"Just Wear Dark Underpants Mainly": Learning from Adolescents' and Young Adults' Experiences with Early Discontinuation of the Contraceptive Implant

Symptomatic hypotensive episodes following Implanon NXT insertion: A case report

This case report describes episodic symptomatic hypotension following Implanon NXT insertion and symptom resolution after removal. We aim to alert clinicians of episodic hypotension as a possible adverse drug reaction to Implanon NXT, facilitating early intervention and improved patient outcomes.

Client Perspectives on Contraceptive Care: A Systematic Review

INTRODUCTION

Contraceptive care is an opportunity for providers to help clients achieve their reproductive health goals. Client-centeredness is a core element of quality care; however, evidence suggests that the provision of client-centered contraceptive counseling needs improvement. This systematic review summarizes recent evidence on client preferences related to contraceptive care, including how client-centered approaches inform outcomes.

METHODS

A systematic review was conducted in PubMed, Cochrane Database of Systematic Reviews, and Scopus to identify articles published between December 1, 2016 and May 1, 2023. Studies that explored client preferences related to contraceptive counseling, education, and/or care, and how client-centered approaches impact clients' perceived experiences with their care were included.

RESULTS

Thirty-nine unique studies met inclusion criteria. Clients want a range of information about contraceptive methods tailored to their preferences through a variety of formats, before, during, and after their appointment. Clients desired providers with similar demographic backgrounds (gender, race, ethnicity) and life experiences (menstruation, contraceptive use, carceral system encounters) to themselves, and who are willing to offer continuous care. Clients reported greater satisfaction when providers engaged in shared decision-making, utilized decision support tools, and supported their autonomy, including prioritizing their family-building goals. When providers shared personal preferences or pressured clients to select one method over another, clients in turn, reported feeling conflicted about which method to select and some subsequently declined using any method.

DISCUSSION

The variation in client preferences highlight the importance of offering tailored, comprehensive information that supports decision-making, prioritizes client autonomy, and recognizes positive interpersonal relationships with providers.

TRIAL REGISTRATION

Prospero: CRD42023414456 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=414456.

A 3-year Retrospective Review of Contraceptive Initiation, Continuation, Switching, and Pregnancy Among Adolescents and Young Adults

PURPOSE

To understand contraceptive use patterns (initiation, switching, discontinuation) as well as associations with pregnancy in adolescents and young adults attending a teen family planning clinic.

METHODS

We performed a chart review of adolescent and young adult patients (ages 12-20) attending a teen family planning clinic in Atlanta, GA between January 1, 2017, and December 31, 2019. Using a standardized abstraction form with quality controls, we collected available data on contraceptive methods used and pregnancy test results during the 3-year period. We analyzed contraceptive use patterns descriptively. We calculated and compared pregnancy incidence according to different contraceptive switch patterns.

RESULTS

Our sample included 2,798 individuals who initiated 2,358 prescribed methods. The most commonly prescribed methods of contraception were the contraceptive injection (28.3%), etonogestrel implant (23.5%) and combined hormonal pill (23.2%). There were 599 discontinuations of prescribed methods; side effects like bleeding and headache were the most cited reasons for discontinuation. Most (75.8%) initiated a moderately or highly effective method after discontinuing a moderately or highly effective method. The incidence rate of pregnancy was highest for those who had discontinued an intrauterine device or implant and started a shorter-acting contraceptive method.

DISCUSSION

Employing patient-centered contraceptive counseling that incorporates contraceptive experiences in addition to facts and allows for exploration and change may be valuable for young people. Successful navigation of contraceptive switches may require additional attention, education, and strategy, which could include hypothetical problem solving, close follow-up, and telehealth or virtual care.

Comparing the reasons for contraceptive discontinuation between parenting adolescents and young women in sub-Saharan Africa: a multilevel analysis

BACKGROUND

Adolescent sexual and reproductive health remains a major public health and development issue of global importance. Given that adolescents and young people are heterogenous groups in terms of many characteristics, this study expands the literature by comparing the reasons for contraceptive discontinuation between parenting adolescents (aged 15-19) and parenting young women (aged 20-24) in sub-Saharan Africa (SSA).

METHODS

Data for the study came from Demographic and Health Surveys of 22 SSA countries. The outcome variable was reasons for discontinuation. We performed multilevel binary logistic regression on analytic samples comprising 1485 parenting adolescents and 10,287 parenting young women across the selected SSA countries.

RESULTS

Findings show that the proportion of respondents who used modern contraceptives was lower among parenting adolescents (35%) relative to their 20-24-year-old counterparts (43%). Higher percentages of parenting adolescents than young women discontinued contraceptives because of reasons such as pregnancy or method failure (i.e., 9.9% and 8.17% accordingly), husband disapproval, access or availability issues, wanting more effective methods, and inconvenience in using methods. The multilevel analysis further highlighted disparities between parenting adolescents and parenting young women who discontinued contraceptives. For instance, parenting young women had 30% lower odds of discontinuing contraceptives due to pregnancy or method failure than parenting adolescents.

CONCLUSION

The study established disparities in the reasons for contraceptive discontinuation between parenting adolescents and parenting young women, with adolescents demonstrating greater vulnerabilities and higher risks. Considerable attention must be given to parenting adolescents in the efforts to achieve equity goals such as the Sustainable Development Goals and universal health coverage in SSA.

Exploring Language Used in Posts on r/birthcontrol: Case Study Using Data From Reddit Posts and Natural Language Processing to Advance Contraception Research

BACKGROUND

Contraceptive choice is central to reproductive autonomy. The internet, including social networking sites like Reddit, is an important resource for people seeking contraceptive information and support. A subreddit dedicated to contraception, r/birthcontrol, provides a platform for people to post about contraception.

OBJECTIVE

This study explored the use of r/birthcontrol, from the inception of the subreddit through the end of 2020. We describe the web-based community, identify distinctive interests and themes based upon the textual content of posts, and explore the content of posts with the most user engagement (ie, "popular" posts).

METHODS

Data were obtained from the PushShift Reddit application programming interface from the establishment of r/birthcontrol to the start date of analysis (July 21, 2011, to December 31, 2020). User interactions within the subreddit were analyzed to describe community use over time, specifically the commonality of use based on the volume of posts, the length of posts (character count), and the proportion of posts with any and each flair applied. "Popular" posts on r/birthcontrol were determined based on the number of comments and "scores," or upvotes minus downvotes; popular posts had 9 comments and a score of ≥3. Term Frequency-Inverse Document Frequency (TF-IDF) analyses were run on all posts with flairs applied, posts within each flair group, and popular posts within each flair group to characterize and compare the distinctive language used in each group.

RESULTS

There were 105,485 posts to r/birthcontrol during the study period, with the volume of posts increasing over time. Within the time frame for which flairs were available on r/birthcontrol (after February 4, 2016), users applied flairs to 78% (n=73,426) of posts. Most posts contained exclusively textual content (n=66,071, 96%), had comments (n=59,189, 86%), and had a score (n=66,071, 96%). Posts averaged 731 characters in length (median 555). "SideEffects!?" was the most frequently used flair overall (n=27,530, 40%), while "Experience" (n=719, 31%) and "SideEffects!?" (n=672, 29%) were most common among popular posts. TF-IDF analyses of all posts showed interest in contraceptive methods, menstrual experiences, timing, feelings, and unprotected sex. While TF-IDF results for posts with each flair varied, the contraceptive pill, menstrual experiences, and timing were discussed across flair groups. Among popular posts, intrauterine devices and contraceptive use experiences were often discussed.

CONCLUSIONS

People commonly wrote about contraceptive side effects and experiences using methods, highlighting the value of r/birthcontrol as a space to post about aspects of contraceptive use that are not well addressed by clinical contraceptive counseling. The value of real-time, open-access data on contraceptive users' interests is especially high given the shifting landscape of and increasing constraints on reproductive health care in the United States.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative

OBJECTIVE

To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative.

STUDY DESIGN

LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience.

RESULTS

Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88).

CONCLUSIONS

LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Leveraging the Client-Provider Interaction to Address Contraceptive Discontinuation: A Scoping Review of the Evidence That Links Them

Despite considerable investment and effort, unmet need for contraception remains an obstacle to improved family planning outcomes. One influencing factor is the frequency of contraceptive discontinuation among users who desire to prevent pregnancy, often due to method-related concerns and side effects. Contraceptive users have the right to be supported during counseling to voluntarily choose methods that align with their individual needs and preferences. Contraceptive counseling, as a key component of quality of care, is particularly important for providers to reduce unmet need among their clients. This scoping review examined the state of the evidence on contraceptive counseling and its impact on discontinuation. The review first examines the association between quality of care and contraceptive discontinuation, then looks to what the current body of evidence suggests are women's contraceptive counseling priorities, and lastly, explores whether specific counseling tools and approaches have been evaluated with discontinuation as an outcome. The results identified general principles and priorities for good counseling including person-centeredness, client-tailored information exchange, clear and concise information on side effects and bleeding changes, reducing providers' implicit and explicit biases, and trust and respect between the client and provider. The review of the literature also found that evidence to support the use of specific counseling tools and approaches to reduce contraceptive discontinuation is insufficient; research should be designed to determine which specific elements of the client-provider interaction can be improved to significantly impact contraceptive discontinuation. This evidence could inform how the global community of practice might improve and leverage specific counseling approaches and tools to address the most common predictors of discontinuation.

The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion

STUDY OBJECTIVE

Temporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation.

DESIGN

Retrospective chart review.

SETTING

The research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents.

PARTICIPANTS

A chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding.

RESULTS

Younger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001).

CONCLUSIONS

Some patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.

Changing lives, dynamic plans: Prospective assessment of 12-month changes in pregnancy timing intentions and personal circumstances using data from HER Salt Lake

OBJECTIVES

To explore the association between changes in personal circumstances and shifts in pregnancy intentions.

STUDY DESIGN

New start contraceptive clients, who desired to prevent pregnancy for at least one year enrolled in the survey arm of the HER Salt Lake Contraceptive Initiative (September 2015 -March 2017) and responded to the question "What are your future pregnancy plans?" at enrollment and 12-month follow-up. We estimated multivariable binary logistic fixed-effects regressions to examine the association between changes in personal circumstances and a change from never desiring a pregnancy at enrollment to considering one in the future at 12-month follow-up.

RESULTS

The majority of the 2825 participants (2246, 79%) maintained their pregnancy timing intention over the 12-month study period. Multivariable analyses of the 208 participants who changed from never desiring a pregnancy to considering pregnancy in the future at 12-month follow-up indicated that entering cohabitation (aOR 3.14, 95% CI 1.30-7.58), increased household income (aOR 1.06, 95% CI 1.00-1.13), and changes from unemployment to full-time employment (aOR 5.94, 95% CI 1.29-27.36) are associated with increased the odds of desiring a future pregnancy after never wanting one a year prior.

CONCLUSIONS

Pregnancy intentions are dynamic over twelve months and covary with partner status, household income, and employment status. Pregnancy intentions are linked to changes in life circumstances. Health care providers need to frequently assess pregnancy intentions and resulting contraceptive or preconception needs.

Best Practices for Counseling Adolescents about the Etonogestrel Implant

Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.

Communication about Contraception with Adolescent Females with Asthma in Pediatric Visits

STUDY OBJECTIVE

The occurrence and characteristics of contraception discussions with adolescents are unexplored. Our study sought to address this gap using transcripts of audiotaped healthcare visits.

DESIGN, SETTING, AND PARTICIPANTS

This study was a secondary analysis of 153 transcripts of medical visits with female adolescents with asthma. Medical visits took place among 4 outpatient clinics in North Carolina.

MAIN OUTCOME MEASURES

Transcripts were reviewed for occurrence and characteristics of contraception discussions. Demographics were collected from adolescent interviews, caregiver questionnaires, and provider questionnaires.

RESULTS

Contraception was mentioned in 3% (n = 5) of office visits. Conversations about contraception included the topics of contraception efficacy (20%), contraception side effects (60%), contraception adherence (20%), and adolescent sexual health (20%). No conversations included the topics of contraception indication or alternative methods.

CONCLUSIONS

Conversations about contraception occurred infrequently in healthcare visits. When conversations did occur, the topics that they covered lacked alignment with guideline recommendations.

Emergency Contraception Use in School-Based Health Centers: A Qualitative Study

STUDY OBJECTIVE

To understand contraceptive behaviors and decision-making in school-based health center (SBHC) female patients who have used emergency contraception (EC).

DESIGN

Qualitative interviews and questionnaires.

SETTING

SBHCs.

PARTICIPANTS

Female adolescents, who self-reported EC use, were recruited from SBHCs.

INTERVENTIONS

Interviews were conducted until thematic saturation was reached on the following themes: reasons for selecting EC, perceived EC efficacy, reasons for use, nonuse, or inconsistent use of nonemergent contraception (NEC), and beliefs surrounding pregnancy risk.

MAIN OUTCOME MEASURES

The team used a modified grounded theory approach and open coding technique to identify common themes. Participants completed a questionnaire to assess demographic information and EC knowledge.

RESULTS

Twenty-eight interviews were completed. Reasons for using EC include not using another contraceptive method, using another method incorrectly, or in combination with another method for added protection. Reasons for EC preference include ease of administration, ease of access, minimal side effects, perceived high efficacy, and because it can be used discreetly. Use of NEC was supported by identifying it as more effective, increased sexual experience and anticipation of sex, belief that excess EC decreases efficacy or is detrimental to health, and social interactions. Participants reported having used EC a mean of 3.5 times. Eighteen of 28 participants (65%) incorrectly believed that EC is 90%-99% effective, and 15 of 28 participants (53%) correctly identified ovulation inhibition as the mechanism of action.

CONCLUSION

EC use is promoted by ease of access and administration, experiencing minimal side effects, and perceived high efficacy. Compliance issues with NEC and condoms and a desire for a discreet contraceptive method support EC use.

Use of Long-Acting Reversible Contraception (LARC) and the Depo-Provera Shot in Adolescents

The intrauterine devices (IUDs) and the subdermal implant, collectively known as long-acting reversible contraceptives (LARC), along with the Depo-Provera shot, represent highly efficacious methods of birth control for all reproductive-age women, including adolescents. They are also safe, private, and convenient, and can be used for their noncontraceptive benefits. Additionally, LARC and Depo-Provera represent methods of contraception that do not contain estrogen and may be safely used in young women who have contraindications to estrogen-containing medications. The LARC methods have traditionally been underused by adolescents due to lack of knowledge and misperceptions about safety and effects on future fertility. However, studies have found that when barriers to the use of LARC are removed, adolescents have increasingly chosen the IUD and implant for birth control and most continue to use these methods with satisfaction. This chapter will provide an overview of IUDs, the subdermal implant and Depo-Provera, address barriers to care for adolescents, efficacy, continuation rates, common side effects and reasons for discontinuation, contraindications, and noncontraceptive benefits.

Contraceptive counseling for continuation and satisfaction

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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