Contraception for adolescents

Long-Acting Reversible Contraception (LARC) and Early Childbearing Revisited: Births and Birth Intendedness After LARC Removal in a State Medicaid Population (2012-2020)

Objectives. To analyze births and birth intendedness after long-acting reversible contraception (LARC) removal among Medicaid-insured women. Methods. We linked all Delaware women with a Medicaid-covered LARC removal in 2012 to 2020 (n = 8047) to birth records and to Pregnancy Risk Assessment Monitoring System (PRAMS) pregnancy intendedness survey responses (n = 241). Results. Births within 3 years of a Medicaid-covered LARC removal were much more likely to be to women in their 20s compared with all Medicaid births (63.5% vs 53.4%; P < .001). The intended proportion for births within 3 years of Medicaid-covered LARC removal (65.2%) was higher than for all Medicaid-covered births (58.8%; P = .08) and was consistently above 60% across all age groups younger than 30 years. Conclusions. A state Medicaid-insured population's use of highly effective reversible contraception was associated with births being concentrated among women in their 20s and with consistently high fractions of intended births across younger ages at birth. Public Health Implications. Programs and policies may consider LARC access for its potential to increase low-income women's reproductive autonomy by enhancing their ability to achieve births at the age of their choosing. (Am J Public Health. 2025;115(1):95-102. https://doi.org/10.2105/AJPH.2024.307844).

Contraceptive Method Usage Pattern and Percentage of New Pregnancies Among Adolescent and Young Adult Family Planning Patients: A Mixed-Methods Retrospective Study

OBJECTIVES

Despite increased access to contraceptive methods (CM), the United States still has the highest rate of adolescent pregnancy among industrialized nations, and adolescents from historically marginalized groups are disproportionately affected. In this study, we sought to (1) understand if differences in CM usage were associated with differential percentages of new pregnancies among adolescents and young adult patients attending a family planning (FP) clinic at an urban community practice and (2) identify areas of improvement in our FP counseling.

METHODS

Mixed-methods study design consisting of (1) a 12-month retrospective chart review and (2) a self-answered cross-sectional survey of FP patients. Chi-square, Fisher's exact tests, and risk ratio were performed to analyze the percentage of new pregnancies according to CM usage.

RESULTS

The percentage of new pregnancies was 11 among our FP patients (N = 555) during this study period. As anticipated, pregnancy was associated with no CM use, CM discontinuation, and, interestingly, multiple CM changes (P < .001). The probability of no-pregnancy significantly decreased among patients on no method, who discontinued their CM or made multiple CM changes compared to those with continuous CM use. There was no association between the percentage of new pregnancies and any particular CM type.

CONCLUSION

Despite adequate access to FP patient services and high patient satisfaction levels, our findings indicate a need to adopt a more patient-centered approach in our FP counseling that addresses patient's reproductive life plans, preferences, and method side effects to increase CM uptake and satisfaction and decrease frequency of CM changes which is associated with increased risk of mistimed pregnancy during method switching.

Is use of Long-Acting Reversible Contraceptives (LARC) associated with reduced well-woman visits and STI testing? Evidence from female Medicaid clients aged 15-24 in Delaware

OBJECTIVE

Contraceptive method type matters to sexually transmitted infection (STI) prevention, but contraceptive counseling often emphasizes method efficacy and the benefits of "forgettable" methods, including long-acting reversible contraceptives (LARCs). We aimed to explore associations between prescription method type and annual STI testing and investigated whether these associations relate to annual well-woman visits.

METHODS

We constructed a panel of 20,949 young women (<25) enrolled in Delaware's Medicaid program from 2012 through 2019. Conditional logit regressions measured associations between contraceptive method type and annual testing for gonorrhea, chlamydia, or syphilis. We stratified contraceptive methods into LARC, short-acting reversible methods (SARC; pills, patch, ring, and injectable), or no prescription method. We estimated three models examining STI testing in year of method initiation, in years afterwards, and attendance to a well-woman visit as a potential mediator of these associations.

RESULTS

STI testing rates did not differ between LARC versus SARC users in the year of method initiation. In the two years after method initiation, LARC versus SARC users were less likely to be tested (OR = 0.73 to OR = 0.87) and less likely to have a well-woman visit (OR = 0.65 to OR = 0.79). In models controlling for attendance to well-woman visits, the decreased likelihood of STI testing in years after initiating LARC versus SARC is largely eliminated, indicating that well-woman visits mediate the relationship between method type and STI testing.

CONCLUSIONS

LARC use relates to reduced STI testing in years after method initiation due to reduced attendance to well-women visits. These findings can inform clinical practice and STI prevention.

Male contraception: Focus on behavioral and barrier methods

INTRODUCTION

Male contraception includes various methods designed to prevent pregnancy by focusing on the male's role in reproduction.

RESULTS

Behavioral methods, such as withdrawal and periodic abstinence, offer non-invasive alternatives that require self-control and precise timing to avoid depositing sperm in the female reproductive tract during fertile periods. However, these methods generally have low effectiveness and rely heavily on user adherence and experience. The male condom, a barrier method, provides both contraception and protection against sexually transmitted infections. Its effectiveness relies on correct and consistent use.

DISCUSSION

Access to comprehensive sexual education and medical counseling is essential to dispel the stigma surrounding contraceptive use and correct misconceptions, ensuring proper usage and ultimately contributing to better reproductive health outcomes.

Exploring primary care physician biases in adolescent contraceptive counseling

OBJECTIVE(S)

While previous literature has shown clinician bias in adult contraceptive counseling, less is known on the biases clinicians may exhibit when counseling adolescents about contraception. Our study aimed to describe long-acting reversible contraception (LARC) counseling and prescribing practices of adolescent-serving clinicians.

STUDY DESIGN

This study used a cross-sectional discrete choice experiment mixed methods design. We sent a survey containing vignettes and items pertaining to demographics and beliefs to a convenience sample of adolescent-serving clinicians across the United States.

RESULTS

Of 296 clinicians, 80% were in pediatrics, and had geographic, practice setting, gender, and racial diversity. Most clinicians reported being up-to-date with current literature regarding contraception. Sixty-eight percent of respondent's practices administer contraceptive injections, but only 17% place intrauterine devices (IUDs). Of those who do insert IUDs, nearly half inserted five or fewer within the last year. Patients' younger age and Hispanic ethnicity were associated with lower odds, and history of pregnancy was associated with higher odds, of clinicians' recommending LARC. Across all vignettes, the top five reasons clinicians chose their first-choice method for the patient were adherence or compliance, efficacy, side effects, patient age, and reversibility.

CONCLUSION(S)

Clinicians often recommend contraceptives based on adherence, efficacy, and age, and we found younger age, minoritized race or ethnicity, and history of pregnancy were all associated with LARC recommendations, indicating potential biases against teen parents and assumptions about adolescents' priorities. This may impede the provision of patient-centered contraceptive counseling for adolescents, and highlights the need for improved education and practice changes post-Dobbs.

IMPLICATIONS

We found that clinicians demonstrated several biases in how they provide contraceptive recommendations to adolescent patients. These biases were often associated with their personal beliefs and experiences. Our findings can guide the development of future interventions aimed at improving adolescent reproductive health counseling and care delivery in primary care settings.

Confidence in adolescent contraceptive counseling among residents and fellows training at the University of Texas Southwestern in Dallas, Texas

OBJECTIVES

Evaluate trainees' perceptions of past training and confidence in counseling about five contraceptive methods.

STUDY DESIGN

Trainees completed an online survey in 2020. Logistic regressions evaluated the relationship between participant characteristics and confidence.

RESULTS

Among 227 respondents (63% response rate), pediatric trainees reported the least confidence in counseling across each contraceptive method. Past training and confidence were associated.

CONCLUSIONS

Gaps in training should be addressed to improve confidence in contraceptive counseling among pediatricians in reproductively restricted states.

IMPLICATIONS

This study highlights gaps in physician trainee confidence regarding adolescent contraception counseling that should be addressed to improve adolescent sexual and reproductive healthcare.

Spatial distribution of pregnancy and early motherhood among late adolescent girls in Ethiopia using data from the Ethiopia Demographics and Health Survey 2019: Spatial and multilevel analyses

BACKGROUND

Various governmental and non-governmental organizations in Ethiopia are striving to decrease adolescent pregnancy by enacting laws against early marriage, developing a national youth and adolescent reproductive health strategy, legalizing abortion, and developing an HIV/AIDS policy for youth; however, the issue of teenage pregnancy& early motherhood remains a major concern.

METHODS

Data were obtained from the Ethiopian Demographics and Health Survey (EDHS) in 2019. A total sample of 2210 adolescents was included in our study. Spatial autocorrelation, hotspot analysis, and spatial interpolation were used to observe significant spatial variation and clustering and to predict the prevalence of pregnancy in an unsampled area among adolescent girls in Ethiopia; a multilevel binary logistic regression model was fitted to identify factors associated with the outcome variable. The adjusted odds ratio was calculated with a 95% confidence interval, and the variables with a p-value 0.05 in the multivariable multilevel logistic regression were determined to be statistically significant.

RESULTS

Global spatial autocorrelation analyses showed that the spatial distribution of late-adolescent pregnancy and early motherhood varied across Ethiopia (the Global Moran's Index I value showed GMI = 0.014, P 0.001). The spatial distribution revealed a high cluster (hot spot) of late-adolescent pregnancy and early motherhood in most parts of Gambella, Afar, Benishangul-Gumuz, the eastern part of Oromia, and Somalia. In the multivariable multilevel analysis, being 17 years old (AOR = 3.43; 95% CI: 1.54-7.59), 18 years old (AOR = 14.92; 95% CI: 6.78-32.8), and 19 years old (AOR = 8.44; 95% CI: 4.06, 17.56), married (AOR = 25.38; 95% CI: 15.33, 42.02), having completed primary, secondary, and higher education (AOR = 0.45; 95% CI: 0.21-0.95), and being at Gambela (AOR = 3.64; 95% CI: 1.04, 12.75) were significant predictors of late adolescent pregnancy and early motherhood.

CONCLUSION

Overall, the prevalence of late-adolescent pregnancy and early motherhood was found to be high. At the individual level, marital status, educational attainment, and age of adolescents were significant predictors of pregnancy and early motherhood, and regions were found at a community level associated with pregnancy and early motherhood among late adolescents. Therefore, late-adolescent girls should be educated about menstruation, sexual intercourse, pregnancy, and contraceptives before they reach early adolescence.

Early contraceptive implant removal and associated factors among women attending public family planning clinics, Mbarara City, Southwestern Uganda: a cross-sectional study

BACKGROUND

Early implant removal not only results in method wastage and strains healthcare resources but also exposes women to the risk of unplanned pregnancies and associated complications if an alternative contraceptive is not promptly adopted. Studies have demonstrated that prevalence and factors associated with contraceptive use vary across different cultures and regions even within Uganda. We determined the prevalence and associated factors of early implant removal, among women attending public family planning clinics in Mbarara City, southwestern Uganda.

METHODS

We conducted a cross-sectional study from April to July 2023 at four public family planning clinics in Mbarara City. We consecutively enrolled women and administered a questionnaire to obtain data on demographic, and medical characteristics. We defined early removal as implant discontinuation within a period < 2 years. We excluded women who did not have a written record of the date of insertion of the contraceptive implants. We used modified Poisson regression analysis to determine factors associated with early implant removal.

RESULTS

We enrolled 406 women, with a mean age of 29 ± 6 years. The prevalence of early contraceptive implant removal was 53% (n = 210; 95%, CI: 48-58%). Factors associated with early implant removal were experiencing side effects (adjusted prevalence ratio [aPR] = 1.63, 95% CI: 1.20-2.21), inserting an implant to achieve career goals (aPR = 1.88, 95% CI: 1.26-2.81) and intending to use the implant for < 24 months (aPR = 1.36, 95% CI: 1.11-1.66).

CONCLUSION

Approximately half of the surveyed women removed their contraceptive implant early. Women who experienced side effects, chose an implant due to career obligations and those whose intended implant use was < 2 years were more likely to have an early contraceptive implant removal compared to their counterparts. We recommend strengthening of pre- and post- insertion counselling to address concerns among those who may experience side-effects. Women who intend to use implants for < 2 years and those who have career obligations should be encouraged to use short-acting methods as an option.

Long-Acting Reversible Contraception Knowledge Among Female Adolescents Presenting to a Pediatric Emergency Department

OBJECTIVES

The objective of this study was to assess awareness and use of long-acting reversible contraception (LARC) among female adolescents presenting to a pediatric emergency department (PED).

STUDY DESIGN

During routine presentation to an urban PED in New Jersey, female adolescents, aged 15-19 years, were asked to voluntarily complete an electronic survey about sexual practices and contraception. The PED is in an urban teaching hospital, treating 35,000 children annually. Patients could schedule a follow-up appointment at the hospital's obstetrics/gynecology clinic. Data were collected over 13 months, and follow-up was monitored to determine if they attended an outpatient appointment, and if so, what the outcome was.

RESULTS

Data for 199 participants were analyzed. The median age of participants was 18 years, whereas 79% self-identified as Black, and 17.6% self-identified as Latina. Twenty-one percent of participants used a form of birth control during their first sexual encounter, the largest percentage being condoms (77.8%). Forty percent of participants reported some prior knowledge about contraceptive implants, and 20% had knowledge about intrauterine devices, whereas only 3 (1.5%) intrauterine devices and 2 (1%) arm implants had been previously used. Of the 78 participants that requested a follow-up, 14 (17.9%) completed their appointment. Of those, 2 (14%) were prescribed contraception (Depo-Provera shot and oral contraceptive pills).

CONCLUSIONS

Knowledge about LARC remains low in our PED, despite it being the most effective method of contraception. Even when interventions were made to link interested respondents to outpatient women's health services, follow-up attendance was poor, and no patients obtained LARC. There is a significant discrepancy between the consensus standard of contraception care across all relevant medical specialties and current utilization by high-risk populations. Future efforts must focus on how to close this gap, and the ED could be pivotal for improving both reproductive health education and intervention among adolescent patients.

Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

"The thing in my arm": Providing contraceptive services for adolescents in primary care

BACKGROUND

Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services.

OBJECTIVES

This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings.

DESIGN

This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative.

METHODS

In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data.

RESULTS

Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients.

CONCLUSION

Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.

"I feel like it gives me what I need to know": A qualitative study on adolescent perceptions of two contraceptive decision aids

OBJECTIVES

We sought to understand how adolescents perceive two commonly used contraceptive decision aids and which elements adolescents identified as most important to them.

STUDY DESIGN

We conducted a cross-sectional qualitative study of adolescents' perceptions of two decision aids, Your Birth Control Choices designed by the Reproductive Health Access Project and Birth Control: What's Important to You? designed by Power to Decide for Bedsider.org. We conducted semistructured interviews with 20 adolescents (aged 15-19 years) who were assigned female sex at birth and attended a single clinic in North Carolina. Interview questions addressed the decision aids' aesthetic design, informational content, inclusivity, and comprehensibility. We transcribed and analyzed interviews using Dedoose software. We developed a codebook using a combination of a priori and inductive codes followed by content analysis to identify themes.

RESULTS

All participants agreed that both decision aids could be helpful with contraceptive decision-making and with patient-provider discussions. However, some phrasing and descriptions of contraceptive methods were confusing. Participants preferred realistic imagery, clear explanations of side effects, and details on method use. Participants expressed a preference for the information contained in the detailed Reproductive Health Access Project decision aid, while most favored the aesthetic design and layout of the Bedsider decision aid.

CONCLUSIONS

Although adolescents expressed sentiments of increased knowledge and empowerment after reviewing the decision aids, this study suggests neither decision aid completely meets adolescent needs and preferences. Additional adaptations are necessary to create adolescent-centered contraceptive decision aids.

IMPLICATIONS

Adolescents in this study found two contraceptive decision aids as useful adjuncts to conversations with providers. The decision aids improved contraceptive knowledge and may facilitate decision-making. However, neither of the studied decision aids fully met the perceived needs of adolescents. Future adaptations or designs should include additional adolescent-centered content.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative

OBJECTIVE

To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative.

METHODS

A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic.

RESULTS

Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds.

DISCUSSION

A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Implementation of a Multisectoral Approach to Address Adolescent Pregnancy: A Case Study of Subnational Advocacy Informing National Scale-Up in Kenya

Adolescent pregnancy continues to be a major concern globally, especially in sub-Saharan Africa, where it contributes to high maternal mortality and morbidity and other non-health consequences, such as school dropouts. Addressing adolescent sexual and reproductive health requires an enabling environment that extends beyond an individual to community and society levels through concerted efforts by various sectors and agencies. From 2016 to 2022, we implemented an advocacy intervention in Kenya that catalyzed multisectoral collaboration to address adolescent sexual and reproductive health issues, specifically adolescent pregnancy, at subnational and national levels. In this article, we document our experiences implementing the intervention by presenting a case study of this initiative, including the processes and lessons learned. Our experience to date demonstrates that multisectoral initiatives can be rolled out to address adolescent pregnancies in countries that continue to have a high burden of adolescent pregnancy. Successful implementation requires inclusivity, commitment, and leadership to fully realize the potential that multisectoral actions have in preventing adolescent pregnancy.

Gen Z and HIV-Strategies for Optimizing the Care of the Next Generation of Adolescents Living with HIV

The management of adolescents living with HIV represents a particular challenge in the global response to HIV. The challenges specific to this age group include difficulties engaging and maintaining them in care, challenges with transition to adult care, and limited therapeutic options for treatment-experienced patients, all of which have been jeopardized by the COVID-19 pandemic. This paper summarizes some of the challenges in managing adolescents living with HIV, as well as some of the most recent and innovative therapeutic approaches in this population.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants

ABSTRACT

Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative

BACKGROUND

Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low.

OBJECTIVE

This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives.

STUDY DESIGN

We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847).

RESULTS

We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices.

CONCLUSION

The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.

Contraceptive methods in adolescence: a narrative review of guidelines

PURPOSE

Adolescent pregnancy, while recently in decline, remains a matter in need of addressing. Education and counselling are deemed crucial and this review aims at comparing published contraceptive guidelines, thus resolving any surrounding misconceptions.

MATERIALS AND METHODS

Recently published contraception guidelines regarding adolescent pregnancy were retrieved. In particular, guidelines and recommendations from ACOG, RCOG, SOCG, AAP, CPS, NICE, CDC, and WHO were compared and reviewed based on each guideline's method of reporting.

RESULTS

Three categories of contraceptive methods are available for adolescents and recommendations on their initiation should be made based on their efficacy, according to all guidelines. Therefore, long acting reversible contraceptives (LARCs) should be highly recommended as the most effective method (typical use failure rate: 0.05%), followed by short-acting hormonal contraceptives (typical use failure rate: 3-9%). The third contraceptive option includes contraceptives used in the moment of intercourse and displays the lowest effectiveness (typical use failure rate: 12-25%), mostly due to its dependence on personal consistency, however offers protection against STI transmission.

CONCLUSION

Adolescents should be encouraged to initiate contraception, with LARCs being the primary choice followed by short-acting hormonal contraception. However, regardless of the chosen effective contraceptive method, the use of condom is necessary for STI prevention.

Management of acne in transgender and gender diverse youth Part 2: Unique considerations and strategies in medical treatment

Acne vulgaris is among the most common skin disorders afflicting adolescents worldwide, and though well-established guidelines of care exist for acne management, these guidelines do not uniformly consider or address the unique psychosocial and medical needs of transgender and gender diverse (TGD) youth. Part 2 of this two-part review provides guidance on a stepwise approach to the medical treatment of acne in TGD youth, with an emphasis on safety, efficacy, and the delivery of medical care in a culturally humble, thoughtful, and gender-affirming manner.

Sexual Health among Youth in Residential Care in Spain: Knowledge, Attitudes and Behaviors

Adolescents in the child welfare system often face multiple maladaptive experiences that predispose them to worse sexual health outcomes. This study aims to (1) describe the sexual health of adolescents in Spanish residential care by exploring their sexual knowledge, attitudes toward sexuality, and sexual behaviors and (2) to find out whether there are certain characteristics that make a subgroup particularly vulnerable to engaging in risky sexual behaviors. A total of 346 adolescents recruited from 47 Spanish residential care facilities (34.1% girls, 65.9% boys) aged between 11 and 19 years old completed some self-report instruments. Descriptive analyses and tests to prove gender and age differences were conducted. Their knowledge of sexuality was lower than observed in the general adolescent population, their attitudes more negative, and their tendency to engage in risky sexual behaviors higher. Girls made very infrequent use of condoms, while boys had more sexist attitudes and made habitual use of withdrawal. Although more than 20% of them had experienced sexual exchange activities before the age of 13 until 17, they did not use condoms systematically. The low level of knowledge, the early initiation of sexual exchange activities, and the scarce use of protection methods, together with sexist attitudes, place this group in a situation of great vulnerability, increasing the risk of unwanted pregnancies, sexually transmitted infections, and even teen dating violence.

Sexual function in Brazilian female adolescents and young adults: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate and compare the sexual function of Brazilian adolescents and young women who were using popular contraceptive methods.

METHODS

This cross-sectional study took place in 2012-2014 in a free family planning clinic of a tertiary teaching hospital in Brazil. Participants were female adolescents (10-19 years) and young adults (20-24 years) who were using barrier (condom) or hormonal contraceptive methods. The Female Sexual Function Index questionnaire was used to assess the sexual function in the last 4 weeks.

RESULTS

A total of 199 women (128 adolescents and 71 young adults) were included. There were no significant differences in the mean total Female Sexual Function Index scores of adolescents and young adults (26.6±5.7 versus 27.6±6.2, respectively, p=0.264). Compared to young adults, adolescents had significantly lower mean scores for orgasm (3.9±1.5 versus 4.4±1.4, p=0.020) and dyspareunia (4.4±1.6 versus 5.2±1.5, p=0.001; lower scores indicate more dyspareunia). There were no significant differences in the proportion of adolescents versus adults classified as being at risk for sexual dysfunction (38.3 versus 42.3%, p=0.651) or at risk of low desire (18.0 versus 21.1%, p=0.579).

CONCLUSION

Nearly 40% of Brazilian female adolescents and young adults are at risk for sexual dysfunctional symptoms and 19% have low desire, without significant differences between the two age groups.

Caregiver Knowledge of and Attitudes Toward the Levonorgestrel-Containing Intrauterine Device for the Treatment of Heavy Menstrual Bleeding in Adolescents and Young Adults

STUDY OBJECTIVE

We evaluated caretaker knowledge of and attitudes toward the levonorgestrel-containing intrauterine device (L-IUD) as a treatment option for adolescents and young adults with heavy menstrual bleeding.

DESIGN

A survey assessed demographic characteristics, menstrual history, perception of the L-IUD, and knowledge of the indications, risks, and benefits of the L-IUD.

SETTING

Participant recruitment occurred in the offices of a pediatric gynecologist, pediatric hematologist, and adolescent medicine physician in a hospital-based practice in New York.

PARTICIPANTS

English-speaking caretakers of patients with a chief concern of heavy menstrual bleeding (<21 years old) were invited to participate.

INTERVENTIONS

Electronic and paper surveys were administered prior to seeing the physician.

MAIN OUTCOME MEASURES

The primary outcome was participant willingness to allow their daughter to use the L-IUD for heavy menstrual bleeding. Additional outcomes were explored by calculating a mean knowledge score and conducting a descriptive analysis of the perception questions.

RESULTS

Forty surveys were included. Seventy percent of participants said they would allow their daughter to use birth control pills for heavy menstrual bleeding, whereas only 10% said the same of the L-IUD. The mean knowledge score was 73.3% (±15.7). Sixty-five percent of participants expressed the need for additional information on the L-IUD.

CONCLUSION

Caretaker acceptance of the L-IUD as treatment for their daughter with heavy menstrual bleeding is limited. Although baseline knowledge was high, many indicated needing additional information. Because heavy menstrual bleeding can negatively impact quality of life, potential caretaker bias must be addressed to ensure full access to this highly effective treatment option.

Associations Between Social Determinants of Health and Adolescent Contraceptive Use: An Analysis From the National Survey of Family Growth

This research assessed social determinants of contraceptive use among a nationally representative sample of adolescents. This study analyzed nationally representative, publicly available data from the 2013-2015 National Survey of Family Growth (NSFG). The sample consisted of sexually active males and females between the ages of 15 and 19 (n = 775). Independent variables were social determinant questions asked on the NSFG, selected based on the Healthy People Social Determinants of Health Framework. We tested associations between adolescents' social determinants of health and 2 outcomes, use of any contraceptive at last sex, and effectiveness level of contraceptive method at last sex. Results indicated high contraceptive use at last intercourse (91.5%) and a significant association between any use of contraceptive and family structure (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [CI] = 1.04-4.03), employment (AOR = 2.00, 95% CI = 1.06-3.77), and education (AOR = 3.43, 95% CI = 1.06-11.13). Few participants reported use of a highly effective method of pregnancy prevention (4.3%). In regression analyses, access to health care (AOR = 0.34, 95% CI = 0.14-0.84) and language and literacy (AOR = 2.92, 95% CI = 1.03-8.26) were found to be associated with using moderately effective contraceptive method to prevent pregnancy compared with not using any method. Although adolescents report overall high rates of contraceptive use, not all contraceptives have the same rates of effectiveness, and adolescents are often choosing those with lower effectiveness. This study found low rates of highly effective contraceptives to prevent pregnancy use (ie, intrauterine device and implant). It is also important to further explore the associations between family structure (measured in this study as intact childhood family) and distal links to contraceptive use. Future research should also further distinguish pathways to adolescent decision-making to use contraceptive methods to protect against STIs and pregnancy.

Determinants of early discontinuation of etonogestrel sub-dermal implant among reproductive-age women in Legambo district, Northeast Ethiopia: An unmatched case–control study

Objective:

Etonogestrel sub-dermal implant discontinuation is very common in the study area. But evidence on the determinants was limited. So, this study aimed to identify determinants of early discontinuation of etonogestrel sub-dermal implant among reproductive-age women in Legambo district, Northeast Ethiopia.

Methods:

An institution-based unmatched case–control study was conducted on 252 reproductive-age women (84 cases and 168 controls) from 1 February up to 30 April 2020. Systematic random sampling was used to select women, and the data were collected by face-to-face interview using a structured, pretested, and interviewer-administered questionnaire. The collected data were entered into Epi Data version 3.1 and analyzed by SPSS version 23. A binary logistic regression model was used to identify determinants of early discontinuation of etonogestrel sub-dermal implant. Statistical significance was declared at a p value of less than 0.05, and adjusted odds ratio with a 95% confidence interval was used to identify determinants of early discontinuation of etonogestrel sub-dermal implant in the final model.

Result:

In this study, not receiving pre-insertion counseling (adjusted odds ratio = 3.19, 95% confidence interval: (1.61, 6.30)), having a history of abortion (adjusted odds ratio = 2.89, 95% confidence interval: (1.50, 5.54)), contraceptive side effects (adjusted odds ratio = 2.45, 95% confidence interval: (1.99, 3.91)), and not receiving an appointment for a follow-up visit at the time of insertion (adjusted odds ratio = 3.45, 95% confidence interval: (1.89, 5.99)) were determinants of early discontinuation of etonogestrel sub-dermal implant.

Conclusion:

Not receiving pre-insertion counseling, having a history of abortion, contraceptive side effects, and not receiving an appointment for a follow-up visit at the time of insertion were predictors of early discontinuation of etonogestrel sub-dermal implant. Thus, healthcare professionals should give an appointment for a follow-up visit at the time of insertion and provide detailed counseling for all women, not only for those who had had an abortion and contraceptive side effects.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs.

OBJECTIVE

To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA.

MATERIALS AND METHODS

A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid).

RESULTS

Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge.

CONCLUSION

Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

ERICA: cardiovascular risks associated with oral contraceptive use among Brazilian adolescents

OBJECTIVE

To investigate the association between oral contraceptive use and cardiovascular risks, including metabolic syndrome and their components in Brazilian adolescents.

METHOD

This study used data from the Study of Cardiovascular Risks in Adolescents (Estudo de Riscos Cardiovasculares em Adolescentes - ERICA), a nationwide, cross-sectional, school-based study with individuals aged 12-17 years. Sociodemographic variables and OC use were assessed by a self-administered questionnaire. International Diabetes Federation criteria were used to define metabolic syndrome. Descriptive statistics were reported as prevalence and their respective confidence interval of 95% of oral contraceptives according to variables. Logistic regression was performed. Crude and adjusted odds ratios were calculated.

RESULTS

This subsample was composed of 22,682 female adolescents, of which 12.65% reported using oral contraceptives and their use was associated with hypertension and hypertriglyceridemia. These associations remained statistically significant after adjusting for age, school region, race, and tobacco use with an increase of 2.68 (1.66 - 4.32) and 3.45 (2.56 - 4.65) times, respectively.

CONCLUSION

The present study was the first to examine the association between the use of oral contraceptives and cardiovascular risk factors among the largest number of female Brazilian adolescents. This method was significantly associated with hypertension, hypertriglyceridemia. Teenagers using oral contraceptives should be monitored for side effects, including blood pressure measurements and advised to avoid smoking.

The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy

A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.

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.

Louisiana Pharmacies' Availability of Emergency Contraception and Counseling Accuracy to Adolescent and Physician Callers

STUDY OBJECTIVE

Adolescents face many barriers to obtaining emergency contraception (EC), despite it being an approved and recommended method to prevent unintended pregnancy. This study examined pharmacy-related barriers to adolescents' access to EC in Louisiana.

DESIGN

Prospective, telephone-call secret shopper study to pharmacies to assess same-day EC availability and barriers to purchase.

SETTING

A total of 182 pharmacies in 5 Louisiana cities.

PARTICIPANTS

Responses provided by pharmacists or other pharmacy staff assessed between July 2018 and November 2019.

INTERVENTIONS

Collected data from secret shopper phone calls and compared responses provided to callers between male and female callers and physician and adolescent callers.

MAIN OUTCOME MEASURES

Same-day levonorgestrel (LNG) availability, same-day ulipristal acetate (UPA) availability, age restrictions on purchase, requirement of parental consent for purchase, and type of staff member that advised the caller.

RESULTS

Of 364 calls to 182 pharmacies, 66% of pharmacists or other pharmacy staff reported same-day LNG access and 5% reported same-day UPA access. An inaccurate age restriction regarding EC purchase was reported in 15% of calls. Female callers were cited this age restriction more frequently than their male counterparts (20% vs 10%). Pharmacists were more likely than other pharmacy staff to counsel female callers compared to male callers (52% vs 27%) and physician callers compared to adolescents (50% vs 30%).

CONCLUSIONS

Many pharmacies in Louisiana have limited same-day availability of EC and often report inconsistent and inaccurate age and consent regulations for its use. Continued outreach and education to pharmacies is necessary to address these barriers to adolescent EC access.

Sexual Health Behaviors and Pregnancy Risk Among Hospitalized Female Adolescents

OBJECTIVES

To describe sexual health behaviors, contraceptive use, and pregnancy risk among hospitalized female adolescents.

METHODS

We conducted a cross-sectional survey of hospitalized female patients aged 14 to 21 years at 2 academic medical centers to assess sexual health behaviors, contraceptive use, contraceptive counseling receipt, and factors associated with pregnancy complications (eg, diabetes, teratogenic exposure). We calculated the validated Pregnancy Risk Index (PRI) (number per 100 who will become pregnant in the next year).

RESULTS

Among 177 participants (mean age 16 years, SD 1.5), 75 (43%) were sexually active. At last vaginal sex, 65% reported condom use; 49%, reversible contraception; and 12%, long-acting reversible contraception (LARC). Past-year contraceptive counseling was reported by 73% of sexually active female participants and was associated with increased use of reversible (P = .001) and dual contraception (P = .03) but not LARC (P = .24). The mean PRI among all participants was 4.75. Nearly three-quarters (73%) had a medical comorbidity or teratogenic exposure. Those with teratogenic medication use had the lowest PRI of 0.32 (P < .05), with 88% using reversible contraception and 31% using LARC.

CONCLUSIONS

Hospitalized female adolescents had a PRI similar to that of adolescents in the general population. However, nearly three-quarters had a medical comorbidity and/or teratogenic exposure, which increased risk for pregnancy complications. Contraceptive counseling was associated with increased reversible and dual contraception use but not LARC use. Efforts to improve comprehensive contraceptive counseling, highlighting LARC, are critically needed in this population.

Contraception in Adolescents

Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.

Addressing long-acting reversible contraception access, bias, and coercion: supporting adolescent and young adult reproductive autonomy

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare.

RECENT FINDINGS

Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services.

SUMMARY

Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.

Attendance of an Initial Follow-up Visit after Long-Acting Reversible Contraception Insertion and Method Continuation Among Adolescents and Young Adults: A Retrospective Study

STUDY OBJECTIVE

To assess attendance of an initial follow-up visit after long-acting reversible contraception (LARC) insertion and whether follow-up was associated with a higher likelihood of method continuation in adolescents and young adults (AYAs).

DESIGN

Retrospective chart review including patients receiving LARC (etonogestrel 68 mg implant, levonorgestrel 52 mg intrauterine device, or copper intrauterine device) between January 1, 2014, and August 1, 2017.

SETTING

An urban adolescent center providing primary care and reproductive health services.

PARTICIPANTS

A total of 331 patients 13-28 years of age.

INTERVENTIONS

Attendance of a follow-up visit 4-8 weeks after LARC insertion.

MAIN OUTCOME MEASURES

Follow-up was defined as visits addressing LARC method or routine physical examinations in the adolescent center or affiliated school-based health clinics. Continuation and discontinuation were defined as documented presence or removal, respectively, of device at various time points. Descriptive analyses, χ² test, Fisher exact test, t test, and survival analysis were used.

RESULTS

Approximately one-third (29.3%) of the patients attended a follow-up visit. Follow-up was associated with a higher likelihood of LARC removal in the first year (hazard ratio [HR] = 2.10, 95% confidence interval [CI] 1.33-3.32). At 500 days post-insertion and beyond, there was no difference in LARC continuation between AYAs who followed-up and those who did not (HR = 1.07, 95% CI 0.67-1.71).

CONCLUSION

Few AYAs attended an initial follow-up visit after LARC placement. These visits were associated with an increased likelihood of LARC removal in the first year; however, this association was not observed long term. More information is needed to determine how to approach follow-up this population.

Outcomes of a two-visit protocol for long acting reversible contraception for adolescents and young adults

PURPOSE

To examine outcomes of a 2-visit protocol for placement of intrauterine or subdermal contraception.

METHODS

We identified all women ages 15 to 27 who received an order for an intrauterine or subdermal contraceptive between January 2014-December 2016. We examined time from order to contraceptive placement and reasons for incomplete orders.

RESULTS

We identified 1,192 unique patients who received 1,323 orders for intrauterine or subdermal contraceptives; 68% were completed at a second visit. The median time from order to placement was 22 days (interquartile range = 15-35). Of incomplete orders, 41% were related to logistics of a subsequent visit. Twenty-eight percent of patients had a subsequent pregnancy within the study period.

CONCLUSIONS

Efforts to provide same-day access for all contraceptive methods are needed.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial

STUDY OBJECTIVE

Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.

DESIGN

Secondary analysis of a cluster-randomized provider educational trial.

SETTING

Forty US-based reproductive health centers.

PARTICIPANTS

We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.

INTERVENTIONS

The parent study assessed the effect of provider training on evidence-based contraceptive counseling.

MAIN OUTCOME MEASURES

We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.

RESULTS

Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).

CONCLUSION

In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

"It's Worked Well for Me": Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

STUDY OBJECTIVE

To understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.

DESIGN

In-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.

SETTING

Two youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.

PARTICIPANTS

Twenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Young women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.

RESULTS

Young women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.

CONCLUSION

Young women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.

Care of Adolescent Parents and Their Children

Teen pregnancy and parenting remain important public health issues in the United States and around the world. A significant proportion of teen parents reside with their families of origin, which may positively or negatively affect the family structure. Teen parents, defined as those 15 to 19 years of age, are at high risk for repeat births. Pediatricians can play an important role in the care of adolescent parents and their children. This clinical report updates a previous report on the care of adolescent parents and their children and addresses clinical management specific to this population, including updates on breastfeeding, prenatal management, and adjustments to parenthood. Challenges unique to teen parents and their children are reviewed, along with suggestions for the pediatrician on models for intervention and care.

The Association Between Nonbarrier Contraceptive Use and Condom Use Among Sexually Active Latina Adolescents

PURPOSE

This study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use.

METHODS

As part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use.

RESULTS

The use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use.

CONCLUSIONS

The use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

Time Trends in Massachusetts Adolescents' Postabortion Contraceptive Uptake

PURPOSE

The purpose of the study was to assess uptake of postabortion contraception across changes in insurance regulations and insurance type used on the day of abortion, accounting for demographic characteristics and consent type (parental vs. judicial) for abortion among Massachusetts adolescents.

METHODS

We conducted a retrospective record review of 1,375 minors (≤17 years) presenting for their first lifetime surgical abortion at a statewide network of abortion clinics between 2010 and 2016. Postabortion contraceptive method was defined as long-acting reversible contraception (LARC) placed onsite, short-acting reversible contraception (SARC) provided onsite, or no method received.

RESULTS

The proportion of minors leaving with no method dropped from 38% in 2010 to 21% in 2016, while LARC placement increased from 19% to 45%. No difference was observed by consent type. Both LARC and SARC were more prevalent among minors with Medicaid or private insurance compared to those not using insurance on the day of abortion. In a multinomial regression model accounting for consent type and demographic characteristics, minors who received care during the final epoch of the study (relative risk ratio [RRR] = 3.30; 95% confidence interval [CI]: 2.23-4.88) or used private insurance (RRR = 3.91; 95% CI: 2.24-6.84) or Medicaid (RRR = 5.54; 95% CI: 3.37-9.11) on the day of service had significantly higher relative risk of receiving LARC versus no method (p < .001), with similar results for LARC versus SARC.

CONCLUSIONS

Postabortion contraceptive uptake changed over time. Disparately low LARC uptake among minors not using insurance to pay for their abortions highlights a need to ensure equitable access to all methods, regardless of ability to pay.

Missed Opportunities for Discussing Contraception in Adolescent Primary Care

BACKGROUND

Over half of adolescents are sexually active by age 18 years and represent half of sexually transmitted infections (STI). These individuals often do not obtain routine medical care, so discussing contraception at each visit becomes imperative. Our study objectives were to determine the frequency of visits before contraception was discussed/initiated, and to assess factors affecting primary care contraception provision.

METHODS

A retrospective chart review (January 2009-June 2019) was conducted for preventive, follow-up, and sick visits; Title X confidential visits were excluded. Questions were asked about method at start and end of the visit. Nonparametric median tests for continuous variables and chi-squared tests for categorical variables assessed for differences for patient age, race, gender, insurance type, visit type, and provider gender. The institutional review board approved the study as exempt.

RESULTS

Patients (n = 12,619; median = 15 years; 58% female) were seen in primary care clinic. Providers asked about contraception for 82% of visits, and averaged 3 visits before contraception was discussed. For patients asked about contraception, 60% were using a contraceptive method, 15% left the visit on a new method (24.9% long-acting reversible contraception [LARC]). For patients not using contraception, 39.9% left the visit on a method. Patients asked about contraception were female, older, Hispanic, had public insurance, and were seen by female providers (P < .001). Follow-up/sick visits represented <20% of patients asked about contraception.

CONCLUSIONS

Multiple visits occur before contraception is discussed in adolescent primary care, and factors including age, race, and gender affect these discussions. Strategies to increase contraception discussions at all visits is essential, as adolescents do not always present for yearly visits.

Drospirenone: a Latin American perspective for oestrogen-free oral contraception

AIM

Combined hormonal contraceptives, despite their high efficacy, are associated with an increased relative risk of cardiovascular events. The contraceptive mechanism of action of combined pills depends fundamentally on their progestin component.

METHODS

A narrative review was performed.

RESULTS

The drospirenone-only pill, including this synthetic progestogen with antimineralocorticoid and antiandrogenic activity, has high contraceptive efficacy that has been demonstrated with a 24-day schedule of 4-day administration of hormone-free pills. Due to its safety profile, the drospirenone-only pill is suitable even in high-risk populations, such as women with high blood pressure, thromboembolism, smoking or dyslipidemia.

CONCLUSION

Considering the increasing prevalence of these comorbidities in Latin America, the 4 mg drospirenone-only pill is suggested as one of the strategies of choice in the region for those women who choose oral contraceptives.

Menstruation and contraception patterns of female adolescent transplant recipients

BACKGROUND

There is a lack of knowledge regarding menstrual cycles and contraception usage for adolescent transplant patients and families. Solid organ transplant patients start teratogenic medications which have pregnancy implications. We explore adolescent female solid organ transplant recipient and guardian's contraceptive knowledge and attitudes as well as menstrual patterns.

METHODS

A cross-sectional descriptive research design was utilized to collect information from adolescent female transplant patients who are on mycophenolate mofetil after solid organ transplant and their guardians within our freestanding children's hospital via a survey. The sample consisted of all female adolescent patients who have completed a solid organ transplant and are on mycophenolate mofetil from April 2016 through May 2017.

RESULTS

Twenty-one patients were approached, of which nineteen patients and seventeen guardians completed the survey. The average age of the patient was 16.2 years. The average age at time of transplant was 12.2 years. The type of transplants includes renal (57.1%), heart (23.8%), and liver (4.8%). There were six patients (33.3%) who had a history of sexual activity; among these patients, the mean number of partners in the last year was 1.2. Menstrual concerns included dysmenorrhea, irregular bleeding, and heavy bleeding pre- and post-transplant, respectively. Participants reported contraceptive counseling prior to and after transplant approximately half of the time.

CONCLUSIONS

Adolescent solid organ transplant patients have multiple reproductive needs including contraception, dysmenorrhea, and irregular bleeding. Integration of contraceptive knowledge into clinical care received by adolescents with solid organ transplants is supported by knowledge gained through this study.

Discontinuation of implants use and associated factors among women attending health facility clinics in Hawassa City, Southern Ethiopia, 2019; cross sectional study

Background

Despite improving the availability and use of Implants, discontinuation is becoming a public health concern. A significant proportion of women discontinuing the service before its due date, which is of concern in the health system and its consequence may lead to a program failure. This might have also social and economic consequences for users. Only 8% of married women in Ethiopia use implants. Apart from its low utilization, premature removal is common for unknown reasons. However, there is paucity of information on discontinuation of implants use and associated factors in the study area.

Objective

The study was aimed to assess discontinuation of implants use and associated factors among women attending health facility clinics in Hawassa city, southern Ethiopia, from March, 01-April, 01/2019.

Methods

Facility based cross sectional study design was used. Out of 16 health facilities, 9 of them were selected for this study using simple random sampling. Total sample size of this study was determined to be 351. Data were collected from study subjects using pretested, structured questionnaire through a face-to-face interview. Data was analyzed using descriptive statistics and logistic regression. The result is presented using the Crude Odds ratio as well as Adjusted Odds Ratio with the corresponding 95% confidence level.

Result

Out of 351 study participants, the overall proportion of implants discontinuation was 49.3%(95% CI: 44.2–55.0). Lack of counseling about side effects (AOR = 2.394; 95% CI: 1.422–4.030), developing side effects (AOR = 6.325; 95% CI: 3.719–10.757) and lack of post insertion follow-up (AOR = 2.241; 95% CI: 1.186–4.234) the major factors associated with discontinuation of Implants.

Conclusion and recommendation

In this study, the overall proportion of discontinuation of Implants among women who were using Implants was high. Health professionals could give pre-insertion counseling about side effects and post insertion dates for follow-up to improve of utilization of implants.

The Role of Reproductive Autonomy in Adolescent Contraceptive Choice and Acceptance of Long-acting Reversible Contraception

STUDY OBJECTIVE

To examine the association between reproductive autonomy and adolescent receptivity toward long-acting reversible contraceptive (LARC) methods.

DESIGN

A survey to assess sexual history and contraceptive practices/knowledge/attitudes was administered. Reproductive autonomy was measured with an adapted validated scale.

SETTING

Adolescent medicine clinic in an urban academic medical center in the Midwestern United States.

PARTICIPANTS

Girls ages 14-21 years who presented for well or contraceptive visits.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Primary outcome was a favorable rating toward the question "How much do you like the idea of LARC for yourself?" The primary independent variable was the reproductive autonomy decision-making subscale score (higher score indicating increased autonomy).

RESULTS

Eighty-nine participants with a mean age of 16 years completed surveys. Almost all (92%) identified as African American. At study enrollment 56.2% were using Depo-Provera (Pfizer), 15.7% oral contraceptives, 3.4% implants, and 24.7% no method. Only 13.5% of participants liked the idea of LARC for themselves. The mean score on the decision-making subscale was 9 (range, 4-12). In bivariable analysis, age was associated with decision-making subscale score, but was not retained as a confounder in multivariable analysis. The odds of liking LARC decreased by 30% with each unit increase in the autonomy decision-making subscale score (odds ratio, 0.70; 95% confidence interval, 0.52-0.94; P = .02).

CONCLUSION

Our findings suggest that adolescents with higher reproductive autonomy, measured according to their score on the decision-making subscale, were less likely to favor LARC. Further research should explore participants' perceptions of autonomy and the relational dynamics between adolescents and their parents/partners in contraceptive choice.

Adolescent Self-Reported Use of Highly Effective Contraception: Does Provider Counseling Matter?

STUDY OBJECTIVE

To examine associations between provider counseling about specific contraceptive methods and method choices reported by adolescents.

DESIGN

A cross-sectional, secondary analysis of the local 2015 Youth Risk Behavior Survey, to which we added 2 new/modified questions about long-acting reversible contraception (LARC).

SETTING

Rochester, New York.

PARTICIPANTS

Female students in 9th-12th grade in the Rochester City School District.

INTERVENTIONS

An anonymous, standardized survey was administered to collect data.

MAIN OUTCOME MEASURES

We studied associations between students' reported contraceptive use and counseling (LARC, short-acting contraception [SAC], neither), health care factors, and potential risk/protective factors. Data were analyzed using bivariate and multivariate methods.

RESULTS

Among 730 sexually active female respondents, 353/730 (49%) were African American and 182/730 (25%) were Other/Mixed race. 416/730 (57%) used no hormonal method at last sex, and 95/730 (13%) used LARC. 210/730 (29%) of participants recalled any LARC-specific counseling, and 265/730 (36%) any counseling on SAC. Recall of LARC and SAC counseling and use were significantly associated with speaking privately with a provider, but were not related to personal risk/protective factors. Multivariate analyses showed that recollection of LARC counseling was significantly associated with higher odds of using either LARC (adjusted odds ratio, 14.3; P < .001) or SAC (adjusted odds ratio, 2.1; P = .007). Recollection of either LARC or SAC counseling was associated with significantly lower odds of using no contraception.

CONCLUSION

Adolescents' use of LARC was only 13%, but those who recalled contraceptive counseling had higher odds of using some hormonal method. Efforts are needed to improve provider counseling, maintain confidentiality, and identify effective methods to engage adolescents in meaningful, memorable discussions of LARC.

Discontinuation of Reversible Long-Acting Contraceptive and Associated Factors among Female Users in Health Facilities of Hawassa City, Southern Ethiopia: Cross-Sectional Study

Background

Despite improvement in the availability and use of reversible long-acting contraception, discontinuation is becoming a public health concern. A significant proportion of women discontinuing the service before its due date, which is of concern in the health system with regard to its consequences, may lead to a program failure. In addition, there is a paucity of information on discontinuation of reversible long-acting contraceptives and associated factors in the study area. Therefore, this study aimed to assess discontinuation of reversible long-acting contraceptives and associated factors among female users in health facilities of Hawassa city, southern Ethiopia, 2019.

Methods

Institution-based cross-sectional design was used. Systematic sampling was used to select study participants. Women who were users of long-acting contraceptives and had come to selected health facilities for method-related reasons were included in the study. Data collectors approached and recruited participants before they contacted their care providers. Data were collected from study subjects using a pretested, structured questionnaire through face-to-face interviews after participants had contacted care providers. Results are presented using the crude and adjusted ORs with corresponding 95% CIs.

Results

The overall proportion of reversible long-acting contraceptive discontinuation was 56.6% (95% CI 52.30%, 61.10%). Maternal education at primary level (AOR 2.33, 95% CI 1.15–4.74), lack of counseling (AOR 2.50, 95% CI 1.01–6.18), side effects (AOR 2.10, 95% CI 1.31–3.34), and desire to be pregnant (AOR 2.22; 95CI 1.50–3.30) were the major factors in discontinuation.

Conclusion

In this study, the overall proportion of discontinuation of reversible long-acting contraceptives was high. Maternal education at primary level, lack of counseling, side effects, and desire to be pregnant were the key factors associated with discontinuation of the contraceptives. Health professionals should provide counseling on the side effects before insertion.

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.