Pregnancy outcomes following routine early provision of intrauterine device after first-trimester induced abortion-A secondary analysis of a randomized controlled trial with a 5-year follow up

INTRODUCTION

Women undergoing an induced abortion are highly fertile and at risk of subsequent unplanned pregnancy. We recently completed a randomized clinical trial showing that routine provision of intrauterine device (IUD) at the time of abortion significantly reduced the risk of subsequent abortion during a 5-year follow up. As the use of highly effective contraception may affect all subsequent pregnancies, we analyzed the rate and distribution of all subsequent pregnancies (deliveries, miscarriages, and abortions), and the risk factors for these various pregnancy outcomes in the above-mentioned randomized clinical trial.

MATERIAL AND METHODS

We enrolled adult women requesting first-trimester induced abortion and candidates for IUD for post-abortion contraception. Women (n = 751) were randomized to receive an IUD (either levonorgestrel-releasing IUD or copper IUD) by the clinic responsible for abortion care vs. routine care of IUD provision in primary health care with oral contraceptives for interval contraception. In the present secondary analysis, we identified all deliveries, miscarriages, and abortions in the intervention (n = 375) and control (n = 373) cohorts during the 5-year follow up using the Finnish national registries. The trial is registered at Clinical Trials (NTC01223521).

RESULTS

The overall delivery, miscarriage, and abortion rates were 42.0, 12.0 and 32.1/1000 years of follow up (yFU). Any new pregnancy occurred in 98 women in the intervention and in 129 women in the control cohort (hazard ratio 0.73, 95% confidence interval 0.56-0.95, p = 0.023). The effect of routine IUD provision in reducing pregnancies was limited to the first 2 yFU. The number of subsequent induced abortions and of women undergoing it were significantly reduced, and time to abortion was prolonged by the intervention. However, the overall number, the number of women with subsequent delivery or miscarriage, and the times to these events were not significantly affected. History of previous pregnancy (delivery or abortion) and smoking were risk factors for subsequent induced abortion, but not for delivery or miscarriage.

CONCLUSIONS

Routine provision of IUD as part of abortion care did not reduce the rates of delivery or miscarriage during the 5-year follow up. The rates of all pregnancies and the need of subsequent induced abortion were reduced by IUD provision during the first 2 yFU.

Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation

BACKGROUND

Tubal ligation remains common in the USA, especially among low-income patients.

OBJECTIVE

To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients.

DESIGN

We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008-2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure.

KEY RESULTS

We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64-0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82-1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65-0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66-0.75) than tubal ligation.

CONCLUSIONS

IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure.

CLINICAL TRIAL REGISTRATION

NCT03438682.

Pain scores at the insertion of the 52 MG levonorgestrel-releasing intrauterine system among nulligravidas and parous women

PURPOSE

This study aimed to assess the pain scores at the insertion of the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) among nulligravidas, parous women with previous vaginal delivery and parous women with elective caesarean-delivery without any previous labour or cervix dilation.

MATERIALS AND METHODS

The present research is a prospective, single-cohort study that included 413 women aged 15-49 years who opted for LNG-IUS placement for contraception or treatment of heavy menstrual bleeding. Women who participated in the present study were not submitted to any pharmacological pain-relieving intervention to perform the procedure. Pain at insertion was evaluated by using a Visual Analogue Scale (VAS). Pain was classified as absent (0), mild (1-3), moderate (4-6), or severe (7-10). The women were divided as: (1) nulligravidas, (2) parous women with a previous vaginal delivery, or (3) parous women with elective caesarean-delivery without any previous labour or cervix dilation.

RESULTS

Nulligravidas women presented a higher mean pain score, when compared to women with elective caesarean-delivery and women with previous vaginal delivery (6.6 ± 2.0 vs 5.5 ± 2.1 and 3.9 ± 2.4, respectively; p < 0.001). Nulligravidas and women with elective caesarean-delivery were more likely to have pain classified as moderate or severe (in relation to absent or mild) than women with previous vaginal delivery (p < 0.001). Multiple Linear Regression Analysis demonstrated that 29.5% of all variability of the pain score was explained by two predictor/independent variables: nulligravidas or women with elective caesarean and difficulty at IUD insertion.

CONCLUSIONS

Women with previous vaginal delivery had lower pain scores at LNG-IUS insertion when compared to nulligravidas and women with elective caesarean-delivery without any previous labour.

[Foreign body in the urinary bladder intrauterine device]

The article provides a rare observation of a 34-year-old woman who, 12 years before admission to a urological clinic, a gynecologist installed an intrauterine contraceptive device (IUD). The subject migrated into the abdominal cavity, and after 10 years the patient developed dysuria and hematuria. In October 2017, ultrasound and cystoscopy revealed the migration of IUD into the bladder. A foreign body was removed from the bladder - an IUD of a T-shape with the formation of a stone on it with a maximum size of 4.5 cm. During a follow-up examination after 2 years, pathology was not established.

Early provision of intrauterine contraception as part of abortion care-5-year results of a randomised controlled trial

STUDY QUESTION

Can the incidence of subsequent termination of pregnancy (TOP) be reduced by providing intrauterine contraception as part of the abortion service?

SUMMARY ANSWER

Provision of an intrauterine device (IUD) as part of TOP services reduced the need for subsequent TOP but the effect was limited to the first 3 years of the 5-year follow-up.

WHAT IS KNOWN ALREADY

An IUD is highly effective in preventing subsequent TOP. Prompt initiation of IUD use leads to a higher usage rate during follow-up, as compliance with post-TOP IUD insertion visits is low.

STUDY DESIGN, SIZE, DURATION

The objective of this randomised controlled trial was to assess the effect of early comprehensive provision of intrauterine contraception after TOP, with primary outcome being the incidence of subsequent TOP during the 5 years of follow-up after the index abortion. This study was conducted at a tertiary care centre between 18 October 2010 and 21 January 2013. Altogether, 748 women undergoing a first trimester TOP were recruited and randomised into two groups. The intervention group (n = 375) was provided with an IUD during surgical TOP or 1-4 weeks following medical TOP at the hospital providing the abortion care. Women in the control group (n = 373) were advised to contact primary health care for follow-up and IUD insertion. Subsequent TOPs during the 5-year follow-up were identified from the Finnish Register on induced abortions.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The inclusion criteria were age ≥18 years, duration of gestation ≤12 weeks, residence in Helsinki and accepting intrauterine contraception. Women with contraindications to IUD were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

The overall numbers of subsequent TOPs were 50 in the intervention and 72 in the control group (26.7 versus 38.6/1000 years of follow-up, P = 0.027), and those of requested TOPs, including TOPs and early pregnancy failures, were 58 and 76, respectively (30.9 versus 40.8/1000, P = 0.080). Altogether 40 (10.7%) women in the intervention and 63 (16.9%) in the control group underwent one or several subsequent TOPs (hazard ratio 1.67 [95% CI 1.13 to 2.49], P = 0.011). The number of TOPs was reduced by the intervention during years 0-3 (22.2 versus 46.5/1000, P = 0.035), but not during years 4-5 (33.3 versus 26.8/1000, P = 0.631).

LIMITATIONS, REASONS FOR CAUTION

Both medical and surgical TOP were used. This may be seen as a limitation, but it also reflects the contemporary practice of abortion care. The immediate post-TOP care was provided by two different organizations, allowing us to compare two different ways of contraceptive service provision following TOP.

WIDER IMPLICATIONS OF THE FINDINGS

Providing TOP and IUD insertion comprehensively in the same heath care unit leads to significantly higher rates of attendance, IUD use and a significantly lower risk of subsequent TOP.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Helsinki University Central Hospital Research funds and by research grants provided by the Jenny and Antti Wihuri Foundation, the Yrjö Jahnsson Foundation and Finska Läkaresällskapet. E.P. has received a personal research grant from the Finnish Medical Society. The City of Helsinki supported the study by providing the IUDs. The funding organisations had no role in planning or execution of the study, or in analysing the study results.

TRIAL REGISTRATION NUMBER

The trial was registered at clinicaltrials.gov (NCT01223521).

TRIAL REGISTRATION DATE

18 October 2010.

DATE OF FIRST PATIENT’S ENROLMENT

18 October 2010.

Contraception during Coronavirus-Covid 19 pandemia. Recommendations of the Board of the Italian Society of Contraception

Purpose: The Italian Society of Contraception identified as one of its priorities the need to give recommendations on management of contraception during Coronavirus-Covid 19 pandemiaMaterials and methods: A concise communication was produced which summarises in an easy-to-read format suitable for clinicians the management of the different contraceptives mostly used. Information how to manage contraception in different conditions is presented.Results: Women may, in general, continue to use either intrauterine and or hormonal contraceptives. The use of condom should be added to any hormonal contraceptive, when the contraceptive efficacy is reduced or when women stop the contraceptive method.Conclusion: At the present time, during the Coronavirus-Covid 19 pandemia, no data contraindicate the use of intrauterine or hormonal contraceptives. Conversely the use of an appropriate contraception is advocate to prevent unintended pregnancies.

Insertion experience of women and health care professionals in the Kyleena® Satisfaction Study

Purpose: The Kyleena^® Satisfaction Study (KYSS) is a prospective, observational study conducted to assess satisfaction with LNG-IUS 12 (Kyleena^®) in clinical practice and aims to provide adequate information for counselling women on what to expect regarding insertion and satisfaction.Materials and methods: Women deciding to use LNG-IUS 12 during routine counselling were informed of the study and provided informed consent. A baseline analysis was conducted to evaluate demographics, ease of insertion assessed by investigators, pain at insertion rated by women, additional interventions for insertion, and adverse events.Results: 1,110 women (536 parous, 574 nulliparous) had an insertion attempt and were included. Insertion was rated as easy in 494 (92.2%) parous and 516 (89.9%) nulliparous women. Pain was assessed as none or mild by 475 (88.6%) parous and 387 (67.4%) nulliparous women. Additional interventions were not required for most insertions (705; 63.6%). Overall 111 (10.0%) women reported adverse events at the time of baseline analysis.Conclusions: This analysis demonstrates that LNG-IUS 12 insertion is easy and associated with no or mild pain in most women. Additional interventions for insertion are not required in most cases. After 3 months, the number of adverse events is low.Implications: The present baseline analysis of the Kyleena^® Satisfaction Study (KYSS) demonstrates that most women rate insertion pain of LNG-IUS 12 as none or mild and clinicians consider insertion easy in the majority of cases.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation

Introduction

Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter‐pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model.

Material and methods

Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow‐up was conducted in‐person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion‐related variables.

Results

Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re‐insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%.

Conclusions

Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re‐insertion and therefore longer‐term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Developing the role of midwives as 'contraceptive champions' to support early access to effective postnatal contraception for women

OBJECTIVE

To evaluate the acceptability of the new contraceptive champion role to the first hospital and community midwives in NHS Lothian trained in this role.

DESIGN

Health service evaluation.

POPULATION

Hospital and community midwives trained as contraceptive champions, NHS Lothian, Scotland, UK.

METHODS

Qualitative research: 1:1 semi-structured interviews (baseline and follow-up) with five contraceptive champions.

MAIN OUTCOME MEASURE

Qualitative data on views of the new contraceptive champions on the first 6 months of the role.

RESULTS

All contraceptive champions stated increased confidence in their knowledge of postnatal contraception. They reported that women had not questioned the role of midwives in inserting contraceptive implants postnatally in hospital and at home. Midwife colleagues and hospital doctors had been supportive.

CONCLUSION

The new role of contraceptive champion is reported by midwives to have been well received in its first year by women, the midwives themselves and their healthcare colleagues.

How do women and health care professionals view hormonal long-acting reversible contraception? Results from an international survey

Purpose: Evidence from real-world settings is important to provide an accurate picture of health care delivery. We investigated use of long-acting reversible contraception (LARC) in women aged 15-49 years.Materials and methods: Two surveys, one of women and one of health care professionals (HCPs), were conducted in parallel across seven countries. Participating women completed an online survey to assess contraceptive awareness, current method of contraception, age, and experience with current contraceptive method. HCPs participated in an online survey to provide practice-level information and three anonymous charts of hormonal LARC users.Results: Of 6903 women who completed the survey, 3225 provided information about their current primary contraception method. Overall, 16% used LARC methods, while 52% used oral contraceptives (OCs). Of hormonal intrauterine system users, 72% described their experience as 'very favourable', compared with only 53% of women using OCs. Anonymous patient records (n = 1605) were provided by 550 HCPs who completed the online survey. Most women (64%) had used short-acting reversible contraception before switching to LARC. Physicians perceived 56-84% of LARC users to be highly satisfied with their current form of contraception.Conclusions: Although usage of LARC was low, most women using LARC were highly satisfied with their method of contraception.

Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review

A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure‐related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement‐related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement‐related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.

Consensus of best practice in intrauterine contraception in France

Objective: Our aim was to provide a consensus of best practice in intrauterine contraception (IUC) for French practitioners. Methods: A meeting of 38 gynaecologists was held to establish a consensus of best practice in IUC, using the validated nominal group (NG) method to reach consensus. Seventy questions were posed covering insertion, monitoring and removal of IUC devices. Two working groups were formed and all proposals were voted on, discussed and approved by the NG. Results: Of the 70 questions asked, answers to only four failed to reach NG consensus. While, in general, the IUC practices of French gynaecologists are in line with international guidelines, some notable differences were identified: for example, when to use the levonorgestrel-releasing intrauterine system versus the copper intrauterine device; practice recommendations in the event of upper genital tract infections; and immediate postpartum insertion. Clinicians are encouraged to inform women about IUC, irrespective of their age or parity. In general, the wishes and characteristics of the woman must be the main criteria informing the choice of IUC, once all potential contraindications have been excluded and information about IUC shared. Conclusions: This consensus paper is intended to update and standardise knowledge about IUC for health care professionals, to address any reticence about use of this contraceptive method.

Vaginal misoprostol before copper IUD insertion after previous insertion failure: a double-blind, placebo-controlled, parallel-group, randomised clinical trial

Objective: The aim of the study was to assess whether vaginal administration of misoprostol before copper intrauterine device (IUD) insertion increased the success of the procedure among parous women with previous insertion failure. Methods: A single-centre, parallel-group, double-blind, placebo-controlled, randomised clinical trial was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt, between October 2015 and August 2016. The study comprised 90 parous women undergoing TCu380A IUD insertion after a failed attempt. A computer-generated list of random numbers was used to assign participants to receive either misoprostol 200 μg or a placebo tablet, applied vaginally 10 h and 4 h prior to the second attempted IUD insertion, without ultrasound guidance. The primary outcome was the success of IUD insertion. Secondary outcomes were to establish the effect on insertion success of cervical dilation, cervical softening and previous mode of delivery. Results: Forty-two women (93.3%) in the misoprostol group and 24 women (53.3%) in the placebo group had a successful IUD insertion (p < .001). Cervical dilation was required in 24 women in the misoprostol group and 44 women in the placebo group. Misoprostol application significantly increased insertion success in women with previous caesarean delivery (p < .001) but did not affect insertion success in women with previous vaginal delivery (p = .481). Conclusion: Vaginal misoprostol before IUD insertion in parous women with previous insertion failure increased the rate of successful insertion, particularly in women with previous caesarean delivery.

Impact of the Levonorgestrel-Releasing Intrauterine System on the Progression of Chlamydia trachomatis Infection to Pelvic Inflammatory Disease in a Baboon Model

Background

Understanding the relationship between the levonorgestrel (LNG)-releasing intrauterine system (IUS) and sexually transmitted infections (STIs) is increasingly important as use of the LNG-IUS grows to include women at higher risk for STIs. This study assessed the impact of the LNG-IUS on development of Chlamydia trachomatis pelvic inflammatory disease, using a baboon model.

Methods

Baboons with and those without the LNG-IUS were cervically inoculated with C. trachomatis and monitored daily, and cervical and fallopian tube swab specimens were collected weekly for C. trachomatis quantitation by nucleic acid amplification testing and culture. Vaginal swab specimens were collected for cytokine analysis, and serum samples were obtained for detection of C. trachomatis antibodies.

Results

The LNG-IUS resulted in an increased C. trachomatis burden in the cervix, with the bacterial burden in the LNG-IUS group diverging from that in the non-LNG-IUS group by 6 weeks after infection. One of 7 baboons in the non-LNG-IUS group and 2 of 6 in the LNG-IUS group developed pelvic inflammatory disease, while 3 animals in each group met criteria suggestive of pelvic inflammatory disease. LNG-IUS increased baseline interleukin 8 levels but failed to further upregulate interleukin 8 during infection. In LNG-IUS recipients, early perturbations in the interleukin 1β axis corresponded to decreased C. trachomatis clearance and increased T-helper type 2 immune responses.

Conclusion

LNG-IUS use results in delayed clearance of C. trachomatis and might alter the reproductive tract immune environment.

Obstetrics and Gynecology and Family Medicine Residents' Training and Knowledge on Emergency Contraception

Background: Emergency contraception (EC) has the potential to play a vital role in preventing unintended pregnancies after unprotected sexual intercourse or contraceptive failure. Residency training can influence practice behaviors, however, the extent to which EC-related information is taught in training programs remains unknown. This study examined where residents obtain information about EC and whether knowledge differs by resident program characteristics. Materials and Methods: Program coordinators of Obstetrics and Gynecology (OB/GYN) and Family Medicine residency programs (n = 689) were emailed and requested to forward the survey link to residents. The survey included measures of EC education (hours, sources, including lectures, grand rounds), and EC-related knowledge. EC knowledge items assessed the three methods of EC (copper intrauterine device, ulipristal acetate, and oral levonorgestrel), effectiveness, mechanism of action, contraindications, and side effects. t-Tests and analysis of variances were used to compare mean knowledge scores (maximum = 20; higher scores indicating higher knowledge). Results: Among participants (n = 676), 61% were Family Medicine residents, 66% were white, and 72% were female. Overall, 34% received <1 hour of EC education, with OB/GYN residents receiving significantly more hours than Family Medicine residents. OB/GYN residents (mean = 14.40, standard deviation [SD] = 2.69) had a significantly higher mean knowledge score than Family Medicine residents (12.12, SD = 2.63; p < 0.000). Mean knowledge score differences were found by region of residency program, with residents in the Northeast reporting higher knowledge. Conclusions: Overall, residents received very little EC education, with OB/GYN residents receiving more training and having higher knowledge than their Family Medicine counterparts. Additional training is needed to ensure that residents are knowledgeable about this effective method to decrease unintended pregnancies.

Intrauterine Contraception: Knowledge and Prescribing Practices of Canadian Health Care Providers

OBJECTIVE

Contraception is an important issue in the lives of women, their partners, and society. Canadians and their health care providers play a critical role in contraceptive decision making that influences individuals and Canadian society. The purpose of this study was to gather data on contraception-related knowledge, counselling, and prescribing practices of Canadian health care providers.

METHODS

This project reported on the outcomes of an educational initiative, designed as a quality improvement initiative (time series level II-3), focused on Canadian health care providers' contraception-related knowledge, counselling, and prescribing practices. Outcomes were intended to inform the development of tools, resources, and educational programming. Part 1 was an online program to identify educational and knowledge gaps for health care providers. Part 2 was a practice assessment exploring and measuring health care providers' contraceptive counselling and prescribing practices.

RESULTS

A total of 4300 health care providers completed the program between July 6, 2015 and August 30, 2016. Knowledge significantly increased; post-test scores were higher than pretest scores. After completion, all participants felt more comfortable, knowledgeable, and inclined to change their practice around prescribing intrauterine contraception (IUC). The 4300 providers reported on their contraception counselling experiences with 10 patients following participation in Part 1. Forty percent of patients were using oral contraceptives, and 53% were dissatisfied with their current type of contraception. After counselling, patients reported being most comfortable with IUC (55%). Both short- and long-acting types of contraception were most often discussed or offered (74% of the time), followed by long-acting reversible contraception only (21%) and short-acting methods only (5%).

CONCLUSION

This training program filled an education need for patients and gave providers tools to change their behaviour and practice around IUC prescribing. On the basis of these data, a practice assessment model was deemed a successful way to change behaviour.

Levonorgestrel intrauterine contraceptive systems (13.5 mg and 52 mg) and risk of ectopic pregnancy

INTRODUCTION

The objective was to investigate the Pearl index for ectopic pregnancy in women using the levonorgestrel intrauterine system (LNG-IUS) at the time of conception.

MATERIAL AND METHODS

This was a substudy of a hospital-based historical cohort including women with an ectopic pregnancy diagnosed in 4 referral hospitals in Stockholm, Sweden between December 2013 and April 2017. Study participants and type of contraception at time of conception were identified through the electronic medical chart system. Cases were defined as women with LNG-IUS 13.5 or 52 mg in situ at the time of diagnosis of ectopic pregnancy who had their LNG-IUS inserted 1 January 2014 or later. Outcome was defined as the incidence rate for ectopic pregnancy during use per 100 woman-years (Pearl index) with 95% confidence interval (95% CI).

RESULTS

The study includes 35 cases with LNG-IUS 13.5 mg and 13 cases with LNG-IUS 52 mg, which occurred in 18 488 (13.5 mg) and 50 246 (52 mg) exposed woman-years. Pearl index for ectopic pregnancy was estimated at 0.19 (95% CI 0.15-0.28) for LNG-IUS 13.5 mg and to 0.006 (95% CI 0.00-0.01) for LNG-IUS 52 mg. The most cases for the LNG-IUS 13.5 mg (n = 26; 74%) occurred during the first year of use with a corresponding Pearl index at 0.23 (95% CI 0.14-0.35).

CONCLUSIONS

The absolute risk of ectopic pregnancy during the use of LNG-IUS remains low. Our method may underestimate as well as overestimate the Pearl index for ectopic pregnancy. The findings underline the importance of identifying risk factors for ectopic pregnancy at insertion, and to rule out ectopic pregnancy for all women presenting with abdominal discomfort during the use of LNG-IUS. Longer observation periods and prospective studies in a general population are a priority for further research.

Sexual well-being after first trimester termination of pregnancy: Secondary analysis of a randomized contraceptive trial

INTRODUCTION

Although termination of pregnancy is one of the most common procedures conducted worldwide, little is known about sexual well-being after termination of pregnancy. The objective of this study was to assess sexual well-being after termination of pregnancy, and factors affecting it during a 1-year follow up.

MATERIAL AND METHODS

In total, 748 women requesting first trimester termination of pregnancy and participating in a randomized controlled trial on early provision of intrauterine contraception were provided with questionnaires regarding their sexual life, anxiety, quality of life and contraceptive method used at the time of termination of pregnancy, 3 and 12 months after termination of pregnancy. Sexual well-being was measured by the 9-item McCoy Female Sexuality Questionnaire. Anxiety and quality of life were assessed by the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL questionnaire (EQoL).

RESULTS

The McCoy index remained unchanged during the follow up. At all three time-points measured, higher (ie, better) McCoy scores were associated with a lower STAI index (mean difference -2.26 [95% CI -3.23 to -1.29], P < 0.001; -3.76 [95% CI -4.79 to -2.74], P < 0.001; -4.50 [95% CI -5.88 to -3.12], P < 0.001) and being in a relationship (1.16 [95% CI 0.08-2.25], P = 0.023; 1.67 [95% CI 0.43-2.89], P < 0.001; 2.81 [95% CI 1.28-4.34], P < 0.001), and correlated positively with a higher EQoL index (r = 0.20, r = 0.20, r = .27, P < 0.001) and higher frequency of intercourse (r = 0.50, r = 0.46, r = 0.42, P < 0.001). Women using intrauterine contraception had higher McCoy index measurements at 3 months compared with others. There were no significant differences between users of hormonal vs non-hormonal contraceptive methods.

CONCLUSIONS

Sexual well-being does not change significantly after termination of pregnancy. Instead, it is strongly and positively associated with quality of life, relationship status and frequency of intercourse. Anxiety is negatively associated with sexual well-being.

Family planning and Zika virus: need for renewed and cohesive efforts to ensure availability of intrauterine contraception in Latin America and the Caribbean

OBJECTIVES

The advantages of intrauterine contraception (IUC) are well established (highly effective, low discontinuation rate, easy to use, low cost, and suitable for immediate postpartum use), but low levels of use in many countries and declining use in others are causes for concern. Due to the ongoing Zika virus outbreak, public health officials are calling for the continued practice of safe sex and the delay of pregnancy. Our study was conducted to assess the current situation of IUC availability and provision in Latin America and to determine the role of national policies in meeting the contraceptive needs of the populations in these countries.

METHODS

A survey was conducted in Latin America and the Caribbean between December 2015 and January 2016 to assess national policies with regard to IUC provision, availability and accessibility. 18 countries participated.

RESULTS

All responding countries had national policies on IUC. Many in the public sector provided the intrauterine device (IUD) free of charge, but the levonorgestrel-releasing intrauterine system (LNG-IUS) was generally available in the private sector. Some countries had very restrictive policies on who was permitted to carry out IUC insertions, but most permitted a range of health professionals to do so. Immediate postpartum IUC insertion was uncommon. Some countries placed restrictions on IUC use in women who were nulliparous, young, at high risk of catching a sexually transmitted infection or who had multiple sexual partners.

CONCLUSIONS

IUC is underused in Latin America. The study reveals policy level barriers that may impede access to IUC, one of the most effective, long-acting, non-hormonal, reversible contraceptive methods. Governments should consider reviewing and rethinking their policies on contraception to ensure IUC service provision among populations at high risk of unplanned pregnancy, especially those vulnerable to Zika virus.

Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: A retrospective cohort study

BACKGROUND

Long-acting reversible contraception (LARC) effectively protects against pregnancy but provides no protection against sexually transmitted infections (STIs).

AIM

To compare rates of chlamydia testing and diagnosis for women initiating long-acting versus oral contraception.

MATERIALS AND METHODS

Retrospective cohort study involving data collection for 6160 women initiating post-abortion contraception at a large New Zealand regional public hospital abortion clinic (2009-2012), with chlamydia testing data obtained from the local laboratory during two-year follow up. Negative binomial regression modelling examined the effect of contraceptive method on two outcome measures: chlamydia testing and chlamydia diagnosis (adjusting for potential covariates of age, ethnicity, past chlamydia infection, pregnancy history) in year one and two of follow up.

RESULTS

Two thousand seven hundred and twenty nine women (44%) received a LARC and 1764 (28.6%) were prescribed oral contraception. Adjusted testing rates differed by contraceptive method only in year one (P < 0.01): with higher rates among copper intrauterine device users (relative risk (RR) 1.2, 95% CI 1.06-1.35), and lower rates for implant users (RR 0.84, 95% CI 0.72-0.99) compared with oral contraceptive users (reference group). No significant differences were observed in chlamydia diagnosis rates by contraceptive method (P > 0.05). Younger age, past chlamydia infection, Maori and Pacific ethnicity were associated with higher rates of chlamydia diagnosis (P < 0.01).

CONCLUSIONS

Known STI-related risk factors (age, ethnicity, past infection) but not contraceptive method were independently related to rates of subsequent chlamydia diagnosis. This suggests that increased LARC uptake would not occur at the expense of chlamydia control. Regular screening and risk reduction advice (including condom use) are important chlamydia control measures for at-risk groups.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years

INTRODUCTION

Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.

Predictors of non-use of intrauterine contraception among women aged 18-49 years in a general practice setting in the UK

Objectives

Our research examined the barriers to the uptake of intrauterine contraception (IUC) by women in a general practice (GP) setting in the UK. This study reports predictors of non-use of IUC in this context.

Design

We used a mixed method Qual/Quant approach in which the initial qualitative research provides a framework for subsequent larger quantitative surveys. Utilizing findings derived from 30 qualitative interviews, a quantitative survey was developed and distributed to a pragmatic sample of 1,195 women, aged 18–49 years, who were recruited through 32 participating GP practices in an area of England, UK. Outcome measures were percentage of attributes or responses in the sample and use or non-use of IUC. Results were analyzed using descriptive statistical analysis and binary logistic regression, using use/non-use as a binary response variable.

Results

Attitudinal variables, which were the strongest predictors of non-use of IUC, were an adverse opinion on long-acting aspect of IUC (odds ratio [OR]=8.34), disliking the thought of IUC inside the body (OR=3.138), concerns about IUC causing difficulties becoming pregnant in the future (OR=2.587), concerns about womb damage (OR=2.224), having heard adverse opinions about levonorgestrel-releasing intrauterine system (Mirena^®) (OR=2.551), having an adverse opinion of having light, irregular periods (OR=2.382) and, having an adverse opinion of having no periods (OR=2.018).

Conclusion

Concerns about the long-acting nature of IUC and persisting concerns about the safety of IUC may act as barriers to its use. Information for women, tailored to specifically address these concerns, is needed.

Implications

Clinicians should provide more reassurance and information to potential users of IUC to increase their confidence about the possibility of removing IUC early or on request. They should also specifically seek to alleviate concerns about internal damage, damage to the womb, or damage to future fertility from using the methods.

Levonorgestrel-releasing intrauterine systems for long-acting contraception: current perspectives, safety, and patient counseling

Unintended pregnancy is a significant global problem. In 2008, there were over 100 million unplanned pregnancies worldwide, representing approximately 41% of global conceptions. Family planning strategies in many countries are shifting from increasing the uptake of contraception among nonusers to increasing the uptake of the most effective methods among users of less effective methods. One of the most effective and acceptable methods of contraception is the levonorgestrel-releasing intrauterine system (LNG IUS); however, its uptake varies widely by country. This article reviews the currently available LNG IUSs, the rationale for increasing uptake of these methods, and evidence regarding safety, and discusses counseling strategies to best inform women about this option for contraception.

A multicentre, open-label, randomised phase III study comparing a new levonorgestrel intrauterine contraceptive system (LNG-IUS 8) with combined oral contraception in young women of reproductive age

OBJECTIVES

To compare user satisfaction and adverse events (AEs) with a levonorgestrel intrauterine system (LNG-IUS 8; average levonorgestrel release rate approximately 8 μg/24 h over the first year [total content 13.5 mg]) and a 30 μg ethinyl estradiol/3 mg drospirenone (EE/DRSP) combined oral contraceptive (COC) in a population of young women.

METHODS

Nulliparous and parous women (aged 18-29 years) with regular menstrual cycles (21-35 days) were randomised to LNG-IUS 8 or EE/DRSP for 18 months. The primary endpoint was the overall user satisfaction rate at month 18/end of study visit.

RESULTS

Overall, 279 women were randomised to LNG-IUS 8 with attempted placement and 281 women were randomised to EE/DRSP and took ≥1 pill; the mean age was 23.7 and 23.9 years, and 77.4% and 73.3% were nulliparous, respectively. At month 18/end of study, 82.1% and 81.9% of women, respectively, reported being 'very satisfied' or 'satisfied' with their treatment; however, significantly more LNG-IUS 8 users reported a preference to continue their treatment post-study (66.2% vs 48.8%; p = 0.0001). There were two pregnancies (one ectopic pregnancy, one spontaneous abortion) reported in the LNG-IUS 8 group and six (three live births, two spontaneous abortions, one induced abortion) in the EE/DRSP group.

CONCLUSIONS

LNG-IUS 8 and EE/DRSP were associated with similarly high user satisfaction rates. However, LNG-IUS 8 users were significantly more likely to prefer to continue their contraceptive method post-study, indicating that a levonorgestrel intrauterine system is an appealing contraceptive option for young women.

A Lower-Cost Option for Intrauterine Contraception

In March 2015, the U.S. Food and Drug Administration approved Liletta (Actavis, Dublin, Ireland), a new intrauterine device for contraception. The Centers for Disease Control and Prevention recommend use of long-acting reversible contraception (LARC) as first-line pregnancy prevention. LARC efficacy rates are similar to those of sterilization, with the possibility for quick return of fertility upon removal of the device. Despite benefits and recommendations for this form of contraception, access and high cost remain barriers to use. Liletta is the first lower-cost option for intrauterine contraception. Available to qualified clinics and health centers at a reduced rate, this device may increase availability and decrease the overall cost to women who desire intrauterine contraception.

Canadian Contraception Consensus (Part 1 of 4)

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index > 25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index > 35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

Acceptability of intrauterine contraception among women living with human immunodeficiency virus: a randomised clinical trial

OBJECTIVES

The aim of our study was to compare acceptability of the copper intrauterine device (Cu-IUD) and levonorgestrel-releasing intrauterine system (LNG-IUS) among women living with the human immunodeficiency virus (HIV).

METHODS

We randomly assigned 703 HIV-positive women in Uganda to receive either a Cu-IUD or an LNG-IUS and followed them for at least one year. During the follow-up visits, face-to-face interviews were conducted with the women and acceptability of the Cu-IUD or LNG-IUS was assessed, using a Likert scale, at one, three, six and twelve months. At the final follow-up visit, women were also assessed for satisfaction with either method.

RESULTS

Between 9 September 2013 and 31 December 2014, 703 women were recruited and assigned as follows: 349 to a Cu-IUD group and 354 to an LNG-IUS group. Acceptability decreased from 94.3% at one month to 87.7% at 12 months in the Cu-IUD group and from 96.3% at one month to 86.7% at 12 months in the LNG-IUS group (p = 0.97). Satisfaction with intrauterine contraception was reported by 83.7% (283/338) in the Cu-IUD group and by 90.4% (302/334) in the LNG-IUS group (p = 0.50).

CONCLUSIONS

There was no significant difference in acceptability between the LNG-IUS and Cu-IUD among HIV-positive women. Satisfaction rates were high and similar in the two groups. Both the Cu-IUD and LNG-IUS are acceptable forms of contraception for HIV-positive women and should be made available to women in HIV care to increase their contraceptive method options.

CLINICAL TRIAL REGISTRATION

The trial is registered at the Pan African Clinical Trials Registry (PACTR 201308000561212).

Canadian Contraception Consensus (Part 2 of 4)

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements  1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2)  2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2)  3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1)  4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2)  5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2)  6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2)  7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements  8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3)  9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index > 25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index > 35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Primary care physicians' concerns may affect adolescents' access to intrauterine contraception

PURPOSE

Although the intrauterine device (IUD) may be safely used in adolescents, few US adolescents use IUDs. Increasing IUD use in adolescents can decrease pregnancy rates. Primary care providers' clinical practices many be one of the many barriers to increasing adolescents access to IUDs. We explored primary care physicians' (PCPs) approaches to contraception counseling with adolescents, focusing on their views about who would be appropriate IUD candidates.

METHODS

Phone interviews were conducted with 28 urban family physicians, pediatricians, and obstetrician-gynecologists. Using standard qualitative techniques, we developed coding template and applied codes.

RESULTS

Most respondents have a patient-centered general contraceptive counseling approach. However, when considering IUDs many PCPs describe more paternalistic counseling. For example, although many respondents believe adolescents' primary concern is pregnancy prevention, many PCPs prioritize sexually transmitted infection (STI) prevention and thus would not offer an IUD. Attributes PCPs associate with an appropriate IUD candidate include responsibility, reliability, maturity, and monogamy.

CONCLUSION

Our findings suggest that when considering IUDs for adolescents some PCPs' subjective assessment of adolescent sexual behavior, attitudes about STI risk factors and use of overly restrictive IUD eligibility criteria impede adolescent's IUD access. Education around best practices may be insufficient to counterbalance attitudes concerning adolescent sexuality and STI risk; there is also a need to identify and discuss PCPs potential biases or assumptions affecting contraception counseling.

Myths and misconceptions about intrauterine contraception among women seeking termination of pregnancy

BACKGROUND

Immediate initiation of an intrauterine device (IUD) or intrauterine system (IUS) following termination of pregnancy (TOP) is associated with a significant reduction in the risk of another TOP. In spite of its high efficacy, uptake of intrauterine contraception in the UK is low. Myths and misconceptions about the method may contribute to the low uptake.

STUDY DESIGN

Anonymous, self-administered questionnaire among women requesting a TOP in a hospital abortion service in Scotland, UK.

METHODS

Misconceptions about intrauterine contraception were extracted from an online social networking and micro-blogging service, and from existing research to develop a questionnaire containing 12 negative statements about intrauterine contraception. Respondents indicated their level of agreement with each statement.

RESULTS

A total of 106/125 (85%) women requesting a TOP completed the questionnaire. The two commonest negative statements that respondents agreed with were that the IUD/IUS 'Is painful to have inserted' (n=36; 34%) and that 'It can move around inside your body' (n=25; 23.6%). The range of women who neither agreed nor disagreed with negative statements was 26.4-56.0%. Twenty-seven (25%) women indicated that the IUD/IUS was their planned method of post-TOP contraception.

CONCLUSIONS

Although myths about intrauterine contraception persist among a small proportion of women requesting a TOP, lack of knowledge about the method is also evident. The consultation prior to TOP is an important opportunity to provide accurate and quality information to women about the IUD/IUS that may serve to increase uptake and prevent repeat abortions.

Management of pain associated with the insertion of intrauterine contraceptives

BACKGROUND

Most intrauterine contraception (IUC) placements do not require pain relief. However, small proportions of nulliparous (∼17%) and parous (∼11%) women experience substantial pain that needs to be proactively managed. This review critically evaluates the evidence for pain management strategies, formulates evidence-based recommendations and identifies data gaps and areas for further research.

METHODS

A PubMed literature search was undertaken. Relevant articles on management of pain associated with IUC insertion, published in English between 1980 and November 2012, were identified using the following search terms: ‘intrauterine contraception’, ‘insertion’ and ‘pain’. RCTs were included; further relevant articles were also identified and included as appropriate.

RESULTS

Seventeen studies were identified and included: 12 RCTs and one non-randomized study of pre-insertion oral analgesia, cervical priming and local anaesthesia; one systematic review and one RCT on post-insertion analgesia and two non-randomized studies on non-pharmacological interventions. There was no conclusive evidence that any prophylactic pharmacological intervention reduces pain associated with IUC insertion. However, most of the regimens studied were adopted from hysteroscopy or abortion and effectiveness in specific subsets of women has not been studied adequately. A systematic review found non-steroidal anti-inflammatory agents (NSAID) to be effective in reactively treating post-insertion pain, but no benefit was found with prophylactic use.

CONCLUSIONS

No prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUC insertion. Women's anxiety about the procedure may contribute to higher levels of perceived pain, which highlights the importance of counselling, and creating a trustworthy, unhurried and professional atmosphere in which the experience of the provider also has a major role; a situation frequently referred to as ‘verbal anaesthesia’.

Identifying counseling needs of nulliparous adolescent intrauterine contraceptive users: a qualitative approach

PURPOSE

To describe the intrauterine contraception (IUC) adoption process among nulliparous adolescents and to identify the role of the medical provider in this trajectory.

METHODS

We conducted semistructured interviews with a clinic-based sample of 20 nulliparous adolescents (aged 15-24 years) with a history of IUC use. Interviews were analyzed using modified grounded theory and cross-case analysis to reveal a process model for IUC adoption, with a focus on the role of the medical provider.

RESULTS

The model includes the following stages: first awareness, initial reaction, information gathering, adoption, and adjustment and reassessment. It is influenced by personal preferences and experiences, friends, family, sexual partner(s), and medical providers. Interactions with medical providers that study participants found helpful in navigating the adoption process included the use of visuals; tailored counseling to address specific contraceptive needs; assurance that IUC discontinuation was an option; information on a wide range of side effects; medical provider self-disclosure regarding use of IUC; and addressing and validating concerns, both before and after IUC insertion.

CONCLUSIONS

Nulliparous adolescents in this study described a complex IUC adoption process in which the medical provider plays a substantial supportive role. Findings from this study may be used to counsel and support future nulliparous adolescents regarding IUC use.