Perceptions of long-acting reversible contraception among women receiving medication for opioid use disorder in Vermont.

OBJECTIVES: To evaluate perceptions of long-acting reversible contraceptives (LARC) among women receiving medication for opioid use disorder. STUDY DESIGN: Cross-sectional survey of 200 women receiving medication for opioid use disorder in Vermont. RESULTS: A considerable proportion of women receiving medication for opioid use disorder in Vermont reported previous use of an IUD (40%) and/or a subdermal contraceptive implant (16%); the majority of prior LARC users were satisfied with their IUD (68%) or their implant (74%). Of the 38% of participants who had never considered IUD use, 85% percent (64/75) said that they knew nothing or only a little about IUDs. Of the 61% of participants who had never considered an implant, 81% percent (98/121) said that they knew nothing or only a little about the contraceptive method. The most commonly reported reasons for a lack of interest in the IUD and/or implant were concerns about side effects and preference for a woman-controlled method. CONCLUSIONS: Gaps in LARC knowledge are common among those who have not used LARCs and concerns about side effects and preferences for a woman-controlled method limit some women's interest in these contraceptives. Additionally, reasons for dissatisfaction among past users are generally similar for IUD and implant and include irregular bleeding and having a bad experience with the method. IMPLICATIONS: Efforts to increase awareness of LARC methods among women receiving medication for opioid use disorder should address concerns about side effects and reproductive autonomy and encourage satisfied LARC users to share their experiences with their social networks.

Modern contraceptive use, unmet need, and demand satisfied among women of reproductive age who are married or in a union in the focus countries of the Family Planning 2020 initiative: a systematic analysis using the Family Planning Estimation Tool.

BACKGROUND: The London Summit on Family Planning in 2012 inspired the Family Planning 2020 (FP2020) initiative and the 120×20 goal of having an additional 120 million women and adolescent girls become users of modern contraceptives in 69 of the world's poorest countries by the year 2020. Working towards achieving 120 × 20 is crucial for ultimately achieving the Sustainable Development Goals of universal access and satisfying demand for reproductive health. Thus, a performance assessment is required to determine countries' progress. METHODS: An updated version of the Family Planning Estimation Tool (FPET) was used to construct estimates and projections of the modern contraceptive prevalence rate (mCPR), unmet need for, and demand satisfied with modern methods of contraception among women of reproductive age who are married or in a union in the focus countries of the FP2020 initiative. We assessed current levels of family planning indicators and changes between 2012 and 2017. A counterfactual analysis was used to assess if recent levels of mCPR exceeded pre-FP2020 expectations. FINDINGS: In 2017, the mCPR among women of reproductive age who are married or in a union in the FP2020 focus countries was 45·7% (95% uncertainty interval [UI] 42·4-49·1), unmet need for modern methods was 21·6% (19·7-23·9), and the demand satisfied with modern methods was 67·9% (64·4-71·1). Between 2012 and 2017 the number of women of reproductive age who are married or in a union who use modern methods increased by 28·8 million (95% UI 5·8-52·5). At the regional level, Asia has seen the mCPR among women of reproductive age who are married or in a union grow from 51·0% (95% UI 48·5-53·4) to 51·8% (47·3-56·5) between 2012 and 2017, which is slow growth, particularly when compared with a change from 23·9% (22·9-25·0) to 28·5% (26·8-30·2) across Africa. At the country level, based on a counterfactual analysis, we found that 61% of the countries that have made a commitment to FP2020 exceeded pre-FP2020 expectations for modern contraceptive use. Country success stories include rapid increases in Kenya, Mozambique, Malawi, Lesotho, Sierra Leone, Liberia, and Chad relative to what was expected in 2012. INTERPRETATION: Whereas the estimate of additional users up to 2017 for women of reproductive age who are married or in a union would suggest that the 120 × 20 goal for all women is overly ambitious, the aggregate outcomes mask the diversity in progress at the country level. We identified countries with accelerated progress, that provide inspiration and guidance on how to increase the use of family planning and inform future efforts, especially in countries where progress has been poor. FUNDING: The Bill & Melinda Gates Foundation, through grant support to the University of Massachusetts Amherst and Avenir Health.

"Without bodily autonomy we are not free": exploring women's concerns about future access to contraception following the 2016 US presidential election.

OBJECTIVE: Following the 2016US presidential election, social media posts and news stories amplified concerns about the potential for reduced access to contraception under the incoming administration and urged women to seek long-acting reversible contraception. We aimed to describe women's concerns about future access to contraception, in their own words. STUDY DESIGN: A social-media-based, anonymous online survey assessing thoughts and concerns about future access to contraception was distributed to reproductive-aged US women for 1 week in mid-January 2017. Participants who were concerned about future access to contraception could share their thoughts and feelings in an open-ended comments box. We qualitatively analyzed 449 written responses for content and themes, with the goal of characterizing key concerns. RESULTS: Women who provided written comments had a mean age of 28years; 85% were white, 88% had at least a college degree, and 93% identified as Democratic or Democratic-leaning. Women were highly concerned about future affordability of contraceptive methods due to potential loss of insurance, reduced insurance coverage for contraceptive methods and reduced access to low-cost care at Planned Parenthood. Many also worried about increased restrictions on abortion. Participants' concerns regarding access to contraception and abortion centered around themes of reproductive and bodily autonomy, which women described as fundamental rights. CONCLUSIONS: Women in this study expressed considerable fear and uncertainty regarding their future access to contraception and abortion following the 2016US presidential election. The potential for restricted access to affordable contraception and abortion was viewed as an unacceptable limitation on bodily autonomy. IMPLICATIONS: As the future of US health care policy is debated, many women are concerned about the impact of policy changes on their ability to access affordable contraception and abortion, which many view as essential to the preservation of bodily and reproductive autonomy.

Knowledge of and concerns about long-acting reversible contraception among women in medication-assisted treatment for opioid use disorder.

OBJECTIVES: To assess interest in, concerns about and knowledge of long-acting reversible contraceptives (LARC) among women in medication-assisted treatment (MAT) for opioid use disorder who were at risk for unintended pregnancy. STUDY DESIGN: Women in MAT completed a survey on contraceptive use, attitudes and knowledge, including LARC methods, as part of eligibility screening for an ongoing trial evaluating family planning interventions for this population. RESULTS: Eighty-three women at risk for unintended pregnancy completed the survey, and a subset of 51 completed supplemental questions about implants. All participants had heard of IUDs and 75/83 (90%) had heard of implants, but only 34/83 (41%) and 14/51 (27%) reported being likely to use IUDs and implants, respectively. Thirty-five women reported they were unlikely to use IUDs, with 29/35 (83%) citing unspecified "other reasons" for this position and 24/35 (69%) endorsing concerns about side effects. Seventeen women reported they were unlikely to use implants, with 8/17 (47%) citing "other reasons" and 9/17 (53%) and 10/17 (59%) reporting concerns about insertion and removal, respectively. Participants reported they knew "a little" about LARCs, but only their knowledge of implants was limited. Only 50/83 (60%) participants were aware of the superior effectiveness of IUDs and 26/51 (51%) were aware of the superior effectiveness of implants relative to other reversible methods. CONCLUSIONS: Participants reported relatively low interest in LARCs. Many women had unspecified reasons for not using LARCs. Participants also lacked information about LARC safety and effectiveness, especially with regard to implants. IMPLICATIONS: Women in medication-assisted treatment for opioid use disorder are at high risk of unintended pregnancy, yet contraceptive use is low and use of less effective methods is common. Women in MAT may benefit from efforts to increase knowledge about implants and assuage concerns about their insertion and removal as well as more general efforts to improve knowledge about the relative efficacy of LARCs. Many women in MAT endorsed unspecified "other reasons" for not using LARCs, which should be explored further.

Motivating factors for dual-method contraceptive use among adolescents and young women: a qualitative investigation.

OBJECTIVE: This qualitative study explores how adolescents and young women perceive the need for and describe the use of dual method contraception. STUDY DESIGN: We interviewed 20 sexually active women aged 16-24 who attended an adolescent-focused Title X family-planning clinic and were using a non-barrier contraceptive method. We used a semi-structured interview guide that included domains related to sexual activity, knowledge of and use of contraceptives and condoms, and relationship factors. We coded transcripts using grounded theory techniques and used an iterative process to develop overarching themes. RESULTS: Dual method contraceptive users primarily discussed pregnancy prevention as their motivating factor. Many expressed anxieties over an unplanned pregnancy and reported condom use as "back-up" contraception. Risk perception for pregnancy or STI acquisition did not necessarily change as relationship trust increased, but rather, their anxiety regarding the negativity of such outcomes decreased. Dual-method contraception use decreased when participants reported that condoms were not readily available, or when they self-described immaturity. Less frequently, participants reported dual method use for sexually transmitted infection (STI) prevention, and many substituted STI testing for condom use. Contraceptive type (short-acting vs. long-acting) did not influence reported attitudes towards dual method use. CONCLUSION: Health educators and clinicians encourage condom use in young women due to the significant morbidity associated with STI acquisition. Most participants in our study view condoms as a way to improve pregnancy prevention. Acknowledging and addressing this divergence in motivation will allow caregivers to improve strategies for communicating the importance of dual method use. IMPLICATIONS: Young women primarily describe pregnancy prevention as the reason for dual method use, STI protection is less salient. Consideration of this viewpoint by health educators and clinicians will allow us to communicate more effectively to prevent STI morbidity.

The effect of internal migration, individual and contextual characteristics on contraceptive use among Nigerian women.

We investigated the relation of internal migration to contraceptive use and adjusted for individual and contextual (community) characteristics. Multilevel logistic regression models were fitted to nationally representative data of 28,876 women from 884 communities in Nigeria. Only about one out of every 10 women (10.4%) currently used a contraceptive method. Contraceptive prevalence according to the migration status were rural-urban (12.5%), urban-rural (13.8%), rural nonmigrants (6.2%) and urban nonmigrants (17.1%). The relationship between internal migration and contraceptive use was fully explained by individual and community characteristics. Programs aimed at increasing contraceptive prevalence should address contextual challenges alongside socioeconomic factors.

Transitions in pregnancy planning in women recruited for a large prospective cohort study.

STUDY QUESTION: Do the rates at which women transition among different intensities of pregnancy planning vary with age, marital status and race/ethnicity? SUMMARY ANSWER: Rates of transition from low or moderate pregnancy probability groups (PPGs) to higher PPGs vary by age, marital status and race/ethnicity. WHAT IS KNOWN ALREADY: The design of prospective studies of the effects of pre- and peri-conception exposures on fecundity, pregnancy and children's health is challenging because at any specific time only a small percentage of reproductive age women is attempting to conceive. To our knowledge, there has been no population-based, prospective study that repeatedly assessed pregnancy planning, which included women who were not already planning pregnancy at enrollment and whose ages spanned the female reproductive age range. STUDY DESIGN, SIZE, DURATION: A longitudinal study was carried out that repeatedly assessed pregnancy probability in 12 916 women for up to 21 months from January 2009 to September 2010. PARTICIPANTS/MATERIALS, SETTING, METHOD: We analyzed data from the National Children's Study Vanguard Study, a pilot study for a large-scale epidemiological birth cohort study of children and their parents. During the Vanguard Study, investigators followed population-based samples of reproductive age women in each of seven geographically dispersed and diverse study locations over time to identify when they sought to become pregnant, providing a unique opportunity to prospectively assess changes in pregnancy planning in a large sample of US women. At study entry and each follow-up contact, which occurred at 1, 3 or 6 month intervals depending on PPG, a questionnaire was used to assess behavior dimensions of pregnancy planning to assign women to low, moderate, high non-tryer and high tryer PPGs. MAIN RESULTS AND THE ROLE OF CHANCE: Crude rates of pregnancy increased with higher assigned PPG, validating the utility of the instrument. The initial PPG and probabilities of transitioning from low or moderate PPG to higher PPG or pregnancy varied with age, marital status and race/ethnicity. Women aged 25 to <35 years had shorter times to transition to higher PPGs or to pregnant compared with women <25 years. Women who were not currently married had longer times to transition from any initial PPG to pregnant, high tryer or high non-tryer status than currently married women. Non-Hispanic Black (NHB) and Hispanic women had shorter time to transition from low or moderate to high non-tryer than non-Hispanic White (NHW) women. NHB women also had shorter time to transition from low to high tryer than NHW women. High tryers are more likely to be aged 25 to <30 years, to be married, and to be Hispanic, NHB or other race/ethnicity than women in the low PPG. LIMITATIONS, REASONS FOR CAUTION: Loss to follow-up varied by age, marital status and race/ethnicity. Although weights were not developed for the Vanguard study, the self-weighting design minimizes the bias of unweighted analysis. Nonetheless, the SEs for some estimates may be under-estimated. WIDER IMPLICATIONS OF THE FINDINGS: Our results show that demographic characteristics are strong predictors of women's behaviors toward pregnancy. The results further show that frequent follow-up assessments of pregnancy planning behavior in large numbers of women are required to recruit an unbiased sample of preconception women. These findings will be useful to investigators designing prospective studies of fecundability, pregnancy outcomes and children's health. STUDY FUNDING/COMPETING INTERESTS: National Institutes of Health (contracts N01-HD53414, N01-HD63416, N01-HD53410, N01-HD53415, N01-HD53396, N01-HD53413 and N01-HD-53411; grant R21 ES016846) and by the University of California Irvine Center for Occupational and Environmental Health. No competing interests. TRIAL REGISTRATION NUMBER: None.

Contraceptive Utilisation Among Mothers of Reproductive Age in Ajman, United Arab Emirates.

OBJECTIVES: This study aimed to determine contraceptive utilisation among mothers aged 18-49 years old in Ajman, United Arab Emirates (UAE). METHODS: This cross-sectional study was carried out from May to November 2013. A total of 400 participants were recruited from two primary healthcare centres and one private hospital in Ajman. An interviewer-administered validated questionnaire was used for data collection. RESULTS: The frequency of previous and current contraceptive use was 68.0% and 61.8%, respectively. Expatriates more frequently used contraceptives in comparison to Emiratis (77.3% versus 54.3%, respectively). Contraceptive use increased significantly with age (75.5% among >35-year-olds versus 57.3% among ≤25-year-olds; P <0.050) and education level (83.3% among postgraduates versus 60.0% among those with primary education; P <0.050). In addition, contraceptive use was significantly higher among those living in a nuclear family system (P <0.050). A univariate analysis indicated significant associations between contraceptive use and age, nationality, education level, type of family system, employment sector, parity, knowledge of birth control measures and source of birth control information (P <0.050 each). However, no significant associations were found via multivariate analysis. CONCLUSION: Healthcare practitioners can play a pivotal role in providing contraceptive advice which could lead to an improvement in contraceptive utilisation. Efforts are recommended to raise awareness regarding newer forms of contraceptives among mothers of reproductive age in the UAE.

Prevalence of contraceptive use in New Zealand women.

AIMS: To estimate the prevalence of contraceptive use among New Zealand women and to measure changes in contraceptive use since the last population-based prevalence estimates were published in 1988. METHODS: Nine hundred and four women, aged 35-69 years were randomly selected from the electoral roll. A postal questionnaire was used to gather information on contraceptive use, socio-demographic characteristics and risk factors for ovarian cancer. Data were collected in 2013-2015. Estimates of current and ever-use of contraceptives were made and compared with the findings of the 1988 study by Paul et al. In both studies, participants were members of the control arm of case-control studies. RESULTS: The study by Paul et al had a response proportion of 84%, whereas that of the current study was 47%. Oral contraceptives had the highest prevalence of ever-use among women aged 35-69 years (89% [347/389]), followed by condom use (54% [211/389]) and vasectomy (44% [170/389]). Compared to the previous study, there has been an increase in ever-use of condoms (24% [185/767] to 64% [148/231]), vasectomy (26% [202/767] to 40% [92/231]) and oral contraceptives (75% [575/767] to 89% [205/231]) among women aged 35-54 years. In contrast, a lower prevalence of tubal ligation (22% [168/767] to 8% [19/231]) was observed. CONCLUSION: The study demonstrates a change in patterns of contraceptive use among women aged 35-54 years. The prevalence of ever-use of oral contraceptives and vasectomy remains high in New Zealand compared with other countries.

Chronic Diseases and Use of Contraception Among Women at Risk of Unintended Pregnancy.

BACKGROUND: Women with chronic diseases are at increased risk of having unintended pregnancies. Little is known whether chronic diseases are associated with increased likelihood of effective/highly effective contraceptive use. METHODS: We analyzed 2008-2010 Florida Behavioral Risk Factor Surveillance System data for women aged 18-44 years who were at risk of unintended pregnancy. Multivariable Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for contraceptive use in relation to diabetes, cardiovascular disease (CVD), and current asthma. We assessed the association of chronic disease status with use of three different contraception outcomes: (1) any method versus none, (2) less effective methods (methods associated with ≥10 unintended pregnancies/100 women/year) versus none, and (3) effective/highly effective methods (<10 unintended pregnancies/100 women/year) versus none. RESULTS: Among 4473 women at risk for unintended pregnancy, 87% were using any method of contraception (22.5% less effective methods and 64.5% effective/highly effective methods). Women with CVD were more likely than those without CVD to use any contraception (aPR = 1.09, 95% CI: 1.04, 1.15), less effective (aPR = 1.39, 95% CI: 1.13, 1.70), and effective/highly effective (aPR = 1.10, 95% CI: 1.03, 1.19) contraception. Women with diabetes were more likely to use less effective methods than women without diabetes (aPR = 1.34, 95% CI: 1.05, 1.72). No significant associations were observed for asthma, regardless of contraceptive effectiveness. CONCLUSIONS: Self-reported use of effective/highly effective contraception was higher than nonuse or use of less effective methods among all women at risk of unintended pregnancy, but could be improved, especially among women with chronic diseases.

Modern contraceptive use among migrant and non-migrant women in Kenya.

BACKGROUND: Manifest socio-economic differences are a trigger for internal migration in many sub-Saharan settings including Kenya. An interplay of the social, political and economic factors often lead to internal migration. Internal migration potentially has significant consequences on an individual's economic growth and on access to health services, however, there has been little research on these dynamics. In Kenya, where regional differentials in population growth and poverty reduction continue to be priorities in the post MDG development agenda, understanding the relationships between contraceptive use and internal migration is highly relevant. METHODS: Using data from the 2008-09 Kenya Demographic and Health Survey (DHS), we analyze data from 5,905 women aged 15-49 years who reported being sexually active in the last 12 months prior to the survey. Bivariate and multivariate logistic regressions are fitted to predict correlates of contraceptive use in the presence of migration streams among other explanatory variables. RESULTS: Modern contraceptive use was significantly higher among women in all migration streams (non-migrant urban (OR = 2.8, p < 0.001), urban-urban (OR = 2.0, p < 0.001), urban-rural (OR = 2.0, p < 0.001), rural-urban (OR = 2.6, p < 0.001), rural-rural (OR = 1.7, p < 0.001), than non-migrant rural women. CONCLUSION: Women who internally migrate within Kenya, whether from rural to urban or between urban centres, were more likely to use modern contraception than non-migrant rural women. This phenomenon appears to be due to selection, adaption and disruption effects which are likely to promote use of modern contraceptives. Programmatically, the differentials in modern contraceptive use by the different migration streams should be considered when designing family planning programmes among migrant and non-migrant women.

Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions.

BACKGROUND: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society--Pakistan implemented an operational research project--'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. METHODS: We conducted a quasi-experimental (pre- and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, (1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and (2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. RESULTS: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14% percentage points, current contraceptive use by 5% percentage points and long term modern method--intrauterine device (IUD) use by 6% percentage points. The CMW model significantly increased contraceptive awareness by 28% percentage points, ever use of contraceptives by 7% percentage points and, IUD use by 3% percentage points. Additionally the Suraj intervention led to a 35% greater prevalence (prevalence ratio: 1.35, 95% CI: 1.22-1.50) of contraceptive use among MWRA. CONCLUSION: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Dual contraceptive method use and pregnancy intention among people living with HIV receiving HIV care at six hospitals in Thailand.

BACKGROUND: Describe dual contraceptive method use and the intention to become pregnant of people living with HIV (PLHIV) and their partners in Thailand. METHODS: From January 2008-March 2009, we systematically selected a cohort of PLHIV from PLHIV seeking care at five tertiary care hospitals and one community hospital to complete a questionnaire assessing sexual activity, intention to become pregnant, and contraceptive practices at baseline and 12 months after enrollment. Participants received short family planning messages every 2-3 months to promote the use of dual contraceptives and were offered family planning services. RESULTS: A total of 1,388 PLHIV enrolled, their median age was 37 years (IQR 33-43), 898 (64.7%) had a steady partner, and 737 (53.1%) were male. Among those with a steady partner, 862 (96.0%) did not intend to become pregnant; 709 (82.3%) had sex during the previous 3 months, 683 (96.3%) used at least one contraceptive method, and 202 (29.6%) used dual contraceptive methods. Of the 317 PLHIV who used a single contraceptive method at baseline, 66 (20.8%) reported using dual methods at 12 months. Participants at two tertiary care hospitals where coordinators facilitated PLHIV referral between HIV and OB/GYN clinics were more likely than participants at the other hospitals to change from single method to dual method (p ≤ 0.03). CONCLUSION: Few PLHIV in this study intended to become pregnant; however, only one-fourth used dual contraceptive methods. Integrating an assessment of the intention to become pregnant and strengthening the PLHIV referral systems in family planning services may contribute to higher rates of dual contraceptive use.

Differences in Family Planning Services by Rural-urban Geography: Survey of Title X-Supported Clinics In Great Plains and Midwestern States.

CONTEXT: Understanding the nature of rural-urban variation in U.S. family planning services would help address disparities in unmet contraceptive need. METHODS: In 2012, some 558 Title X-supported clinics in 16 Great Plains and Midwestern states were surveyed. Rural-urban commuting area (RUCA) codes were used to categorize clinic locations as urban, large rural city, small rural town or isolated small rural town. Bivariate analyses examined key domains of service provision by RUCA category and clinic type. RESULTS: The proportion of clinics offering walk-in appointments was lower in isolated small rural towns (47%) than in the other RUCA categories (67-73%). Results were similar for sites that do not specialize in family planning or reproductive health, but no variation was seen among specialty clinics. Overall, availability of evening or weekend appointments varied in a linear fashion, falling from 73% in urban areas to 29% in isolated small rural towns. On-site provision of most hormonal methods was most common in urban areas and least common in isolated small rural towns, while provision of nonhormonal methods was similar across RUCA categories. Sixty percent of clinics provided IUDs or implants. For clinics that did not, the only barriers that varied geographically were low IUD demand and lack of trained IUD providers; these barriers were most common in isolated rural towns (42% and 70%, respectively). CONCLUSIONS: While important characteristics, such as clinics' specialization (or lack thereof), are linked to the provision of family planning services, geographic disparities exist.

Women's fertility desires and contraceptive behavior in three peri-urban communities in sub Saharan Africa.

BACKGROUND: Fertility desires and contraceptive behavior often change over time. This study examined the influence of change in fertility desires on change in modern contraceptive use over time in three peri-urban communities in sub-Saharan Africa. METHODS: This multi-site study includes baseline and follow up data from 3 sites in the Family Health and Wealth Study. Following a census in each site, a probability sample of at least 500 households was obtained. Generalized linear models were employed. RESULTS: Modern contraceptive use increased in Ipetumodu, Nigeria (29.4% to 36.7%), but declined slightly in Sebeta, Ethiopia (66.9% to 61.3%) and Asawase, Ghana (12.6% to 10.8%). Across sites, at baseline and follow up, women who wanted no more children reported more contraceptive use, compared with those who wanted more children, and were more likely to shift to being contraceptive users in Ipetumodu [aOR(95% CI):1.55 (1.07,2.26)]. CONCLUSIONS: Women's fertility desires influenced their contraceptive behavior, although there were cross-site differences. Changing contraceptive demand and program factors will be important to enable peri-urban women to frame and act on their fertility desires.

Factors associated with discussion of sexual activity and contraception in women with HIV.

OBJECTIVES: Contraceptive use is important for reproductive-aged women living with HIV to plan and optimise safety of pregnancies. Clinicians play a vital role in counselling patients about contraception and safe sexual activity. This study aimed to determine the frequency and predictors of discussions regarding sexual activity and contraceptive use. METHODS: Retrospective clinical study of all reproductive-aged women (n=128) treated for HIV between 2010 and 2012 at two metropolitan hospitals. Evidence of discussion between treating doctors and patients regarding sexual activity and contraception and variables including patient age, gender of doctor, time since HIV diagnosis, previous pregnancy, country of birth and antiretroviral regimen were obtained from medical records. RESULTS: Sexual activity status was documented for 54% of the women and discussion regarding contraception was recorded for less than one-third of the study participants. Contraceptive use was not recorded in 63% of the medical records. In the study cohort 27% of the women used contraception, 10% did not use contraception, and when a discussion regarding sexual activity was documented, contraception was 3.7 times more likely to also be discussed (p=0.04). Excluding women who were pregnant, women who were documented as using contraception were 1.8 times as likely to have had a discussion about contraception documented (p=0.05). After adjustment for other factors, previous pregnancy, gender of doctor and age of patient were not associated with discussions regarding sexual activity or contraception. CONCLUSIONS: Discussions regarding sexual activity and contraception between HIV-infected women of reproductive age and their clinicians were inconsistent and suboptimal. Mechanisms to facilitate regular discussion about sexual activity and contraception between clinicians and women with HIV warrant further investigation.

Estimating family planning coverage from contraceptive prevalence using national household surveys.

BACKGROUND: Contraception is one of the most important health interventions currently available and yet, many women and couples still do not have reliable access to modern contraceptives. The best indicator for monitoring family planning is the proportion of women using contraception among those who need it. This indicator is frequently called demand for family planning satisfied and we argue that it should be called family planning coverage (FPC). This indicator is complex to calculate and requires a considerable number of questions to be included in a household survey. OBJECTIVES: We propose a model that can predict FPC from a much simpler indicator - contraceptive use prevalence - for situations where it cannot be derived directly. DESIGN: Using 197 Multiple Indicator Cluster Surveys and Demographic and Health Surveys from 82 countries, we explored least-squares regression models that could be used to predict FPC. Non-linearity was expected in this situation and we used a fractional polynomial approach to find the best fitting model. We also explored the effect of calendar time and of wealth on the models explored. RESULTS: Given the high correlation between the variables involved in FPC, we managed to derive a relatively simple model that depends only on contraceptive use prevalence but explains 95% of the variability of the outcome, with high precision for the estimated regression line. We also show that the relationship between the two variables has not changed with time. A concordance analysis showed agreement between observed and fitted results within a range of ±9 percentage points. CONCLUSIONS: We show that it is possible to obtain fairly good estimates of FPC using only contraceptive prevalence as a predictor, a strategy that is useful in situations where it is not possible to estimate FPC directly.

The influence of partnership on contraceptive use among HIV-infected women accessing antiretroviral therapy in rural Uganda.

OBJECTIVE: The objective was to determine individual and dyadic factors associated with effective contraceptive use among human immunodeficiency virus (HIV)-infected women accessing antiretroviral therapy (ART) in rural Uganda. STUDY DESIGN: HIV-infected women enrolled in the Uganda AIDS Rural Treatment Outcomes cohort completed questionnaires (detailing sociobehavioral characteristics, sexual and reproductive history, contraceptive use, fertility desires) and phlebotomy (October 2011-March 2013). We describe prevalence of effective contraceptive use (i.e., consistent condom use and/or oral contraceptives, injectable hormonal contraception, intrauterine device, female sterilization) in the previous 6 months among sexually active, nonpregnant women (18-40 years). We assessed covariates of contraceptive use using multivariable logistic regression. RESULTS: A total of 362 women (median values: age 30 years, CD4 count 397 cells/mm(3), 4.0 years since ART initiation) were included. Among 284 sexually active women, 50% did not desire a(nother) child, and 51% had a seroconcordant partner. Forty-five percent (n=127) reported effective contraceptive use, of whom 57% (n=72) used condoms, 42% (n=53) injectables, 12% (n=15) oral contraceptives and 11% (n=14) other effective methods. Dual contraception was reported by 6% (n=8). Only "partnership fertility desire" was independently associated with contraceptive use; women who reported that neither partner desired a child had significantly increased odds of contraceptive use (adjusted odds ratio: 2.40, 95% confidence interval: 1.07-5.35) compared with women in partnerships where at least one partner desired a child. CONCLUSIONS: Less than half of sexually active HIV-infected women accessing ART used effective contraception, of which 44% (n=56) relied exclusively on male condoms, highlighting a continued need to expand access to a wider range of longer-acting female-controlled contraceptive methods. Association with partnership fertility desire underscores the need to include men in reproductive health programming. IMPLICATIONS STATEMENT: Less than half of sexually active HIV-infected women accessing ART in rural Uganda reported using effective contraception, of whom 44% relied exclusively on the male condom. These findings highlight the need to expand access to a wider range of longer-acting, female-controlled contraceptive methods for women seeking to limit or space pregnancies. Use of contraception was more likely when both the male and female partner expressed concordant desires to limit future fertility, emphasizing the importance of engaging men in reproductive health programming.

Nonuse of contraception among women at risk of unintended pregnancy in the United States.

OBJECTIVE: This paper seeks to determine factors associated with nonuse of contraception by women at risk of unintended pregnancy in the United States. This nonuse may be associated with about 900,000 unintended births in the US each year. STUDY DESIGN: The 2002 and 2006-2010 National Surveys of Family Growth were combined to yield a nationally representative sample of 9,445 women at risk of unintended pregnancy. Logistic regression analyses identified factors associated with nonuse of contraception. RESULTS: This analysis reveals previously undocumented patterns of nonuse: controlling for confounding variables, cohabiting women [adjusted odds ratio (AOR)=2.3, 95% confidence interval (CI)=1.45-3.52] had higher odds of nonuse than married women; women who reported a difficulty getting pregnant (AOR=2.5, 95% CI=2.01-3.01) had higher odds of nonuse than those who did not. Nonuse was also more common among women with a master's degree or more (AOR=1.5, 95% CI=1.11-2.08) compared with those with some college or bachelor's degree, and it was more common among women in their first year after first intercourse than after the first year (AOR 1.6, 95% CI=1.12-2.22). Among women who had a recent unintended birth, the most common reason for not using contraception prior to conception was that she did not think she could get pregnant. CONCLUSIONS: This study establishes national estimates of reasons for nonuse of contraception and identifies some new subgroups at risk of nonuse. IMPLICATIONS: These results may help better understand factors affecting nonuse of contraception and develop strategies for preventing unintended pregnancy in the United States.

Women living with HIV still lack highly effective contraception: results from the ANRS VESPA2 study, France, 2011.

OBJECTIVES: Advances in antiretroviral treatment (ART) have led to improvements in reproductive health for women living with HIV. This paper aims to investigate the pattern of contraceptive use among women living with HIV in France. STUDY DESIGN: Data were drawn from the ANRS VESPA2 study, which included a representative sample of HIV-positive people. Contraception methods were documented, including condoms, highly effective contraception methods (HEC) and traditional methods. We measured the frequency of not using any modern contraception (neither condoms nor HEC) and of HEC use and studied their correlates (i.e., geographic origin, age, parity, partnership status, education level, material deprivation, employment status, health insurance, visits to a gynecologist, being on ART, cardiovascular risk) among women at risk of an unintended pregnancy. RESULTS: Of the 662 women of reproductive age, 327 were in need of contraception. Overall, 20.5% used HEC, 58.8% used condoms and 20.7% used traditional or no methods, with no difference according to geographic origin [sub-Saharan African (SSA) women vs. French and other migrant women]. Among SSA women, being <30years old [odds ratio (OR) 16.39, 95% confidence interval (95%CI) 2.77-97.01], having had at least one child (OR 3.75, 95%CI 1.75-8.04) and being employed (OR 2.36, 95%CI 0.99-5.61) were associated with HEC use; among French and other migrant women, HEC use was associated with being in a stable partnership (OR 4.5, 95%CI 1.2-17.2) and material deprivation (OR 3.3 95%CI 1.4-9.8). Gynecologist visits, health insurance status and cardiovascular risk were not associated with HEC use. CONCLUSIONS: Condoms remained the predominant contraceptive method despite the absence of restrictions on hormonal contraception and intrauterine device use for HIV-positive women. The recent recommendations about dual method protection should be actively promoted, targeting HIV-positive women, HIV specialists and gynecologists to overcome the barriers to effective contraception. IMPLICATIONS: The information provided in this study constitutes a major contribution to comprehensively inform the scientific community on contraception practices among women living with HIV in France in the early 2010s. Our results show that the therapeutic advances since the late 1990s and the removal of restrictions on hormonal contraception use have not led to the expected shift in contraception patterns. There is an urgent need to promote dual method protection, as condom use may decrease in the future in the context of the preventive effect of ART.