Bridge over troubled waters: considerations in transitioning emergency contraceptive users to hormonal methods

BackgroundAs emergency contraceptive pills (ECPs) become increasingly available through pharmacies, concerns about potential overuse of this product have emerged. In response, bridging women from ECPs to ongoing contraception was advanced as a solution.Study DesignWe collected information in Ghanaian pharmacies on ECP users' sexual activity, use of contraceptive methods and reasons for buying ECPs. Further, two behavioral indicators were examined to determine whether a woman should consider using an ongoing contraceptive method: how often she has sex and how she uses ECPs.ResultsOf the four types of ECP users, stratified by those two indicators, only women who have sex frequently and use ECPs as their main contraceptive method would be appropriate for, but not necessarily amenable to, bridging.ConclusionsThe challenges of bridging to meet the contraceptive needs of women are discussed in light of the characteristics of emergency contraceptive users and suggest that bridging is not as straightforward as initially conceived.     

Emergency contraception: knowledge and attitudes of health care providers in a health maintenance organization.

One hundred sixty-four health care providers in a health maintenance organization were surveyed in 1996 regarding their knowledge of, attitudes toward, and perception of barriers regarding emergency contraceptive pills (ECPs), as well as their ECP prescribing practices. Providers reported primarily positive attitudes regarding ECPs. Only 42% reported having ever prescribed ECPs; those who had prescribed had more positive attitudes about ECPs. Knowledge of ECP provision was incomplete, with 40% believing treatment had to be initiated in 48 hours or less. Barriers identified by providers included lack of a dedicated product, lack of awareness of ECPs among providers, and liability issues.     

Safety and effectiveness data for emergency contraceptive pills among women with obesity: a systematic review

ObjectiveThis study aims to determine whether emergency contraceptive pills (ECPs) are less safe and effective for women with obesity compared with those without obesity.Study designWe searched PubMed for articles through November 2015 regarding the safety and effectiveness of ECPs [ulipristal acetate (UPA), levonorgestrel (LNG) and combined estrogen and progestin] among obese users. We assessed study quality using the United States Preventive Services Task Force evidence grading system.ResultsWe identified four pooled secondary analyses (quality: poor to fair), two of which examined UPA and three examined LNG formulations. Three analyses pooled overlapping data from a total of three primary studies and demonstrated significant associations between obesity and risk of pregnancy after ECP use. One analysis reported a 4-fold increased risk of pregnancy among women with obesity (BMI ≥ 30 kg/m²) compared with women within normal/underweight categories (BMI < 25 kg/m²) after use of LNG ECPs [odds ratio (OR) 4.4; 95% confidence interval (CI) 2.0–9.4]. Further analysis of the same LNG data found that, at an approximate weight of 80 kg, the rate of pregnancy rose above 6%, which is the estimated pregnancy probability without contraception; at weights less than 75 kg, the rate of pregnancy was less than 2%. Two analyses examining UPA suggested an approximate 2-fold increased risk of pregnancy among women with obesity compared with either normal/underweight women or nonobese (BMI < 30 kg/m²) women (OR 2.6; 95% CI 0.9–7.0 and OR 2.1; 95% CI 1.0–4.3, respectively), but CIs were wide. Finally, the fourth secondary analysis pooled data from three separate randomized controlled trials on LNG ECPs and found no increase in pregnancy risk with increasing weight or BMI and found no consistent association between pregnancy and both factors when adjusted for other covariates.ConclusionWhile data are limited and poor to fair quality, findings suggest that women with obesity experience an increased risk of pregnancy after use of LNG ECP compared with those normal/underweight. Women with obesity may also experience an increased risk of pregnancy compared with women without obesity after use of UPA ECP, though differences did not reach statistical significance. Providers should counsel all women at risk for unintended pregnancy, including those with obesity, about the effectiveness of the full range of emergency contraception options in order for them to understand their options, to receive advanced supplies of emergency contraception as needed and to understand how to access an emergency copper intrauterine device if desired.     

Contraceptive use at first sexual intercourse among adolescent and young adult women with disabilities: The role of formal sex education

ObjectivesThis study examines receipt of formal sex education as a potential mechanism that may explain the observed associations between disability status and contraceptive use among young women with disabilities.Study designUsing the 2011?2017 National Survey of Family Growth, we analyzed data from 2861 women aged 18 to 24 years, who experienced voluntary first sexual intercourse with a male partner. Women whose first intercourse was involuntary (7% of all women reporting sexual intercourse) were excluded from the analytic sample. Mediation analysis was used to estimate the indirect effect of receipt of formal sex education before first sexual intercourse on the association between disability status and contraceptive use at first intercourse.ResultsCompared to nondisabled women, women with cognitive disabilities were less likely to report receipt of instruction in each of 6 discrete formal sex education topics and received instruction on a fewer number of topics overall (B = ?0.286, 95% CI = ?0.426 to ?0.147), prior to first voluntary intercourse. In turn, the greater number of topics received predicted an increased likelihood of contraceptive use at first voluntary intercourse among these women (B = 0.188, 95% CI = 0.055?0.321). No significant association between noncognitive disabilities and receipt of formal sex education or contraceptive use at first intercourse was observed.ConclusionsGiven the positive association between formal sex education and contraceptive use among young adult women with and without disabilities, ongoing efforts to increase access to formal sex education are needed. Special attention is needed for those women with cognitive disabilities.     

Provider Practices and Young Women's Experiences with Provider Self-disclosure during Emergency Contraceptive Visits

BackgroundResearch on the impact of providers disclosing personal contraceptive experiences with patients is limited. In this study, we examine patient and provider perspectives about provider self-disclosure (PSD) of personal contraceptive experiences and its effects on contraceptive decision making and the provider–patient relationship.MethodsWe conducted 18 one-on-one telephone interviews with clinicians who provide contraceptive services to young women and 17 patients seeking emergency contraception from three Bay Area community-based, youth-friendly clinics regarding their contraceptive counseling practices and experiences, respectively. After transcribing and coding all interviews, we summarized structural codes related to contraceptive counseling and PSD.ResultsAlthough providers noted that PSD could help to build rapport and increase patient comfort, most did not report self-disclosing their contraceptive experiences, primarily owing to concerns that it might cross professional boundaries or compromise patient autonomy. All patients held positive attitudes toward and welcomed PSD practices, with many noting that it increased their comfort and trust in their provider.ConclusionsThere were notable differences between patient and provider attitudes toward PSD of contraceptive method use, with patients expressing more positive feelings about the practice than providers. Community-based providers should consider that many young women welcome self-disclosure of provider contraceptive experiences and that more research is needed to understand the effects of PSD practices around contraception on the patient–provider relationship and autonomous contraceptive decision making.     

Experiences with Prenatal and Postpartum Contraceptive Services among Women with a Preterm Birth

BackgroundProviding postpartum contraception can help to achieve recommended interpregnancy intervals (≥18 months from birth to next pregnancy), decrease the risk of preterm birth, and thus improve maternal and infant health outcomes of future pregnancies. However, the experiences of women with preterm birth regarding contraceptive services have not been documented. We sought to better understand contraceptive counseling experiences and postpartum contraception of women with a preterm birth.MethodsWe interviewed 35 women, ages 18–42 years, with a recent preterm birth in California. The transcribed interviews were analyzed using ATLAS.ti v.8.ResultsWomen had public (n = 15), private (n = 16), or no insurance (n = 4) at the time of the interview. Women were mainly Latina (n = 14), Caucasian (n = 9), or African American (n = 6); 15 women were foreign born. Women's experiences ranged from spontaneous preterm births to births with severe medical complications. We identified five themes that were associated with women's engagement in the contraceptive method choice and understanding of birth spacing: 1) timing and frequency of contraceptive counseling; 2) quality of patient–provider interaction and ability to follow up on questions; 3) women's personal experiences with contraceptive use and experiences of other women; 4) context in which contraceptive counseling was framed; and 5) system barriers to contraceptive use.ConclusionsPostpartum contraceptive counseling should address women's preterm birth experience, medical conditions, age, contraceptive preference, and childbearing plans. Having a preterm birth intensifies gaps in hospital and outpatient clinic coordination and provider–patient communication that can lead to use of less effective or no contraceptive methods and risk of early subsequent unplanned pregnancies.     

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.     

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India

PurposeYouth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15–24 and mothers aged 25–48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers.MethodsData come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months.ResultsResults showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months.DiscussionAs India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.     

How can Primary Care Physicians Best Support Contraceptive Decision Making? A Qualitative Study Exploring the Perspectives of Baltimore Latinas

ObjectivesU.S. Latinas experience disproportionately high rates of unintended pregnancy and low rates of consistent contraception use. Not well known are Latinas' perspectives about how primary care physicians (PCPs) might facilitate or deter contraceptive decision making. The theory of planned behavior has been used previously to explain contraceptive behaviors. This study used the theory of planned behavior as a guide to help describe Latinas' perspectives regarding specific factors that influence their contraceptive decision making and to describe their perspectives about the role of PCPs in the decision making.Study Design and MethodsWe conducted focus groups (n = 3) and interviews (n = 8) of Latinas ages 15 to 24 years, recruited from urban primary care sites in Baltimore, Maryland. Concepts from the theory of planned behavior were used to develop a coding scheme and guide identification of themes.ResultsSixteen Latinas participated; all were immigrants.ThemesThe desire to avoid unintended pregnancy is dominant and, not surprisingly, is the main driver of contraceptive intentions. The role of PCPs in contraceptive decision making is to build strong patient relationships through heightened communication and trust. PCPs should develop trust and foster communication by using a shared decision-making approach in contraceptive counseling. Religious norms rarely operate as barriers to contraceptive use, yet positive reinforcement from family, friends, and schools is viewed as supportive.Conclusions and ImplicationsFor this group of young, immigrant Latinas, there is a pervasive desire for effective communication and trusting relationships with PCPs. Findings suggest that providers can facilitate contraceptive decision making for this population by using a shared decision-making approach to contraceptive counseling.     

Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana

ABSTRACT

Little is known about the multilevel social determinants of adolescent sexual and reproductive health (SRH) that shape the use of family planning (FP) among young women in Africa. We conducted in-depth, semi-structured, qualitative interviews with 63 women aged 15–24 years in Accra and Kumasi, Ghana. We used purposive, stratified sampling to recruit women from community-based sites. Interviews were conducted in English or local languages, recorded, and transcribed verbatim. Grounded theory-guided thematic analysis identified salient themes. Three primary levels of influence emerged as shaping young women’s SRH experiences, decision-making, and behaviors. Interpersonal influences (peers, partners, and parents) were both supportive and unsupportive influences on sexual debut, contraceptive (non) use, and pregnancy resolution. Community influences included perceived norms about acceptability/unacceptability of adolescent sexual activity and its consequences (pregnancy, childbearing, abortion). Macro-social influences involved religion and abstinence and teachings about premarital sex, lack of comprehensive sex education, and limited access to confidential, quality SRH care. The willingness and ability of young women in our study to use FP methods and services were affected, often negatively, by factors operating within and across each level. These findings have implications for research, programs, and policies to address social determinants of adolescent SRH.     

Should Providers Give Women Advance Provision of Emergency Contraceptive Pills? A Cost-Effectiveness Analysis

PurposeWe sought to determine the potential effect and cost-effectiveness of different means of accessing emergency contraceptive pills (ECP) on unintended pregnancy rates in sexually active women.MethodsWe used a computer simulation model to compare the effects of advance provision, on-demand provision, and no use of ECP on unintended pregnancies and costs of care in three hypothetical cohorts of 1 million sexually active women. Data on effectiveness of ECP from the single-use clinical trials, and costs from Medi-Cal, California's Medicaid program were used for the model.FindingsAdvance provision of ECP is projected to avert a greater or the same percentage of unintended pregnancies compared with on-demand provision, with the greatest percentage of pregnancies averted (66%) in low-risk women with advance provision. In the simulation model, the percentage of pregnancies averted decreases as the frequency of unprotected intercourse increases and ECP use decreases. In all scenarios, the cost-savings ratio—the number of dollars saved on averted pregnancy expenditures for each dollar spent on advance ECP—is greater than one.ConclusionAdvance provision of ECP has the potential to avert unintended pregnancies and reduce medical expenditures. The most likely reason that the advance provision trials fail to demonstrate reductions in pregnancy rates is a result of a combination of small study sizes, the use of ECP in both treatment and control groups, and a failure to take into account a realistic range of rates of unprotected intercourse and imperfect ECP use.