The potential of long-acting reversible contraception to decrease unintended pregnancy

Knowledge and attitudes about long-acting reversible contraception among Latina women who desire sterilization

BACKGROUND

There is growing interest in increasing the use of long-acting reversible contraception (LARC), and suggestions that such methods may serve as an alternative to sterilization. However, there is little information about whether women who do not want more children would be interested in using LARC.

METHODS

We conducted semistructured interviews with 120 parous Latina women in El Paso, Texas, who wanted a sterilization but had not obtained one. We assessed women's awareness of and interest in using the copper intrauterine device (IUD), levonorgestrel intrauterine system (LNG-IUS), and etonogestrel implant.

FINDINGS

Overall, 51%, 23%, and 47% of women reported they had heard of the copper IUD, LNG-IUS, and implant, respectively. More women stated they would use the copper IUD (24%) than the LNG-IUS (14%) or implant (9%). Among women interested in LARC, the most common reasons were that, relative to their current method, LARC methods were more convenient, effective, and provided longer-term protection against pregnancy. Those who had reservations about LARC were primarily concerned with menstrual changes. Women also had concerns about side effects and the methods' effectiveness in preventing pregnancy, preferring to use a familiar method.

CONCLUSIONS

Although these findings indicate many Latina women in this setting do not consider LARC an alternative to sterilization, they point to an existing demand among some who wish to end childbearing. Efforts are needed to improve women's knowledge and access to a range of methods so they can achieve their childbearing goals.

Evaluating the impact a proposed family planning model would have on maternal and infant mortality in Afghanistan

OBJECTIVE

This study aimed to assess the potential impact a proposed family planning model would have on reducing maternal and infant mortality in Afghanistan.

BACKGROUND

Afghanistan has a high total fertility rate, high infant mortality rate, and high maternal mortality rate. Afghanistan also has tremendous socio-cultural barriers to and misconceptions about family planning services.

METHODS

We applied predictive statistical models to a proposed family planning model for Afghanistan to better understand the impact increased family planning can have on Afghanistan's maternal mortality rate and infant mortality rate. We further developed a sensitivity analysis that illustrates the number of maternal and infant deaths that can be averted over 5 years according to different increases in contraceptive prevalence rates.

RESULTS

Incrementally increasing contraceptive prevalence rates in Afghanistan from 10% to 60% over the course of 5 years could prevent 11,653 maternal deaths and 317,084 infant deaths, a total of 328,737 maternal and infant deaths averted.

CONCLUSION

Achieving goals in reducing maternal and infant mortality rates in Afghanistan requires a culturally relevant approach to family planning that will be supported by the population. The family planning model for Afghanistan presents such a solution and holds the potential to prevent hundreds of thousands of deaths.

Short interpregnancy intervals in the United States

OBJECTIVE

To investigate the prevalence and correlates of short interpregnancy intervals in the United States.

METHODS

We analyzed pregnancy data from a nationally representative sample of 12,279 women from the 2006-2010 National Survey of Family Growth. We limited our sample to second and higher-order births within 5 years of the interview. Interpregnancy intervals were calculated as the interval between the delivery date of the preceding live birth and the conception date of the index pregnancy, with short interpregnancy intervals defined as intervals less than 18 months. We used simple and multivariate logistic regression analyses to examine associations between short interpregnancy intervals and maternal demographic and childbearing characteristics, including pregnancy intention.

RESULTS

Among the 2,253 pregnancies in our sample, one third (35%) were conceived within 18 months of a previous birth. After adjusting for sociodemographic and childbearing characteristics, women were significantly more likely to have a short interpregnancy interval if they were aged 15-19 years or married at the time of conception of the index pregnancy, initiated childbearing after age 30 years, or reported the pregnancy as unintended. Short interpregnancy intervals were more likely to be intended among more advantaged women (married, non-Hispanic white, college-educated, or non-Medicaid delivery). We estimate that preventing unintended pregnancies would reduce the proportion of short interpregnancy intervals from 35% to 23%.

CONCLUSION

Providing counseling about the potential negative consequences of short interpregnancy intervals and improving women's contraceptive use to reduce rates of unintended pregnancy likely would reduce the proportion of short interpregnancy interval pregnancies in the United States.

LEVEL OF EVIDENCE

II.

Trends and determinants of use of long-acting reversible contraception use among young women in France: results from three national surveys conducted between 2000 and 2010

OBJECTIVE

To investigate trends and determinants in the use of long-acting reversible contraceptives (LARCs), including intrauterine devices and implants, over the last decade among young women in France.

DESIGN

Data drawn from three cross-sectional national probability surveys.

SETTING

Not applicable.

PATIENT(S)

A total of 1,204 women, ages 15 to 29, who are at potential risk of an unintended pregnancy in 2000; 1,921 in 2005; and 1,281 in 2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Logistic regression models were used to explore trends in LARC use since 2000 and to examine determinants of LARC use in 2010.

RESULT(S)

A minority of women were using LARC methods, with a significant increase between 2000 and 2010, from 4.6% to 6.4%. The odds of LARC use in 2010 were higher among women 20 to 29 years, parous women, women with a history of unintended pregnancy, women in difficult financial situations, smokers, and women in the care of a gynecologist.

CONCLUSION(S)

This study shows that little progress has been made in LARC use among young women in France, despite these methods being widely available and reimbursed by the national health system.

Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents

Cost is a major barrier to adolescents' ability to obtain long-acting reversible contraception (LARC). By reviewing the available literature on this issue, we provide a framework to understand how insurance coverage, out-of-pocket expenses, parental involvement, and recent pregnancy can impact access. We provide examples of cost-free access to LARC for adolescents, such as the Contraceptive CHOICE Project. Universal coverage for contraception, without cost-sharing, could increase use of LARC among adolescents resulting in fewer unintended pregnancies, improved health outcomes, and considerable cost savings to the healthcare system.

Long-acting reversible contraception for adolescents and young adults: patient and provider perspectives

STUDY OBJECTIVE

To describe and explore provider- and patient-level perspectives regarding long-acting reversible contraception (LARC) for teens and young adults (ages 16-24).

METHODS

Data collection occurred between June and December 2011. We first conducted telephone interviews with administrative directors at 20 publicly funded facilities that provide family planning services. At 6 of these sites, we conducted a total of 6 focus group discussions (FGDs) with facility staff and 48 in-depth interviews (IDIs) with facility clients ages 16-24.

RESULTS

Staff in the FGDs did not generally equate being a teen with ineligibility for IUDs. In contrast to staff, one-quarter of the young women did perceive young age as rendering them ineligible. Clients and staff agreed that the "forgettable" nature of the methods and their duration were some of LARC's most significant advantages. They also agreed that fear of pain associated with both insertion and removal and negative side effects were disadvantages. Some aspects of IUDs and implants were perceived as advantages by some clients but disadvantages by others. Common challenges to providing LARC-specific services to younger patients included extra time required to counsel young patients about LARC methods, outdated clinic policies requiring multiple visits to obtain IUDs, and a perceived higher removal rate among young women. The most commonly cited strategy for addressing many of these challenges was securing supplementary funding to support the provision of these services to young patients.

CONCLUSION

Incorporating young women's perspectives on LARC methods into publicly funded family planning facilities' efforts to provide these methods to a younger population may increase their use among young women.

New york city physicians' views of providing long-acting reversible contraception to adolescents

PURPOSE

Although the US adolescent pregnancy rate is high, use of the most effective reversible contraceptives-intrauterine devices (IUDs) and implantable contraception-is low. Increasing use of long-acting reversible contraception (LARC) could decrease adolescent pregnancy rates. We explored New York City primary care physicians' experiences, attitudes, and beliefs about counseling and provision of LARC to adolescents.

METHODS

We conducted in-depth telephone interviews with 28 family physicians, pediatricians, and obstetrician-gynecologists using an interview guide based on an implementation science theoretical framework. After an iterative coding and analytic process, findings were interpreted using the capability (knowledge and skills), opportunity (environmental factors), and motivation (attitudes and beliefs) conceptual model of behavior change.

RESULTS

Enablers to IUD counseling and provision include knowledge that nulliparous adolescents are appropriate IUD candidates (capability) and opportunity factors, such as (1) a clinical environment supportive of adolescent contraception, (2) IUD availability in clinic, and (3) the ability to insert IUDs or easy access to an someone who can. Factors enabling motivation include belief in the overall positive consequences of IUD use; this is particularly influenced by a physicians' perception of adolescents' risk of pregnancy and sexually transmitted disease. Physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the device (opportunity).

CONCLUSION

Knowledge, skills, clinical environment, and physician attitudes, all influence the likelihood a physician will counsel or insert LARC for adolescents. Interventions to increase adolescents' access to LARC in primary care must be tailored to individual clinical practice sites and practicing physicians, the methods must be made more affordable, and residency programs should offer up-to-date, evidence-based teaching.

Contraception technology: past, present and future

Steady progress in contraception research has been achieved over the past 50 years. Hormonal and nonhormonal modern contraceptives have improved women's lives by reducing different health conditions that contributed to considerable morbidity. However, the contraceptives available today are not suitable to all users, and the need to expand contraceptive choices still exists. Novel products such as new implants, contraceptive vaginal rings, transdermal patches and newer combinations of oral contraceptives have recently been introduced in family planning programs, and hormonal contraception is widely used for spacing and limiting births. Concerns over the adverse effects of hormonal contraceptives have led to research and development of new combinations with improved metabolic profile. Recent developments include use of natural compounds such as estradiol and estradiol valerate with the hope to decrease thrombotic risk, in combination with newer progestins derived from the progesterone structure or from spirolactone, in order to avoid the androgenic effects. Progesterone antagonists and progesterone receptor modulators are highly effective in blocking ovulation and preventing follicular rupture and are undergoing investigations in the form of oral pills and in semi-long-acting delivery systems. Future developments also include the combination of a contraceptive with an antiretroviral agent for dual contraception and protection against sexually transmitted diseases, to be used before intercourse or on demand, as well as for continuous use in dual-protection rings. Although clinical trials of male contraception have reflected promising results, limited involvement of industry in that area of research has decreased the likelihood of having a male method available in the current decade. Development of nonhormonal methods is still at an early stage of research, with the identification of specific targets within the reproductive system in ovaries and testes, as well as interactions between spermatozoa and ova. It is hoped that the introduction of new methods with additional health benefits would help women and couples with unmet needs to obtain access to a wider range of contraceptives with improved acceptability.

Revitalizing long-acting reversible contraceptives in settings with high unmet need: a multicountry experience matching demand creation and service delivery

BACKGROUND

Contraception in many developing countries is characterized by high unmet need, irregular access, low utilization and presumed demand for long-acting reversible contraceptives (LARCs).

STUDY DESIGN

A 13-country initiative focused on increasing consumer demand and high quality services for intrauterine devices (IUDs) began in 2009. Services were provided through (a) private sector-franchised or affiliated clinics; (b) providers seconded to the public sector and (c) special "event" days. Client intake data are used to compare the profile of IUD acceptors with IUD users from representative national datasets of select countries, as well as examine trends in IUD uptake.

RESULTS

During 2009-2010, 575,601 IUDs were inserted across the 13 countries. Compared to national IUD users, users in this project were slightly younger and less educated. Among IUD acceptors, 24% used no modern method at the time of IUD initiation, and 28% reported injectable use in the three previous months.

CONCLUSIONS

Convenient, quality, affordable services with demand creation can result in significant uptake of LARCs in settings with low use.

Demand for long acting and permanent methods of contraceptives and factors for non-use among married women of Goba Town, Bale Zone, South East Ethiopia

BACKGROUND

Contraceptive use including short acting, long acting and permanent methods positively influence the socio-economic development of a nation by allowing families to space and limit their family size to their economic capacity. Demand for LAPMs of contraception as detrmined by utilization and unmet need for LAPMs of contraception can provide realiable information for providers.

OBJECTIVE

To determine the utilization of long acting and permanent contraception and its associated factors among married women of Goba town, South East Ethiopia.

METHODS

A cross sectional community based study was conducted among 734 systematically selected married women of reproductive age in Goba town in September/ 2009. A structured and pretested, interview questionaire was used to collect data on socio-demographic, behavioral factors and data related to demand for LAPMs of contraception. Data were analyzed using EPI INFO and SPSS version 16.

RESULT

The demand for Long Acting and Permanent Methods (LAPMs) of contraception was 18.1%. Utilization of LAPMs of contraception in the town was 64 (8.7%) and the unmet need for LAPMs was 69 (9.4%). Information on LAPMs in the town was 636 (86.6%). Media (radio and television) was the major sources of information 641 (87.3%). The use of LAPMs was significatly associated with ever use AOR[17.43, 95% CI:9.19, 33.03], number of times discussions made on methods AOR[4.6, 95% CI: 1.72,12.17] and main decider of using methods AOR[ 2.2, 95% CI:1.03, 4.65]. It was not associated with socio-demographic variables.

CONCLUSION AND RECOMMENDATION

The utilization of LAPMs in the town was less although higher than the Ethiopian demographic and health survey 2005 result. Moreover, there was a considerable unmet need. Increase the method mix of LAPMs by incorporating varaies of implnats in order to increase utilization. Proper counseling of client and partners discussion were some of the recommendation forwarded.

Strategies for the prevention of unsafe abortion

Unsafe abortion is one of the main causes of maternal mortality and severe morbidity in countries with restrictive abortion laws. In 2007, the International Federation of Gynecology and Obstetrics (FIGO) created a Working Group on the Prevention of Unsafe Abortion and its Consequences (WGPUA). This led to a FIGO initiative with that aim which has the active participation of 43 FIGO member societies. The WGPUA has recommended that the plans of action of the countries participating in the initiative consider several levels of prevention shown to have the potential to successfully reduce unsafe abortions: (1) primary prevention of unintended pregnancy and induced abortion; (2) secondary prevention to ensure the safety of an abortion procedure that could not be avoided; (3) tertiary prevention of further complications of an unsafe abortion procedure that has taken place already, through high-quality postabortion care; and (4) quaternary prevention of repeated abortion procedures through postabortion family planning counseling and contraceptive services. This paper reviews these levels of prevention and the evidence that they can be effective.

Unprotected intercourse among women wanting to avoid pregnancy: attitudes, behaviors, and beliefs

OBJECTIVE

To better understand the behaviors associated with unintended pregnancy, including the frequency and reasons why women engage in unprotected intercourse (UI), to help guide efforts to prevent unintended pregnancy.

METHODS

We surveyed 1,392 women with no history of abortion in 13 family planning clinics across the United States regarding the frequency with which they engaged in UI, the reasons for engaging in UI, attitudes toward UI, and their knowledge about the risks of conception.

RESULTS

Nearly half (46%) of respondents engaged in UI within the past 3 months, mostly owing to barriers accessing birth control (49%), not planning to have sex (45%), and the belief that they could not get pregnant (42%). The most prevalent attitudes about UI were that it "feels better" (42%) or "more natural" (41%). Factors associated with an increased odds of having engaged in UI, included holding the views that UI is okay at certain times, feels better, and is more natural, underestimating the risk of conception from 1 year of UI, experiencing difficulty getting birth control prescriptions, having less than a college education, being ages 20 to 24, and being African American/Black.

CONCLUSION

Compared with our research on abortion clients, family planning clients report high, yet somewhat lower, rates of UI, similar reasons for having UI, and misconceptions about the risk of conception from repeated acts of UI. Long-acting, reversible contraception may offer some of the benefits of UI in terms of spontaneity and pleasure, while reducing women's pregnancy risk.

Predictors of long-acting reversible contraception use among unmarried young adults

OBJECTIVE

The objective of the study was to improve the understanding of long-acting reversible contraception (LARC) use patterns among unmarried, young adults at risk of unintended pregnancy.

STUDY DESIGN

We performed a secondary data analysis of a national survey conducted by Guttmacher Institute of unmarried women and men aged 18-29 years. LARC is defined as an intrauterine device (IUD) or implant. Predictors of LARC use and IUD knowledge among those at risk for unintended pregnancy (n = 1222) were assessed using χ(2) analysis and logistic regression models.

RESULTS

LARC use was associated with older age, high IUD knowledge, and earlier onset of sexual activity. Respondents with high IUD knowledge were 6 times more likely to be current LARC users (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.4-28.8). Sociodemographic variables did not predict use. Respondents with lower education (OR, 1.76; 95% CI, 1.0-3.0), an external locus of control (OR, 1.6; 95% CI, 1.1-2.3), male sex (OR, 2.8; 95% CI, 1.9-4.1), and foreign language had less knowledge of IUD.

CONCLUSION

Increasing knowledge of IUD among certain groups may improve LARC use among young, unmarried adults and in turn decrease unintended pregnancy.

Awareness and knowledge of the intrauterine device in adolescents

BACKGROUND

The purpose of this study was to explore intrauterine device (IUD) awareness and knowledge in a diverse, multiethnic population.

METHODS

We conducted a self-administered, anonymous survey addressing awareness of the IUD as a contraceptive method and knowledge about aspects of IUD use in a group of women aged 14 to 19 years. Demographic and medical information was obtained to compare awareness and knowledge between demographic groups. Chi-square, Fisher exact test, and t tests were used for analysis. Multiple logistic regression was utilized to confirm relationships.

RESULTS

Of the 106 respondents, 76.4% (81/106) were sexually active and 56.6% (60/106) reported a history of ever being pregnant. There were 21.1% (33/106) of respondents who had heard of the IUD as a contraceptive method. Of the subjects who had heard of the IUD, 39.4 % (13/33) were able to identify key features of the IUD. Although a history of pregnancy was predictive of having heard of the IUD, age, insurance status, education, and all other demographic factors were not associated with IUD awareness.

CONCLUSION

Over 70% of the adolescents had not heard of the IUD and less than half of adolescents who had heard of the IUD were able to identify key features about this contraceptive method. The lack of knowledge of this effective and safe contraceptive option is concerning given that most participants were at high risk for unintended pregnancy.

Contraceptive considerations in overweight teens

PURPOSE OF REVIEW

The purpose of this review is to explore the efficacy and safety of contraceptives in overweight adolescents.

RECENT FINDINGS

There are few studies exploring hormonal contraceptive efficacy and safety in overweight and obese adults and almost none addressing these issues in adolescents. Luckily for teens, in terms of safety, many of the comorbidities associated with obesity are yet to transpire and their options for contraception remain relatively unrestricted. Studies of the combined oral contraceptive pill and patch in adults suggest that efficacy may be decreased in overweight adolescents. There is no evidence to suggest that the efficacy of the contraceptive implant or intrauterine device (IUD) is decreased in overweight adolescents. Indeed, these long-acting reversible methods will be the best choice for many adolescents because of their high efficacy. Although the literature is not definitive, there is probably a subset of adolescents who are susceptible to weight gain with use of depot medroxyprogesterone acetate.

SUMMARY

Although there is little research regarding contraceptive efficacy in overweight adolescents, IUDs and implants will be the best methods for many adolescents because of their high efficacy, reversibility, and safety.

Impact of long-acting reversible contraception on return for repeat abortion

OBJECTIVE

The objective of the study was to determine the rate of return for repeat abortion in relation to postabortion contraceptive method choice 24 months onward from an intervention study.

STUDY DESIGN

This was a prospective cohort study involving a hospital note search for 510 women 24 months after an abortion.

RESULTS

Women using long-acting reversible contraceptive (LARC) methods (intrauterine device [IUD] and depot medroxyprogesterone acetate) had significantly lower return rates for repeat abortion (6.45%; 95% confidence interval [CI], 4.0-9.8) than non-LARC users, of whom 14.5% returned (95% CI, 9.9-20.2). A Cox proportional hazard analysis showed that the postabortion method choice was significantly related to the likelihood of returning for a repeat abortion (P = .002), controlling for major demographic factors and previous pregnancy history. Using the pill as a reference group for risk of repeat abortion, the IUD hazard ratio (HR) was 0.36 (95% CI, 0.17-0.77), the depot medroxyprogesterone acetate HR was 0.55 (95% CI, 0.21-1.45), and the HR for all other methods was 1.8 (95% CI, 0.83-3.92).

CONCLUSION

This study provides strong support for the promotion of immediate postabortion access to LARC methods (particularly intrauterine devices) to prevent repeat abortion.

An evidence-based guideline for unintended pregnancy prevention

Despite the frequency of and significant costs related to unintended pregnancy, it has received less attention in research and prevention guidelines development than other important health threats. This lack of attention has resulted in a system-wide failure to provide care to reproductive aged women who are at risk of unintended pregnancy. An evidence-based blueprint for a coordinated system of primary, secondary, and tertiary prevention is proposed for health professionals who provide care for patients at risk for unintended pregnancy.

Associations between recent contraceptive use and quality of life among women

BACKGROUND

Whether contraception affects health-related quality of life (HRQoL) is unclear.

STUDY DESIGN

We conducted a cross-sectional analysis of routine intake data collected from women aged 18-50 years, including the RAND-36 (Research and Development Corporation) measure of HRQoL, pregnancy intentions and recent contraceptive use. We used multivariable logistic regression to test the relationship between HRQoL and use of any and specific contraceptives. Physical and mental HRQoLs were dichotomized based on US population averages. Models were adjusted for age, race, marital status, education and pregnancy intentions.

RESULTS

Among the 726 women, those using any form of contraception were more likely to have average or better mental HRQoL than women using no contraception [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI) 1.01-2.53]. Women using injectable contraception were less likely than those using combined hormonal methods to have average or better physical HRQoL (aOR=0.26, 95% CI 0.09-0.80) and mental HRQoL (aOR=0.24, 95% CI 0.06-0.86).

CONCLUSIONS

Measures of women's HRQoL differ with contraceptive use.

Characteristics of users of intrauterine devices and other reversible contraceptive methods in the United States

OBJECTIVE

To evaluate the determinants of intrauterine device (IUD) use and reasons for choosing IUDs over other reversible contraceptive methods.

DESIGN

Descriptive statistics and multinomial logistic regression were used to assess multiple factors associated with IUD use and the use of other reversible methods in the United States.

SETTING

Not applicable.

PATIENT(S)

Women at risk of pregnancy from the 2006 to 2008 National Survey of Family Growth and a 2004 Guttmacher Institute survey.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sociodemographic and reproductive characteristics, family background, and health insurance coverage.

RESULT(S)

IUD use was positively associated with women's parity and the highest education level of respondent's mother; it was less common among women who had ≥4 sexual partners in the last 12 months and those who were widowed, divorced, or separated. IUD users reported pregnancy prevention, provider recommendation, and no interruption of sex as the most important reasons for choosing the method and reported a high level of satisfaction.

CONCLUSION(S)

IUD users differed substantially from users of other reversible contraceptives. IUD use was especially uncommon among nulliparae. Most current IUD users were satisfied with their choice.

Revival of the intrauterine device: increased insertions among US women with employer-sponsored insurance, 2002-2008

BACKGROUND

Use of the intrauterine device (IUD) in the United States has recently increased. New evidence for women with employer-sponsored health insurance permits analysis of variation and trends in such use.

STUDY DESIGN

A retrospective analysis of annual IUD insertion rates between 2002 and 2008 was conducted by evaluating claims from the MarketScan® Commercial Research Databases for US women insured by plans that covered IUD insertions. Estimates were weighted to be nationally representative.

RESULTS

IUD insertion rates increased from 1.6/1000 women of reproductive age to 9.8/1000 over 2002-2008 and varied substantially by state. Insertion rates of the levonorgestrel-releasing intrauterine system (LNG-IUS) increased from 0.4/1000 to 7.7/1000, whereas the insertion rates of copper T380A IUD (copper IUD) increased from 0.6/1000 to 1.5/1000. IUD insertions, which are most common among women aged 25-34 years, increased at roughly the same rate across all age groups.

CONCLUSIONS

The sixfold increase in IUD insertion rates between 2002 and 2008 was accompanied by an increase in the share IUD use with the LNG-IUS from 40% to 85%. Substantial geographic and age variations existed.

Characteristics of women in the United States who use long-acting reversible contraceptive methods

OBJECTIVE

To examine characteristics of U.S. women that are associated with use of long-acting reversible contraception and changes in these characteristics between 2002 and 2006-2008.

METHODS

We analyzed data from two nationally representative samples of women aged 15-44 in the National Survey of Family Growth, including 7,643 women in 2002 and 7,356 women in 2006-2008. We conducted simple and multinomial logistic regression analyses to identify demographic and reproductive health characteristics associated with use of long-acting reversible contraception.

RESULTS

Long-acting reversible contraception (intrauterine devices and subdermal implants) use among U.S. women using contraception increased from 2.4% in 2002 to 5.6% in 2006-2008. The largest increases in long-acting reversible contraception use during this time occurred among the youngest and oldest age groups, non-Hispanic white and non-Hispanic African American women, foreign-born women, and those in the highest income group. High prevalence of long-acting reversible contraception use in 2006-2008 was seen among women who had given birth once or twice (10%), foreign-born women (8.8%), and Hispanic women (8.4%). After adjusting for key demographic and reproductive health characteristics, in comparison with users of other contraceptive methods and with those not using contraception who were at risk for unintended pregnancy, foreign-born women and women who experienced coitarche before age 18 were approximately twice as likely to be using long-acting reversible contraception as women without those characteristics.

CONCLUSION

A more diverse population of women used long-acting reversible contraception in 2006-2008 compared with 2002. However, there is likely more potential for increased uptake, especially among populations historically not considered to be candidates for these methods.

Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice

BACKGROUND

Poor contraception adherence contributes to unintended pregnancy. Intrauterine contraception (IUC) is user-independent thus adherence is not an issue, yet few US women use IUC. We compared family physicians (FPs) who do and do not insert IUC in order to ascertain determinants of inserting IUC.

STUDY DESIGN

We surveyed 3500 US FPs. The primary outcome variable was whether a physician inserts IUC in their current clinical practice. We also sought to describe their clinical practice with IUC insertions.

RESULTS

FPs who insert IUC had better knowledge about IUC (adjusted OR 1.85, 95% CI 1.32-2.60), more comfort discussing IUC (adjusted OR 2.35, 95% CI 1.30-4.27), and were more likely to believe their patients are receptive to discussing IUC (adjusted OR 2.96, 95% CI 2.03-4.32). The more IUC inserted during residency, the more likely to insert currently (adjusted OR 1.44, 95% CI 1.12-1.84). Only 24% of respondents inserted IUC in the prior 12 months.

CONCLUSIONS

US FPs have training and knowledge gaps, as well as attitudes, that result in missed opportunities to discuss and provide IUC for all eligible patients.

Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand

BACKGROUND

Many misconceptions still prevail about the appropriateness of use of the intrauterine device (IUD), particularly for younger women. This study examines the factors associated with post abortion IUD use as compared to the combined oral contraceptive pill (COC). It then examines the effect of type of post abortion contraception with the likelihood of seeking subsequent abortions.

STUDY DESIGN

This prospective cohort study followed, for a period of 3 years, 1422 women who had a first trimester surgical abortion between November 2004 and January 2005 in Auckland's public abortion clinic.

RESULTS

Compared to women who left the clinic with COC, those leaving with an IUD (OR 0.3) at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, younger women were less likely than older women to have had an IUD inserted post abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.

CONCLUSIONS

Young and nulliparous women are less likely to use an IUD as a method of contraception following an abortion. However, those women who have an IUD inserted following an abortion are much less likely to return for a subsequent abortion. IUDs are a safe and effective method of contraception that are currently still underused among the younger population.

Condoms for dual protection: patterns of use with highly effective contraceptive methods

OBJECTIVES

U.S. women experience high rates of unplanned pregnancy and sexually transmitted infections (STIs), yet they seldom combine condoms with highly effective contraceptives for optimal protection. Because oral contracep tives (OCs) have been the predominant form of highly effective contraceptio in the U.S., it is unknown whether condom use is similarly low with increasingly promoted user-independent methods.

METHODS

We used weighted data from the National Survey of Family Growth to assess condom use odds among women relying on OCs vs. user-independent methods (i.e., injectibles, intrauterine devices, and implants). We also estimated the expected reduction in unplanned pregnancies and abortions if half or all of the women currently using a single highly effective method also used condoms.

RESULTS

Across every demographic subgroup based on age, partner status, race/ethnicity, household income, and education, condom use prevalence was lower for women relying on user-independent methods vs. OCs. Multivariable models for adult women also revealed a significant reduction within most demographic subgroups in the odds of condom use among women relying on user-independent methods vs. OCs. Population estimates suggested that if half of all women using highly effective methods alone also used condoms, approximately 40% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 393,000 unplanned pregnancies and nearly 76,000 abortions. If all highly effective method users also used condoms, approximately 80% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 786,000 unplanned pregnancies and nearly 152,000 abortions.

CONCLUSIONS

Adding condoms to other methods should be considered seriously as the first line of defense against unplanned pregnancy and STls. This analysis can serve to target interventions where dual-method promotion is needed most.

Damage control: unintended pregnancy in the United States military

Women's access to reproductive health care is an ongoing source of conflict in U.S. politics; however, women in the military are often overlooked in these debates. Reproductive health care, including family planning, is a fundamental component of health care for women. Unintended pregnancy carries substantial health risks and financial costs, particularly for servicewomen. Compared with their civilian counterparts, women in the military experience greater challenges in preventing unwanted pregnancy and have less access to contraceptive services and abortion. Current military policies, federal laws, and health care practices are not always consistent with evidence-based research and patient-centered care. A multidisciplinary effort on the part of military personnel, lawmakers, and health care providers is needed to eliminate these disparities. We discuss recommendations in the following categories: improving contraceptive education and adherence, expanding research, broadening access to the full range of contraceptive options including emergency contraception, and ensuring access to safe abortion.

Family planning: today and in the future

This review covers the state of contraceptive development noting new entries in the clinic (mainly steroidal and different delivery methods) and novel leads for nonsteroidal female- and male-methods in the pipeline. The time taken to market and the absence of partnerships with industry are stressed as major factors for the slow progress in their development.

Expanding access to intrauterine contraception

The intrauterine device is a safe, highly effective, long-lasting, yet reversible method of contraception. Expanding access to intrauterine contraception is an important measure to reduce the rate of unintended pregnancy in the United States. Clinicians should consider intrauterine contraception in appropriate candidates, including women who are nulliparous, adolescent, immediately postpartum or postabortal, and desiring emergency contraception, and as an alternative to permanent sterilization. Barriers to intrauterine contraception such as requiring cervical cancer screening before insertion, routine testing for gonorrhea and chlamydial infection in low-risk women, or scheduling insertion only during menses are unnecessary.