Urban minority women's perceptions of and preferences for postpartum contraceptive counseling

Introduction: Focused antenatal contraceptive counseling about postpartum contraception may reduce the risk of contraceptive nonuse and misuse, although the optimal timing, content, and communication style of such counseling remain controversial. This study used an in‐depth, qualitative approach in a population of young, postpartum, urban, minority group women in order to examine women's perspectives toward the optimal provision of comprehensive contraceptive counseling. Methods: Brief surveys and semistructured interviews were conducted with 30 consenting postpartum women. In‐person, one‐on‐one interviews were then reviewed for themes, by using an iterative process. Qualitative analysis techniques identifying emergent themes were applied to interview data. Results: In this cohort of African American (63%) and Hispanic (37%) women (median age 26 y), 73% had unplanned pregnancies. Women preferred frequent, short sessions of provider‐initiated comprehensive contraceptive counseling throughout the antepartum period with reinforcement of decisions during the postpartum period. Participants valued patient‐centered counseling that was inclusive of all appropriate methods and personalized to individual needs. Discussion: We recommend that frequent, provider‐initiated, multiple‐modality discussions of appropriate postpartum contraceptive options should take place throughout pregnancy in an open, individualized manner. Further work should address the long‐term effects of improved patient‐centered antenatal contraceptive counseling on rates of unintended pregnancy.     

产后妇女避孕节育干预与效果评价

目的:评价在上海市静安区产后妇女中进行避孕节育干预对提高产后避孕率并降低产后意外妊娠的效果。方法:对居住在静安区的产后1年内已婚妇女进行避孕服务干预,并于干预前和干预后进行问卷调查。结果:干预后0~3个月、4~6个月、7~9个月和9个月以上各时段避孕率均显著高于干预前,尤其是在有性生活的产后妇女中,产后的前6个月累积避孕率从干预前的58.9%提高到干预后的97.6%。产后1年内意外妊娠发生率为1.4%,意外妊娠主要原因为未避孕和避孕套、安全期避孕失败。结论:产后定期避孕干预能有效提高产后1年内妇女的避孕率,降低产后妇女意外妊娠率。     

Urgent need to change clinical practices about postpartum contraception

In the United States, maternal mortality and unintended pregnancy rates are increasing. There are growing disparities in maternal health between indigent, minority women and Caucasian women of higher socioeconomic status. Family planning has long been viewed as a solution to these problems. As reliance on permanent contraception has diminished, timely access to highly effective contraceptive methods, namely long acting reversible contraceptives, which includes the contraceptive hormonal implant and intrauterine device- has become even more important. For women in the United States and abroad, the time of delivery is the one reliable opportunity for women to receive medical care. Consistently, research has shown that providing contraception in the immediate postpartum period is safe, effective, feasible and cost effective. However, misperceptions, lack of supplies, and reimbursement issues combine to defeat attempts to provide the most effective methods of contraception during that hospitalization. We believe that it is time to tackle the problem of unintended and rapid repeat pregnancy using an evidence-based, patient-centered paradigm and to eradicate systemic barriers blocking access to contraceptive methods during hospital stay. This editorial will outline some of the more compelling evidence supporting this move and will provide insights from successful programs.     

Systematic Review of the Literature on Postpartum Care: Selected Contraception Methods,Postpartum Papanicolaou Test,and Rubella Immunization

Abstract: Background : The postpartum period is a time when many routine interventions are provided to mothers. This review examined the published evidence for the effectiveness of selected contraceptive methods, Papanicolaou (Pap) tests, and rubella immunization. Methods : MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women. The initial literature search was done in 1999, and was enhanced in 2003. Studies were categorized and reviewed by topic areas. Data were extracted in a systematic method, and the quality of each study was reviewed. Results : In the 1999 search, 140 studies were randomized controlled trials that met the selection criteria: 5 related to postpartum contraception, 1 to timing of the postpartum Pap test, and 2 to postpartum rubella immunization. In the 2003 searches, 1 additional study related to postpartum contraception was identified. From the published literature on selected contraceptive methods, the intrauterine devices examined were effective in preventing pregnancy and had comparable side effect profiles. No clear recommendation can be made because insertion timing was not randomized in the included trials. Although delaying the postpartum Pap smear until 8 weeks reduces the proportion of inflammatory smears, it is uncertain whether a Pap smear is of benefit to postpartum women. The RA 27/3 postpartum rubella vaccine appears to be more effective than the Cendehill vaccine, but a small proportion of women may develop acute and chronic joint manifestations. Conclusions : Some evidence is available to support selected postpartum contraceptive methods and the postpartum rubella vaccine, but data are lacking on the effectiveness and optimal timing of the postpartum Pap smear.     

Contraception options: Aspects unique to adolescent and young adult

Sexual health for adolescents is based on three components: recognizing sexual rights, sexuality education and counseling, and thirdly confidential high quality services. Contraception needs to include prevention of both STIs and pregnancies. The first option for adolescents is condoms backed-up by emergency contraception; and later hormonal contraceptives in a longer, mutually monogamous relationship. Condoms and hormonal contraception together can be well recommended for adolescents for dual protection. Long acting reversible contraception (LARC) including both intrauterine contraception and implants are safe and highly effective and thus well suited for adolescents.Improved contraceptive methods do not automatically lead to reduced numbers of adolescent abortions. When sexuality education, proper counseling and sexual health services are all provided, it is possible to profoundly improve adolescent sexual health.     

Acceptance of Contraceptive Methods Among Postpartum Women in a Tertiary Care Center

Background

In India, a large proportion of women with an unmet need for contraception are within their first year after childbirth. Therefore, concentrating efforts to educate postpartum women on the importance of attending contraceptive clinics could have a proportionally bigger impact on increasing postpartum contraception usage.

Methods

Hundred and seventy-eight (178) women were followed up to determine the proportion of postpartum women who attended the family planning clinics for contraceptive counseling. The reason for non-attendance, choice and effectiveness of contraceptive method selected was determined.

Results

Out of 178 postpartum women who were followed up, only 12 (6.8 %) attended the contraceptive clinic. IUD, POPs and Inj-DMPA are the preferred contraceptive methods selected by postpartum women. Hundred percent of the postpartum women who attended contraceptive selected a contraceptive method as compared to only 44 % of the postpartum women who did not attend a contraceptive clinic. Only 29.2 % of these postpartum women selected highly effective contraceptive methods as compared to 83.3 % by the postpartum women who attended family planning clinics. The common reasons cited for not attending contraceptive clinic was found to be time constraint (43.9 %) followed by ‘stay far away’ (39 %), followed by ‘already have information’ (9.7 %).

Conclusions

Family planning service that is scheduled to be delivered at the 6-week postpartum is rarely attended. The common reason cited by postpartum women for poor attendance in these family planning clinics was time constraint.

     

Contraception and lactation

The benefits of breastfeeding for both the infant and the mother are undisputed. Longer intervals between births decrease fetal/infant and maternal complications. Lactation is an effective contraceptive for the first 6 months postpartum only if women breastfeed exclusively and at regular intervals, including nighttime. Because a high percentage of women in the United States supplement breastfeeding, it is important for these women to choose a method of contraception to prevent unintended pregnancies. Both the method of contraception and the timing of the initiation of contraceptives are important decisions that a clinician must help the breastfeeding woman make. Ideally, the chosen method of contraception should not interfere with lactation. This article reviews the research on the effect of contraceptives, including hormonal contraceptives, on lactation.     

Efficacy of natural family planning methods

Abstract

Objective To determine the influence of multiple contraceptive counselling sessions during antenatal care on use of modern postpartum contraception.

Method A total of 216 eligible pregnant women were randomised into antenatal and postnatal counselling groups. The ‘Antenatal group’ received one-to-one antenatal contraceptive counselling on several occasions while the ‘Postnatal group’ received a single one-to-one contraceptive counselling session at the sixth week postnatal check, as is routinely practised. All participants were contacted six months postpartum by telephone or personal visit, and questioned about their contraceptive use, if any.

Results More women who had multiple antenatal contraceptive counselling sessions used modern contraceptive methods than those who had a single postnatal counselling session (57% vs. 35%; p = 0.002). There was also a significantly more frequent use of contraception among previously undecided patients in the Antenatal group (p = 0.014).

Conclusion Multiple antenatal contraceptive counselling sessions improve the use of modern postpartum contraception.     

Long acting reversible contraception

Long-acting reversible contraception (LARC) is the collective name for intrauterine contraception (copper intrauterine devices and levonorgestrel intrauterine systems) and the subdermal contraceptive implant. LARC methods are highly effective, require minimal user effort and do not require regular healthcare appointments; however the insertion and removal procedures can only be undertaken by clinicians trained to do so. The progestogen-only subdermal implant is the most effective method of reversible contraception in the United Kingdom and is licensed for 3 years. The copper intrauterine device is the most effective non-hormonal method of contraception. These devices are licensed for five or 10 years and can also be used as emergency contraception. The levonorgestrel intrauterine systems (LNG-IUS) are licensed for 3, 5, or 6 years. The Mirena LNG-IUS is also licensed for use in treating heavy menstrual bleeding and for endometrial protection as part of hormone replacement therapy.     

Postpartum contraception

Recently-delivered women who wish to avoid pregnancy should initiate contraception before ovulation. Since the return of ovulation is not predictable, regardless of the woman's lactation status and duration of postpartum amenorrhea, contraception should be initiated as soon as is reasonable after delivery. The choice of contraceptive method will depend on several factors, including: the woman's lactation status, the preference of the woman and her partner, and the health status of the newborns. For women who do not wish to have additional children, tubal sterilization through a minilaparotomy incision is the procedure of choice. For other women who are not lactating, all methods, with the exception of the use of cervical caps and diaphragms, may be initiated immediately after delivery. However, preference should be given to IUD use by lactating and non-lactating woman, especially for women who may not return for any additional postpartum care.     

Implanon: a new contraceptive implant

Women who cannot use hormonal contraception containing estrogen have a variety of progestin-only contraceptive methods from which to choose. Implanon is a new single-rod progestin-only contraceptive implant that is easily inserted and can remain in place for up to 3 years. It is highly effective with a rapid onset of action and an equally rapid return of fertility once removed. Counseling is important to help women decide if this method is appropriate for their needs.     

The Association between Immediate Postpartum Etonogestrel Implants and Positive Postpartum Depression Screens in Adolescents and Young Adults

ObjectiveWe aimed to compare rates of positive postpartum depression screens at 6 weeks postpartum among adolescents and young adults (AYA) initiating immediate postpartum contraceptive implants and those initiating other methods.DesignThrough a retrospective observational design, we collected data on demographics, reproductive history, prenatal and postnatal depression, and postpartum contraception.SettingPatients participating in an AYA prenatal-postnatal program were eligible for inclusion.ParticipantsA total of 497 patients were enrolled between January 2013 and December 2016. The median age was 19 years (range 13-22 years); 86% were primiparous, 50% were Latina, 24% were black, and 16% were white; 34% initiated immediate postpartum implants (n = 169).InterventionThose initiating a contraceptive implant within the first 14 days postpartum were included in the intervention group.Main Outcome MeasureWe compared rates of positive Edinburgh Postpartum Depression Scales (EDPS) (scores ≥10) in AYA initiating immediate postpartum implants and those initiating other contraceptive methods.ResultsThe AYA initiating immediate postpartum implants were similar to the rest of the cohort in baseline characteristics, aside from an increased rate of preterm births among the intervention group (19.4% vs 12.1%; P = .03). Prenatally, 14% had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) scores (11.5% immediate postpartum implants vs 15.4% comparison, P = .25). At 6 weeks postpartum, 7.6% had a positive postpartum depression screen; this rate was significantly lower for those initiating immediate postpartum implants compared to those choosing other methods (4.1% vs 9.5%, P = .04).ConclusionsProviders should continue to encourage AYA to choose whichever highly effective contraceptive method they prefer for postpartum use.     

Factors Influencing Contraceptive Choice During the Postpartum Period: A Qualitative Systematic Review

Introduction

The objective of this article is to identify the factors that influence the choice of contraceptive methods in the postpartum period.

Methods

We conducted a qualitative systematic review including articles published between 2000 and 2021 on postpartum contraception and its related influential factors. Relying on Preferred Reporting Items for Systematic Reviews and Meta-Analyses and synthesis without meta-analysis checklists, the search strategy relied on a combination of 2 lists of keywords applied to 9 databases. A bias assessment was carried out with the help of the Cochrane's randomized controlled trial tool, the checklist from Downs and Black, and Consolidated criteria for reporting qualitative research (CoreQ). A thematic analysis was performed to identify categories of influential factors.

Results

A total of 34 studies met our inclusion criteria and enabled us to isolate 4 categories of factors: (1) demographic and economic factors (geographic and ethnic origin, age, living environment, education/wealth), (2) clinical elements (parity, evolution of pregnancy, childbirth and afterwards, contraception used previously and its mechanism, pregnancy planning), (3) health care delivery (pregnancy monitoring, sessions about contraception, health care system, place of delivery), and (4) sociocultural factors (knowledge and beliefs about contraception, religion, the influence of family and society). The decision process related to postpartum contraception is influenced by a combination of socioenvironmental factors and clinical elements.

Discussion

The main influential factors (parity, level of education, knowledge and beliefs about contraception, and influence of family) need to be addressed by clinicians during consultations. Further multivariate research should provide quantitative data on this topic.     

产后1年内意外妊娠妇女避孕状况调查

目的通过调查产后意外妊娠妇女的避孕状况,探讨产后避孕失败的原因。方法将2008年11月至2013年5月北京大学人民医院计划生育科189例产后1年内意外妊娠妇女作为研究组,同期326例产后1年内未妊娠妇女作为对照组,对其临床资料进行回顾性分析。结果研究组妇女的平均年龄[（30．15±4．15）岁]与对照组[（33．51±6．03）岁]比较,差异有统计学意义（P〈0．05）;两组妇女的文化程度及职业比较,差异无统计学意义（P〉0．05）。研究组未避孕率（28．57％,54／189）与对照组（19．94％,65／326）比较,差异有统计学意义（P〈0．05）。研究组妇女中,阴道分娩组未避孕率（20．93％,27／129）与剖宫产组（45．00%,27／60）比较,差异有统计学意义（P〈0．05）。研究组因避孕措施失败而导致意外妊娠135例（71．43％）,其采用的避孕方法分别为避孕套107例（79．26％）,安全期21例（15．56％）,体外排精6例（4．44%）,宫内节育器1例（0．74％）。结论不避孕或使用效果不稳定的避孕方法,是导致妇女产后1年内意外妊娠的主要原因。     

Family planning in the postpartum period

Contraception during the postpartum period presents additional problems in view of physiologic and psychodynamic considerations that are unique at this time. Focus is on these special considerations in the following review of contraceptive technology. Most recent evaluations of continued lactation for contraception have indicated that the risk of ovulatory activity within 9 weeks of delivery is 1:1250. Although this figure suggests that full-time breastfeeding functions as a better contraceptive method than do more sophisticated techniques within the first 6 weeks postpartum, supplemental feedings significantly decrease the effectiveness of this method. Oral contraception (OC), the most effective contraceptive method for the contemporary female if no contraindications to its use, should be avoided in the breastfeeding mother. It does remain the method of choice for the not breastfeeding mother. Due to the fact that the postpartum period has been recognized as a hypercoagulable state, the use of OCs in the immediate postpartum period can be questioned. The IUD probably represents the most effective contraceptive method for the breastfeeding mother. Fitting of the diaphragm is best deferred until the 6-week postpartum examination. Since a high percentage of patients resume coital activity by 3-4 weeks postpartum, a combination of foam and condom contraception is recommended on a temporary basis. Sterilization in the immediate postpartum period is the most effective method of fertility control other than total abstinence.     

Immediate Postpartum Contraception: Intrauterine Device Insertion

Insertion of an intrauterine device (IUD) in the immediate postpartum period is a safe, evidence‐based form of contraception appropriate for most women. Despite the higher risk of expulsion as compared with interval insertion, the benefits of insertion in the immediate postpartum period are significant and include improved rates of contraception continuance and reduced instances of short interval birth. Through shared decision making, midwives and other clinicians can assist women in clarifying their reproductive goals and understanding of contraceptive options, including this method. In response to identified gaps in knowledge and insertion technique among midwives, this article provides an overview of immediate postpartum IUD insertion, risks and benefits, and eligibility criteria and describes preinsertion, insertion, and postinsertion care.     

Post pregnancy contraception

Ovulation resumes as quickly as 21 days after birth in a non-fully breastfeeding woman. Traditionally, contraceptive services have been offered 6 weeks post-partum. This is far from ideal and results in unnecessary abortions or inadequate birth spacing which both carry an increased risk of morbidity to mother and potential newborn as well as costs to the health care service. It is now clear that contraception should be discussed during the pregnancy so that the method of choice can be offered immediately post pregnancy prior to discharge from hospital. Long acting reversible contraceptive methods such as implants and IUDs are highly effective as they are user-independent. Large studies have demonstrated that they can be safely inserted during the immediate post-partum period with no increase in complication rates. Policy makers should strive to overcome barriers to offering quality post pregnancy contraceptive services.     

Reproductive and contraceptive issues in chronically ill adolescents

Objectives?To address reproductive and contraceptive issues in adolescent girls with chronic medical conditions in order to assist health-care providers when they counsel teenagers about contraceptive methods.

Methods?The review is based on a literature search in Medline (1973–2010) about specific contraceptive use by adolescents with obesity, endocrine, cardiovascular, haematologic, oncologic, neurological, psychiatric, gastrointestinal, hepatobiliary, autoimmune, renal, pulmonary conditions and disabilities. The latest recommendations from the World Health Organisation for adolescents are also added. Contraceptive methods studied were combined hormonal contraceptives, progestogen-only contraceptives, and intrauterine contraceptives.

Results?Adolescents are eligible to use any method of contraception. Contraceptive choices of chronically ill adolescents have changed over time. Given new developments in the field of adolescent sexual and reproductive health care, safe and effective forms of contraception are available for almost every adolescent with a chronic condition. When selecting a method, the nature of the medical illness and the expressed desires of the teenager must be taken into account.

Conclusions?Adolescents, including those with chronic conditions, are sexual beings; they are entitled to sexual and reproductive health care. Decisions on appropriate contraception must be based upon informed choice, after adequate sexual health education.     

避孕药具不良反应研究现状

避孕药具包括激素避孕、宫内避孕法、紧急避孕及外用避孕等,不同方法避孕原理不同、不良反应也各不相同,文章系统地回顾了近年来国内外在避孕药具不良反应方面的研究现状。虽然不良反应多种多样,轻重程度不一,但严重不良反应少见。避孕药具使用者及咨询医生均应做到科学认识不良反应,减低严重不良反应发生的风险,同时避免由于对避孕药具过度恐惧而限制应用。