Attitudes Toward Long-Acting Reversible Contraception Among Young Women Seeking Abortion

Contraceptive values and preferences of pregnant women, postpartum women, women seeking emergency contraceptives, and women seeking abortion services: A systematic review

OBJECTIVE

We sought to systematically review the literature on contraceptive values and preferences of pregnant women, postpartum women, women seeking emergency contraception, and women seeking abortion services, globally.

STUDY DESIGN

We searched ten electronic databases for articles from January 1, 2005 through July 27, 2020 regarding users' values and preferences for contraception. Results were divided into four sub-groups.

RESULTS

Twenty-three studies from 10 countries met the inclusion criteria. Values and preferences across all four sub-groups were influenced by method effectiveness, access, availability, convenience, cost, side effects, previous experience, partner approval, and societal norms. Similarities and differences were evident across sub-groups, especially concerning contraceptive benefits and side effects. No contraceptive method had all the features users deemed important. Many studies emphasized values and preferences surrounding long-acting reversible contraception (LARC), including convenience of accessing LARCs and concerns about side effect profiles.

DISCUSSION

Individuals must have access to a full range of safe and effective modern contraceptive options, allowing people to make decisions based on evolving contraceptive preferences over time. Future contraception guideline development, policy, and programmatic implementation should continue considering the added influence of these specific reproductive experiences on contraceptive values and preferences of users to improve access, counseling, and method choice.

Women's perspectives on long-acting reversible contraception: a critical scoping review of qualitative research

Long-acting Reversible Contraception (LARC) has significant promise both from a public health outlook and a social justice perspective. However, if women's empowerment is to be supported, then perspectives and experiences of LARC must be considered. This scoping review assesses research about contraceptive users' perspectives and experiences of contraceptive decision-making and practices. A content analysis was conducted to identify research trends in qualitative studies of contraceptive-user perspectives (n = 54), located by means of a systematic search. Interpreting findings through a reproductive justice lens, three main limitations in the scholarship were identified, viz., (1) an instrumentalist, individual-level focus; (2) a lack of consideration for diverse perspectives; and (3) an uncritical focus on young women. While the small body of qualitative research on LARC offers some valuable insights, when viewed from a sexual and reproductive justice perspective, it is not sufficiently user-centered or grounded within the reproductive politics surrounding contraceptive care and provision. Research is needed that draws on appropriate social theory; widens its focus beyond dominant groups; and is cognizant of the multi-level power relations surrounding LARC. Such work provides a nuanced picture of the complex social and contextual factors at play and inform person-centered approaches in sexual and reproductive health policy and programming.

Contraceptive values and preferences of adolescents and young adults: A systematic review

OBJECTIVE

We sought to systematically review the literature on values and preferences for contraception among adolescents and young adults globally.

STUDY DESIGN

We searched ten electronic databases for articles from January 1, 2005 through July 27, 2020 regarding end-users' values and preferences for contraception. We included studies that report specifically on people up to 25 years old.

RESULTS

Fifty-five studies out of 7,846 met our inclusion criteria. These studies included participants aged 10-25 years and were conducted in 16 countries. Through open coding, we identified 18 content areas. The five most commonly discussed content areas were: (1) general preferences regarding contraception, (2) contraceptive method benefits, (3) contraceptive method drawbacks, (4) the influence of the social context, and (5) the influence of myths and misconceptions, including safety and side effects, on contraceptive choice. Privacy and autonomy were important overarching themes, along with safety of the method. These considerations affected participants' access to and use of contraception.

CONCLUSION

Various social, cultural, and method-specific factors influence a young person's values and preferences around contraceptive methods. Understanding their values and preferences can help providers and programs improve contraceptive care for young people.

Time Trends in Massachusetts Adolescents' Postabortion Contraceptive Uptake

PURPOSE

The purpose of the study was to assess uptake of postabortion contraception across changes in insurance regulations and insurance type used on the day of abortion, accounting for demographic characteristics and consent type (parental vs. judicial) for abortion among Massachusetts adolescents.

METHODS

We conducted a retrospective record review of 1,375 minors (≤17 years) presenting for their first lifetime surgical abortion at a statewide network of abortion clinics between 2010 and 2016. Postabortion contraceptive method was defined as long-acting reversible contraception (LARC) placed onsite, short-acting reversible contraception (SARC) provided onsite, or no method received.

RESULTS

The proportion of minors leaving with no method dropped from 38% in 2010 to 21% in 2016, while LARC placement increased from 19% to 45%. No difference was observed by consent type. Both LARC and SARC were more prevalent among minors with Medicaid or private insurance compared to those not using insurance on the day of abortion. In a multinomial regression model accounting for consent type and demographic characteristics, minors who received care during the final epoch of the study (relative risk ratio [RRR] = 3.30; 95% confidence interval [CI]: 2.23-4.88) or used private insurance (RRR = 3.91; 95% CI: 2.24-6.84) or Medicaid (RRR = 5.54; 95% CI: 3.37-9.11) on the day of service had significantly higher relative risk of receiving LARC versus no method (p < .001), with similar results for LARC versus SARC.

CONCLUSIONS

Postabortion contraceptive uptake changed over time. Disparately low LARC uptake among minors not using insurance to pay for their abortions highlights a need to ensure equitable access to all methods, regardless of ability to pay.

Differences in knowledge and attitudes toward the intrauterine device: Do age and race matter?

AIM

The intrauterine device (IUD) is highly effective birth control, but US IUD usage lags. Barriers to usage, including patient attitudes and lack of knowledge, are not well-characterized. This study sought to investigate how attitudes and knowledge about IUD vary by age and race.

METHODS

A survey was distributed to all women in the outpatient obstetrics and gynecology office of a large, urban, academic medical center in Philadelphia. Exclusion criteria included inability to read English or age less than 14 years. Surveys queried participant demographics, knowledge about and opinions of IUD. The authors performed exploratory bi-variable analysis using t tests and chi-square testing to determine which outcomes differed by age and race. For those differing significantly, the authors performed regression analysis to assess for confounding by other factors.

RESULTS

Of 1366 women approached, 521 completed the survey (38% response rate). After controlling for confounding, only responses to the statement 'Hormonal birth control is safe and effective' differed significantly by age. Knowledge about IUD did not differ significantly by race, but black women were significantly more likely to perceive that they had insufficient knowledge about IUD compared to white women (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.06-3.46). Black women had a more negative opinion of IUD safety (OR: 5.0; 95% CI: 2.35-10.66) and reliability (OR: 5.5; 95% CI: 2.20-14.13) than white women.

CONCLUSION

Attitudes and knowledge about IUD do not differ significantly by age. While knowledge about IUD is similar between races, black women may have more negative opinions of IUD.

Patient Opinions About Foreign Body Contraceptives

Background: Prior studies have noted patient reluctance to use contraceptive devices that require insertion into their bodies. We sought to better understand this “foreign body” concern, as well as to clarify how women perceive long-acting reversible contraception (LARC) devices compared with other implanted medical devices.

Materials and Methods: We performed semistructured qualitative individual interviews with female obstetric/gynecologic patients and probed their opinions regarding LARC devices. Trained coders analyzed interview content using an inductive iterative approach and identified key themes.

Results: We found three major themes in our analysis. First, women frequently expressed uncertainty about where in the body intrauterine devices reside and the impact of a foreign body in that space. Second, women expressed discomfort with the invisibility of the device itself and the “set and forget” feature of LARCs. Finally, when asked to consider contraceptive devices in the context of other implantable medical devices, patients highlighted that contraceptive devices are elective and have alternative options.

Conclusions: When women express concerns about contraceptive devices “up in them,” they are expressing concerns about how these devices interact with their anatomy and the possibilities of harm and failure. These perceived risks of LARCs may not compare favorably with other contraceptive methods that are not foreign bodies. Understanding this perspective improves our ability to participate in shared decision-making.

Prevalence of and factors associated with unplanned pregnancy among women in Koshu, Japan: cross-sectional evidence from Project Koshu, 2011-2016

Background

Unplanned pregnancy is a public health issue with adverse consequences for maternal and neonatal health. In Japan, the prevalence of unplanned pregnancy was 46.2% in 2002. However, few studies have investigated this topic, and there is little recent data from Japan. We described and examined the prevalence and determinants of unplanned pregnancy among rural women in Japan from 2011 to 2016.

Methods

We used cross-sectional data from a community-based cohort study (Project Koshu). Data were collected from 2011 to 2016 via a self-report questionnaire included in the Maternal and Child Health Handbook of Japan. Pregnancy intention was measured as a binary variable (planned or unplanned). Univariate and multivariate logistic regression analyses were performed to examine factors associated with unplanned pregnancy, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). We conducted sensitivity analyses with different definitions of pregnancy intention to assess the robustness of the results. The significance level was set at 5%.

Results

Of the 932 participants (mean ± standard deviation age at baseline: 31.3 ± 5.2 years), 382 (41%) pregnancies were reported as unplanned. The multivariate analyses showed that maternal age (+ 1 year: OR = 0.94, 95% CI: 0.92–0.97, p <  0.001), ‘other’ family structure (OR = 2.76, 95% CI: 1.12–6.76, p = 0.03), three or more pregnancies (OR = 2.26, 95% CI: 1.66–3.08, p <  0.001), current smoking (OR = 2.60, 95% CI: 1.26–5.35, p = 0.01), balanced diet (OR = 0.62, 95% CI: 0.47–0.83, p <  0.001) and current depression (OR = 1.63, 95% CI: 1.24–2.16, p <  0.001) were strongly associated with unplanned pregnancy. These associations were consistent across definitions of pregnancy intention, supporting the robustness of our results.

Conclusions

The prevalence of unplanned pregnancy in the study population was high (41%). Risk factors for unplanned pregnancy were age, number of pregnancies, smoking, having a balanced diet and current depression. These results suggest greater efforts are needed to enhance sex education for young people, improve access to family planning services and provide comprehensive health care for high-risk women to help reduce unplanned pregnancies.

Perception And Use Of Intrauterine Contraceptive Devices (IUCD) Among Married Women Of Reproductive Age In Bhaktapur, Nepal

Purpose

The copper-T (TCu-380A), an intrauterine contraceptive device (IUCD), is widely available and is highly effective in terms of safety and effectiveness. Despite this fact, there is low utilization of IUCD in Nepal. This paper describes the perception and use of IUCD among married women of reproductive age attending an institutional clinic in Bhaktapur, Nepal.

Methods

An institution-based cross-sectional study was conducted among 273 married women attending the institutional clinic of Bhaktapur hospital who were interviewed by trained staff nurses using semi-structured questionnaires. Systematic random sampling method was applied to select the participants. Logistic regression analysis was used to determine the relationship between factors associated with utilization of IUCD.

Results

Just below half (48.7%) of the participants had heard about IUCD. Only 7.0% of the potential users were currently using IUCD, and all of them had discussed using it with their husbands. Among women aware of IUCD, nearly a quarter of them (23.8%) did not want to use it because of their husband's disapproval and their assumed fear of decreased sexual pleasure. There was a significant association between previous abortion and use of IUCD, where the women who had a history of abortion had increased odds of using the IUCD by 5.45-times compared to those who had not (p=0.01). The women who were counseled about IUCD by health workers were 2.83-times more likely to use an IUCD than those who were not. The women who had a good knowledge level about IUCD as a method of modern contraception had 2.85-times increased odds of using the IUCD compared to those who had poor or no knowledge about it.

Conclusion

The use of IUCD depends on the support of husbands, knowledge about its safety, efficacy, and counseling.

Association Between Women's Use of Long-Acting Reversible Contraception and Declining Abortion Rates in New Zealand

Background: To investigate the hypothesis that increased uptake of long-acting reversible contraception (LARC) by women played a role in the declining abortion rates observed in New Zealand between 2008 and 2014. Materials and Methods: This quantitative ecological study analyzed routinely collected national data pertaining to abortion numbers, contraceptive prescriptions, and census population estimates for the period 2004-2014. Annual prescription and prevalence rates (per 1000 women) were calculated for short- and long-acting methods to investigate changes over time. Poisson's regression was used to (1) test whether the abortion rate changed by year; (2) whether 2010 (when the contraceptive implant became subsidized) was a significant point of change; and (3) test the relationship between declining abortions and patterns of contraceptive use. Results: Estimated LARC prevalence increased from 2009 to 2014, with a corresponding decrease observed in prescription of short-acting methods. The declining abortion rate accelerated each year from 2008 to 2014 (with a faster decline from 2010 to 2014), but 2010 was not a significant point of change. Three factors had statistically significant associations with declining abortion rates (p < 0.01): year (acting as a surrogate for all social changes), women's use of the levonorgestrel (LNG)-implant, and the combined model: use of the LNG-implant and copper intrauterine device (CuIUD) had the best fit (using Akaike's Information Criterion), indicating that this variable explained more of the year-to-year variability in abortion rates. Conclusions: The shift toward women's increased use of the two publically funded LARC methods (LNG-implants and CuIUD) was significantly associated with the declining abortion rates in New Zealand.

Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden

BACKGROUND

Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception.

METHODS

Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data.

RESULTS

Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion.

CONCLUSION

The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements

Introduction

Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal.

Methods

This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities.

Findings

Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02–1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01–1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75–8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06–7.75) compared with private sector health facilities.

Conclusion

The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial

BACKGROUND

With advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge.

METHODS

This was a pilot randomised controlled trial. Prior to their abortion visit, participants were randomised to the intervention message, a standardised notification about the availability, effectiveness and safety of long-acting (LARC) and short-acting reversible contraception (SARC) on the day of the abortion, or to the control message, a reiteration of appointment logistics without information about contraception. At the visit, participants completed a pre-procedure survey to assess contraceptive knowledge and usefulness of the intervention. The primary outcome was knowledge of LARC availability immediately after surgical abortion. A secondary outcome was contraceptive method uptake.

RESULTS

We enrolled 234 subjects. The pre-visit telephone notification improved knowledge that LARC is available immediately after surgical abortion (71.3% vs 50.9%, P<0.01). Participants in both study arms found the telephone notifications useful. Post-abortion contraceptive method choice did not differ between study arms.

CONCLUSIONS

Advance notice about contraception was acceptable to surgical abortion patients and improved their contraceptive knowledge.

TRIAL REGISTRATION NUMBER

NCT02836561.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes

INTRODUCTION

Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review.

METHODS

We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers.

RESULTS

We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains.

CONCLUSIONS

Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

Long-acting reversible contraceptive use in the post-abortion period among women seeking abortion in mainland China: intentions and barriers

Background

This study aimed to describe the intentions of and barriers to the use of long-acting reversible contraceptives (LARCs) in the post-abortion period among women seeking abortion in mainland China.

Methods

A cross-sectional study was conducted from July 2015 to December 2015 using a waiting room questionnaire. A total of 381 women seeking abortions were recruited at a public hospital abortion clinic. The outcome variable was an ‘intention-to-use’ LARCs in the immediate post-abortion period. Chi-square tests were used to assess associations between categorical variables. Statistically significant variables (p ≤ 0.05) were then further analyzed by logistic regression.

Results

Among 381 respondents, 42.5% intended to use LARCs in the immediate post-abortion period; 35.2% intended to use intra-uterine devices (IUDs); and 13.9% intended to use implants. Previous use of LARC was a predictor for an intention to use LARCs (odds ratio [OR] = 2.41; 95% confidence interval [CI]: 1.06–5.47). Participants with one or no child had reduced odds for an intention to use LARC (OR = 0.32, 95% CI: 0.15–0.47 and OR = 0.29, 95% CI: 0.13–0.68, respectively). Women with a higher sex frequency (at least once per week) showed increased odds for LARC use (OR = 3.34; 95% CI: 1.03–10.78) and married women were more likely to use LARC than single women (OR = 1.57; 95% CI:1.00–2.47). Women who planned to have another baby within two years were more likely not to use LARCs in the immediate post-abortion period (OR = 0.97; 95% CI: 0.43–2.12). Barriers to the use of LARCs were anxiety relating to impaired future fertility (56.2%), LARCs being harmful to health (45.2%), irregular bleeding (44.3%), risk of IUD failure (41.6%) and lack of awareness with respect to LARCs (36.1%).

Conclusions

Intention to use LARCs was predicted by marital status, frequency of sexual activity, number of children, planned timing of next pregnancy, and previous LARC use. Impaired future fertility, being harmful to health, irregular bleeding, risk of complications, and lack of awareness with regards to LARCs were the main barriers in their potential use.

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.

[Contraception in Mexican adolescents in upper secondary schools: use and unmet needs]

OBJECTIVE

To describe sexual behavior and contraceptive use in adolescent students.

MATERIALS AND METHODS

National representative survey in upper secondary schools in Mexico 2014. Logistic regressions identify the factors associated with contraceptive use and unmet needs for contraception (UNC).

RESULTS

For male adolescents, non-contraceptive use in the last sexual relation is associated with non-contraceptive use in the sexual debut (OR=11.5; IC95%:5.6,23.4) and not recognizing effective contraceptive methods (OR=2.4;IC95%:1.04,5.5). For female adolescents, non-contraceptive use is associated with non-contraceptive use in sexual debut (OR=4.5;IC95%:2.3,8.4) and low self-efficacy towards condom use and negotiation (OR=3.1; IC95%:1.1,8.2). UNC were associated with insecure attitudes towards condom use and negotiation (OR=3.5;IC95%:1.3,9.4), non-contraceptive use in sexual debut (OR=9.0;IC95%:2.5,32.4) and use of alcohol or drugs during sexual relations (OR=3.0;IC95%:1.1,8.1).

CONCLUSIONS

Strategies to ensure contraceptive use from sexual debut onwards are required, promoting self-efficacy and safe sex practices among adolescents.

A Snapshot of Urban Adolescent Women's Contraceptive Knowledge at the Onset of a Community Long-Acting Reversible Contraceptive Promotion Initiative

STUDY OBJECTIVE

To contextualize young women's knowledge and attitudes regarding contraception at the outset of an intervention promoting long-acting reversible contraceptive (LARC) use for teen pregnancy prevention.

DESIGN AND SETTING

Our intervention was on the basis of diffusion of innovation theory, and at the outset we were interested in likely early adopters' existing knowledge and attitudes toward contraception. This mixed methods study consisted of focus groups within positive youth development programs in Rochester, New York; we discussed young women's knowledge and sources of information for all US Food and Drug Administration-approved contraceptive methods.

PARTICIPANTS

Seven focus groups and 24 female adolescent participants aged 15-19 years.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Quantitative ranking of all contraceptive methods; qualitative themes from focus group discussions.

RESULTS

Our findings showed a high level of knowledge about a select group of methods, which included LARC methods, and that participants received contraceptive information from peers and family. Participants had more concerns than positive impressions regarding the effectiveness, safety, practicality, and partner reception of the contraceptive methods, with the exception of the condom. Quantitatively, the condom received the highest average rating.

CONCLUSION

The importance of personal anecdotes in our findings supports the use of outreach and information campaigns; providing medically accurate information and spreading positive personal anecdotes will be key to improving young women's impressions of the safety and acceptability of LARC use. This snapshot of contraceptive knowledge indicates that young women can be mature, informed consumers of sexual and reproductive health care, and through diffusion of innovation could be key players in promoting the most effective means of pregnancy prevention.

Postabortion Contraceptive Use and Continuation When Long-Acting Reversible Contraception Is Free

OBJECTIVE

To compare preference for long-acting contraception (LARC) and subsequent use, year-long continuation, and pregnancy among women after induced abortion who were and were not eligible to participate in a specialized funding program that provided LARC at no cost.

METHODS

Between October 2014 and March 2016, we conducted a prospective study of abortion patients at Planned Parenthood in Austin, Texas (located in Travis County). We compared our primary outcome of interest, postabortion LARC use, among women who were eligible for the specialized funding program (low-income, uninsured, Travis County residents) and two groups who were ineligible (low-income, uninsured, non-Travis County residents, and higher income or insured women). Secondary outcomes of interest included preabortion preference for LARC and 1-year continuation and pregnancy rates among the three groups.

RESULTS

Among 518 women, preabortion preference for LARC was high among all three groups (low-income eligible: 64% [91/143]; low-income ineligible: 44% [49/112]; and higher income 55% [146/263]). However, low-income eligible participants were more likely to receive LARC (65% [93/143] compared with 5% [6/112] and 24% [62/263], respectively, P<.05). Specifically, after adjusting for age, race-ethnicity, and education, low-income eligible participants had a 10-fold greater incidence of receiving postabortion LARC compared with low-income ineligible participants (incidence rate ratio 10.13, 95% confidence interval [CI] 4.68-21.91). Among low-income eligible and higher income women who received postabortion LARC, 1-year continuation was 90% (95% CI 82-97%) and 86% (95% CI 76-97%), respectively. One-year pregnancy risk was higher among low-income ineligible than low-income eligible women (hazard ratio 3.28, 95% CI 1.15-9.31).

CONCLUSION

Preference for postabortion LARC was high among all three eligibility groups, yet women with access to no-cost LARC were more likely to use and continue these methods. Low-income ineligible women were far more likely to use less effective contraception and become pregnant. Specialized funding programs can play an important role in immediate postabortion contraceptive provision, particularly in settings where state funding is limited.

Bone Mineral Density and Weight Changes in Adolescents Randomized to 3 Doses of Depot Medroxyprogesterone Acetate

STUDY OBJECTIVE

To assess the association between medroxyprogesterone acetate exposure and bone mineral density (BMD) loss and weight change in adolescents.

DESIGN

Forty-eight-week prospective, randomized trial conducted May 2012-April 2014.

SETTING

Recruitment occurred in the general community and outpatient clinics in central Ohio.

PARTICIPANTS

Self-referred sample of 34 female adolescents aged 12-21 years initiating depot medroxyprogesterone acetate (DMPA).

INTERVENTIONS

Randomization to 1 of 3 DMPA doses (150, 104, or 75 mg) given intramuscularly every 12 weeks for 48 weeks.

MAIN OUTCOME MEASURES

Absolute and percent change in BMD from 0-48 weeks at the L1-L4 lumbar spine, total hip, and femoral neck; absolute and percent change in weight at 48 weeks.

RESULTS

DMPA dose was associated with medroxyprogesterone acetate exposure as evidenced by a direct relationship (P < .001) between dose group and area under the concentration time curve. At 48 weeks, no significant BMD decreases were seen in the 75 mg dose group. The 104 and 150 mg dose groups experienced significant (P < .01) decreases in L1-L4 lumbar spine BMD (3.1% and 4.0%, respectively). The 150 mg group also had significant (P < .05) decreases in total hip (3.0%) and femoral neck (4.0%) BMD. No group differences in weight change were observed. No pregnancies occurred in any DMPA dose group.

CONCLUSIONS

Our data provide evidence of a dose-response relationship between DMPA and BMD loss. Intramuscular DMPA doses less than 150 mg can decrease risk of BMD loss in adolescents. The risk/benefit ratio of lower-dose DMPA should be further investigated in larger and more diverse adolescent populations.

Postabortion Initiation of Long-Acting Reversible Contraception by Adolescent and Nulliparous Women in New Zealand

PURPOSE

To describe changes in receipt of immediate postabortion long-acting reversible contraception (LARC) by adolescent and nulliparous women in New Zealand.

METHODS

Nationally collected data on immediate postabortion receipt of an intrauterine method (intrauterine device [IUD]/intrauterine system [IUS]) or contraceptive implant were analyzed to describe proportions and demographic characteristics of women receiving LARC between 2007 and 2013. Changes in uptake over time were presented for adolescent, nulliparous, and parous women.

RESULTS

Postabortion LARC uptake increased between 2007 and 2013, rising from 7.9% to 42.7% for adolescents and from 8.8% to 36.9% for nulliparous women. The increase was highest among nulliparous adolescents with a seven-fold increase in LARC uptake between 2007 and 2013. Adolescents had a five-fold increase and nulliparous women (of all ages) a four-fold increase. In 2013, IUD/IUS use was lowest among adolescents (22.4%) and increased with increasing age (43% by ages 40+ years), whereas implant use was highest among adolescents (20.3%) and decreased with increasing age (to 4.6% by age 40+ years). Nulliparous women had the lowest use of both IUD/IUS and implants in 2013, with 24.6% receiving an intrauterine method (compared with 43.2% for para 3+), and 12.3% an implant (compared with 17.5% for para 3+).

CONCLUSIONS

Despite an overall trend toward increased uptake of postabortion LARC by adolescent and nulliparous women, uptake in these groups still lags behind that of parous and older women. Reasons for differential uptake need to be explored and addressed if necessary to ensure all women have equitable access to the most effective methods of contraception.

Adolescent Experiences With Intrauterine Devices: A Qualitative Study

PURPOSE

The purpose of this study was to improve understanding of adolescents' reasons for choosing an intrauterine device (IUD) and to explore experiences that led to continuation or discontinuation of the levonorgestrel intrauterine system (LNG-IUS) and the copper IUD (copper IUD).

METHODS

We conducted focus groups (FGs) with adolescents and young women who were current or former IUD users stratified by IUD type and 12-month IUD continuation or discontinuation. All subjects were participants from the Contraceptive CHOICE Project. FG data were supplemented with in-depth interviews (IDIs). Data collection was continued until thematic saturation was reached. Transcripts were independently coded by two researchers, and interrater reliability was calculated using a Kappa coefficient. Analysis followed a standard text-analysis approach.

RESULTS

Thirteen FGs and seven IDIs were conducted with 43 young women. Effectiveness, duration of use, convenience, and potential bleeding changes emerged as themes for both choosing and continuing IUDs. Some women chose the LNG-IUS to achieve amenorrhea, whereas copper IUD users wanted a nonhormonal method and continued menses. Copper IUD users cited expulsion and bleeding irregularities as reasons for discontinuation, whereas LNG-IUS users reported bleeding irregularities and continued pain as reasons for removal. IUD users noted an adjustment period of weeks to months in which side effects were present before lessening.

CONCLUSIONS

Effectiveness, duration of use, convenience, and potential changes in bleeding patterns drove adolescents' choice and continuation of an IUD. Bleeding changes and pain contributed to IUD discontinuation. Discussion of effectiveness, duration and convenience, and anticipatory guidance regarding post-insertion side effects may be important in counseling young women about IUDs.

Perspectives on family planning services among adolescents at a Boston community health center

STUDY OBJECTIVE

The aim of this project was to investigate adolescent perspectives on family planning services at a community-health center, with the intent to inform health center programs aimed at stemming the adolescent pregnancy rate.

DESIGN

This project was cross-sectional and employed mixed methods, including surveys and interviews, for the purposes of quality improvement.

SETTING

The project was conducted in the obstetrics and gynecology clinic at an urban community health center in Boston.

PARTICIPANTS

Twenty adolescent females (age 16-20) who used services at the health center.

INTERVENTION

Participants were individually interviewed to assess perspectives on family planning services and to identify major influences on methods of pregnancy prevention.

MAIN OUTCOME MEASURE

Major themes were categorized into contraceptive usage, reproductive health knowledge, adult influence and communication, barriers to contraceptive care and expectations of a family planning clinic.

RESULTS

All participants were sexually active and 80% had experienced pregnancy. Reproductive health knowledge was variable and in many cases limited. Concern about disapproval was a prominent barrier to going to a clinician for contraception or advice and parents were not often involved in the initial contraception discussion. Other barriers to use of contraception included forgetting to use the methods and fear of side effects.

CONCLUSION

We identified several potentially modifiable factors, including lack of knowledge, concern for provider disapproval and fear of side effects that may limit effective use of family planning services by adolescents. Further attention should be paid to these factors in designing and improving youth-friendly services in ob-gyn clinics.

An exploratory analysis of contraceptive method choice and symptoms of depression in adolescent females initiating prescription contraception

OBJECTIVE

We examine the association between depressive symptoms and contraceptive method choice among adolescents initiating prescription contraception.

STUDY DESIGN

This cross-sectional study analyzes baseline data of 220 urban, minority adolescent females (ages 15-19 years) presenting for prescription contraceptive initiation at a comprehensive, free-of-cost, adolescent health center in New York City. All participants met with a health care provider who provided standard contraception counseling before initiating contraception. Each participant then selected a short- or long-acting contraceptive: a 3-month supply of the pill, patch, ring or a medroxyprogesterone acetate depot injection (short-acting), or placement/referral for an intrauterine device (IUD; long-acting). We assess the independent association between contraceptive method selection and symptoms of depression [assessed by the Center for Epidemiological Studies - Depression (CES-D) scale].

RESULTS

Ten percent (n=21/220) of adolescent females selected an IUD. Bivariate analysis revealed that those with elevated levels of depressive symptoms were more likely to select an IUD as compared to those with minimal symptoms (mean CES-D score 20 vs. 13; t=3.052, p=.003). In multivariate logistic regressions, adolescent females had increased odds of selecting an IUD if they reported moderate to severe depressive symptoms (adjusted odds ratio=4.93; confidence interval, 1.53-15.83; p=.007) after controlling for ethnicity/race, education, number of lifetime partners and gravidity.

CONCLUSIONS

Inner-city, minority adolescents with elevated symptoms of depression who present for prescription contraceptive initiation may be more likely to select an IUD rather than shorter-acting methods. By recognizing adolescent females with depressive symptoms, providers can strategize their approach to effective contraception counseling.

Time to second abortion or continued pregnancy following a first abortion: a retrospective cohort study

STUDY QUESTION

What proportions of women have a second abortion or continued pregnancy within 12-46 months of a first abortion?

SUMMARY ANSWER

Estimated return rates for a second abortion were 5, 10.9 and 19.8% at 12, 24 and 46-months, respectively, and rates of continued pregnancy were 5.6, 12.9 and 24.3% at the same intervals.

WHAT IS KNOWN ALREADY

Studies attempting to identify women at risk for 'repeat abortion' for intervention purposes have described a range of demographic and behavioural characteristics associated with presentation for more than one abortion, but few have taken timing of abortions into account.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study involving women presenting for a first abortion at a public hospital abortion clinic in New Zealand (2007-2010).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Electronically stored records were analysed for women discharged from a public hospital abortion clinic in New Zealand. Outcome measures were the proportion of women having a second abortion or continued pregnancy within 24 months of a first abortion, and characteristics associated with shorter time to subsequent pregnancy. Cox proportional hazards modelling was used to detect factors associated with time to a second abortion or continued pregnancy, and Kaplan-Meier survival analyses were used to estimate time to one of these two pregnancy outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 6767 women had a first abortion between 2007 and 2010. Some data were missing for 11 women so were excluded from the cohort and analyses. Return rates for a second abortion estimated from survival analyses were 5, 10.9 and 19.8% at 12, 24 and 46 months, respectively. Estimated rates of continued pregnancies were 5.6, 12.9 and 24.3% at 12, 24 and 46 months, respectively. Younger age, non-European ethnicity and greater parity were significantly associated with shorter time to a second abortion and to a subsequent continued pregnancy (P < 0.01 for all factor P-values). Hazard ratios (HR) for a second abortion were highest among those aged 16-19 years (HR 1.6, 95% confidence interval (CI) 1.3-1.9, Reference 20-24), of Pacific Island (HR 1.35, 95% CI 1.1-1.7) or Maori ethnicity (HR 1.26, 95% CI 1.1-1.5, Reference New Zealand European), and with 1 (HR 1.41, 95% CI 1.1-1.7) or 2 (HR 1.41, 95% CI 1.1-1.9, Reference nulliparous) children at the time of the first abortion. Both pregnancy outcomes were observed among 120 women (1.8%), with 60% of these women having a second abortion before the continued pregnancy.

LIMITATIONS, REASONS FOR CAUTION

This study was limited to analysis of routinely collected clinical and demographic data for women presenting for abortion over a 4-year period. Conclusions could not be drawn about a wider range of personal and situational factors influencing pregnancy and pregnancy outcomes. Data were drawn from only one clinic but characteristics of the study sample were broadly representative of those reported nationally. Loss to follow-up for women seeking a second abortion elsewhere in the country cannot be ruled out and would serve to underestimate return rates reported here.

WIDER IMPLICATIONS OF THE FINDINGS

To date, the most effective public health measure known to reduce abortion return rates within 24 months is the initiation of long-acting reversible contraception (LARC) at the time of an abortion. The high proportion of women seeking a second abortion <4 years after a first abortion (20%) could be significantly reduced by use of LARC, as could unintended pregnancies that are continued soon after a first abortion, particularly among teenaged and young women. Barrier-free access to a range of LARC methods should be prioritized to prevent unintended and mistimed pregnancies.

STUDY FUNDING/COMPETING INTERESTS

Funded by a Lottery Health Research Grant and a University of Otago Research Grant. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Long-acting reversible contraception for adolescents and young adults: patient and provider perspectives

STUDY OBJECTIVE

To describe and explore provider- and patient-level perspectives regarding long-acting reversible contraception (LARC) for teens and young adults (ages 16-24).

METHODS

Data collection occurred between June and December 2011. We first conducted telephone interviews with administrative directors at 20 publicly funded facilities that provide family planning services. At 6 of these sites, we conducted a total of 6 focus group discussions (FGDs) with facility staff and 48 in-depth interviews (IDIs) with facility clients ages 16-24.

RESULTS

Staff in the FGDs did not generally equate being a teen with ineligibility for IUDs. In contrast to staff, one-quarter of the young women did perceive young age as rendering them ineligible. Clients and staff agreed that the "forgettable" nature of the methods and their duration were some of LARC's most significant advantages. They also agreed that fear of pain associated with both insertion and removal and negative side effects were disadvantages. Some aspects of IUDs and implants were perceived as advantages by some clients but disadvantages by others. Common challenges to providing LARC-specific services to younger patients included extra time required to counsel young patients about LARC methods, outdated clinic policies requiring multiple visits to obtain IUDs, and a perceived higher removal rate among young women. The most commonly cited strategy for addressing many of these challenges was securing supplementary funding to support the provision of these services to young patients.

CONCLUSION

Incorporating young women's perspectives on LARC methods into publicly funded family planning facilities' efforts to provide these methods to a younger population may increase their use among young women.

Preventing unintended pregnancies by providing no-cost contraception

OBJECTIVE

To promote the use of long-acting reversible contraceptive (LARC) methods (intrauterine devices [IUDs] and implants) and provide contraception at no cost to a large cohort of participants in an effort to reduce unintended pregnancies in our region.

METHODS

We enrolled 9,256 adolescents and women at risk for unintended pregnancy into the Contraceptive CHOICE Project, a prospective cohort study of adolescents and women desiring reversible contraceptive methods. Participants were recruited from the two abortion facilities in the St. Louis region and through provider referral, advertisements, and word of mouth. Contraceptive counseling included all reversible methods but emphasized the superior effectiveness of LARC methods (IUDs and implants). All participants received the reversible contraceptive method of their choice at no cost. We analyzed abortion rates, the percentage of abortions that were repeat abortions, and teenage births.

RESULTS

We observed a significant reduction in the percentage of abortions that were repeat abortions in the St. Louis region compared with Kansas City and nonmetropolitan Missouri (P<.001). Abortion rates in the CHOICE cohort were less than half the regional and national rates (P<.001). The rate of teenage birth within the CHOICE cohort was 6.3 per 1,000, compared with the U.S. rate of 34.3 per 1,000.

CONCLUSION

We noted a clinically and statistically significant reduction in abortion rates, repeat abortions, and teenage birth rates. Unintended pregnancies may be reduced by providing no-cost contraception and promoting the most effective contraceptive methods.