The safety of intrauterine devices during breastfeeding: an updated systematic review

Objectives: To update a 2016 review and answer three questions: (1) Among women using an intrauterine device (IUD), does breastfeeding increase the risk of adverse events? (2) Among breastfeeding women, does IUD use increase the risk of adverse events? (3) Among breastfeeding women, does copper (Cu)-IUD use increase risk of adverse breastfeeding or infant outcomes? Methods: We searched multiple databases from inception to August 2023. We extracted prespecified data and assessed risk of bias (RoB) for each article and certainty of evidence for each outcome. Results: Thirty-eight articles met the inclusion criteria; 16 were newly identified since the previous review, most with high RoB. Evidence suggested no effect of breastfeeding on IUD-related adverse events (ie, expulsion, bleeding, pain and infection) compared with not breastfeeding; however, an increased relative risk of perforation was observed with breastfeeding at the time of IUD insertion compared with not breastfeeding. For perforation, relative measures of association ranged from 1.4 to 10.1, and absolute rates varied (eg, 0.6-7% or 6.8 per 1000). Evidence suggested no effect of IUD use on risk of adverse events (ie, bleeding, pain and infection) among breastfeeding women compared with no IUD use. Evidence suggested no effect of Cu-IUD use on breastfeeding or infant outcomes among breastfeeding women compared with no Cu-IUD use. Conclusions: We continued to find an increased relative risk of IUD perforation among breastfeeding women compared with no breastfeeding; however, the absolute risk is low. No other adverse effects with IUD use and breastfeeding were observed. The certainty of evidence for all outcomes was very low

Family planning and abortion service availability and utilisation during the COVID-19 pandemic in Ghana

Background: The effect of COVID-19 has manifested both in the capacity of healthcare systems to provide services as well as create a good balance between pandemic management and maintenance of essential health services. Earlier studies in Ghana during the pandemic reported low patronage of family planning (FP) services but a sudden spike in emergency contraceptive pill utilization. This paper seeks to assess health service availability and readiness, client needs for, and utilization of FP and abortion services during the COVID-19 pandemic period in Ghana. Methods: This study was a panel study with two-time data collection points six to nine months apart. Both quantitative and qualitative approaches were used. A one-time survey was used to assess SRH service utilization by 997 clients. Qualitative data involved a total of 24 Focus Group Discussions (FGDs), 128 In-depth Interviews (IDIs) with female clients and their male partners, and 32 IDIs with healthcare practitioners in the four selected facilities. Also, the WHO Service Availability, Readiness and Assessment tool was completed for the health facilities at baseline and endline. Descriptive statistics and thematic analysis were conducted for quantitative and qualitative data respectively. Results: Age of clients and their male partners participating in IDIs ranged between 18 and 50 years (mean = 33.2 years) while participants for community FGDs ranged between 16 and 56 years (mean = 32.0 years). The majority (68%) of clients visiting the health facility for SRH care sought FP services while 5% sought abortion/post-abortion care of which 71% needed post-abortion care. Attendance data showed sensitivity to the occurrence of the different waves of COVID-19. Family planning and abortion services were generally available but witnessed some short-lived disruption. Healthcare managers reported financial stress which led to innovations in procurement of PPEs and hand sanitizers. Telemedicine facilities did not provide SRH care. Fear of stigma was a major barrier to access to abortion care. Conclusion: The relatively low COVID-19 infection rates in Ghana preceded by the national COVID-19 preparedness strategy may explain the low impact on disruption of FP and abortion services. Development of SRH specific guidelines and strengthening telemedicine facilities to include SRH care may reduce future disruption

Progress in reducing socioeconomic inequalities in the use of modern contraceptives in 48 focus countries as part of the FP2030 initiative between 1990 and 2020: a population-based analysis

Background: Despite increases in modern contraception use, socioeconomic inequalities in family planning persist. In this study, we aimed to measure progress in reducing socioeconomic inequalities in modern contraceptive prevalence rate (mCPR) and demand for family planning satisfied by modern methods (mDFPS) in 48 countries as part of the Family Planning 2030 (FP2030) initiative between 1990 and 2020 for which Demographic and Health Survey data were available. Methods: We analysed two rounds of Demographic and Health Survey data per country. Changes in concentration indices between two survey rounds were compared to measure reductions in overall socioeconomic-related inequalities in modern contraceptive use. Poisson regression models were used to measure the adjusted average annual rate of change across wealth quintiles. Findings: In this population-based analysis study, all countries reduced socioeconomic-related inequalities in modern contraceptive use among in-union women of reproductive age (15-49 years) during the observed 30-year period. On average, mCPR increased at an annual rate of 2·1% (95% CI 2·1-2·2), and the rate of increase for the poorest women was 3·1% (3·0-3·2), which outpaced the rate of increase for the richest women of 1·3% (1·3-1·4%). The pattern of progress was similar for mDFPS, but at a slower pace. Overall, levels of mCPR and mDFPS increased, and socioeconomic-related inequalities were reduced during this period. Interpretation: Substantial progress has been made in reducing socioeconomic-related inequalities in family planning across the 48 studied countries, which account for 86% of the population of the 82 FP2030 initiative countries. During the past three decades, poorer women have seen greater improvements in modern contraceptive use and demand satisfaction compared with richer women. As contraceptive prevalence rates are near their maximum, it is crucial to ensure marginalised and vulnerable groups are not left behind. Funding: Bill & Melinda Gates Foundation. Translations: For the French and Spanish translations of the abstract see Supplementary Materials section

Assessing the impact of hormonal contraceptive use on menstrual health among women of reproductive age – a systematic review

Background: Contraceptive methods are well-established in their ability to prevent pregnancy and increase individual agency in childbearing. Evidence suggests that contraceptives can also be used to treat adverse conditions associated with menstruation, including abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders.This review investigates the effects of contraceptive techniques such as contraceptive pills, and long-acting reversible contraceptives (e.g. intrauterine devices, implants) on menstrual morbidity. Methods: Over ten databases with no geographical boundaries were searched from inception until October 2023. Study designs were one of the following types to be included: parallel or cluster randomised controlled trials, controlled clinical trials, controlled before and after studies, interrupted time series studies, cohort or longitudinal analyses, regression discontinuity designs, and case-control studies. Ten team members screened the papers in pairs with a Kappa score of more than 7, and Covidence was used. Conflicts were resolved by discussion, and the full papers were divided among the reviewers to extract the data from eligible studies. Results: Hormonal contraceptives are considered a well-tolerated, non-invasive, and clinically effective treatment for abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders. Our studies investigating quality of life or well-being in women with heavy menstrual bleeding, endometriosis, or uterine fibroids have found improvements in all dimensions assessed. Conclusions: Hormonal contraceptives significantly reduce pain, symptom severity, and abnormal bleeding patterns associated with women who suffer from heavy menstrual bleeding, endometriosis, and uterine fibroids

Assessing the impact of contraceptive use on mental health among women of reproductive age - a systematic review

Background: Contraceptive use is the principal method by which women avoid unintended pregnancy. An unintended pregnancy can induce long-term distress related to the medical, emotional, and social consequences of carrying that pregnancy to term. Objectives: This review investigates the effects of modern contraception techniques such as birth control pills, long-acting reversible contraceptives (e.g., intrauterine devices, implants), and condoms on mental health status. Methods: We searched multiple databases from inception until February 2022, with no geographical boundaries. RCTs underwent a quality assessment using the GRADE approach while the quality of observational studies was assessed using the Downs and Black scoring system. Data were analyzed through meta-analysis and relative risk and mean difference were calculated and forest plots were created for each outcome when two or more data points were eligible for analysis. Main results: The total number of included studies was 43. In women without previous mental disorders, both RCTs (3 studies, SMD 0.18, 95% CI [0.02, 0.34], high quality of evidence) and cohort studies (RR 1.04 95% CI [1.03, 1.04]) detected a slight increase in the risk of depression development. In women with previous mental disorders, both RCTs (9 studies, SMD - 0.15, 95% CI [-0.30, -0.00], high quality of evidence) and cohort studies (SMD - 0.26, 95% CI [-0.37, -0.15]) detected slight protective effects of depression development. It was also noticed that HC demonstrated protective effects for anxiety in both groups (SMD - 0.20, 95% CI [-0.40, -0.01]). Conclusions: Among women with pre-existing mental disorders who use hormonal contraceptives, we reported protective association with decreased depressive symptoms. However, the study also draws attention to some potential negative effects, including an increase in the risk of depression and antidepressant use among contraceptive users, a risk that is higher among women who use the hormonal IUD, implant, or patch/ring methods. Providers should select contraceptive methods taking individual aspects into account to maximize benefits and minimize risks