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

Effect of progestin-based contraceptives on HIV-associated vaginal immune biomarkers and microbiome in adolescent girls

Adolescent girls bear a disproportionate burden of both the HIV epidemic and unintended pregnancies; yet important questions remain unanswered regarding the effects of hormonal contraceptives on the vaginal immune microenvironment, which can impact HIV susceptibility in this group. Multiple studies report genital immune alterations associated with the progestin-based contraceptive Depot medroxyprogesterone acetate (DMPA) in adult women, but there is little available data in adolescents. The objective of this longitudinal cohort study was to evaluate the effects of short-term use of three progestin-based contraceptives, levonorgestrel intrauterine device (LNG-IUD), subdermal etonogestrel (ETNG), and injectable DMPA, on HIV-associated vaginal immune biomarkers and microbiome in adolescent girls. Fifty-nine sexually active, HIV-uninfected girls aged 15-19, were recruited from the Washington DC metro area and self-selected into Control (condoms only), combined oral contraceptive pills, LNG-IUD, ETNG and DMPA groups. Vaginal swabs were collected at baseline prior to contraceptive use and at 3-month follow-up visit. Vaginal secretions were tested for pro-inflammatory (IL-1α, IL-1β, TNF-α, IL-6, IL-8, MIP-3α, IP-10, RANTES, MIP-1α, MIP-1β) and anti-inflammatory/anti-HIV (Serpin-A1, Elafin, Beta-Defensin-2, SLPI) immune biomarkers using ELISA and for anti-HIV activity using TZM-bl assay. Vaginal microbiome was evaluated using 16S rRNA gene sequencing. Data were analyzed using SAS Version 9. Among the 34 participants who completed both visits, no significant changes in median biomarker concentrations, HIV inhibition and microbiome composition were observed between baseline and follow-up visits for any of the contraceptive groups. IL-8 (p<0.01), MIP-3α (0.02), Elafin (p = 0.03) and RANTES (p<0.01) differed significantly by race whereas IL-6 was significantly different by age (p = 0.03). We conclude that 3-month use of LNG-IUD, ETNG and DMPA have minimal effects on adolescent vaginal immune microenvironment, and therefore unlikely to impact HIV risk. Future studies with larger sample size and longer follow-up are recommended to continue to evaluate effects of contraceptives on the lower genital tract immunity and susceptibility to sexually transmitted infections.

Correlates of Sexual Behavior Across Fatherhood Status: Finding From the National Longitudinal Study of Adolescent to Adult Health (Add Health), 2016-2018

Amid national trends in postponed parenthood and more diverse family structures, the fatherhood identity may be important to men's sexual behaviors. This study examined factors associated with reports of consistent contraceptive use and multiple sexual partners across fatherhood status. Using public data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), Wave V (2016-2018), two sexual behaviors were examined among 1,163 men aged 32 to 42 years. Outcomes were two binary indicators: consistent contraceptive use with partner and having multiple (≥2) sexual partners in the past year. Fatherhood status was categorized as nonfather, resident father, and nonresident father. Demographic (e.g., race/ethnicity, education, income, and relationship type) and health-related (e.g., drinking, perceived stress, depressive symptoms, and insurance status) factors were considered. Logistic regression analysis produced odds ratios and 95% confidence intervals and were stratified by fatherhood categories. In the sample, 72% of men were resident fathers, 10% were nonresident fathers, and 18% were nonfathers; 28% reported consistent contraceptive use and 16% reported multiple sexual partners. For nonfathers, relationship type and race were associated with reporting multiple sexual partners. For resident fathers, relationship type was the crucial factor associated with consistent contraceptive use and reporting multiple sexual partners. In nonresident fathers, relationship type, education, and income were important factors to consistent contraceptive use and reporting multiple sexual partners. Key findings suggest that relationship type, income, and education are crucial factors to men's sexual behavior. Heterogeneous effects were observed across fatherhood status. This study adds to limited research on fatherhood and sexual behavior among men transitioning from young adulthood to middle age.

Respondent Demographics and Contraceptive Use Patterns in the United States: A National Survey of Family Growth Analysis

INTRODUCTION

Contraception is an important tool for helping to prevent both unintended pregnancies and sexually transmitted infections (STIs). Medical costs related to STIs are high and impose a large burden on both patients and the healthcare system. In addition, unintended pregnancies account for a large portion of pregnancies in the United States (US) and are associated with adverse maternal and infant health outcomes. Both STIs and unintended pregnancies are continuous public health concerns, and this study aims to identify patterns in contraceptive method use in relation to specific social determinants of health.

METHODS

Utilizing the Centers for Disease Control and Prevention (CDC)'s 2017-2019 National Survey of Family Growth report on current contraceptive status, we isolated data from 3,572 respondents who reported using one of the following contraceptive methods: oral contraceptive pills (OCPs), male condoms, partner's vasectomy, female sterilization, withdrawal, medroxyprogesterone acetate injections (Depo-Provera), hormonal implant, or an intrauterine device (IUD). We analyzed these contraceptive methods among age, race, education, marital status, and insurance status. Data were analyzed in RStudio 2022.02.0 (RStudio Team, RStudio: Integrated Development for R. RStudio, PBC, Boston, MA) through a test of equal proportions for a significance of P < 0.05. A concurrent Yates' continuity correction was performed in order to limit erroneous significant findings based on small sample sizes where applicable. The study conception and data analysis were performed independently with oversight from our preceptor at HCA Florida Brandon Hospital, Brandon, Florida.

RESULTS

There were statistically significant differences for all our selected methods of contraception across different age groups. There were statistically significant differences for OCPs, male condoms, partner's vasectomy, female sterilization, Depo-Provera, hormonal implant, and IUD across different race groups and different insurance statuses. There were statistically significant differences for OCPs, male condoms, partner's vasectomy, female sterilization, withdrawal, hormonal implant, and IUD across different education levels and different marital statuses.

CONCLUSION

This analysis highlights gaps that are present in female reproductive autonomy through the statistical differences in contraceptive methods across various demographics and warrants continued focus on the role that social determinants of health play in the prevention of unintended pregnancies and STIs. In order to promote fairness and equality in healthcare, it is essential to increase education on these topics both within and beyond medical settings. This effort aims to provide patients with equitable access to healthcare and attempt to address health disparities that are prevalent in multiple different sectors.

Employment Status in the United States and Use of Long-Acting Reversible Contraception or Moderately Effective Contraception before and after the Affordable Care Act: National Survey of Family Growth 2006-2010 and 2015-2017

Employment status has been previously associated with contraceptive use among women of reproductive age. We assessed the association between employment status and method of contraception among US women of reproductive age, before and after the implementation of the Affordable Care Act (ACA) passed in 2010. We conducted a cross-sectional study using data from the National Survey of Family Growth (NSFG): 2006-2010 survey for our pre-ACA analysis and 2015-2017 survey for post-ACA analysis. We combined the use of moderately-effective or long-acting reversible contraceptives (LARC) as the main study outcome. Multivariable logistic regression was used to estimate adjusted prevalence odds ratios (aPOR) and 95% confidence intervals (CI). Our study included 5,572 women pre-ACA and 2,340 women post-ACA. Pre-ACA, non-Hispanic white women who were employed were significantly more likely to use moderately-effective or LARC contraceptives (aPOR = 1.66; 95% CI = 1.28, 2.14), but post-ACA, this association was non-significant (aPOR = 0.94; 95% CI = 0.67, 1.33). Findings were not significant for other race/ethnic groups in either time frame. Our study shows that being employed was no longer associated with contraceptive method during a post-ACA time period among non-Hispanic white women. Modifications to the ACA should be scrutinized to further evaluate the impact it may have on women's access to moderately-effective or LARC contraception.

Medicaid Expansion and Contraceptive Use Among Female High-School Students

INTRODUCTION

Access to effective contraception prevents unintended pregnancies among sexually active female youth. Potentially impacted by the Affordable Care Act's Medicaid-related policies, contraception use increased among sexually active high-school students from 2013 to 2019.

METHODS

Analyses conducted in 2021 assessed state-level Youth Risk Behavior Survey data among female students in grades 9-12 who reported being sexually active. States that expanded Medicaid were compared with other states in 2013 (baseline) and 2019 (after expansion). Measured outcomes included self-reported use of moderately effective or highly effective, long-acting reversible contraception at last sex. Long-acting reversible contraception included intrauterine devices and implants. Moderately effective contraception included birth control pills, injectables, patches, or rings. Results were weighted and adjusted for age and race/ethnicity.

RESULTS

Students in Medicaid expansion states (n=27,564) did not differ significantly from those in nonexpansion states (n=6,048) at baseline or after expansion with respect to age, age at first sex, or the number of sexual partners in the past 3 months; however, race/ethnicity population characteristics changed over time. Postexpansion increased use of intrauterine devices/implants was greater in Medicaid expansion states than in nonexpansion states (238.1% increase vs 120.0% increase, adjusted p=0.047). For those aged 16-17 years, Medicaid expansion states had a 283.3% increase in intrauterine device/implant use compared with an increase of 69.7% in nonexpansion states (adjusted p=0.004).

CONCLUSIONS

Medicaid expansion was associated with a greater population-level increase in intrauterine device/implant use among sexually active female high-school students aged 16-17 years. These findings point to the possibility that the Affordable Care Act's Medicaid-related policies played a role in young women's use of intrauterine devices/implants.

Doctor Knows Best? Provider Bias in the Context of Contraceptive Counseling in the United States

OBJECTIVES

The study examined how clinicians described their patients in relation to their practices of contraceptive counseling.

STUDY DESIGN

This qualitative study involved individual interviews with 15 clinicians working in obstetrics and gynecology in South Carolina about their approaches to contraceptive counseling. We analyzed the data using a combination of deductive and inductive approaches.

RESULTS

Clinicians attributed challenges of working with diverse patient populations to patients' race/ethnicity, socioeconomic status, and age. Clinicians often interpreted patient concerns about or refusal to use effective contraceptive methods as a problem with patients themselves. When clinicians described patients in disparaging ways, they often focused on adolescent patients.

CONCLUSION

Bias informed by structural inequalities and power relations influences how clinicians perceive their patients and approach counseling them about contraception. Such practices may limit patients' informed decision-making and autonomy when making decisions about initiating or continuing contraceptive use.

Structural Inequity and Pregnancy Desires in Emerging Adulthood

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