Immediate versus delayed postpartum insertion of long-acting reversible contraception methods: meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to conduct a meta-analysis of randomized trials comparing the immediate versus delayed provision of long-acting reversible contraceptives in postpartum subjects, focusing on short-interval pregnancies, utilization rates, and adverse events. DATA SOURCES: Cochrane Central, Embase, PubMed and ClinicalTrials.gov were systematically searched from inception up to December 19, 2023, without filters or language limitation. STUDY ELIGIBILITY CRITERIA: We selected randomized controlled trials assessing the immediate insertion of long-acting reversible contraceptives in women during postpartum period in comparison with the delayed provision. STUDY APPRAISAL AND SYNTHESIS METHODS: We calculated relative risks (RR) with 95% confidence intervals to analyze the primary outcome of utilization rates and secondary endpoints, including initiation rates, pregnancy, any breastfeeding, exclusive breastfeeding, and serious adverse events. A random effects model was employed in the R software. Moreover, we assessed the risk of bias of selected RCTs using version 2 of the Cochrane Risk of Bias Assessment Tool. RESULTS: We included 24 randomized trials comprising 2,507 participants, of whom 1,293 (51.6%) were randomized to the immediate insertion. Postpartum women in the immediate group had lower risk of pregnancy (RR 0.16; 95% CI 0.04-0.71; P = 0.02) compared with delayed group, and higher rates of long-acting reversible contraceptives at 6 months of follow-up (RR 1.23; 95% CI 1.09-1.37; P < 0.01). CONCLUSIONS: Inserting long-acting reversible contraceptives before hospital discharge was associated with a reduction in the risk of pregnancy, and increased rates of its utilization at 6 months of follow-up. This intervention may be an effective contraception strategy for postpartum women.

A Review of Concordance and Quality in Clinical Guidelines for Hormonal Contraceptives to Mitigate Drug-Drug Interactions in Women With Epilepsy.

PURPOSE: Concomitant use of hormonal contraceptive agents (HCAs) and enzyme-inducting antiepileptic drugs (EIAEDs) may lead to contraceptive failure and unintended pregnancy. This review identified and evaluated concordance and quality of clinical treatment guidelines related to the use of HCAs in women with epilepsy (WWE) receiving EIAEDs. METHODS: Relevant clinical guidelines were identified across four databases and were independently evaluated for quality utilizing the AGREE-II protocol instrument. Quality in this context is defined as the rigor and transparency of the methodologies used to develop the guideline. Guidelines were further assessed in terms of concordance and discordance with the latest body of knowledge concerning the use of hormonal contraception in the presence of EIAEDs. RESULTS: A total of n = 5 guidelines were retrieved and evaluated. Overall guideline scores ranged from 17% to 92%, while individual domain scores ranged from 0% to 100%. Contraceptive guidelines consistently recommended the use of intrauterine systems and long-acting injectables in the presence of EIAEDs, recommended against the use of oral, transdermal, and vaginal ring contraceptives, and differed regarding recommendations related to implants. Guidelines agreed regarding recommendations that women treated with EIAEDs should receive intrauterine systems and long-acting injectables; however, the suggested frequency of administration of injectable contraceptives differed. The use of intrauterine systems in this population is supported by evidence, but there is uncertainty surrounding the use of long-acting injectables and contraceptive implants. CONCLUSIONS: To mitigate the risk of unintended pregnancy and its consequences, recommendations related to implants and long-acting injectable contraceptives should be evidence-based.

Strategies to enhance indigenous men's support for utilisation of long-acting reversible contraceptives among women in Kiboga and Rubanda rural districts in Uganda.

Unintended pregnancies, a global public health concern with an annual incidence of about 74 million, significantly impact Africa, representing 25% of cases. These pregnancies, linked to health risks and mortalities, underscore the critical need for effective family planning especially the Long-acting reversible contraceptives (LARCs). Long-acting reversible contraceptives offer a significant solution, yet their uptake in Uganda faces challenges due to insufficient male support. This qualitative study in Rubanda and Kiboga revealed negative perceptions and belief systems among rural Indigenous Ugandan men regarding the use of LARCs by their wives, which acted as barriers to utilization. Recommendations include enhancing Social and Behavioural Change Communication (SBCC) and improving LARCs service delivery to counter limited knowledge and service concerns, aiming to foster better understanding and correcting the negative perceptions, belief sytems and acceptance of these contraceptive methods for improved maternal and child health outcomes.

Les grossesses non désirées, une préoccupation mondiale en matière de santé publique avec une incidence annuelle d'environ 74 millions, impactent significativement l'Afrique, représentant 25 % des cas. Ces grossesses, liées à des risques sanitaires et à des mortalités, soulignent le besoin critique d'une planification familiale efficace, en particulier des contraceptifs réversibles à longue durée d'action (LARCs). Les contraceptifs réversibles à longue durée d'action offrent une solution significative, mais leur adoption en Ouganda est confrontée à des défis en raison du manque de soutien des hommes. Cette étude qualitative menée à Rubanda et Kiboga a révélé des perceptions négatives et des systèmes de croyances parmi les hommes indigènes ougandais ruraux concernant l'utilisation des LARCs par leurs épouses, ce qui a agi comme des obstacles à leur utilisation. Les recommandations incluent le renforcement de la communication pour le changement social et comportemental (SBCC) et l'amélioration de la prestation de services de LARCs pour contrer le manque de connaissance et les préoccupations concernant les services, visant à favoriser une meilleure compréhension et à corriger les perceptions négatives, les systèmes de croyances et l'acceptation de ces méthodes contraceptives pour des résultats améliorés en matière de santé maternelle et infantile.

One-year follow up of contraceptive use and pregnancy rates after early medical abortion: Secondary outcomes from a randomized controlled trial of immediate post-abortion placement of intrauterine devices.

INTRODUCTION: Intrauterine devices (IUDs) effectively prevent unwanted pregnancies. Little is known about long-term outcomes of women choosing an IUD after early medical abortion. MATERIAL AND METHODS: We present secondary outcome data of continuation rates, factors associated with continuation and discontinuation, choice of IUD type, women's satisfaction with IUD, and IUD expulsions, subsequent pregnancies, and abortions within 1 year post-abortion in a randomized, controlled, multicenter trial on IUD placement within 48 hours compared with placement 2-4 weeks after medical abortion up to 63 days' gestation (ClinicalTrials.gov NCT03603145). RESULTS: Of the 240 women studied, 112/120 (93.3%) in the intervention group vs 113/120 (94.2%) in the control group completed the 12-month follow-up. The rate of IUD use at 12 months was 84/112 (75%) in the intervention group vs 75/113 (66.4%) in the control group (P = 0.19). Attendance at the IUD placement visit was the only predictor of long-term IUD use (relative risk [RR] = 5.7, 95% confidence interval [CI] 2.03-16.0; P = 0.001). The main reason for choosing an IUD was high contraceptive effectiveness. The most common reasons for IUD discontinuation were bleeding problems and abdominal pain. IUD expulsion was rare and did not differ between groups. Satisfaction among IUD users at 1 year was high (>94%) and the majority of all participants would recommend IUD to a friend (65.8%). Use of no contraception and experience of unprotected intercourse were less common in the intervention group (11/112 [9.8%] vs 25/113 [22.1%], P = 0.02 and 17/112 [15.2%] vs 32/113 [28.3%], P = 0.02, respectively). There was no difference in the rate of subsequent pregnancies and abortions (pregnancies 14/112, 12.5% in the intervention group vs 8/113, 7.1% in the control group, P = 0.19; abortions 5/112, 4.5% vs 3/113, 2.7%, P = 0.5). CONCLUSIONS: IUD placement after medical abortion led to high continuation and satisfaction rates with no difference between groups. We found no difference in IUD expulsions after immediate compared with later placement. Unprotected intercourse was significantly less common in the immediate group. In clinical practice, immediate placement of IUDs available free of charge at the abortion clinic is likely to increase attendance to the placement visit and continued use of IUDs after abortion.

Women's sexual empowerment and utilization of long-acting reversible contraceptives in Ghana: evidence from the 2014 demographic and health survey.

BACKGROUND: Long-Acting Reversible Contraceptives (LARC) contribute significantly to a decline in unintended pregnancies globally. However, not much is known about women's sexual empowerment and their utilization of Long-Acting Reversible Contraceptives in Ghana. The main objective of this study was to examine the association between women's sexual empowerment and LARC utilization in Ghana. METHODS: We used data from 5116 sexually active women who participated in the 2014 Ghana Demographic and Health Survey. Women's sexual empowerment was defined as women's perception of their right to self-determination and equity in sexual relations, and their ability to express themselves in sexual decision-making. A sum of scores was created with four dichotomous items as sexual empowerment score (0 = low sexual empowerment; 1, 2, and 3 = medium sexual empowerment; and 4 = high sexual empowerment). Multivariable binary logistic regression analyses were performed to establish the association between women's sexual empowerment and the use of LARC. Pearson Chi-square test was used in data analysis. The results are presented as adjusted odds ratios (aOR), with their respective confidence intervals (CIs) at a statistical significance of p < 0.05. RESULTS: The prevalence of LARC utilization among sexually active women in Ghana was 6%. Majority of the women had medium sexual empowerment (91%). Although not statistically significant, the likelihood of utilizing LARC was lowest among women with high level of sexual empowerment (aOR = 0.62; CI = 0.27-1.43). On the other hand, Utilization of LARC increased with an increase in age. Women with parity four or more had higher odds of utilizing LARC as compared to women with zero birth (aOR = 9.31; CI = 3.55-24.39). Across religion, women who belong to the Traditional religion (aOR = 0.17; CI = 0.04-0.71) and Islam religion (aOR = 0.52; CI = 0.36-0.76) had lower odds of LARC utilisation as compared to Christian women. Women who make health decisions with someone else (aOR = 1.52; CI = 1.12-2.09) had higher odds of LARC utilisation as compared to women who make health decision alone. CONCLUSION: Age, health decision maker, parity and religion were found to have a significant relationship with LARC utilization. Specifically, uneducated women, unemployed women and women who practice traditional religion were less likely to utilise LARC. However, women's sexual empowerment did not have a significant relationship with LARC. There is therefore the need for planning interventions for LARC utilization in line with educating women on the benefits and potential side effects of LARC. Also, there is a need for interventions targeted at increasing access to LARC among sexually active women.

No-daily hormonal contraception today: general overview and application in specific clinical settings.

No-daily hormonal contraception includes short-acting reversible contraceptives (SARC), which contain estrogen and progestin (vaginal ring and transdermal patch), and long-acting reversible contraceptives (LARC), which contain only progestin (levonorgestrel-releasing intrauterine device and etonogestrel subdermal implant). No-daily hormonal contraceptives are reversible, avoid oral daily intake and have high contraceptive efficacy. They offer advantages over the traditional oral route, increasing user compliance, and reducing forgetfulness. Furthermore, they have several non-contraceptive benefits. This review aims to highlight the strengths of choices other than the traditional 'pill', with the goal of implementing contraceptive counseling, which should be personalized and tailored to each woman. Different subsets of patients may use no-daily contraception at different stages of their lives, with the option of either LARC or SARC. Specific contexts for its use are adolescence, perimenopause, obese women, eating disorders or intestinal malabsorption, breastfeeding, and post voluntary termination of pregnancy. Non-daily contraceptives can be an attractive alternative to the daily contraceptive pill, with benefits that are relevant to each woman desiring contraception, especially in unique and specific settings where customization of the contraceptive method is essential.

Acceptability of telemedicine for follow up after contraceptive implant initiation at an obstetrics and gynecologic training center.

BACKGROUND: During the COVID-19 pandemic, telemedicine has become a popular adjunct to in-person visits, including for family planning services. This study determined the proportion of clients participated in telemedicine services and the association between sociodemographic factors and telemedicine participation during the COVID-19 pandemic. The adverse effects within the first seven days post-insertion were also reported. METHODS: This retrospective cohort study considered data from all women initiating contraceptive implantation between June 2020 and August 2021 at King Chulalongkorn Memorial Hospital. Clients were offered the following two options for follow-up visits: in-person or communication via an online LINE® Official Account (LINE® OA), a free chat application widely used among the Thais. Logistic regression analyses were used to assess the association between socio-demographic factors and telehealth usage. RESULTS: In total, 574 of 947 (60.6%) clients participated in telemedicine follow-up services during the period considered. A significant association between telemedicine usage and the following were observed: the peak of second wave COVID-19 outbreak in Thailand, using the period preceding the second wave as a reference [adjusted odds ratio (aOR) = 1.47 (95% confidence interval [CI]: 1.12-1.96)]; participants receiving governmental benefits for contraceptive implant payment (aOR: 3.23, 95% CI: 1.86-5.60), and timing of contraceptive implant(s) initiation, using interval insertion as a reference for which aORs of postpartum and immediate postpartum insertions were 0.62 (95% CI: 0.43-0.90) and 0.35 (95% CI: 0.24-0.52), respectively. Significant ecchymosis at the insertion site was observed in 13.1% of participants. CONCLUSION: This study emphasizes the significance of telemedicine during the COVID-19 epidemic, particularly in facilitating contraceptive implant initiation. Our data show a significant increase in the uptake and utilization of telemedicine during the pandemic's peak. The data also shows that during the period of Thailand's second COVID-19 epidemic, government benefits for contraceptive implant payment, and the timing of contraceptive implant initiation, are significantly associated with telemedicine use. This finding supports the continued use of telemedicine in healthcare, particularly for services like family planning, where remote follow-ups can provide safe, efficient, and timely care.

Barriers and facilitators influencing utilization of intrauterine contraceptive device (IUCD) in Zimbabwe.

IUCD (Copper-T) is a safe, effective and long-acting reversible contraceptive and its uptake in Zimbabwe is currently less than 1%. Interventions to improve the uptake of IUCD require evidence on key factors contributing to its low uptake. The study was conducted to identify the gaps and offer opportunities for evidence-based family planning aimed at improving demand for IUCD, supply-side conditions, and influencing attitudes towards IUCD. A descriptive qualitative study design was conducted to explore and understand the perceptions of 169 women, 22 men, 16 community leaders and 20 health care providers regarding the use of IUCDs (Copper-T). In-depth interviews, Key informant interviews and focus group discussions with IUCD users, former IUCD users, and users of modern contraceptives (15-49 years) and men were conducted. Rural women showed reluctance to use IUCD because of myths, misconceptions and fears associated with the method which include barrenness, cancers, birth deformities and pregnancy complications. Negative community perceptions, dominant social norms, religious and socio-cultural beliefs, limited awareness of IUCD among men and weak health service delivery platforms were the major barriers to IUCD uptake in Zimbabwe. Evidence-based strategies on demand generation, supply-side interventions, advocacy and communication for development (C4D) are crucial in improving the uptake and provision of IUCD in Zimbabwe.

The acceptability of asking women to delay removal of a long-acting reversible contraceptive to take part in a preconception weight loss programme: a mixed methods study using qualitative and routine data (Plan-it).

BACKGROUND: Having a body mass index (BMI) which is classified as overweight (BMI ≥ 25) or obese (BMI ≥ 30) increases the risk of complications during pregnancy and labour. Weight-management interventions which target excess gestational weight gain during pregnancy have had limited success. Women who use long-acting reversible contraception (LARC) are in contact with services as part of their preparation for conception, creating a potential opportunity to offer a preconception weight-loss intervention. The aims of this mixed methods study were to assess the acceptability and practicability of a weight-loss intervention which asked people to delay LARC removal in order to lose weight before conceiving. METHODS: Routine UK NHS data were analysed to identify pathways from LARC removal to pregnancy. Qualitative surveys and advisory group discussions with service providers and LARC users with experience of being overweight were conducted and analysed thematically. RESULTS: Three hundred fifteen thousand seven hundred fifty-five UK women aged 16-48 years between 2009-2018 had at least one LARC-related event (e.g. insertion, removal) and 1.7% of those events were recorded as related to planning a pregnancy. BMI was included in 62% of women's records, with 54% of those BMI being classified as overweight or obese. Online surveys were completed by 100 healthcare practitioners and 243 LARC users. Stakeholders identified facilitators and barriers associated with the proposed intervention including sensitivities of discussing weight, service-user past experiences, practitioner skills, the setting and ethical implications of the proposed intervention. CONCLUSIONS: Although women and service providers recognised potential benefits, a preconception weight-loss intervention asking people to delay LARC removal posed many barriers, due mainly to the acceptability of such an intervention to women and healthcare practitioners. Weight-loss interventions that target the general population, together with a focus on improving public knowledge of preconception health, may be more acceptable than interventions which solely focus on LARC users. Many of the barriers identified, including communication, understanding and beliefs about weight and risk, appointment systems and the limitations of routine datasets also have relevance for any preconception weight-loss intervention. Work to improve routine datasets and reducing communication barriers to discussing weight are priorities. TRIAL REGISTRATION: ISRCTN14733020 registered 10.05.2019.

Change of contraceptive preference after the free-LARC program for Thai teenagers.

BACKGROUND: In 2014, the Thai government launched a free-of-charge long-acting reversible contraception (LARC) program for Thai female adolescents. However, its acceptance had not been reported. Therefore, this study aimed to describe contraceptive use among women of reproductive age before and after the program was implemented. METHODS: This retrospective cross-sectional study was carried out from the medical records of 9000 women of reproductive age, who attended the Family Planning Clinic at Maharaj Nakorn Chiang Mai Hospital between 2009 and 2018. The Chi-square test was used to compare the contraceptive methods administered before and after the program was implemented, and binary logistic regression was used to find the factors associated with implant use after completion of the program. RESULTS: Depot medroxy progesterone acetate (DMPA) injection was the most popular contraceptive method used among 40.9% of the women. The rates of subdermal implant use were increased significantly after the program was implemented (2.3-9.3%, p < 0.001). Implant use for adolescents aged less than 20 years increased from 2.6% to 56.4%, while DMPA was the most popular method used among adult women at 36.4%. Factors associated significantly with implant use after implement of the program included age of less than 20 years (aOR = 4.17 (CI: 1.84-9.44); p = 0.001) and nulliparity (aOR = 8.55 (CI: 3.77-19.39); p < 0.001). CONCLUSION: This study showed a significant increase in contraceptive implant use after the free-LARC program for adolescents had been applied. STATEMENT OF IMPLICATIONS: Contraceptive implant is the most effective hormonal reversible contraception. Its use rate is low among all age groups, but increased clearly after the free-of-charge program was applied for adolescents.

Prevalence and factors associated with the use of long-acting reversible and permanent contraceptive methods among women who desire no more children in high fertility countries in sub-saharan Africa.

BACKGROUND: The proportion of women with family planning needs increased from 74 to 76% between 2000 and 2019, and this improvement has not transcended to a fertility rate stall or decrease in sub-Saharan Africa (SSA). In the face of a continuous increase in the fertility rate in SSA, population experts agreed that the efficient use of reliable family planning methods such as long-acting reversible and permanent contraceptive methods (LARC/PMs) could help reduce the high fertility rate and associated adverse reproductive health outcomes in the region. However, despite the effectiveness of LARC/PMs, its use remains elusive in SSA. Thus, this study examines the prevalence and factors associated with the use of LARC/PMs among women who desire no more children in high-fertility countries in SSA. METHODS: Secondary datasets from the demographic health surveys conducted in 20 countries in SSA between 2010 and 2019 were included in the study. A total sample size of 46,290 sexually active women of reproductive age who desire no more children and who met the study inclusion criteria was pooled and analysed. Prevalence of LARC/PMs use was displayed using a graph whilst binary logistic regression was used to determine the associated factors, and results were presented as unadjusted odds ratio and adjusted odds ratio with a statistical significance of p < 0.05. RESULTS: The prevalence of LARC/PMs use among women who desire no more children was 7.5%. Ranging from 20.9% in Senegal and as low as 0.4% in Congo. Women within the richest wealth index [aOR = 1.18, 95% CI = 1.03-1.36] and those exposed to mass media [aOR = 1.54, 95% CI = 1.41-1.68] had higher odds of LARC/PMs use among sexually active women of reproductive age who desire no more children compared to those within poorest wealth index and women with no mass media exposure. CONCLUSION: The study concluded that LARC/PMs use among sexually active women who desire no more children was very low, and women within the richest wealth index and those with mass media exposure were likely to use LARC/PMs. Interventions that will encourage using LARC/PMs should be prioritised to reduce fertility rates in SSA.

The Impact of a Home Visiting Program Enhanced to Address Repeat Adolescent Pregnancy-A Randomized Controlled Trial of Steps to Success.

INTRODUCTION: A small but growing body of evidence suggests individualized support services and improved access to contraception can promote healthy birth spacing among adolescent mothers. This study examines the effectiveness of Steps to Success, a 2-year home visiting program in San Angelo, Texas, enhanced with content designed to reduce rapid repeat pregnancy among young mothers, increase fathers' involvement, and support mothers' education and career aspirations. METHODS: The study used a randomized controlled trial, with 594 young mothers ages 14-20 randomly assigned to either a program group that received Steps to Success or a control group that received an existing home visiting program focused only on parenting and child development. Women in both research groups completed a baseline survey upon enrolling in the study and 1- and 2-year follow-up surveys. RESULTS: After 2 years, participants in the Steps to Success and existing home visiting groups had similar rates of repeat pregnancy. However, women in the Steps to Success group were more likely to use long-acting reversible contraceptives (effect size = 0.18, p = 0.066), particularly younger adolescent mothers ages 14-18 (effect size = 0.34, p = 0.010). Steps to Success also decreased the incidence of unprotected sex for younger adolescent mothers (effect size = -0.25, p = 0.035). Steps to Success did not improve outcomes in other domains. DISCUSSION: Steps to Success improved some outcomes related to healthy birth spacing among younger adolescent mothers. Communities interested in similar programming may want to consider focusing their services on this age group.

Association of the Delaware Contraceptive Access Now Initiative with Postpartum LARC Use.

OBJECTIVES: Although multi-component policy interventions can be important tools to increase access to contraception, we know little about how they may change contraceptive use among postpartum women. We estimate the association of the Delaware Contraceptive Access Now (DelCAN) initiative with use of postpartum Long-Acting Reversible Contraception (LARC). DelCAN included Medicaid payment reform for immediate postpartum LARC use, provider training and technical assistance in LARC provision, and a public awareness campaign. METHODS: We used a difference-in-differences design and data from the 2012 to 2017 pregnancy risk assessment monitoring system to compare changes in postpartum LARC use in Delaware versus 15 comparison states, and differences in such changes by women's Medicaid enrollment. RESULTS: Relative to the comparison states, postpartum LARC use in Delaware increased by 5.26 percentage points (95% CI 2.90-7.61, P < 0.001) during the 2015-2017 DelCAN implementation period. This increase was the largest among Medicaid-covered women, and grew over the first three implementation years. By the third year of the DelCAN initiative (2017), the relative increase in postpartum LARC use for Medicaid women exceeded that for non-Medicaid women by 7.24 percentage points (95% CI 0.12-14.37, P = 0.046). CONCLUSIONS FOR PRACTICE: The DelCAN initiative was associated with increased LARC use among postpartum women in Delaware. During the first 3 years of the initiative, LARC use increased progressively and to a greater extent among Medicaid-enrolled women. Comprehensive initiatives that combine Medicaid payment reforms, provider training, free contraceptive services, and public awareness efforts may reduce unmet demand for highly effective contraceptives in the postpartum months.

Uptake and determinants of post-partum intra-uterine contraceptive device use among women in Kwazulu-Natal, South Africa: A prospective cohort study.

This study aimed to determine the uptake of the post-partum intra-uterine contraceptive device (PPIUD) and characteristics of women choosing PPIUD. The authors evaluated safety, efficacy and satisfaction following PPIUD insertion via a prospective cohort study. 276 pregnant women (age: 16-50 years) gave informed consent and received a PPIUD. Follow up was between 6-8 weeks postpartum. The mean age was 25.8 years with 74.9% being gravida 2-4. The follow up rate was 60.5%. PPIUD was found to be safe and acceptable with 79.6% of participants experiencing no side effects and 74.3% expressing high satisfaction. No pregnancies were reported. Expulsions (n=15) were not associated with gravidity, parity, gestational age or medical and surgical risk factors. (p-value >0.05). PPIUD is a safe, effective and acceptable form of contraception. Participants experienced few side effects and high satisfaction. Low follow-up is a concern.

Evaluation of satisfaction with a model of structured contraceptive counseling: Results from the LOWE trial.

INTRODUCTION: Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers' and participants' satisfaction with an intervention used in a large trial in Sweden. MATERIAL AND METHODS: A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03269357). RESULTS: Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package. CONCLUSIONS: The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods.

Role of social network in decision making for increasing uptake and continuing use of long acting reversible (LARC) methods in Pakistan.

INTRODUCTION: Despite evidence from recent Demographic Health Surveys that show 98% of the adult Pakistani population have an awareness of at least one modern contraceptive method, only 25% of married couples in Pakistan used a modern method of contraception. Of the modern contraceptive methods, LARC usage has increased only from 2.1 to 3%. This low uptake is puzzling in the context of high awareness of LARC methods and its availability through public sector facilities at subsidized costs. This study aimed to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan. METHODS: In-depth interviews were conducted with 27 women who were using a LARC method for contraception. Data was managed using NVivo 12 and themes were identified using a content analysis approach to analyze the transcripts. RESULTS: Four key themes, supported by sub-themes relating to a temporal model, were identified to explain women's experiences with initiating and continuing use of a LARC. The themes were (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC. Results highlight the significant role of immediate social network of female family members in supporting the women in initiating LARCs and maintaining the method's use. CONCLUSION: This study contributes to an in depth understanding of the decision-making process of women who adopted LARC and maintained its use. Women who proceeded to use an LARC and who persisted with its use despite the experience of side effects and social pressures, were able to do so with support from other female family members and spouse.

The significant influence of history of induced abortion on the utilisation of long-acting reversible contraceptive methods in the immediate post abortion period, Northern Ethiopia.

BACKGROUND: Rapid population growth, untended pregnancy, and related consequences remain the concern of Sub-Saharan African countries, including Ethiopia. Despite this, long-acting reversible contraceptives methods are still underutilised and no studies have sought the factors in this study setting. Therefore, this study conducted to assess the prevalence and determining factors of long-acting reversible contraceptives utilisation following an abortion in Northern Ethiopia. METHOD: Facility-based cross-sectional study design was employed. A total of340 post aborted women selected by a systematic sampling method from August 1 to October 30, 2018. Data were entered into Epi-Info version 7 software and exported to SPSS version 20 for analysis. Both bivariate and multivariate logistic regression models were used to identify factors associated with the outcome variable. RESULTS: The overall post-abortion long-acting reversible contraceptives utilisation was 57(16.76%) with 47(82.46%) implantand 10 (17.54%) intrauterine devices. Age range 20-29 years (AOR = 0.09, 95% CI 0.02-0.37), employed (AOR = 5.22, 95% CI 1.99-13.67), had ≥2 alive children (AOR = 7.02, 95% CI 1.58-31.23), induced abortion (AOR = 8.41, 95% CI 3.28-21.59), surgical abortion (AOR = 5.99, 95% CI 2.25-15.94), previous awareness (AOR = 3.18, 95% CI 1.14-8.82) and history of prior utilisation (AOR = 3.59, 95% CI 1.08-11.97) were the factors significantly associated with utilisation of post-abortion long-acting reversible contraceptives. CONCLUSION: Long-acting reversible contraceptive methods level of utilisation following an abortion in this study was low. Advocating and raising awareness should always consider on benefits and effectiveness of long-acting reversible contraceptives for all type of abortion and methods of termination as an integral part of reproductive health care services.

Real-world cost-effectiveness of etonogestrel implants compared to long-term and short term reversible contraceptive methods in France.

BACKGROUND: To estimate the cost-effectiveness (CE) of etonogestrel implants compared to other long-term and short-term reversible contraceptive methods available in France. RESEARCH DESIGN AND METHODS: A 6-year Markov model compared effectiveness between the implant and six other contraceptive methods in sexually active, not-pregnancy-seeking French females of reproductive age. Contraception efficacy, switch rates and outcomes were based on French current medical practice. Incremental CE ratios (ICERs) were calculated as incremental cost per unintended pregnancy (UP) avoided. Efficiency frontier was plotted to identify cost-effective methods. Uncertainty was explored through sensitivity analyses. RESULTS: The implant was on the efficiency frontier along with combined oral contraceptive pill (COC) and copper IUD. Implant avoids between 0.75% and 3.53% additional UP per person-year compared to copper IUD and second generation COC, respectively, with an ICER of €2,221 per UP avoided compared to copper IUD. For the 240,000 French women currently using the implant, up to 8,475 UPs and up to 1,992 abortions may be prevented annually. CONCLUSION: With more unintended pregnancies avoided and comparable costs to copper IUD, the implant is a cost-effective option among long-term and short-term reversible contraceptive methods.

Contraceptive practices in women with chronic medical conditions.

Contraception in women with severe medical conditions is a potential measure to reduce maternal mortality. We sought to determine the contraceptive use in women with medical conditions at the University Hospital of the West Indies (UHWI) in Jamaica to determine if there is room for improvement in contraceptive use. Participants were identified from the medical out-patient departments and questionnaires administered. Two hundred and sixty females between 18 and 44 years with varied chronic medical conditions were included. Those included were systemic lupus erythematosus (SLE), diabetes, hypertension (HTN), thyroid disease, cardiac and renal disease. The total current use of contraception was 58.4%, while 41.6% were not on contraceptives. The use of barrier methods and long-acting reversible contraceptives (LARCs) was 71% and 10%, respectively. The current use of contraception in patients with sickle cell disease (SCD) was 84% (p=.004) and in rheumatoid arthritis (RA), 14% (p=.028). Fifty-eight (58, 24.2%) of the women were using two or more methods of contraception. There is a role for improving contraceptive use among women with medical conditions as they are at increased risk of pregnancy complications.IMPACT STATEMENTWhat is already known on this subject? Women with medical comorbidities significantly contribute to both direct and indirect causes of maternal mortality. Contraception may play an integral role in reducing the risk of dying in chronically ill women; however, the use of contraception in this group is often suboptimal.What the results of this study add? This study adds to the literature that in this high-risk group, there is an underuse of long-acting reversible contraceptives, which is ideal for this population.What the implications are of these findings for clinical practice or further research? The results will provide evidence that this high-risk group of women should be targeted and counselled regarding their risk of morbidity and mortality in pregnancy as well as contraception use while their condition is optimised. From this evidence, services may be put in place in institutions, especially in low-resource settings.

A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia.

BACKGROUND: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. OBJECTIVE: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. STUDY DESIGN: A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. RESULTS: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). CONCLUSION: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.