Validity of Partner Reports of Recent Condomless Sex.

BACKGROUND: Prostate-specific antigen (PSA), a biomarker of vaginal semen exposure, is less susceptible to bias than self-reported condom use behaviors. We examined the agreement of self-reported recent condomless sex (RCS) within couples and how these reports related to PSA detection. METHODS: We analyzed data from a study conducted in Vietnam, 2017 to 2020, of 500 different-sex couples using condoms and no other contraceptive method to prevent pregnancy for 6 months. We assessed enrollment and 6-month data from vaginal swabs and questionnaires from both partners. We calculated Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) to evaluate agreement of men's and women's reports. Among couples with detected PSA, we assessed partner concordance of RCS reporting. RESULTS: At enrollment (n = 499), 79.8% of couples reported no RCS, 16.4% reported RCS, and 3.8% had partner-discordant reports (PABAK, 0.93; 95% confidence interval, 0.91-0.97). At 6 months (n = 472), 91.7% reported no RCS, 5.7% reported RCS, and 2.5% had partner-discordant reports (PABAK, 0.98; 95% confidence interval, 0.96-1.0). Among couples with detected PSA at baseline (11%, n = 55), 36% reported no RCS, 55% reported RCS, and 6% had discordant reports; at 6 months (6.6%, n = 31), 58% reported no RCS, 35% reported RCS, and 3% had discordant reports. CONCLUSIONS: We observed high agreement regarding condomless sex within couples in a population using condoms as contraception in Vietnam; however, a high proportion of couples with detected PSA had both partners reporting no RCS, indicating that concordant reporting of no RCS does not indicate lack of semen exposure.

Prevalence and correlates of very rapid repeat pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2009-2020.

BACKGROUND: Most rapid repeat pregnancies, defined as those occurring within 18 months of a previous birth, are unintended. These pregnancies are associated with later initiation of prenatal care and are more common among people with lower socio-economic status and among racially and ethnically minoritised populations. OBJECTIVES: To assess prevalence and correlate pregnancies occurring in the immediate period after a live birth in the United States, using the Pregnancy Risk Assessment Monitoring System (PRAMS). METHODS: We assessed data from the 2009-2020 PRAMS, a population-based survey of perinatal maternal characteristics of mothers of liveborn infants in US locations. We assessed pregnancies reported during the immediate postpartum period (approximately 2-6 months post-delivery), and term this 'very rapid repeat pregnancy' (VRRP). We assessed the adjusted prevalence of VRRP from 2009 to 2020. From 2016 to 2020, we calculated adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) for maternal characteristics. RESULTS: The adjusted prevalence of VRRP ranged from 0.38% (95% CI: 0.29, 0.48) in 2009 to 0.76% (95% CI: 0.61, 0.91) in 2020. Demographic characteristics associated with VRRP included younger age, lower educational attainment, and being unmarried. Black mothers had a higher prevalence of VRRP compared to white mothers. Mothers who attended a healthcare visit in the 12 months preconception had a lower prevalence of VRRP as did mothers who attended a postpartum check-up, compared to their counterparts without these visits. Among those receiving prenatal care, mothers whose prenatal healthcare provider asked about postpartum contraception birth had a lower prevalence of VRRP, compared to those not asked about postpartum contraception. CONCLUSIONS: VRRP appeared to increase over time in 2009-2020. Mothers who are younger, Black, have lower educational attainment, or who did not attend healthcare visits before or after pregnancy had a higher prevalence of VRRP and may comprise a population who would benefit from additional family planning resources.

Free, but at what cost? How US crisis pregnancy centres provide services.

In the USA, the most popular form of anti-abortion activism, crisis pregnancy centres (CPCs), provide a variety of services to prevent abortions. Moving beyond debate about misinformation and the ethics of CPCs, this study considers the services they provide and given their popularity among state legislatures, their connection to the state. Using interviews with ten CPC staff in Ohio (a state providing support to CPCs) and supplemental data from both state and CPC organisations, we find three relevant themes. First, CPC services reflect ideas about personal responsibility and Christianity held by the CPC staff. Second, we show that CPCs have assumed a variety of state duties (e.g. pregnancy testing and parenting classes), appealing to lawmakers in conservative states eager to transfer responsibility for disadvantaged residents to other entities. Finally, we consider the future direction of CPCs, highlighting tension between organisational goals (focusing on abortion prevention) and the on-the-ground experience of CPC staff (where non-pregnant clients need material aid). Drawing theoretical connections between CPC staff and social service workers sheds light on whose responsibility it is to address poverty in a post-welfare era.

Housing Stability and Access to General Healthcare and Reproductive Healthcare Among Women in Ohio.

BACKGROUND: The relationship between housing instability and reproductive healthcare is understudied. We examined the association between housing insecurity and access and utilization of general healthcare, contraceptive healthcare, and abortion care. METHODS: Using data from a population-representative survey of adult reproductive-age Ohio women (N = 2,529), we assessed housing insecurity (not paying rent/mortgage on time in the past year). We examined associations between housing insecurity and the following outcomes: (1) not being able to access general healthcare in the past year; (2) experiencing delays or difficulties in accessing contraceptive healthcare in the past year; and (3) ever having an abortion. We used unadjusted and adjusted logistic regression models. We selected confounders a priori and included age, socioeconomic status, and healthcare status. RESULTS: Overall, 10.6% of Ohio women of adult reproductive age experienced housing insecurity. Approximately 27.5% of respondents were not able to access general healthcare and 10.4% experienced delays or difficulties in accessing contraceptive care. Compared to housing-secure respondents, housing-insecure women were less able to access general healthcare (adjusted odds ratio [aOR]:2.16; 95% confidence interval [CI]:1.45-3.23) and more likely to experience delays or difficulties when accessing contraceptive care (aOR:1.74; 95% CI:1.00-3.04). Insecure housing was not statistically associated with ever having an abortion (aOR:1.76; 95% CI:0.93-3.34). CONCLUSIONS: In this study, recent housing insecurity was associated with poorer access to general and contraceptive healthcare. Studies utilizing multidimensional measures of housing insecurity and other material insecurity measures are needed to further explore the relationship between material insecurity and access to general and contraceptive care.

Passage of abortion ban and women's accurate understanding of abortion legality.

BACKGROUND: Legislative and judicial procedures related to banning abortion after 6 weeks of gestation in Ohio occurred from November 2018 to July 2019. These activities could have increased the belief that abortion has become illegal even though the 6-week abortion ban has never been in effect to date. OBJECTIVE: We sought to determine the prevalence and correlates of holding the belief that abortion is illegal in Ohio and to evaluate whether this belief increased over the time in which the 6-week abortion ban was introduced, passed twice, and then blocked in Ohio. STUDY DESIGN: We analyzed data from the first wave of the Ohio Survey of Women, a population-based survey of adult, reproductive-aged Ohioan women conducted from October 2018 to June 2019. During each of the 8 survey months, a median of 240 women (range, 70-761) completed the survey, including the survey question "Based on what you know or have heard, is it legal to get an abortion in your state?" We used multivariable logistic regression to assess the prevalence and correlates of believing that abortion is illegal in the state of Ohio. In addition, we used multinomial logistic regression to evaluate whether this belief increased over the interval during which women completed the survey, which roughly corresponded to the interval marked by legislative and judicial activities surrounding the 6-week abortion ban. RESULTS: Most of the 2359 participants understood that abortion is legal in the state of Ohio (64.0%) with the remainder believing it to be illegal (9.8%) or being unsure (26.2%). Correlates of believing abortion to be illegal included younger age, lower socioeconomic status, never married or married status, and Black, non-Hispanic race and ethnicity. Being unsure about legality did not change over time; however, the proportion of women who believed that abortion is illegal increased from the first month (4.5%) to the last month (15.9%) of the study period. Each additional study month was associated with a 17% increase in the odds of believing abortion to be illegal, in both unadjusted and adjusted models (odds ratio, 1.17; 95% confidence interval, 1.08-1.27). CONCLUSION: Attempts to restrict abortion access could contribute to women mistakenly believing that abortion is illegal despite it being unsuccessful.

Role of temporal discounting in a conditional cash transfer (CCT) intervention to improve engagement in the prevention of mother-to-child transmission (PMTCT) cascade.

BACKGROUND: Temporal discounting, the tendency of individuals to discount future costs and benefits relative to the present, is often associated with greater engagement in risky behaviors. Incentives such as conditional cash transfers (CCTs) have the potential to counter the effects of high discount rates on health behaviors. METHODS: With data from a randomized trial of a CCT intervention among 434 HIV-positive pregnant women in the Democratic Republic of Congo, we used binomial models to assess interactions between discount rates (measured using a delay-discounting task) and the intervention. The analysis focused on two outcomes: 1) retention in HIV care, and 2) uptake of prevention of mother-to-child transmission (PMTCT) services. RESULTS: The effect of high discount rates on retention was small, and we did not observe evidence of interaction between high discount rates and CCT on retention. However, our findings suggest that CCT may mitigate the negative effect of high discount rates on uptake of PMTCT services (interaction contrast (IC): 0.18, 95% CI: - 0.09, 0.44). CONCLUSIONS: Our findings provide evidence to support the continued use of small, frequent incentives, to motivate improved uptake of PMTCT services, especially among women exhibiting high rates of temporal discounting. TRIAL REGISTRATION: Clinicaltrials.gov number NCT01838005 , April 23, 2013.

Contraceptive knowledge among women at risk of unintended pregnancy in Kingston, Jamaica.

Low contraceptive knowledge may limit contraception initiation or continuation and, consequently, could represent an important, modifiable cause of unintended pregnancy. The objective of this analysis was to identify correlates of knowledge among women at risk of unintended pregnancy. We analyzed data from a study of 222 young women attending a public clinic in Kingston in November 2018 to March 2019. We measured contraceptive knowledge with seven questions on method reversibility, ability to use covertly, contraindications, and side effects. We used multivariable linear regression to evaluate the correlates of summary knowledge scores and report beta coefficients, which represent differences in mean summary knowledge scores. The mean knowledge score was low (2.7; range = 0-7). Only 30.2% of the participants correctly identified intrauterine devices as more effective than oral contraception, male condoms, and withdrawal. Women who reported that their provider discussed contraception scored higher (adjusted ß = 0.37, p = 0.05) than those not reporting this. Women who perceived implants as very/mostly safe scored higher (adjusted ß = 0.45, p = 0.01) than those perceiving the device as mostly/very unsafe. Finally, compared to contraception non-users, women using less-effective contraception had a lower score (adjusted ß = -0.40, p = 0.04) while those using effective contraception did not differ in scores (ß = -0.30, p = 0.18). Overall, we found poor contraceptive knowledge among young women in Kingston. Providers appeared to hold an important role in women's understanding of contraception.

Correlates of use of withdrawal for contraception among women in Vietnam.

BACKGROUND: Despite its relatively low effectiveness, withdrawal is a common contraceptive practice. In Vietnam, health concerns about hormonal contraception are strong and account for substantial method discontinuation. Given the paucity of evidence on withdrawal, our objective was to identify correlates of using withdrawal among women not desiring pregnancy. METHODS: We conducted a secondary analysis of data from a cross-sectional study of sexually-active adult women attending a public hospital in Hanoi, who did not desire pregnancy. We enrolled a stratified sample of women using the intrauterine device, combination oral contraception, or neither method. Participants completed a questionnaire on demographics and reproductive history and behaviors. We used multinomial logistic regression to evaluate correlates of using a tier 3 contraception method (without withdrawal) and using withdrawal (alone or with a tier 3 method) compared to the referent category of using a tier 1 or 2 method (without withdrawal). RESULTS: Of the 489 participants in the analysis, 52.3% reported using tier 1 or 2 method (without withdrawal); 19.8% reported tier 3 contraception (without withdrawal) and 27.9% reported using withdrawal (alone or with a tier 3 method). Compared to those using a tier 1 or 2 method, women using withdrawal had lower odds of reporting that avoiding pregnancy was very important or important to them (aOR, 0.4; 95% CI, 0.3-0.7). Women using withdrawal had higher odds of reporting that their husband/partner refuses to give them money for household expenses, even when he has the money (aOR, 2.8; 95% CI, 1.4-5.6). CONCLUSIONS: Women using withdrawal might have less relationship power than nonusers. They also might rely on the practice because they are more ambivalent about pregnancy.

Underestimation of pregnancy risk among women in Vietnam.

BACKGROUND: Addressing women's inaccurate perceptions of their risk of pregnancy is crucial to improve contraceptive uptake and adherence. Few studies, though, have evaluated the factors associated with underestimation of pregnancy risk among women at risk of unintended pregnancy. METHODS: We assessed the association between demographic and behavioral characteristics and underestimating pregnancy risk among reproductive-age, sexually-active women in Hanoi, Vietnam who did not desire pregnancy and yet were not using highly-effective contraception (N = 237). We dichotomized women into those who underestimated pregnancy likelihood (i.e., 'very unlikely' they would become pregnant in the next year), and those who did not underestimate pregnancy likelihood (i.e., 'somewhat unlikely,' 'somewhat likely' or 'very likely'). We used bivariable and multivariable logistic regression models to identify correlates of underestimating pregnancy risk. RESULTS: Overall, 67.9% (n = 166) of women underestimated their pregnancy risk. In bivariable analysis, underestimation of pregnancy risk was greater among women who were older (> 30 years), who lived in a town or rural area, and who reported that it was "very important" or "important" to them to not become pregnant in the next year. In multivariable analysis, importance of avoiding pregnancy was the sole factor that remained statistically significantly associated with underestimating pregnancy risk (odds ratio [OR]: 0.11; 95% confidence interval [CI], 0.05-0.25). In contrast, pregnancy risk underestimation did appear to vary by marital status, ethnicity, education or other behaviors and beliefs relating to contraceptive use. CONCLUSIONS: Findings reinforce the need to address inaccurate perceptions of pregnancy risk among women at risk of experiencing an unintended pregnancy.

Strategies to improve adherence and continuation of shorter-term hormonal methods of contraception.

BACKGROUND: Worldwide, hormonal contraceptives are among the most popular reversible contraceptives. Despite high perfect-use effectiveness rates, typical-use effectiveness rates for shorter-term methods such as oral and injectable contraceptives are much lower. In large part, this disparity reflects difficulties in ongoing adherence to the contraceptive regimen and low continuation rates. Correct use of contraceptives to ensure effectiveness is vital to reducing unintended pregnancy. OBJECTIVES: To determine the effectiveness of strategies aiming to improve adherence to, and continuation of, shorter-term hormonal methods of contraception compared with usual family planning care. SEARCH METHODS: We searched to July 2018 in the following databases (without language restrictions): The Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), PubMed via MEDLINE, POPLINE, Web of Science, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing strategies aimed to facilitate adherence and continuation of shorter-term hormonal methods of contraception (such as oral contraceptives (OCs), injectable depot medroxyprogesterone acetate (DMPA or Depo-Provera), intravaginal ring, or transdermal patch) with usual family planning care in reproductive age women seeking to avoid pregnancy. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane. Primary outcomes were continuation or discontinuation of contraceptive method, rates of discontinuation due to adverse events (menstrual disturbances and all other adverse events), and adherence to method use as indicated by missed pills and on-time/late injections. Pregnancy was a secondary outcome. MAIN RESULTS: We included 10 RCTs involving 6242 women. Six trials provided direct in-person counseling using either multiple counseling contacts or multiple components during one visit. Four trials provided intensive reminders of appointments or next dosing, of which two provided additional educational health information as well as reminders. All trials stated 'usual care' as the comparison.The certainty of the evidence ranged from very low to moderate. Main limitations were risk of bias (associated with poor reporting of methodological detail, lack of blinding, and incomplete outcome data), inconsistency, indirectness, and imprecision.Continuation of hormonal contraceptive methodsIt is uncertain whether intensive counseling improves continuation of hormonal contraceptive methods compared with usual care (OR 1.28, 95% CI 1.07 to 1.54; 2624 participants; 6 studies; I2 = 79%; very low certainty evidence). The evidence suggested: if the chance of continuation with usual care is 39%, the chance of continuation with intensive counseling would be between 41% and 50%. The overall pooled OR suggested continuation of improvement, however, when stratified by contraceptive method type, the positive results were restricted to DMPA.It is uncertain whether reminders (+/- educational information) improve continuation of hormonal contraceptive methods compared with usual care (OR 1.33, 95% CI 1.03 to 1.73; 933 participants; 2 studies; I2 = 69%; very low certainty evidence).The evidence suggested: if the chance of continuation with usual care is 52%, the chance of continuation with reminders would be between 52% and 65%.Discontinuation due to adverse eventsThe evidence suggested that counseling may be associated with a decreased rate of discontinuation due to adverse events compared with usual care, with a lower rate of discontinuation due to menstrual disturbances (OR 0.20, 95% CI 0.11 to 0.37; 350 participants; 1 study; low certainty evidence), but may make little or no difference to all other adverse events (OR 0.73, 95% CI 0.36 to 1.47; 350 participants; 1 study; low certainty evidence). The evidence suggested: if the chance of discontinuation with usual care due to menstrual disturbances is 32%, the chance of discontinuation with intensive counseling would be between 5% and 15%; and that if the chance of discontinuation with usual care due to other adverse events is 55%, the chance of discontinuation with intensive counseling would be between 30% and 64%.Discontinuation was not reported among trials that investigated the use of reminders (+/- educational information).Adherence Adherence was not reported among trials that investigated the use of intensive counseling.Among trials that investigated reminders (+/- educational information), there was no conclusive evidence of a difference in adherence as indicated by missed pills (MD 0.80, 95% CI -1.22 to 2.82; 73 participants; 1 study; moderate certainty evidence) or by on-time injections (OR 0.84, 95% CI 0.54 to 1.29; 350 participants; 2 studies; I2 = 0%; low certainty evidence). The evidence suggested: if the chance of adherence to method use as indicated by on-time injections with usual care is 50%, the chance of adherence with method use as indicated by on-time injections with reminders would be between 35% and 56%.PregnancyThere was no conclusive evidence of a difference in rates of pregnancy between intensive counseling and usual care (OR 1.24, 95% CI 0.98 to 1.57; 1985 participants; 3 studies; I2 = 0%, very low certainty evidence). The evidence suggested: if the chance of pregnancy with usual care is 18%, the chance of pregnancy with counseling would be between 18% and 25%.Pregnancy was not reported among trials that investigated the use of reminders (+/- educational information). AUTHORS' CONCLUSIONS: Despite the importance of this topic, studies have not been published since the last review in 2013 (nine studies) with only one study added in 2019 that neither changed the results nor improved the certainty of evidence.Overall, the certainty of evidence for strategies to improve adherence and continuation of contraceptives is low. Intensive counseling and reminders (with or without educational information) may be associated with improved continuation of shorter-term hormonal contraceptive methods when compared with usual family planning care. However, this should be interpreted with caution due to the low certainty of the evidence. Included trials used a variety of shorter-term hormonal contraceptive methods which may account for the high heterogeneity. It is possible that the effectiveness of strategies for improving adherence and continuation are contingent on the contraceptive method targeted. There was limited reporting of objectively measurable outcomes (e.g. electronic monitoring device) among included studies. Future trials would benefit from standardized definitions and measurements of adherence, and consistent terminology for describing interventions and comparisons. Further research requires larger studies, follow-up of at least one year, and improved reporting of trial methodology.

Progression of care among women who use a midwife for prenatal care: Who remains in midwife care?

BACKGROUND: Prenatal care provided by midwives provides a safe and cost-effective alternative to care provided by physicians. However, no studies have evaluated the frequency of women who leave midwifery care, in a hospital setting. Our study objectives were to measure the frequency of transfers of care to physicians, to describe the sociodemographic and pregnancy-related characteristics of women who transferred to the care of a physician during prenatal care and at delivery, and to assess correlates of these transfers. METHODS: We used electronic medical records to perform a retrospective cohort study of women who delivered at The Ohio State University Wexner Medical Center (OSUWMC) and had at least one prenatal care visit within OSUWMC's network. We report descriptive findings, using proportions and means with standard deviations. We used logistic regression, with Firth's bias correction as necessary, to assess correlates of transferring to a physician during prenatal care and at delivery. RESULTS: Most women who initiated prenatal care with a midwife remained in midwifery care throughout delivery, with 4.7% transferring to a physician during prenatal care, and an additional 21.4% transferring to a physician during delivery. After adjusting for pregnancy-related factors, the black race was statistically significantly associated with leaving midwifery care during prenatal care (adjusted odds ratio AOR 3.0 [95% CI 1.4-6.6]) and delivery (AOR 2.5 [95% CI 1.5-4.3]). CONCLUSION: Findings indicate that most women remain in midwifery care throughout pregnancy, but raise important questions with respect to the possible role that race has in pregnancy care.

Prevalence and attitudes on female genital mutilation/cutting in Egypt since criminalisation in 2008.

Female genital mutilation/cutting (FGM/C), which can result in severe pain, haemorrhage and poor birth outcomes, remains a major public health issue. The extent to which prevalence of and attitudes toward the practice have changed in Egypt since its criminalisation in 2008 is unknown. We analysed data from the 2005, 2008 and 2014 Egypt Demographic and Health Surveys to assess trends related to FGM/C. Specifically, we determined whether FGM/C prevalence among ever-married, 15-19-year-old women had changed from 2005 to 2014. We also assessed whether support for FGM/C continuation among ever-married reproductive-age (15-49 years) women had changed over this time period. The prevalence of FGM/C among adolescent women statistically significantly decreased from 94% in 2008 to 88% in 2014 (standard error [SE] = 1.5), after adjusting for education, residence and religion. Prevalence of support for the continuation of FGM/C also statistically significantly decreased from 62% in 2008 to 58% in 2014 (SE = 0.6). The prevalence of FGM/C among ever-married women aged 15-19 years in Egypt has decreased since its criminalisation in 2008, but continues to affect the majority of this subgroup. Likewise, support of FGM/C continuation has also decreased, but continues to be held by a majority of ever-married women of reproductive age.

Sexual Relationship Power and Semen Exposure Among Female Patients at a Sexually Transmitted Infection Clinic in Kingston, Jamaica.

Women's power in sexual relationships is thought to be an important predictor of condom use. However, research on correlates of condom use often relies on participant reporting of behavior, which has questionable validity. We evaluated the association between scores from the modified Sexual Relationship Power Scale (SRPS-M) and biological detection of semen exposure in a prospective study of adult women attending a sexually transmitted infection clinic in Kingston, Jamaica with cervicitis or abnormal vaginal discharge in 2010-2011. At enrollment, women were counseled to avoid sex while on treatment and were asked to return in 6 days for a follow-up visit. At both study visits, women were administered a questionnaire and had vaginal swabs collected to test for prostate-specific antigen (PSA), a biological marker of recent semen exposure. We found no significant association at enrollment or follow-up between SRPS-M scores and semen exposure, as measured with either self-reported data or PSA positivity. Semen biomarkers could be used to develop and validate new scales on relationship power and self-efficacy related to condom use.

Postpartum intentions on contraception use and method choice among breastfeeding women attending a university hospital in Ohio: a cross-sectional study.

BACKGROUND: Few postpartum women use effective contraception and those who use less effective methods have increased rates of unintended pregnancy. Little is known about postpartum contraception intentions among breastfeeding women. Our objectives were to measure the extent of prenatal contraceptive counseling, to assess contraceptive intentions, and to identify correlates of both among postpartum women who were planning to breastfeed. METHODS: We conducted a cross-sectional study using a convenience sample of 100 breastfeeding women before their discharge following delivery at a large university hospital in 2015. We used logistic regression to assess three outcomes of interest: not intending to use contraception before 6 months postpartum, reporting receiving counseling on postpartum contraception during prenatal care, and considering the effects of contraception methods on the breastfeeding mother-infant dyad when choosing a postpartum contraception method. RESULTS: Most women (91%) intended to use contraception. Prior history of no contraception use was the sole factor related to not intending to use contraception. The most commonly cited reason for the intended choice of contraceptive method was convenience (35%). Few women (21%) reported considering the effects of contraception methods on the breastfeeding dyad when choosing a postpartum contraception method. Nearly half of women reported never discussing postpartum contraception options with their healthcare provider during prenatal care. In the multivariate analysis, receiving public assistance was the only factor that remained statistically significantly associated with reporting having received contraception counseling during prenatal care. CONCLUSIONS: Although most women intended to use contraception, they did not appear to have received adequate prenatal counseling on postpartum contraception.

Fertility treatments and multiple births in the United States.

BACKGROUND: The advent of fertility treatments has led to an increase in the rate of multiple births in the United States. However, the trends in and magnitude of the contribution of fertility treatments to the increase are uncertain. METHODS: We derived the rates of multiple births after natural conception from data on distributions of all births from 1962 through 1966 (before fertility treatments were available). Publicly available data on births from 1971 through 2011 were used to determine national multiple birth rates, and data on in vitro fertilization (IVF) from 1997 through 2011 were used to estimate the annual proportion of multiple births that were attributable to IVF and to non-IVF fertility treatments, after adjustment for maternal age. Trends in multiple births were examined starting from 1998, the year when clinical practice guidelines for IVF were developed with an aim toward reducing the incidence of multiple births. RESULTS: We estimated that by 2011, a total of 36% of twin births and 77% of triplet and higher-order births resulted from conception assisted by fertility treatments. The observed incidence of twin births increased by a factor of 1.9 from 1971 to 2009. The incidence of triplet and higher-order births increased by a factor of 6.7 from 1971 to 1998 and decreased by 29% from 1998 to 2011. This decrease coincided with a 70% reduction in the transfer of three or more embryos during IVF (P<0.001) and a 33% decrease in the proportion of triplet and higher-order births attributable to IVF (P<0.001). CONCLUSIONS: Over the past four decades, the increased use of fertility treatments in the United States has been associated with a substantial rise in the rate of multiple births. The rate of triplet and higher-order births has declined over the past decade in the context of a reduction in the transfer of three or more embryos during IVF. (Funded by the Centers for Disease Control and Prevention.).

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial.

BACKGROUND: Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI). METHODS: Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs. RESULTS: Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication. CONCLUSIONS: Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis. TRIAL REGISTRATION NUMBER: NCT00137670.

Recent Biomarker-Confirmed Unprotected Vaginal Sex, But Not Self-reported Unprotected Sex, Is Associated With Recurrent Bacterial Vaginosis.

BACKGROUND: Self-reported unprotected vaginal sex seems to increase risk of bacterial vaginosis (BV). However, the validity of self-reports is questionable, given their inconsistency with more objective measures of recent semen exposure such as detection of prostate-specific antigen (PSA). We examined whether recent unprotected sex, as measured both by PSA detection on vaginal swabs and by self-report, was associated with increased BV recurrence. METHODS: We analyzed randomized trial data from nonpregnant, BV-positive adult women recruited from a sexually transmitted disease clinic. Participants received BV therapy at enrollment and were scheduled to return after 4, 12, and 24 weeks. Bacterial vaginosis (by Nugent score) and PSA were measured at each visit. We used Cox proportional hazards models to examine the association between PSA positivity and recurrent BV. We also evaluated associations between self-reported unprotected sex (ever/never since the last visit and in the last 48 hours, analyzed separately) and recurrent BV. RESULTS: Prostate-specific antigen and BV results were available for 96 women who contributed 226 follow-up visits. Prostate-specific antigen positivity was associated with increased BV recurrence (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.28-4.21). In contrast, we observed no significant increase in BV recurrence among women self-reporting unprotected sex since the last visit (aHR, 1.63; 95% CI, 0.77-3.43) or in the last 48 hours (aHR, 1.28; 95% CI, 0.70-2.36). CONCLUSIONS: Estimates from earlier studies linking self-reported unprotected sex and BV may be biased by misclassification. Biomarkers can improve measurement of unprotected sex, a critical exposure variable in sexual health research.

Risk of Bacterial Vaginosis Among Women With Herpes Simplex Virus Type 2 Infection: A Systematic Review and Meta-analysis.

BACKGROUND: Bacterial vaginosis (BV) is a perturbation of vaginal flora characterized by reduced levels of lactobacilli and concomitant overgrowth of anaerobic bacterial species. BV is highly prevalent and associated with multiple adverse outcomes, including enhanced human immunodeficiency virus transmission. Because recent reports reveal that herpes simplex virus type 2 (HSV-2) infection may increase BV risk, we initiated a systematic review and meta-analysis of the link between HSV-2 infection and BV. METHODS: We searched the MEDLINE, EMBASE, and CENTRAL databases to identify articles posted before 1 December 2014. Two screeners independently reviewed the titles and abstracts of all identified articles, reviewed the full text of articles deemed potentially eligible, and extracted data from 14 cross-sectional and 3 prospective studies. Using random-effects models, we computed separate pooled estimates for cross-sectional and prospective studies. RESULTS: The pooled odds ratio for cross-sectional studies was 1.60 (95% confidence interval, 1.32-1.94). Stronger support for the causal effect of HSV-2 infection on BV risk was revealed by the summary relative risk for the prospective studies, which was 1.55 (95% confidence interval, 1.30-1.84), with minimal heterogeneity (I(2) = 0). CONCLUSIONS: These analyses imply that HSV-2 infection is an important BV risk factor. Pharmacologic HSV-2 suppression may reduce BV incidence and BV-associated adverse events.

Differences in misreporting of sexual behavior over time: implications for HIV trials.

We used data from a prospective study of 300 women attending a sexually transmitted infection clinic in Kingston, Jamaica, to compare participant self-report of recent semen exposure to actual semen exposure measured by prostate-specific antigen in vaginal swabs. Underreporting of semen exposure was significantly more frequent at follow-up than baseline, suggesting that the accuracy of reports of sexual behavior may vary over time.

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation.

BACKGROUND: Postpartum contraception improves the health of mothers and children by lengthening birth intervals. For lactating women, contraception choices are limited by concerns about hormonal effects on milk quality and quantity and passage of hormones to the infant. Ideally, the contraceptive chosen should not interfere with lactation or infant growth. Timing of contraception initiation is also important. Immediately postpartum, most women have contact with a health professional, but many do not return for follow-up contraceptive counseling. However, immediate initiation of hormonal methods may disrupt the onset of milk production. OBJECTIVES: To determine the effects of hormonal contraceptives on lactation and infant growth SEARCH METHODS: We searched for eligible trials until 2 March 2015. Sources included the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, POPLINE, Web of Science, LILACS, ClinicalTrials.gov, and ICTRP. We also examined review articles and contacted investigators. SELECTION CRITERIA: We sought randomized controlled trials in any language that compared hormonal contraception versus another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception includes combined or progestin-only oral contraceptives, injectable contraceptives, implants, and intrauterine devices.Trials had to have one of our primary outcomes: breast milk quantity or biochemical composition; lactation initiation, maintenance, or duration; infant growth; or timing of contraception initiation and effect on lactation. Secondary outcomes included contraceptive efficacy while breastfeeding and birth interval. DATA COLLECTION AND ANALYSIS: For continuous variables, we calculated the mean difference (MD) with 95% confidence interval (CI). For dichotomous outcomes, we computed the Mantel-Haenszel odds ratio (OR) with 95% CI. Due to differing interventions and outcome measures, we did not aggregate the data in a meta-analysis. MAIN RESULTS: In 2014, we added seven trials for a new total of 11. Five reports were published before 1985 and six from 2005 to 2014. They included 1482 women. Four trials examined combined oral contraceptives (COCs), and three studied a levonorgestrel-releasing intrauterine system (LNG-IUS). We found two trials of progestin-only pills (POPs) and two of the etonogestrel-releasing implant. Older studies often lacked quantified results. Most trials did not report significant differences between the study arms in breastfeeding duration, breast milk composition, or infant growth. Exceptions were seen mainly in older studies with limited information.For breastfeeding duration, two of eight trials indicated a negative effect on lactation. A COC study reported a negative effect on lactation duration compared to placebo but did not quantify results. Another trial showed a lower percentage of the LNG-IUS group breastfeeding at 75 days versus the nonhormonal IUD group (reported P < 0.05) but no significant difference at one year.For breast milk volume, two older studies indicated lower volume for the COC group versus the placebo group. One trial did not quantify results. The other showed lower means (mL) for the COC group, e.g. at 16 weeks (MD -24.00, 95% CI -34.53 to -13.47) and at 24 weeks (MD -24.90, 95% CI -36.01 to -13.79). Another four trials did not report any significant difference between the study groups in milk volume or composition with two POPs, a COC, or the etonogestrel implant.Seven trials studied infant growth; one showed greater weight gain (grams) for the etonogestrel implant versus no method for six weeks (MD 426.00, 95% CI 58.94 to 793.06) but less compared with depot medroxyprogesterone acetate (DMPA) from 6 to 12 weeks (MD -271.00, 95% CI -355.10 to -186.90). The others studied POPs, COCs versus POPs, or an LNG-IUS. AUTHORS' CONCLUSIONS: Results were not consistent across the 11 trials. The evidence was limited for any particular hormonal method. The quality of evidence was moderate overall and low for three of four placebo-controlled trials of COCs or POPs. The sensitivity analysis included six trials with moderate quality evidence and sufficient outcome data. Five trials indicated no significant difference between groups in breastfeeding duration (etonogestrel implant insertion times, COC versus POP, and LNG-IUS). For breast milk volume or composition, a COC study showed a negative effect, while an implant trial showed no significant difference. Of four trials that assessed infant growth, three indicated no significant difference between groups. One showed greater weight gain in the etonogestrel implant group versus no method but less versus DMPA.