"My BMI is too high for Plan B." A changing population of women seeking ulipristal acetate emergency contraception online.

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

Short- and long-term effect of contraceptive methods on fecundity.

Objective: The aim of the study was to compare the effect of previously used contraceptive methods on women's short- and long-term fecundity. Use of hormonal contraception (HC) was compared with the use of a contraceptive mobile application (app). Methods: This real-life prospective observational study comprised 2874 women who were attempting to become pregnant using the Natural Cycles mobile app to monitor their fertility. The women registered to use the app between August 2014 and June 2016 with the intention of planning a pregnancy and had previously either used the same app to prevent pregnancy or had recently discontinued HC use. We calculated the average time to pregnancy (TTP) for all women who became pregnant during the study and performed Kaplan-Meier life-table analysis to examine the cumulative probabilities of pregnancy for all women in the study. Results: The average TTP was 2.3 (95% confidence interval [CI] 2.1, 2.4) and 3.7 (95% CI 3.4, 3.9) cycles for women who had previously used Natural Cycles and HC, respectively. The time to reach 30% pregnancy probability for women previously on HC was 1.6 (95% CI 1.5, 1.8) times longer than for women previously using Natural Cycles. There was no significant difference in the 13 cycle cumulated pregnancy probability between the two groups. Conclusion: The results show that fertility awareness-based methods of contraception increase short-term pregnancy rates relative to HC, but have no effect on long-term pregnancy rates.

Progestin-only contraceptives: effects on weight.

BACKGROUND: Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. POCs include injectables, intrauterine contraception, implants, and oral contraceptives. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users. OBJECTIVES: The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight. SEARCH METHODS: Until 4 August 2016, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. For the initial review, we contacted investigators to identify other trials. SELECTION CRITERIA: We considered comparative studies that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight. DATA COLLECTION AND ANALYSIS: Two authors extracted the data. Non-randomized studies (NRS) need to control for confounding factors. We used adjusted measures for the primary effects in NRS or the results of matched analysis from paired samples. If the report did not provide adjusted measures for the primary analysis, we used unadjusted outcomes. For RCTs and NRS without adjusted measures, we computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% CI. MAIN RESULTS: We found 22 eligible studies that included a total of 11,450 women. With 6 NRS added to this update, the review includes 17 NRS and 5 RCTs. By contraceptive method, the review has 16 studies of depot medroxyprogesterone acetate (DMPA), 4 of levonorgestrel-releasing intrauterine contraception (LNG-IUC), 5 for implants, and 2 for progestin-only pills.Comparison groups did not differ significantly for weight change or other body composition measure in 15 studies. Five studies with moderate or low quality evidence showed differences between study arms. Two studies of a six-rod implant also indicated some differences, but the evidence was low quality.Three studies showed differences for DMPA users compared with women not using a hormonal method. In a retrospective study, weight gain (kg) was greater for DMPA versus copper (Cu) IUC in years one (MD 2.28, 95% CI 1.79 to 2.77), two (MD 2.71, 95% CI 2.12 to 3.30), and three (MD 3.17, 95% CI 2.51 to 3.83). A prospective study showed adolescents using DMPA had a greater increase in body fat (%) compared with a group not using a hormonal method (MD 11.00, 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00, 95% CI -6.93 to -1.07). A more recent retrospective study reported greater mean increases with use of DMPA versus Cu IUC for weight (kg) at years 1 (1.3 vs 0.2), 4 (3.5 vs 1.9), and 10 (6.6 vs 4.9).Two studies reported a greater mean increase in body fat mass (%) for POC users versus women not using a hormonal method. The method was LNG-IUC in two studies (reported means 2.5 versus -1.3; P = 0.029); (MD 1.60, 95% CI 0.45 to 2.75). One also studied a desogestrel-containing pill (MD 3.30, 95% CI 2.08 to 4.52). Both studies showed a greater decrease in lean body mass among POC users. AUTHORS' CONCLUSIONS: We considered the overall quality of evidence to be low; more than half of the studies had low quality evidence. The main reasons for downgrading were lack of randomizations (NRS) and high loss to follow-up or early discontinuation.These 22 studies showed limited evidence of change in weight or body composition with use of POCs. Mean weight gain at 6 or 12 months was less than 2 kg (4.4 lb) for most studies. Those with multiyear data showed mean weight change was approximately twice as much at two to four years than at one year, but generally the study groups did not differ significantly. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

Differences in reporting Pearl Indices in the United States and Europe: Focus on a 91-day extended-regimen combined oral contraceptive with low-dose ethinyl estradiol supplementation.

BACKGROUND: Regulatory agencies in the United States (US) and Europe differ in requirements for defining pregnancies after the last dose of oral contraceptive, sometimes resulting in discrepant Pearl Indices (PIs) for the same product despite identical clinical data. This brief report highlights one such example, a 91-day extended-regimen combined oral contraceptive (COC). METHODS: The US- and European-based PI methodologies were compared for a 91-day extended-regimen COC consisting of 84 days of active levonorgestrel/EE 150 µg/30 µg tablets, followed by seven days of EE 10 µg tablets in place of placebo. CONCLUSIONS: At the times of approval of the 91-day extended-regimen COC in the US and Europe, the requirements for defining 'on-treatment' pregnancies differed (14-day vs. 2-day rule, respectively). This difference resulted in a higher PI in the US- vs. European-based calculation (1.34 and 0.76, respectively). The differences in the PI should not be interpreted as the extended-regimen COC being less effective in preventing pregnancy in the US compared with Europe.

No Exceptions: Documenting the Abortion Experiences of US Peace Corps Volunteers.

Since 1979, US federal appropriations bills have prohibited the use of federal funds from covering abortion care for Peace Corps volunteers. There are no exceptions; unlike other groups that receive health care through US federal funding streams, including Medicaid recipients, federal employees, and women in federal prisons, abortion care is not covered for volunteers even in cases of life endangerment, rape, or incest. We interviewed 433 returned Peace Corps volunteers to document opinions of, perceptions about, and experiences with obtaining abortion care. Our results regarding the abortion experiences of Peace Corps volunteers, especially those who were raped, bear witness to a profound inequity and show that the time has come to lift the "no exceptions" funding ban on abortion coverage.

The Cost of Unintended Pregnancies in Canada: Estimating Direct Cost, Role of Imperfect Adherence, and the Potential Impact of Increased Use of Long-Acting Reversible Contraceptives.

OBJECTIVE: Unintended pregnancies (UPs) are associated with a significant cost burden, but the full cost burden in Canada is not known. The objectives of this study were to quantify the direct cost of UPs in Canada, the proportion of cost attributable to UPs and imperfect contraceptive adherence and the potential cost savings with increased uptake of long-acting reversible contraceptives (LARCs). METHODS: A cost model was constructed to estimate the annual number and direct costs of UP in women aged 18 to 44 years. Adherence-associated UP rates were estimated using perfect- and typical-use contraceptive failure rates. Change in annual number of UPs and impact on cost burden were projected in three scenarios of increased LARC usage. One-way sensitivity analyses were conducted to assess the impact of key variables on scenarios of increased LARC use. RESULTS: There are more than 180 700 UPs annually in Canada. The associated direct cost was over $320 million. Fifty-eight percent (58%) of UPs occurred in women aged 20 to 29 years at an annual cost of $175 million; 82% of this cost ($143 million) was attributable to contraceptive non-adherence. Increased LARC uptake produced cost savings of over $34 million in all three switching scenarios; the largest savings ($35 million) occurred when 10% of oral contraceptive users switched to LARCs. The minimum duration of LARC usage required before cost savings was realized was 12 months. CONCLUSION: The cost of UPs in Canada is significant and much of it can be attributed to imperfect contraceptive adherence. Increased LARC uptake may reduce contraceptive non-adherence, thereby reducing rates of UP and generating significant cost savings, particularly in women aged 20 to 29.

Objectif : Les grossesses non planifiées (GNP) sont associées à un fardeau financier considérable; au Canada, l'ampleur de ce fardeau demeure inconnue. Cette étude avait pour objectif de quantifier les coûts directs des GNP au Canada, la proportion des coûts liés aux GNP attribuables à une observance imparfaite du schéma posologique contraceptif et les économies potentielles associées à un accroissement de l'utilisation de modes de contraception réversible à action prolongée (CRAP). Méthodes : Un modèle de coût a été conçu pour estimer le nombre annuel de GNP et leurs coûts directs chez les femmes âgées de 18 à 44 ans. Les taux de GNP associés à l'observance ont été estimés au moyen des taux d'échec de la contraception en utilisation parfaite et en utilisation typique. Les modifications du nombre annuel de GNP et les effets sur le fardeau financier ont été projetés dans le cadre de trois scénarios prévoyant un accroissement du recours aux modes de CRAP. Des analyses simples de la variance en matière de sensibilité ont été menées pour évaluer les effets de variables clés sur les scénarios prévoyant un accroissement du recours aux modes de CRAP. Résultats : On compte plus de 180 700 GNP chaque année au Canada. Les coûts directs qui leur sont associés sont de plus de 320 millions de dollars. Cinquante-huit pour cent (58 %) des GNP se sont manifestées chez des femmes de 20 à 29 ans, ce qui représente un coût annuel de 175 millions de dollars; 82 % de ce coût (143 millions de dollars) étaient attribuables à la non-observance du schéma posologique contraceptif. L'accroissement du recours aux modes de CRAP a généré des économies de plus de 34 millions de dollars dans le cadre des trois scénarios de transition envisagés; les économies les plus importantes (35 millions de dollars) ont été constatées dans le cadre du scénario prévoyant que 10 % des utilisatrices de contraceptifs oraux adopteraient un mode de CRAP. La durée minimale d'utilisation d'un mode de CRAP nécessaire pour l'obtention d'économies était de 12 mois. Conclusion : Au Canada, le coût des GNP est considérable; de plus, une bonne partie de ce coût est attribuable à une observance imparfaite du schéma posologique contraceptif. L'accroissement du recours aux modes de CRAP pourrait mener à une baisse du taux de non-observance du schéma posologique contraceptif, ce qui entraînerait une baisse des taux de GNP et générerait des économies considérables, particulièrement chez les femmes de 20 à 29 ans.

Emergency contraception review: evidence-based recommendations for clinicians.

Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile, and availability. The most effective emergency contraceptive is the copper intrauterine device (IUD), followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, whereas ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.

Progestin-only contraceptives: effects on weight.

BACKGROUND: Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users. OBJECTIVES: The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight. SEARCH METHODS: Through May 2013, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. The 2010 search also included EMBASE. For the initial review, we contacted investigators to identify other trials. SELECTION CRITERIA: All comparative studies were eligible that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight. DATA COLLECTION AND ANALYSIS: Two authors extracted the data. We computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated. MAIN RESULTS: We found 16 studies; one examined progestin-only pills, one studied the levonorgestrel-releasing intrauterine system (LNG-IUS), four examined an implant, and 10 focused on depot medroxyprogesterone acetate (DMPA). Outcomes examined were changes in body weight only (14 studies), changes in both body weight and body composition (1 study), and changes in body composition only (1 study). We did not conduct meta-analysis due to the various contraceptive methods and weight change measures.Comparison groups did not differ significantly for weight change in 12 studies. However, three studies showed weight change differences for POC users compared to women not using a hormonal method. In one study, weight gain (kg) was greater for the DMPA group than the group using a non-hormonal IUD in years one through three [(MD 2.28; 95% CI 1.79 to 2.77), (MD 2.71, 95% CI 2.12 to 3.30), and (MD 3.17; 95% CI 2.51 to 3.83), respectively]. The differences were notable within the normal weight and overweight subgroups. Two implant studies also showed differences in weight change. The implant group (six-capsule) had greater weight gain (kg) compared to the group using a non-hormonal IUD in both studies [(MD 0.47 (95% CI 0.29 to 0.65); (MD 1.10; 95% CI 0.36 to 1.84)]. In one of those studies, the implant group also had greater weight gain than a group using a barrier method or no contraceptive (MD 0.74; 95% CI 0.52 to 0.96).The two studies that assessed body composition change showed differences between POC users and women not using a hormonal method. Adolescents using DMPA had a greater increase in body fat (%) compared to a group not using a hormonal method (MD 11.00; 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00; 95% CI -6.93 to -1.07). The other study reported differences between an LNG-IUS group and a non-hormonal IUD group in percent change in body fat mass (2.5% versus -1.3%, respectively; reported P value = 0.029) and percent change in lean body mass (-1.4% versus 1.0%, respectively; reported P value = 0.027). AUTHORS' CONCLUSIONS: The overall quality of evidence was moderate to low, given that the studies were evenly divided across the evidence quality groups (high, moderate, low, or very low quality). We found limited evidence of weight gain when using POCs. Mean gain was less than 2 kg for most studies up to 12 months. Weight change for the POC group generally did not differ significantly from that of the comparison group using another contraceptive. Two studies that assessed body composition showed that POC users had greater increases in body fat and decreases in lean body mass compared to users of non-hormonal methods. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

How effective are the components of active management of the third stage of labor?

BACKGROUND: Active management of the third stage of labor is recommended for the prevention of post-partum hemorrhage and commonly entails prophylactic administration of a uterotonic agent, controlled cord traction, and uterine massage. While oxytocin is the first-choice uterotonic, it is not known whether its effectiveness varies by route of administration. There is also insufficient evidence regarding the value of controlled cord traction or uterine massage. This analysis assessed the independent and combined effectiveness of all three interventions, and the effect of route of oxytocin administration on post-partum blood loss. METHODS: Secondary data were analyzed from 39202 hospital-based births in four countries and two clinical regimens: one in which oxytocin was administered following delivery of the baby; the other in which it was not. We used logistic regression to examine associations between clinical and demographic variables and post-partum blood loss ≥ 700 mL. RESULTS: Among those with no oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by nearly 50% as compared with expectant management (P < 0.001). Among those with oxytocin prophylaxis, provision of controlled cord traction reduced hemorrhage risk by 66% when oxytocin was intramuscular (P < 0.001), but conferred no benefit when oxytocin was intravenous. Route of administration was important when oxytocin was the only intervention provided: intravenous administration reduced hemorrhage risk by 76% as compared with intramuscular administration (P < 0.001); when combined with other interventions, route of administration had no effect. In both clinical regimens, uterine massage was associated with increased hemorrhage risk. CONCLUSIONS: Recommendations for active management of the third stage of labor should account for setting-related differences such as the availability of oxytocin and its route of administration. The optimal combination of interventions will vary accordingly.

The link between substance use and reproductive health service utilization among young U.S. women.

BACKGROUND: The authors sought to investigate associations between young women's use of alcohol and other substances and their sexual and reproductive health (SRH) service utilization. METHODS: The authors used data from 4421 young women aged 15-24 years in the nationally representative study, National Survey of Family Growth, 2002-2008. The authors examined associations between frequency of tobacco, alcohol, marijuana, and illicit drug use and SRH service use in the past year using logistic regression. RESULTS: Over half (59%) of the young women used SRH services, including contraception (48%), gynecological examination (47%), and sexually transmitted infection (STI) testing/treatment (17%) services. Proportions of SRH service use increased with higher frequencies of substance use (all P values <.001); service use was particularly common among daily substance users (range: 72% of daily marijuana users to 83% of daily binge drinkers). In multivariable analyses, associations between substance and SRH service use varied by substance and service type: weekly marijuana (odds ratio [OR] = 2.5, 95% confidence interval [95% CI] = 1.4, 4.3, P = .002) and alcohol (OR = 1.7, 95% CI = 1.1, 2.4, P = .01) use were positively associated with gynecological service use. All substances were positively associated with STI service use. However, daily smoking was negatively associated with contraceptive service use (OR = 0.6, 95% CI = 0.4, 0.8, P = .001). CONCLUSION: SRH service use was common among women reporting frequent substance use. SRH settings provide an opportunity to deliver substance use screening and preventive care to young women.

Religiosity, religious affiliation, and patterns of sexual activity and contraceptive use in France.

OBJECTIVE: To examine the association between religiosity and sexual and contraceptive behaviours in France. METHODS: Data were drawn from the 2005 Health Barometer survey, a random sample of 7495 women and 5634 men aged 15 to 44. We used logistic regression models to study the associations between religiosity and sexual and contraceptive behaviours, by gender and religious denomination. RESULTS: Three quarters of respondents (73%) reported no religious practice, 20% practised occasionally, and 7% regularly. Regular practice was associated with later sexual debut, regardless of religious denomination. Among participants less than 30 years old, religious respondents were less likely to have used a condom at first sexual intercourse (odds ratio [OR] = 0.2 for women, OR = 0.4 for men) or any form of contraception (OR = 0.2 for women). At the time of the survey, sexually experienced adolescents who reported regular religious practice were less likely to use contraception (84.7% vs. 98.1%, p < 0.001). Regular practice was associated with a 50% decrease in the odds of using very effective methods for Catholics, but had no effect among Muslims. CONCLUSION: This study, conducted in the French secularised context, shows a complex relationship between religiosity and sexual behaviours, which varies by gender, religious affiliation and during the life course.

Rates of serious infection after changes in regimens for medical abortion.

BACKGROUND: From 2001 through March 2006, Planned Parenthood health centers throughout the United States provided medical abortion (abortion by means of medication) principally by a regimen of oral mifepristone followed 24 to 48 hours later by vaginal misoprostol. In response to concern about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration from vaginal to buccal and required either routine provision of antibiotics or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine treatment with antibiotics for all medical abortions. METHODS: We performed a retrospective analysis assessing the rates of serious infection after medical abortion during a time when misoprostol was administered vaginally (through March 2006), as compared with rates after a change to buccal administration of misoprostol and after initiation of additional infection-reduction measures. RESULTS: Rates of serious infection dropped significantly after the joint change to buccal misoprostol from vaginal misoprostol and to either testing for sexually transmitted infection or routine provision of antibiotics as part of the medical abortion regimen. The rate declined 73%, from 0.93 per 1000 abortions to 0.25 per 1000 (absolute reduction, 0.67 per 1000; 95% confidence interval [CI], 0.44 to 0.94; P<0.001). The subsequent change to routine provision of antibiotics led to a further significant reduction in the rate of serious infection - a 76% decline, from 0.25 per 1000 abortions to 0.06 per 1000 (absolute reduction, 0.19 per 1000; 95% CI, 0.02 to 0.34; P=0.03). CONCLUSIONS: The rate of serious infection after medical abortion declined by 93% after a change from vaginal to buccal administration of misoprostol combined with routine administration of antibiotics.

The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience.

BACKGROUND: Intrauterine devices (IUDs) have been studied for use for emergency contraception for at least 35 years. IUDs are safe and highly effective for emergency contraception and regular contraception, and are extremely cost-effective as an ongoing method. The objective of this study was to evaluate the existing data to estimate the efficacy of IUDs for emergency contraception. METHODS: The reference list for this study was generated from hand searching the reference lists of relevant articles and our own article archives, and electronic searches of several databases: Medline, Global Health, Clinicaltrials.gov, Popline, Wanfang Data (Chinese) and Weipu Data (Chinese). We included studies published in English or Chinese, with a defined population of women who presented for emergency contraception and were provided with an IUD, and in which the number of pregnancies was ascertained and loss to follow-up was clearly defined. Data from each article were abstracted independently by two reviewers. RESULTS: The 42 studies (of 274 retrieved) that met our inclusion criteria were conducted in six countries between 1979 and 2011 and included eight different types of IUD and 7034 women. The maximum timeframe from intercourse to insertion of the IUD ranged from 2 days to 10 or more days; the majority of insertions (74% of studies) occurred within 5 days of intercourse. The pregnancy rate (excluding one outlier study) was 0.09%. CONCLUSIONS: IUDs are a highly effective method of contraception after unprotected intercourse. Because they are safe for the majority of women, highly effective and cost-effective when left in place as ongoing contraception, whenever clinically feasible IUDs should be included in the range of emergency contraception options offered to patients presenting after unprotected intercourse. This review is limited by the fact that the original studies did not provide sufficient data on the delay between intercourse and insertion of the IUD, parity, cycle day of intercourse or IUD type to allow analysis by any of these variables.

Male circumcision for HIV prevention: clinical practices and attitudes among healthcare providers in South Africa and Zimbabwe.

BACKGROUND: This study aimed to document the clinical practices and attitudes of health care providers in South Africa and Zimbabwe on male circumcision for human immunodeficiency virus (HIV) prevention. METHODS: We conducted national surveys of physicians and nurses in both countries in 2008-2009 (N = 1444). Data on male circumcision for HIV prevention were analyzed; outcomes were patient counseling, provision of services, and desire for training. We used multivariable logistic regression to examine associations between these outcomes and clinician, practice, and attitudinal variables. RESULTS: Overall, 57% of clinicians reported counseling male patients on male circumcision, 17% were offering services (49% referrals), and 61% desired training. In the multivariable analyses, provision of services was more common in South Africa (P ≤ 0.001) but desire for training higher in Zimbabwe (P ≤ 0.01). Provision of services was highest among physicians (P ≤ 0.01) and in hospital settings (P ≤ 0.001). However, nurses had greater desire for training (P ≤ 0.05) as did younger clinicians (P ≤ 0.001). Clinicians in rural and clinic settings were just as likely to express training interest. Clinician attitudes that patients would be upset due to cultural beliefs and would increase risky behaviors were associated with less counseling and service provision (P ≤ 0.05). CONCLUSIONS: Many clinicians in South Africa and Zimbabwe showed willingness to integrate new HIV prevention evidence into practice and to become trained to offer the procedure to patients. Results suggest that both countries should consider involving nurses in male circumcision for HIV prevention, including those in rural areas, and should help clinicians to address cultural concerns.

Determinants of and disparities in reproductive health service use among adolescent and young adult women in the United States, 2002-2008.

OBJECTIVES: We investigated determinants of and disparities in reproductive health service use among young women in the United States from 2002 to 2008. METHODS: Using data on 4421 US women aged 15 to 24 years from the National Survey of Family Growth (2002, n = 2157; 2006-2008, n = 2264), we employed descriptive and univariate statistics and multivariate regression models to examine service use across women's sociodemographic and reproductive characteristics and to investigate potential disparate changes in service use over time. RESULTS: More than half the sample (59%) had used services in the past year. In regression models, predictors of service use included age, education, birthplace, insurance, religious participation, mother's education, childhood family situation, age at menarche, sexual intercourse experience, recent number of partners, and previous gynecological diagnosis. Although service use decreased by 8% overall from 2002 to 2006-2008 (P < .001), the magnitude of decline was similar across demographic and socioeconomic groups. CONCLUSIONS: Inequalities in reproductive health service use exist among women in the United States, particularly among the youngest and socially disadvantaged women, which may translate to poor and disparate reproductive outcomes. Public health and policy strategies are needed to eliminate inequities in reproductive health service.

Young women's perceived health and lifetime sexual experience: results from the national survey of family growth.

INTRODUCTION: Sexuality is a component of health and well-being for all women, including adolescents. Yet relationships between young women's health perceptions and sexual behavior are unclear. AIM: We examined associations between perceived health and lifetime sexual experiences among young U.S. women. METHODS: We used data from 4,413 young women ages 15-24 years in the National Survey of Family Growth, 2002-2008. Descriptive, bivariate, and multivariate statistics estimated relationships between categories of perceived health and types of lifetime sexual experience. MAIN OUTCOME MEASURES: A self-rated health Likert item and sexual history questions were administered with a computer-assisted survey instrument. RESULTS: Young women reported excellent (30%), very good (41%), good (23%), and fair-poor (6%) health. Sexual experiences included vaginal (64%), oral (64%), and anal (20%) sex. Negative experiences included involuntary sex (11%) and sexually transmitted infection (STI) history (8%). In multivariate logistic regression models, lower perceived health ("good" rather than "excellent") was positively associated with vaginal (odds ratio [OR] 1.5, confidence interval [CI] 1.1-2.1, P = 0.02), oral (OR 1.5, CI 1.1-2.1, P = 0.005), and anal (OR 1.4, CI 1.0-2.0, P = 0.03) sex. In models stratified by age, point estimates for vaginal (OR 1.8, CI 1.2-2.6, P = 0.002) and oral (OR 1.9, CI 1.4-2.6, P < 0.001) sex were higher among adolescents ages 15-19 years, but associations were insignificant among young adults ages 20-24 years. When controlling for negative sexual experiences, point estimates were stable in models including STI history but statistically insignificant when including involuntary sexual experience. Other characteristics associated with sexual experiences varied by type of experience and included age, race/ethnicity, employment situation, poverty level, insurance status, childhood family situation, religious service participation, cohabitation/marital experience, and body mass index. CONCLUSIONS: Further investigation is warranted to disentangle potentially negative relationships between perceived health (as well as response bias and more objective health outcomes), sociodemographic factors, and diverse sexual experiences among young women in the United States.

Discouraging trends in reproductive health service use among adolescent and young adult women in the USA, 2002-2008.

BACKGROUND: To investigate reproductive health service use by young women in the USA between 2002 and 2008. METHODS: Using data from two waves of The National Survey of Family Growth, we investigated reproductive health service utilization among women aged 15-24 years (2002 n=2157; 2006-2008 n=2264). Descriptive and univariate statistics and multivariate regression models were employed to describe types of reproductive health services used and compare service use across years. Analyses focused on questions regarding specific recent use of reproductive health services (within the previous 12 months). RESULTS: Over half the pooled sample (n=4421) reported lifetime family planning clinic (58%) and recent reproductive health service (59%) use, including contraceptive (48%), gynecological exam (47%) and counseling (37%) services. Lifetime family planning service use declined by 15% from 2002 to 2008 (P<0.001) and recent reproductive health service use by 8% (P=0.01), including gynecological exam (8%, P= 0.03) and contraceptive (6%, P= 0.02) services. By 2006-2008, women were less likely to use reproductive health and contraceptive services than in 2002 [odds ratio (OR) 0.6, confidence interval (CI) 0.5, 0.8, P< 0.001 and OR 0.7, CI 0.6, 0.9, P= 0.005, respectively]. Trends were similar but smaller in magnitude among the sexually experienced women, with a 5% decline in both reproductive health (OR 0.7, CI 0.6, 1.0, P= 0.02) and contraceptive (OR 0.8, CI 0.6, 1.0, P= 0.03) service use. CONCLUSIONS: Reproductive health service use among young women in the USA has declined over the past decade. Public health and policy strategies are needed to promote service use, ultimately to improve reproductive health outcomes.