PrEP Method Switching: Will it Yield Greater Coverage of HIV Protection? Applying Lessons Learned from Family Planning to Guide Future Research in the Context of PrEP Choice.

PURPOSE OF REVIEW: Despite the growing availability of oral PrEP, coverage remains suboptimal. Through the introduction of additional PrEP methods, including vaginal rings and long-acting injectable formulations, health systems globally are on the cusp of offering PrEP methods that vary by route of administration, efficacy, and frequency of use. With PrEP choice, it will be important to explore PrEP use patterns to better understand how the ability to choose and switch products affects coverage and continuation. In this review, we draw parallels with family planning (FP) by summarizing how method choice and product switching affected contraceptive coverage globally, synthesize what is known about PrEP product switching, and outline evidence gaps to help guide future research on PrEP switching in the context of choice. RECENT FINDINGS: Decades of research in FP has demonstrated that product switching is common and can lead to more satisfaction and increases in contraceptive use. While research on PrEP product switching is nascent, findings suggest switching is common, and that providing more than one PrEP option can increase coverage. Key evidence gaps include understanding product switching in the context of full versus constrained choice, switching in the context of temporary need, and developing interventions that promote product switching for those who could benefit. Providing choice and allowing people to start, stop, and switch products according to their needs and desires is a core component of a rights-based approach to HIV prevention. More research is needed to better understand what drives use patterns, including switching, and how to leverage choice to improve coverage. Standard definitions -some of which have been proposed in this review-are needed to inform comparable measurement. Finally, there is a need to holistically frame PrEP use to acknowledge changes in need over the life course, thus making method switching a standard part of HIV prevention.

Evaluation of two serum free light chain quantitation methods, Freelite and Seralite, in the clinical laboratory with a view to switching immunoassay.

BACKGROUND: Serum free light chain (sFLC) quantitation is central for plasma cell dyscrasias. Several assays are available and switching sFLC methods may be advantageous in certain laboratories. This study performed Freelite and Seralite simultaneously for samples received by the clinical laboratory over a 10 month period and compared quantitation and its impact on interpretation of patient results. METHODS: Patients (N = 189) included multiple myeloma (MM) and related plasma cell cancers, monoclonal gammopathy of unknown significance (MGUS), AL amyloidosis and renal impairment. sFLC quantitation and clinical agreement was assessed between methods. RESULTS: Clinical agreement was substantial at diagnosis (κ = 0.647, p < .01) and moderate for monitoring (κ = 0.591, p < .01). Good concordance was seen for MM and related plasma disorders and MGUS, with poorer agreement seen for AL amyloidosis. Case studies illustrated agreement in pattern of myeloma disease activity. Bland-Atman plots showed small mean bias but increasing variation between methods with increasing FLC concentrations. Passing-Bablok analysis confirmed systematic differences in quantitation between methods. CONCLUSIONS: Despite differences in quantitation, overall, agreement was seen between the different sFLC platforms in relation to the clinical interpretation. As a rapid test without the need for large and expensive analysers, Seralite may be highly applicable in certain laboratories to enable in-house testing.

A systematic review of contraceptive continuation among women living with HIV.

BACKGROUND: Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors. METHODS: We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation. RESULTS: Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle-Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%-91% continuation rates at ≥12months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes. CONCLUSIONS: Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12months are needed to strengthen integration of RH and HIV care.

Long-acting family planning method switching among revisit clients of public health facilities in Dire Dawa, Ethiopia.

BACKGROUND: "Contraceptive switching" from one method to another is a common phenomenon. Switching from a more effective long-acting method to a less effective method exposes women for unplanned pregnancy. The aim of this study was to assess the level and factors associated with long-acting family planning method switching to other methods. METHOD: A facility-based cross-sectional study was conducted from January to March 2013 on 634 women attending public health facilities in Dire Dawa City Administration, Ethiopia. Participants of the study were revisit clients of family planning service and were interviewed as they appear in the clinics. Data were analyzed using crude and adjusted logistic regression, and results were reported using OR and corresponding 95 % CI. RESULTS: Long-acting family planning method switching among revisit clients was 40.4 %; switching from implant was 29.8 % and from IUCD, it was 10.6 %. The main reasons for methods switching were side effects of the methods such as bleeding, weight loss, and feeling of arm numbness. The tendency of switching was less among married women (AOR = 2.41, 95 % CI: 1.01, 5.74), women who had 2-4 and 5 and more children (AOR 3.00, 95 % CI: 1.59, 5.67) and (AOR 2.07, 95 % CI: 1.17, 3.66), respectively. It was also less among women who want to stop birth (AOR 5.11, 95 % CI: 1.15, 24.8), among those who mentioned health care providers as source of information for family planning (AOR 1.88, 95 % CI: 1.18, 3.01), and among women whose husbands were aware of their use of the methods (AOR 3.05, 95 % CI: 1.88, 4.94). CONCLUSIONS: Method switching from long-acting contraceptives to less effective methods is high. Method switching was significant among unmarried women, who had one child, plan to postpone fertility, and whose husbands were not aware of their wive's use of the method. In the provision of family planning service, the health care providers should give adequate information about each method and risks of method switching. Appropriate family planning Information Education and Communication (IEC) and Behavioral Change Communication (BCC) strategies should be emphasized.

Unintended pregnancies and use, misuse and discontinuation of oral contraceptives.

Unintended pregnancies are a recognized occurrence among women using oral contraceptives (OCs) as a consequence of both user and method failure. However, OCs also influence the occurrence of unintended pregnancies through an additional, poorly recognized, route: cessation of OC use by women who do not wish to become pregnant but stop using OCs because of side effects or other reasons. Many such women fail to immediately substitute a new contraceptive and/or adopt a less reliable contraceptive. This is a particularly important consideration for the approximately 3.7 million women who begin taking OCs in the United States each year since this group commonly experiences side effects and has a high discontinuation rate. Using a decision tree to follow a cohort of OC users over one year, we estimate that over 1 million unintended pregnancies are related to OC use, misuse or discontinuation. The greatest proportion of these, 61%, occur in women who discontinue OCs; of these, 66.6% occur in women who fail to immediately substitute other contraceptives and 33.3% because of the adoption of less reliable contraceptive methods. Of continuing OC users, the majority, exhibiting good compliance, contribute 24% of pregnancies because of their large numbers. Continuing OC users who are poor compliers, though many fewer, are responsible for 15% due to their high pregnancy rate. Unintended pregnancies in women who discontinue OCs account for approximately 20% of the 3.5 million annual unintended pregnancies in the United States, incurring costs of nearly +2.6 billion.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Findings from clinical trials and a survey of 10,000 users of oral contraceptives (OCs) formed the basis for developing a decision tree or chart that reproductive medicine specialists used to follow a cohort of OC users annually. They used a sensitivity analysis to estimate that OC use, misuse, or discontinuation are associated with 1,045,000 unintended pregnancies in the US each year. 61% of these unintended pregnancies occur to women who discontinue OCs. About 20% of women who discontinue OCs do not immediately adopt another contraceptive method. 33.3% occur because the women substituted OCs with less reliable contraceptive methods. Continuing OC users with good compliance account for 24% of the unintended pregnancies. Continuing OC users with poor compliance make up 15% of unintended pregnancies. Their number was much lower than that of good compliers (2.05 vs. 11.6 million). If all women used OCs correctly, about 687,000 unintended pregnancies would not occur. Physicians need to stress the need for immediate adoption of another reliable contraceptive if OC use is discontinued and the patient does not wish to conceive. They should counsel new OC adopters to expect side effects (e.g., bleeding) and that these side effects are temporary. This should reduce OC discontinuation.

Helping patients choose an appropriate method of birth control.

PIP: In the US, nurse practitioners and nurse midwives handle most family planning visits, (e.g., 60% in Georgia). These are prime opportunities to counter the often incomplete and misleading information imparted by friends and mass media about contraceptives. Age, health status, childbearing plans, coital frequency changes, and changing lifestyle priorities determine women's contraceptive needs throughout the reproductive years. Nurses should provide patients accurate information about failure rates of various family planning methods. When counseling patients about these methods, nurses should consider coital frequency. For example, women who partake in intercourse often should consider methods providing the greatest protection against pregnancy, e.g., oral contraceptives (OCs), IUD, and implants; but those who do not, may consider barrier methods. Nurses should also determine how a woman would respond to an unplanned pregnancy to help guide her in making a decision about contraceptive use. Other factors to consider include age, fertility, and childbearing intentions. They also should counsel patients about protection from sexually transmitted diseases. Nurses and their patient need to discuss the importance of spontaneity and convenience and comfort level with touching their own bodies. Health history is also an integral factor in making a decision about using a safe family planning method. For example, women over 35 years old who smoke and those with a history of thromboembolic and cerebrovascular conditions and breast cancer should not use OCs. Similarly, women with active thromboembolic disorders, acute liver disease, jaundice, unexplained vaginal bleeding, and breast cancer should not use implants. Women with multiple sex partners should not choose the IUD because of the risk of pelvic inflammatory disease. Barrier methods are relatively safe and effective contraceptives when used correctly. Consistent use of natural family planning methods can adequately prevent pregnancy. Nurses have a special responsibility to inform adolescents about reproductive health and family planning.^ieng

[Risk of an unintentional pregnancy after only one unprotected coitus; observations concerning today's hormonal postcoital contraceptive agents]. / Het risico van een onbedoelde zwangerschap na één onbeschermde coïtus; beschouwing bij de huidige hormonale postcoïtale anticonceptiemethoden.

PIP: Tietze and Dixon have studied the average chance of getting pregnant after a single act of unprotected coitus. Tietze concluded that the chance lay between 2% and 4%. Dixon calculated that if the coitus occurred 1 day before ovulation the chance was 17.3%, gradually decreasing to zero toward the 9th day before and 6th day after ovulation. The commonly used hormonal postcoital contraceptive methods are 1) the morning-after pill consisting of 5 mg of ethinyl estradiol/day for 5 consecutive days, also called the 5x5 method; and 2) the 2x2 method comprised of taking 50 mg of ethinyl estradiol twice within an 12-hour interval. 3016 women were treated with the 5x5 method, and 17 pregnancies occurred with a failure rate of .6. According to Tietze the real number lay between 60 (2%) and 120 (4%) without treatment yielding a real rate of 14.2-28.4 for these 17 pregnancies. In a group of 1990 women with midcycle coitus, 11 pregnancies occurred yielding a failure rate of 4.9%, although according to Dixon 222 pregnancies were expected. 867 women were also treated with the 2x2 method, 93 women were excluded, and 18 pregnancies occurred, which corresponds to a failure rate of 2.1. According to Tietze the real number was 17 (2%) and 35 (4%), thus the 18 pregnancies yielded a real failure rate of 51.4 and 100. The 5x5 method was found effective in dogs and apes in the doses used, however, neither the method of administration, nor the indications were established for humans, thus at least in 90% of cases women are treated unnecessarily with an outright toxic medicine because of the exorbitantly high doses of synthetic estrogen. The 2x2 method has a high failure rate partly because of deficient instruction by doctors. The effectiveness of the 2x2 method is very meager, thus the medical ethical question arises of deceiving as many as 20,000 women who are prescribed this treatment every year.^ieng

Teenagers swap pill for condom.

PIP: The General Household Survey, which was conducted by the Office of Population Censuses and Surveys in 1993, showed that teenagers had switched their main method of contraception from the pill to the condom. The latter method had become the most popular contraceptive among women aged 16-19; nearly half had asked their parents to use it. Since 1986, when the Health Education Authority began to warn about acquired immunodeficiency syndrome (AIDS), condom use has risen from 6 to 20% in this age group, the largest increase in any age group. Overall, 17% of women used the condom, 12% were sterilized, and 12% had partners who were sterilized. Sterilization was more common among married women, especially those who already had children. More than 70% of the women were using at least one form of contraception at the time of the survey. 5% had used emergency contraception; 1%, on more than one occasion. Usage was highest in the 18-24 age group, and most had obtained the "morning after pill" from their general practitioner.^ieng

How we can save Norplant contraceptive implants. Trouble in paradise?

PIP: Norplant is a safe, effective contraceptive which is associated with long continuation rates. However, the problem of irregular bleeding causes many women to request removal of the implants. This situation can be ameliorated if women are properly counseled and advised to avoid the contraceptive implant if an altered pattern of bleeding will likely be unacceptable. Women must also be in charge of when the implant is removed. The client's decision to remove the implants should never be refused or postponed by the clinician; to do so turns a voluntary method of contraception into a compulsory one. If clinicians are inserting Norplant, they should be able to remove it. Several techniques have been developed, and the new Emory technique may prove to be helpful to clinicians experiencing difficulties. Only by urging women to return with problems and by removing the implant on demand will the future use of this excellent contraceptive be insured. A reproducible chart of precautions and early warning signs for Norplant users is attached to this article.^ieng

Multistate survival models for transitions and reverse transitions: an application to contraceptive use data.

PIP: This paper extends the use of the multistate proportional hazards model proposed by R. Kay for transitions, reverse transitions, and repeated transitions. A simple method of testing the equality of vectors of parameters for transitions and repeated transitions is also shown in addition to estimates for the underlying cumulative hazards for different types of transition. The multistate survival models applied to contraceptive use data collected by the International Center for Diarrheal Disease Research, Bangladesh, for the period January 1978 to December 1982 provide useful findings relating to interstate transitions. The author stresses the need to not treat separately states of contraceptive use given their link to the acceptance of the first method, transitions from one method to another, first method discontinuation, periods of non-use, the use of subsequent methods, loss to follow-up, the use of irreversible methods, and subsequent periods of non-use. Religion is an important indicator for the acceptance of an irreversible method as a first or subsequent method; compared to women of other religions, Muslims were less likely to accept an irreversible method as a first or subsequent method. Religion is not, however, associated with the acceptance or subsequent use of a reversible method or with discontinuation of a reversible method. Higher age in the study area is associated with both lower acceptance and longer continuation of a method. Women with a larger number of living sons tend to accept their first method and subsequent methods at an higher rate than women with fewer or no sons. As for educational status, women with higher education proved to be serious users of contraception, although women with less or no education tend to accept an irreversible method at an higher rate than the women with an higher level of education. Further, the desire for more children is a strong predictor for non-use of a method even if contraception is used to space births. The score test suggested in the paper for testing the equality of parameters in models 1-4 reveals that there is no significant difference in the parameters of the models. This paper shows that the factors which affect the acceptance of any reversible method of contraception are different from those for an irreversible method. Moreover, the factors which affect a transition differ from those for a reverse transition in the case of adopting reversible methods.^ieng

Women's patterns of contraceptive use.

Our purpose in conducting this research was to examine women's patterns of contraceptive use. Records for 800 women receiving care at a private, nonprofit agency providing well-woman and contraceptive care over a 15-year period constitute the data set. The records were examined for patterns of reported method choice and use, method destinations, first method choice, and demographic variables. Women reported making 1,889 method choices from among 16 different methods. Seventy-five percent of the women changed methods at least once and the women gave 1,036 reasons for changing methods. Oral contraceptives and condoms were the methods most commonly tried by the women. The women's patterns of contraceptive use were very individualized, were neither linear nor predictive as other investigators have reported, and method destinations could not be predicted from previous method use.

PIP: Patterns of contraceptive use were investigated in a retrospective review of the records of 800 US women receiving well-woman and family planning care at a private, nonprofit agency in Massachusetts. Overall, women made 1889 method choices from among 16 different methods during the 15-year study period. Oral contraceptives and condoms were the methods most commonly selected. 75.2% changed methods at least once (mean number of changes, 2.2) and gave 1036 reasons for their method switching. The 55.5% of women whose first contraceptive method was hormonal reported fewer methods of any type over the 15-year study period than those who began with a non-hormonal method. This factor accounted for 12% of the variation in total number of methods women reported using. Overall, contraceptive use patterns were individualized and non-linear, with few women choosing the same methods in the same order. Method choices could not be predicted from previous method use. Contrary to the findings of other studies, no trend from less effective to more effective methods was observed.

Choice and changes of contraceptive methods after primiparous delivery in Shanghai.

PIP: This study assessed the contraceptive method of choice and tendency of method switching of women after their first birth in Shanghai, China. The assessment was based on 15 months follow-up after the first delivery. Included in the study were 3701 primiparous women aged 18-43 years, with 1833 women living in an urban area and 1868 living in a rural area. Results showed that 15 months after delivery 95.46% had already used a contraceptive method. The leading first choice among urban women was the condom (50.72%), followed by the IUD (29.09%), while the leading first choice among rural women was the IUD (56.65%), followed by the condom (30.60%). Among women who had never used a contraceptive method, 33.77% of urban women and 18.52% of rural women switched method 15 months after delivery. The major reason for the contraceptive method switching was method failure attributed to improper use. Furthermore, the choice of contraceptive method after first birth varied significantly by women's characteristics. Urban, well-educated women, breast-feeding women and older women preferred the condom and the rhythm method over oral contraceptives. Family planning workers should increase women's awareness of the benefits and disadvantages of different contraceptive methods, dispel myths, and improve women's informed choice.^ieng

Experts debate pill switching to combat noncompliance. Special report: annual pill survey.

PIP: Oral contraceptive (OCs) users continue to complain of side effects such as headaches, mood swings, and weight gain, and switch pill formulations. Questionnaires for an annual oral contraceptive survey were mailed to subscribers in the May 1992 issue of Contraceptive Technology Update (CTU) 137 of 1600 surveys mailed were returned for a response rate of 8.5%. 64% of the respondents were nurse practitioners, 19% were physicians, 7% were physician assistants, 5% were registered nurses, and 5% were other types of providers. OC users tend to blame headaches, mood swings, or gaining weight on the pills. The CTU survey found that more than 60% of health care providers would advocate switching to a lower-dose estrogen pill or to a progestin-only pill for headaches and mood swings. For weight gain their first choice of treatment would be counseling about life style changes. 50-60% of American women discontinue OCs in the first year, mainly because of side effects such as breakthrough bleeding, headaches, nausea, weight gain, and acne. 89% of respondents said few women had sever, recurring headaches, but should that occur 66% of respondents would change to a lower-dose estrogen pill. Only 9% of respondents would recommend relaxation exercises and analgesics. 67% of respondents would change the pill formulation before suggesting a life style change when patients complain about mood swings. Ortho Novum 7/7/7 was the pill of choice for 61% of survey respondents, and Triphasil was the 2nd choice by 43%. An international group of physicians recommended that manufacturers, physicians, and OC providers take the lead in providing patients with acceptable counseling concerning correct OC use.^ieng

Lifestyle changes most often suggested for weight complaints. Special report: annual pill survey.

PIP: Family planners responding to an annual oral contraceptives (OC) survey tended to recommend switching pills for complaints of headaches and mood swings and life style changes for the complaint of weight gain. Nearly 3/4 of survey respondents indicated that headaches and mood swings affected less than 5% of their patients. On the other hand, 29% reported that less than 5% of patients complained of weight gain; 27% said 10% complained; 19% said 10-15% complained; 10% said 15 to 20% complained; and 14% said more than 20% of patients complained of weight gain. 57% of the 137 respondents would instruct patients to exercise more and reduce calorie intake, and only 13% would change a patient's pill formulation because of weight gain. Nausea, breast changes, breakthrough bleeding, and compliance issues seem to be more relevant to birth control pills. However, a study indicated that women who discontinue more often do it because more often do it because of weight gain or acne than because of irregular bleeding or amenorrhea. Some women have gained 10-30 lbs using OCs. Researchers in Sweden recorded the secretion of the satiety hormone cholecystokinin during a 24-hour period before and during administration of OCs to 9 women, and found that pills suppressed the serum profiles of cholecystokinin inducing the feeling of hunger. Further studies are needed to evaluate the mechanism of this effect.^ieng

The determinants of IUD discontinuation in China: a discrete-time competing risk model analysis.

This research examines the social, demographic, and family-planning-program factors that influence the occurrence of IUD discontinuation among Chinese women, using a sample of 14,639 IUD use segments from the 1988 Chinese National Survey of Fertility and Contraceptive Prevalence. A discrete-time competing-risk event history method is employed to identify the determinants of IUD discontinuation by five kinds of reasons: contraceptive failure, expulsion, switching method, side-effects and other nonmethod-related reasons. The predictors of IUD discontinuation suggest that a number of mechanisms are in operation. Some of the determinants may reflect the effects of the family planning program; some may illustrate women's physiological and biological reactions to IUD's; some may be related to women's previous history of contraceptive use; and still others may indicate social characteristics of women that lead them to have their IUD's removed.

Family planning in Nepal: an update.

PIP: Between 1976 and 1991, awareness of at least one modern contraceptive method among currently married women of reproductive age in Nepal increased from 21% to 93%. The largest increase in awareness occurred for spacing methods (2.6-7.2%, vs. 2-2.2% for permanent methods). Knowledge remained highest among permanent methods, however (in 1991, 85-89% vs. 19-66%). Among women familiar with any modern method, 24.1% currently used a method in 1991. The current contraceptive prevalence rate was linked to a reduction of around 1.5 potential births. Permanent methods remained the most popular contraceptive method used among currently married women (in 1991, 7.5-12.1% vs. 0.2-7.5%). During 1981-1991, contraceptive use increased on average 1.6%/year. The percentage of women who knew where to obtain family planning methods increased more than two-fold (33-74%), likely reflecting a combination of new service outlets and increased knowledge about existing and new service outlets. In 1991, for 75% of currently married women, service outlets were still at least one hour from their homes. Public health facilities, especially hospitals and health posts, were the main source of contraceptive methods (93%). In the private sector, pharmacies were the main source of oral contraceptives and condoms while hospitals were for other methods. In 1991, 86% of current users had never switched contraceptive methods. As each contraceptive method became available, a new pool of users emerged. Between 1976 and 1991, the desired family size fell by 0.8 children. These statistics suggest that Nepal has begun its fertility transition and an accelerated increase in contraceptive use. Nepal's family planning program is now challenged to expand and strengthen consistent quality services to meet the increased demand for contraceptives.^ieng

Contraceptive choice and reproductive morbidity in Istanbul.

A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of bearing a considerable burden of ill health, with 81 percent reporting at least one episode of illness in the three months prior to the interview. Current users of the intrauterine device were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small amount of switching between methods suggests that most users tended to stay with the same method once chosen and that health concerns played an important part only in the initial choice of the method.

PIP: A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of their bearing a considerable burden of ill health, with 81% reporting at least one episode of illness in the 3 months prior to the interview. Current IUD users were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small degree of switching between methods suggests that most users tended to stay with the same method, once chosen, and that health concerns played an important part only in the initial choice of the method.

Fundamental elements of the quality of care: a simple framework.

This article argues for attention to a neglected dimension of family planning services--their quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service-giving process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.

PIP: A framework for analyzing quality of family planning services is offered. Quality is a property that all programs have. The framework is made up of 6 parts: 1) choice of methods; 2) information given to clients; 3) technical competence; 4) interpersonal relations; 5) follow- up and continuity mechanisms; and 6) the appropriate "constellation" of services. Switching contraceptive methods is common. The ability of people to switch satisfies them. First use with temporary contraception methods is usually under 2 years. Having different contraceptive methods helps the program respond to the individual's need. Choice is not possible without an adequately developed delivery system. A positive relationship exists between a wide range of methods being available and contraceptive prevalence rates. Of Indonesian client who had reported not receiving the contraceptive method that they wanted, 85% discontinued within the year. Of those who got the method that they wanted, the discontinuation rate was 25%. Clients who wanted to practice contraception will be discouraged if not given information that can be used, or if the method is not available. How much contraception information should be given to the client? Enough so that they know that these are choices and that methods can be changed. There appears to be poor knowledge among clients of use, risks, and benefits of contraceptives. Many different monitoring technics are needed to analyze technical competence. The disparity between standards of competence in the West and what is found in the field should be addressed. Interpersonal relations is the affective content of the provider/client transaction. The characteristics of programs and clients have changed since the idea of follow-up was first brought about. The appropriate constellation of services should respond to clients rather than some artificial demarcation. Ways in which the framework may be used as an analytical and practical tool are discussed. Quality can be seen from the structure of the program, the service- giving process, and the outcome of care. The outcome of care consists of knowledge, behavior, and service satisfaction.

[Rationale for prescribing oral contraceptives]. / Rationale für die Verordnung oraler Kontrazeptiva.

Strategies for prescribing oral contraceptives (OC) are explained with particular emphasis on individual conditions which can be helpful to optimize the selection process out of the numerous on the market. While contraceptive efficacy unequivocally is regarded as high additional non-contraceptive benefits become substantial criteria for an individual decision. Antiandrogenic properties of progestogens like cyproteroneacetate clearly determine their preference in the presence of unwanted clinical signs and symptoms of hyperandrogenism. In most of the non androgen-related conditions the estrogenicity of a preparation as a result of the dose of ethinylestradiol and dose as well as antiestrogenic potency of the progestogen accounts for the majority of non contraceptive effects. Different progestogens are evaluated with respect to their antiestrogenic property. It is suggested to start treatment after selection of an appropriate progestogen with the lowest daily dose of both hormonal components and to continue intake at least for 3 to 4 cycles as long as no serious adverse events occur. In cases of persisting problems i.e. bleeding irregularities doses or dosing-schemes should be altered preferentially without switching to another gestagen.

PIP: It is vital when one is prescribing oral contraceptives to choose antiestrogenic gestagens with antiandrogenic properties if conditions like acne, alopecia, or hirsutism are present. Cyproterone acetate, chlormadinoacetate, and dienogest are the most effective antiandrogens. Sex hormone-binding globulin (SHGB) is the most important parameter for the effect of estrogen on the liver, and its measurement can help determine the total estrogen content of various preparations. The SHGB increase should always be measured after at least 3 cycles of treatment with monophasic combination preparations of different gestagens. The dose of ethinyl estradiol for levonorgestrel (LNG), gestoden, desogestrel, and dienogest, respectively, used to be 30 mcg, and for norgestimate and norethindrone it was 35 mcg; the dose would be assessed to ascertain the antiestrogenic effect of these preparations. LNG is the gestagen with the strongest antiestrogenic effect. This has been qualitatively supported by findings from an investigation with a combination of 20 mcg ethinyl estradiol plus 100 mcg LNG, which showed that no change of the SHGB level occurred after 3 cycles. It is reasonable to choose a preparation with the lowest estrogen and gestagen dose and to change the dosage only after 3-4 months of use at the earliest if side effects such as bleeding irregularities occur. Other options are gestagen monopreparations or an LNG-containing IUD system. For women in the last third of their fertile phase, the use of a gestagen-containing system allows for the balancing of an existing estradiol deficit.

The dynamics of contraceptive use in Peru.

In 1986, the Demographic and Health Surveys project administered the first six-year calendar history of events that included women's contraceptive use and their reasons for discontinuation in experimental surveys in Peru and the Dominican Republic. In this report the experimental survey from Peru is examined to demonstrate how the calendar data can be used to calculate multiple increment-decrement life table rates of contraceptive discontinuation--including contraceptive failure, method switching, and abandonment of use--and of resumption of method use following discontinuation. These analyses reveal that nearly half of all Peruvian women who begin to use a method will stop using it within one year; 29 percent of women discontinue method use for nonpregnancy-related reasons within one year of initiating use. Women who switch methods do so frequently, and many will return to a method used previously, or move on to a third method. Women who become pregnant after abandoning contraceptive use have similar contraceptive-use patterns to women who experience a contraceptive failure.

PIP: An analysis of calendar data from January 1981 to interview date in 1986 (Demographic and Health Survey) on 1065 ever married Peruvian women who had ever used a contraceptive was used to show how researcher can use these data to calculate multiple increment-decrement life table rates of contraceptive discontinuation and renewed method use after discontinuation. 46.4% of women discontinued a method within 1 year. 29% discontinued a method for nonpregnancy related reasons within 1 year of use. Women who stopped using a method were more likely to switch directly to another method than not use any method. The risk of unplanned pregnancy was therefore low for these women. Women who discontinued use of a method but not switch directly to another method likely ceased having sexual intercourse, while others either ran out of supplies, were dissatisfied with the method, or could not find acceptable alternative methods. Regardless of the reason for not switching to another method after discontinuation, these women were at an increased risk of unplanned pregnancy. Women who discontinued a method and did not directly switch to another method were just as likely to return to the abandoned method as they were to switch to another method, but were likely to become pregnant before they returned to the abandoned method or switched to another method. Contraceptive use patterns of such pregnant women matched those of women whose contraceptives failed. Both groups of women tended to return to the method that failed. The considerable amount of method switching in a population may demonstrate either that women profit from a wide range of contraceptive choices or they cannot easily obtain and are not satisfied with currently available contraceptives. Since Peru had one of the weakest family planning programs in Latin America during the 1980s, the latter 2 reasons were most likely the case.