Attitudes towards long-acting reversible methods of contraception in general practice in the UK

Common myths and misconceptions surrounding hormonal contraception

Numerous community and professional myths and misconceptions around hormonal contraception exist, many promulgated through social media. As a result of these and other factors, people are moving away from hormonal methods and potentially exposing themselves to increased risk of unintended pregnancy. A number of key myths and misconceptions have been identified in a range of papers and here we summarise the evidence around the basis for these misunderstandings. The themes we explore are the physical side effects, the mental health effects, the impact on sexuality, the concerns about infertility, the concept of "unnaturalness", concerns about menstruation, concerns about safety and destigmatisation of side effects. For many of these themes, there is some evidence justifying the concern, but overall for most people, we argue that the benefits of hormonal contraception outweigh the disadvantages.

Understanding barriers to using long-acting reversible contraceptives (LARCs) in primary care: a qualitative evidence synthesis

BACKGROUND

Long-acting reversible contraceptives (LARCs) are highly effective. In primary care, LARCs are prescribed less frequently than user-dependent contraceptives despite higher efficacy rates. Unplanned pregnancies are rising in the UK, and LARCs may have a role in reducing these through and redressing inequitable contraceptive access. To provide contraceptive services that offer maximal choice and patient benefit, we must understand what contraception users and healthcare professionals (HCPs) think about LARCs and uncover barriers to their use.

METHODS

A systematic search using CINAHL, MEDLINE via Ovid, PsycINFO, Web of Science and EMBASE identified research about LARC use for pregnancy prevention in primary care. The approach adhered to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' methodology, critically appraised the literature, and used NVivo software to organise data and perform thematic analysis to determine key themes.

RESULTS

Sixteen studies met our inclusion criteria. Three themes were identified: (1) trustworthiness (where and from whom participants obtained information regarding LARCs), (2) control (whether LARCs detract from personal autonomy) and (3) systems (how HCPs influenced LARC access). Misgivings about LARCs frequently arose from social networks and fears of surrendering control over fertility were prominent. HCPs perceived access issues and lack of familiarity or training as the main barriers to prescribing LARCs.

CONCLUSIONS

Primary care plays a key role in improving access to LARC but barriers need to be addressed especially those involving misconception and misinformation. Access to LARC removal services are key to empower choice and prevent coercion. Facilitating trust within patient-centred contraceptive consult is essential.

Knowledge, beliefs and practices of nurses with long-acting reversible contraception, Cape Town

BACKGROUND

Implanon and copper intrauterine contraceptive device (IUCD) are long-acting reversible contraceptives (LARC) available in public primary health care (PHC) South Africa. These methods are the most effective forms of contraception.

AIM

To evaluate the knowledge, beliefs and practices on provision of LARC.

SETTING

Primary health care facilities within the Khayelitsha Eastern Substructure, Cape Town.

METHODS

A descriptive survey of all permanent nurses who provided contraception. Data were collected from 72/90 (80% response rate) via a validated questionnaire and evaluated using Statistical Package for Social Sciences (SPSS).

RESULTS

Knowledge of eligibility for LARC was tested. The mean knowledge scores for Implanon were 8.56/11 (s.d. 1.42) for the trained and 7.16/11 (s.d. 2.83) for the untrained (p = 0.007). The mean knowledge scores for IUCD were 10.42/12 (s.d. 1.80) for the trained and 8.03/12 (s.d. 3.70) for the untrained (p = 0.019). Participants believed that inaccessibility to training courses (29%), no skilled person available (24%) and staff shortages (35%) were barriers. Less than 50% of women were routinely counselled for LARC. Forty-one percent of nurses were trained and performed IUCD insertion, and 64% were trained and performed Implanon insertion, while 61% and 45% required further training. Confidence was low, with 32% trained and confident in IUCD and 56% trained and confident in Implanon insertion.

CONCLUSION

Lack of training, poor confidence and deficient counselling skills were barriers to effective LARC provision. The identified system-specific barriers must be addressed to improve uptake.Contribution: The first study to evaluate knowledge, beliefs and practices on LARC in providers in the Western Cape.

Real-world satisfaction and menstrual bleeding pattern with available LNG-IUD among Spanish young women

OBJECTIVE

The aim of this study was to evaluate the satisfaction and menstrual bleeding pattern with levonorgestrel-releasing intrauterine systems (LNG-IUD) in young women.

METHODS

A prospective, multicentre, non-interventional study with 1-year follow-up was conducted in Spain. Participants were women between 18 and 30 years old who freely choose any available LNG-IUD for contraception. Satisfaction with LNG-IUD was measured with a 5-point Likert scale. Type of LNG-IUD, menstrual bleeding pattern and satisfaction with it, easiness of insertion and pain during procedure were collected.

RESULTS

A total of 555 women (37.3% parous, 62.7% nulliparous) (mean age 25.8 ± 3.5) completed the study. After 12 months, 92.4% of women were satisfied or very satisfied with the LNG-IUD, with no differences by parity status, type of IUD or baseline menstrual bleeding pattern. Satisfaction with the LNG-IUD correlated with satisfaction with menstrual bleeding pattern at 12 months. Up to 88.7% of women were satisfied or very satisfied with their menstrual bleeding pattern at 12 months in comparison to 41.5% at baseline (p < 0.001). Adverse events (AE)-related discontinuation rate was low (2.2%).

CONCLUSIONS

Satisfaction with LNG-IUD is very high among young Spanish women, regardless of parity and menstrual bleeding pattern at baseline.

Opportunities for Increasing Access to Effective Contraception in Australia

Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.

Relationships between Penile-Vaginal Intercourse Frequency and Condom/Contraceptive Use from 2009 to 2018: Findings from the National Survey of Sexual Health and Behavior

Objectives

To examine changes over time in event-level condom/contraceptive use and the association between past year penile-vaginal intercourse frequency and event-level condom/contraceptive use.

Methods

Data were from the 2009 and 2018 National Survey of Sexual Health and Behavior, an online probability survey of U.S. adolescents and adults.

Results

Use of condoms and highly effective hormonal contraceptives decreased while long-acting reversible contraceptive use increased from 2009 to 2018 among adults. Increased penile-vaginal intercourse frequency was associated with decreased use of most contraceptive methods but an increase in condom use for adolescents.

Conclusions

Sexual frequency should be considered when assessing condom/contraceptive use.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Health workers' values and preferences regarding contraceptive methods globally: A systematic review

OBJECTIVE

We sought to systematically review the literature on health workers' values and preferences related to contraceptive methods.

STUDY DESIGN

As part of a larger review, we searched ten electronic databases for published articles from January 1, 2005 through July 27, 2020. We included studies that reported qualitative or quantitative data from the perspective of health workers providing family planning services globally.

RESULTS

Forty-one studies met our inclusion criteria. These studies included 12,643 health workers and were conducted in 27 countries. Health worker values and preferences for contraceptive methods were affected by factors related to contraceptive method characteristics (e.g., bleeding pattern and convenience), the contraceptive user (e.g., medical history, parity), and the health worker themselves (e.g., training, environment). Differences were also noted between various professions/specialties (e.g., comfort level with contraceptive methods, depth of experience). While contraceptive counseling and provision were influenced by health worker values and preferences, they were also affected by health worker misconceptions and biases.

CONCLUSION

Health worker values and preferences for contraception are affected by the client's history, medical eligibility, and the health worker context. Provision of contraception that is affected by harmful bias towards certain populations or about certain methods can negatively affect patient-centered care. Future work should address knowledge gaps and health worker biases by improving and standardizing education and training globally, to ensure high-quality, rights-based, and patient-centered contraceptive services.

The effect of mobile video training for healthcare providers on long-acting reversible contraceptive (LARC) use among adolescents and young women

STUDY OBJECTIVE

To assess whether improving providers' education by video training using a mobile phone could affect providers' knowledge and attitude toward long-acting reversible contraceptives (LARCs), and thus further affect adolescents' and young nulliparous women's decisions to use LARCs. DESIGN, SETTING, PARTICIPANTS, INTERVENTION, AND MAIN OUTCOME MEASURES: This prospective case-control study was performed between 2019 and 2020. A total of 40 healthcare providers participated, of which 20 received "LARC First" video training, whereas the other 20 served as the control group and received no training. Surveys were conducted of 244 adolescents and young women who were consulted by these 2 groups of healthcare providers before abortion surgery. The data were used to analyze the relationship between providers' knowledge scores and the percentage of women who received counseling on LARCs decided to use LARCs, and what percentage continued to do so 12 months after surgery.

RESULTS

Providers from the study group scored higher in LARC knowledge than the control group. Compared to the control group, women in the study group reported receiving more counseling on LARCs (81.4% vs 7.9%) and more often chose to use LARCs (24.6% vs 2.4%). Twelve months later, there was no significant difference in contraceptive continuation between study and control groups, but study group participants were more likely to be using LARCs (P < .001).

CONCLUSION

Video training for providers improved both their knowledge and willingness to recommend LARCs and increased the probability of adolescent and young nulliparous women using these methods to reduce unintended pregnancy.

Reasons for rejecting hormonal contraception in Western countries: A systematic review

Over the past decade, women in Western countries have taken to various social media platforms to share their dissatisfactory experiences with hormonal contraception, which may be pills, patches, rings, injectables, implants or hormonal intrauterine devices (IUDs). These online testimonials have been denounced as spreading "hormonophobia", i.e. an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception. In order to move toward a reproductive justice framework, we propose to study the arguments that women and men (as partners of female users) recently put forward against hormonal contraception to see whether they are related to hormonophobia. The aim of this article is to conduct a systematic review of the recent scientific literature in order to construct an evidence-based typology of reasons for rejecting hormonal contraception, in a continuum perspective from complaints to choosing not to use it, cited by women and men in Western countries in a recent time. The published literature was systematically searched using PubMed and the database from the French National Institute for Demographic Studies (Ined). A total of 42 articles were included for full-text analysis. Eight main categories emerged as reasons for rejecting hormonal contraception: problems related to physical side effects; altered mental health; negative impact on sexuality; concerns about future fertility; invocation of nature; concerns about menstruation; fears and anxiety; and the delegitimization of the side effects of hormonal contraceptives. Thus, arguments against hormonal contraception appeared complex and multifactorial. Future research should examine the provider-patient relationship, the gender bias of hormonal contraception and demands for naturalness in order to understand how birth control could better meet the needs and expectations of women and men in Western countries today.

Women's satisfaction with and ongoing use of hormonal long-acting methods compared to the oral contraceptive pill: Findings from an Australian general practice cluster randomised trial (ACCORd)

BACKGROUND

The Australian Contraceptive ChOice pRoject (ACCORd) aimed to assess the impact of a complex general practice intervention on the uptake of long-acting reversible contraceptives (LARC).

AIMS

Using survey data from enrolled women, we aimed to compare the ongoing use and satisfaction of women who chose one of the hormonal LARC methods including the levonorgestrel intrauterine system (LNG-IUS) or levonorgestrel implant compared to the oral contraceptive pill (OCP).

MATERIALS AND METHODS

We used the data from participants' baseline, six and 12-month surveys to identify new users of implants, LNG-IUS or OCP. We included demographic information, ongoing use of the contraceptive method, reasons for dissatisfaction and discontinuation and experience of side-effects. Proportions were compared using χ² tests.

RESULTS

Of the 740 women enrolled in ACCORd, 176 started using a hormonal LARC or OCP in the study's first six months with 76 using the IUS (43%), 60 the implant (34%) and 40 (23%) the OCP. Twelve-month continuation rates for the LNG-IUS, implant and OCP were 93, 83 and 65% respectively (P < 0.001). Satisfaction was highest among the LNG-IUS users; 86% were very/somewhat satisfied compared to 75% of implant users and 61% of OCP users (P < 0.001). Main reasons for method dissatisfaction were irregular bleeding and mood changes which were similar for all methods.

CONCLUSIONS

This study provides further evidence that hormonal LARC methods have higher continuation and satisfaction rates compared to the OCP with similar side-effects. Since hormonal LARC methods have the highest contraceptive efficacy, these should be offered first-line to women.

Barriers to prescribing of long-acting reversible contraception (LARC) by general practitioner registrars: A cross-sectional questionnaire

Long-acting reversible contraception (LARC) is highly effective but uptake in Australia is low. We aimed to establish general practitioner (GP) registrars' (vocational trainees') perspectives on barriers to prescribing LARC. We conducted a cross-sectional questionnaire-based study of 191 GP registrars in NSW and ACT. Outcome factors were levels of agreement with eight barriers to prescribing LARC. We found the most-reported barriers to prescribing LARC were limited access to training and limited opportunities to maintain skills. Registrars perceived greater barriers to the use of intrauterine devices, compared to contraceptive implants, regarding indemnity insurance, difficulty accessing training, and insufficient insertion opportunities to maintain skills.

[Preventive activities in women's care]

A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.

The French pill scare and the reshaping of social inequalities in access to medical contraceptives

While the consequences of various "pill scares" have been relatively well-documented in the public health literature revealing a drop in pill use and a rise in unplanned pregnancies and abortion rates, researchers rarely considered that these controversies would affect women contraceptive practices differently according to their social background. Indeed, social differentiations in reaction to "pill scares" could contribute to reinforce the social gradient in the use of contraceptive methods and choice of visiting the health professionals who prescribe them. These could contribute to an increase in health inequalities on access to contraceptive methods. Using data from three state nationally representative cross-sectional surveys conducted in France in 2010, 2013 and 2016, we studied the changes in women's contraceptive uses around the French "pill scare" that occurred in 2012-2013. We focused on the changes in the use of all contraceptives available under medical prescription (called medical contraceptives) on one hand, and on each specific method (pill, IUD, implant, patch or vaginal ring, and female sterilization) on the other hand according to the women's social background. We saw a social gradient in contraceptives changes. The decline in the use of contraceptive methods available under medical prescription was particularly marked for women from lower and higher classes in which we observe a decrease in pill use between 2010 and 2013, whereas it was observed only between 2013 and 2016 among middle class women. Moreover, while some women from upper class shifted from pill to IUD between 2010 and 2013, this was not the case for their less privileged counterparts. As a consequence, it seems that the French "pill scare" led to the reshaping of social inequalities in access to medical contraceptives.

Changes in the prevalence and profile of users of contraception in Britain 2000-2010: evidence from two National Surveys of Sexual Attitudes and Lifestyles

AIM

To describe prevalence and trends in contraceptive method use in Britain through a comparison of the second and third National Surveys of Sexual Attitudes and Lifestyles (Natsal-2 and Natsal-3).

METHODS

Cross-sectional probability sample surveys. General population sample of women aged 16-44 years, resident in Britain, with ever-experience of vaginal sex and, for analysis by sociodemographic characteristics, vaginal sex in the last year. Main outcome measure was current contraceptive method use ('usual these days'), categorised by effectiveness.

RESULTS

Prevalence of current contraceptive use among women who had ever had vaginal sex declined between Natsal-2 and Natsal-3, 83.5% (95% CI 82.4 to 84.5) and 76.4% (95% CI 75.0 to 77.7), respectively. The condom and oral contraceptive pill remain the most commonly used methods. One in five women reported use of a most effective method. While no difference was found between surveys in use of most effective methods, a decline in sterilisation use was compensated by an increase in long-acting reversible contraceptive (LARC) use. Increased LARC use was particularly evident among under-25s compared with women aged 40-44 years (OR 11.35, 95% CI 3.23 to 39.87) and a decline was observed among those with two or more children relative to those with none (OR 0.21, 95% CI 0.13 to 0.35).

CONCLUSIONS

Strategies to improve access to LARC methods have been particularly successful in increasing uptake among young people in the first decade of the 21st century. Whether this trajectory is maintained given changing sociodemographic characteristics and more recent financial cuts to sexual health service provision will warrant investigation.

Use of prescribed contraception in Northern Ireland 2010-2016

Objective: The aim of this study was to describe the use of prescribed contraceptives in Northern Ireland (NI) and how this varies with a woman's age, the deprivation in the area in which she lives and characteristics of her general practice (GP).Method: A population-based cohort study was conducted including 560,074 females, aged 12-49 registered with a GP (2010-2016) contributing 3,255,500 woman-years of follow-up. Dispensed contraceptive prescriptions were linked to demographic details.Results: A contraceptive prescription was dispensed in 26.2% of woman-years with women aged 20-24 most likely to have a contraceptive dispensed (45.7% of woman-years). After adjusting for patient and other practice characteristics, practices in the least deprived quintile prescribed 6% more contraception than those in the most deprived quintile. The combined oral contraceptives (16.6% of woman-years) and progesterone only pill (8.0% of woman-years) were the most commonly dispensed methods. Patient and practice level characteristics were found to be related to the specific contraceptive methods dispensed which also changed during the time frame of the study.Conclusions: This is the first population-based assessment of contraceptive prescription in NI. It is useful for health service planning and to inform broader reproductive policy debates. The impact of practice area-based deprivation, above that of the woman's residence, on contraceptive dispensing is a new finding that deserves more exploration.

Provider-based barriers to provision of intrauterine contraception in general practice

OBJECTIVES

Intrauterine contraception (IUC) is highly effective, safe and long-lasting, but is not a popular method of contraception among British women. This study examined barriers to the uptake of IUC in general practice in England.

METHOD

A sequential mixed-method approach to explore the views of practitioners regarding the provision of IUC. We e-surveyed 208 practitioners from 69 practices in a region of England and subsequently interviewed 14 practitioners from eight practices.

RESULTS

Just under half of general practitioners (GPs) (46.8%; 58/124), and only 8.2% (4/49) of nurses reported being trained to fit IUC. Lack of knowledge of IUC was a barrier to fitting, and also to recommending IUC, especially by practitioners who were not trained to fit. There was discordance between reported knowledge of eligibility for IUC and the likelihood of recommending IUC. Respondents were less likely to recommend IUC to young, nulliparous women, women who had experienced a previous ectopic pregnancy, a recent sexually transmitted infection (STI), or an abnormal cervical smear. The qualitative data indicate that risk aversion and limited training, together with practitioners' assessments that women are uninterested, may lead to IUC being precluded as a suitable method.

CONCLUSIONS

Increased practitioner education, for those not trained to fit IUC, may remove a barrier to the uptake of IUC in general practice. More research is required on the discordance between the practitioners' views on the characteristics of women considered suitable for IUC, and the criteria set out in the UK Medical Eligibility Criteria (UKMEC) guidelines.

Using Program Data to Improve Access to Family Planning and Enhance the Method Mix in Conflict-Affected Areas of the Democratic Republic of the Congo

Analysis of program data and a formative assessment informed several program changes, including improved coaching and supportive supervision, introduction of postpartum IUDs and the levonorgestrel-releasing intrauterine system, and enhanced behavior change communication. These changes substantially increased family planning adoption, from a monthly average of 14 adopters per facility to 37 per facility. Implants continued to be the most popular method, but the percentage of adopters choosing the IUD increased from 2% in 2012 to 13% in 2016, and it was the most popular method among postabortion care clients.

Unmet need for family planning in the conflict-affected area of eastern Democratic Republic of the Congo (DRC) has been reported to be as high as 38%, and women in such conflict settings are often the most at risk for maternal mortality. The International Rescue Committee implements the Family Planning and Post-Abortion Care in Emergencies program in 3 provinces of eastern DRC to provide women and couples access to family planning, including long-acting reversible contraceptives (LARCs). This article presents routine program data from June 2011 through December 2013 from 2 health zones as well as results from a qualitative assessment of family planning clients and of male and female non-users, conducted in 2013. It then describes how these findings were used to make program adjustments to improve access to family planning services and client informed choice and assesses the effects of the program design changes on family planning uptake and method mix using routine program data from January 2014 through December 2016. Between 2011 and 2013, 8,985 clients adopted family planning, with an average 14 clients adopting a method per facility, per month. The method mix remained stable during this period, with implants dominating at 48%. Barriers to uptake identified from the qualitative research were both supply- and demand-related, including misconceptions about certain modern contraceptive methods on the part of providers, users, and other community members. The program implemented several program changes based on the assessment findings, including clinical coaching and supportive supervision to improve provider skills and attitudes, introduction of immediate postpartum insertion of the intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS), and behavior change communication campaigns to raise awareness about family planning. After these program changes, the mean number of clients adopting modern family planning per facility, per month increased from 14 to 37 and the percentage of family planning adopters choosing LARCs increased from 50% to 66%. While implants continued to be the most dominant method, reaching 60% of the method mix in 2016, the percentage of clients adopting IUDs increased each year, from 3% in 2014 to 13% in 2016. In total, 39,399 clients started family planning methods during the post-program design change period (2014–2016). Our experience in eastern DRC demonstrates that women and their partners affected by conflict want family planning, and that it is feasible to deliver the full range of modern contraceptive methods when programs are adapted and sensitive to the local context.

Are medical educators in general practice untapped potential to increase training capacity in sexual and reproductive healthcare? Results of a survey in London, UK

Background

Long waiting times for training in sexual and reproductive healthcare (SRH) including long acting reversible contraception (LARC) might lead to attrition from training programmes, leading to reduced capacity for sexual health services, and reduced access to such contraception for women.

Setting

General practice in London, UK.

Question

Can medical educators in general practice be used as untapped potential to train other health care professionals in sexual and reproductive healthcare?

Method

We conducted an online survey to find out the qualifications, skills and willingness of established educators in primary care in London to train other clinicians in sexual and reproductive healthcare, including LARC.

Results

We received 124 responses from medical educators (10.1% response rate from general practitioner (GP) trainers and 59.0% of clinical supervisors for Foundation Year doctors). 86 (69.9%) had diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) qualification and further 18 (14.6%) were interested in obtaining this qualification. Eleven respondents were trained to fit intrauterine contraception only, three for contraceptive implants only and 37 were trained to fit both. 50 (40.3%) of 124 respondents were willing get involved in DFSRH training; 74% of these were willing to teach on any component of DFSRH including LARC.

Discussion

There is a shortage of training places and long waiting list for clinicians who wish to train in SRH. This survey suggests there is a pool of GP educators with skills and experience in SRH and are willing to train others. This can potentially increase the training capacity and improve overall access to good contraception and LARC for women.

Consideration Sets and Their Role in Modelling Doctor Recommendations About Contraceptives

Decisions about prescribed contraception are typically the result of a consultation between a woman and her doctor. In order to better understand contraceptive choice within this environment, stated preference methods are utilized to ask doctors about what contraceptive options they would discuss with different types of women. The role of doctors is to confine their discussion to a subset of products that best match their patient. This subset of options forms the consideration set from which the ultimate recommendation is made. Given the existence of consideration sets we address the issue of how to model appropriately the ultimate recommendations. The estimated models enable us to characterize doctor recommendations and how they vary with patient attributes and to highlight where recommendations are clear and when they are uncertain. The results also indicate systematic variation in recommendations across different types of doctors, and in particular we observe that some doctors are reluctant to embrace new products and instead recommend those that are more familiar. Such effects are one possible explanation for the relatively low uptake of more cost effective longer acting reversible contraceptives and indicate that further education and training of doctors may be warranted. Copyright © 2015 John Wiley & Sons, Ltd.

Models of health behaviour predict intention to use long acting reversible contraception use

The aim of this study was to investigate women’s intention to use long-acting reversible contraception using two established models of health behaviour: the theory of planned behaviour and the health belief model. A questionnaire was completed by a convenience sample of 128 women attending a community sexual health clinic. The independent variables were constructs of theory of planned behaviour (attitude, subjective norm and perceived behavioural control) and health belief model (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, health motivation and cues to action). The dependent variable was intention to use long-acting reversible contraception. The theory of planned behaviour and the health belief model accounted for 75% of the variance in intention to use. Perceived behavioural control, perceived barriers and health motivation predict the use of long-acting reversible contraception. Public health information for women considering using long-acting reversible contraception should be based around addressing the perceived barriers and promoting long-acting reversible contraception as a reliable contraceptive method.

Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial protocol

INTRODUCTION

The increased use of long-acting reversible contraceptives (LARCs), such as intrauterine devices and hormonal implants, has the potential to reduce unintended pregnancy and abortion rates. However, use of LARCs in Australia is very low, despite clinical practice guidance and statements by national and international peak bodies advocating their increased use. This protocol paper describes the Australian Contraceptive ChOice pRojet (ACCORd), a cluster randomised control trial that aims to test whether an educational intervention targeting general practitioners (GPs) and establishing a rapid referral service are a cost-effective means of increasing LARC uptake.

METHODS AND ANALYSIS

The ACCORd intervention is adapted from the successful US Contraceptive CHOICE study and involves training GPs to provide 'LARC First' structured contraceptive counselling to women seeking contraception, and implementing rapid referral pathways for LARC insertion. Letters of invitation will be sent to 600 GPs in South-Eastern Melbourne. Using randomisation stratified by whether the GP inserts LARCs or not, a total of 54 groups will be allocated to the intervention (online 'LARC First' training and rapid referral pathways) or control arm (usual care). We aim to recruit 729 women from each arm. The primary outcome will be the number of LARCs inserted; secondary outcomes include the women's choice of contraceptive method and quality of life (Short Form Health Survey, SF-36). The costs and outcomes of the intervention and control will be compared in a cost-effectiveness analysis.

ETHICS AND DISSEMINATION

The ACCORd study has been approved by the Monash University Human Research Ethics Committee: CF14/3990-2014002066 and CF16/188-2016000080. Any protocol modifications will be communicated to Ethics Committee and Trial Registration registry. The authors plan to disseminate trial outcomes through formal academic pathways comprising journal articles, nation and international conferences and reports, as well as using more 'popular' strategies including seminars, workshops and media engagements.

TRIAL REGISTRATION NUMBER

ACTRN12615001346561.

Sociodemographic profiles and use-dynamics of Jadelle (levonorgestrel) implants in Jos, Nigeria

Background:

Contraceptive implants (including Jadelle) are highly effective, safe, and easy to use and have a long duration of action. They do not interfere with intercourse with immediate return to fertility after removal. However, disruption of the menstrual bleeding pattern is almost inevitable and coercive prescription may be a problem because insertion and removal of implants are provider dependent. The objective of this study was to determine the sociodemographic profiles of acceptors of Jadelle and the reasons for discontinuation in Jos, Nigeria.

Materials and Methods:

This was a 6-year retrospective chart review carried out at the Jos University Teaching Hospital.

Results:

About 1401 women accepted Jadelle with a mean (±standard deviation) of 33.4 ± 5.9 years. About 88% of the women were Christians and almost three-quarters (73.5%) had at least secondary school education. The means of parity and number of children still alive at the time of accepting Jadelle were 4.1 and 3.8, respectively. Half of the women (49.5%) were breastfeeding and over half (55.9%) had future fertility desires at the time of commencing Jadelle. About 82% had previously used other contraceptives (mostly short-acting methods such as injectables, pills, and condoms), with only 18% starting Jadelle as the first-ever contraceptive method. About 90% of the women had regular menstrual cycles. The major reason for discontinuation of Jadelle was desire for pregnancy although menstrual pattern disruption was the most common reason for removal in the first 6 months of use.

Conclusion:

The main reason for discontinuation of Jadelle was to have more children although menstrual pattern disruptions accounted for earlier discontinuation.

A Qualitative Study of Prescription Contraception Use: The Perspectives of Users, General Practitioners and Pharmacists

BACKGROUND

The oral contraceptive pill (OCP) remains the most popular form of prescription contraception in many countries, despite adherence difficulties for many. Uptake of long acting reversible contraceptives (LARCs), which are less reliant on user adherence, remains low. The aim of this study was to explore the experiences of, and attitudes towards, prescription contraception amongst samples of contraception users, general practitioners (GPs) and pharmacists.

METHODOLOGY AND FINDINGS

We conducted a qualitative study using semi-structured interviews with 18 contraception users, 18 GPs and 9 pharmacists. The study took place in Galway, Republic of Ireland between June and September 2014. Thematic analysis was used to analyse the data. Overall, contraception users were more familiar with the OCP, and all the women interviewed began their prescription contraception journey using this method. All participants identified episodes of poor adherence throughout the reproductive life course. The identified barriers for use of LARCs were lack of information, misconceptions, lack of access and high cost. In contrast, GPs believed that adherence to the OCP was good and stated they were more likely to prescribe the OCP than other methods, as they were most familiar with this option. Barriers to prescribing LARCSs were time, cost to practice, training and deskilling. Pharmacists also believed that adherence to the OCP was generally good and that their role was limited to dispensing medication and providing information when asked.

DISCUSSION AND CONCLUSION

There are contrasting perspectives between contraception service providers and contraceptive users. Training for healthcare providers is required to support informed contraceptive choice and adherence. It is necessary to address the practice barriers of cost and lack of time, to promote better communication around adherence issues and prescription contraception options. There is a need for more easily-accessible public health information to promote awareness on all methods of prescription contraception.

A retrospective evaluation of the intrauterine device in a patient population in Buenos Aires, Argentina

BACKGROUND

The intrauterine device (IUD) is a long-acting reversible contraceptive method that is safe for a wide range of women, including adolescents and nulliparous women. Globally, it is often underutilised due to misperceptions among patients. Examination of characteristics associated with IUD discontinuation including adverse effects and IUD expulsion can inform provider practices to improve contraception success and patient satisfaction with this method. We studied IUD performance at a public family planning clinic in Buenos Aires, Argentina, serving a predominantly immigrant, low-income population.

METHODS

We conducted a retrospective evaluation of 1047 IUD insertions between 2002 and 2007 with 5 years of follow-up data. We performed bivariate and survival analysis to examine characteristics associated with IUD discontinuation: adverse outcomes including pain, bleeding, and IUD expulsion, and time to removal.

FINDINGS

Of 1047 patients, only 188 (18%) had their IUD removed within 5 years. The main causes of IUD discontinuation were involuntary (38%) reasons such as an IUD expulsion and personal choice (34%) such as desiring pregnancy.

CONCLUSIONS

Findings suggest overall good long-term performance with IUD insertion, with minimal complaints or adverse outcomes. These findings may help to support providers serving similar populations in promoting this method.

Prescription contraception use: a cross-sectional population study of psychosocial determinants

OBJECTIVE

Many forms of contraception are available on prescription only for example, the oral contraceptive pill (OCP) and long-acting reversible contraceptives (LARCs). In this analysis we aim to identify key determinants of prescription contraceptive use.

DESIGN

Cross-sectional population survey. Data on sociodemographic indices, concerns about the OCP and perceived barriers to access were collected.

SETTING

Data set constructed from a representative population-based telephone survey of community dwelling adults in the Republic of Ireland (RoI) PARTICIPANTS: 1515 women aged between 18 and 45 years

MAIN OUTCOME MEASURE

Self-reported user of the OCP or LARCs (intrauterine contraception, contraceptive injections or subdermal contraceptive implants) in the previous 12 months.

RESULTS

For at least some of the previous year, 35% had used the OCP and 14% had used LARCs, while 3% had used two or more of these methods. OCP users were significantly younger, more likely to be unmarried and had higher income than non-users. Overall, 68% agreed with the statement 'that taking a break from long-term use of the contraceptive pill is a good idea' and 37% agreed with the statement that 'the OCP has dangerous side effects' and this was the strongest predictor variable of non-use of the OCP. Intrauterine contraception users were significantly older, more likely to be married and had lower income than non-users. Injections or subdermal contraceptive implant users were significantly younger, less likely to be married, had lower income and were less likely to agree that taking a break from long-term use of the pill is a good idea than non-users.

CONCLUSIONS

Prescription contraceptive use is sociodemographically patterned, with LARCs in particular being associated with lower incomes in the RoI. Concerns about the safety of the OCP remain prevalent and are important and modifiable determinants of contraceptive-related behaviour.

Aligning product development and user perspectives: social-behavioural dimensions of multipurpose prevention technologies

Multipurpose prevention technologies provide a compelling response to the multiple and reinforcing sexual and reproductive health risks faced by women globally. To ensure that this potential is realised, product-specific characteristics and their social-behavioural correlates must be considered early in the product development process. This paper provides an overview of the key user-related social and behavioural dimensions of three broad categories of multipurpose prevention technologies: 1) sustained release vaginal rings, 2) pericoital vaginal products, and 3) co-formulated or co-administered injectables. The authors build upon the broad parameters of Target Product Profiles for such products, aligning them with user perspective considerations.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic

STUDY QUESTION

What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago.

SUMMARY ANSWER

Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted.

WHAT IS KNOWN ALREADY

LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce.

STUDY DESIGN, SIZE AND DURATION

We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted.

MAIN RESULTS AND THE ROLE OF CHANCE

We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted.

LIMITATIONS, REASONS FOR CAUTION

The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world.

WIDER IMPLICATIONS OF THE FINDINGS

LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population.

STUDY FUNDING/COMPETING INTERESTS

This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.

Contraception counselling of female soldiers in primary healthcare facilities

BACKGROUND

Effectiveness of barrier and oral contraceptive pills is dependent on daily adherence and consistency that cannot always be guaranteed by military lifestyle. Long-acting reversible contraceptive (LARC) methods could provide a good alternative to guarantee effective contraception in unpredictable scenarios, and recent studies have suggested they could provide wider non-contraceptive benefits. LARC has been proven to be more cost effective than the combined oral contraceptive pill. The National Institute of Health and Care Excellence (NICE) has released guidelines on contraception provision to ensure all women receive the contraception method that is most appropriate to the individual.

METHOD

A retrospective audit of 105 sets of primary healthcare notes of serving female soldiers was assessed to establish contraceptive choices and whether appropriate information had been provided within the last year of their last consultation.

RESULTS

100% had seen a healthcare provider capable of providing contraceptive advice in the last year. 69% documented as using some form of non-surgical contraception versus 58% quoted as national usage. 21% were using some form of LARC versus 8% national usage. 66% of eligible women had not had LARC discussed with them, and of these 50% did not have any contraceptive usage documented. Among other consultations, 41% had had a medical within the year period, of which over half had no documented contraceptive status.

CONCLUSIONS

As military healthcare providers, we have more exposure to our patients than NHS equivalents and this small study suggests there is an increased demand for contraception. Contraceptive choice counselling should be a mandatory part of routine initial medicals. If the situation demands a medical for any other reason, a documented contraception status should form an important part of the risk assessment process.

Young women's attitudes towards, and experiences of, long-acting reversible contraceptives

OBJECTIVES

To identify factors involved in women's decisions to choose particular contraceptive methods and more specifically, incentives and disincentives to use three long-acting reversible contraceptive (LARC) methods: injectables, implants, and intrauterine devices/systems (IUDs/IUSs).

METHODS

A total of 502 women aged 18 to 30 completed a cross-sectional online questionnaire.

RESULTS

The three most important factors in choosing a contraceptive method were: high efficacy at preventing pregnancy, protection against sexually transmitted infections, and non-interference with sexual intercourse. The most common incentives for LARC use were the high efficacy and long duration of action. Disincentives included the possibility of irregular bleeding and concerns about effects on fertility; fear of needles and pain was a particular disincentive for IUD/IUS use. Only 93 (18%) of the participants reported ever having used a LARC.

CONCLUSIONS

Reported disincentives to LARC use (e.g., concern about effects on future fertility) indicated that many young women hold inaccurate beliefs about these methods. The relatively high proportions of women who held neutral attitudes about LARCs (21-40%, depending on the method) highlight the importance of education and contraceptive counselling to improve knowledge about the advantages of these methods.

Impact of pay for performance on prescribing of long-acting reversible contraception in primary care: an interrupted time series study

BACKGROUND

The aim of this study was to evaluate the impact of Quality and Outcomes Framework (QOF), a major pay-for-performance programme in the United Kingdom, on prescribing of long-acting reversible contraceptives (LARC) in primary care.

METHODS

Negative binomial interrupted time series analysis using practice level prescribing data from April 2007 to March 2012. The main outcome measure was the prescribing rate of long-acting reversible contraceptives (LARC), including hormonal and non hormonal intrauterine devices and systems (IUDs and IUSs), injectable contraceptives and hormonal implants.

RESULTS

Prescribing rates of Long-Acting Reversible Contraception (LARC) were stable before the introduction of contraceptive targets to the QOF and increased afterwards by 4% annually (rate ratios  = 1.04, 95% CI = 1.03, 1.06). The increase in LARC prescribing was mainly driven by increases in injectables (increased by 6% annually), which was the most commonly prescribed LARC method. Of other types of LARC, the QOF indicator was associated with a step increase of 20% in implant prescribing (RR =  1.20, 95% CI =  1.09, 1.32). This change is equivalent to an additional 110 thousand women being prescribed with LARC had QOF points not been introduced.

CONCLUSIONS

Pay for performance incentives for contraceptive counselling in primary care with women seeking contraceptive advice has increased uptake of LARC methods.

Impact of family planning health talks by lay health workers on contraceptive knowledge and attitudes among HIV-infected patients in rural Kenya

OBJECTIVE

To determine if a health talk on family planning (FP) by community clinic health assistants (CCHAs) will improve knowledge, attitudes and behavioral intentions about contraception in HIV-infected individuals.

METHODS

A 15-min FP health talk was given by CCHAs in six rural HIV clinics to a sample of 49 HIV-infected men and women. Effects of the health talk were assessed through a questionnaire administered before the health talk and after completion of the participant's clinic visit.

RESULTS

Following the health talk, there was a significant increase in knowledge about contraceptives (p<.0001), side-effects (p<.0001), and method-specific knowledge about IUCDs (p<.001), implants (p<.0001), and injectables (p<.05). Out of 31 women and 18 men enrolled, 14 (45%) women and 6 (33%) men intended to try a new contraceptive. Participant attitudes toward FP were high before and after the health talk (median 4 of 4).

CONCLUSION

A health talk delivered by CCHAs can increase knowledge of contraception and promote the intention to try new more effective contraception among HIV-infected individuals.

PRACTICE IMPLICATIONS

FP health talks administered by lay-health providers to HIV-infected individuals as they wait for HIV services can influence FP knowledge and intention to use FP.

Provision of hormonal and long-acting reversible contraceptive services by general practices in Scotland, UK (2004-2009)

BACKGROUND

In the UK, a large proportion of contraceptive services are provided from general practice. However, little is known about which contraceptive services are provided and to whom.

STUDY DESIGN

Descriptive serial cross-sectional study of women aged 12-55&emsp14;years, registered with 191 general practices in Scotland, UK between 2004 and 2009.

RESULTS

Annual incidence of provision of hormonal and long-acting reversible contraceptives (LARCs) increased from 27.7% in 2004 to 30.1% in 2009. Amongst those women registered with a general practice for the full 5-year period the provision of LARCs increased from 8.8% to 12.5% (p<0.001). For the same group, the provision of emergency hormonal contraception (EHC) decreased from 5.2% to 2.6% (p<0.001).

CONCLUSIONS

With the exception of EHC, there was an increase over time in the provision of hormonal contraceptives and LARCs from general practices. It is important that a full range of contraceptive options remains easily available to women.

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.

Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices

Objective

The purpose of this paper is to review the experience with the frameless, anchored, GyneFix copper-releasing intrauterine contraceptive devices (IUCDs/IUDs) (Contrel Europe, Belgium), and to demonstrate their high acceptability and low rate of discontinuation of use, which could contribute to current efforts that aim to reduce radically the high number of unintended pregnancies and induced abortions, particularly in young women.

Materials and methods

This paper is based on studies that examined the differences in uterine volume and cavity size, related to age and parity, and on original clinical research data and practical experience with frameless copper IUDs, as well as on literature data on the IUD–endometrial cavity relationship of conventional IUDs, with special reference to side effects and user discontinuation.

Results

The mean transverse diameter in nulliparous and parous women is significantly less than the length of the transverse arm of the TCu380A IUD (ParaGard, Duramed, NY, USA) or the levonorgestrel intrauterine system (Mirena, Bayer, Germany). Small, frameless, flexible, and unidimensional copper IUDs appear to be well tolerated, with less impact on menstrual bleeding, resulting in low discontinuation rates when compared with standard-size conventional IUDs, which often result in increased expulsion rates, complaints of pain and erratic or increased menstrual bleeding, and subsequent high rates of discontinuation, particularly in young women.

Conclusion

The unidimensional GyneFix IUDs fit the majority of uterine cavities. An IUD that fits is likely to result in increased tolerance and continued use of the method. As this would appeal to women, the logical result should be greater use of the method and fewer unintended pregnancies and induced abortions. Recommending the standard TCu380A (ParaGard) IUD or the Mirena levonorgestrel intrauterine system, primarily developed for use in parous women, for general use in nulliparous and adolescent women should be done with caution in the light of current scientific evidence, except if 3-D sonography indicates that the uterine cavity is sufficiently large.

Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section

BACKGROUND

Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group.

METHODS

Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain.

RESULTS

Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section.

CONCLUSIONS

Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.

Current methods and attitudes of women towards contraception in Europe and America

Background

The choice of available contraceptive methods has increased in recent years; however, recent data on women’s awareness of methods and reasons for their method choice, or reasons for changing methods, is limited. The aim of this study was to examine the use and awareness of contraceptive methods in the USA, UK, Germany, Italy and Spain.

Methods

Quantitative survey of heterosexual women aged 25–44 years (n=2544), with no known infertility. Questions related to knowledge and use of contraceptive methods, reasons for choice and for changing methods, and sources of advice.

Results

There was generally good awareness of most forms of contraception in all five countries. Awareness and current usage was greatest for the contraceptive pill (awareness >98%, usage varied from 35% [Spain] to 63% [Germany]); and male condom (awareness >95%, usage varied from 20% [Germany] to 47% [Spain]); awareness of other methods varied between countries. Doctors have the greatest influence on women’s choice of contraceptive method (>50% for all countries), and are most likely to suggest the contraceptive pill or male condom.

Women’s contraceptive needs change; 4–36% of contraceptive pill users were likely to change their method within 12 months. For previous contraceptive pill users (n=377), most common reason for change was concern about side effects (from 26% [Italy] to 10% [UK]); however, awareness of many non-hormonal contraceptive methods was low.

Conclusions

Women aged 25–44 are aware of a wide variety of contraceptive methods, but knowledge and usage of the contraceptive pill and condoms predominates. Changing contraception method is frequent, occurring for a variety of reasons, including change in life circumstances and, for pill users, concerns about side effects.