Associations Among Menstrual Cycle Length, Coronavirus Disease 2019 (COVID-19), and Vaccination

OBJECTIVE

To assess whether coronavirus disease 2019 (COVID-19) is associated with menstrual cycle length changes and, if so, how that compares with those undergoing vaccination or no event (control).

METHODS

We conducted a retrospective cohort analysis in which we analyzed prospectively tracked cycle-length data from users of a period tracker application who also responded to a survey regarding COVID-19 symptoms and vaccination. We restricted our sample to users aged 16-45 years, with normal cycle lengths (24-38 days) and regular tracking behavior during the five cycles around COVID-19 symptoms or vaccination or a similar time period for those experiencing no event (control group). We calculated the within-user change in cycle length (days) from the three consecutive cycles preevent average (either vaccination, disease, or neither; cycles 1-3) to the event (cycle 4) and postevent (cycle 5) cycles. We used mixed-effects models to estimate the age- and country-adjusted difference in change in cycle length across the groups.

RESULTS

We included 6,514 users from 110 countries representing 32,570 cycles (COVID-19 symptoms: 1,450; COVID-19 vaccination: 4,643; control: 421). The COVID-19 cohort experienced a 1.45-day adjusted increase in cycle length during cycle 4 (COVID-19) compared with their three preevent cycles (95% CI 0.86-2.04). The vaccinated group experienced a 1.14-day adjusted increase in cycle length during cycle 4 (COVID-19 vaccine) compared with their preevent average (95% CI 0.60-1.69). The control group (neither vaccine nor disease) experienced a 0.68-day decrease (95% CI -1.18 to -0.19) in a similar time period. Post hoc tests showed no significant differences in the magnitude of changes between the COVID-19 and vaccination cohorts. In both cohorts, cycle length changes disappeared in the postevent cycle.

CONCLUSION

Experiencing COVID-19 is associated with a small change in cycle length similar to COVID-19 vaccination. These changes resolve quickly within the next cycle.

Evaluating the Acceptability and Feasibility of a Sexual Health-Focused Contraceptive Decision Aid for Diverse Young Adults: User-Centered Usability Study

BACKGROUND

Young adults with low sexual health literacy levels may find it difficult to make informed decisions about contraceptive methods. We developed and pilot-tested a web-based decision aid-Healthy Sex Choices-designed to support diverse young adults with their contraceptive decision-making.

OBJECTIVE

This pilot study aimed to evaluate whether the Healthy Sex Choices decision aid is acceptable and feasible to patients and clinicians.

METHODS

We used the Ottawa Decision Support Framework and the International Patient Decision Aid Standards to develop and pilot the decision tool. We first conducted a needs assessment with our advisory panel (5 clinicians and 2 patients) that informed decision aid development. All panelists participated in semistructured interviews about their experience with contraceptive counseling. Clinicians also completed a focus group session centered around the development of sex education content for the tool. Before commencing the pilot study, 5 participants from ResearchMatch (Vanderbilt University Medical Center) assessed the tool and suggested improvements.

RESULTS

Participants were satisfied with the tool, rating the acceptability as "good." Interviewees revealed that the tool made contraceptive decision-making easier and would recommend the tool to a family member or friend. Participants had a nonsignificant change in knowledge scores (53% before vs 45% after; P=.99). Overall, decisional conflict scores significantly decreased (16.1 before vs 2.8 after; P<.001) with the informed subscale (patients feeling more informed) having the greatest decline (23.1 vs 4.7; mean difference 19.0, SD 27.1). Subanalyses of contraceptive knowledge and decisional conflict illustrated that participants of color had lower knowledge scores (48% vs 55%) and higher decisional conflict (20.0 vs 14.5) at baseline than their white counterparts.

CONCLUSIONS

Participants found Healthy Sex Choices to be acceptable and reported reduced decisional conflict after using the tool. The development and pilot phases of this study provided a foundation for creating reproductive health decision aids that acknowledge and provide guidance for diverse patient populations.

Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis

BACKGROUND

The effectiveness and harms of contraceptive counseling and provision interventions are unclear.

PURPOSE

To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms.

DATA SOURCES

English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews.

STUDY SELECTION

Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control.

DATA EXTRACTION

Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model.

DATA SYNTHESIS

A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I ² = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I ² = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I ² = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I ² = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I ² = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I ² = 0.0%; 6 trials).

LIMITATION

Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes.

CONCLUSION

Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion.

PRIMARY FUNDING SOURCE

Resources Legacy Fund. (PROSPERO: CRD42020192981).

Long and short interpregnancy intervals increase severe maternal morbidity

BACKGROUND

Severe maternal morbidity is a composite variable that includes adverse maternal outcomes during pregnancy that are associated with maternal mortality. Previous literature has shown that interpregnancy interval is associated with preterm birth, fetal growth restriction, and low birthweight, but the association of interpregnancy interval and composite severe maternal morbidity is not well studied.

OBJECTIVE

We sought to determine the relationship between interpregnancy interval (stratified as <6, 6-11, 12-17, 18-23, 24-59, and ≥60 months) and severe maternal morbidity, which we considered both with and without blood transfusion.

STUDY DESIGN

This was a retrospective cohort study of multiparous women 15 to 54 years old with singleton, nonanomalous births between 23 and 42 weeks gestation in California (2007-2012). We defined severe maternal morbidity as the composite score of a published list of the International Classification of Diseases, ninth Revision, diagnoses and procedure codes, provided by the Centers for Disease Control and Prevention. We used chi-square tests for categorical variables, and multivariable logistic regression models were used to determine the association of interpregnancy interval (independent variable) with severe maternal morbidity (dependent variable), adjusted for maternal race and ethnicity, age, education, body mass index, insurance, prenatal care, smoking status, and maternal comorbidity index score.

RESULTS

Here, 1,669,912 women met the inclusion criteria, and of these women, 14,529 (0.87%) had severe maternal morbidity and 4712 (0.28%) had nontransfusion severe maternal morbidity. Multivariable logistic regression models showed that compared with women with 18 to 23 months interpregnancy interval, women with an interpregnancy interval of <6 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.14-1.34) and ≥60 months (adjusted odds ratio, 1.11; 95% confidence interval, 1.04-1.19) had significantly higher adjusted odds of severe maternal morbidity. The odds of nontransfusion severe maternal morbidity is higher in women with long interpregnancy intervals (≥60 months) after controlling for the same potential confounders (adjusted odds ratio, 1.17, 95% confidence interval, 1.04-1.31). In addition, we found significantly higher odds of requiring ventilation (adjusted odds ratio, 1.34; 95% confidence interval, 1.03-1.75) and maternal sepsis (adjusted odds ratio, 2.08; 95% confidence interval, 1.31-3.31) in women with long interpregnancy interval.

CONCLUSION

The risk of severe maternal morbidity was higher in women with short interpregnancy interval (<6 months) and long interpregnancy interval (≥60 months) compared with women with normal interpregnancy interval (18-23 months). The risk of nontransfusion severe maternal morbidity was significantly higher in women with long interpregnancy interval (≥60 months). Interpregnancy interval is a modifiable risk factor, and counseling women to have an adequate gap between pregnancies may be an important strategy to decrease the risk of severe maternal morbidity.

Comparison of immediate postpartum contraception among women with a high versus low risk pregnancy in Mexico: a retrospective cohort study

OBJECTIVE

We tested whether women who reported high-risk pregnancies or deliveries were more likely to receive immediate postpartum contraception prior to discharge compared with normal-risk women in Mexico.

METHODS

This is a retrospective study using the National Health and Nutrition Survey. We classified women as high-risk based on reported complications in pregnancy and delivery. We used multivariable logistic regression to test the association of high-risk status and receipt of postpartum contraception (any modern method and Tier one methods) prior to discharge.

RESULTS

Our sample included 5030 deliveries (population N=3 923 657). Overall, 19.1% of the sample were high risk. Over 60% of women in the high-risk and normal-risk group received immediate postpartum contraception, but a greater proportion of high-risk women received a method (67% vs 61% normal risk; p<0.001). However, in multivariable models, there were no significant differences in receipt of any modern method or tier 1 method by risk group.

CONCLUSION

Women with high-risk pregnancies were not more likely to receive postpartum contraception than the normal-risk group, once accounting for sociodemographic and clinical factors. Prenatal and postpartum contraception counselling should address the health effects of high-risk pregnancies and interpregnancy intervals to improve maternal health outcomes.

Medical indications for primary cesarean delivery in women with and without disabilities

Background: Prior research has found that women with disabilities are more likely to deliver by cesarean than are women without disabilities. It is not clear whether all of the cesarean deliveries among women with disabilities are medically necessary.Objectives: To examine the associations between maternal disability status and type, mode of delivery, and medical indications for cesarean delivery in California deliveries.Study design: Retrospective cohort study of all nulliparous births in California between 2000 and 2012. We classified births as to whether or not women underwent a trial of labor and determined if medical indications for cesarean delivery were present. Multivariable logistic regression models examined the association of disability with trial of labor and indications for cesarean delivery.Results: Women with disabilities had lower odds of having a labored delivery, compared to women without disabilities (adjusted odds ratio (aOR) = 0.45, 95% confidence interval (CI) 0.41-0.49). In the sample of women who labored (90.5% of total), women with disabilities were more likely to have a medical indication for cesarean delivery (aOR = 1.15, 95% CI 1.10-1.21) and were more likely to have a cesarean delivery (aOR = 1.46, 95% CI = 1.38-1.54). In the subsample of unlabored cesarean deliveries, women with disabilities were less likely to have documented medical indications for cesarean delivery (aOR = 0.45, 95% CI = 0.41-0.50).Conclusions: Women with disabilities were less likely to labor, and these unlabored cesarean deliveries were less likely to have a medical indication for cesarean, compared to women without disabilities.

Mass media exposure and modern contraceptive use among married West African adolescents

PURPOSE

The purpose of this study was to examine whether family planning (FP) messaging is reaching married adolescent women in West Africa, and whether such messaging is associated with increased contraceptive use.

MATERIALS AND METHODS

We utilised data from the 2010 Demographic and Health Surveys (DHS) for Burkina Faso and Senegal (women 15-49; N = 17,067 and N = 15,688, respectively). We used chi-square tests to evaluate whether FP messaging exposure (via TV, radio, and/or print) differed according to socio-demographic characteristics. Subsequent analysis focussed on married adolescents (15-19; N = 961 in Burkina Faso, N = 996 in Senegal) which utilised propensity score matching and multivariable logistic regression models to test the association between self-reported FP messaging exposure and modern contraceptive use, knowledge of a modern contraceptive method, and future intention to use contraception.

RESULTS

A higher proportion of women 15-49 who reported FP messaging exposure were urban, from higher wealth quintiles, and had higher education levels, compared with unexposed women. A smaller proportion of adolescents reported exposure compared to older age groups. Among married adolescents, there was a positive but non-significant association between FP messaging exposure and use of a modern contraceptive method in Senegal (adjusted odds ratio (aOR) = 2.3; 95% CI: 0.92, 5.73). No such association was found in Burkina Faso (aOR = 0.98; 95% CI: 0.43, 2.26).

CONCLUSIONS

Mass media campaigns are not reaching the most vulnerable populations in West Africa, such as adolescents and poorer rural women. Adapting mass media campaigns to address these gaps is important for increasing exposure to FP messaging.

Dissonant health transition in the states of Mexico, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time.

METHODS

We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors.

FINDINGS

From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1-3·8), from 72·1 years (71·8-72·3) to 75·5 years (75·3-75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9-14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6-23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013.

INTERPRETATION

Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state.

FUNDING

Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.