transdermal patch (39.8%, 37/93; all P values < .001). There was no statistically significant difference in 12-month continuation between the IUD and another LARC method, the subdermal etonogestrel implant (85.3%, 4671/5474). CONCLUSION Findings of this SR suggest that continuation rates for IUDs are generally higher compared with other contraceptive methods for women aged 25 years and younger. In a population with high rates of unintended pregnancies, generally low adherence, and imperfect use with other non-LARCs, IUD use should be encouraged.
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Affiliation(s)
- K M Usinger
- Columbia University School of Nursing, New York, New York
| | - S B Gola
- Columbia University School of Nursing, New York, New York
| | - M Weis
- Columbia University School of Nursing, New York, New York
| | - A Smaldone
- Columbia University School of Nursing, New York, New York.
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Theall KP, Wallace M, Wesson DM. Zika: A Missed Opportunity to Protect Women's Health and Prevent Unwanted Pregnancies. Womens Health Issues 2016; 27:2-4. [PMID: 27876484 DOI: 10.1016/j.whi.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Katherine P Theall
- Department of Global Community Health and Behavioral Sciences, Tulane School of Public Health Tropical Medicine, New Orleans, Louisiana; Mary Amelia Douglas-Whited Community Women's Health Education Center, New Orleans, Louisiana.
| | - Maeve Wallace
- Department of Global Community Health and Behavioral Sciences, Tulane School of Public Health Tropical Medicine, New Orleans, Louisiana
| | - Dawn M Wesson
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
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Troskie C, Soon JA, Albert AY, Norman WV. Regulatory approval time for hormonal contraception in Canada, the United States and the United Kingdom, 2000-2015: a retrospective data analysis. CMAJ Open 2016; 4:E654-E660. [PMID: 28018878 PMCID: PMC5173460 DOI: 10.9778/cmajo.20160017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Access to a wide range of contraceptive methods improves prevention of unintended pregnancy by ensuring the best method fit for each individual. We compared approval times of new hormonal contraceptives by Health Canada, the US Food and Drug Administration (FDA), and the UK Medicines and Healthcare Products Regulatory Agency (MHRA). METHODS We obtained dates of applications to Health Canada, the FDA and the MHRA for contraceptive methods approved from January 2000 to January 2015. We used public data sources and direct correspondence, and excluded generic versions of previously approved drugs. The primary outcome of interest was median time to approval for novel hormonal contraceptives. Secondary outcomes included the median time to approval for all hormonal contraceptives and the number of approved hormonal contraceptives comparing countries studied, as well as the median time for approval of novel compared with nonnovel hormonal contraceptives within each country. RESULTS During this period 16 contraceptives were approved in Canada, 26 in the US and 14 in the UK. Applications for novel contraceptives were initiated later in Canada, and time to approval was longer in Canada than in the US (p = 0.03). The median time to approval for all contraceptives in Canada was 529.5 (interquartile range [IQR] 420.8 to 784.0) days, compared with 396.0 (IQR 308.0 to 594.5) days in the US and 341.0 (IQR 244.8 to 512.2) days in the UK. No subdermal implant contraceptives are approved in Canada. INTERPRETATION Canadian women wait longer for novel contraceptive methods and have fewer options. Canada could improve population health by addressing the regulatory barriers associated with the unmet need for contraception. Facilitation for approval of a contraceptive implant, and improvement to prolonged novel drug approval times, could support Canadians to plan and space their pregnancies.
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Affiliation(s)
- Christine Troskie
- Faculty of Pharmaceutical Sciences (Troskie, Soon), University of British Columbia; Contraception Access Research Team (Troskie, Soon, Albert, Norman), Women's Health Research Institute; Department of Family Practice, Faculty of Medicine (Soon, Norman), University of British Columbia, Vancouver, BC
| | - Judith A Soon
- Faculty of Pharmaceutical Sciences (Troskie, Soon), University of British Columbia; Contraception Access Research Team (Troskie, Soon, Albert, Norman), Women's Health Research Institute; Department of Family Practice, Faculty of Medicine (Soon, Norman), University of British Columbia, Vancouver, BC
| | - Arianne Y Albert
- Faculty of Pharmaceutical Sciences (Troskie, Soon), University of British Columbia; Contraception Access Research Team (Troskie, Soon, Albert, Norman), Women's Health Research Institute; Department of Family Practice, Faculty of Medicine (Soon, Norman), University of British Columbia, Vancouver, BC
| | - Wendy V Norman
- Faculty of Pharmaceutical Sciences (Troskie, Soon), University of British Columbia; Contraception Access Research Team (Troskie, Soon, Albert, Norman), Women's Health Research Institute; Department of Family Practice, Faculty of Medicine (Soon, Norman), University of British Columbia, Vancouver, BC
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Pazol K, Daniels K, Romero L, Warner L, Barfield W. Trends in Long-Acting Reversible Contraception Use in Adolescents and Young Adults: New Estimates Accounting for Sexual Experience. J Adolesc Health 2016; 59:438-42. [PMID: 27449328 PMCID: PMC5511686 DOI: 10.1016/j.jadohealth.2016.05.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The purposes of the analysis were to compare long-acting reversible contraception (LARC) use estimates that include all reproductive age women with estimates that are limited to women at risk for unintended pregnancy and to examine trends for adolescents (15-19 years) and young adults (20-24 years). METHODS Using the 2006-2010 and 2011-2013 National Surveys of Family Growth, we compared LARC estimates for all women with estimates limited to women at risk for unintended pregnancy (those who were sexually experienced, and neither pregnant, seeking pregnancy, postpartum or infecund). We used t tests to detect differences according to the population included and to evaluate trends for adolescents and young adults. RESULTS Among adolescents and young adults, 56% and 14%, respectively, have never had vaginal intercourse, versus 1%-4% for women aged 25-44 years. Given the high percentage of adolescents and young adults who never had vaginal intercourse, LARC estimates were higher for these age groups (p < .05), but not for women aged 25-44 years, when limited to those at risk for unintended pregnancy. Among adolescents at risk, the increase in LARC use from 2006-2008 (1.1%) to 2008-2010 (3.6%) was not significant (p = .07), and no further increase occurred from 2008-2010 to 2011-2013 (3.2%); by contrast, among young adults at risk, LARC use increased from 2006-2008 (3.2%) to 2008-2010 (6.9%) and from 2008-2010 to 2011-2013 (11.1%). CONCLUSIONS Because many adolescents and young adult women have never had vaginal intercourse, for these groups, including all women underestimates LARC use for pregnancy prevention. Among young adults, use of LARC for pregnancy prevention has increased but remains low among adolescents.
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Affiliation(s)
- Karen Pazol
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Kimberly Daniels
- Division of Vital Statistics, Reproductive Statistics Branch, National Center for Health Statistics, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lee Warner
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wanda Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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26
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Affiliation(s)
- Susan B. Moskosky
- US Department of Health and Human Services, Office of Population Affairs, Washington, D.C., USA
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27
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Tang JH, Kopp DM, Stuart GS, O'Shea M, Stanley CC, Hosseinipour MC, Miller WC, Mwale M, Kaliti S, Bonongwe P, Rosenberg NE. Association between contraceptive implant knowledge and intent with implant uptake among postpartum Malawian women: a prospective cohort study. Contracept Reprod Med 2016; 1:13. [PMID: 29201402 PMCID: PMC5693581 DOI: 10.1186/s40834-016-0026-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/11/2016] [Indexed: 11/17/2022] Open
Abstract
Background Long-acting reversible contraception (LARC) can assist women with birth spacing and reduce unintended pregnancies. Sub-Saharan Africa has low uptake of the two available methods of LARC, the subdermal implant and intrauterine contraception (IUC). Our primary objectives were to: 1) calculate the incidence of LARC use among postpartum Malawian women, and 2) assess if LARC knowledge and intent to use LARC were associated with LARC uptake. Methods This study was a prospective cohort study of 634 postpartum women who were recruited from the postpartum ward of Bwaila Hospital in Lilongwe, Malawi. Study participants completed a baseline survey in the postpartum ward. Follow-up telephone surveys about contraceptive use were conducted at 3, 6, and 12 months postpartum. Cox proportional hazards regression analysis was performed to evaluate if implant knowledge and intent to use implant were associated with implant uptake. Results One hundred thirty-seven implant and 10 IUC placements were reported over 12 months of follow-up; given the low rate of IUC uptake, further analysis was only done for implant uptake. The incidence rate for implant uptake was 35.6 per 100 person-years (95 % CI 30.0, 42.2). Correct implant knowledge (adjusted HR = 1.69; 95 % CI 1.06, 2.68) and intent to use implant (adjusted HR 1.95; 95 % CI 1.28, 2.98) were both associated with implant uptake. Conclusions More women reported implant use than IUC use in our study. Correct implant knowledge and intent to use implant were both associated with implant uptake, with a stronger association for intent. Interventions to increase LARC uptake should focus on improving LARC knowledge and removing barriers to LARC. Trial registration Clinical Trial Registration #: NCT01893021
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Affiliation(s)
- Jennifer H Tang
- UNC Project-Malawi, 100 Mzimba Road, Private Bag A-104, Lilongwe, Malawi.,Department of Obstetrics & Gynecology, University of North Carolina, 101 Manning Drive, CB #7570, Chapel Hill, NC 27599-7570 USA
| | - Dawn M Kopp
- UNC Project-Malawi, 100 Mzimba Road, Private Bag A-104, Lilongwe, Malawi
| | - Gretchen S Stuart
- Department of Obstetrics & Gynecology, University of North Carolina, 101 Manning Drive, CB #7570, Chapel Hill, NC 27599-7570 USA
| | - Michele O'Shea
- UNC Project-Malawi, 100 Mzimba Road, Private Bag A-104, Lilongwe, Malawi.,Department of Obstetrics & Gynecology, Northwestern University, 250 East Superior Street, Suite 03-2303, Chicago, IL 60611 USA
| | | | - Mina C Hosseinipour
- UNC Project-Malawi, 100 Mzimba Road, Private Bag A-104, Lilongwe, Malawi.,Department of Medicine, University of North Carolina, 130 Mason Farm Road, CB #7030, Chapel Hill, NC 27599-7030 USA
| | - William C Miller
- Department of Medicine, University of North Carolina, 130 Mason Farm Road, CB #7030, Chapel Hill, NC 27599-7030 USA.,Department of Epidemiology, University of North Carolina, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435 USA
| | - Mwawi Mwale
- Bwaila Hospital, Old Malangalanga Road, Lilongwe, Malawi
| | - Stephen Kaliti
- Bwaila Hospital, Old Malangalanga Road, Lilongwe, Malawi
| | - Phylos Bonongwe
- Department of Obstetrics & Gynaecology, Malawi College of Medicine, Mahatma Gandhi Road, Private Bag 360, Blantyre, Malawi
| | - Nora E Rosenberg
- UNC Project-Malawi, 100 Mzimba Road, Private Bag A-104, Lilongwe, Malawi.,UNC Institute for Global Health and Infectious Diseases, 130 Mason Farm Road, CB #7030, Chapel Hill, NC 27599-7030 USA
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28
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Sok C, Sanders JN, Saltzman HM, Turok DK. Sexual Behavior, Satisfaction, and Contraceptive Use Among Postpartum Women. J Midwifery Womens Health 2016; 61:158-65. [DOI: 10.1111/jmwh.12409] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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29
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Siveregi A, Dudley L, Makumucha C, Dlamini P, Moyo S, Bhembe S. Does counselling improve uptake of long-term and permanent contraceptive methods in a high HIV-prevalence setting? Afr J Prim Health Care Fam Med 2015; 7:779. [PMID: 26842525 PMCID: PMC4685656 DOI: 10.4102/phcfm.v7i1.779] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 08/07/2015] [Accepted: 08/06/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Studies have shown a reduced uptake of contraceptive methods in HIV-positive women of childbearing age, mainly because of unmet needs that may be a result of poor promotion of available methods of contraception, especially long-term and permanent methods (LTPM). AIM To compare the uptake of contraceptive methods, and particularly LTPM, by HIV-positive and HIV negative post-partum mothers, and to assess the effects of counselling on contraceptive choices. SETTING Three government district hospitals in Swaziland. METHODS Interviews were conducted using a structured questionnaire, before and after counselling HIV negativeand HIV-positive post-partum women in LTPM use, unintended pregnancy rates, future fertility and reasons for contraceptive choices. RESULTS A total of 711 women, of whom half were HIV-positive, participated in the study. Most (72.3% HIV-negative and 84% HIV-positive) were on modern methods of contraception, with the majority using 2-monthly and 3-monthly injectables. Intended use of any contraceptive increased to 99% after counselling. LTPM use was 7.0% in HIV-negative mothers and 15.3% in HIV-positive mothers before counselling, compared with 41.3% and 42.4% in HIV-negative and HIV-positive mothers, respectively, after counselling. Pregnancy intentions and counselling on future fertility were significantly associated with current use of contraception, whilst current LTPM use and level of education were significantly associated with LTPM post-counselling. CONCLUSION Counselling on all methods including LTPM reduced unmet needs in contraception in HIV positive and HIV-negative mothers and could improve contraceptive uptake and reduce unintended pregnancies. Health workers do not always remember to include LTPM when they counsel clients, which could result in a low uptake of these methods. Further experimental studies should be conducted to validate these results.
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Foster DG, Barar R, Gould H, Gomez I, Nguyen D, Biggs MA. Projections and opinions from 100 experts in long-acting reversible contraception. Contraception 2015; 92:543-52. [PMID: 26515195 DOI: 10.1016/j.contraception.2015.10.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/13/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods. STUDY DESIGN We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions. RESULTS The most commonly identified barrier was the cost of the device (63%), followed by women's knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25-29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion. CONCLUSIONS Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women's contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women's individual needs. IMPLICATIONS Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women's reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.
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Affiliation(s)
- Diana Greene Foster
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA.
| | - Rana Barar
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Heather Gould
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Ivette Gomez
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - Deborah Nguyen
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
| | - M Antonia Biggs
- University of California, San Francisco, Advancing New Standards in Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA
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