Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception

Background Use of more effective contraception may lead to less condom use and increased incidence of sexually transmitted infection. Objective The objective of this study was to compare changes in condom use and incidence of sexually transmitted infection acquisition among new initiators of long-acting reversible contraceptives to those initiating non-long-acting reversible contraceptive methods. Study Design This is a secondary analysis of the Contraceptive CHOICE Project. We included 2 sample populations of 12-month continuous contraceptive users. The first included users with complete condom data (baseline, and 3, 6, and 12 months) (long-acting reversible contraceptive users: N = 2371; other methods: N = 575). The second included users with 12-month sexually transmitted infection data (long-acting reversible contraceptive users: N = 2102; other methods: N = 592). Self-reported condom use was assessed at baseline and at 3, 6, and 12 months following enrollment. Changes in condom use and incident sexually transmitted infection rates were compared using χ2 tests. Risk factors for sexually transmitted infection acquisition were identified using multivariable logistic regression. Results Few participants in either group reported consistent condom use across all survey time points and with all partners (long-acting reversible contraceptive users: 5.2%; other methods: 11.3%; P < .001). There was no difference in change of condom use at 3, 6, and 12 months compared to baseline condom use regardless of method type (P = .65). A total of 94 incident sexually transmitted infections were documented, with long-acting reversible contraceptive users accounting for a higher proportion (3.9% vs 2.0%; P = .03). Initiation of a long-acting reversible contraceptive method was associated with increased sexually transmitted infection incidence (odds ratio, 2.0; 95% confidence ratio, 1.07–3.72). Conclusion Long-acting reversible contraceptive initiators reported lower rates of consistent condom use, but did not demonstrate a change in condom use when compared to preinitiation behaviors. Long-acting reversible contraceptive users were more likely to acquire a sexually transmitted infection in the 12 months following initiation

Long-acting reversible contraception use among residents in obstetrics/gynecology training programs

Background: The objective of the study was to estimate the personal usage of long-acting reversible contraception (LARC) among obstetrics and gynecology (Ob/Gyn) residents in the United States and compare usage between programs with and without a Ryan Residency Training Program (Ryan Program), an educational program implemented to enhance resident training in family planning. Materials and methods: We performed a web-based, cross-sectional survey to explore contraceptive use among Ob/Gyn residents between November and December 2014. Thirty-two Ob/Gyn programs were invited to participate, and 24 programs (75%) agreed to participate. We divided respondents into two groups based on whether or not their program had a Ryan Program. We excluded male residents without a current female partner as well as residents who were currently pregnant or trying to conceive. We evaluated predictors of LARC use using bivariate analysis and multivariable Poisson regression. Results: Of the 638 residents surveyed, 384 (60.2%) responded to our survey and 351 were eligible for analysis. Of those analyzed, 49.3% (95% confidence interval [CI]: 44.1%, 54.5%) reported current LARC use: 70.0% of residents in Ryan Programs compared to 26.8% in non-Ryan Programs (RRadj 2.14, 95% CI 1.63-2.80). Residents reporting a religious affiliation were less likely to use LARC than those who described themselves as non-religious (RRadj 0.76, 95% CI 0.64-0.92). Of residents reporting LARC use, 91% were using the levonorgestrel intrauterine device. Conclusion: LARC use in this population of women's health specialists is substantially higher than in the general population (49% vs. 12%). Ob/Gyn residents in programs affiliated with the Ryan Program were more likely to use LARC

Association of Baseline Bleeding Pattern on Amenorrhea with Levonorgestrel Intrauterine System Use

OBJECTIVE To evaluate the effect of baseline bleeding patterns on rates of amenorrhea reported at 12 months in LNG (levonorgestrel) 52 mg IUS (intrauterine system) users. We also assessed the effect of baseline bleeding patterns at three and six months post-insertion. STUDY DESIGN In this secondary analysis of the Contraceptive CHOICE Project, we included participants who had a LNG-IUS inserted within one month of enrollment and continued use for 12 months. Using 12-month telephone survey data, we defined amenorrhea at 12 months of use as no bleeding or spotting during the previous six months. We used chi-square and multivariable logistic regression to assess the association of baseline bleeding pattern with amenorrhea while controlling for confounding variables. RESULTS Of 1802 continuous 12-month IUS users, amenorrhea was reported by 4.9%, 14.8% and 15.4% of participants at three, six, and 12 months, receptively. Participants with light baseline bleeding or short duration of flow reported higher rates of amenorrhea at three and six months post-insertion (p<0.03), while LNG-IUS users with heavy or prolonged flow were less likely to report amenorrhea at 3 and 6 months (p<0.03). In a multivariable analysis, participants with self-reported heavy bleeding at baseline were less likely to report amenorrhea at 12 months than those who reported moderate bleeding (ORadj, 0.36; 95% CI, 0.16–0.69). CONCLUSION Women with heavier menstrual bleeding are less likely than women with moderate flow to report amenorrhea following 12 months of LNG-IUS use

Socioeconomic Status As a Risk Factor for Unintended Pregnancy in the Contraceptive CHOICE Project

OBJECTIVE: To evaluate the association of low socioeconomic status as an independent risk factor for unintended pregnancy. METHODS: We performed a secondary analysis of data from the Contraceptive CHOICE project. Between 2007 and 2011, 9,256 participants were recruited and followed for up to 3 years. The primary outcome of interest was unintended pregnancy; the primary exposure variable was low socioeconomic status, defined as self-report of either receiving public assistance or having difficulty paying for basic necessities. Four contraceptive groups were evaluated: 1) long-acting reversible contraceptive method (hormonal or copper intrauterine device or subdermal implant); 2) depot medroxyprogesterone acetate injection; 3) oral contraceptive pills, a transdermal patch, or a vaginal ring; or 4) other or no method. Confounders were adjusted for in the multivariable Cox proportional hazard model to estimate the effect of socioeconomic status on risk of unintended pregnancy. RESULTS: Participants with low socioeconomic status experienced 515 unintended pregnancies during 14,001 women-years of follow-up (3.68/100 women-years; 95% CI 3.37-4.01) compared with 200 unintended pregnancies during 10,296 women-years (1.94/100 women-years; 95% CI 1.68-2.23) among participants without low socioeconomic status. Women with low socioeconomic status were more likely to have an unintended pregnancy (unadjusted hazard ratio [HR] 1.8, 95% CI 1.5-2.2). After adjusting for age, education level, insurance status, and history of unintended pregnancy, low socioeconomic status was associated with an increased risk of unintended pregnancy (adjusted HR 1.4, 95% CI 1.1-1.7). CONCLUSION: Despite the removal of cost barriers, low socioeconomic status is associated with a higher incidence of unintended pregnancy

Prolonged Use of the Etonogestrel Implant and Levonorgestrel Intrauterine Device - Two Years Beyond FDA-Approved Duration

The subdermal contraceptive implant, and the 52mg levonorgestrel intrauterine device (IUD) are currently FDA-approved for three and five years of use respectively. Limited available data has suggested both of these methods are effective beyond that time. Demonstration of prolonged effectiveness will improve the cost-effectiveness of the device, and potentially patient continuation and satisfaction. Objective To evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device (IUD) in women using the method for two years beyond the current FDA-approved duration. Study Design We initiated this ongoing prospective cohort study in January 2012. We are enrolling women using the contraceptive implant or 52-mg levonorgestrel IUD for a minimum of 3 and 5 years, respectively (started IUD in 2007 or later or implant in 2009 or later). Demographic and reproductive health histories, as well as objective body mass index (BMI) were collected. Implant users were offered periodic venipuncture for analysis of serum etonogestrel levels. The primary outcome, unintended pregnancy rates, was calculated per 100 woman-years. We analyzed baseline demographic characteristics using chi-square test and Fisher Exact test, and compared serum ENG levels stratified by body mass index using the Kruskal-Wallis test. Results Implant users (n=291) have contributed 444.0 women-years of follow-up. There have been no documented pregnancies in implant users during the two years of post-expiration follow-up. Calculated failure rates in the fourth and fifth years for the implant are calculated as 0 (one-sided %97.5 confidence interval (CI) 0–1.48) per 100 woman years at four years and 0 (one-sided %97.5 CI 0–2.65) per 100 women years at five years. Among 496 levonorgestrel IUD users, 696.9 women-years of follow-up have been completed. Two pregnancies have been reported. The failure rate in the sixth year of use of the levonorgestrel IUD is calculated as 0.25(%95 CI 0.04–1.42) per 100 women year; failure rate during the seventh year is 0.43 (%95 CI 0.08–2.39) per 100 women years. Among implant users with serum etonogestrel results, the median etonogestrel level at the time of method expiration was 207.7 pg/mL (range 63.8–802.6 pg/mL), 166.1 pg/mL (range 67.9 25.0 – 470.5 pg/mL) at the end of the fourth year, and 153.0 pg/mL (range 72.1–538.8 pg/mL) at the end of the fifth year. Median ENG levels were compared by BMI at each time point and a statistical difference was noted at the end of four years of use with overweight women having the highest serum ENG (195.9 pg/ml: range 25.0–450.5) when compared to normal (178.9 pg/ml: range 87.0–463.7) and obese (137.9 pg/ml: range 66.0–470.5) women (p=0.04). Conclusion This study indicates that the contraceptive implant and 52-mg hormonal IUD continue to be highly effective for at least two additional years of use. Serum etonogestrel evaluation demonstrates median levels remain above the ovulation threshold of 90pg/ml for women of in all BMI classes

Provision of no-cost, long-acting contraception and teenage pregnancy.

BACKGROUND: The rate of teenage pregnancy in the United States is higher than in other developed nations. Teenage births result in substantial costs, including public assistance, health care costs, and income losses due to lower educational attainment and reduced earning potential. METHODS: The Contraceptive CHOICE Project was a large prospective cohort study designed to promote the use of long-acting, reversible contraceptive (LARC) methods to reduce unintended pregnancy in the St. Louis region. Participants were educated about reversible contraception, with an emphasis on the benefits of LARC methods, were provided with their choice of reversible contraception at no cost, and were followed for 2 to 3 years. We analyzed pregnancy, birth, and induced-abortion rates among teenage girls and women 15 to 19 years of age in this cohort and compared them with those observed nationally among U.S. teens in the same age group. RESULTS: Of the 1404 teenage girls and women enrolled in CHOICE, 72% chose an intrauterine device or implant (LARC methods); the remaining 28% chose another method. During the 2008–2013 period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1000, respectively. CONCLUSIONS: Teenage girls and women who were provided contraception at no cost and educated about reversible contraception and the benefits of LARC methods had rates of pregnancy, birth, and abortion that were much lower than the national rates for sexually experienced teens. (Funded by the Susan Thompson Buffett Foundation and others.

How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response : results from a global survey of providers, researchers, and policy-makers

Introduction We aimed to give a global overview of trends in access to sexual and reproductive health and rights (SRHR) during the coronavirus disease 2019 (COVID-19) pandemic and what is being done to mitigate its impact. Material and methods We performed a descriptive analysis and content analysis based on an online survey among clinicians, researchers, and organizations. Our data were extracted from multiple-choice questions on access to SRHR services and risk of SRHR violations, and written responses to open-ended questions on threats to access and required response. Results The survey was answered by 51 people representing 29 countries. Eighty-six percent reported that access to contraceptive services was less or much less because of COVID-19, corresponding figures for surgical and medical abortion were 62% and 46%. The increased risk of gender-based and sexual violence was assessed as moderate or severe by 79%. Among countries with mildly restrictive abortion policies, 69% had implemented changes to facilitate access to abortion during the pandemic, compared with none among countries with severe restrictions (P < .001), 87.5% compared with 46% had implemented changes to facilitate access to contraception (P = .023). The content analysis showed that (a) prioritizations in health service delivery at the expense of SRHR, (b) lack of political will, (c) the detrimental effect of lockdown, and (d) the suspension of sexual education, were threats to SRHR access (theme 1). Requirements to mitigate these threats (theme 2) were (a) political will and support of universal access to SRH services, (b) the sensitization of providers, (c) free public transport, and (d) physical protective equipment. A contrasting third theme was the state of exception of the COVID-19 pandemic as a window of opportunity to push forward women's health and rights. Conclusions Many countries have seen decreased access to and increased violations of SRHR during the COVID-19 pandemic. Countries with severe restrictions on abortion seem less likely to have implemented changes to SRHR delivery to mitigate this impact. Political will to support the advancement of SRHR is often lacking, which is fundamental to ensuring both continued access and, in a minority of cases, the solidification of gains made to SRHR during the pandemic

Institutionalizing the founder\u27s charism: An inquiry into the exercise of leadership by principals of American Dominican schools

The purpose of this study was to identify and describe whether and how selected Dominican secondary school principals communicate the Dominican charism through their leadership vision and empower the faculty to integrate this charism into their professional activity. The study examined the leadership beliefs and behavior of five Dominican Sisters who serve as principals in secondary schools owned by their respective Dominican congregations and compared the leadership of these principals to discover similarities in the articulation of the charism. The examination of the Dominican charism was limited to three components: an orientation to study, a contemplative attitude and prayer, and collaboration based on mutual respect. Non-participant observation and semi-structured interviews were the methods used to assess the principals\u27 influence on the expression of these components in the beliefs and activities of selected faculty, the staff development program, the academic tone, the fine arts curriculum, the religious practices, and governance structures within the school. The study found that (a) there was some diversity among the principals in relationship to their understanding of the charism, (b) there were common elements and values, communicated by four of the five principals and empowered in four of the five faculties, which illustrated the presence of the three components of the charism within the life of the school, and (c) the basic difference within the leadership of the principals was in the degree of communication and empowerment across the five principals and faculties. It concluded that these commonalities and differences speak to the issue of future leadership of Dominican secondary schools. The study recommended that a task force of experienced Dominican principals develop a leadership renewal program which allows current principals to generate discussion on the charism with implications for educational leadership. It further recommended that models be developed which orient future principals to Dominican leadership from both a theoretical and practical perspective. This study is significant because it seeks to initiate a discussion on the complex issue of institutionalizing the charism within Dominican secondary schools and points out that the role of leadership is crucial to this institutionalization

Combined oral contraceptive treatment for bleeding complaints with the etonogestrel contraceptive implant: a randomised controlled trial.

ObjectiveEstimate symptom improvement rate of women with bleeding complaints using the etonogestrel contraceptive implant when started on continuous combined oral contraceptives (COC).MethodsWe conducted a double-blinded randomised controlled trial of women reporting troublesome bleeding related to their etonogestrel contraceptive implant and desiring intervention. Participants received continuous COCs or placebo for four weeks to evaluate self-reported bleeding improvement at four weeks. Participants could continue study treatment or prescribed COCs for another eight weeks if desired. We planned to enroll 130 participants between two sites (80% power to detect a 20% effect size at a 0.05 significance level, with 10% loss to follow up).ResultsWe closed the study after enrolling 26 participants due to recruitment futility. All women on COCs and 75% of placebo users reported bleeding improvement at four weeks (p = 0.09), with 92% and 42%, respectively, reporting significant improvement (p = 0.03). The median number of days until bleeding stopped for at least four days in COC and placebo users was 1 day (range 1-9) and 4.5 days (range 1-28), respectively (p = 0.63). Eight (75%) COC and five (42%) placebo users opted to continue study treatment (p = 0.41). Despite bleeding improvement, women who desired implant removal at enrollment were more likely to re-request removal than those who initially considered other interventions (3 of 5 [60%] vs 1 of 17 [6%], p = 0.03).ConclusionAlthough women who have troublesome bleeding while using the contraceptive implant may experience improvement with no treatment over 4 weeks, women using COCs are more likely to report significant improvement. Clinicaltrials.gov registration number: NCT01963403