Medicaid and receipt of interval postpartum long-acting reversible contraception

Objective

We sought to evaluate the impact of insurance type on receipt of an interval postpartum LARC, controlling for demographic and clinical factors.

Exposure to routine availability of immediate postpartum LARC: effect on attitudes and practices of labor and delivery and postpartum nurses

Objectives

Nurses play an integral role in intrapartum and postpartum patient education. This exploratory study aims to assess the attitudes, knowledge, and practices of labor and delivery and postpartum nurses regarding contraception and evaluate for changes in these measures 1 year after an institutional initiative allowing routine availability of immediate postpartum long-acting reversible contraception (LARC).

产后妇女中长效可逆避孕措施的使用现状及影响因素的研究

目的:探讨长效可逆避孕措施(LARC)在产后妇女中的使用现状及影响因素。方法:采用容量比例概率抽样选择湖南省石门县3岁以下儿童母亲503例,采用自行设计的结构式问卷进行调查,用SPSS20.0统计软件对相关资料进行统计分析。结果:被调查的503例3岁以下儿童母亲中,产后采取避孕措施的比例为68.2%,采取LARC的比例有12.7%。logistic回归分析显示:初产妇(OR=3.43,95%CI:1.49~7.89)、26~30岁年龄组(OR=5.26,95%CI:1.43~19.40,处于哺乳期(OR=3.77,95%CI 1.80~7.63)以及剖宫产(OR=3.70,95%CI 1.80~7.63)是被调查者产后未使用LARC避孕的风险因素。结论:目前产后妇女LARC使用率偏低,提高产后避孕率,尤其是提高LARC使用率应是提高我国生殖健康工作的重点之一。     

产后妇女对产后避孕的认知与态度调查

目的:了解产后服务对象有关产后避孕的知识、态度、行为,为医院开展产后避孕服务提供科学依据。方法:随机抽取2013年10~12月在天津医科大学总医院及天津市永久医院住院分娩且自愿接受调查的939名产后服务对象进行问卷调查,获取服务对象产后避孕的知识、态度、行为情况。结果:产后服务对象产后避孕知识问卷回答总正确率28.9%,总分100分,得分28.45±14.8分;70%的调查对象认为产后避孕有必要或非常有必要;70%的服务对象在产前、分娩后、出院前或产后返诊时未接受指导或落实避孕措施。结论:产后妇女对产后避孕的态度积极,然而提供的宣教不足,产后避孕知识严重匮乏。医疗机构应积极开展产后避孕服务,借助网络、公共传媒、社区卫生服务等辅助设施,在产前、分娩后、出院前及产后返诊时全面展开产后避孕宣教并积极落实避孕措施。     

Frustrated demand for postpartum female sterilization in Brazil

During the last three decades, Brazilians have relied almost exclusively on two contraceptive methods, the pill and female sterilization, with sterilization use increasing over time. Until a new law was passed in 1997, sterilization was virtually illegal and not covered by either public or private health insurance. It was, however, frequently provided in public and private hospitals in conjunction with a cesarean section. The new law regulating sterilization provided for reimbursement for interval sterilizations by public health insurance, but placed restrictions on availability intended to reduce the use of cesareans. These restrictions included the prohibition of postpartum sterilizations. This paper focuses on women's sterilization intentions during pregnancy and their experiences postpartum. In a prospective study of 1612 pregnant women carried out in four Brazilian cities, there was substantial demand for postpartum sterilization in both the private and public sectors among women who wanted no more children. However, public patients were much less likely to be sterilized than private patients. Thus, the new law may not have reduced inequities in access or, paradoxically, the incentive for unnecessary cesarean sections.     

Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery

Objectives

To identify barriers to postpartum permanent contraception procedures after vaginal delivery and to explore contraceptive and reproductive outcomes of women who experience unfulfilled requests.

Prenatal intent and postpartum receipt of long-acting reversible contraception among women receiving medication-assisted treatment for opioid use disorder

Background

Many women with opioid use disorder (OUD) do not use highly effective postpartum contraception such as long-acting reversible contraception (LARC). We evaluated factors associated with prenatal intent and postpartum receipt of LARC among women receiving medication-assisted treatment (MAT) for OUD.

产后避孕的国内外指南

产后避孕方法的选择受妇女生理状态和哺乳的影响,产后即时或尽早落实常规避孕措施,对预防人工流产及其并发症有重要作用。本综述对产后避孕的国内外指南进行复习和比较,重点讨论经产妇可优先选择的宫内节育器(intrauterine contraceptive device,IUD)、雌孕激素复方和单纯孕激素避孕方法及女性绝育术在产后不同时期使用的医学标准,为临床医生在产后帮助妇女选用安全、适宜的避孕方法提供指导。     

产后服务对象避孕节育现状与需求相关调查研究

目的:了解服务对象产后避孕知识、产后访视、避孕节育状况与服务需求,为完善社区产妇健康管理及产后避孕服务模式提供科学的理论依据。方法:2013年10月1日~11月10日,对在天津医科大学总医院以及天津永久医院住院分娩的575名产后服务对象进行问卷调查,分别于产后42±7d、90±7d、180±7d进行电话随访。结果:(1)服务对象产后避孕相关知识总正确率为26.8%,其中有关宫内节育器(IUD)、单纯孕激素避孕法(POC)、复方口服避孕药(COC)、哺乳闭经避孕法(LAM)的正确率,分别是31.1%、18.6%、23.7%、44.9%。(2)服务对象产后3~7天访视率为94.0%,产后42d检查率为89.0%,其差异有统计学意义(P0.05)。两次访视中进行产后避孕宣教与指导的分别有50.7%和78.3%。(3)服务对象喜欢的避孕宣教形式为发放宣传手册资料(64.6%)、向医生护士咨询(17.4%)、热线电话(13.4%)。认为产后避孕宣教的最佳时间为产后42d健康检查(51.3%)、产后3~7d访视时(29.9%)。(4)服务对象母乳喂养率为86.5%,纯母乳喂养坚持到产后6个月的有40.0%。(5)服务对象性生活的恢复和开始使用避孕措施的平均时间为产后81.7±35.0d、产后98.4±39.1d,其中产后未避孕及未即时避孕的有27.3%。(6)服务对象选择的避孕方法前4位是男用避用套、体外排精、IUD、安全期,分别占83.2%、1.8%、1.8%、1.6%。至产后6个月依赖LAM避孕有20.8%。结论:服务对象产后访视率较好,访视内容不完善。服务对象避孕措施的平均落实时间滞后于性生活的恢复时间。服务对象产后避孕知识匮乏,在产后访视中有关避孕的宣教和指导不足。服务提供者可以通过发放宣传手册资料、鼓励服务对象向医生护士咨询、相关科室建立产后避孕热线电话等途径开展产后避孕的宣教和指导。将产后避孕的宣教和指导的时间着重放在产后42d健康检查、产后3~7d访视时。     

Cross-border procurement of contraception. estimates from a postpartum survey in El Paso, Texas

Along the US-Mexico border, US residents have the option of crossing to Mexico in order to purchase hormonal contraception sold over-the-counter at very low prices in pharmacies. We investigated the prevalence of cross-border contraceptive procurement by way of a survey of 3134 women who delivered in a large public hospital in El Paso, Texas, between 1996 and 1997. Pills, injectables, condoms and IUDs were the most commonly used methods by women in the birth interval preceding delivery. Among multiparous women, 41% of pills and 54% of injectables were obtained in Mexico. However, almost all condoms were obtained in the United States. In this largely Hispanic population, the prevalence of cross-border procurement was highest among women who were born and educated in Mexico. Discontinuation of pills and injectables was lower when obtained across the border than in the United States. These findings support the proposition that reducing the medical requirements to acquire pills and injectables and making them available at low cost would augment their use in low-income populations.     

Sterilization in Finland: From eugenics to contraception

The purpose of this paper was to describe the transition of sterilization in Finland from an eugenic tool to a contraceptive. Historical data were drawn from earlier reports in Finnish. Numbers of and reasons for sterilizations since 1950 were collected from nationwide sterilization statistics. Prevalence, characteristics of sterilized women, and women's satisfaction with sterilizations were studied from a 1994 nationwide survey (74% response rate). Logistic regression was used for adjustments. In the first half of the 20th century, eugenic ideology had influence in Finland as in other parts of Europe, and the 1935 and 1950 sterilization laws had an eugenic spirit. Regardless of this, the numbers of eugenic sterilizations remained low, and in practice, family planning was the main reason for sterilization. Nonetheless, prior to 1970 not all sterilizations were freely chosen, because sterilizations were sometimes used as a precondition for abortion. Female sterilizations showed remarkable fluctuation over time. Male sterilizations have been rare. The reasons stipulated by the law did not explain the numbers of sterilizations. In a 1994 survey, 9% of Finnish women reported they were using sterilization as their current contraceptive method (n = 189). Compared to women using other contraceptive methods, sterilized women were older, had had more births and pregnancies, and came from lower social classes. Sterilized women were satisfied with their sterilization, but there were women (8.5%) who regretted it. In conclusion, sterilizations have been and are likely to continue to be an important family planning method in Finland. The extreme gender ratio suggests a need for promoting male sterilizations, and women's expressed regrets suggest consideration of a higher age limit.     

A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: a feasibility study

Background

The study was conducted to test the feasibility of conducting a randomized controlled contraceptive trial in postpartum teens and to assess whether postpartum advanced supply of emergency contraception (EC) to teenaged mothers helps to prevent repeat pregnancies of close proximity.

Study Design

We performed a randomized controlled trial of 50 postpartum teens at an urban academic medical center. Participants in the intervention arm received routine postpartum contraceptive care and advanced supply of one pack of EC pills with unlimited supply thereafter upon request. The routine care arm (RCA) received routine postpartum contraceptive care. We asked open-ended questions about how we might maximize study retention and implemented the participants' requests in both arms.

Results

Our retention rate was 78%. There were three (13%) pregnancies out of 23 participants in the intervention arm and eight (30%) pregnancies out of 27 participants in the RCA. The risk of pregnancy occurring in the intervention arm was 0.57 times that of the RCA (95% CI 0.20-1.60; p=.23).

Conclusions

A randomized controlled trial of postpartum teens to receive and not to receive advanced supply of EC is both feasible and necessary. Our study provides preliminary data to suggest that advanced supply of EC may help decrease repeat teen pregnancies.     

Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States

Objective

To examine the hospital and state costs of offering the option of a postpartum intrauterine device (IUD) to an underinsured population of recent immigrants to the United States with Emergency Medicaid (EM) insurance coverage only.

Study Design

This study is a retrospective cohort study comparing the costs of offering a reversible long-acting method of contraception (IUD) postpartum to women with EM and the current policy of covering the obstetrical delivery only. A cost-benefit analysis from the perspective of both the hospital and the state was conducted. A database of EM obstetrical patients from 2002 to 2006 was created from hospital billing records to calculate mean pregnancy costs and revenue, as well as the probability of repeat pregnancy and pregnancy outcome. Probability of IUD uptake and continuation was obtained from hospital records and the literature.

Results

A postpartum IUD program is not cost beneficial from the hospital's perspective, losing 70 cents per dollar spent on the program. However, the state government would save $2.94 for every dollar spent on a state-financed IUD program.

Conclusion

Considering only the direct costs associated with a repeat pregnancy, a program offering the option of postpartum IUD placement to underinsured women would significantly reduce state expenditures on subsequent pregnancies.     

Correlates of long-acting reversible contraception versus sterilization use in advanced maternal age

Purpose

To identify correlates associated with choosing long-acting reversible contraception (LARC) over female sterilization (FS) from a subsample of women aged 35 to 44 years in a nationally representative survey.

Pharmacy-based interventions for initiating effective contraception following the use of emergency contraception: a pilot study

Objectives

In Scotland most women get emergency contraception (EC) from pharmacies. Pharmacists currently cannot provide effective ongoing contraception after EC. In this pilot study, we aimed to determine the feasibility of a larger study designed to ascertain if pharmacy-based interventions can increase the uptake of effective contraception after EC.

Study design

This is a pilot study of women presenting for levonorgestrel EC to community pharmacies in Edinburgh, UK, in 2012. Pharmacies were cluster randomized to provide either standard care or one of two interventions: (a) one packet of progestogen-only pills (POPs), giving women 1 month to arrange ongoing contraception; (b) invitation to present the empty EC packet to a family planning clinic (FPC) for contraceptive advice (rapid access).

Results

One hundred sixty-eight women were recruited from 11 pharmacies to POP (n=56), rapid access (n=58) and standard care (N=54) groups, respectively. Telephone follow-up was conducted successfully in 102 women (61%) 6–8 weeks later to determine current contraceptive use. In the POP arm, 35/39 (90%) women used the pills provided, and 9/28 women (32%) in the rapid access arm attended the FPC. The proportion of women using effective contraception at follow-up was significantly greater in both POP [56% (22/39), p=<0.001] and rapid access [52% (13/25), p=0.006] groups compared to standard care [16% (5/31)]. The relative probability of a woman using an effective method of contraception versus barrier/no method, after use of EC, was 3.13 [95% confidence interval (CI), 1.90–5.13] in the POP group and 2.57 (95% CI, 1.55–4.27) in the rapid access group.

Conclusions

This promising pilot study suggests that simple pharmacy-based interventions may increase the uptake of effective contraception after EC. A larger study is required to provide further validation of these findings.

Implications statement

For women obtaining EC from a pharmacy, simple interventions such as supplying 1 month of a POP, or offering rapid access to a FPC, hold promise as strategies to increase the uptake of effective contraception after EC.     

Exploring young mothers' experiences with postpartum contraception in Ottawa: results from a multimethods qualitative study

Objectives

Postpartum contraception plays a significant role in reducing subsequent pregnancy. However, young mothers in Ottawa, the capital of Canada, face various barriers when trying to access contraception after delivery. Through this project, we aimed to explore these barriers and understand the decision-making processes of young mothers surrounding postpartum contraception.

产后避孕服务的研究进展

产后近期意外妊娠对育龄妇女的生殖健康影响较大，产后1年内人工流产率高于育龄妇女的平均水平，低文化程度、低经济收入和社会贫困层次的妇女以及未婚青少年是产后近期意外妊娠的高危人群。尽管目前产后避孕技术成熟，但推广不足，尚未形成针对高危人群和高危行为有效的产后避孕服务规范。随着生育高峰的到来，在加强产前、产时安全的同时，预防产后意外妊娠、减少高危人工流产的发生是生殖健康领域的重要内容。     

Barriers to intrauterine device insertion in postpartum women

OBJECTIVE: The objective of this study was to determine the proportion of postpartum women at the University of New Mexico who choose an IUD for contraception, the number who actually obtain one and the barriers to postpartum IUD insertion. METHOD: We conducted a retrospective chart review of 1627 postpartum women who delivered at the University of New Mexico. Those women who indicated at hospital discharge that they desired an IUD comprised the study group of 193 women. Medical records were reviewed to identify the timing of IUD placement. If an IUD was not inserted, we attempted to determine the reason by reviewing clinic records. RESULTS: Twelve percent of postpartum women requested an IUD. Records were available for 114 women. Of these, only 69 (60%) actually obtained an IUD. Barriers to postpartum IUD insertion included provider advice against the IUD, patient failure to return for a postpartum visit and early repeat pregnancy. CONCLUSION: We conclude that postpartum women desiring an IUD may have difficulty obtaining one.     

The effect of immediate postpartum compared to delayed postpartum and interval etonogestrel contraceptive implant insertion on removal rates for bleeding

Objective

To determine whether the discontinuation rate of the etonogestrel contraceptive implant due to irregular vaginal bleeding among women with immediate postpartum insertion is increased compared to delayed postpartum and interval placement.

Study Design

This retrospective cohort study compared women who underwent immediate postpartum etonogestrel contraceptive implant insertion (within 96h of delivery) to delayed postpartum (6 to 12weeks postpartum) and interval insertion between January 2008 and December 2010. Charts were reviewed for date and reason for removal. A chi-squared test was used to compare discontinuation due to bleeding between cohorts. Baseline characteristics predictive of implant removal were evaluated by simple logistic regression.

Results

There were 259 women in the immediate postpartum group, 49 in the delayed postpartum group and 106 in the interval group. Average age at insertion was 22.6 (±5.5) years. Overall, 19.3% of women in the immediate postpartum group requested removal due to irregular bleeding compared to 18.4% in the delayed postpartum group [odds ratio (OR) 1.06, 95% confidence interval (CI) 0.48–2.33] and 20.8% in the interval group (OR 0.91, 95% CI 0.52–1.60). There was no difference between groups in premature removal rates for any side effect. There were no sociodemographic or clinical characteristics predictive of removal in any group.

Conclusion

One-fifth of etonogestrel contraceptive implant users requested premature removal due to irregular bleeding. Immediate postpartum implant insertion does not lead to increased removal rates and may help reduce unintended pregnancy. Mechanisms to help women manage irregular bleeding due to the implant are needed.

Implications

Immediate postpartum insertion of the etonogestrel contraceptive implant does not lead to increased removal rates due to vaginal bleeding compared to delayed postpartum or interval insertion. Immediate postpartum implant insertion may increase uptake of long-acting reversible contraception and help reduce short interpregnancy intervals and unintended pregnancy.     

Randomized trial to compare perioperative outcomes of Filshie clip vs. Pomeroy technique for postpartum and intraoperative cesarean tubal sterilization: a pilot study

OBJECTIVE: To compare, by conducting a randomized trial, Filshie clip and Pomeroy techniques for postpartum and intrapartum cesarean sterilizations in a United States teaching hospital with respect to surgeon preference and perioperative outcomes. METHOD: Thirty-two obstetric patients consented for sterilization were randomized to Pomeroy technique or Filshie clip placement. Following the surgical procedure, surgeons and operating room technicians completed a survey regarding their experience with the procedures and preference. Patient demographic data, time for procedure and follow-up visits were obtained by chart review. RESULTS: For most postpartum sterilizations, the mean duration of the procedure was almost 7 min faster for the Filshie clip technique (p = 0.08); perioperative outcomes were equivalent (p = 0.05). Application of the Filshie clip was rated easier than Pomeroy suture application and, overall, the Filshie clip sterilization procedure was rated less difficult (p = 0.03). Seventy percent of surgeons preferred the Filshie clip technique and would choose it if only one postpartum sterilization method was available. CONCLUSION: For obstetric sterilization, surgeons preferred the Filshie clip over the Pomeroy technique. In addition, operating time was shorter for the Filshie clip. This pilot study suggests that use of the Filshie clip technique has the potential to establish a new standard of care for postpartum and intrapartum cesarean sterilization.