Racial and ethnic differences in women's preferences for features of contraceptive methods

Self-removal of long-acting reversible contraception: A content analysis of YouTube videos

OBJECTIVE

To explore publicly available information about the self-removal of long-acting reversible contraception (LARC) on a popular video-sharing website.

STUDY DESIGN

We conducted a comprehensive keyword search of YouTube videos related to self-removal of LARC-namely intrauterine devices and implants. We analyzed video content to explore demographic characteristics, method and duration of LARC use, and motivations and experiences of self-removal.

RESULTS

Our keyword search identified 58 videos that met the criteria for inclusion, including 48 videos that featured individuals who removed an intrauterine device and 10 who removed an implant. Collectively, videos had over 4 million views. We identified most video creators as white (53%), 31% as Black, and 14% as Latinx. Users were motivated to remove their own device by both preferences and barriers to formal care. Most individuals in our sample (n = 56/58) successfully removed their device and described their experience in positive terms related to the ease of removal. Reasons for LARC discontinuation included negative side effects, fear of potential side effects, and desire for pregnancy.

CONCLUSION

This study builds upon prior research by describing publicly available information about LARC self-removal. The over representation of Black women in our sample may reflect a higher prevalence of LARC self-removal among this population. Positive experiences of self-removal and high levels of viewer engagement with online videos suggest a need for provider counseling on LARC removal at the time of insertion.

IMPLICATIONS

Prior to LARC insertion, patients should be made aware of any financial requirements for discontinuation. Provider counseling for self-removal at the time of insertion will likely minimize health risks and affirm patient reproductive autonomy.

Mi Familia Entera: Contraceptive Use Among Spanish-Speaking Mothers of Young Children

OBJECTIVES

To characterize contraceptive method use and satisfaction among Spanish-speaking Latina immigrants who attend their child's well care visit.

METHODS

Spanish-speaking women whose youngest child was ≤ 4 years old completed an orally-administered Spanish-language survey in a pediatric clinic (N = 194). Survey items were based on previously published contraceptive use assessments among diverse populations. We used chi-square and Fisher exact test to describe maternal characteristics by contraceptive method effectiveness categories: Tier 1, most effective methods (hormonal implant, intrauterine device, tubal ligation, and vasectomy); Tier 2, very effective methods (hormonal injection, oral contraceptive pill, hormonal patch, and hormonal ring); Tier 3, effective methods (condoms), and no method.

RESULTS

34% of women were using a Tier 1 method, 40% were using a Tier 2 method, and 17% had unmet contraceptive need (no pregnancy intention, no birth control); 84% were satisfied with their current method and 82% of women were uninsured. Tier 2 method or no method users were more likely than women using a Tier 1 method to have children < 9 months old (X² (6, N = 190) = 20.4, p = .002).

CONCLUSIONS

Latina immigrants with young children who attend their child's pediatric visit are mostly using effective contraceptives and are satisfied with their method. A culturally supportive medical home and access to no-cost long-acting reversible contraceptives through a temporary private grant likely contributed to high contraceptive use and satisfaction in our study. Describing maternal contraceptive use among Latina immigrant mothers can inform future equitable, culturally tailored, approaches to pediatric maternal contraceptive need screening.

Contraceptive counselling experiences in Spain in the process of creating a web-based contraceptive decision support tool: a qualitative study

Background

The choice of contraceptive method is a complex decision, and professionals should offer counselling based on the preferences, values and personal situation of the user(s). Some users are unsatisfied with the counselling received, which may, among other consequences, adversely affect method use adherence. In view of this situation, we propose exploring the experiences and needs of users and professionals for contraceptive counselling, in the context of creating a web-based contraceptive decision support tool.

Methods/design

Qualitative research was conducted through focus group discussions (64 users split into eight groups, and 19 professionals in two groups, in Tarragona, Spain) to explore the subjects’ experiences and needs. The data were categorized and the categories were defined and classified based on the three-step protocol or framework for Quality on Contraceptive Counseling (QCC), created by experts, which reviews the quality of interactions between user and professional during the counselling process.

Results

In counselling, users demand more information about the different methods, in an environment of erroneous knowledge and misinformation, which lead to false beliefs and myths in the population that are not contrasted by the professional in counselling. They complain that the method is imposed on them and that their views regarding the decision are not considered. Professionals are concerned that their lack of training leads to counselling directed towards the methods they know best. They acknowledge that a paternalistic paradigm persists in the healthcare they provide, and decision support tools may help to improve the situation.

Conclusions

Users feel unsatisfied and/or demand more information and a warmer, more caring approach. Professionals are reluctant to assume a process of shared decision-making. The use of a contraception DST website may solve some shortcomings in counselling detected in our environment.

In Spain, individuals can use a variety of contraceptive methods. Professionals involved in contraceptive counselling should help users to choose and properly use the method that best suits their preferences, personal situation and health status. However, there is a high number of unplanned pregnancies and the population feels dissatisfied with the counselling received. In the context of creating a website dealing with contraceptive methods, we wished to find out how counselling was taking place, giving voice those directly concerned. A qualitative study was proposed to explore the experiences and needs of users and professionals during counselling. Ten focus groups were conducted involving 64 users and 19 professionals from Tarragona (Spain). The results were ordered based on the Quality on Contraceptive Counseling (QCC) framework, created by experts, which determines what the relationship between user and professional should be like during the counselling process. Our analysis highlighted users’ little knowledge and false beliefs concerning contraception who, moreover, complained of receiving little information during counselling. They expressed their discontent with methods being imposed on them by the professional without exploring their preferences or needs. Meanwhile, the professionals argued that they often prescribe the method with which they are most familiar due to the lack of time during consultations at their office and/or because they are unfamiliar with other methods. These results, among others, offer the possibility of improving contraceptive counselling in Spain, if solutions to the difficulties and/or barriers detected are posed and implemented.

Exploring Readiness for Birth Control in Improving Women Health Status: Factors Influencing the Adoption of Modern Contraceptives Methods for Family Planning Practices

Background: Pakistan is the world’s sixth most populated country, with a population of approximately 208 million people. Despite this, just 25% of legitimate couples say they have used modern contraceptive methods. A large body of literature has indicated that sexual satisfaction is a complex and multifaceted concept, since it involves physical and cultural components. The purpose of this study is to investigate the impact of influencing factors in terms of contraceptive self-efficacy (CSE), contraceptive knowledge, and spousal communication on the adoption of modern contraceptive methods for family planning (FP) under the moderating role of perceived barriers. Methods: Data were collected using an adopted questionnaire issued to married women of reproductive age belonging to the Rawalpindi and Neelum Valley regions in Pakistan. The sample consisted of 250 married women of reproductive age. SPSS was used to analyze the respondents’ feedback. Results: The findings draw public attention towards CSE, contraceptive knowledge, and spousal communication, because these factors can increase the usage of modern methods for FP among couples, leading to a reduction in unwanted pregnancies and associated risks. Regarding the significant moderation effect of perceived barriers, if individuals (women) are highly motivated (CSE) to overcome perceived barriers by convincing their husbands to use contraceptives, the probability to adopt modern contraceptive methods for FP practices is increased. Conclusions: Policymakers should formulate strategies for the involvement of males by designing male-oriented FP program interventions and incorporating male FP workers to reduce communication barriers between couples. Future research should address several other important variables, such as the desire for additional child, myths/misconceptions, fear of side effects, and partner/friend discouragement, which also affect the adoption of modern contraceptive methods for FP practices.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

"I'm not going to be a guinea pig:" Medical mistrust as a barrier to male contraception for Black American men in Los Angeles, CA

BACKGROUND

Racial disparities in unintended pregnancy and contraceptive use in the United States are not mediated by access to family planning services alone. Rather, a history of medical mistrust underlies Black Americans' adoption of new medical technologies, inclusive of contraception. Efforts to develop hormonal male contraceptives need to incorporate Black Americans' experiences and perspectives so that new contraceptives enable their reproductive goals and promote gender equity.

STUDY DESIGN

Working with our community-based partner, Healthy African American Families in Los Angeles, California, we conducted six 60-minute focus group discussions with 39 Black men over age 18, in ongoing heterosexual relationships, to explore attitudes towards and willingness to use hormonal male contraceptives.

RESULTS

Just over one-third (35%) of respondents reported willingness to use or rely on hormonal male contraceptives. The majority held negative attitudes about hormonal male contraceptives, citing concerns about side effects and safety. Several respondents expressed mistrust of the medical community and medical research, noting that hormonal male contraceptives could be used against Black communities; several expressed unwillingness to trial hormonal male contraceptives without years of testing. However, all groups described scenarios where they would use them despite stated concerns.

CONCLUSIONS

Black men's hypothetical willingness to use hormonal male contraceptives is limited by medical mistrust, which may be overcome by their concerns about the unreliability of current options or the contraceptive behaviors of female partners. Nevertheless, addressing Black Americans' history of medical mistreatment and exploitation will be essential for hormonal male contraceptives to positively contribute to Black men's reproductive options and agency.

IMPLICATIONS

While the development of reversible, hormonal male contraception intends to fulfill unmet global needs for contraception, the utility of these hormonal male contraceptive methods among Black men living on low incomes in Los Angeles, California cannot be fully realized until developers address and overcome historical and ongoing medical mistrust.

Contraceptive use and preferences among females with sickle cell disease

INTRODUCTION

Females with sickle cell disease now have a life expectancy that extends well into and beyond their reproductive years. Pregnancy and childbirth are accompanied by high morbidity and mortality in this population, rendering contraception a critical part of their health care.

METHODS

We approached adult female patients of the Hospital of the University of Pennsylvania hematology clinic who were of reproductive age (ages 18-45) and carried a diagnosis of sickle cell disease. We evaluated contraceptive method uptake and method characteristic preferences, as well as other reproductive history, and compared contraceptive uptake rates to that from female respondent data from the National Survey of Family Growth (2017-2019).

RESULTS

Of 95 eligible patients, we completed surveys with 48 participants (response rate of 51%). Over half (n = 27, 56%) of participants were not currently using any form of contraception-double the rate of the general United States population (25%). The most common contraceptives currently used were the depot medroxyprogesterone (DMPA) injection (n = 6, 13%) and the progestin intrauterine device (IUD) (n = 6, 13%). DMPA uptake was significantly higher, and permanent contraceptive and oral contraceptive pill uptake significantly lower, among these participants with sickle cell disease compared to the general United States population. Participants' preferred contraceptive characteristics included effectiveness (n = 39, 81%), control over when to use the contraceptive (n = 39, 81%), and lack of side effects (n = 38, 79%).

CONCLUSIONS

Contraceptive uptake was significantly lower and method mix different among females with sickle cell disease compared to the general United States population. Further research is needed on contraceptive safety, non-contraceptive benefits, and contraceptive decision-making for females with sickle cell disease.

IMPLICATIONS

This study sheds light on the contraceptive choices and preferences of females with sickle cell disease, who are at disproportionate risk for pregnancy complications. In order to maximize the reproductive health of females with sickle cell disease, we must consider how their disease interacts with contraception and better understand how they approach contraceptive decision-making.

Structural Inequity and Pregnancy Desires in Emerging Adulthood

Public health discourses often claim that delaying pregnancy is associated with social and economic benefits. Yet research suggests that, for young people, structural inequity is most influential in future outcomes, regardless of childbearing. We conducted in-depth interviews with 50 young women (ages 18-24) and their male partners (n = 100) and investigated the influence of structural inequity on pregnancy desires and plans. Three themes emerged, stratified by social advantage. In the "Things Will Be Different Later" theme, socially advantaged participants envisioned that their future lives would surely be different due to achievement of educational, professional, and economic goals; thus, their pregnancy plans aligned with their desires, often reflected in use of highly effective contraception. In the "I Don't Have Everything I Need" theme, participants expressed delaying desired pregnancies (primarily through condom use) until they could contend with structural barriers. Their pregnancy plans, shifted by way of structural inequity, were not aligned with their desires. Under the "I'll Never Have Everything I Need" theme, socially disadvantaged participants expressed significant doubt about ever realizing ideal circumstances for pregnancy preparedness; as pregnancy prevention was not salient, these participants used condoms or no contraception. This analysis indicates that structural inequities constrain reproductive self-determination in emerging adulthood, creating a chasm between desired and actual childbearing that was reflected in contraceptive decision-making. Public health narratives emphasizing the importance of pregnancy prevention for socially disadvantaged groups without addressing the manifestation of structural inequity in their lives perpetuate reproductive oppression vis-à-vis emphasis on contraceptive use to ensure future economic success.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Initiation of Long-Acting Reversible Contraception in Hospitalized Adolescents in the United States

OBJECTIVES

To analyze factors associated with the initiation of long-acting reversible contraception (LARC) among adolescent patients in inpatient settings in the United States.

METHODS

This study is a secondary data analysis of the national Kids' Inpatient Database 2016 data (N = 4200 hospitals). Eligible patients were hospitalized girls 10 to 20 years old. The primary outcome was initiation of LARC (ie, subdermal implant and/or intrauterine device [IUD]) while hospitalized. Covariables included age, race or ethnicity, insurance type, postpregnancy status, geographic region, hospital type (rural or urban), hospital size, and children's hospital status. Bivariable statistics were calculated by using survey-weighted analysis, and a design-based logistic regression model was used to determine the adjusted odds of LARC initiation and of implant versus IUD initiation.

RESULTS

LARC initiation occurred in 0.4% (n = 3706) of eligible hospital admissions (n = 874 193). There were differences in LARC initiation by patient age, insurance type, race or ethnicity, postpregnancy status, hospital type, and hospital status (all P < .01). In the adjusted model, older age, public insurance, nonwhite race or ethnicity, postpregnancy status, and urban, teaching or larger hospitals were independently associated with LARC initiation (all P < .01). Smaller hospital size and postpregnancy status increased the odds of implant versus IUD initiation after stratifying by hospital region.

CONCLUSIONS

LARC initiation occurred in <1% of adolescent hospitalizations, with 90% of those occurring in postpregnancy adolescents. Addressing LARC capacity in rural, nonteaching, and smaller hospitals is important in increasing access. Future research is needed to identify and close gaps in the number of adolescents desiring and initiating LARC in hospital settings.

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

STUDY OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Exploring contraceptive care practices at Rural Health Clinics in the southern United States

OBJECTIVE

With declining numbers of obstetrician-gynecologists operating in rural areas across the United States, primary care providers have stepped in to fill contraceptive service gaps. Many of these providers operate in Rural Health Clinics; however, little is known about the provision of contraception in these clinics.

METHODS

This exploratory qualitative descriptive study used a purposive sampling strategy to recruit South Carolina Rural Health Clinic providers from across regions and income levels. Eleven providers participated in semi-structured, in-person interviews. Contraceptive care practices were identified using a combination of inductive and deductive coding.

RESULTS

Participants described their typical contraceptive patient as a low-income woman under 22 years. While providers were open to providing contraception, their on-site services were limited. Each included clinic offered the oral contraceptive pill and the shot, but only one offered the implant, and none offered the intrauterine device.

CONCLUSION

Rural Health Clinic providers have limited capacity to offer a full range of contraception due to financial, training, and staffing constraints. Despite these limitations, Rural Health Clinics remain a contact point that helps meet national recommendations for increasing access to reproductive health services for rural women. Efforts to increase access to contraceptive care for rural women must include resources for these providers.

Lessons Learned from Replicating a Randomized Control Trial Evaluation of an App-Based Sexual Health Program

This study presents findings from a randomized control trial replication evaluation of Pulse, an app-based pregnancy prevention program implemented with Black and Latinx women aged 18-20, a population with high rates of unplanned pregnancy. We used social media advertisements to enroll 1013 women online across the U.S. and automatically randomized participants to either the Pulse reproductive health app or a general health control app, stratifying by age and race/Latinx ethnicity. Participants received reminder text messages to view the app as well as text messages with app-related content throughout the intervention. Linear probability models were conducted on the analytic sample of 871 participants who completed the six-week survey and 798 who completed the six-month survey and adjusted for permuted block randomization and multiple hypothesis testing. Compared to the control group, intervention group participants had higher contraceptive knowledge (p = 0.000), which replicates findings from an earlier evaluation. However, these impacts were not sustained at six-month follow-up (p = 0.162). We found no other significant program impacts. This contrasts with an earlier evaluation that found intervention participants were less likely to have had sex without a hormonal or long-acting reversible contraceptive (LARC) method and had greater self-confidence to use contraception consistently than the control group. Different demographic characteristics, lower app usage, and more negative attitudes about and usage of hormonal/LARC contraception in the current sample may help to explain fewer impacts than the earlier evaluation.

Contraception among women on probation and parole on the United States-Mexico border

OBJECTIVE

Effective contraception prevents unintended pregnancy which disproportionately affects women in the criminal justice system. This study examined selected variables associated with contraceptive use by women on probation and parole living on the United States-Mexico border.

DESIGN

This quantitative correlational study examined individual and interpersonal variables-age, parity, ethnicity, prior contraception, self-efficacy, pregnancy attitudes, and reproductive autonomy-that may influence contraception among 52 women under community supervision.

MEASURES

Variable were examined with bivariate, multivariate analyses, and hierarchical logistic regression. Data were collected from a demographic and contraceptive use survey, and validated scales measuring reproductive autonomy and pregnancy attitudes.

RESULTS

Contraceptive methods were used by 89% of the women; 65% used effective methods, but this decreased to 35% among those released within the past year. Reproductive autonomy was associated with effective contraceptive use. Prior contraception and contraceptive self-efficacy were significant, but wide confidence intervals suggested instability. The remaining variables were insignificant.

CONCLUSION

No known studies have examined contraception use among women on probation and parole on the border. More women used some form of contraception than might be predicted. Collaborative efforts between correctional facilities and the community are needed to expand access to contraception.

Socioeconomic differences persist in use of permanent vs long-acting reversible contraception: An analysis of the National Survey of Family Growth, 2006 to 2010 vs 2015 to 2017

OBJECTIVE

Permanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC.

STUDY DESIGN

We performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006 to 2017, with multivariable analyses of the 2006 to 2010 and 2015 to 2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception vs LARC, lower-efficacy contraception vs LARC) in reproductive-aged women.

RESULTS

Total 8161 respondents were included in 2 distinct but analogous regression analyses: (1) the most recent survey cohort, 2015 to 2017 and (2) the cohort a decade prior, 2006 to 2010. Over this period, the prevalence of LARC increased nearly 3-fold (6.2%-16.7%), while permanent contraception use trended downwards (22%-18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (vs LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45 [95% confidence interval 0.21, 0.97]) and Hispanic women (OR 0.41 [0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33 [0.13, 0.84] and 0.47 [0.23, 0.97]). Multiparity, advanced age (over ≥35), and marital status remained strong predictors of permanent contraception.

CONCLUSION

Although use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women.

IMPLICATIONS

Comparing 2006-2010 to 2015-2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

Contraceptive selection and practice: Associations with self-identified race and socioeconomic disadvantage

Many researchers and policymakers have linked contraceptive programs to improvements in women's and children's socioeconomic outcomes. However, these studies have overlooked how socioeconomic status may be an initial driver of contraceptive choice and behavior. Here, I examine the relationship between a comprehensive measure of socioeconomic disadvantage, self-identified race, and contraceptive method selection at enrollment in a unique longitudinal study of contraceptive clients who received a new type of method at no cost. I then examine whether socioeconomic disadvantage has an association with contraceptive switching or discontinuation. I demonstrate that socioeconomic disadvantage decreases the chance of selecting any IUD, while Black racial membership increases the chance of selecting the 3-month injectable and Multiracial membership increases the chance of selecting the Vaginal Ring. I then demonstrate that socioeconomic disadvantage and self-identified race have intersectional and variable associations with switching, and, to a lesser extent, discontinuing methods. These findings offer an important insight for implementation in contraceptive programs: eliminating financial barriers to access contraceptive services does not eliminate the socioeconomic contexts that influence method selection and use that occur as part of everyday lived experiences. Taken cumulatively, these results suggest that contraceptive services should be offered to women in ways that ensure access to reproductive justice without obscuring the need for social changes in the institutions that create disadvantage and shape contraceptive use itself.

Racial and Ethnic Differences in the Relationship Between Risk-Taking and the Effectiveness of Adolescents' Contraceptive Use

CONTEXT

Little is known about whether adolescents' risk-taking in areas other than sex is associated with the effectiveness of their contraceptive method use, or whether any such associations vary by race and ethnicity.

METHODS

Data from the 2011, 2013 and 2015 National Youth Risk Behavior Surveys were used to examine nonsexual risk behaviors and contraceptive method choice among 5,971 sexually active females aged 13-18. Risk-taking profiles for White, Black and Hispanic adolescents were identified using latent class analysis. Multinomial logistic regression was used to estimate the associations between these risk profiles and use of less- or more-effective contraceptive methods at last sexual intercourse.

RESULTS

Three distinct risk-taking profiles were identified for White and Hispanic adolescents and two for Black adolescents. Compared with their counterparts in the low-risk "abstainer" group, White adolescents in the "high substance use and violence" group were less likely to use condoms alone (relative risk, 0.4) or a prescription contraceptive paired with condoms (0.3) rather than no contraceptive at all, and more likely to use withdrawal or no method rather than condoms alone (2.4 each). However, higher risk-taking among Whites was positively associated with using prescription contraceptives rather than condoms (1.9). Among Black and Hispanic females, lower risk-taking was associated only with more condom use.

CONCLUSIONS

Future studies should examine whether interventions designed to reduce adolescent risk-taking improve the effectiveness of contraceptive use, particularly among White females. However, efforts to increase Black and Hispanic adolescents' use of more-effective contraceptives should target barriers other than risk-proneness. Perspectives on Sexual and Reproductive Health, 2020, 52(4):TK, doi:10.1363/psrh.12165.

Long-Acting Reversible Contraceptive Attitudes and Acceptability in Adolescents and Young Adults: A Key to Patient-Centered Contraceptive Counseling

PURPOSE

To examine the attitudes of adolescent and young adults (AYA) toward long-acting reversible contraception (LARC), and to assess how attitudes are associated with acceptability.

DESIGN

Survey.

SETTING

Children's Hospital Colorado Adolescent Family Planning Clinic in Aurora, Colorado.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

Young persons 14-24 years of age presenting for any type of visit between March and August 2018.

RESULTS

A total of 332 participants were enrolled; the majority (62.3%) had high LARC acceptability. We found 5 "attitude" factors: 77.7% of the sample endorsed "Effective" attitudes (eg, wants most effective method), 37.3% endorsed "Good attributes" (eg, discreet, convenient), 23.1% endorsed "Scary" (eg, fears device will move), 16.1% endorsed "Bad for health," (eg, too many side effects), and 9% endorsed "Not for me" (eg, concerns about pain). Although participants who endorsed "Effective" (OR 6.60, 95% CI 3.01-14.49) and "Good attributes" (OR 3.17, 95% CI 1.51-6.66) were more likely to have high LARC acceptability than those who endorsed "Scary" (OR 0.28, 95% CI: (0.13-0.61)) and "Not for me" (OR 0.07, 95% CI 0.01-0.41) factors, approximately 10% of participants with high LARC acceptability endorsed "Scary" or "Bad for health" attitudes, whereas 54% of those with low LARC acceptability endorsed "Effective" attitudes.

CONCLUSION

Although most participants had high LARC acceptability and valued contraceptive effectiveness, the association between LARC attitudes and acceptability is nuanced. Providers should identify and discuss young people's contraceptive knowledge, attitudes, and acceptability.

Material Hardship and Contraceptive Use During the Transition to Adulthood

Decades of research have attempted to understand the paradox of stubbornly high unintended pregnancy rates despite widespread use of contraception. Much of this research has focused on socioeconomic disparities in rates of unintended pregnancy, finding that economically disadvantaged women tend to use less effective contraceptive methods and use them less consistently. Building on this research, this study examines how material hardship is associated with less consistent contraceptive use among women who do not desire to become pregnant. Using the Relationship Dynamics and Social Life (RDSL) Study, a weekly longitudinal survey, I find lower levels of contraceptive use and less consistent use of contraception among women experiencing material hardship, relative to those without hardship experiences. I also investigate the extent to which this association is explained by access barriers and lower contraceptive efficacy among women experiencing hardship. Using structural equation modeling, I find that these mediators significantly explain the relationship between hardship and risky contraceptive behaviors, suggesting that hardship creates mental and resource constraints that impede successful implementation of contraception. However, net of these mediators, material hardship remains associated with riskier contraceptive behaviors among young women, calling for further research on how hardship exposes women to greater risk of unintended pregnancies.

Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.

Efficacy as safety: Dominant cultural assumptions and the assessment of contraceptive risk

To reduce rates of unintended pregnancy, medical and public health associations endorse a contraceptive counseling model that ranks birth control methods by failure rate. This tiered model outlines all forms of birth control but recommends long-acting reversible contraceptives (LARC) to eliminate user error and increase continuation. Our critical discourse analysis of gynecology textbooks and medical recommendations examines how gendered and neoliberal ideas influence risk assessments underlying the tiered contraceptive counseling model. Specifically, we explore how embodied, lifestyle, and medical risks are constructed to prioritize contraceptive failure over adverse side effects and reproductive autonomy. We find that the tiered model's focus on contraceptive failure is justified by a discourse that speciously conflates distinct characteristics of pharmaceuticals: efficacy (ability to produce intended effect) and safety (lack of unintended adverse outcomes). Efficacy discourse, which filters all logic through the lens of intended effect, magnifies lifestyle and embodied risks over medical risks by constructing two biased risk assessments. The first risk assessment defines ovulation, menstruation, and pregnancy as hazardous (i.e., embodied risk); the second insinuates that cisgender women who do not engage in contraceptive self-management are burdensome to society (i.e., lifestyle risk). Combined, these assessments downplay side effects (i.e., medical risks), suggesting that LARC and other pharma-contraceptives are worth the risk to protect cisgender women from their fertile bodies and to guard society against unintended pregnancy. Through this process, ranking birth control methods by failure rates rather than by side effects or reproductive autonomy becomes logical as efficacy is equated with safety for cisgender women and society. Our analysis reveals how technoscientific solutions are promoted to address social problems, and how informed contraceptive choice is diminished when pharma-contraceptives are framed as the most logical option without cogent descriptions of their associated risks.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans

BACKGROUND

Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services.

OBJECTIVES

The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care.

STUDY DESIGN

Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex.

RESULTS

Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex.

CONCLUSION

Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

Beyond safety and efficacy: sexuality-related priorities and their associations with contraceptive method selection

Objectives

Sexuality-related preferences have been understudied in contraceptive selection and uptake. Investigators endeavored to assess contraceptive preferences among patients selecting new methods at family planning clinics and to evaluate the degree to which two sexuality-related preferences are (a) valued and (b) associated with method selection.

Study design

Data were derived from the HER Salt Lake Contraceptive Initiative, a longitudinal cohort nested in a quasi-experimental, observational study enrolling 18–45-year-old patients at four family planning health centers in Salt Lake County. At the time of selecting the new method of their choice, participants reported the importance of nine factors in contraceptive method selection, including two sexuality-related preferences: a method's lack of impact on libido and its lack of sexual interruption. Analyses involved multinomial logistic regression with method selected as the outcome, sexuality-related factors as the main explanatory variables, and a range of controls and covariates.

Results

Among 2188 individuals seeking new contraceptive methods, the factors most frequently cited as quite or extremely important were safety (98%), effectiveness (94%), not interrupting sex (81%), not impacting libido (81%) and lack of side effects (80%). Less frequently cited factors included partner acceptability (46%), lack of hormones (39%), friend recommendation (29%) and alignment with religious beliefs (11%). Multivariate models documented no significant associations between sexual-related priorities and method selection.

Conclusions

Many contraceptive seekers rank sexual-related priorities alongside safety and efficacy as very important, but a range of methods align with people's sexual priorities.

Implications

Since patients endorse the importance of sexual-related contraceptive factors (impact on libido, impact on sexual interruption) alongside safety and efficacy, contraceptive research, counseling and care should attend to people's sexuality.

Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

CE: An Evidence-Based Update on Contraception

Contraception is widely used in the United States, and nurses in all settings may encounter patients who are using or want to use contraceptives. Nurses may be called on to anticipate how family planning intersects with other health care services and provide patients with information based on the most current evidence. This article describes key characteristics of nonpermanent contraceptive methods, including mechanism of action, correct use, failure rates with perfect and typical use, contraindications, benefits, side effects, discontinuation procedures, and innovations in the field. We also discuss how contraceptive care is related to nursing ethics and health inequities.

No Perfect Method: Exploring How Past Contraceptive Methods Influence Current Attitudes Toward Intrauterine Devices

Little research on contraceptive decision-making takes a holistic perspective to understand women's contraceptive journeys throughout the reproductive life course. This analysis investigated how Black and Latina women's past experiences with contraceptive use and acquisition impact their feelings and attitudes toward future use of intrauterine devices (IUDs). We utilized data from in-depth interviews that explored contraceptive decision-making and knowledge of, interest in, and attitudes toward IUDs among 38 young Black and Latina women collected in 2013 in the San Francisco Bay Area. Here, we focused on the IUD decision-making process among a subsample of 32 women who were not using or had not previously used an IUD. Overall, we found a strong link between past contraceptive experiences and attitudes regarding future use of IUDs. Notably, participants often referenced experiences of side effects with previous methods when explaining their interest-or lack thereof-in IUD use, as well as made links between contraceptive attributes they had experienced positively and attributes of the IUD. A minority of participants described being satisfied with their current method, resulting in a lack of interest in considering IUD use. More than half of participants described distrust, either in healthcare providers owing to previous negative interactions and contraceptive failures of provider-recommended methods or owing to family members' and friends' negative experiences with IUDs. This distrust undergirded their lack of interest in the IUD. These findings highlight the importance of locating contraceptive decision-making in the broader context of reproductive journeys.

Perceptions of long-acting reversible contraception among women receiving medication for opioid use disorder in Vermont

OBJECTIVES

To evaluate perceptions of long-acting reversible contraceptives (LARC) among women receiving medication for opioid use disorder.

STUDY DESIGN

Cross-sectional survey of 200 women receiving medication for opioid use disorder in Vermont.

RESULTS

A considerable proportion of women receiving medication for opioid use disorder in Vermont reported previous use of an IUD (40%) and/or a subdermal contraceptive implant (16%); the majority of prior LARC users were satisfied with their IUD (68%) or their implant (74%). Of the 38% of participants who had never considered IUD use, 85% percent (64/75) said that they knew nothing or only a little about IUDs. Of the 61% of participants who had never considered an implant, 81% percent (98/121) said that they knew nothing or only a little about the contraceptive method. The most commonly reported reasons for a lack of interest in the IUD and/or implant were concerns about side effects and preference for a woman-controlled method.

CONCLUSIONS

Gaps in LARC knowledge are common among those who have not used LARCs and concerns about side effects and preferences for a woman-controlled method limit some women's interest in these contraceptives. Additionally, reasons for dissatisfaction among past users are generally similar for IUD and implant and include irregular bleeding and having a bad experience with the method.

IMPLICATIONS

Efforts to increase awareness of LARC methods among women receiving medication for opioid use disorder should address concerns about side effects and reproductive autonomy and encourage satisfied LARC users to share their experiences with their social networks.

Agreement between Self-Reported "Ideal" and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System

BACKGROUND

Women veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported "ideal" methods as a potential marker of contraceptive access and preference matching.

METHODS

This mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, "If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?" and selected a single "ideal" method. If applicable, participants were additionally asked, "Why aren't you currently using this method of contraception?" We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal-current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse.

RESULTS

Overall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.92) were negatively associated with ideal-current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03-1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word "ideal."

CONCLUSIONS

Many women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.

The history of tiered-effectiveness contraceptive counseling and the importance of patient-centered family planning care

Public health workers, clinicians, and researchers have tried to increase long-acting reversible contraceptive (LARC) use by changing contraceptive counseling between patients and providers. Several major health organizations now recommend tiered-effectiveness counseling, in which the most effective methods are explained first so that patients can use information about the relative efficacy of contraceptive methods to make an informed choice. Some scholars and practitioners have raised concerns that, given histories of inequitable treatment and coercion in reproductive health care, tiered-effectiveness counseling may undermine patient autonomy and choice. This Clinical Opinion examines the development of tiered-effectiveness contraceptive counseling, how its rise mirrored the focus on promoting LARC to decrease the unintended pregnancy rate, and key considerations and the potential conflicts of a LARC-first model with patient-centered care. Finally, we discuss how reproductive justice and shared decision making can guide efforts to provide patient-centered contraceptive care.

Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people's contraceptive needs and support reproductive autonomy.

Experiences of Reproductive Coercion Among Latina Women and Strategies for Minimizing Harm: "The Path Makes Us Strong"

INTRODUCTION

Latina women disproportionately report experiencing reproductive coercion (RC), a set of behaviors that interfere with autonomous reproductive decision making. Given RC's associations with intimate partner violence (IPV) and unintended pregnancy, it is critical to identify and address RC to assist women to achieve safety, autonomy, and reproductive life plans. The purpose of this study was to describe and understand the context of RC and the use of RC safety strategies among Latina women receiving services at an urban clinic, through listening to the experiences of the women in their own words.

METHODS

Qualitative descriptive methodology was used. Semistructured interviews were conducted with a purposive sample of 13 Latina women recruited from a Federally Qualified Health Center in the Washington, DC, area.

RESULTS

Data were organized into 3 a priori categories: (1) RC behaviors, (2) co-occurrence of RC and IPV, and (3) RC harm reduction strategies. New RC behaviors emerged, and immigration status was used as a method of coercive control. From these a priori categories emerged 4 themes: impact of immigrant and citizenship status, machismo, strength and bravery, and importance of family. Harm reduction strategies included less detectable contraception; some sought community services, but others resorted to deception and stalling as the only tools available to them.

DISCUSSION

Less detectable methods of contraception remained useful harm reduction strategies for women experiencing RC. Midwives should inquire about method fit and be mindful of honoring the request when patients ask to change methods. Women's strength and resilience emerged as a vital source of power and endurance. This diverse sample and the powerful voices of the women who participated make a significant contribution to the understanding of RC experienced by Latina women in the United States.

Factors Associated with Choice of Sterilization Among Women Veterans

Background: We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. Materials and Methods: This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Results: Six hundred twelve women Veterans aged 18-44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94-7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29-0.98). Conclusion: Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.

Pregnancy preferences and contraceptive use among US women

OBJECTIVES

An understanding of the relationship between individuals' pregnancy preferences and contraceptive use is essential for appropriate patient-centered counseling and care. We examined the relationship between women's pregnancy preferences and contraceptive use using a new prospective measure, the Desire to Avoid Pregnancy (DAP) scale.

STUDY DESIGN

As part of a study examining women's suspicion and confirmation of new pregnancies, we recruited patients aged 15 - 45 from seven reproductive health and primary health facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016-2017. We used multivariable logistic, multinomial logistic, and linear regression models to examine the associations among DAP scores (range: 0 - 4) and contraceptive use outcomes and identify factors associated with discordance between DAP and use of contraception.

RESULTS

Participants with a greater preference to avoid pregnancy had higher odds of contraceptive use (aOR = 1.63, 95% CI: 1.31, 2.04) and used contraceptives more consistently (aβ = 8.9 percentage points, 95% CI: 5.2, 12.7). Nevertheless, 63% of women with low preference to avoid pregnancy reported using a contraceptive method. Higher preference to avoid pregnancy was not associated with type of contraceptive method used: women with the full range of pregnancy preferences reported using all method types.

CONCLUSION

When measured using a rigorously developed instrument, pregnancy preferences were associated with contraceptive use and consistency of use. However, our findings challenge assumptions that women with the highest preference against pregnancy use more effective methods and that women who might welcome pregnancy do not use contraception.

IMPLICATIONS

Women's preferences about pregnancy contribute significantly to their use of contraception. However, health care providers and researchers should consider that contraceptive features besides effectiveness in preventing pregnancy shape contraceptive decision-making and use.

Perceptions and Behaviors Related to Contraceptive Use in the Postpartum Period Among Women With Pregestational Diabetes Mellitus

OBJECTIVE

To describe perceptions and behaviors related to contraception and preconception care and to test the association between these perceptions and contraceptive use in the postpartum period among women with pregestational diabetes mellitus.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Three high-risk obstetric clinics in the Southeastern United States.

PARTICIPANTS

Fifty-five women who were 18 years or older with pregestational Type 1 or Type 2 diabetes mellitus.

METHODS

Between 4 and 8 weeks after birth, we used investigator-developed items and psychometrically validated scales to measure participants' perceptions and behaviors related to contraception and preconception care. We dichotomized use of contraception in the postpartum period as procedure/prescription or nonprescription/no method. We used multiple logistic regression to test the hypothesis that perceptions are associated with contraceptive use.

RESULTS

When data were collected 4 to 8 weeks after birth, almost half (49%, n = 27) of the participants had resumed sexual activity; however, most (95%, n = 52) did not want another pregnancy in the next 18 months. Fifty-six percent (n = 31) of participants used procedure/prescription contraception, and 44% (n = 24) used nonprescription/no method. Those who perceived contraception use and preconception care to be beneficial were more likely to use procedure/prescription contraception (adjusted odds ratio = 1.52; 95% confidence interval [1.07, 2.17]).

CONCLUSION

When caring for women in the postpartum period, providers should be mindful that women's perceptions of the benefits of contraception and preconception care may have implications for whether their use aligns with their reproductive goals and optimizes outcomes for future pregnancies.

The Association of Public Insurance with Postpartum Contraception Preference and Provision

BACKGROUND

Prior studies have noted that public insurance status is associated with increased uptake of postpartum contraception whereas others have pointed to public insurance as a barrier to accessing highly effective forms of contraception.

OBJECTIVE

To assess differences in planned method and provision of postpartum contraception according to insurance type.

STUDY DESIGN

This is a secondary analysis of a retrospective cohort study examining postpartum women delivered at a single hospital in Cleveland, Ohio from 2012-2014. Contraceptive methods were analyzed according to Tier-based effectiveness as defined by the Centers for Disease Control and Prevention. The primary outcome was postpartum contraception method preference. Additional outcomes included method provision, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 8281 patients in the study cohort, 1372 (16.6%) were privately and 6990 (83.4%) were publicly insured. After adjusting for the potentially confounding clinical and demographic factors through propensity score analysis, public insurance was not associated with preference for a Tier 1 versus Tier 2 postpartum contraceptive method (matched adjusted odds ratio [maOR] 0.89, 95% CI 0.69-1.15), but was associated with a preference for Tier 1/2 vs Tier 3/None (maOR 1.41, 95% CI 1.17-1.69). There was no difference between women with private or public insurance in terms of method provision by 90 days after delivery (maOR 0.94, 95% CI 0.75-1.17). Public insurance status was also associated with decreased postpartum visit attendance (maOR 0.54, 95% CI 0.43-0.68) and increased rates of subsequent pregnancy within 365 days of delivery (maOR 1.29, 95% CI 1.05-1.59).

CONCLUSION

Public insurance status does not serve as a barrier to either the preference or provision of effective postpartum contraception. Women desiring highly- or moderately effective methods of contraception should have these methods provided prior to hospital discharge to minimize barriers to method provision.

Pattern and determinants of contraceptive usage among women of reproductive age in the United Arab Emirates

Introduction:

Women in the UAE and Muslim countries are a largely understudied population with significant disparities in knowledge to most basic health concerns and family planning. Our objective was to identify UAE contraceptive knowledge similarities and variances to other world regions, and to inform efforts to improve contraceptive care at Arab world and Muslim countries.

Methods:

Structured questionnaire consisting of socio-demographic characteristics, knowledge, beliefs and attitudes related to contraception methods.

Results:

The use of effective contraception methods was associated with higher educational levels of UAE national women who desired to conceive. These women had knowledge of contraception that was associated with an identified impact of their spouse on their choice of contraception. Religion plays an essential role in knowledge on the risk of contraception and safe type of contraceptive methods in the UAE. Statistically significant predictors of having knowledge on different methods of contraception were nationality, P < 0.002; education level, P < 0.03; number of marriages P < 0.002; monthly income, P < 0.04; and the number of children, P < 0.015.

Conclusions:

Our results demonstrate that higher education and communication of the benefits and risks of different types of contraceptive methods are needed to improve the use of contraception in the UAE population. We recommend additional training in this area for healthcare providers. The involvement of the spouse in the mutual understanding of contraception and its choice coupled with third party insurance coverage may decrease knowledge and utilization gaps further assisting in providing a best contraceptive method.

Contraceptive utilization and counseling among breast cancer survivors

PURPOSE

To explore contraceptive counseling and utilization among breast cancer survivors.

METHODS

We enrolled reproductive-aged women with a history of breast cancer for a cross-sectional study. Participants were recruited via the Athena Breast Health Network and via the Young Survival Coalition's social media postings. Descriptive statistics were calculated to understand utilization of and feelings about contraceptive methods before, during, and after breast cancer treatment.

RESULTS

Data presented here are from an online survey of 150 breast cancer survivors who completed the survey. Seventy-one percent (n = 105) of respondents reported being sexually active and not pregnant during their primary cancer treatment (surgery, chemotherapy, and/or radiation). Of these, 90% (n = 94) reported using any form of contraceptive, and the most common method was condoms (n = 55, 52%). Respondents reported that safety concerns had the biggest influence on their contraception method choice. Sixty-one percent (n = 92) reported receiving contraceptive counseling by their oncologist either before or after treatment; however, 49% (n = 45) of those did not receive a specific recommendation for a contraceptive method. Of respondents who reported receiving contraceptive counseling from their gynecologist, 44% (n = 35) reported that their gynecologist specifically recommended a copper intrauterine device (IUD). The majority of respondents (n = 76, 52%) wanted their oncologist to discuss contraceptive options with them and preferred to receive this counseling at the time of diagnosis (n = 81, 57%).

CONCLUSIONS

Breast cancer survivors in this study remained sexually active across the cancer care continuum and predominantly used condoms as their contraceptive method during treatment. Breast cancer patients would prefer contraceptive counseling from their oncologist at the time of their cancer diagnosis.

IMPLICATION FOR CANCER SURVIVORS

Education efforts in the future should focus on initiatives to improve comprehensive contraceptive counseling at the time of diagnosis by an oncologist.

Do Adolescent Women's Contraceptive Preferences Predict Method Use and Satisfaction? A Survey of Northern California Family Planning Clients

PURPOSE

Contraceptive satisfaction may influence not only contraceptive use but also long-term engagement in care. We investigated the extent to which adolescent and young women's desired contraceptive features are associated with their current contraceptive method and if the presence of preferred features in their current method is associated with satisfaction.

METHODS

We performed a secondary analysis of a cross-sectional survey at five Northern California family planning clinics, including women aged 13-24 years. Descriptive statistics and multivariate logistic regression identified associations between desired features and sociodemographic characteristics. Multivariate logistic regression was used to examine associations between desired features and current contraceptive method, as well as the presence of desired features and satisfaction with current method.

RESULTS

Among 814 participants, the features most frequently rated "very important" included effectiveness (87%, n = 685), safety (85%, n = 664), and side effects (72%, n = 562). Contraceptive feature preferences varied by age, race/ethnicity, intimate partner violence history, and sexually transmitted infection history. Having a preference for a specific contraceptive feature was not associated with using a method with that feature, except for sexually transmitted infection prevention (adjusted odds ratio [aOR]: 1.59, confidence interval [CI; 1.18-2.16]). However, respondents with preferences for effectiveness, partner independence, or privacy who used methods that were congruent with their preferences were more likely to express satisfaction (aOR_{effectiveness}: 1.57, CI [1.03-2.37], aOR_{partner independent}: 1.75 [1.03-2.96], and aOR_privacy: 1.81 [1.01-3.23]).

CONCLUSION

Adolescent and young women have varied contraceptive preferences that are associated with demographics and reproductive health experiences. Adolescent and young women's use of contraceptive methods that matched their preferences may improve satisfaction and engagement in care.

Contraceptive Use Among Women with Prediabetes and Diabetes in a US National Sample

INTRODUCTION

Although elevated blood glucose is associated with adverse maternal and fetal health outcomes, evidence suggests that women with diabetes may not be receiving comprehensive reproductive health care, including family planning and preconception care. Using a population-based sample, we evaluated the relationship between contraceptive use and biomarker-identified diabetes.

METHODS

This cross-sectional study used data from 5548 women in the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health) from 2007 to 2009. Women were aged 24 to 32 years, sexually active with men, and not pregnant. Hemoglobin A1C identified prediabetes and diabetes from blood specimens. The primary outcome was most effective contraception used in the past year: more effective (sterilization, intrauterine device, implant, combined hormonal methods, or injectable), less effective (condoms, diaphragms, spermicides, natural family planning, or withdrawal), or none. Multinomial regression models were adjusted for race and ethnicity, education, insurance, health care access, and body mass index.

RESULTS

Of the women with diabetes, 37.6% used more effective contraception, 33.6% less effective contraception, and 28.8% none. Women with diabetes had higher odds of using no contraception, rather than more effective contraception, than women with normoglycemia (adjusted odds ratio [aOR], 1.90; 95% CI, 1.25-2.87). Women with diabetes who were undiagnosed had greater odds of using less effective contraception, rather than more effective contraception, compared with those who were diagnosed (aOR 3.39; 95% CI, 1.44-7.96). Contraceptive use did not differ between women with prediabetes and normoglycemia.

DISCUSSION

Less effective contraceptive methods were commonly used by women with diabetes. Midwives and other women's health care providers can support women with diabetes to reach their pregnancy goals by providing preconception care and family planning.

The State of the Science of Natural Family Planning Fifty Years after Humane Vitae: A Report from NFP Scientists' Meeting Held at the US Conference of Catholic Bishops, April 4, 2018

A one-day meeting of physicians, professional nurses, and scientists actively involved in Natural Family Planning (NFP) research was held to review the state of the science of NFP and consider future priorities. The meeting had four objectives: (i) determine the gaps in research evidence for secure methods of NFP among women of all reproductive categories, (ii) determine the gaps in the research and development of new technology for providing NFP services, (iii) determine the gaps in the research that determine the benefits and challenges with use of NFP among married couples, and (iv) provide prioritized ideas for future research needs from the analysis of evidence gaps from objectives above. This article summarizes the discussion and conclusions drawn from topics reviewed. While much has been accomplished in the fifty years since Humane vitae, there are still many gaps to address. Five areas for future research in NFP were identified as high priority: (1) well-designed method effectiveness studies among various reproductive categories including important subpopulations (postpartum, perimenopause, posthormonal contraceptive), normally cycling women (especially US women), and comparative studies between NFP methods; (2) validation studies to establish the benefit of charting fertility signs (both currently known and potential new indicators) as a screening tool for women's health issues; (3) ongoing independent evaluation of fertility monitoring apps to provide users perspective on the relative merits of each and to identify those most worthy of further effectiveness testing; (4) studies evaluating the impact of new technologies on NFP adoption, use, and persistence; and (5) creation of a shared database across various NFP methods to collaborate on shared research interests, longitudinal studies, and so on. This summarizes a meeting to review the scientific and medical progress related to natural family planning made in the 50 years since Humane Vitae and to define priorities for future work. Areas reviewed included the evidence for avoiding pregnancy in normally cycling, postpartum, and perimenopausal women, the impact of new technology, including fertility charting apps, on NFP, and the impact on relationships and personal well-being from use of NFP. Five priority focus areas for future research were also identified.

Impact of Contraceptive Education on Knowledge and Decision Making: An Updated Systematic Review

CONTEXT

Educational interventions can help individuals increase their knowledge of available contraceptive methods, enabling them to make informed decisions and use contraception correctly. This review updates a previous review of contraceptive education.

EVIDENCE ACQUISITION

Multiple databases were searched for articles published March 2011-November 2016. Primary outcomes were knowledge, participation in and satisfaction/comfort with decision making, attitudes toward contraception, and selection of more effective methods. Secondary outcomes included contraceptive behaviors and pregnancy. Excluded articles described interventions that had no comparison group, could not be conducted feasibly in a clinic setting, or were conducted outside the U.S. or similar country.

EVIDENCE SYNTHESIS

A total of 24,953 articles were identified. Combined with the original review, 37 articles met inclusion criteria and described 31 studies implementing a range of educational approaches (interactive tools, written materials, audio/videotapes, and text messages), with and without healthcare provider feedback, for a total of 36 independent interventions. Of the 31 interventions for which knowledge was assessed, 28 had a positive effect. Fewer were assessed for their effect on attitudes toward contraception, selection of more effective methods, contraceptive behaviors, or pregnancy-although increased knowledge was found to mediate additional outcomes (positive attitudes toward contraception and contraceptive continuation).

CONCLUSIONS

This systematic review is consistent with evidence from the broader healthcare field in suggesting that a range of interventions can increase knowledge. Future studies should assess what aspects are most effective, the benefits of including provider feedback, and the extent to which educational interventions can facilitate behavior change and attainment of reproductive health goals.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Contraceptive counseling for continuation and satisfaction

PURPOSE OF REVIEW

Quality contraceptive counseling has been identified as a potential means to reduce unintended pregnancy and to increase contraceptive continuation and satisfaction. Past approaches that focused on autonomous decision making and directive counseling have not been shown to meet these goals consistently. Women's health organizations globally are calling for improved counseling through more thorough discussion of side-effects and bleeding changes, and renewed focus on shared decision making and patient-centered care.

RECENT FINDINGS

Reproductive life planning can help initiate contraceptive counseling but does not resonate with all patients. A client-centered approach using shared decision making, building trust, and eliciting client preferences has been shown to increase satisfaction and continuation. Patient preferences vary widely and may or may not prioritize extremely high effectiveness. Decision support tools have mixed results, but generally can help improve the method choice process when they are well designed.

SUMMARY

Clinicians should strive for good interpersonal relationships with patients, and elicit patient experiences and preferences to tailor their counseling to each individual's needs. Shared decision making with input from both the patient and clinician is preferred by many women, and clinicians should be cognizant of perceptions of pushing any method too strongly, especially among marginalized populations. More research on long-term satisfaction and continuation linked to different counseling practices is needed.

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011-2015

OBJECTIVE

To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion.

STUDY DESIGN

Data derived from the 2011-2013 and 2013-2015 National Surveys of Family Growth (NSFG). Our study sample included 9321 women aged 15-44. Logistic regression analyses predicted current LARC use (yes vs. no). We tested interaction terms between race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic) and covariates (for example, education, parity, poverty level) to explore whether their effects on LARC use vary by race-ethnicity.

RESULTS

In the race-interactions model, data did not show that low income and education predict LARC use more strongly among Black and Hispanic women than among White women. There was just one statistically significant race-interaction: experience of unintended pregnancy (p=.014). Among Whites and Hispanics, women who reported ever experiencing an unintended pregnancy had a higher predicted probability of LARC use than those who did not. On the other hand, among Black women, the experience of unintended pregnancy was not associated with a higher predicted probability of LARC use.

CONCLUSIONS

With the exception of the experience of unintended pregnancy, findings from this large, nationally representative sample of women suggest similar patterns in LARC use by race-ethnicity.

IMPLICATIONS

Results from this analysis of NSFG data do not provide evidence that observed differences in LARC use by race-ethnicity represent socioeconomic disparities, and may assuage some concerns about reproductive coercion among women of color. Nevertheless, it is absolutely critical that providers use patient-centered approaches for contraceptive counseling that promote women's autonomy in their reproductive health care decision-making.

Trends in long-acting reversible contraceptive (LARC) use, LARC use predictors, and dual-method use among a national sample of college women

OBJECTIVE

Assess long-acting reversible contraceptive (LARC) and other contraceptive use trends, identify LARC use predictors, and examine dual method use.

PARTICIPANTS

Women in the American College Health Association-National College Health Assessment (ACHA-NCHA) II, aged 18-24 years, who reported having vaginal sex (N = 37,899).

METHODS

Secondary analyses of Fall 2011-2014 ACHA-NCHA II data.

RESULTS

Statistically significant increases in LARC usage and, specifically, implant usage, were found. Characteristics associated with LARC use included age, race/ethnicity, relationship status, and school type. Students reporting LARC use had lower odds of condom usage compared with non-LARC hormonal method users.

CONCLUSION

This analysis of LARC predictors and dual LARC/condom use has implications for research and health promotion efforts. Findings suggest that college health services are well positioned to meet the sexual and reproductive health needs of diverse populations of students. College health professionals should elicit students' individual and/or relationship priorities to tailor messaging/services offered for pregnancy/STI prevention.