Trends in the use of contraceptive methods and voluntary interruption of pregnancy in the Spanish population during 1997-2007

Differential rates of induced abortion in Spain: educational attainment and age among native and immigrant women

OBJECTIVE

Analyzing the variations in induced abortion (IA) rates across different subpopulations in Spain based on country of origin, while considering educational and age composition.

METHOD

Using 2021 Voluntary Termination of Pregnancy register and 2021 Spanish Census microdata, we calculated crude IA rates and age-specific abortion rates. We used age-standardized IA rates (ASIAR) to account for the confounding effect of age composition. We compared seven subpopulations residing in Spain, taking into account simple ages and educational levels aggregated into four categories.

RESULTS

Immigrant women, especially those from Sub-Saharan and Latin American countries, consistently had higher IA rates compared to native Spanish women. According to age-specific IA rates, university-educated women had considerably fewer abortions than women with other education levels at any age. Age-standardized rates stratified by migratory origin revealed that native Spanish women with primary education or less had higher IA rates than their immigrant counterparts. There was a clear non-linear, association between educational level and IA rates among immigrants. The highest propensity for IA was found among secondary school graduates, while university graduates had the lowest IA rate.

CONCLUSIONS

The study demonstrated that variability in sociodemographic characteristics had an impact on IA rates. Young women with middle educational attainment and immigrant background had a higher likelihood of undergoing IA in Spain. The relationship between educational level and IA rates was complex, with variations observed among different groups and changes over time.

Hormonally Active Contraceptives, Part II: Sociological, Environmental, and Economic Impact

To investigate the sociological, environmental, and economic impact of hormonally active contraceptives, a series of comprehensive literature surveys were employed. Sociological effects are discussed including abortion, exploitation of women, a weakening of marriage, and an increase in divorce with deleterious effects on children such as child poverty, poorer health, lower educational achievement, suicide risks, drug and alcohol abuse, criminality, and incarceration, among others. The environmental impact is discussed briefly and includes the feminization and trans-gendering of male fish downstream from the effluent of city wastewater treatment plants with declining fish populations. The potential economic impact of most of these side effects is estimated based on epidemiologic data and published estimates of costs of caring for the diseases which are linked to the use of hormonally active contraceptives. Hormonally active contraceptives appear to have a deleterious impact on multiple aspects of women's health as well as negative economic and environmental impacts. These risks can be avoided through the use of nonhormonal methods and need to be more clearly conveyed to the public.

SUMMARY

Hormonal contraceptives have wide-ranging effects.  The potential economic impact of the medical side effects is estimated. Sociological effects are discussed including abortion, exploitation of women, a weakening of marriage and an increase in divorce with negative effects on children such as child poverty, poorer health, lower educational achievement, suicide risks, drug and alcohol abuse, criminality and incarceration among others. The environmental impact includes hormonal effects on fish with declining fish populations. Women seeking birth control have a right to know about how to avoid these risks by using effective hormone-free methods like Fertility Awareness Methods.

Effect of cost on early removal of contraceptive implants: a prospective cohort study

OBJECTIVES

To evaluate the effect of the cost of subdermal etonogestrel implant (SEI) on the continuation rate one year after insertion, and to assess the reasons given by users to remove the implant before the expiration date.

METHODS

Prospective cohort study conducted among 265 women who chose the SEI as a contraceptive method in a sexual and reproductive health center in the eastern region of Spain, between October/2012 and October/2017. The sample was divided into two cohorts depending on the cost of the implant for the user (free-of-charge or requiring partial payment). Kaplan-Meier survival curves were used to compare the cumulative removal rates of free implants with partially paid implants within the first year of insertion. Cox proportional hazards models were used to control for confounders.

RESULTS

After adjusting for confounders, no significant associations were found between the cost of the implant and its removal within a year of insertion. No significant associations were found in the reasons given for implant removal and for the duration of implant use.

CONCLUSIONS

Cost was not associated with SEI continuation rates within the first year of use. No other significant variables were found to explain implant removal within one year of use.

Risk factors for voluntary interruption of pregnancy and possible preventive public health actions

Introduction

Voluntary interruption of pregnancy (VIP) is one of the most frequent healthcare procedures in the world and a Public Health concern in many countries, especially after liberalization of the abortion laws. The study has been carried out to identify the factors that still influence a fraction of female population towards abortion in the absence of fetal malformations.

Methods

We conducted a cross-sectional study in the period 2012-2016. The survey was carried out on all VIPs performed at the Gynecology and Obstetrics Unit of the University Hospital “G. Martino” in Messina, Italy.

Results

The analyzed sample consisted of 1131 women, aged between 16 and 50 years. Only 4% of VIPs was due to a diagnosis of fetal malformation. In relation to the presence or absence of fetal malformations as the possible reason for VIP, the sample was split up into two groups and the socio-demographic characteristics were considered. VIPs in the absence of malformations were significantly more frequent in younger women with a lower educational level, in unmarried and unemployed women and in women who already had children. These results were confirmed to Pearson test that indicated that all these variables were related to VIP in the absence of malformations.

Conclusions

Based on our results, it is crucial to further prevent requests for VIPs through information and sex education programs for adolescents in schools and consultants, and responsible procreation promotion programs.

Influence of Contraception Use on the Reproductive Health of Adolescents and Young Adults

Oral contraceptives (OCs) are often prescribed to adolescents and young adults for the treatment of health problems and to avoid unwanted pregnancies. We hypothesized that the use of OCs, among adolescents and young adults, is associated with a greater likelihood of pregnancy, abortion, sexually transmitted diseases (STDs), pelvic inflammatory disease (PID), and sexual behaviors that will enhance those problems (i.e., earlier sexual debut and more sexual partners) than adolescents and young adults not using OCs. To test this hypothesis, data from 1,365 adolescents and young adults in the 2011-2013 National Survey of Family Growth (NSFG) were used to describe the influence of ever use of OCs on ever having sex, sexual debut, multiple sexual partners, STDs, PID, pregnancy, and abortion. A secondary purpose was to evaluate protective factors from unhealthy sexual practices like religiosity, church attendance, and intact families. We found that the "ever use" of OCs by US adolescents and young adults results in a greater likelihood of ever having sex, STDs, PID, pregnancy, and abortion compared with those adolescents and young adults who never used OCs. Furthermore, those adolescents who ever used OCs had significantly more male sexual partners than those who never used OCs, and they also had an earlier sexual debut by almost two years. Conversely, we found that frequent church attendance, identification of the importance of religion, and having an intact family among adolescents were associated with less likelihood of unsafe sexual practices. We concluded that the use of OCs by adolescents and young adults might be considered a health risk. Further research is recommended to confirm these associations. Summary: The purpose of this article was to show the correlation between contraceptive use in adolescents and negative sexual outcomes. We used data from the 2011-2013 NSFG and demonstrated that never married adolescents who used oral hormonal contraception were three times more likely to have an STD, have PID, and to become pregnant, and, surprisingly, ten times more likely of having an abortion compared to noncontracepting adolescents. These are outcomes that contraception is intended to prevent. These data also showed that the contraceptors had significantly more male partners than their contraceptive counterparts. Protective factors such as church attendance and family cohesiveness were associated with a decreased likelihood of sexual activity.

Economic Burden of Contraception Management in Spain

BACKGROUND

A wide variety of contraceptive methods are available, some of them reimbursed by the Spanish National Health System (SNHS). However, the number of unintended pregnancies (UP) is still significant, leading to a high economic burden, mainly derived from non-adherence to and the incorrect use of contraceptive methods.

OBJECTIVES

This study aims to estimate the economic burden associated with reversible contraception management in Spain, from the perspectives of both the SNHS and women, over a 5-year period.

METHODS

A survey was performed to identify contraception management in Spain based on the experience of a panel of six expert gynecologists. An economic model was conducted to quantify the current burden of contraception according to healthcare resources use over 5 years. The costs included in the analysis were diagnostic tests, initial and follow-up consultations, methods acquisition costs, and UP derived from therapy failure.

RESULTS

Reversible contraception costs in Spain amount to €12.5 billion over a 5-year period. Condoms and combined oral contraceptives (COC) account for 86.8% of the total cost and the other methods only 13.2%. There are differences in contraceptive use according to women's age. Short-acting reversible contraceptives (SARC) such as COC, condom and vaginal ring, are most commonly used by younger women. However, SARC are correlated with the highest failure rate, resulting in over €7.2 billion cost, explained by the high number of UP. Long-acting reversible contraceptives (LARC), such as the levonorgestrel-releasing intrauterine system (LNG-IUS20), implant and copper intrauterine devices (IUD), are selected by women over 35 years of age due to user-independent compliance. SARC methods result in a higher cost per woman over 5 years: vaginal ring €2427.8, patch €2402.6, condom €2060.1 and COC €1895.1; while LARC methods are the most economic option per women: LNG-IUS20 €630.4, copper IUD €658.2, LNG-IUS12 €703.8, intramuscular injectable €907.8 and implant €940.5.

CONCLUSIONS

LARC methods result in lower costs compared with SARC options from the perspectives of the SNHS and women, explained by user-independent compliance, preventing a significant number of UP and its elevated economic burden. An increased LARC methods use could avoid UP events, leading to significant cost-savings for the SNHS.

Unmet/met need for contraception and self-reported abortion in Ghana

BACKGROUND

Unmet need for contraception in several sub-Saharan African countries, including Ghana, remains high, with implications for unintended pregnancies and unsafe abortion, associated maternal morbidity and mortality. In this paper, we analysed for any associations between unmet/met need for contraception and the prevalence of abortion.

METHODS

The paper utilizes the 2014 Ghana Demographic Health Survey dataset. Applying descriptive statistics initially, and later, a binary logistic regression, we estimate two different models, taking into account, unmet/met need for contraception (Model 1) and a multivariable one comprising socioeconomic, spatial, cultural and demographic behaviour variables (Model 2) to test the associations between unmet/met need for contraception in Ghana.

RESULTS

One-fourth (25%) of sampled women in 2014 had ever had an abortion. The bivariate results showed that women who reported "no unmet" considerably tended to report abortion more than the reference category - not married and no sex in the last 30days. The elevated odds among respondents who indicated "no unmet need" persisted even after controlling for all the relevant confounders. Relatedly, unlike women with an unmet need for spacing, women who desired to limit childbearing had a slightly higher tendency to report an abortion.

CONCLUSION

The linkage between unmet need for contraception appears more complex, particularly when the connections are explored post-abortion. Thus, while an abortion episode is most likely due to unintended pregnancy, contraception may still not be used, after an abortion, probably because of failure, side effects or simply, a dislike for any method.

Trends in the use of oral contraceptives among adolescents and young women in Spain

Background

We aimed to determine the prevalence of consumption of oral contraceptives (OCs) among adolescents and young women living in Spain and to identify the factors associated with this consumption.

Methods

We performed a cross-sectional study on the consumption of OCs by women aged 15–30 years residing in Spain. We used secondary individualized data from the 2006 (n = 2513) and 2012 (n = 1530) Spanish National Health Surveys. The dependent variable was the use of OCs in the previous 2 weeks. Independent variables included sociodemographic characteristics, comorbidity, lifestyle, and healthcare resource utilization.

The prevalence of OC consumption was analysed by investigating the changes observed between 2006 and 2012. We used multivariate logistic regression to identify the independent factors associated with OC use in each year.

Results

In 2006, 14.42 % of women reported using OCs; this percentage dropped to 10.21 % in 2012 (p < 0.05). Multivariate analysis revealed an association between OC use and visits to the gynaecologist (AOR, 5.60 [95 % CI, 2.93–10.73] in 2006; and AOR, 3.55 [95 % CI, 1.30–9.73] in 2012), Pap smear tests (AOR, 1.8 [95 % CI, 1.23–2.87] in 2006; and AOR, 2.42 [95 % CI, 1.30–4.51] in 2012), and smoking in 2006 (AOR, 1.42 [95 % CI, 1.04–1.93]).

Conclusions

There was a significant decrease in OC use from 2006 to 2012 among adolescents and young women living in Spain. In the present study, consumers of OCs were women who visited a gynaecologist more often and complied more with preventive measures such as Pap smear testing. Also, women who reported having used OCs were more likely to smoke than the rest of the study population, although the smoking habit is a risk factor for thrombotic events in women who take OCs.

Hormonal contraception and postmenopausal hormone therapy in Spain: time trends and patterns of use

OBJECTIVE

This study aims to describe time trends in and patterns of use of hormonal contraception and postmenopausal hormone therapy and to identify factors associated with their use among Spanish women.

METHODS

We performed a cross-sectional analysis using data from 1,954 population controls (aged 24-85 y) in 12 provinces of Spain who were enrolled in the Multi Case-Control Spain study (2007-2013). Data were collected from a questionnaire conducted face-to-face by trained personnel. We collected information on sociodemographic factors, lifestyle, sleep patterns, reproductive history, and occupational history.

RESULTS

Overall, 48.5% of Spanish women reported ever use of hormonal contraception, and 9.8% of women in the postmenopausal group reported use of postmenopausal hormone therapy. Younger cohorts used hormonal contraception for a longer period, whereas postmenopausal hormone therapy use dramatically dropped in the 2000s. Women with higher education levels (including education of partners) and smoking history were the most probable users of hormonal contraception, whereas inverse associations were observed among housewives, obese women, and nulliparous women. Postmenopausal hormone therapy use was associated with a surgical or therapeutic cause of menopause and with occupational history of rotating shifts.

CONCLUSIONS

In this Spanish population, several demographic, lifestyle, occupational, and reproductive factors are associated with use of hormonal compounds. Characterizing hormonal users and monitoring trends in the use of these hormonal compounds are essential from a public health perspective.

Effect on quality of life of switching to combined oral contraception based on natural estrogen: an observational, multicentre, prospective phase IV study (ZOCAL Study)

OBJECTIVES

This observational, multicentre, prospective phase IV study examined change in health-related quality of life (QOL) from baseline to 6 months in women initiating combined oral contraception (COC) based on natural estrogen.

METHODS

Eligible women attending a baseline and 6-month gynaecology appointment belonged to one of three groups: group 1 used barrier contraception (condoms) and elected to continue this method; group 2 used condoms and elected to switch to COC based on natural estrogen; group 3 used COC based on ethinylestradiol and elected to switch to COC based on natural estrogen. The Spanish Society of Contraception (SEC)-QOL scale assessed health-related QOL. Secondary outcomes included symptoms of premenstrual syndrome, intermenstrual bleeding, duration and intensity of menstrual bleeding, contraception continuation rate, and tolerability.

RESULTS

A total of 857 women were enrolled and 785 completed the study. Group 2 (n = 224 completed) had significantly lower SEC-QOL global and dimension scores at baseline and significantly greater increases in SEC-QOL from baseline to 6 months compared with groups 1 (n = 72) and 3 (n = 489). Group 3 reported a similar SEC-QOL score to that of group 1 at baseline but showed significantly greater improvement in SEC-QOL global and psychological scores from baseline to 6 months. Among women receiving COC based on natural estrogen, the contraception continuation rate was 713/780 (91.4%); treatment-related adverse events were reported by 13/780 (1.7%).

CONCLUSIONS

Improved SEC-QOL after 6 months was found in women who were dissatisfied with their current contraception at baseline and chose to switch to COC based on natural estrogen.

Contraception and abortion: Fruits of the same rotten tree?

This article seeks to show how contraception, when generally accepted in a society, helps to bring about a radical change in social perceptions of sexual intercourse, human life, the human person, science, and morality in general. On account of this, contraception helps to ingrain abortion and other anti-life practices into the culture that accepts it and, therefore, in no sense can be considered as a panacea for abortion. Particular attention is given to the thought of John Paul II on this matter who noted that "despite their differences of nature and moral gravity, contraception and abortion are often closely connected, as fruits of the same tree" (Evangelium vitae, n. 13). Lay summary: The article considers the connection between contraception and abortion and defends Pope John Paul II's claim that "despite their differences of nature and moral gravity, contraception and abortion are often closely connected, as fruits of the same tree." The thesis is that contraception is a "game-changer" in the sense that it changes the way we think about some very fundamental realities such as attitudes to sex, to life, to science, to the human person, and to morality. Any one of these changes would have a significant impact on a society in terms of promoting a culture of death: together they are devastating.

Emergency contraceptive pill safety profile. Comparison of the results of a follow-up study to those coming from spontaneous reporting

BACKGROUND

The emergency contraceptive pill (ECP) containing levonorgestrel is dispensed without a prescription in Spain since 2009. An easy access could diminish unwanted pregnancies; however, there is a risk of misuse and, in any case, of developing some adverse events. The aim of the present study is to further learn the adverse effects of this ECP.

METHODS

An ad hoc follow-up study was carried out in three community pharmacies in a city of Central Spain; the sample was composed of those women asking for the ECP; they were interviewed by telephone after at least a month since the last menses. We completed the safety profile obtained with that coming from spontaneous reporting in Spain.

RESULTS

Out of 139 women surveyed, 113 developed any adverse event--two considered as severe; the most frequently reported events were menstrual disturbances, which accounted for 21% of all events. Through spontaneous reporting, 36 cases of whatever adverse events related to levonorgestrel as ECP were identified. Twenty-five cases were considered as severe. Both types of reaction and severity were significantly different in the follow-up study and in the spontaneous reporting. Some of the reactions identified, such as miscarriage, febrile neutropenia, and porphyria, are not included in the Summary of Product Characteristics.

CONCLUSIONS

Levonorgestrel as an ECP is mostly safe. Attention should be paid to some severe events and particularly to those risk factors for them to appear. Combining spontaneous reporting with an ad hoc follow-up study, the whole safety profile of a given medication can be obtained.

Effectiveness of family planning policies: the abortion paradox

OBJECTIVE

The relation between levels of contraceptive use and the incidence of induced abortion remains a topic of heated debate. Many of the contradictions are likely due to the fact that abortion is the end point of a process that starts with sexual activity, contraceptive use (or non-use), followed by unwanted pregnancy, a decision to terminate, and access to abortion. Trends in abortion rates reflect changes in each step of this process, and opposing trends may cancel each other out. This paper aims to investigate the roles played by the dissemination of contraception and the evolving norms of motherhood on changes in abortion rates.

METHODS

Drawing data from six national probability surveys that explored contraception and pregnancy wantedness in France from 1978 through 2010, we used multivariate linear regression to explore the associations between trends in contraceptive rates and trends in (i) abortion rates, (ii) unwanted pregnancy rates, (iii) and unwanted birth rates, and to determine which of these 3 associations was strongest.

FINDINGS

The association between contraceptive rates and abortion rates over time was weaker than that between contraception rates and unwanted pregnancy rates (p = 0.003). Similarly, the association between contraceptive rates and unwanted birth rates over time was weaker than that between contraceptive rates and unwanted pregnancy rates (p = 0.000).

Trends in contraception use in Spanish adolescents and young adults (15 to 24 years) between 2002 and 2008

OBJECTIVE

To assess changes in the use of contraceptive methods, and induced abortion rates, in Spanish adolescents and young adults aged 15 to 24 years, between 2002 and 2008.

STUDY DESIGN

Representative samples of Spanish men and women aged 15 to 24 years were surveyed in 2002 (N = 1826) and 2008 (N = 2000).

RESULTS

The rate of use of contraceptive methods increased from 61% in men and 60% in women in 2002 to 80% and 75%, respectively, in 2008. The most commonly used method was the condom (51% in 2002 and 71% in 2008), followed by the contraceptive pill (18% in 2002 and 18% in 2008). None of the adolescents and young adults surveyed used natural methods or the diaphragm, or had undergone sterilisation. The induced abortion rate increased from 9.28 to 13.48 per 1000 women in the group aged between 15 and 19 years, and from 14.37 to 21.05 per 1000 women in the group aged 20 to 24 years.

CONCLUSION

Despite an increase in the use of effective birth control methods, the rates of abortion rose during the study period, which may indicate that compliance with the use of condoms is inadequate. There is an urgent need to develop educational campaigns or to design specific policies addressing contraception-related issues for young people.

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.

Continuation rate of combined hormonal contraception: a prospective multicenter study

BACKGROUND

Data from clinical trials regarding continuation of use and contraceptive efficacy do not always apply to the general public. Therefore, a study among typical users was conducted to assess the continuation rate at the end of 12 cycles of combined hormonal contraceptive methods, reasons for discontinuation, and the Pearl index.

METHODS

Prospective, observational, and multicenter study of 3443 women aged 18 to 49 years starting one of the three combined hormonal contraception methods available in Spain (the vaginal ring, the contraceptive pill, and the transdermal skin patch).

RESULTS

The study population (intention-to-treat analysis) included 3443 women, of whom 45.4% were included in the vaginal ring group, 42.6% the pill group, and 12.1% the skin patch group. The continuation rate at 12 cycles was 45.9% for the pill, 42.3% for the vaginal ring, and 26.0% for the skin patch. The Pearl index was 0.61 (95% confidence interval [CI] 0-1.2) for the pill, 0.61 (95% CI 0-1.1) for the vaginal ring, and 2.34 (95% CI 0.3-9) for the skin patch (p<0.001).

CONCLUSION

At 12 cycles, the vaginal ring and the pill showed similar continuation rates and effectiveness, which were significantly higher than the skin patch.

Predictors of contraceptive methods among adolescents and young women residing in Spain

INTRODUCTION

Preventing unwanted pregnancy is considered one of the main preventive measures of a developed health system.

AIMS

The aim of the study were to determine the prevalence of contraceptive methods and identify factors associated with the use of contraception by adolescents and young women residents in Spain.

METHODS

Descriptive cross-sectional epidemiologic study on the factors determining use of a contraceptive method among sexually active adolescents and young women aged 16-29 years, living in Spain. As the dependent variable, we took the answer to the questions "During the last 12 months, what contraceptive method have you generally used in your sexual relations?" Independent variables were socio-demographic factors, sexual habits, and variables associated with perception of sexual health. Using logistic multivariate regression models, we have estimated the independent effect of each of these variables on the contraceptive methods use.

MAIN OUTCOME MEASURES

We used secondary individualized data drawn from the first National Sexual Health Survey conducted in Spain.

RESULTS

The male condom seems to be the most widely used (56.7%). The likelihood of using a condom is greater to those who have more than two sexual partners (adjusted odds ratio [AOR]=3.11; 95% confidence interval [CI], 1.72-5.60). Predictors of use of oral contraceptives as the only method are age and having a positive view of one's sexual health (AOR=2.65; 95% CI, 1.28-5.45). Young women with two or more sexual partners were three times likelier to use the double method (AOR=3.83; 95% CI, 1.52-9.65).

CONCLUSIONS

The number of sexual partners, information on and importance of sexuality in one's life predicted the use of the condom as the only method. The factors associated with use of oral contraceptives were having a stable sexual partner and good perception of sexual health. The variable most strongly associated with use of the double method was number of sexual partners.