How does intimate partner violence affect condom and oral contraceptive Use in the United States?: A systematic review of the literature

INTRODUCTION

Intimate partner violence (IPV) is estimated to affect 25% of adult women in the United States alone. IPV directly impacts women's ability to use contraception, resulting in many of unintended pregnancies and STIs. This review examines the relationship between IPV and condom and oral contraceptive use within the United States at two levels: the female victim's perspective on barriers to condom and oral contraceptive use, in conjunction with experiencing IPV (Aim 1) and the male perpetrator's perspective regarding condom and oral contraceptive use (Aim 2).

STUDY DESIGN

We systematically reviewed and synthesized all publications meeting the study criteria published since 1997. We aimed to categorize the results by emerging themes related to each study aim.

RESULTS

We identified 42 studies that met our inclusion criteria. We found 37 studies that addressed Aim 1. Within this we identified three themes: violence resulting in reduced condom or oral contraceptive use (n=15); condom or oral contraceptive use negotiation (n=15); which we further categorized as IPV due to condom or oral contraceptive request, perceived violence (or fear) of IPV resulting in decreased condom or oral contraceptive use, and sexual relationship power imbalances decreasing the ability to use condoms or oral contraceptives; and reproductive coercion (n=7). We found 5 studies that addressed Aim 2. Most studies were cross-sectional, limiting the ability to determine causality between IPV and condom or oral contraceptive use; however, most studies did find a positive relationship between IPV and decreased condom or oral contraceptive use.

CONCLUSIONS

Quantitative, qualitative, and mixed methods research has demonstrated the linkages between female IPV victimization/male IPV perpetration and condom or oral contraceptive use. However, additional qualitative and longitudinal research is needed to improve the understanding of dynamics in relationships with IPV and determine causality between IPV, intermediate variables (e.g., contraceptive use negotiation, sexual relationship power dynamics, reproductive coercion), and condom and oral contraceptive use. Assessing the relationship between IPV and reproductive coercion may elucidate barriers to contraceptive use as well as opportunities for interventions to increase contraceptive use (such as forms of contraception with less partner influence) and reduce IPV and reproductive coercion.

The scientific body of knowledge - Whose body does it serve? A spotlight on oral contraceptives and women's health factors in neuroimaging

Women constitute half of the world's population, yet neuroscience research does not serve the sexes equally. Fifty years of preclinical animal evidence documents the tightly-coupled relationship between our endocrine and nervous systems, yet human neuroimaging studies rarely consider how endocrine factors shape the structural and functional architecture of the human brain. Here, we quantify several blind spots in neuroimaging research, which overlooks aspects of the human condition that impact women's health (e.g. the menstrual cycle, hormonal contraceptives, pregnancy, menopause). Next, we illuminate potential consequences of this oversight: today over 100 million women use oral hormonal contraceptives, yet relatively few investigations have systematically examined whether disrupting endogenous hormone production impacts the brain. We close by presenting a roadmap for progress, highlighting the University of California Women's Brain Initiative which is addressing unmet needs in women's health research.

Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy

OBJECTIVE

An unsettling aspect of the US opioid epidemic is the high rate of in utero exposure, especially since most of these pregnancies are unintended, due in part to low rates of effective contraceptive use among opioid-using women. This study tested an intervention informed by behavioral economic theory and aimed at promoting effective contraceptive use among opioid-maintained women at risk of unintended pregnancy in the Burlington, VT, area between 2011 and 2013.

METHODS

Thirty-one women were assigned (initial 5 consecutively, subsequent 26 randomly) to either usual care or an experimental intervention. Participants in usual care received condoms, a dose of emergency contraception, and referral to local providers. Participants in the experimental condition received usual care plus the World Health Organization's contraception initiation protocol, including free prescription contraceptives, and financial incentives for attending 13 follow-up visits over 6months to help manage side effects and other issues.

RESULTS

Significantly more women in the experimental vs. usual care control conditions initiated prescription contraceptive use (100% vs. 29%) and reported prescription contraceptive use at 1-month (63% vs. 13%), 3-month (88% vs. 20%), and 6-month (94% vs. 13%) assessments. None of the experimental condition participants became pregnant during the 6-month protocol vs. three women (20%) in the control condition.

CONCLUSIONS

These results provide the first experimental evidence supporting the efficacy of an intervention for increasing prescription contraceptive use among opioid-maintained women at risk of unintended pregnancy.

The Use of Telehealth to Teach Reproductive Health to Female Rural High School Students

STUDY OBJECTIVE

To evaluate the use of telehealth to teach reproductive health to rural areas with high rates of teen pregnancy.

DESIGN

Prospective cohort study.

SETTING

Two high schools in rural West Virginia.

PARTICIPANTS

High school female students who attended telehealth sessions.

INTERVENTIONS

Teleconferencing equipment connected rural high schools to a distal academic institution. Telehealth sessions included reproductive health and life skills topics. Demographic information, session pre- and post-tests, and 6- month assessment was obtained.

MAIN OUTCOME MEASURES

Reproductive health knowledge, behavior, and self-efficacy were assessed at intervention and at 6 months, along with Likert scale evaluation of telehealth as an educational tool.

RESULTS

Fifty-five students participated in the program with an average age of 16.14 (SD 1.24) years. Only 20% (10/50) of subjects' mothers and 12% (6/50) of subjects' fathers had achieved education beyond high school, and 20% (10/50) of subject's mothers had experienced teen pregnancies (age 18 or younger). Sexual activity was reported among 52% (26/50) of subjects, 4/50 (8%) reported desire to become pregnant within the next year, and 4/50 (8%) reported already pregnant. Thirty-seven students completed the 6-month follow-up survey. Reported condom use increased from 20% (10/50) at baseline to 40% (15/37) at 6 months (P = .04) and hormonal contraception use increased from 22% (11/50) to 38% (14/37) (P = .12). Report of human papillomavirus vaccination increased from 38% (10/26) to 70% (26/37) (P = .001) among all subjects. At 6 months, 91.8% (34/37) reported the use of telehealth was "very effective" as a means to teach the material.

CONCLUSIONS

Telehealth is an effective tool to teach reproductive health to rural areas.

Factors Associated With Contraceptive Method Choice and Initiation in Adolescents and Young Women

PURPOSE

The purpose of the study was to identify factors associated with uptake of contraceptive implants or intrauterine devices (IUDs) by adolescents and young women.

METHODS

For this prospective cohort study, we recruited English-speaking female contraceptive initiators aged 14-24 years attending a Title X-supported, youth-focused clinic. Immediately prior to their visits, participants completed surveys assessing demographic and reproductive characteristics and awareness of, interest in, and intent to initiate specific contraceptive methods. Participants also answered questions about their social contacts' contraceptive experiences. Following the visit, participants reported the method initiated and the perceived importance of provider counseling. We used a multivariable regression model to ascertain factors associated with initiation of an IUD, an implant, or a short-acting reversible method.

RESULTS

We enrolled 1,048 contraceptive initiators: 277 initiated short-acting methods, 384 IUDs, and 387 implants. High previsit personal acceptability of the method was associated with choosing that method for both implants and IUDs. Knowing someone who uses a specific method and likes it was predictive of personal acceptability of that method (IUD adjusted odds ratio: 10.9, 95% confidence interval: 3.8-31.1; implant adjusted odds ratio: 7.0, 95% confidence interval: 2.3-21.0). However, 10.4% of those initiating IUDs and 14.2% of those initiating implants had never heard of the method before their appointment. Even women with previsit intent to initiate a specific method found importance in contraceptive counseling.

CONCLUSIONS

Previsit personal acceptability, which was associated with social contacts' experiences, was the strongest predictor of specific method uptake in our study. However, counseling informed the decisions of those with low previsit awareness and supported patients with formed intent.

Emergency Contraception Pill Awareness and Knowledge in Uninsured Adolescents: High Rates of Misconceptions Concerning Indications for Use, Side Effects, and Access

STUDY OBJECTIVE

To determine the awareness of, access to, and knowledge of the proper use of emergency contraception pills (ECPs) among uninsured adolescents.

DESIGN

Anonymous surveys were used to assess awareness of, knowledge of, and access to ECPs.

SETTING

From 2010 to 2012 at mobile primary care clinic in the San Francisco Bay Area.

PARTICIPANTS

Patients were uninsured adolescents aged 13 to 25; 40% of the participants were currently or had been homeless in the past year. Ethnicity was 50% Asian, 22% Hispanic, 17% Pacific Islanders, 5.5% white, and 5.5% other/mixed ethnicity.

INTERVENTIONS

Post survey completion, patients received one-on-one 15-minute dedicated ECP education.

MAIN OUTCOME MEASURES

Awareness of, knowledge of, and access to ECPs.

RESULTS

Of the study population of 439, 30% of the participants were 13-16 years old and 70% were 17-25 years old (mean age 17.8 years); 66% were women. Young women (86%) reported higher rates of "hearing about emergency contraception" than did young men (70%) (P < .0001). Many incorrectly identified or were uncertain if ECPs were an abortion pill (40%) or could be used as regular birth control (40%) or to prevent sexually transmitted infections (19%). Only 40% of women and 43% of men aged 17 and older correctly answered that they could obtain EC over the counter; 72% did not know that males could receive EC for use by their partner; 12% incorrectly selected that infertility was a side effect; 44% were under the false impression that EC had to be taken within 1 day of unprotected sex.

CONCLUSIONS

Uninsured adolescents have high rates of ECP awareness but low ECP knowledge. These adolescents need more ECP education to alleviate misconceptions and increase practical knowledge, specifically, education about male access, side effects, over-the-counter availability for young men and women, and the 120-hour window of use.

Circulating cortisol levels after exogenous cortisol administration are higher in women using hormonal contraceptives: data from two preliminary studies

Exogenous cortisol administration has been used to test the influence of glucocorticoids on a variety of outcomes, including memory and affect. Careful control of factors known to influence cortisol and other endogenous hormone levels is central to the success of this research. While the use of hormonal birth control (HBC) is known to exert many physiological effects, including decreasing the salivary cortisol response to stress, it is unknown how HBC influences circulating cortisol levels after exogenous cortisol administration. To determine those effects, we examined the role of HBC on participants' cortisol levels after receiving synthetic cortisol (hydrocortisone) in two separate studies. In Study 1, 24 healthy women taking HBC and 26 healthy men were administered a 0.1 mg/kg body weight intravenous dose of hydrocortisone, and plasma cortisol levels were measured over 3 h. In Study 2, 61 participants (34 women; 16 were on HBC) received a 15 mg hydrocortisone pill, and salivary cortisol levels were measured over 6 h. Taken together, results from these studies suggest that HBC use is associated with a greater cortisol increase following cortisol administration. These data have important methodological implications: (1) when given a controlled dose of hydrocortisone, cortisol levels may increase more dramatically in women taking HBC versus women not on HBC or men; and (2) in studies manipulating cortisol levels, women on hormonal contraceptives should be investigated as a separate group.

Differences in contraceptive use between family planning providers and the U.S. population: results of a nationwide survey

OBJECTIVES

To describe contraceptive use among U.S. female family planning providers and to compare their contraceptive choices to the general population.

STUDY DESIGN

We surveyed a convenience sample of female family planning providers ages 25-44 years, including physicians and advanced practice clinicians, via an internet-based survey from April to May 2013. Family planning providers were compared to female respondents ages 25-44 years from the 2011-2013 National Survey of Family Growth.

RESULTS

A total of 488 responses were eligible for analysis; 331 respondents (67.8%) were using a contraceptive method. Providers' contraceptive use differed markedly from that of the general population, with providers significantly more likely to use intrauterine contraception, an implant, and the vaginal ring. Providers were significantly less likely to use female sterilization and condoms. There were no significant differences between providers and the general population in use of partner vasectomy or the pill. Long-acting reversible contraception (LARC) use was significantly higher among providers than in the general population (41.7% vs. 12.1%, p<.001). These results were consistent when stratifying by variables including self-identified race/ethnicity and educational level.

CONCLUSIONS

The contraceptive choices of this sample of female family planning providers differed significantly from the general population. These findings have implications for clinical practice, patient education, and health policy.

IMPLICATIONS

Family planning providers report higher use of LARC than the general population. This may reflect differences in preferences and access. Providers might consider sharing these findings with patients, while maintaining patient choice and autonomy.

Who takes responsibility for contraception, according to young Australian women?

OBJECTIVE

Developments in reversible forms of female contraception are more advanced than developments in male contraception - which are still limited to the condom. These technological advancements have arguably shaped views around who should take responsibility for contraception. We investigate the notion that responsibility relates to gender-specific contraceptives.

METHODS

We aimed to explore young women's reports of contraceptive responsibility based on the last time they had sex, using demographic and free-text data from 1906 women who completed a longitudinal survey about contraceptive use. We analysed four patterns of responsibility: the woman took responsibility; the sexual partner took responsibility; both took responsibility; neither took responsibility.

RESULTS

Our quantitative analyses found significant differences between the four groups on the following variables: contraceptive use at last sex, relationship status, ever been pregnant, parity, and medical consultations for contraception in the past six months. Our qualitative analysis identified distinct variability within and between the four patterns of responsibility in terms of contraceptive use and gender responsible.

CONCLUSIONS

These findings challenge the gendered portrayal of contraceptive responsibility, in that women's responsibility is not necessarily tied to women-specific methods and vice versa. We encourage increased dialogue around contraceptive responsibility and decision-making in both clinical and educational settings.

An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception

OBJECTIVE

We examine the association between depressive symptoms and contraceptive method choice among adolescents initiating prescription contraception.

STUDY DESIGN

This cross-sectional study analyzes baseline data of 220 urban, minority adolescent females (ages 15-19 years) presenting for prescription contraceptive initiation at a comprehensive, free-of-cost, adolescent health center in New York City. All participants met with a health care provider who provided standard contraception counseling before initiating contraception. Each participant then selected a short- or long-acting contraceptive: a 3-month supply of the pill, patch, ring or a medroxyprogesterone acetate depot injection (short-acting), or placement/referral for an intrauterine device (IUD; long-acting). We assess the independent association between contraceptive method selection and symptoms of depression [assessed by the Center for Epidemiological Studies - Depression (CES-D) scale].

RESULTS

Ten percent (n=21/220) of adolescent females selected an IUD. Bivariate analysis revealed that those with elevated levels of depressive symptoms were more likely to select an IUD as compared to those with minimal symptoms (mean CES-D score 20 vs. 13; t=3.052, p=.003). In multivariate logistic regressions, adolescent females had increased odds of selecting an IUD if they reported moderate to severe depressive symptoms (adjusted odds ratio=4.93; confidence interval, 1.53-15.83; p=.007) after controlling for ethnicity/race, education, number of lifetime partners and gravidity.

CONCLUSIONS

Inner-city, minority adolescents with elevated symptoms of depression who present for prescription contraceptive initiation may be more likely to select an IUD rather than shorter-acting methods. By recognizing adolescent females with depressive symptoms, providers can strategize their approach to effective contraception counseling.

Characteristics of scheduled bleeding manipulation with combined hormonal contraception in university students

BACKGROUND

There is a lack of information concerning the decision factors and sources of information influencing women who purposefully deviate from the prescribed use of their combined hormone contraceptives to exert elective control of their scheduled bleeding.

STUDY DESIGN

A self-administered email survey of scheduled bleeding practices and beliefs was distributed to 11,900 female students at the University of Oregon. Assessment of survey participant characteristics, scheduled bleeding manipulation features and attitudes and knowledge toward hormonal contraception was analyzed.

RESULTS

Of 1719 respondents to the survey, 1374 (79.9%) reported using combined hormonal contraception currently or recently. Approximately 17% of these women altered their scheduled bleeding pattern by deviating from package instructions. Of these, 50% indicated they delayed or skipped their scheduled bleeding for convenience or personal choice. Within this group, 47% of women indicated they learned to modify their scheduled bleeding from health care professionals, while 30% indicated such knowledge was obtained from family or friends. Characteristics that decreased the likelihood of this practice included being of Asian race, use of hormonal contraceptive for bleeding cycle regulation, following a regular exercise program, and personal preference for a monthly cycle.

CONCLUSIONS

The majority of university females who choose to modify their scheduled bleeding cycle with combined hormonal contraceptives do so for convenience rather than to avoid menstrual symptoms, and many learn from nonmedical sources. There is some disparity between the preferences of menstruation frequency and actual scheduled bleeding pattern behaviors, suggesting potential for improvement in patient education.

Intimate partner violence and postpartum contraceptive use: the role of race/ethnicity and prenatal birth control counseling

OBJECTIVES

Intimate partner violence (IPV) is a major problem that could affect reproductive decision making. The aim of this study is to examine the association between IPV and contraceptive use and assess whether the association varies by receipt of prenatal birth control counseling and race/ethnicity.

STUDY DESIGN

This study analyzed the 2004-2008 national Pregnancy Risk Assessment Monitoring System (PRAMS) that included 193,310 women with live births in the United States. IPV was determined by questions that asked about physical abuse by a current or former partner in the 12 months before or during pregnancy. The outcome was postpartum contraceptive use (yes vs. no). Multiple logistic regression analyses were conducted to assess the influence of experiencing IPV at different periods (preconception IPV, prenatal IPV, both preconception and prenatal IPV, preconception and/or prenatal IPV). Data were stratified to assess differential effects by race/ethnicity and receipt of birth control counseling.

RESULTS

Approximately 6.2% of women reported IPV, and 15.5% reported no postpartum contraceptive use. Regardless of the timing of abuse, IPV-exposed women were significantly less likely to report contraceptive use after delivery. This was particularly true for Hispanic women who reported no prenatal birth control counseling and women of all other racial/ethnic groups who received prenatal birth control counseling.

CONCLUSIONS

IPV victimization adversely affects the use of contraceptive methods following delivery in women with live births. Birth control counseling by health providers may mitigate these effects; however, the quality of counseling needs further investigation. Better integration of violence prevention services and family planning programs is greatly needed.

IMPLICATIONS

Consistent with national recommendations by the U.S. Preventive Service Task Force, clinicians and public health workers are strongly encouraged to screen for IPV. Health providers should educate women on effective contraceptive options and discuss long-acting reversible contraceptives that are not partner dependent within the context of abusive relationships.

Youth Perspectives on Pharmacists' Provision of Birth Control: Findings From a Focus Group Study

PURPOSE

Young women face numerous obstacles to accessing contraception, including lack of money, time, or transportation to visit a doctor. In addition, concerns about confidentiality deter many adolescents from seeking contraceptive care. Pharmacists in Washington, D.C. will soon be able to prescribe hormonal birth control, which can potentially increase contraceptive access for adolescents. This study explores the needs and concerns of teens and young women residing in Washington, D.C. to inform implementation of this service.

METHODS

In this community-based participatory research study, four focus group discussions were conducted in February 2017, two with teen females aged 14-17 years and two with young women aged 18-24 years. A youth advisory council, comprising 13 women aged 16-22 years living in Washington, D.C., helped develop the discussion guide and interpret findings. Data were analyzed thematically by age group using inductive and deductive codes.

RESULTS

Young people viewed pharmacies as convenient locations to access contraceptives but expressed concerns about privacy, affordability, and pharmacist approachability. Younger participants viewed these concerns as significant barriers for their peers. Participants suggested pharmacies protect privacy and confidentiality by offering private consultation spaces and clear information about what insurance plans can disclose to parents. Participants also recommended pharmacies create a youth-friendly, nonjudgmental environment and offer pharmacists training on contraceptive counseling for young women.

CONCLUSIONS

Addressing concerns about privacy, costs, and pharmacist approachability can help ensure that youth seeking contraceptives can easily access their preferred method. Pharmacies should continuously incorporate young people's feedback to ensure this service remains accessible and acceptable to adolescents.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

Predictors of adherence to hormonal contraceptives in a female veteran population

OBJECTIVE

The objective was to identify predictors of adherence to hormonal contraceptives in a female veteran population.

STUDY DESIGN

This was a retrospective cohort study of female veterans from the VA San Diego Healthcare System. The study period was April 1, 2010, to March 31, 2012. Each patient was followed for 1 year from the index date, defined as the date of first contraceptive prescription in the study time period. Adherence was defined as a medication possession ratio ≥ 0.9. Income was estimated using zip-code-based median household income and split into quintiles (quintile 1 being the lowest-earning group). Logistic regression was used to analyze the association between adherence and the independent variables.

RESULTS

A total of 805 patients were included in the final analysis. The majority of the population was white (62.2%) and receiving a 3-month supply of medication (87.6%). The following independent variables were predictive of increased adherence: 3-month supply versus 1-month supply [odds ratio (OR) 1.79, 95% confidence interval (CI) 1.03-3.13], age group 40-45 versus 18-24 (OR 2.57, 95% CI 1.16-5.70) and income quintiles 3 (OR 1.96, 95% CI 1.16-3.29), 4 (OR 1.77, 95% CI 1.06-2.98) and 5 (OR 1.75, 95% CI 1.03-2.98) each versus quintile 1 as reference group. The following were associated with decreased adherence: new start versus continuing user (OR 0.25, 95% CI 0.18-0.37), OB/GYN provider versus primary care provider (OR 0.60, 95% CI 0.38-0.95), and highest weight group versus lowest weight group (OR 0.40, 95% CI 0.17-0.94).

CONCLUSION

Hormonal contraceptive adherence in the veteran population is below optimal. Providing 3-month supplies of high-value therapies such as hormonal contraceptives is one strategy that may improve adherence. Initiatives to target lower socioeconomic status or new start populations to increase contraceptive adherence should also be considered.

IMPLICATIONS

Adherence to hormonal contraceptives is not as well studied in the literature as some other high-value therapies. Identifying predictive variables for adherence may have implications for establishing possible interventions, or refining benefit structures, in order to increase adherence.

Contraceptive practice after surgical repair of obstetric fistula in southeast Nigeria

OBJECTIVE

To determine the contraceptive practices of women after surgical repair of obstetric fistula and to assess determinants of uptake and the pregnancy rate in the first year.

METHODS

A prospective cohort study enrolled women who had a successful surgical repair of obstetric fistula at a center in Nigeria between 2011 and 2013. Patients were followed up for 1year. Data were obtained through record review and completion of a semi-structured questionnaire.

RESULTS

Among 188 participants, 180 (95.7%) were aware of contraception, but only 70 (37.2%) used contraceptive methods after surgery. The most commonly used methods were the male condom (50 [71.4%] of 70) and hormonal injections (14 [20.0%]). The main reasons for non-use were fear of adverse effects (48 [40.7%] of 118 women), future desire for more children (35 [29.7%]), religious prohibition (26 [22.0%]), cultural beliefs (29 [24.6%]), and partner disapproval (42 [35.6%]). The risk of unplanned pregnancy in the first year was significantly lower among women who used contraceptives than among those who did not (relative risk 0.14, 95% confidence interval 0.02-1.06; P=0.03).

CONCLUSION

Contraceptive uptake for birth control after fistula repair surgery was low because of socioeconomic reasons, religious and cultural beliefs, and myths, resulting in unplanned pregnancies.

Side effects unrelated to disease activity and acceptability of highly effective contraceptive methods in women with systemic lupus erythematosus: a randomized, clinical trial

OBJECTIVES

To assess the side effects unrelated to disease activity and the acceptability of combined oral contraceptives (COCs), progestin-only pills (POPs) and copper-releasing intrauterine devices (IUDs) in women with systemic lupus erythematosus (SLE).

STUDY DESIGN

A randomized clinical trial including 162 women with SLE, assigned to COC (n=54), POP (n=54) or IUD (n=54). Follow-up visits were conducted after 1, 2, 3, 6, 9 and 12 months of treatment to monitor the presence of symptoms, changes in body weight and blood pressure as well as the development of health problems other than those relating to lupus. Reasons for discontinuation and satisfaction with the use of the assigned method were recorded at the end of treatment. Statistical analysis included descriptive statistics, repeated measure analyses and Kaplan-Meier curves.

RESULTS

Significantly different discontinuation rates due to any reason [35%, 55%, 29% (p<0.01)] or nonmedical reasons [(11%, 31%, 4% (p<0.05)] were observed among the COC, POP and IUD groups. Nausea was most frequent among COC users, dysmenorrhea among IUD users and acne and hirsutism among POP users. Mean blood pressures remained unchanged. Mild increases in body weight were observed over time in all treatment groups. Most women were satisfied with the use of the assigned contraceptive method.

CONCLUSIONS

Oral contraceptives and IUD are acceptable birth control methods for patients with lupus, when counseling and specialized health attention are provided; however, the acceptability of POP appears to be inferior. Side effects unrelated to lupus disease activity are not frequent reasons to discontinue the contraceptive methods.

IMPLICATIONS

This study delves into an area that has not been explored among patients with lupus. Our findings on the associated side effects and reasons for discontinuing COCs, POPs or copper-bearing IUDs may be useful in improving contraceptive counseling for women with lupus. Furthermore, they also heighten our knowledge on the reasons that may preclude the widespread use of effective contraceptives among lupus patients.

Malthus in the Bedroom: Birth Spacing as Birth Control in Pre-Transition England

We use duration models on a well-known historical data set of more than 15,000 families and 60,000 births in England for the period 1540-1850 to show that the sampled families adjusted the timing of their births in accordance with the economic conditions as well as their stock of dependent children. The effects were larger among the lower socioeconomic ranks. Our findings on the existence of parity-dependent as well as parity-independent birth spacing in England are consistent with the growing evidence that marital birth control was present in pre-transitional populations.

The effect of parental involvement laws on teen birth control use

In Volume 32, Issue 5 of this journal, Colman, Dee, and Joyce (CDJ) used data from the National Youth Risk Behavior Surveys (NYRBS) and found that parental involvement (PI) laws had no effect on the probability that minors abstain from sex or use contraception. We re-examine this question, augmenting the NYRBS with data from the State Youth Risk Behavior Surveys (SYRBS), and use a variety of identification strategies to control for state-level time-varying unmeasured heterogeneity. Consistent with CDJ, we find that PI laws have no effect on minor teen females' abstinence decisions. However, when we exploit additional state policy variation unavailable to CDJ and use non-minor teens as a within-state control group, we find evidence to suggest that PI laws are associated with an increase in the probability that sexually active minor teen females use birth control.

Perinatal contraceptive counselling: Effectiveness of a reinforcement intervention on top of standard clinical practice

OBJECTIVE

To assess the effectiveness of supplemental perinatal contraceptive counselling in addition to standard Spanish postpartum contraceptive counselling with regard to contraceptive use and use of effective contraception up to 1 year postpartum. Women's satisfaction with counselling and the method chosen was also assessed.

DESIGN

Community-randomized trial.

SETTING

"Reproductive and Sexual Health Care" units of the National Health Care System at twenty public Primary Care facilities in Catalonia (Spain).

PARTICIPANTS

1,004 consecutive pregnant women (~week 30) receiving prenatal care between 1st October 2015 and 31st March 2016. Women were considered eligible for analysis if appropriate information was available.

INTERVENTIONS

At half of the centres, midwives provided the standard Spanish postpartum contraceptive counselling (control group, CG). At the other half, supplemental perinatal contraceptive counselling was provided in addition to standard counselling (intervention group, IG) at different time points during pregnancy and postpartum. This consisted of a leaflet and a blog with practical information about all contraceptive options plus a short reminder message in the mobile phone during the third quarter of pregnancy and a face-to-face or a virtual meeting lasting 20 min in the first 15 days postpartum. Midwives used ad hoc questionnaires to collect information at week 30 of pregnancy (recruitment), and week 6, month 6 and month 12 postpartum.

MEASUREMENTS AND FINDINGS

975 women were eligible for analysis (482 in the CG and 493 in the IG). ~33% women had resumed sexual intercourse by week 6, and nearly all by months 6 and 12. Use and effectiveness of contraceptives was similar in both groups at week 6 and month 6. At month 12, more women in the IG used more effective contraception and less women used contraceptives considered somewhat effective vs. those of the CG (P = 0.006). When considering the place of origin, this was only true for Spanish women. Women of other origins had a much higher use of very effective contraceptives at month 12 also in the CG, with contraceptive counselling having scarce effect. On multivariate analysis, conducted only in Spanish women, the additional counselling resulted in a higher use of highly effective methods while having a university degree increased 3.6 times the OR for this behaviour. A bias towards fostering use of very effective contraceptives among women with low education was seen in standard clinical practice. Satisfaction with counselling and the type of contraception chosen was higher in the IG.

KEY CONCLUSIONS

Our study has shown that the supplemental counselling tested has a moderate impact on contraceptive use and use of effective contraception in postpartum women. Results of this effort were seen after 6 months postpartum. A possible bias towards women who were more socially vulnerable was found in standard clinical practice, which reduced the effectiveness of the intervention in women who were otherwise the most needy.

IMPLICATIONS FOR PRACTICE

Despite the benefits provided by supplemental support in perinatal contraceptive counselling, the existence of a possible bias affecting the effectiveness of these interventions should be investigated and addressed.

Depo-medroxyprogesterone acetate, weight gain and amenorrhea among obese adolescent and adult women

Objective: The aim of the study was to evaluate the correlation between obesity and the use of depot medroxyprogesterone (DMPA) with regard to weight gain and changes in bleeding pattern.Methods: A retrospective chart review was conducted of women receiving 150 mg DMPA via intramuscular injection at inpatient and outpatient clinics at the University of Mississippi Medical Centre between 1 June 2012 and 31 December 2016. Body mass indices (BMI) were assessed at baseline and at the time of final injection. Data on race, medical history, age at first DMPA injection, number and timing of injections, reported side effects, indication for DMPA use and reason for discontinuation, if applicable, were collected.Results: Of the 240 women included in the study, 3.3% were underweight, 30.8% were normal weight, 23.3% were overweight, 15% were class I obese, 9.6% were class II obese and 17.9% were class III obese; 87.9% of the population were African American. Women gained 2.40 kg (95% confidence interval 1.34-3.45) while they were on DMPA (p < .01), which after adjusting for confounding variables was inversely associated with age at initial injection (β coefficient -0.13; p = .02). Amenorrhoea was the most commonly reported change in bleeding pattern.Conclusion: Women who started DMPA at an earlier age gained the most weight over time, independently of initial BMI. Similar rates of amenorrhoea were found among all BMI categories.

Development and conceptual validation of a questionnaire to help contraceptive choice: CHLOE (Contraception: HeLping for wOmen's choicE)

OBJECTIVE

The aim of this research was to develop a questionnaire to facilitate choice of the most appropriate contraceptive method for individual women.

METHODS

A literature review was conducted to identify key aspects influencing contraceptive choice and inform development of a questionnaire for online completion. Questionnaire development was overseen by a steering committee consisting of eight gynaecologists from across Europe. The initial draft underwent conceptual validation through cognitive debriefing interviews with six native English-speaking women. A qualitative content analysis was conducted to accurately identify potential issues and areas for questionnaire improvement. A revised version of the questionnaire then underwent face-to-face and online evaluation by 115 international gynaecologists/obstetricians with expertise in contraception, prior to development of a final version.

RESULTS

The final conceptually validated Contraception: HeLping for wOmen's choicE (CHLOE) questionnaire takes ≤10 min to complete and includes three sections to elicit general information about the individual, the health conditions that might influence contraceptive choice, and the woman's needs and preferences that might influence contraceptive choice. The questionnaire captures the core aspects of personalisation, efficacy and safety, identified as key attributes influencing contraceptive choice, and consists of 24 closed-ended questions for online completion prior to a health care provider (HCP) consultation. The HCP receives a summary of the responses.

CONCLUSION

The CHLOE questionnaire has been developed to help women choose the contraception that best suits their needs and situation while optimising the HCP's time.

Psychological side effects of hormonal contraception: a disconnect between patients and providers

BACKGROUND

Existing literature about the psychological side effects of hormonal contraception (HC) is limited. The goal of this study is to better characterize patients' subjective experiences with HC, its side effects, and contraception counseling.

METHODS

This is a cross-sectional, survey-based study using a convenience sample of patients who had used HC at some point in their lives. Recruitment occurred from June 2021-February 2022.

RESULTS

Of the 188 responses included in the analysis, 43.6% reported experiencing mood changes as a side effect of HC at some point in their lives. The most common reason participants cited for discontinuing or switching contraception methods was side effects (48.3%). Participants with a history of psychiatric illness were significantly more likely to report mood changes as a side effect of their HC (61.2%) compared to participants with no history of psychiatric illness (29.5%). Among patients with a history of psychiatric illness, 38.8% responded that their psychiatric symptoms worsened with HC while only 11.2% responded that their symptoms improved with HC. The majority (83%) of participants responded that their provider never mentioned the possibility of psychological side effects during contraception counseling. If/when they experienced side effects associated with their HC, 22.7% of participants disagreed that their provider adequately addressed their concerns.

CONCLUSION

These findings suggest that mood changes may be among the most common perceived side effects of HC and speak to a disconnect between patients and providers when it comes to discussing the possibility of psychological side effects with HC.

Predictors of unmet need for family planning in Ethiopia 2019: a systematic review and meta analysis

Background

unmet need for family planning is a common cause of uninteded pregnancy which mostly end up with abortion. Many studies were conducted on predictors of unmet need of family planning in Ethiopia. But, up until now, single evidence has not been synthesized and various point prevalence estimates of unmet need for family planning have been reported. Therefore, this sytematic review and meta analysis was established to identify the predictors of unmet need for family planning in Ethiopia.

Methods

search engines including PubMed, Embase, CINAHL, Google Scholar, HINARI portal, and Cochrane Library were used to retrieve included articles and reported using the preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was applied for critical appraisal. All observational studies done on reproductive age women and reported on unmet need for family planning were included. Unmet need for family planning is the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning to stop or delay childbearing. Random effect model was done to estimate the pooled prevalence of unmet need for family planning. Odds ratio with 95% confidence interval was considered to determine the association of identified variables with unmet need of family planning. Cochran’s Q statistic, Egger’s and Begg’s test were carried out to assess heterogeneity and publication bias.

Results

Fifteen articles and 17, 585 reproductive aged women were included to estimate the pooled prevalence of unmet need for family planning and its predictors in Ethiopia. The prevalence of unmet need for family planning in Ethiopia ranges from 26.52 to 36.39%. Age at first marriage < 18 yrs. with OR = 2.3 (95% CI: 1.08, 4.87), women with no formal education with OR = 1.9 (95%CI: 1.19, 3.04), partner with no formal education with OR = 1.78 (95%CI: 1.18, 2.68) and absence of discussion with their partner about family planning with OR = 3.52 (95%CI, 2.56, 4.87) were predictors of unmet need of family planning in Ethiopia.

Conclusion

This meta analysis revealed that, the prevalence of unmet need for family planning in Ethiopia was high as compared with the United Nations sphere standard of unmet need for planning, considered to be high if it is greater than 25%. Early marriage, no formal eduaction and lack of discussion with partner on family planning were predictors of unmet need for family planning. Therefore, efforts are needed to empower women through eduaction, avoiding early marriage and facilitating dicussion of partners about family planning in order to improve family planning usage.

Medical contraindications to combined hormonal contraceptive use among women using methods prescribed by a pharmacist

OBJECTIVE

To determine whether pharmacist prescription of combined hormonal contraception is associated with inappropriate prescription to women with medical contraindications.

STUDY DESIGN

We conducted a retrosopective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016 to December 31, 2018. Our primary outcome was the proportion of women receiving a combined hormonal method who had a Medical Eligibility Category (MEC) 3 or 4 condition. We identified potential contraindications using International Classification of Disease codes. We conducted descriptive analyses of contraindication prevalence and prescription error rate by prescriber type. We used a multivariable logistic regression model to test the association between pharmacist prescriber and population characteristics.

RESULTS

Our study sample consisted of 439,240 contraceptive users, of which 3782 (0.86%) received their prescriptions from a pharmacist. Women aged 25 to 29 were more likely than women over age 35 to receive contraception from a pharmacist (adjusted odds ratio (aOR) 2.74, 95% confidence interval [CI] 2.44-3.08). Pharmacist prescriptions were slightly less likely in rural areas (aOR 0.78, 95% CI 0.69-0.89) and among women on Medicaid, relative to those with commercial insurance (aOR 0.21, 95% CI 0.19-0.24). Among women given contraception in a clinical setting, 4.25% had evidence of an MEC 3 or 4 contraindication, compared to 0.9% for women seen by a pharmacist. Rates of prescribing a combined method to women with a potential contraindication were not meaningfully different by prescriber type (2.16% for clinicians vs 0.74% for pharmacists).

CONCLUSION

Rates of contraceptive prescribing with a contraindication were relatively low and did not differ between clinicians and pharmacists.

IMPLICATIONS

Pharmacists can safely screen for medical contraindications to combined hormonal contraception.