Offering extended use of the contraceptive implant via an implementation science framework: a qualitative study of clinicians' perceived barriers and facilitators.

BACKGROUND: The etonogestrel contraceptive implant is currently approved by the United States Food and Drug Administration (FDA) for the prevention of pregnancy up to 3 years. However, studies that suggest efficacy up to 5 years. There is little information on the prevalence of extended use and the factors that influence clinicians in offering extended use. We investigated clinician perspectives on the barriers and facilitators to offering extended use of the contraceptive implant. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured qualitative interviews. Participants were recruited from a nationwide survey study of reproductive health clinicians on their knowledge and perspective of extended use of the contraceptive implant. To optimize the diversity of perspectives, we purposefully sampled participants from this study. We used content analysis and consensual qualitative research methods to inform our coding and data analysis. Themes arose deductively and inductively. RESULTS: We interviewed 20 clinicians including advance practice clinicians, family medicine physicians, obstetrician/gynecologist and complex family planning sub-specialists. Themes regarding barriers and facilitators to extended use of the contraceptive implant emerged. Barriers included the FDA approval for 3 years and clinician concern about liability in the context of off-label use of the contraceptive implant. Educational materials and a champion of extended use were facilitators. CONCLUSIONS: There is opportunity to expand access to extended use of the contraceptive implant by developing educational materials for clinicians and patients, identifying a champion of extended use, and providing information on extended use prior to replacement appointments at 3 years.

Assessing the impact of CHARM2, a family planning program on gender attitudes, intimate partner violence, reproductive coercion, and marital quality in India.

Using a two-armed cluster randomised controlled trial, CHARM2 (Counselling Husbands to Achieve Reproductive health and Marital equity), a 5-session gender equity and family planning intervention for couples in rural India, showed an impact on family planning outcomes in primary trial analyses. This study examines its effects on gender-equitable attitudes, intimate partner violence, reproductive coercion, and marital quality. We used multilevel mixed-effects models to assess the intervention impact on each outcome. Both male (aIRR at 9 months: 0.64, C.I.: 0.45,0.90; aIRR at 18 months: 0.25, C.I.: 0.18,0.39) and female (aIRR at 9 months: 0.57, C.I.: 0.46,0.71; aIRR at 18 months: 0.38, C.I.: 0.23,0.61) intervention participants were less likely than corresponding control participants to endorse attitudes accepting physical IPV at 9- and 18-month follow-ups. Men in the intervention, compared to those in the control condition, reported more gender-equitable attitudes at 9- and 18 months (ß at 9 months: 0.13, C.I.: 0.06,0.20; ß at 18 months: 0.26, C.I.: 0.19,0.34) and higher marital quality at the 18-month follow-up (ß: 0.03, C.I.: 0.01,0.05). However, we found no effects on women's experiences of IPV, reproductive coercion, or marital quality. CHARM2 shows promise in improving men's and women's attitudes towards gender equality and male perceptions of marital quality. Still, IPV and reproductive coercion reductions may require more intensive programming than that provided within this 5-session model focused on family planning.

Barriers and Facilitators of Extended Use of the Contraceptive Implant: A Cross-Sectional Survey of Clinicians.

BACKGROUND: The U.S. Food and Drug Administration (FDA) approved the etonogestrel contraceptive implant for 3 years of use. Evidence suggests that it may be used for up to 5 years for pregnancy prevention, also known as extended use. METHODS: We conducted a national cross-sectional survey among a group of reproductive health clinicians. We developed an online survey using the Consolidated Framework for Implementation Research (CFIR) and distributed it through e-mail listservs and social media groups from May to June 2021. We analyzed results using multivariable logistical regression. RESULTS: Among the 300 respondents, 195 (65.0%) reported that they always offer extended use, and 50 (16.7%) reported that they sometimes offer extended use. Fifty-five respondents (18.3%) reported that they never offer extended use. After adjusting for age, gender, and clinical setting, we found that complex family planning sub-specialists (adjusted odds ratio [aOR] = 9.32; 95% confidence interval [CI] [1.81, 48.03]) and family medicine physicians (aOR = 4.37, 95% CI [1.58, 12.10]) were significantly more likely to recommend extended use compared with general obstetrics and gynecology (OBGYN) physicians. Clinicians from private practices or health maintenance organizations were significantly less likely to offer extended use than those from academic centers (aOR = 0.19, 95% CI [0.07, 0.51]; aOR = 0.06, 95% CI [0.01, 0.31]). The most common barriers to offering extended use were concerns about pregnancy risk, bleeding, and lack of FDA approval in the past 3 years. Meanwhile, clinicians identified strong published evidence supporting extended use as a key facilitator for offering it, and they perceived that prior counseling on extended use from a past clinician was a key facilitator for patients to adopt it. CONCLUSIONS: One-third of clinicians in this study did not consistently offer extended use of the contraceptive implant. An opportunity exists to expand access to extended use by focusing on education interventions for clinicians and seeking FDA approval for 5 years of use.

Examining the association between men's gender equitable attitudes and contraceptive outcomes in rural Maharashtra, India.

Background: Previous literature suggests that men reporting more gender-equitable attitudes are more likely to use condoms, but there is a paucity of data evaluating whether these attitudes are associated with contraceptive communication and use. The objective of this study is to test the hypothesis that men reporting more gender-equitable attitudes will be more likely to (a) engage in contraceptive communication with their wives and (b) that they and/or their wives will be more likely to use all forms of family planning, compared to men with less equitable attitudes. Methods: Using cross-sectional dyadic survey data from young married couples from rural Maharashtra, India (N = 989), we assessed the associations between men's gender role attitudes and a) spousal contraceptive communication and b) contraceptive use by type (none, traditional, condoms, pills, or IUD). The contraceptive use outcome is based on wives' report. We assessed these associations via bivariate t-test (communication outcome) or ANOVA test (contraceptive type outcome), as well as unadjusted and adjusted logistic (communication outcome) and multinomial logistic (contraceptive type outcome) regression models. Adjusted models included sociodemographic factors selected a priori based on established associations with gender-equitable attitudes and/or our assessed outcomes. Findings: Men with more gender-equitable attitudes were more likely to discuss family planning with their wives (AOR = 1·05, 95%CI 1·03-1·07, p < 0·001) and to use condoms (ARRR = 1·03, 95%CI 1·00-1·06, p = 0·07). There was no association between gender-equitable attitudes and use of other types of contraception. Interpretation: While gender-equitable attitudes among men may facilitate condom use and family planning communication in marriage, they do not appear to be linked with greater likelihood of use of more effective types of contraceptive use. This suggests that males supportive of gender equity may take greater responsibility for family planning vis a vis a less effective contraceptive, condoms, in the absence of more effective short-acting contraceptives for men. Funding: The National Institutes of Health [Grant number 5R01HD084453-01A1] and the Bill & Melinda Gates Foundation, Seattle, WA [grant number INV-002967].

Social determinants of choosing telemedicine for contraceptive care: A retrospective cohort study.

OBJECTIVES: Compare demographic characteristics and contraception choices among individuals seeking contraception care via telemedicine versus in-person. STUDY DESIGN: Retrospective cohort study of contraception visits from June-September 2021 at Planned Parenthood of the Pacific Southwest. We assessed demographics and contraception choices. We used multivariable logistic regression to evaluate effect of language, age, income, having children, and insurance type on choosing telemedicine. RESULTS: We included 16,855 patients: 2383 (14.1%) telemedicine visits and 14,472 (85.9%) in-person visits; 149/2383 (6.3%) non-English speakers used telemedicine compared to 1194/14,472 (8.3%) who used in-person care. A higher proportion of the telemedicine cohort had public insurance compared to the in-person cohort (2312/2383 [97.0%] telemedicine vs 11,646/14,472 [80.5%] in-person). Among the telemedicine cohort, a higher proportion of patients chose a barrier method (691/2363 [29.2%] telemedicine vs 1564/14,215 [11.0%] in-person) and short-acting method (1248/2363 [52.8%] telemedicine vs 5834/14,215 [41.0%] in-person) compared to in-person. A higher proportion of in-person patients chose long-acting reversible contraception (2681/14,215 [18.9%] in-person vs 179/2363 [7.6%] telemedicine) and injection (3779/14,215 [26.6%] in-person vs 115/2363 [4.9%] telemedicine) compared to telemedicine. Speaking Spanish was associated with decreased odds of choosing telemedicine after adjusting for covariates (aOR 0.53 [95% CI 0.44-0.64], p < 0.001). Older age, having children, lower income, and public insurance were associated with increased odds of choosing telemedicine. CONCLUSIONS: Telemedicine for contraception visits was associated with language, age, parity, income, and insurance. Despite small absolute difference in the proportion of patients that speak Spanish, in adjusted multivariate analysis speaking Spanish was associated with lower odds of choosing telemedicine. IMPLICATIONS: Increasing access for people with limited technology as well as those who prefer non-English languages is essential to promote equitable reproductive care. Prospective research that focuses on patient experience and preferences is needed to better guide access to equitable, person-centered contraception care.

Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California.

OBJECTIVE: Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion. STUDY DESIGN: Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center. RESULTS: Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion. CONCLUSIONS: Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access. IMPLICATIONS: Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.

Pharmacist provision of medication abortion: A pilot study.

OBJECTIVES: This study aimed to perform a "proof of concept" pilot and assess patient satisfaction of pharmacist provision of medication abortion utilizing an implementation toolkit. STUDY DESIGN: Pharmacists completed an online and in-person training followed by an online assessment prior to participating in the pilot. Pharmacists provided medication abortion care using a "no-test" protocol and an implementation toolkit. Participants were administered 200 mg of mifepristone orally on the day of their abortion visit and instructed to take 800 mcg of misoprostol buccally 24 to 48 hours later (with an additional 800 mcg buccally 4 hours after the first dose for patients 63-70 days' gestation). Visits were completed in person in a private room adjacent to the pharmacy. We assessed the rate of completed abortions and any complications. Following their abortion, patients completed a brief interviewer-administered survey and semistructured qualitative interview. RESULTS: Ten patients completed medication abortion visits. Nine of 10 participants had complete abortions. One participant identified that she did not pass her pregnancy and underwent an in-office aspiration. One participant visited an emergency department for pain and received pain medication. No serious adverse events occurred. All patients completed the postabortion survey, and all were "very satisfied" with their abortion experience. Nine patients completed postabortion interviews. CONCLUSIONS: In this pilot study, pharmacists were successful at providing medication abortion to patients. Satisfaction was high, and complications were uncommon. IMPLICATIONS: Patients were highly satisfied with pharmacist provision of medication abortion and are likely to utilize this service if available.

The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India.

Purpose: To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion. Patients and Methods: The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India. Results: On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18). Conclusion: These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.

Understanding feasibility and acceptability of implementation of linking delivery of family planning and infant vaccination care in rural Maharashtra, India: a qualitative study.

BACKGROUND: Linking family planning with infant vaccination care has the potential to increase contraceptive use among postpartum women in rural settings. We explored the multilevel factors that can facilitate or impede uptake of contraception at the time of infant vaccination among postpartum women and couples in rural Maharashtra, India. METHODS: We conducted 60 semi-structured interviews with key stakeholders including: postpartum married women (n = 20), husbands (n = 10), and mothers-in-law (n = 10) of postpartum women, frontline healthcare workers (auxiliary nurse midwives (ANMs) and Accredited Social Health Activists (ASHAs), (n = 10), and community leaders (physician medical officers and village panchayat leaders) (n = 10). We sought to assess the feasibility and acceptability of delivering community-based postpartum family planning care in rural India at the time of infant vaccination. The Consolidated Framework for Implementation Research (CFIR) was used to design a structured interview guide and codebook. Data were analyzed via directed content analysis. RESULTS: Three major themes emerged: (1) Social fertility and gender norms including son preference and male control over contraceptive decision-making influence postpartum contraceptive access and choice. (2) Linking contraceptive care and infant vaccination is perceived as potentially feasible and acceptable to implement by families, health workers, and community leaders. The intervention provides care to women and families in a convenient way where they are in their community. (3) Barriers and facilitators to linked infant postpartum contraception and infant vaccination were identified across the five CFIR domains. Key barriers included limited staff and space (inner setting), and contraceptive method targets for clinics and financial incentives for clinicians who provide specific methods (outer setting). Key facilitators included convenience of timing and location for families (intervention characteristics), the opportunity to engage husbands in decision-making when they attend infant vaccination visits (participant characteristics), and programmatic support from governmental and community leaders (process of implementation). CONCLUSIONS: Linked provision of family planning and infant vaccination care may be feasible and accessible in rural India utilizing strategies identified to reduce barriers and facilitate provision of care. A gender-transformative intervention that addresses gender and social norms has greater potential to impact reproductive autonomy and couples' contraceptive decision-making.

A qualitative analysis of pharmacists' attitudes towards provision of medication abortion.

BACKGROUND: 90% of United States' counties do not have a single clinic offering abortion care, and barriers to care disproportionately affect low-income families. Novel models of abortion care delivery, including provision of medication abortion in pharmacies, with pharmacists prescribing medication, have the potential to expand access to abortion care. Pharmacists are well-positioned to independently provide abortion care and are highly accessible to patients, however medication abortion provision by pharmacists is not currently legal or available in the United States. To assess the potential acceptability of pharmacist provision of medication abortion and to identify anticipated barriers and facilitators to this model of care, we explored pharmacists' attitudes towards providing medication abortion, inclusive of patient selection, counseling, and medication prescribing. METHODS: From May to October 2021, we conducted 20 semi-structured qualitative interviews with pharmacists across the United States, guided by the domains of the Consolidated Framework for Implementation Science Research. RESULTS: Major themes included there is a need for pharmacist provision of medication abortion and pharmacists perceive provision of medication abortion to be potentially acceptable if anticipated barriers are addressed. Anticipated barriers identified included personal, religious, and political beliefs of pharmacists and lack of space and systems to support the model. Ensuring adequate staffing with pharmacists willing to participate, private space, time for counseling, safe follow-up, training, and reimbursement mechanisms were perceived strategies to facilitate successful implementation. CONCLUSIONS: Pharmacist identified implementation strategies are needed to reduce anticipated barriers to pharmacist provision of medication abortion.

The association between quality of contraceptive counseling and selection of contraceptive method post-counseling among women in Ethiopia.

OBJECTIVES: To better understand the relationship between high-quality contraceptive counseling and met family planning needs, we examined the association between quality of counseling and selection of a method postvisit among women requesting contraception in Ethiopia. STUDY DESIGN: We used post-counseling survey data from women receiving care in public health centers and nongovernmental clinics in three regions in Ethiopia. Among women whose reason for visit was requesting a contraceptive method, we examined the association between scores on the validated quality of contraceptive counseling (QCC) scale and subscales and selection of a method post-counseling (primary analysis) and type of method selected (secondary analysis). We conducted mixed-effects multivariable logistic regression for the primary analysis and multinomial regression for the secondary analysis. RESULTS: There was a nonsignificant increase in odds of selecting contraception with increasing total QCC scale scores (adjusted odds ratio [aOR] 2.35, 0.43-12.95). However, among women experiencing no disrespect and abuse, there was increasing odds of selecting contraception (aOR 3.46, 95% CI 1.09-10.99) and likelihood of selecting injectable contraception (adjusted relative risk ratio 4.27, 95% CI 1.34-13.60) compared to women experiencing disrespect and abuse. Additionally, 168 (32.1%) of women felt pressured by their provider to use a certain method of which>50% selected long-acting reversible contraception. CONCLUSIONS: Increasing QCC is associated with selecting contraception among women requesting contraception. Additionally, probing for negative experiences can reveal feelings of disrespect and abuse that could lead women to avoid selecting contraception or feeling pressured to use methods heavily promoted by providers. IMPLICATIONS: Our study assesses contraceptive counseling quality using a validated tool with items on provider pressure and other forms of disrespect and abuse; findings highlight the importance of respectful treatment in meeting women's needs and the potential influence of disrespect on decision to select contraception and type of method selected.

Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial.

Importance: The early postpartum period, 2 to 4 weeks after birth, may be a convenient time for intrauterine device (IUD) placement; the placement could then coincide with early postpartum or well-baby visits. Objective: To determine expulsion rates for IUDs placed early postpartum compared with those placed at the standard interval 6-week visit. Design, Setting, and Participants: In this randomized noninferiority trial, people who had a vaginal or cesarean birth were randomly assigned to undergo early (14-28 days) or interval (42-56 days) postpartum IUD placement. Clinicians blinded to participant study group used transvaginal ultrasonography to confirm IUD presence and position at the 6-month postpartum follow-up. The study assessed 642 postpartum people from 4 US medical centers, enrolled a consecutive sample of 404 participants from March 2018 to July 2021, and followed up each participant for 6 months postpartum. Interventions: Early postpartum IUD placement, at 2 to 4 weeks postpartum, vs standard interval placement 6 to 8 weeks postpartum. Main Outcomes and Measures: The primary outcome was complete IUD expulsion by 6 months postpartum; the prespecified noninferiority margin was 6%. Secondary outcomes were partial IUD expulsion, IUD removal, pelvic infection, patient satisfaction, uterine perforation, pregnancy, and IUD use at 6 months postpartum. IUD malposition was an exploratory outcome. Results: Among 404 enrolled participants, 203 participants were randomly assigned to undergo early IUD placement and 201 to undergo interval IUD placement (mean [SD] age, 29.9 [5.4] years; 46 [11.4%] were Black, 228 [56.4%] were White, and 175 [43.3%] were Hispanic). By 6 months postpartum, 53 participants (13%) never had an IUD placed and 57 (14%) were lost to follow-up. Among the 294 participants (73%) who received an IUD and completed 6-month follow-up, complete expulsion rates were 3 of 149 (2.0% [95% CI, 0.4%-5.8%]) in the early placement group and 0 of 145 (0% [95% CI, 0.0%-2.5%]) in the interval placement group (between-group difference, 2.0 [95% CI, -0.5 to 5.7] percentage points). Partial expulsion occurred in 14 (9.4% [95% CI, 5.2%-15.3%]) participants in the early placement group and 11 (7.6% [95% CI, 3.9%-13.2%]) participants in the interval placement group (between-group difference, 1.8 [95% CI, -4.8 to 8.6] percentage points). IUD use at 6 months was similar between the groups: 141 (69.5% [95% CI, 62.6%-75.7%]) participants in the early group vs 139 (67.2% [95% CI, 60.2%-73.6%]) in the interval group. Conclusions and Relevance: Early IUD placement at 2 to 4 weeks postpartum compared with 6 to 8 weeks postpartum was noninferior for complete expulsion, but not partial expulsion. Understanding the risk of expulsion at these time points may help patients and clinicians make informed choices about the timing of IUD placement. Trial Registration: ClinicalTrials.gov Identifier: NCT03462758.

Understanding quality of contraceptive counseling in the CHARM2 gender-equity focused family planning intervention: Findings from a cluster randomized controlled trial among couples in rural India.

OBJECTIVES: The CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) intervention engages health care providers to deliver gender-equity and family planning sessions to couples using a person-centered shared decision-making approach for contraception counseling. We previously showed that the intervention improved contraceptive use at 9-month follow-up. We sought to assess whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use. STUDY DESIGN: This is a planned secondary analysis of the effect of the CHARM2 intervention on 1201 married couples in rural Maharashtra, India in a cluster randomized controlled trial completed between 2018 and 2020. We assessed the effect of CHARM2 on perceived quality of care as measured by the Interpersonal Quality of Family Planning (IQFP) scale using a difference-in-differences linear regression approach including a mixed-effects model with nested random effects to account for clustering. We assessed whether the association between CHARM2 and modern contraceptive use was mediated by quality of family planning care. RESULTS: Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, SD 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% CI 0.07-0.50). CONCLUSION: Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve women's perceived quality of care. Effects on quality of care mediate observed effects of the intervention on contraceptive use. IMPLICATIONS: Contraceptive interventions should focus on improving person-centered outcomes, such as quality of care, rather than contraceptive use targets. By focusing on improving person-centered care, interventions will improve contraceptive use among those who desire a method while meeting the holistic reproductive health needs of clients and couples.

Association of traditional marital practices with contraceptive decision-making, couple communication, and method use among couples in rural Maharashtra, India.

In India, traditional social practices around marriage, such as non-involvement of prospective brides in choice of partner and timing of marriage, child/early marriage, dowry and purdah, compromise women's agency at the time of marriage and may also affect contraceptive practices in marriage. This paper examines the associations between traditional marital practices and contraceptive behaviours, including women's control over contraceptive decision-making, couples' communication about contraception, and ever use of contraceptives, among married women aged 18-29 years (N = 1,200) and their husbands in rural Maharashtra, India. Multivariable logistic regression was used to examine the association between these marginalising social practices and family planning behavioural outcomes, adjusting for demographic and parity confounders. Wives who were the primary decision-makers on who to marry had higher odds of ever having communicated with their husband on pregnancy prevention (AOR 1.76, 95% CI 1.16-2.68), and ever using modern contraceptives (AOR 2.19, 95% CI 1.52-3.16). Wives who were the primary decision-makers on when to marry also had higher odds of ever having used modern contraceptives (AOR 1.86, 95% CI 1.21-2.93). Women's involvement in marital choice may facilitate couples' engagement related to family planning, possibly via the establishment of better communication between partners.

Using machine learning to understand determinants of IUD use in India: Analyses of the National Family Health Surveys (NFHS-4).

Intra-uterine devices (IUDs) are a safe and effective method to delay or space pregnancies and are available for free or at low cost in the Indian public health system; yet, IUD uptake in India remains low. Limited quantitative research using national data has explored factors that may affect IUD use. Machine Learning (ML) techniques allow us to explore determinants of low prevalence behaviors in survey research, such as IUD use. We applied ML to explore the determinants of IUD use in India among married women in the 4th National Family Health Survey (NFHS-4; N = 499,627), which collects data on demographic and health indicators among women of childbearing age. We conducted ML logistic regression (lasso and ridge) and neural network approaches to assess significant determinants and used iterative thematic analysis (ITA) to offer insight into related variable constructs generated from a series of regularized models. We found that couples' shared family planning (FP) goals were the strongest determinants of IUD use, followed by receipt of FP services and desire for no more children, higher wealth and education, and receipt of maternal and child health services. Findings highlight the importance of male engagement and family planning services for IUD uptake and the need for more targeted efforts to support awareness of IUD as an option for spacing, especially for those of lower SES and with lower access to care.

Associations between Contraceptive Decision-Making and Marital Contraceptive Communication and use in Rural Maharashtra, India.

Women's contraceptive decision-making control is crucial for reproductive autonomy, but research largely relies on the Demographic and Health Survey (DHS) measure which asks who is involved with decision-making. In India, this typically assesses joint decision-making or male engagement. Newer measures emphasize female agency. We examined three measures of contraceptive decision-making, the DHS and two agency-focused measures, to assess their associations with marital contraceptive communication and use in rural Maharashtra, India. We analyzed follow-up survey data from women participating in the CHARM2 study (n = 1088), collected in June-December 2020. The survey included the DHS (measure 1), Reproductive Decision-Making Agency (measure 2), and Contraceptive Final Decision-Maker measures (measure 3). Only Measure 1 was significantly associated with contraceptive communication (adjusted odds ratio [AOR]: 2.75, 95 percent confidence interval [CI]: 1.69-4.49) and use (AOR: 1.73, 95 percent CI: 1.14-2.63). However, each measure was associated with different types of contraceptive use: Measure 1 with condom (adjusted relative risk ratio [aRRR]: 1.99, 95 percent CI: 1.12-3.51) and intrauterine device (IUD) (aRRR: 4.76, 95 percent CI: 1.80-12.59), Measure 2 with IUD (aRRR: 1.64, 95 percent CI: 1.04-2.60), and Measure 3 with pill (aRRR: 2.00, 95 percent CI: 1.14-3.52). Among married women in Maharashtra, India, male engagement in decision-making may be a stronger predictor of contraceptive communication and use than women's agency, but agency may be predictive of types of contraceptives used.

Immediate versus delayed postpartum insertion of contraceptive implant and IUD for contraception.

BACKGROUND: Long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and contraceptive implants, are highly effective, reversible methods of contraception. Providing LARC methods during the postpartum period is important to support contraceptive choice, and to prevent unintended pregnancy and short interpregnancy intervals. Delaying offering contraception to postpartum people until the first comprehensive postpartum visit, traditionally at around six weeks postpartum, may put some postpartum people at risk of unintended pregnancy, either due to loss to follow-up or because of initiation of sexual intercourse prior to receiving contraception. Therefore, immediate provision of highly effective contraception, prior to discharge from hospital, has the potential to improve contraceptive use and prevent unintended pregnancies and short interpregnancy intervals. OBJECTIVES: To compare the initiation rate, utilization rates (at six months and 12 months after delivery), effectiveness, and adverse effects of immediate versus delayed postpartum insertion of implants and IUDs for contraception. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE for eligible studies up to December 2020. We examined review articles and contacted investigators. We checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies. SELECTION CRITERIA: We sought randomized controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant and IUDs for contraception. DATA COLLECTION AND ANALYSIS: Two review authors (JS, SK) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL, SA or PP). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel or inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables. MAIN RESULTS: In this updated review, 16 studies met the inclusion criteria; five were studies of contraceptive implants (715 participants) and 11 were studies of IUDs (1894 participants). We identified 12 ongoing studies. We applied GRADE judgements to our results; the overall certainty of the evidence for each outcome ranged from moderate to very low, with the main limitations being risk of bias, inconsistency, and imprecision. Contraceptive implants Immediate insertion probably improves the initiation rate for contraceptive implants compared with delayed insertion (RR 1.48, 95% CI 1.11 to 1.98; 5 studies, 715 participants; I2 = 95%; moderate-certainty evidence). We are uncertain if there was a difference between the two groups for the utilization rate of contraceptive implants at six months after delivery (RR 1.16, 95% CI 0.90 to 1.50; 3 studies, 330 participants; I2 = 89%; very low-certainty evidence) or at 12 months after insertion (RR 0.98, 95% CI 0.93 to 1.04; 2 studies, 164 participants; I2 = 0%; very low-certainty evidence). People who received an immediate postpartum contraceptive implant insertion may have had a higher mean number of days of prolonged vaginal bleeding within six weeks postpartum (mean difference (MD) 2.98 days, 95% CI -2.71 to 8.66; 2 studies, 420 participants; I2 = 91%; low-certainty evidence) and a higher rate of other adverse effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; 1 study, 215 participants; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups for prolonged bleeding at six months after delivery (RR 1.19, 95% CI 0.29 to 4.94; 2 studies, 252 participants; I2 = 0%; very low-certainty evidence). There may be little or no difference between the two groups for rates of unintended pregnancy at six months (RR 0.20, 95% CI 0.01 to 4.08; one study, 205 participants; low-certainty evidence). We are uncertain whether there was a difference in rates of unintended pregnancy at 12 months postpartum (RR 1.82, 95% CI 0.38 to 8.71; 1 study, 64 participants; very low-certainty evidence). There may be little or no difference between the two groups for any breastfeeding rates at six months (RR 0.97, 95% CI 0.92 to 1.01; 2 studies, 225 participants; I2 = 48%; low-certainty evidence). IUDs Immediate insertion of IUDs probably improves the initiation rate compared with delayed insertion, regardless of type of IUD (RR 1.27, 95% CI 1.07 to 1.51; 10 studies, 1894 participants; I2 = 98%; moderate-certainty evidence). However, people who received an immediate postpartum IUD insertion may have had a higher expulsion rate at six months after delivery (RR 4.55, 95% CI 2.52 to 8.19; 8 studies, 1206 participants; I2 = 31%; low-certainty evidence) than those who received a delayed postpartum insertion. We are uncertain if there was a difference between the two groups in the utilization of IUDs at six months after insertion (RR 1.02, 95% CI 0.65 to 1.62; 6 studies, 971 participants; I2 = 96%; very low-certainty evidence) or at 12 months after insertion (RR 0.86, 95% CI 0.5 to 1.47; 3 studies, 796 participants; I2 = 92%; very low-certainty evidence). Immediate IUDs insertion may reduce unintended pregnancy at 12 months (RR 0.26, 95% CI 0.17 to 0.41; 1 study, 1000 participants; low-certainty evidence). We are uncertain whether there was difference in any breastfeeding rates at six months in people receiving progestin-releasing IUDs (RR 0.90, 95% CI 0.63 to 1.30; 5 studies, 435 participants; I2 = 54%; very low-certainty evidence). AUTHORS' CONCLUSIONS: Evidence from this updated review indicates that immediate postpartum insertion improves the initiation rate of both contraceptive implants and IUDs by the first postpartum visit compared to delayed insertion. However, it is not clear whether that there are differences in utilization rates at six and 12 months postpartum. We are uncertain whether there is any difference in the unintended pregnancy rate at 12 months. Provision of progestin-releasing implants and IUDs immediately postpartum may have little or no negative impact on breastfeeding. However, the expulsion rate of IUDs and prolonged vaginal bleeding associated with immediate implants appears to be higher.