The Rise of Female Sterilization: A Closer Look at Colombia

Objective In the 1970s, OCPs and IUDs were the most popular contraceptive methods in Colombia. According to data from the most recent Demographic and Health Survey (DHS), sterilization has become the most common form of birth control in Colombia. This study aims to examine the characteristics of Colombian women desiring long-acting contraception. Methods This study uses the 2005 and 2010 Colombian DHS dataset. Women who choose long-acting contraception were divided into those using female sterilization and those using long-acting reversible contraception (LARC). A multivariate logistic regression model was used to compare demographic and social determinants of contraceptive choice among reproductive age women seeking long-acting contraception between the years 2005 and 2010. Results Among women using a long-acting contraceptive method in 2010, compared to 2005, women were significantly more likely to be sterilized (1.14 OR, 95% CI 1.09–1.18) and less likely to use LARC (0.88 OR, 95% CI 0.85–0.92). Of women seeking long-acting contraception, those exposed to a family planning provider were less likely to undergo sterilization (0.54 OR, 95% CI 0.51–0.58) and more likely to use LARC (1.84 OR, 95% CI 1.73–1.96). When compared to all contraceptive users, younger women and women with less than two children were more likely to use LARC than sterilization. Conclusion Between 2005 and 2010, an increase in the proportion of contracepting women being sterilized in Colombia occurred. Our findings suggest that exposure to a family planning provider and appropriate contraceptive counseling appears to be key determinants of long-acting contraceptive choice. To improve use of long-acting, effective contraception, efforts should be made to increase access to family planning providers.     

A Novel Approach to Postpartum Contraception Provision Combined with Infant Care: A Randomized,Controlled Trial

BackgroundUnintended pregnancy among women with short interpregnancy intervals remains common. Women's attendance at the 4- to 6-week postpartum visit, when contraception provision often occurs, is low, whereas their attendance at well-baby visits is high. We aimed to evaluate if offering co-located contraceptive services to mothers at well-baby visits increases use of long-acting reversible contraception (LARC) at 5 months postpartum compared with usual care in a randomized, controlled trial.MethodsWomen with infants aged 4.5 months or younger who were not using a LARC method and had not undergone sterilization were eligible. Generalized linear models were used to estimate risk ratios. Likability and satisfaction of the contraception visit were assessed.ResultsBetween January 2015 and January 2017, 446 women were randomized. LARC use at 5 months was 19.1% and 20.9% for the intervention and control groups, respectively, and was not significantly different after controlling for weeks postpartum (risk ratio, 0.85; 95% confidence interval, 0.59–1.23). Uptake of the co-located visit was low (17.7%), but the concept was liked; insufficient time to stay for the visit was the biggest barrier to uptake. Women who accepted the visit were more likely to use a LARC method at 5 months compared with women in the control group (risk ratio, 1.97; 95% confidence interval, 1.26–3.07).ConclusionsWomen perceived co-located care favorably and LARC use was higher among those who completed a visit; however, uptake was low for reasons including inability to stay after the infant visit. Intervention effects were possibly diluted. Future research should test a version of this intervention designed to overcome barriers that participants reported.     

Contraception After Surgical Abortion in Patients With Opioid Use Disorder

ObjectivesThis study describes the prevalence of medications for opioid use disorder (MOUD) among surgical abortion patients, evaluates long-acting reversible contraception (LARC) uptake after surgical abortion among patients on MOUD, and identifies predictors of immediate postabortion LARC uptake among individuals on MOUD.MethodsWe performed a secondary analysis of data from a retrospective observational cohort study of LARC uptake immediately after surgical abortion up to 21^0/7 weeks gestation at Planned Parenthood League of Massachusetts between October 2012 and April 2017. We estimated proportions and analyzed predictors of LARC uptake among women on MOUD using logistic regression analysis to control for possible confounders.ResultsDuring the study period, 26,858 patients had an abortion procedure; 768 (2.9%; 95% confidence interval, 2.7%–3.1%) used MOUD. In the primary study, controlling for demographic factors, MOUD was not an independent predictor of LARC uptake. In this analysis, patients on MOUD differed demographically from non-MOUD users and were significantly more likely to initiate a LARC method immediately after their procedure: 30.1% versus 25.3% (p = .002), including 22.7% who obtained an intrauterine device and 7.4% who obtained an implant. Among patients on MOUD, a prior live birth and public insurance predicted LARC uptake at the time of abortion.ConclusionWomen on MOUD had higher postabortion LARC uptake compared with those not on MOUD in a setting with easy access to postabortion LARC. Public insurance coverage for abortion was associated with LARC uptake among women on MOUD.     

Contraceptive Use Patterns among Women of Reproductive Age in Two Southeastern States

BackgroundUnintended pregnancies remain an important public health issue. Modern contraception is an important clinical service for reducing unintended pregnancy. This study examines contraception use among a representative sample of women residing in two southeastern U.S. states.MethodsA cross-sectional statewide survey assessing women's contraceptive use and reproductive health experiences was conducted in Alabama and South Carolina. Characteristics of the study population were compared across contraceptive use categories and multivariable regression analysis was performed examining relationships between covariates of interest and contraceptive use outcomes.ResultsApproximately 3,775 women were included in the study population. Overall, 26.5% of women reported not using any contraception. Short-acting hormonal methods were the most commonly reported (26.3%), followed by permanent methods (24.4%), long-acting reversible contraception (LARC; 14.3%), and barrier/other methods (8.5%). Nonuse was more prevalent among women with some college or an associate's degree, incomes between $25,000 and $50,000, no health insurance, and longer gaps in care. LARC use among women with Medicaid as a pay source was higher than use among privately insured women and higher in South Carolina than Alabama. Both nonuse and LARC use were higher among women with no insurance.ConclusionsStudy findings are largely consistent with previous research using similar population-based surveys. LARC use was higher among the study population relative to what is observed nationally. Factors enabling access to contraceptive services, particularly for lower income women, were associated with contraception use patterns. These findings provide important context for understanding individuals’ access to resources and are important for fostering increased access to contraceptive services among women in these two states.     

Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011–2015

Objective

To investigate whether demographic, socioeconomic, and reproductive health characteristics affect long-acting reversible contraceptive (LARC) use differently by race-ethnicity. Results may inform the dialogue on racial pressure and bias in LARC promotion.

Condom use in adolescents and young women following initiation of long- or short-acting contraceptive methods

Objective

The objective was to determine if young women initiating long-acting reversible contraceptives (LARCs) who report new sexual partner(s) would be less likely to report use of a condom than women using short-acting reversible contraceptive (SARC) methods.

Contraception methods used among women with HIV starting antiretroviral therapy in a large United States clinical trial, 2009–2011

Objective(s)We describe contraception and dual method use among women with HIV initiating antiretroviral therapy (ART) in a U.S. clinical trial and examine associated factors.Study designWe analyzed data from ART-naïve women aged 45 years and under initiating one of 3 regimens as part of A5257 (May 2009–June 2011) which required that women at risk for pregnancy use contraception. We classified self-reported methods as more effective (Tier 1 [intrauterine device, hysterectomy, permanent contraception] and Tier 2 [hormonal rings, patches, injections, pills]) versus less effective (Tier 3 [condoms alone] and Tier 4 [withdrawal, none]). We used logistic regression models to assess associations with use of (a) more effective, and (b) dual methods (condoms with a more effective method).ResultsOf 285 women, majority were Black (59%), had annual income <$20,000 (54%), and had government insurance (68%). The most common contraceptive methods reported at baseline were permanent contraception (37%), male condoms alone (31%), and injectable progestin (8%); 41% and 16% reported Tier 1 and 2 use, respectively; 36% reported dual method use. Use of more effective and dual methods did not change 48 and 96 weeks after ART initiation (p > 0.05). In multivariable analyses, baseline use of more effective and dual methods was associated with age at least 40 years versus 18 to 29 years (odds ratio [OR] 4.46, 95% confidence interval [CI] 2.12, 9.35) and having at least one child (OR 2.31, 95%CI 1.27, 4.20).ConclusionsIn women initiating modern ART in a clinical trial, permanent contraception was common, while use of other more effective contraceptive methods was low and did not change after ART initiation. Efforts are needed to improve integration of family planning services for women within the context of HIV clinical trials.ImplicationsThe findings highlight the importance of improving integration of HIV and family planning services, including in the context of clinical trials.     

Contraceptive method and self-reported HIV status among women in Malawi

ObjectivesWe aimed to describe contraceptive methods used by women in Malawi and determine whether contraceptive use differed by self-reported HIV status. Effective contraception is a primary method of preventing mother-to-child transmission of HIV.Study designAnalysis is based on 12,658 nonpregnant, sexually debuted women ages 15–49 years in the 2010 Malawi Demographic and Health Survey. Analysis was restricted to respondents with contraceptive need (i.e., fecund and did not want a child in the next 12 months) who reported their last HIV test result. We accounted for the two-stage cluster sampling design by applying cluster, stratum and sample weights. We assessed differences in contraceptive method use by HIV status with χ² tests and multivariable logistic regression.ResultsA total of 893 (7.0%) of respondents reported being HIV positive. Use of long-acting reversible contraception (LARC) was low and did not differ between HIV-positive (1.4%) and HIV-negative (1.9%) women [adjusted odds ratio (aOR)=0.7, 95% confidence interval (CI), 0.4–1.4]. HIV-positive women (15.6%) were less likely than HIV-negative women (30.4%) to use progestin-only injectable contraception (aOR, 0.7; 95% CI, 0.5–0.8). Prevalence of female sterilization was higher among HIV-positive women (17.9%) compared to HIV-negative women (9.2%; aOR=1.7; 95% CI, 1.2–2.3).ConclusionsLARC use was low among adult women with contraceptive need in Malawi. HIV-positive women were less likely to report progestin-only injectable use but more likely to report having undergone female sterilization compared to their HIV-negative counterparts. Noncoercive interventions that provide highly effective methods of contraception to HIV-positive women with contraceptive need are valuable methods of vertical transmission prevention in Malawi.ImplicationsContraceptive use differed by self-reported HIV status among adult women with contraceptive need in Malawi. Female sterilization was significantly higher, and use of progestin-only injectables was significantly lower, among HIV-positive women compared to their HIV-negative counterparts. Use of long-acting reversible contraception was low among both HIV-positive and HIV-negative women.     

Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data

ObjectiveWe sought to examine rural/urban differences in postpartum contraceptive use, which are underexplored in the literature.MethodsWe analyzed phase 5 (2004–2008) of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Using Rural–Urban Commuting Area codes and weighted multinomial logistic regression, we examined the association between self-reported postpartum contraceptive method and rural/urban residence among postpartum women not desiring pregnancy (n = 6,468).ResultsPostpartum (mean, 16.5 weeks after delivery), 14.4% of respondents were using sterilization, 6.7% long-acting reversible contraception (LARC), 37.3% moderately effective hormonal methods, 38.4% less effective methods or no method, and 3.2% abstinence. Multivariable analysis yielded sporadic geographic patterns. Odds of method use varied significantly by age, parity, body mass index, and breastfeeding status. Not discussing contraception with a prenatal healthcare provider decreased odds of postpartum LARC use (odds ratio, 0.52; 95% CI, 0.36–0.75). Number of prenatal visits and weeks since delivery were not associated with postpartum contraception method.ConclusionsWe did not observe strong variation in postpartum contraceptive use based on geography. Low uptake of highly effective contraception across rural and urban areas suggests a need for education and outreach regarding these methods.     

‘But you can't reverse a hysterectomy!’ Perceptions of long acting reversible contraception (LARC) among young women aged 16–24 years: a qualitative study

ObjectivesLong Acting Reversible Contraception (LARC) methods are highly effective in reducing the incidence of unwanted pregnancy. Recent data indicates that the rate of abortion in Grampian, North East of Scotland is above the Scottish average and LARC uptake among young women low. This study sought to explore young women's perceptions of LARC, with the aim of developing a strategy to increase LARC uptake.Study designQualitative study.MethodsSixty five women aged 16–24 were randomly recruited to this qualitative study from community centres and shopping areas. Recruitment and interviews were conducted in friendship pairs, triads or one-to-one basis. Participants were asked about current and past contraception use, views of contraception methods including LARC; and sources of information about contraception. Data were analysed using thematic content analysis.ResultsWomen interviewed were aware of some of the delivery systems used for long acting contraception (intrauterine devices, implants and injections) but did not recognise them as ‘LARC’. ‘Long acting’ was equated with permanency and the term ‘reversible’ appeared to have the opposite effect to its intention. Intrauterine devices were commonly referred to as ‘coil’. The women often relied on verbal testimonies from those who had experienced using LARC, many of which were negative and inaccurate. A lack of in-depth knowledge about LARC and the opinion that LARC methods were for older women were also cited as barriers to use.ConclusionsThis study shows that negative testimonies and the belief that LARC are not appropriate for young women may discourage LARC uptake.     

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.

Effect of ACASI on Reporting of Abortion and Other Pregnancy Outcomes in the US National Survey of Family Growth

Abortion is a behavior that is stigmatized and difficult to measure. To improve reporting of abortion and other sensitive behaviors in the United States, the National Survey of Family Growth (NSFG) supplements the interviewer administered face‐to‐face (FTF) interview with audio computer‐assisted self‐interviewing (ACASI). This paper estimates differential reporting of abortion and other pregnancy outcomes (miscarriage, live birth) in the NSFG (2002, 2006–2010, 2011–2015) between women's ACASI and FTF interviews. Examining reporting of less stigmatized pregnancy outcomes can help understand the relative contributions of stigma and survey‐level factors in reporting of abortions. More women reported abortions, miscarriages and births in the ACASI than the FTF interview. Differences in reporting were moderated by the length of recall. The ACASI elicited relatively more reporting of abortions and miscarriages among non‐white and low‐income women. Reporting ratios increased over time. ACASI is a tool that may work differently across time, for different measures, and with varying survey contexts.     

Comparison of contraceptive use between the Contraceptive CHOICE Project and state and national data

Background

We compared contraceptive prevalence reported in the Contraceptive CHOICE Project (CHOICE) at time of enrollment with estimates from representative surveys, the 2006–2008 National Survey of Family Growth (NSFG) and 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS).

Study design

We calculated survey weights for CHOICE participants and compared selected demographic characteristics and prevalence estimates of current contraceptive methods being used at the time of enrollment.

Results

Compared with the NSFG, CHOICE participants at the time of enrollment were less likely to be contraceptive pill users (16.1% vs. 24.0%) and more likely to use condoms (23.8% vs. 13.8%). Compared with the BRFSS, CHOICE participants were more likely to use condoms (20.4% vs. 12.9%) and withdrawal (6.6% vs. 0.4%).

Conclusion

Despite differences in sampling strategies between CHOICE and state and national surveys, the contraceptive prevalence estimates were largely similar. This information combined with the high rates of long-acting reversible contraception (LARC) use after enrollment by CHOICE particiants that have been previously reported by study participants may imply that cost and restricted access to LARC could be essential factors in the low rates of LARC use in the United States.     

Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception

BackgroundThis study evaluated the total costs of unintended pregnancy (UP) in the United States (US) from a third-party health care payer perspective and explored the potential role for long-acting reversible contraception (LARC) in reducing UP and resulting health care expenditure.Study DesignAn economic model was constructed to estimate direct costs of UP as well as the proportion of UP costs that could be attributed to imperfect contraceptive adherence. The model considered all women requiring reversible contraception in the US: the pattern of contraceptive use and the rates of UP were derived from published sources. The costs of UP in the United States and the proportion of total cost that might be avoided by improved adherence through increased use of LARC were estimated.ResultsAnnual medical costs of UP in the United States were estimated to be $4.6 billion, and 53% of these were attributed to imperfect contraceptive adherence. If 10% of women aged 20–29 years switched from oral contraception to LARC, total costs would be reduced by $288 million per year.ConclusionsImperfect contraceptive adherence leads to substantial UP and high, avoidable costs. Improved uptake of LARC may generate health care cost savings by reducing contraceptive non-adherence.     

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services

BackgroundAlthough the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods.MethodsUsing data from 771 nonpregnant, non–pregnancy-seeking women receiving gynecological services in the Cincinnati—Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed.FindingsRLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison.ConclusionsIn this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.