Etonogestrel-releasing subdermal contraceptive implant: Budget impact analysis based on the Brazilian private healthcare system.

High rates of unplanned pregnancies persist despite pharmacological developments and advancements in contraceptive methods. Here, we demonstrate that the etonogestrel-releasing subdermal contraceptive implant (IMP-ETN) may be an appropriate and cost-effective alternative to levonorgestrel-releasing intrauterine systems (LNG-IUSs) for women in Brazil. For our pharmacoeconomic analysis, we reviewed the literature on IMP-ETN regarding its acceptance, eligibility criteria, choice, relations with age, adverse events and, finally, the unmet need in the fee-for-service private healthcare sector. We considered qualitative observations in combination with quantitative analysis and performed a deterministic sensitivity analysis to investigate whether this technology can be self-sustainable over a period of five years. The target population for this analysis comprised 158,696 women. Compared with the continued use of LNG-IUSs, adopting the IMP-ETN can result in a cost avoidance of $ 7.640.804,02 in the first year and $ 82,455,254.43 in five years. Disseminating information among physicians will promote this change and strengthen the potential cost avoided by private health system payers. These savings can be used to improve other healthcare programs and strategies. Moreover, the principles of care can be promoted by improving and adapting healthcare systems and expanding treatment and follow-up strategies. This would also provide support to women's reproductive rights and improve their quality of life. Our results suggest that the IMP-ETN has a favorable cost-effectiveness profile. Given all its advantages and negative incremental cost impact over a period of five years, the IMP-ETN may be a more favorable alternative to LNG-IUSs. Therefore, it should be offered to beneficiaries with a private healthcare plan. This analysis overcomes previous barriers to the use of cost-benefit models, and our results may help balance decision-making by policymakers, technical consultants, and researchers.

Pregnancy and pregnancy outcomes in a prospective cohort study: Final results from the Nexplanon Observational Risk Assessment Study (NORA).

OBJECTIVES: To monitor pregnancy occurrence and outcomes among Nexplanon users in the United States during standard clinical practice. STUDY DESIGN: The Nexplanon Observational Risk Assessment (NORA) study was a large prospective cohort study conducted in the United States (US). Study participants with a newly inserted Nexplanon implant were recruited by health care professionals (HCPs) who had completed the Nexplanon clinical training. Via a survey, study participants were followed up at 6-month intervals for 36 months and 6 months after implant removal. Reported unintended pregnancies were validated and classified as noninsertion, preinsertion, during-use, or postremoval. RESULTS: Four hundred and twenty-eight HCPs in 47 states recruited 7364 Nexplanon users. Pregnancies included one noninsertion, eight preinsertion, three during-use, and 14 postremoval pregnancies; of these 26 pregnancies, 22 resulted in the birth of a healthy child, two resulted in an induced abortion, one resulted in a spontaneous abortion, and one resulted in an ectopic pregnancy. Six pregnancies occurred during-use (n = 3) or within 7 days following implant removal (n = 3), yielding a Pearl Index of 0.04 (95% CI, 0.02-0.09). CONCLUSIONS: Nexplanon is an effective contraceptive in real-world users; the Pearl Index was 0.02 (95% CI, 0.00-0.06) for during-use pregnancies, and 0.04 when including pregnancies that occurred within 7 days following implant removal. IMPLICATIONS: This large real-world-use study indicates that Nexplanon is as effective as shown in the preapproval clinical trials.

Does access to no-cost contraception change method selection among individuals who report difficulty paying for health-related care?

BACKGROUND: Out-of-pocket costs continue to be a barrier to accessing necessary healthcare services, including contraception. We explored how eliminating out-of-pocket cost affects contraceptive method choice among people reporting difficulty paying for healthcare in the previous year, and whether method satisfaction differed by method choice. METHODS: We used data from the HER Salt Lake Contraceptive Initiative. This prospective cohort study provided participants with no-cost contraception (April 2016-March 2017) following a control period that provided no reduction in cost for the contraceptive implant, a reduced price for the hormonal IUD, and a sliding scale that decreased to no-cost for the copper IUD (September 2015-March 2016). We restricted the study population to those who reported difficulty paying for healthcare in the past 12 months. For our primary outcome assessing changes in method selection between intervention and control periods, we ran simultaneous multivariable logistic regression models for each method, applying test corrections for multiple comparisons. Among participants who continued their method for 1 year, we explored differences in method satisfaction using multivariable logistic regression. RESULTS: Of the 1,029 participants reporting difficulty paying for healthcare and controlling for other factors, participants more frequently selected the implant (aOR 6.0, 95% CI 2.7, 13.2) and the hormonal IUD (aOR 3.2, 95% CI 1.7, 5.9) during the intervention than control period. Comparing the same periods, participants less frequently chose the injection (aOR 0.5, 95% CI 0.3, 0.8) and the pill (aOR 0.4, 95% CI 0.3, 0.6). We did not observe a difference in uptake of the copper IUD (aOR 2.0, 95% CI 1.0, 4.1).Contraceptive satisfaction scores differed minimally by contraceptive method used among contraceptive continuers (n = 534). Those who selected LNG IUDs were less likely to report low satisfaction with their method (aOR 0.5, 95% CI 0.3, 0.97). CONCLUSION: With costs removed, participants who reported difficulty paying for healthcare were more likely to select hormonal IUDs and implants and less likely to select the injectable or contraceptive pills. Among continuers, there were few differences in method satisfaction. CLINICALTRIALS: gov Identifier NCT02734199.

Use of Immediate Postpartum Long-Acting Reversible Contraception Before and After a State Policy Mandated Inpatient Access.

OBJECTIVE: To assess the rate of immediate postpartum long-acting reversible contraceptive (LARC) use in a multihospital health care system 2 years before and after the policy was implemented, and to assess factors associated with LARC use and repeat pregnancy rates within 12 months after delivery. METHODS: We conducted a retrospective chart review of all patients giving birth at three Cleveland Clinic Ohio hospitals from July 1, 2015, to June 30, 2019. We reviewed the inpatient medication reconciliation to identify the LARC initiation rate. We compared all patients who received inpatient postpartum LARC to a 1:3 matched sample of patients who did not receive LARC, matched by delivery date and location, to identify patient characteristics associated with LARC use. The electronic medical record (Epic) was reviewed to identify new pregnancies occurring within 12 months postdelivery. RESULTS: We identified 17,848 deliveries prepolicy and 18,555 deliveries postpolicy. Immediate postpartum LARC was used by 0.5% (monthly range 0-2.1%) of patients prepolicy and 11.6% (monthly range 8.3-15.4%) of patients postpolicy. Levonorgestrel intrauterine devices (IUDs) were used by 56.5%, implants by 29.1%, and copper IUDs by 14.5% of LARC users. Characteristics associated with LARC use included younger age, public insurance, non-White race, Hispanic or Latina ethnicity, higher body mass index, sexually transmitted infection in pregnancy, and tobacco use. Long-acting reversible contraceptive users had a lower rate of repeat pregnancy at 12 months postpartum compared with the non-LARC group (1.9% vs 3.6%, P<.001). CONCLUSION: Immediate postpartum LARC use increased after a state policy change mandated universal access and was associated with decreased pregnancy rates in the first year postdelivery.

Unmet contraceptive needs among female sex workers (FSWs) in semi urban Blantyre, Malawi.

BACKGROUND: Research has paid limited attention to understanding factors that are associated with unmet contraceptive needs among female sex workers. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined associated factors among FSWs in semi urban Blantyre, Malawi. METHODS: We used systematic sampling to recruit 290 female sex workers in semi urban Blantyre between February and March 2019. In this cross sectional study, we used questionnaire interviews to collect quantitative data. We calculated the mean and standard deviation for continuous variables and proportions for categorical variables to describe the data. Logistic regression analysis was used to investigate the association between unmet needs (the outcome variable) and explanatory variables such as: having a steady partner, fear of contraceptives' side effects and having a history of sexually transmitted infections. RESULTS: Out of the 290 study participants 102 (35.2%) reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: female sex workers' history of physical and sexual violence by clients [OR 3.38, 95% CI (1.10, 10.43)], p < 0.03, participants with a steady partner [OR 3.28, 95% CI (1.89, 5.68)], p < 0.001, and participants who feared side effects of contraceptives [OR 2.99, 95% CI (1.73, 5.20)], p < 0.001. CONCLUSION: Reproductive Health services should address barriers to contraceptives use for instance: violence by female sex workers' clients, fear and misinformation on contraceptives. There is need to improve awareness of contraceptives. Specific health promotion interventions on female sex workers engaged in a steady partnership are recommended. It is important to enhance the knowledge, attitudes, and counseling skills of health care providers in order to address unmet contraceptive needs among female sex workers in semi-urban Blantyre. Unmet contraceptive needs are defined as lack of contraceptives use in heterosexually active women of childbearing age who do not wish to become pregnant. Unmet contraceptive needs are the main cause of short inter-pregnancy intervals, early childbearing, physical abuse, unintended pregnancy, poor maternal and child health outcomes. Several studies have documented low contraceptives use among female sex workers (FSWs), but research has paid limited attention to understanding factors associated with unmet contraceptive needs among this population in semi urban Blantyre Malawi. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined factors that were associated with unmet contraceptive needs among FSWs in semi urban Blantyre, Malawi. We recruited 290 FSWs and collected quantitative data. These data were analyzed to obtain descriptive statistics. Logistic regression analysis was used to investigate the association between unmet contraceptive needs (the outcome variable) and explanatory variables such as: FSWs with history of physical and sexual violence by clients, having a steady partner, fear of contraceptives' side effects and having a history of sexually transmitted infections. Out of the 290 FSWs, 35% reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: FSWs' history of physical and sexual violence by clients, participants with a steady partner and participants who feared contraceptive side effects. Sexual and Reproductive Health services should address barriers to contraceptives use, female sex workers exposure to violence, having a steady partners and concerns about side effects. There is also a need to improve the knowledge, attitudes, and counseling skills of health providers in order to address unmet contraceptive needs among FSWs.

Impact of perceived contraceptive policy changes on long acting reversible contraception dispensing trends.

OBJECTIVE: We observed the long-term trend of Long Acting Reversible Contraception (LARC) usage before and after the 2016 presidential election. METHODS: We observed the rate of LARC dispensed at a university student health centre in the 18 months preceding and 27 months following the 2016 U.S. presidential election which posed threat to contraception access. We applied a segmented regression model using two linear regression line segments to evaluate whether there is a time point where the trend of LARC dispensing changed. We fit the regression models with a breakpoint at month 0 (election month) and 3 months with a Locally Estimated Scatterplot Smoothing (LOESS) estimate with parameters obtained by estimating simple linear regression models separately below and above the breakpoint '0'. RESULTS: There were a total of 2067 LARC methods dispensed from May 2015 to February 2019. The average number of LARC methods dispensed before November 2016 was 38/month and increased to 51/month post-presidential election. The LARC dispense rate significantly increased each month (0.38, 1.74; 95% confidence level, p < 0.05) until a breakpoint at 6 months (standard error 4.11) post-election followed by slower decrease (-0.59/month, 95% confidence level: -1.37, 0.20; p=not significant). CONCLUSION: Our study is the first to report long-term trends (27 months post-election) in LARC uptake amidst the public discourse that suggested the end of a policy that provided LARC insurance coverage. Although this observational study cannot suggest causality, the findings could reflect actions taken to prevent unintended pregnancy in response to the event of uncertain national policy.

Quality of Family Planning Counseling in Ethiopia: Trends and determinants of information received by female modern contraceptive users, evidence from national survey data, (2014- 2018).

BACKGROUND: Family planning counseling is critical for women to make informed reproductive and sexual health decisions. Despite Ethiopia's success in expanding access to family planning services, information on the quality of family planning counseling is limited. The objectives of this study were to assess whether the quality of counseling from the female client´s perspective has changed over time (2014 to 2018) and to investigate determinants associated with the quality of counseling to provide a more nuanced understanding of disparities in sexual and reproductive health outcomes in Ethiopia. METHODS: Data were obtained from five rounds of the Ethiopian Performance Monitoring and Accountability 2020 female survey questionnaire. Quality of counseling was categorized into four levels based on the responses of the questions that compose the Method Information Index, a core Family Planning 2020 indicator that serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The proportion of female contraceptive users that received good counseling were examined over time by each region, demographic characteristics, and contraception method type and source. Ordinal logistic regression was applied to the last survey round (2018) to investigate determinants associated with counseling quality. RESULTS: The proportion of female contraception users that reported receiving information on all three questions did not significantly change over the period 2014 to 2018. Overall quality of counseling on family planning was low, with only 30% of women reporting receiving sufficient information during counseling. The likelihood of good quality counseling was the least among those who had no formal schooling when compared to those who had higher educational attainment (OR = 0.70, 95% CI: 0.50, 0.97). Women from the wealthiest quintile were 1.72 times more likely (95% CI: 1.10, 2.69) to receive good quality counseling when compared to women in the lower wealth quintile. Women from rural areas were 1.51 times more likely to have received good counseling when compared to those in urban areas (95% CI: 1.04, 2.18). Amhara residents were less likely to receive good counseling when compared to the SNNPR (OR: 0.51, 95% CI: 0.32, 0.81). Women who acquired their method from the private sector had worse counseling (OR: 0.31, 95% CI: 0.23, 0.41) when compared to the public sector. Those using short-acting methods were more at risk of receiving lesser quality counseling when compared to users of long-acting methods (OR: 0.58, 95% CI: 0.46, 0.72). CONCLUSION: The results of this analysis indicated that Ethiopia's overall progress in modern contraceptive use has not been accompanied by a corresponding increase in the quality of family planning counseling. Improving the quality of contraception counseling for women across all demographics, including wealth quintiles and education, is a crucial strategy to support positive reproductive health outcomes with a rights-based focus. Based on the findings of this study, it is essential to emphasize the need to do proper counseling for all methods including short-acting methods especially for those working the private sector and some of the regions which have lower prevalence of good counseling. Further community-based participatory and qualitative research should focus on understanding the root causes and barriers to the delivery of high-quality counseling in Ethiopia.

Use of prescribed contraception in Northern Ireland 2010-2016.

Objective: The aim of this study was to describe the use of prescribed contraceptives in Northern Ireland (NI) and how this varies with a woman's age, the deprivation in the area in which she lives and characteristics of her general practice (GP).Method: A population-based cohort study was conducted including 560,074 females, aged 12-49 registered with a GP (2010-2016) contributing 3,255,500 woman-years of follow-up. Dispensed contraceptive prescriptions were linked to demographic details.Results: A contraceptive prescription was dispensed in 26.2% of woman-years with women aged 20-24 most likely to have a contraceptive dispensed (45.7% of woman-years). After adjusting for patient and other practice characteristics, practices in the least deprived quintile prescribed 6% more contraception than those in the most deprived quintile. The combined oral contraceptives (16.6% of woman-years) and progesterone only pill (8.0% of woman-years) were the most commonly dispensed methods. Patient and practice level characteristics were found to be related to the specific contraceptive methods dispensed which also changed during the time frame of the study.Conclusions: This is the first population-based assessment of contraceptive prescription in NI. It is useful for health service planning and to inform broader reproductive policy debates. The impact of practice area-based deprivation, above that of the woman's residence, on contraceptive dispensing is a new finding that deserves more exploration.

Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception.

Background: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods (p = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.

Breaking down barriers to birth control access: An assessment of online platforms prescribing birth control in the USA.

INTRODUCTION: In the USA, the requirement that individuals obtain a prescription for hormonal contraception is a significant barrier for women who lack the time, finances, insurance coverage or means of transportation to visit a provider. The emergence of telemedicine services has removed some of these barriers by providing women with the opportunity to conveniently obtain birth control prescriptions through their computer or smartphone. METHODS: In this article, we compare the prescribing processes and policies of online platforms that prescribe hormonal contraceptives to women in the USA, and use the recommendations of the 2016 US medical eligibility criteria for contraceptive use to evaluate whether online prescribers are providing evidence-based care. RESULTS: As of February 2018, nine online platforms prescribed hormonal birth control to women across various states in the USA. These platforms varied in regard to their prescribing processes, range of methods offered, locations of operation, fees for services, and policies regarding age restrictions. DISCUSSION: An assessment of each platform's online health questionnaire reveals that these telemedicine services are adequately screening for contraindications and safely providing birth control methods to patients, although efforts could be made to strengthen the rigour of online health questionnaires to ensure they adequately screen for all contraindications.

Reproductive Life Planning and Contraceptive Action Planning for Privately Insured Women: The MyNewOptions Study.

CONTEXT: Although reproductive life planning (RLP) is recommended in federal and clinical guidelines and may help insured women make personalized contraceptive choices, it has not been systematically evaluated for effectiveness. METHODS: In 2014, some 984 privately insured women aged 18-40 who were not intending to become pregnant in the next year were randomly assigned to receive RLP, RLP with contraceptive action planning (RLP+) or information only (the control group). Women's contraceptive use, prescription contraceptive use, method adherence, switching to a more effective method, method satisfaction and contraceptive self-efficacy were assessed at six-month intervals during the two-year follow-up period. Differences between groups were identified using binomial logistic regression, linear regression and generalized estimating equation models. RESULTS: During the follow-up period, the proportion of women using any contraceptive method increased from 89% to 96%, and the proportion using a long-acting reversible contraceptive or sterilization increased from 8% to 19%. Contraceptive adherence was high (72-76%) in all three groups. In regression models, the sole significant finding was that women in the RLP+ group were more likely than those in the RLP group to use a prescription method (odds ratio, 1.3). No differences were evident between the intervention groups and the control group in overall contraceptive use, contraceptive adherence, switching to a more effective method, method satisfaction or contraceptive self-efficacy. CONCLUSIONS: The study does not provide evidence that web-based RLP influences contraceptive behaviors in insured women outside of the clinical setting. Further research is needed to identify strategies to help women of reproductive age identify contraceptive methods that meet their needs and preferences.

Provision of Contraception in New York City School-Based Health Centers: Impact on Teenage Pregnancy and Avoided Costs, 2008-2017.

CONTEXT: Since 2008, the School-Based Health Center Reproductive Health Project (SBHC RHP) has supported SBHCs in New York City (NYC) to increase the availability of effective contraception; however, its impact on teenage pregnancy and avoided costs has not been estimated. METHODS: The impact of the SBHC RHP on patterns of contraceptive use and on the numbers of pregnancies, abortions and births averted in 2008-2017 was estimated using program data and public data from the NYC Bureau of Vital Statistics and Youth Risk Behavior Survey. Data from the Guttmacher Institute on the cost of publicly funded births and abortions were used to estimate costs avoided; NYC-specific teenage pregnancy outcome data were employed to estimate the proportion of overall declines attributable to the SBHC RHP. RESULTS: Between 2008 and 2017, the SBHC RHP supported a substantial increase in the proportion of sexually active female clients using effective contraceptives. Most dramatically, 14% of clients in the SBHC RHP method mix used LARCs in 2017, compared with 2% in the non-SBHC RHP mix. The project averted an estimated 5,376 pregnancies, 2,104 births and 3,085 abortions, leading to an estimated $30,360,352 in avoided one-time costs of publicly funded births and abortions. These averted events accounted for 26-28% of the decline in teenage pregnancies, births and abortions in NYC. CONCLUSIONS: When comprehensive reproductive health services are available in SBHCs, teenagers use them, resulting in substantially fewer pregnancies, abortions and births, and lower costs to public health systems.

Prevalence of early discontinuation and associated factors among a retrospective cohort of etonogestrel contraceptive implant users.

Purpose: To characterise the frequency of and predictors of contraceptive implant discontinuation within 12 months of insertion in our clinical setting.Materials and methods: This retrospective cohort study included women receiving the etonogestrel contraceptive implant at our hospital between May 2007 and May 2012. We abstracted data from charts including implant removal date, bleeding complaints, reproductive and demographic characteristics, prior contraceptive use, tobacco use and implant insertion timing. Our primary outcome was implant discontinuation within 12 months following insertion. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used to generate frequencies, bivariate analyses and multivariate logistic regression models.Results: Implant discontinuation was documented in 16% of implant users prior to 12 months (89/544). Women with documented bleeding complaints in the medical record were more likely to discontinue within 12 months (OR: 4.36, CI: 2.71, 7.00). No other demographic or clinical characteristics were associated with premature discontinuation. Having less than two prior pregnancies and tobacco use were associated with documented bleeding complaints.Conclusions: Discontinuation of the implant is associated with bleeding complaints. Women with lower parity and tobacco users may be more likely to experience bleeding or to find it intolerable.

Modern Contraceptive Use and Associated Factors among Women with Disabilities in Gondar City, Amhara Region, North West Ethiopia: A Cross Sectional Study.

Attention to the sexual reproductive health needs of persons with disabilities is important to ensure the protection and promotion of their human rights, to move forward the international development agenda, and to build a truly inclusive society. The objective of this study was to assess modern contraceptive use and associated factors among women with disabilities in Gondar city, Ethiopia. A community-based cross- sectional study was employed, from 25 June to 05 August 2013. All 280 reproductive age women with disabilities who were found in the town during study period were included. Data were coded, entered and cleaned using EPI INFO statistical software version 3.5.2, and analysed by Software Statistical Packages for Social Sciences version 16. About 18% of participants had ever used modern contraceptive and the contraceptive prevalence rate among study participants and currently married women were 13.1% and 20.2% respectively. One fourth of respondents believed that existing family planning service delivery points were not accessible. The proportion of modern contraceptive use among participants was low. Age, marital status, education, income, and type of disability were significant predictors of modern contraceptive use. Therefore, social behavioural change communication interventions should be designed to improve the awareness of people living with disabilities on modern contraceptives based on the needs and type of disabilities.

Assessment of Contraceptive Counseling and Contraceptive Use in Women After Bariatric Surgery.

BACKGROUND: Reproductive-aged women are, according to American and European guidelines, recommended to avoid pregnancy for 12-24 months after bariatric surgery. Oral contraceptives may have suboptimal efficacy after malabsorptive bariatric procedures. AIM: The aim of this study was to assess contraceptive use pre- and postoperatively in women who underwent bariatric surgery in two obesity clinics in The Netherlands. Also, the recall of contraceptive and pregnancy counseling was investigated. METHODS: A validated questionnaire was performed among women aged 18-45 years who underwent bariatric surgery from October 2017 through August 2018. RESULTS: In total, 230 women were eligible for final analysis. Postoperatively, 60% used safe contraception, 16.1% unsafe contraception, and 23.9% no contraception. In this study, 43.7% of women using a potential unsafe contraceptive method preoperatively switched to a safe method of contraception postoperatively (p < 0.0001). Only 62.6% of women confirmed to have received contraceptive counseling, mainly preoperatively. The odds ratio for receiving contraceptive counseling and using safe contraceptive methods compared with not receiving contraceptive counseling was 2.20 (95% CI, 1.27-3.79; p = 0.005). Eighty-three percent confirmed that they have received counseling regarding delaying a pregnancy, and 52.6% were familiar with the recommendation to avoid a pregnancy for 24 months postoperatively. CONCLUSIONS: In our study, 60% of women are using safe contraception postoperatively. Contraceptive counseling is suboptimal as 62.6% recall receiving counseling. Those who confirmed receiving counseling were more likely to use safe contraception after bariatric surgery. More counseling and monitoring in the postoperative and in the outpatient setting is recommended.

Two year continuation rates of contraceptive methods in France: a cohort study from the French national health insurance database.

OBJECTIVE: The aim of this study was to evaluate the continuation rates of reimbursed contraceptive methods in French real-world conditions. METHODS: A retrospective cohort study using a representative sample of the national health insurance database, the General Sample of Beneficiaries (Echantillon Généralistes des Bénéficiaires [EGB]), was performed between 2006 and 2012. Selected women were ≥15 years of age and had started a reimbursed contraceptive method between 2009 and 2012 without prior reimbursement for an implant or an intrauterine contraceptive method between 2006 and 2008. The outcome of interest was the continuation rates, defined as the probability of women initiating a contraceptive method and continuing to use the same method over time. Continuation rates were assessed for up to 2 years. Only the first contraceptive method used during the study period was considered in the analysis. Non-parametric Kaplan-Meier survival analysis was used to assess continuation rates. RESULTS: A population of 42,365 women representative of the 4,109,405 French women initiating any reimbursed method between 2009 and 2012 was identified in the EGB: 74.5% of women used oral contraceptives, 12.8% the levonorgestrel-releasing intrauterine system (LNG-IUS), 9.2% the copper intrauterine device (Cu-IUD) and 3.5% the subdermal etonogestrel (ENG) implant. The 2 year continuation rates varied from 9.1% for progestin-only oral contraceptives, 27.6% for first to second generation combined oral contraceptives (COCs) and 33.4% for third generation COCs to 83.6% for the ENG implant, 88.1% for the Cu-IUD and 91.1% for the LNG-IUS. CONCLUSION: This study conducted in real-world conditions showed that long-acting reversible contraceptive (LARC) methods remain rarely used in France despite high continuation rates over 2 years. Increasing the use of LARC methods is therefore a public health priority.

Expanding adolescent access to hormonal contraception: an update on over-the-counter, pharmacist prescribing, and web-based telehealth approaches.

PURPOSE OF REVIEW: Hormonal contraceptives are largely responsible for recent declines in unintended adolescent pregnancies, with oral contraceptives being the most commonly used. Young people face multiple barriers to accessing effective contraception in clinical settings. This article reviews innovations in contraceptive access. RECENT FINDINGS: The three biggest innovations are over-the-counter oral contraceptives (OTC-OCs), pharmacist-prescribing, and web-based telehealth platforms. In many countries, oral contraceptives are available OTC, and FDA trials for OTC-OCs are underway in the United States. Many states have passed legislation allowing pharmacists to prescribe contraceptives after a brief health screening. Web-based telehealth platforms also provide prescription contraceptive access. There is a small but growing body of literature that demonstrates young people's interest in, and capacity to consent to, hormonal contraceptives in nontraditional settings. State-to-state variability in minor consent, pharmacist prescribing, and telehealth laws act as barriers to young people's access to these newer options. SUMMARY: Access to hormonal contraception is expanding outside of clinical settings, reducing barriers. Adolescents' unique needs should be considered in the design, implementation, and evaluation of these new approaches. More data is needed to ensure that adolescents are not excluded from expanded contraceptive access options, as they are disproportionately affected by unintended pregnancy.

Experiences with the levonorgestrel-releasing intrauterine system in Kenya: qualitative interviews with users and their partners.

OBJECTIVES: The levonorgestrel-releasing intrauterine system (LNG-IUS) is an underused contraceptive method in sub-Saharan Africa. A recent market assessment in Kenya found that if a more affordable version of the method were available it may increase demand and uptake of the method. We therefore aimed to examine attitudes and perceptions around the LNG-IUS and experiences of method use, including exploring attributes such as bleeding changes, contraceptive-related amenorrhoea and perceived non-contraceptive benefits. METHODS: Qualitative interviews were conducted among 29 women who were current or recent users of the LNG-IUS, and among a subset (n = 9) of their husbands/partners. RESULTS: Our findings indicate that women's main reason for choosing the LNG-IUS for contraception was their perception that the method had fewer side effects compared with other contraceptive methods. Women had favourable attitudes towards using the LNG-IUS. Husbands were also very positive about their partner's use of the method. CONCLUSION: Understanding the motivations and experiences of early adopters of the LNG-IUS can help inform the development of demand creation and communication strategies to influence uptake and continuation of the LNG-IUS both in Kenya and perhaps more broadly. Communication efforts that emphasise the positive attributes of the LNG-IUS could help promote wider use of the method, especially if new, more affordable product(s) become available.

The Impact of Insurance Coverage on Utilization of Prescription Contraceptives: Evidence from the Affordable Care Act.

The Affordable Care Act (ACA) mandates that prescription contraceptives be covered by private health insurance plans with no cost sharing. Using medical and prescription claims from a large national insurer, I estimate individual claim rates and out-of-pocket (OOP) costs of prescription contraceptives for 329,642 women aged 13 to 45 who were enrolled in private health insurance between January 2008 and December 2013. I find that OOP spending on contraceptives has decreased sharply since the implementation of the ACA mandate. Using a difference-in-difference model that leverages employer level variation in compliance with the mandate, I estimate the effect of the mandate on use of both short- and long-term methods of prescription birth control. I find that the mandate has increased insurance claims for short-term contraceptive methods (the pill, patch, ring, shot, diaphragms/cervical caps, and prescription emergency contraception) by 4.8 percent and increased initiation of long-term methods (intrauterine devices, implant, or sterilization) by 15.8 percent. Using data from a national survey of reproductive age women during this same time period, a back-of-the-envelope calculation suggests that the mandate increased total use of any method of prescription contraceptive use by 2.95 percentage points among privately insured women in 2013, or a 6.57 percent relative increase. These increases in use of prescription contraceptives among privately insured women in the United States as a result of the ACA mandate have important potential implications for fertility rates, health care spending, and economic outcomes for women and their families.