A Content Analysis of Reddit Users' Posts about Challenges to Contraceptive care-seeking during COVID-19-related Restrictions in the United States.

The COVID-19 pandemic in the United States caused disruptions in care seeking and delivery during the spring of 2020, including for contraceptive care. We examined how some individuals experienced and responded to barriers to accessing contraceptive care by conducting a content analysis of relevant Reddit posts. We collected 2666 posts by scraping relevant subreddits from February 1, 2020, to April 15, 2020, and filtering by selected keywords. Among the 101 posts on contraception and the COVID-19 pandemic, we explored three main themes: barriers to accessing general healthcare during the early pandemic, problems and concerns specific to contraceptive use, and attempts to navigate the obstacles to contraceptive care or use-related concerns. The Reddit posts demonstrated the disruptive force the early pandemic had on contraceptive care and provided a unique window into the concerns posters expressed on Reddit during this time. Many posters asked questions related to accessing contraception and side effects and sought reassurance from these online forums. Our results suggest that there were barriers to accessing reliable, high-quality, and evidence-based information about contraception during this disruption in care. The findings also underscore that conversational and interactive means of seeking out information are important modes for learning about and discussing contraception for some and may be especially helpful during clinic closures and other restrictions on access.

Impacts of COVID-19 on contraceptive and abortion services in low- and middle-income countries: a scoping review.

The COVID-19 pandemic has disproportionate effects on people living in low- and middle-income countries (LMICs), exacerbating weak health systems. We conducted a scoping review to identify, map, and synthesise studies in LMICs that measured the impact of COVID-19 on demand for, provision of, and access to contraceptive and abortion-related services, and reproductive outcomes of these impacts. Using a pre-established protocol, we searched bibliographic databases (December 2019-February 2021) and key grey literature sources (December 2019-April 2021). Of 71 studies included, the majority (61%) were not peer-reviewed, and 42% were based in Africa, 35% in Asia, 17% were multi-region, and 6% were in Latin America and the Caribbean. Most studies were based on data through June 2020. The magnitude of contraceptive service-related impacts varied widely across 55 studies (24 of which also included information on abortion). Nearly all studies assessing changes over time to contraceptive service provision noted declines of varying magnitude, but severe disruptions were relatively uncommon or of limited duration. Twenty-six studies addressed the impacts of COVID-19 on abortion and postabortion care (PAC). Overall, studies found increases in demand, reductions in provision and increases in barriers to accessing these services. The use of abortion services declined, but the use of PAC was more mixed with some studies finding increases compared to pre-COVID-19 levels. The impacts of COVID-19 varied substantially, including the country context, health service, and population studied. Continued monitoring is needed to assess impacts on these key health services, as the COVID-19 pandemic evolves.

Global research and learning agenda for building evidence on contraceptive-induced menstrual changes for research, product development, policies, and programs.

Background: Contraceptive-induced menstrual changes (CIMCs) can affect family planning (FP) users' lives in both positive and negative ways, resulting in both opportunities and consequences. Despite this, and despite the important links between FP and menstrual health (MH), neither field adequately addresses CIMCs, including in research, product development, policies, and programs globally. Methods: In November 2020, a convening of both MH and FP experts reviewed the existing evidence on CIMCs and identified significant gaps in key areas. Results: These gaps led to the establishment of a CIMC Task Force in April 2021 and the development of the Global Research and Learning Agenda: Building Evidence on Contraceptive-Induced Menstrual Changes in Research, Product Development, Policies, and Programs Globally (the CIMC RLA) , which includes four research agendas for (1) measurement, (2) contraceptive research and development (R&D) and biomedical research, (3) social-behavioral and user preferences research, and (4) programmatic research. Conclusions: Guided by the CIMC RLA, researchers, product developers, health care providers, program implementers, advocates, policymakers, and funders are urged to conduct research and implement strategies to address the beneficial and negative effects of CIMCs and support the integration of FP and MH. CIMCs need to be addressed to improve the health and well-being of women, girls, and other people who menstruate and use contraceptives globally. Disclaimer : The views expressed in this article are those of the authors. Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

The infrastructural capacity of Ghanaian health facilities to provide safe abortion and post-abortion care: a cross-sectional study.

BACKGROUND: Ghana is one of few countries in sub-Saharan Africa with relatively liberal abortion laws, but little is known about the availability and quality of abortion services nationally. The aim of this study was to describe the availability and capacity of health facilities to deliver essential PAC and SAC services in Ghana. METHODS: We utilized data from a nationally representative survey of Ghanaian health facilities capable of providing post-abortion care (PAC) and/or safe abortion care (SAC) (n = 539). We included 326 facilities that reported providing PAC (57%) or SAC (19%) in the preceding year. We utilized a signal functions approach to evaluate the infrastructural capacity of facilities to provide high quality basic and comprehensive care. We conducted descriptive analysis to estimate the proportion of primary and referral facilities with capacity to provide SAC and PAC and the proportion of SAC and PAC that took place in facilities with greater capacity, and fractional regression to explore factors associated with higher structural capacity for provision. RESULTS: Less than 20% of PAC and/or SAC providing facilities met all signal function criteria for basic or comprehensive PAC or for comprehensive SAC. Higher PAC caseloads and staff trained in vacuum aspiration was associated with higher capacity to provide PAC in primary and referral facilities, and private/faith-based ownership and rural location was associated with higher capacity to provide PAC in referral facilities. Primary facilities with a rural location were associated with lower basic SAC capacity. DISCUSSION: Overall very few public facilities have the infrastructural capacity to deliver all the signal functions for comprehensive abortion care in Ghana. There is potential to scale-up the delivery of safe abortion care by facilitating service provision all health facilities currently providing postabortion care. CONCLUSIONS: SAC provision is much lower than PAC provision overall, yet there are persistent gaps in capacity to deliver basic PAC at primary facilities. These results highlight a need for the Ghana Ministry of Health to improve the infrastructural capability of health facilities to provide comprehensive abortion care.

Contraceptive and abortion practices of young Ghanaian women aged 15-24: evidence from a nationally representative survey.

BACKGROUND: Young Ghanaian women experience high rates of unmet need for contraception and unintended pregnancy, and face unique barriers to accessing sexual and reproductive health services. This study provides a comprehensive national analysis of young women's contraceptive and abortion practices and needs. METHODS: In 2018, we conducted a nationally representative survey of women aged 15-49, including 1039 women aged 15-24. We used descriptive statistics, multivariable logistic and multinomial regression to compare young versus older (25-49 year-old) women's preferred contraceptive attributes, reasons for discontinuing contraception, quality of counseling, use of Primolut N-tablet, method choice correlates, and friends' and partners' influence. We also examined youth's self-reported abortion incidence, abortion methods, post-abortion care, and barriers to safe abortion. RESULTS: Among Ghanaian 15-24 year-olds who had ever had sex, one-third (32%) were using contraception. Compared to older women, they had higher desires to avoid pregnancy, lower ever use of contraception, more intermittent sexual activity, and were more likely to report pregnancies as unintended and to have recently ended a pregnancy. Young contraceptors most commonly used condoms (22%), injectables (21%), withdrawal (20%) or implants (20%); and were more likely than older women to use condoms, withdrawal, emergency contraception, and N-tablet. They valued methods for effectiveness (70%), no risk of harming health (31%) nor future fertility (26%), ease of use (20%), and no effect on menstruation (19%). Infrequent sex accounted for over half of youth contraceptive discontinuation. Relative to older women, young women's social networks were more influential on contraceptive use. The annual self-reported abortion rate among young women was 30 per thousand. Over half of young women used abortion methods obtained from non-formal providers. Among the third of young women who experienced abortion complications, 40% did not access treatment. CONCLUSIONS: Young people's intermittent sexual activity, desire for methods that do not harm their health, access barriers and provider bias, likely contribute to their greater use of coital-dependent methods. Providers should be equipped to provide confidential, non-discriminatory counseling addressing concerns about infertility, side effects and alternative methods. Use of social networks can be leveraged to educate around issues like safe abortion and correct use of N-tablet.

Young Ghanaian women can experience difficulties accessing sexual and reproductive health services, and many are not using contraception despite wanting to avoid pregnancy. To better understand their needs, we describe their preferences and behaviors around contraception and abortion. We surveyed a nationally representative sample of women aged 15­49, and compared young (15­24) versus older (25­49) women's contraceptive preferences, reasons for stopping contraception, quality of counseling, friends' and partners' influence on contraceptive use, and use of abortion. One-third of 15­24 year-olds who ever had sex were using contraception. Compared to older women, young women's pregnancies were more likely to be unintended and to end in abortion. Young women most commonly used condoms, injectables, withdrawal or implants; and were more likely than older women to use condoms, withdrawal, emergency contraception, and Primolut N-tablet. They preferred methods that were effective, did not harm their health or future fertility, were easy to use, and did not disrupt their menstrual cycle. Over half of young women who stopped contraception did so because they were not having sex regularly. Friends had more influence on contraceptive use among young women than older women. Each year on average, there were 30 abortions per 1000 young women. Over half of young women who had abortions used methods from non-formal providers, and 40% of those who had complications did not get treated. Providers should be equipped to provide confidential, non-discriminatory counseling about contraceptive side effects and options. Social networks can be used to educate women about safe abortion.

Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey.

Few studies in low- and middle-income countries have examined the use of fertility awareness-based methods (FABMs) for pregnancy prevention. Understanding the prevalence of FABM use among Ghanaian contraceptors and the characteristics and practices of users is essential. Our 2018 nationally representative survey of Ghanaian women included detailed questions on the use of rhythm and Standard Days Method/Cycle Beads (SDM). After considering multimethod use patterns, we estimated likely FABM prevalence among contraceptors, identified characteristics associated with current use of an FABM (vs. current use of a hormonal method/intrauterine device [IUD]), and described how women report using FABMs. At least 18% of contracepting Ghanaian women likely use an FABM, though this may be underreported. Among FABM users, 57% reported current use of an FABM alone; the remainder reported concurrent use of other methods. Women who were older, richer, more educated, and had fewer children had higher odds of current FABM use versus IUD/hormonal method. Although FABM users were more likely than other contraceptors to correctly identify the approximate fertile time, only 50% of FABM users did so correctly. Most (92%) rhythm users were interested in making their method use more effective. While 72% had heard of SDM, less than 25% had heard of various other ways to make the rhythm method more effective. Only 17% of rhythm users had ever discussed the method with a health professional. Rhythm users indicated substantial willingness to track additional biomarkers (e.g., daily temperature or cervical mucus) or to use a phone to enhance the effectiveness of their method, and most indicated no substantial difficulty getting partners to abstain or withdraw on fertile days. A nontrivial proportion of reproductive age Ghanaian women are using an FABM, nearly all of whom are interested in learning how to improve its effectiveness. The family planning field should better address these women's contraceptive needs in commitment to reproductive autonomy and choice.

Hormonal contraceptive use in Ghana: The role of method attributes and side effects in method choice and continuation.

OBJECTIVE: To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy. STUDY DESIGN: We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. RESULTS: Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. CONCLUSIONS: Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. IMPLICATIONS: Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

Prevalence and Correlates of Perceived Infertility in Ghana.

Perceived infertility is an understudied phenomenon in low- and middle-income countries, where biomedical infertility can have severe consequences, particularly for women. We conducted a nationally representative survey of Ghanaian women, estimated the prevalence of and reasons for perceived infertility, and assessed factors associated with higher levels of perceived infertility using a partial proportional odds model. Among 4,070 women, 13 percent believed they were "very likely" to have difficulty getting pregnant when they wanted to, 21 percent believed this was "somewhat likely," and 66 percent believed this was "not at all likely." Reasons for perceived infertility varied by whether the respondent was currently seeking pregnancy. In multivariable analysis, several factors were associated with higher levels of perceived infertility, while unexpectedly, women who reported ever using contraception were less likely to report perceived infertility. Acknowledging the need to address infertility globally and understanding the role of perceived infertility are important components in supporting people's ability to decide whether and when to have children.

Perceived Infertility Among Young Adults in Balaka, Malawi.

CONTEXT: Perceived infertility-an individual's belief that she or he is unable to conceive or impregnate a partner-may lead to contraceptive nonuse and unintended pregnancy, among other concerns, but has not been widely studied in low-income settings. METHODS: A measure of perceived infertility previously used in the United States was included in a 2015 survey of young adults in Balaka, Malawi. The prevalence of potential perceived infertility (i.e., believing it is a little or substantially likely that one is infertile, or would have difficulty getting pregnant or impregnating a partner; PPI) was estimated among the analytic sample of 1,064 women and 527 men aged 21-29. Multivariable logistic regression was used to identify variables associated with PPI; respondents' reasons for PPI and their estimates of the probability of pregnancy after unprotected sex were also investigated. RESULTS: The prevalence of PPI was 8% overall, and 20% among nulliparous women. Factors associated with PPI and reasons for PPI varied by gender. For women, PPI was significantly associated with age, education, an interaction term between age and education, number of sexual partners, feelings if she were to become pregnant next month, parity and contraceptive use. For men, PPI was associated with an interaction term between age and education, number of sex partners and marital status. Respondents tended to overestimate the probability of pregnancy after unprotected sex. CONCLUSIONS: Perceived infertility was lower in Malawi than in the United States, although substantial among certain subgroups. Educational interventions aimed at increasing knowledge about pregnancy probabilities and the return of fertility after contraceptive discontinuation may reduce concerns around perceived infertility.

RESUMEN Contexto: La infecundidad percibida ­ la creencia de una persona de que ella o él no puede concebir o embarazar a una pareja ­ podría conducir a la falta de uso de anticonceptivos y al embarazo no planeado, entre otras preocupaciones, pero esto no se ha estudiado ampliamente en entornos de bajos ingresos. Métodos: Una medida de la infecundidad percibida utilizada anteriormente en los Estados Unidos se incluyó en una encuesta de 2015 aplicada a adultos jóvenes en Balaka, Malawi. La prevalencia de infecundidad potencial percibida (es decir, creer que es poco o muy probable que una persona es infecunda, o que tendría dificultades para quedar embarazada o para embarazar a una pareja; IPP) se estimó entre la muestra analítica de 1,064 mujeres y 527 hombres de 21 a 29 años de edad. Se usó regresión logística multivariable para identificar variables asociadas con la IPP; también se investigaron las razones de las personas encuestadas para experimentar IPP y sus estimaciones de la probabilidad de embarazo después de tener relaciones sexuales sin protección. Resultados: La prevalencia de IPP fue del 8% en general y del 20% entre mujeres nulíparas. Los factores asociados con la IPP y las razones para experimentar IPP variaron según el género. Para las mujeres, la IPP se asoció significativamente con la edad, la escolaridad, un período de interacción entre la edad y la escolaridad, el número de parejas sexuales, los sentimientos si quedara embarazada el próximo mes, la paridad y el uso de anticonceptivos. Para los hombres, la IPP se asoció con un período de interacción entre edad y escolaridad, número de parejas sexuales y estado conyugal. Las personas encuestadas tendieron a sobreestimar la probabilidad de embarazo después de tener relaciones sexuales sin protección. Conclusiones: La infecundidad percibida fue menor en Malawi que en los Estados Unidos, aunque fue sustancial entre ciertos subgrupos. Las intervenciones educativas destinadas a aumentar el conocimiento sobre las probabilidades de embarazo y el retorno de la fecundidad después de la interrupción de los anticonceptivos pueden reducir las preocupaciones sobre la infecundidad percibida.

RÉSUMÉ Contexte: L'infertilité perçue ­ le fait de croire, pour une personne, qu'elle ne peut pas concevoir ou causer une grossesse ­ peut conduire, entre autres préoccupations, à l'absence de contraception et à la grossesse non planifiée, sans toutefois avoir été largement étudiée dans les contextes à faible revenu. Méthodes: Une mesure de l'infertilité perçue utilisée précédemment aux États-Unis a été incluse dans une enquête menée en 2015 auprès de jeunes adultes de Balaka (Malawi). La prévalence d'une éventuelle infertilité perçue (c'est-à-dire croire qu'il est légèrement ou fortement probable qu'on soit infertile, ou qu'on aurait des difficultés à concevoir ou à causer la grossesse d'une partenaire; IPP) a été estimée dans l'échantillon analytique de l'étude, composé de 1 064 femmes et de 527 hommes âgés de 21 à 29 ans. Les variables associées à l'IPP ont été identifiées par régression logistique multivariable. Les raisons d'IPP données par les répondants et leurs estimations de la probabilité d'une grossesse après un rapport sexuel non protégé ont aussi été étudiées. Résultats: La prévalence de l'IPP était de 8% au total, et de 20% parmi les femmes nullipares. Les facteurs associés à l'IPP et les raisons de l'IPP variaient suivant le sexe. Pour les femmes, l'IPP était significativement associée à l'âge, à l'éducation, à un terme d'interaction entre l'âge et l'éducation, au nombre de partenaires sexuels, aux sentiments que susciterait la découverte d'une grossesse le mois suivant, à la parité et à la pratique contraceptive. Pour les hommes, l'IPP était associée à un terme d'interaction entre l'âge et l'éducation, au nombre de partenaires sexuelles et à la situation matrimoniale. Les répondants tendaient à surestimer la probabilité d'une grossesse après un rapport sexuel non protégé. Conclusions: L'infertilité perçue s'est révélée inférieure au Malawi, par rapport aux États-Unis, bien qu'elle soit apparue considérable dans certains sous-groupes. Les interventions éducatives visant à accroître les connaissances sur les probabilités de grossesse et le retour à la fertilité après l'arrêt de la contraception peuvent réduire les préoccupations concernant l'infertilité perçue.

Estimating the incidence of abortion: using the Abortion Incidence Complications Methodology in Ghana, 2017.

Introduction: Induced abortion is legally permitted in Ghana under specific conditions, but access to services that meet guidelines approved by government is limited. As part of a larger project comparing five methodologies to estimate abortion incidence, we implemented an indirect estimation approach: the Abortion Incidence Complications Methodology (AICM), to understand the incidence of abortion in Ghana in 2017. Methods: We drew a nationally representative, two-stage, stratified sample of health facilities. We used information from 539 responding facilities to estimate treated complications stemming from illegal induced abortions, and to estimate the number of legal abortions provided. We used information from 146 knowledgeable informants to generate zonal multipliers representing the inverse of the proportion of illegal induced abortions treated for complications in facilities in Ghana's three ecological zones. We applied multipliers to estimates of treated complications from illegal abortions, and added legal abortions to obtain an annual estimate of all induced abortions. Results: The AICM approach suggests that approximately 200 000 abortions occurred in Ghana in 2017, corresponding to a national abortion rate of 26.8 (95% CI 21.7 to 31.9) per 1000 women 15-49. Abortion rates were lowest in the Northern zone (18.6) and highest in the Middle zone (30.4). Of all abortions, 71% were illegal. Conclusion: Despite Ghana's relatively liberal abortion law and efforts to expand access to safe abortion services, illegal induced abortion appears common. A concurrently published paper compares the AICM-derived estimates presented in this paper to those from other methodological approaches.

Global Contraceptive Failure Rates: Who Is Most at Risk?

Contraceptive failure is a major contributor to unintended pregnancy worldwide. DHS retrospective calendars, which are the most widely used data source for estimating contraceptive failure in low-income countries, vary in quality across countries and surveys. We identified surveys with the most reliable calendar data and analyzed 105,322 episodes of contraceptive use from 15 DHSs conducted between 1992 and 2014. We estimate contraceptive method-specific 12-month failure rates. We also examined how failure rates vary by age, education, socioeconomic status, contraceptive intention, residence, and marital status using multilevel piecewise exponential hazard models. Our failure rate estimates are significantly lower than results from the United States and slightly higher than previous studies that included more DHS surveys, including some with lower-quality data. We estimate age-specific global contraceptive failure rates and find strong, consistent age patterns with the youngest users experiencing failure rates up to ten times higher than older women for certain methods. Failure also varies by socioeconomic status, with the poorest, and youngest, women at highest risk of experiencing unintended pregnancy due to failure.

Pharmacokinetic, biologic and epidemiologic differences in MPA- and NET-based progestin-only injectable contraceptives relative to the potential impact on HIV acquisition in women.

Access to safe and effective contraceptive choices is a reproductive right and contributes tremendously to improvements in maternal and child health. Progestin-only injectables, particularly intramuscularly injected depot medroxyprogesterone acetate (DMPA-IM), have received increased attention given findings suggesting a potential association with increased HIV risk. For women at high risk of HIV, the World Health Organization's Medical eligibility criteria for contraceptive use currently aggregate recommendations for all progestin-only injectables, including DMPA-IM, subcutaneously injected DMPA (DMPA-SC) and intramuscularly injected norethindrone/ norethisterone enanthate (NET-EN), except in the case of some drug interactions. We considered whether published data indicate differences or similarities between these injectables relevant to risk of acquiring HIV. In vitro data confirm different biological activities of these distinct progestins, including that MPA, and not NET, binds and activates the glucocorticoid receptor resulting in different biological effects relevant to immune function. Limited clinical data suggest changes in immunologic activity following DMPA-IM and NET-EN initiation, but interstudy variation and study design differences diminish ability to determine clinical relevance and the degree to which DMPA-IM and NET-EN could act differentially. The highest-quality epidemiologic studies suggest a potential 40% increase in HIV incidence in users of DMPA-IM relative to women not using hormonal contraception but no significant increase in risk in users of NET-EN. In our opinion, most of the available biologic activity and epidemiologic data indicate that DMPA and NET-EN are likely to act differently, and data remain too limited to evaluate differences between DMPA-IM and DMPA-SC.

Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention: A Systematic Review.

OBJECTIVE: To summarize best available prospective data on typical and perfect use effectiveness of fertility awareness-based methods for avoiding pregnancy. DATA SOURCES: We conducted a systematic review of studies published in English, Spanish, French, or German by June 2017 in MEDLINE, EMBASE, CINAHL, Web of Science, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We reviewed 8,755 unique citations and included 53 studies that contained 50 or greater women using a specific fertility awareness-based method to avoid pregnancy, calculated life table pregnancy probabilities or Pearl rates, and prospectively measured pregnancy intentions and outcomes. We systematically evaluated study quality. TABULATION, INTEGRATION, AND RESULTS: Of 53 included studies, we ranked 0 high quality, 21 moderate quality, and 32 low quality for our question of interest. Among moderate-quality studies, first-year typical use pregnancy rates or probabilities per 100 woman-years varied widely: 11.2-14.1 for the Standard Days Method, 13.7 for the TwoDay Method, 10.5-33.6 for the Billings Ovulation Method, 4-18.5 for the Marquette Mucus-only Method, 9.0-9.8 for basal body temperature methods, 13.2 for single-check symptothermal methods, 11.2-33.0 for Thyma double-check symptothermal methods, 1.8 for Sensiplan, 25.6 for Persona, 2-6.8 for the Marquette Monitor-only Method, and 6-7 for the Marquette Monitor and Mucus Method. First-year perfect use pregnancy rates or probabilities among moderate-quality studies were 4.8 for the Standard Days Method, 3.5 for the TwoDay Method, 1.1-3.4 for the Billings Ovulation Method, 2.7 for the Marquette Mucus Method, 0.4 for Sensiplan, 12.1 for Persona, and 0 for the Marquette Monitor. CONCLUSION: Studies on the effectiveness of each fertility awareness-based method are few and of low to moderate quality. Pregnancy rates or probabilities varied widely across different fertility awareness-based methods (and in some cases, within method types), even after excluding low-quality studies. Variability across populations studied precludes comparisons across methods.

Published analysis of contraceptive effectiveness of Daysy and DaysyView app is fatally flawed.

BACKGROUND: In March 2018, Dr. Martin C. Koch and colleagues published an analysis purporting to measure the effectiveness of the Daysy device and DaysyView app for the prevention of unintended pregnancy. Unfortunately, the analysis was flawed in multiple ways which render the estimates unreliable. Unreliable estimates of contraceptive effectiveness can endanger public health. MAIN BODY: This commentary details multiple concerns pertaining to the collection and analysis of data in Koch et al. 2018. A key concern pertains to the inappropriate exclusion of all women with fewer than 13 cycles of use from the Pearl Index calculations, which has no basis in standard effectiveness calculations. Multiple additional methodological concerns, as well as prior attempts to directly convey concerns to the manufacturer regarding marketing materials based on prior inaccurate analyses, are also discussed. CONCLUSION: The Koch et al. 2018 publication produced unreliable estimates of contraceptive effectiveness for the Daysy device and DaysyView app, which are likely substantially higher than the actual contraceptive effectiveness of the device and app. Those estimates are being used in marketing materials which may inappropriately inflate consumer confidence and leave consumers more vulnerable than expected to the risk of unintended pregnancy. Prior attempts to directly convey concerns to the manufacturer of this device were unsuccessful in preventing publication of subsequent inaccurate analyses. To protect public health, concerns with this analysis should be documented in the published literature, the Koch et al. 2018 analysis should be retracted, and marketing materials on contraceptive effectiveness should be subjected to appropriate oversight.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes.

INTRODUCTION: Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review. METHODS: We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers. RESULTS: We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains. CONCLUSIONS: Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015.

OBJECTIVES: Contraceptive prevalence in the United States is typically calculated according to the most effective method of contraception reported. This could theoretically underestimate the number of women using fertility-awareness based methods (FABMs), including those who use other methods (e.g., condoms) during the fertile window, but the extent of any such underestimation has not been assessed. STUDY DESIGN: We used data from the 2013-2015 National Survey of Family Growth to examine the extent to which women report use of an FABM alone or with other methods. We investigated FABM use patterns and compared demographic profiles of FABM users versus other contraceptive users. We considered how to most appropriately define FABM prevalence. RESULTS: One in six (16.5%) female contraceptors 15-44 reported use of multiple contraceptive methods in their month of interview. Among women reporting current FABM use, 67% used it alone or with withdrawal, 24% also used condoms or emergency contraception, and 9% also used hormonal contraception or sterilization. An FABM was the most effective method reported for 2.2% of current contraceptive users; while 3.2% of contraceptors reported any current FABM use. We posit an FABM prevalence of 3% (1,113,000 users) among US female contraceptors (2013-2015). FABM users had similar sociodemographic characteristics as other method users, but were more likely married. CONCLUSIONS: Currently, consideration of multiple method use has modest implications for estimation of FABM prevalence among contraceptors (i.e., an increase from 2.2% to 3%). However, multiple method use patterns with FABMs may merit special consideration if FABM use continues to increase. IMPLICATIONS: Researchers and providers need to be familiar with the unique patterns of use among FABM users in order to more effectively measure and counsel about these methods.