Breastfeeding by Disability Status in the United States: Pregnancy Risk Assessment Monitoring System, 2018-2020.

Objectives. To describe breastfeeding initiation and breastfeeding at 1, 2, and 3 months, and information sources on breastfeeding among women with a recent live birth by disability status. Methods. We analyzed October 2018 to December 2020 data from the Pregnancy Risk Assessment Monitoring System for 24 sites in the United States that included the Washington Group Short Set of Questions on Disability (seeing, hearing, walking or climbing stairs, remembering or concentrating, self-care, communicating). We defined disability as reporting "a lot of difficulty" or "cannot do this at all" on any of these questions. Results. Among 39 673 respondents, 6.0% reported disability. In adjusted analyses, breastfeeding was lower among respondents with disability at 2 (62.6% vs 66.6%; adjusted prevalence ratio [APR] = 0.94; 95% confidence interval [CI] = 0.89, 0.99) and 3 months (54.7% vs 59.6%; APR = 0.92; 95% CI = 0.86, 0.98) than those without disability. Respondents with disability were less likely to receive information from health care providers or support professionals (89.3% vs 92.3%), but as likely from breastfeeding or lactation specialists (78.1% vs 75.3%). Conclusions. Strategies to ensure women with disability, receive breastfeeding support, including breastfeeding information, could improve breastfeeding outcomes. (Am J Public Health. 2024;114(1):108-117. https://doi.org/10.2105/AJPH.2023.307438).

Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020.

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate.

U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), adapted by CDC from global guidance developed by the World Health Organization (WHO), provides evidence-based guidance on contraceptive use for U.S. health care providers (1). During January-February, 2021, CDC evaluated the 2019 WHO recommendation on self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (2). CDC adopted the WHO recommendation on the basis of moderate-certainty evidence that self-administered DMPA-SC is safe and effective, and has higher continuation rates compared with provider-administered DMPA. The new U.S. SPR recommendation states that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception. Provider-administered DMPA should remain available. Self-administered DMPA-SC is a user-controlled method that has the potential to improve contraceptive access and increase reproductive autonomy. Self-administered DMPA-SC should be offered in a noncoercive manner through a shared decision-making process between patients and their health care providers, with a focus on patient preferences and equitable access to the full range of contraceptive methods.

Need for Contraceptive Services Among Women of Reproductive Age - 45 Jurisdictions, United States, 2017-2019.

Ensuring access to contraceptive services is an important strategy for preventing unintended pregnancies, which account for nearly one half of all U.S. pregnancies (1) and are associated with adverse maternal and infant health outcomes (2). Equitable, person-centered contraceptive access is also important to ensure reproductive autonomy (3). Behavioral Risk Factor Surveillance System (BRFSS) data collected during 2017-2019 were used to estimate the proportion of women aged 18-49 years who were at risk for unintended pregnancy* and had ongoing or potential need for contraceptive services.† During 2017-2019, in the 45 jurisdictions§ from which data were collected, 76.2% of women aged 18-49 years were considered to be at risk for unintended pregnancy, ranging from 67.0% (Alaska) to 84.6% (Georgia); 60.7% of women had ongoing or potential need for contraceptive services, ranging from 45.3% (Puerto Rico) to 73.7% (New York). For all jurisdictions combined, the proportion of women who were at risk for unintended pregnancy and had ongoing or potential need for contraceptive services varied significantly by age group, race/ethnicity, and urban-rural status. Among women with ongoing or potential need for contraceptive services, 15.2% used a long-acting reversible method (intrauterine device or contraceptive implant), 25.0% used a short-acting reversible method (injectable, pill, transdermal patch, or vaginal ring), and 29.5% used a barrier or other reversible method (diaphragm, condom, withdrawal, cervical cap, sponge, spermicide, fertility-awareness-based method, or emergency contraception). In addition, 30.3% of women with ongoing or potential need were not using any method of contraception. Data in this report can be used to help guide jurisdictional planning to deliver contraceptive services, reduce unintended pregnancies, ensure that the contraceptive needs of women and their partners are met, and evaluate efforts to increase access to contraception.

COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians.

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis.

OBJECTIVES: To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019. STUDY ELIGIBILITY CRITERIA: We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion. STUDY APPRAISAL AND SYNTHESIS METHODS: We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression. RESULTS: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65). CONCLUSION: Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.

Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Updated Recommendations for the Use of Contraception Among Women at High Risk for HIV Infection.

"U.S. Medical Eligibility Criteria for Contraceptive Use" (U.S. MEC) 2016 provides evidence-based guidance for the safe use of contraceptive methods among U.S. women with certain characteristics or medical conditions (1). The U.S. MEC is adapted from global guidance from the World Health Organization (WHO) and kept up to date through continual review of published literature (1). CDC recently evaluated the evidence and the updated WHO guidance on the risk for human immunodeficiency virus (HIV) acquisition among women using hormonal contraception and intrauterine devices (IUDs) (2). After careful review, CDC adopted WHO's 2019 updated guidance for inclusion in the U.S. MEC guidance; CDC's updated guidance states that progestin-only injectable contraception (including depot medroxyprogesterone acetate [DMPA]) and IUDs (including levonorgestrel-releasing and copper-bearing) are safe for use without restriction among women at high risk for HIV infection (U.S. MEC category 1 [previously U.S. MEC category 2, advantages outweigh risks]) (Box). CDC's guidance also adds an accompanying clarification for women who wish to use IUDs, which states "Many women at a high risk for HIV infection are also at risk for other sexually transmitted diseases (STDs). For these women, refer to the recommendations in the 'U.S. Medical Eligibility Criteria for Contraceptive Use' for women with other factors related to STDs, and the 'U.S. Selected Practice Recommendations for Contraceptive Use' on STD screening before IUD insertion" (1,3). Recommendations for other hormonal contraceptive methods (including combined hormonal methods, implants, and progestin-only pills) remain the same; there is also no restriction for their use among women at high risk for HIV infection (U.S. MEC category 1). Finally, CDC clarified that the U.S. MEC recommendations for concurrent use of hormonal contraceptives or IUDs and antiretroviral use for treatment of HIV infection also apply to use of antiretrovirals for prevention of HIV acquisition (preexposure prophylaxis [PrEP]).

Factors associated with postpartum use of long-acting reversible contraception.

BACKGROUND: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low. OBJECTIVES: We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception. STUDY DESIGN: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception). RESULTS: The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level. CONCLUSION: Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.

Dissemination and use of WHO family planning guidance and tools: a qualitative assessment.

BACKGROUND: As countries continue to improve their family planning (FP) programmes, they may draw on WHO's evidence-based FP guidance and tools (i.e. materials) that support the provision of quality FP services. METHODS: To better understand the use and perceived impact of the materials and ways to strengthen their use by countries, we conducted qualitative interviews with WHO regional advisors, and with stakeholders in Ethiopia and Senegal who use WHO materials. RESULTS: WHO uses a multi-faceted strategy to directly and indirectly disseminate materials to country-level decision-makers. The materials are used to develop national family planning guidelines, protocols and training curricula. Participants reported that they trust the WHO materials because they are evidence based, and that they adapt materials to the country context (e.g. remove content on methods not available in the country). The main barrier to the use of national materials is resource constraints. CONCLUSIONS: Although the system and processes for dissemination work, improvements might contribute to increased use of the materials. For example, providers may benefit from additional guidance on how to counsel women with characteristics or medical conditions where contraceptive method eligibility criteria do not clearly rule in or rule out a method.

U.S. Selected Practice Recommendations for Contraceptive Use, 2016.

The 2016 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a select group of common, yet sometimes controversial or complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26-28, 2015. The information in this report updates the 2013 U.S. SPR (CDC. U.S. selected practice recommendations for contraceptive use, 2013. MMWR 2013;62[No. RR-5]). Major updates include 1) revised recommendations for starting regular contraception after the use of emergency contraceptive pills and 2) new recommendations for the use of medications to ease insertion of intrauterine devices. The recommendations in this report are intended to serve as a source of clinical guidance for health care providers and provide evidence-based guidance to reduce medical barriers to contraception access and use. Health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26-28, 2015. The information in this report updates the 2010 U.S. MEC (CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010:59 [No. RR-4]). Notable updates include the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs or St. John's wort; revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate; and revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases, and human immunodeficiency virus; and women who are receiving antiretroviral therapy. The recommendations in this report are intended to assist health care providers when they counsel women, men, and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance, health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.

Contraception for women with multiple sclerosis: Guidance for healthcare providers.

Family planning is essential for any comprehensive treatment plan for women of reproductive age with multiple sclerosis (MS), including counseling on using effective contraception to optimally time desired and prevent unintended pregnancies. This topical review summarizes the first evidence-based recommendations on contraception safety for women with MS. In 2016, evidence-based recommendations for contraceptive use by women with MS were included in US Medical Eligibility Criteria for Contraceptive Use. They were developed after review of published scientific evidence on contraception safety and consultation with experts. We summarize and expand on the main conclusions of the Centers for Disease Control and Prevention guidance. Most contraceptive methods appear based on current evidence to be safe for women with MS. The only restriction is use of combined hormonal contraceptives among women with MS with prolonged immobility because of concerns about possible venous thromboembolism. Disease-modifying therapies (DMTs) do not appear to decrease the effectiveness of hormonal contraception although formal drug-drug interaction studies are limited. Neurologists can help women with MS make contraceptive choices that factor their level of disability, immobility, and medication use. For women with MS taking potentially teratogenic medications, highly effective methods that are long-acting (e.g. intrauterine devices, implants) might be the best option.

Trends in contraceptive use according to HIV status among privately insured women in the United States.

BACKGROUND: There is limited information on the patterns and trends of contraceptive use among women living with HIV, compared with noninfected women in the United States. Further, little is known about whether antiretroviral therapy correlates with contraceptive use. Such information is needed to help identify potential gaps in care and to enhance unintended pregnancy prevention efforts. OBJECTIVE: We sought to compare contraceptive method use among HIV-infected and noninfected privately insured women in the United States, and to evaluate the association between antiretroviral therapy use and contraceptive method use. STUDY DESIGN: We used a large US nationwide health care claims database to identify girls and women ages 15-44 years with prescription drug coverage. We used diagnosis, procedure, and National Drug Codes to assess female sterilization and reversible prescription contraception use in 2008 and 2014 among women continuously enrolled in the database during 2003 through 2008 or 2009 through 2014, respectively. Women with no codes were classified as using no method; these may have included women using nonprescription methods, such as condoms. We calculated prevalence of contraceptive use by HIV infection status, and by use of antiretroviral therapy among those with HIV. We used multivariable polytomous logistic regression to calculate unadjusted and adjusted odds ratios and 95% confidence intervals for female sterilization, long-acting reversible contraception, and short-acting hormonal contraception compared to no method. RESULTS: While contraceptive use increased among HIV-infected and noninfected women from 2008 through 2014, in both years, a lower proportion of HIV-infected women used prescription contraceptive methods (2008: 17.5%; 2014: 28.9%, compared with noninfected women (2008: 28.8%; 2014: 39.8%, P < .001 for both). Controlling for demographics, chronic medical conditions, pregnancy history, and cohort year, HIV-infected women compared to HIV-noninfected women had lower odds of using long-acting reversible contraception (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86 compared to no method) or short-acting hormonal contraception method (adjusted odds ratio, 0.59; 95% confidence interval, 0.50-0.70 compared to no method). In 2014, HIV-infected women using antiretroviral therapy were significantly more likely to use no method (76.8% vs 64.1%), and significantly less likely to use short-acting hormonal contraception (11.0% vs 22.7%) compared to HIV-infected women not using antiretroviral therapy. Those receiving antiretroviral therapy had lower odds of using short-acting hormonal contraception compared to no method (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63). There was no significant difference in female sterilization by HIV status or antiretroviral therapy use. CONCLUSION: Despite the safety of reversible contraceptives for women with HIV, use of prescription contraception continues to be lower among privately insured HIV-infected women compared to noninfected women, particularly among those receiving antiretroviral therapy.

Use of combined hormonal contraceptives among women with migraines and risk of ischemic stroke.

BACKGROUND: Migraine with aura and combined hormonal contraceptives are independently associated with an increased risk of ischemic stroke. However, little is known about whether there are any joint effects of migraine and hormonal contraceptives on risk of stroke. OBJECTIVE: We sought to estimate the incidence of stroke in women of reproductive age and examine the association among combined hormonal contraceptive use, migraine type (with or without aura), and ischemic stroke. STUDY DESIGN: This study used a nationwide health care claims database and employed a nested case-control study design. Females ages 15-49 years with first-ever stroke during 2006 through 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification inpatient services diagnosis codes. Four controls were matched to each case based on age. Migraine headache with and without aura was identified using inpatient or outpatient diagnosis codes. Current combined hormonal contraceptive use was identified using the National Drug Code from the pharmacy database. Conditional logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals of ischemic stroke by migraine type and combined hormonal contraceptive use. RESULTS: From 2006 through 2012, there were 25,887 ischemic strokes among females ages 15-49 years, for a cumulative incidence of 11 strokes/100,000 females. Compared to those with neither migraine nor combined hormonal contraceptive use, the odds ratio of ischemic stroke was highest among those with migraine with aura using combined hormonal contraceptives (odds ratio, 6.1; 95% confidence interval, 3.1-12.1); odds ratios were also elevated for migraine with aura without combined hormonal contraceptive use (odds ratio, 2.7; 95% confidence interval, 1.9-3.7), migraine without aura and combined hormonal contraceptive use (odds ratio, 1.8; 95% confidence interval, 1.1-2.9), and migraine without aura without combined hormonal contraceptive use (odds ratio, 2.2; 95% confidence interval, 1.9-2.7). CONCLUSION: The joint effect of combined hormonal contraceptives and migraine with aura was associated with a 6-fold increased risk of ischemic stroke compared with neither risk factor. Use of combined hormonal contraceptives did not substantially further increase risk of ischemic stroke among women with migraine without aura. Determining migraine type is critical in assessing safety of combined hormonal contraceptives among women with migraine.

Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection.

CDC's U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) (first published in 2010 and updated in 2016) provides evidence-based guidance for the safe use of contraceptive methods among U.S. women with certain characteristics or medical conditions (1), and is adapted from global guidance from the World Health Organization (WHO) and kept up to date based on continual review of published literature (2).* CDC recently evaluated the evidence and the updated WHO guidance on the risk for human immunodeficiency virus (HIV) acquisition among women using hormonal contraception.† After careful review, CDC adopted the updated WHO guidance for inclusion in the U.S. MEC guidance; this guidance states that the advantages of progestin-only injectable contraceptive use (including depot medroxyprogesterone acetate [DMPA]) by women at high risk for HIV infection outweigh the theoretical or proven risks (U.S. MEC category 2). The guidance also includes an accompanying updated clarification, which states that "there continues to be evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. Uncertainty exists about whether this is due to methodological issues with the evidence or a real biological effect. In many settings, unintended pregnancies and/or pregnancy-related morbidity and mortality are common, and progestin-only injectables are among the few types of methods widely available. Women should not be denied the use of progestin-only injectables because of concerns about the possible increased risk. Women considering progestin-only injectables should be advised about these concerns, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV." Recommendations for other hormonal contraceptive methods (including combined hormonal methods, implants, and progestin-only pills) remain the same; there is no restriction for their use among women at high risk for HIV infection (U.S. MEC category 1).

Identifying psychosocial and social correlates of sexually transmitted diseases among black female teenagers.

BACKGROUND: Black teenagers have relatively high rates of sexually transmitted diseases (STDs), and recent research suggests the role of contextual factors, as well as risk behaviors. We explore the role of 4 categories of risk and protective factors on having a biologically confirmed STD among black, female teenagers. METHODS: Black teenage girls (14-19 years old) accessing services at a publicly funded family planning clinic provided a urine specimen for STD testing and completed an audio computer-assisted self-interview that assessed the following: risk behaviors, relationship characteristics, social factors, and psychosocial factors. We examined bivariate associations between each risk and protective factor and having gonorrhea and/or chlamydia, as well as multivariate logistic regression among 339 black female teenagers. RESULTS: More than one-fourth (26.5%) of participants had either gonorrhea and/or chlamydia. In multivariate analyses, having initiated sex before age 15 (adjusted odds ratio [aOR], 1.87) and having concurrent sex partners in the past 6 months (aOR, 1.55) were positively associated with having an STD. Living with her father (aOR, 0.44), believing that an STD is the worst thing that could happen (aOR, 0.50), and believing she would feel dirty and embarrassed about an STD (aOR, 0.44) were negatively associated with having an STD. CONCLUSIONS: Social factors and attitudes toward STDs and select risk behaviors were associated with the risk for STDs, suggesting the need for interventions that address more distal factors. Future studies should investigate how such factors influence safer sexual behaviors and the risk for STDs among black female teenagers.

Sporadic contraceptive use and nonuse: age-specific prevalence and associated factors.

OBJECTIVE: The purpose of this study was to characterize age-group specific patterns in the stability of contraceptive use and to evaluate whether factors that are associated with nonuse and sporadic use, compared with stable use, differ by age among women who are at risk for unintended pregnancy. STUDY DESIGN: We used data from the 2006-2010 National Survey of Family Growth to characterize the prevalence of stable and sporadic contraceptive use and nonuse by age over a 1-year period. We used polytomous logistic regression models to assess the odds of contraceptive nonuse and sporadic use vs stable use. Age-stratified models were used to show age-group differences in associated characteristics. RESULTS: Over a 1-year period, stable contraceptive use decreased across age groups from 80% for teens 15-19 years old to 74% for women 20-24 years old, and 70-71% for women 25-34 and 35-44 years old. Contraceptive nonuse increased across age groups from 5% for teens 15-19 years old to 9-20% for older women. By contrast, sporadic use was least common for women 35-44 years old (10% compared with 16-17% for younger women). Among teens 15-19 years old, a history of method discontinuation because of dissatisfaction was associated with nonuse. Among older women, intentions to have children in the future and reported difficulty achieving pregnancy were associated with nonuse and sporadic use. CONCLUSION: Because the stability of contraceptive use and associated factors differ by age, providers may need to consider these differences when talking to women about contraception. To address nonuse, helping teens identify a method that they are comfortable using may be especially important; for older women, discussing the potential for continuing fertility may be more important. To address sporadic use, discussing the benefits of user-independent methods may be helpful, with a particular emphasis on long-acting reversible contraceptives for younger women and teens who are less likely to have completed their desired childbearing and who have tended to rely on methods that are more difficult to use consistently.

Contraceptive counseling and postpartum contraceptive use.

OBJECTIVE: The objective of the study was to examine the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use. STUDY DESIGN: The Pregnancy Risk Assessment Monitoring System 2004-2008 data were analyzed from Missouri, New York state, and New York City (n = 9536). We used multivariable logistic regression to assess the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use, defined as any method and more effective methods (sterilization, intrauterine device, or hormonal methods). RESULTS: The majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both. Compared with those who received no counseling, those counseled during 1 time period (adjusted odds ratio [AOR], 2.10; 95% confidence interval [CI], 1.65-2.67) and both time periods (AOR, 2.33; 95% CI, 1.87-2.89) had significantly increased odds of postpartum use of a more effective contraceptive method (32% vs 49% and 56%, respectively; P for trend < .0001). Results for counseling during both time periods differed by type of health insurance before pregnancy, with greater odds of postpartum use of a more effective method observed for women with no insurance (AOR, 3.51; 95% CI, 2.18-5.66) and Medicaid insurance (AOR, 3.74; 95% CI, 1.98-7.06) than for those with private insurance (AOR, 1.87; 95% CI, 1.44-2.43) before pregnancy. Findings were similar for postpartum use of any contraceptive method, except that no differences by insurance status were detected. CONCLUSION: The prevalence of postpartum contraceptive use, including the use of more effective methods, was highest when contraceptive counseling was provided during both prenatal and postpartum time periods. Women with Medicaid or no health insurance before pregnancy benefited the most.

Sexually transmitted disease partner notification among African-American, adolescent women.

OBJECTIVE: To better understand preferences and practices regarding partner notification of sexually transmitted infection (STI) among female, African-American adolescents. METHODS: Participants completed a questionnaire and STI testing at baseline. Those diagnosed with Chlamydia or gonorrhea were recruited for a follow-up study, involving another questionnaire and repeat STI testing after three months. RESULTS: At baseline, most participants (85.1%) preferred to tell their partner about an STI diagnosis themselves instead of having a health care provider inform him, and 71.0% preferred to bring their partner for clinic treatment instead of giving him pills or a prescription. Two-thirds of participants were classified as having high self-efficacy for partner notification of a positive STI diagnosis. In the multivariable analysis, older participants and those with fewer lifetime sexual partners were more likely to have high self-efficacy. Ninety-three participants (26.6%) had Chlamydia or gonorrhea and, of this subset, 55 participated in the follow-up study. Most adolescents in the follow-up study (76.4%) notified their partner about their infection. CONCLUSION: Although participants were willing to use most methods of partner notification, most preferred to tell partners themselves and few preferred expedited partner therapy. Traditional methods for partner notification and treatment may not be adequate for all adolescents in this population.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020.

OBJECTIVE: We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic. METHODS: We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth. RESULTS: Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020. CONCLUSIONS: Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.