First-trimester surgical abortion practice in Canada in 2012.

OBJECTIVE: To evaluate practices among first-trimester surgical abortion facilities and providers in Canada in 2012 and examine the characteristics of the surgical abortion work force. DESIGN: Self-administered paper or electronic survey adapted from a survey previously fielded in the United States. SETTING: Canada. PARTICIPANTS: Facility administrators and physicians. MAIN OUTCOMES MEASURES: Descriptive statistics on reported first-trimester surgical abortion practice and provider demographic characteristics. RESULTS: Eighty-three percent of identified facilities (78 of 94) and 178 physicians responded. Of the respondents, 99% of facilities and 96% of physicians provided first-trimester surgical abortions. Responding facilities provided 68,154 first-trimester surgical abortions in 2012. This represented 96% of their reported total (combined medical and surgical) first-trimester abortions. More than half (55%) of responding facilities were community based, while 45% were hospital affiliated. Most physician providers were female (68%) and were family doctors (59%). Preoperatively, 96% of physicians routinely used ultrasound and 89% gave perioperative antibiotics. Almost half (48%) used manual vacuum aspiration, but less than 35% did so beyond 9 weeks after the last menstrual period. At most facilities, most procedures were performed under combined local anesthesia and intravenous sedation (73%); only 7% indicated deep sedation or general anesthesia were used exclusively. Postoperatively, 81% of physicians performed immediate tissue examination and 96% offered postabortion contraception on the same day as the abortion. Other assessed outcomes included medication regimens and cervical preparation, with a high degree of consistency among facilities and physicians. CONCLUSION: First-trimester surgical abortion providers are mostly family physicians and most are female. Practices across Canada were mostly uniform and followed evidence-based guidelines. Uptake of the most recent Canadian practice guidelines may help further standardize patient care and improve routine perioperative antibiotic use and immediate tissue examination.

Continuation rates of two different-sized copper intrauterine devices among nulliparous women: Interim 12-month results of a single-blind, randomised, multicentre trial.

Background: The most widely used copper intrauterine device (IUD) in the world (the TCu380A), and the only product available in many countries, causes side effects and early removals for many users. These problems are exacerbated in nulliparous women, who have smaller uterine cavities compared to parous women. We compared first-year continuation rates and reasons/probabilities for early removal of the TCu380A versus a smaller Belgian copper IUD among nulliparous users. Methods: This 12-month interim report is derived from a pre-planned interim analysis of a sub population and focused on key secondary comparative endpoints. In this participant-blinded trial at 16 centres in the USA, we randomised participants aged 17-40 in a 4:1 ratio to the NT380-Mini or the TCu380A. In the first year, participants had follow-up visits at 6-weeks and 3, 6, and 12-months, and a phone contact at 9 months; we documented continued use, expulsions, and reasons for removal. Among participants with successful IUD placement, we compared probabilities of IUD continuation and specific reasons for discontinuation using log-rank tests. This trial is registered with ClinicalTrials.gov number NCT03124160 and is closed to recruitment. Findings: Between June 1, 2017, and February 25, 2019, we assigned 927 nulliparous women to either the NT380-Mini (n = 744) or the TCu380A (n = 183); the analysis population was 732 (NT380-Mini) and 176 (TCu380A). Participants using the NT380-Mini, compared to the TCu380A, had higher 12-month continuation rates (78·7% [95% CI: 72·9-84·5%] vs. 70·2% [95% CI: 59·7-80·7], p = 0·014), lower rates of removal for bleeding and/or pain (8·1% vs. 16·2%, p = 0·003) and lower IUD expulsion rates (4·8% vs. 8·9%, p = 0·023), respectively. Interpretation: The NT380-Mini offers important benefits for a nulliparous population compared to the TCu380A in the first twelve months, when pivotal experiences typically occur. Higher continuation rates with the NT380-Mini may avert disruptions in contraceptive use and help users avoid unintended pregnancy. Funding: Bill & Melinda Gates Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Mona Lisa, N.V. (Belgium).

Contraceptive decision making among pregnancy-capable individuals with opioid use disorder at a tertiary care center in Massachusetts.

OBJECTIVE: To explore contraceptive decision making among recently pregnant patients with a history of opioid use disorder. STUDY DESIGN: We conducted semi-structured qualitative interviews, based on principles of the Ottawa Decision Support Framework, with 20 recently pregnant individuals diagnosed with opioid use disorder at a tertiary care medical center in Massachusetts. We audio-recorded the interviews and they were transcribed verbatim. We analyzed our interview data using inductive and deductive coding. RESULTS: Participants value the availability of barrier methods as a means of preventing both sexually transmitted infections and pregnancy. For some participants, housing instability makes storing contraceptive methods and managing personal hygiene related to bleeding patterns difficult. For others, housing instability impacts their overall fertility goals. Side effects including weight gain, interactions with mood stabilizing medications, concern regarding post-operative opioids, or intrinsic aspects of a method that serve as reminders of opioid use may be unacceptable given the risk of relapse. The relapsing and remitting arc of recovery make remembering important aspects of both short- and long-acting contraceptive method use difficult, yet participants offer strategies to aid in doing so. CONCLUSION: When choosing a contraceptive method participants in our study exhibit similarities to individuals with other chronic medical conditions as well as motivations specific to opioid use disorder. Their contraceptive decisions are grounded in integrating a method into a chaotic life, preventing relapse, and protecting future fertility. IMPLICATIONS: Our data highlight how lived experiences at the intersection of active opioid use disorder and recovery fundamentally shape the lens through which pregnancy-capable individuals with opioid use disorder view their contraceptive decisions.

Obstetric Outcomes After Failed Hysteroscopic and Laparoscopic Sterilization Procedures.

OBJECTIVE: To compare obstetric outcomes after failed hysteroscopic and laparoscopic sterilization. METHODS: This retrospective cohort study examined pregnancy outcomes including live birth, preterm birth, stillbirth, spontaneous abortion, therapeutic abortion, ectopic pregnancies, and gestational trophoblastic disease using a commercial claims administrative database for the years 2007-2013. We used a Z-test to compare pregnancy outcomes per 100 person-years based on type of sterilization. Cox proportional hazard models controlled for patient age, geographic region, urbanicity, comorbidities, and insurance type. RESULTS: We evaluated 997 pregnancy outcomes among 817 women from a total of 70,115 women with a history of either hysteroscopic sterilization (n=387 pregnancies/27,724 cases) or laparoscopic sterilization (n=610 pregnancies/42,391 cases). Women undergoing hysteroscopic sterilization were slightly older than, but otherwise similar to, women undergoing laparoscopic sterilization. The most common outcome was live birth, which was more likely after hysteroscopic sterilization compared with laparoscopic sterilization (adjusted hazard ratio 1.32, 95% CI 1.09-1.60). The rate of spontaneous abortion was not statistically significantly different between the two groups. Therapeutic abortion occurred more often after hysteroscopic sterilization (adjusted hazard ratio 1.49, 95% CI 1.10-2.01), whereas ectopic pregnancies occurred less often (adjusted hazard ratio 0.12, 95% CI 0.05-0.29) compared with laparoscopic sterilization. CONCLUSION: Hysteroscopic sterilization is associated with higher rates of live birth and lower rates of ectopic pregnancy compared with laparoscopic sterilization. Spontaneous abortion and preterm birth rates were similar in both groups. These data do not support an adverse effect of hysteroscopic sterilization on subsequent pregnancy outcomes.

Intra-fetal Compared With Intra-amniotic Digoxin Before Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To compare the effectiveness of 1.0 mg intra-fetal or intra-amniotic digoxin to achieve fetal asystole before second-trimester surgical pregnancy termination. METHODS: In a randomized trial, women received 1.0 mg transabdominal intra-fetal or intra-amniotic digoxin on the day of laminaria placement before dilation and evacuation between 20 and 24 weeks of gestation. The primary outcome was incidence of fetal asystole, documented immediately before dilation and evacuation. We planned to analyze the primary outcome by original group assignment as well as by as-treated and per-protocol populations. A sample size of 270 was needed to detect an 8% difference in failure rates between groups. Prespecified secondary outcomes included the incidence of adverse events, side effects, and procedural differences. RESULTS: Between January 2012 and January 2013, we screened 381 women and randomized 270 women to receive intra-fetal (n=136) or intra-amniotic (n=134) digoxin. Characteristics were similar across groups; the mean gestational age was 21.6 weeks (standard deviation 1.2). The proportion of fetal asystole was higher in the intra-fetal group (128/135 [94.8%]) than the intra-amniotic group (107/130, 82.3%; relative risk of failure to achieve asystole 3.41, 95% confidence interval 1.52-7.68). Results were similar in the as-treated and per-protocol populations. There were no significant differences in adverse events or side effects and no differences in injection duration, operative time, or estimated blood loss. CONCLUSION: Administration of intra-fetal injection of digoxin led to a higher proportion of participants achieving fetal asystole within 24 hours than intra-amniotic injection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01047748.

Abortion health services in Canada: Results of a 2012 national survey.

OBJECTIVE: To determine the location of Canadian abortion services relative to where reproductive-age women reside, and the characteristics of abortion facilities and providers. DESIGN: An international survey was adapted for Canadian relevance. Public sources and professional networks were used to identify facilities. The bilingual survey was distributed by mail and e-mail from July to November 2013. SETTING: Canada. PARTICIPANTS: A total of 94 abortion facilities were identified. MAIN OUTCOME MEASURES: The number and location of services were compared with the distribution of reproductive-age women by location of residence. RESULTS: We identified 94 Canadian facilities providing abortion in 2012, with 48.9% in Quebec. The response rate was 83.0% (78 of 94). Facilities in every jurisdiction with services responded. In Quebec and British Columbia abortion services are nearly equally present in large urban centres and rural locations throughout the provinces; in other Canadian provinces services are chiefly located in large urban areas. No abortion services were identified in Prince Edward Island. Respondents reported provision of 75 650 abortions in 2012 (including 4.0% by medical abortion). Canadian facilities reported minimal or no harassment, in stark contrast to American facilities that responded to the same survey. CONCLUSION: Access to abortion services varies by region across Canada. Services are not equitably distributed in relation to the regions where reproductive-age women reside. British Columbia and Quebec have demonstrated effective strategies to address disparities. Health policy and service improvements have the potential to address current abortion access inequity in Canada. These measures include improved access to mifepristone for medical abortion; provincial policies to support abortion services; routine abortion training within family medicine residency programs; and increasing the scope of practice for nurses and midwives to include abortion provision.

First-trimester medical abortion practices in Canada: National survey.

OBJECTIVE: To understand the current availability and practice of first-trimester medical abortion (MA) in Canada. DESIGN: Using public sources and professional networks, abortion facilities across Canada were identified for a cross-sectional survey on medical and surgical abortion. English and French surveys were distributed by surface or electronic mail between July and November 2013. SETTING: Canada. PARTICIPANTS: A total of 94 abortion facilities were identified. MAIN OUTCOME MEASURES: Descriptive statistics on MA practice and facility and provider characteristics, as well as comparisons of MA practice by facility and provider characteristics using χ2 and t tests. RESULTS: A total of 78 of 94 (83.0%) facilities responded. Medical abortion represented 3.8% of first-trimester abortions reported (2706 of 70 860) in 2012. Among the facilities offering MA, 45.0% performed fewer than 500 first-trimester abortions a year, while 35.0% performed more than 1000. More MAs were performed in private offices or ambulatory health centres than in hospitals. Sixty-two physicians from 28 of 78 facilities reported providing first-trimester MA; 87.1% also provided surgical abortion. More than three-quarters of MA physicians were female and 56.5% were family physicians. A preponderance (85.2%) of providers offered methotrexate with misoprostol. Nearly all physicians (90.3%) required patients to have an ultrasound before MA, and 72.6% assessed the completion of the abortion with ultrasonography. Most physicians (74.2%) offered MA through 49 days after the onset of the last menstrual period, and 21.0% offered MA through 50 to 56 days; 37.1% reported providing MA to patients who lived more than 2 hours away. Four physicians from 1 site provided MA via telemedicine. CONCLUSION: In Canada, MA provision using methotrexate and misoprostol is consistent with best-practice guidelines, but MA is rare and its availability is unevenly distributed.

Randomized clinical trial of self versus clinical administration of subcutaneous depot medroxyprogesterone acetate.

OBJECTIVES: To evaluate feasibility, acceptability, continuation, and trough serum levels following self-administration of subcutaneous (sc) depot medroxyprogesterone acetate (DMPA). STUDY DESIGN: Women presenting to a family planning clinic to initiate, restart or continue DMPA were offered study entry. Participants were randomized in a 2:1 ratio to self- or clinician administered sc DMPA 104 mg. Those randomized to self-administration were taught to self-inject and were supervised in performing the initial injection; they received printed instructions and a supply of contraceptive injections for home use. Participants randomized to clinician administration received usual care. Continued DMPA use was assessed by self-report and trough medroxyprogesterone acetate levels at 6 and 12 months. RESULTS: Two hundred fifty women were invited to participate, and 137 (55%) enrolled. Of these, 91 were allocated to self-administration, and 90/91 were able to correctly self-administer sc DMPA. Eighty-seven percent completed follow-up. DMPA use at 1 year was 71% for the self-administration group and 63% for the clinic group (p=0.47). Uninterrupted DMPA use was 47% and 48% for the self and clinic administration groups at 1 year (p=0.70), respectively. Serum analyses confirmed similar mean DMPA levels in both groups and therapeutic trough levels in all participants. CONCLUSIONS: Sixty-three percent of women approached were interested in trying self-administration of DMPA, even in the context of a randomized trial, and nearly all eligible for enrollment were successful at doing so. Self-administration and clinic administration resulted in similar continuation rates and similar DMPA serum levels. Self-administration of sc DMPA is feasible and may be an attractive alternative for many women. IMPLICATIONS: Self-administration of sc DMPA is a feasible and attractive option for many women. Benefits include increased control over contraceptive measures and less time spent on contracepting behaviors. Globally, self-administration has the potential to revolutionize contraceptive uptake by increasing the number of women with access to DMPA.

Should we do more to improve oral contraceptive continuation?

Oral contraceptives are commonly chosen methods whose contraceptive effectiveness is very user-dependent. Approaches to significantly improving oral contraceptive continuation have been largely unsuccessful. Long-acting reversible methods are the most highly effective reversible contraceptives, with the highest continuation rates, and should be the first-line methods offered to reproductive-aged women.

An exploratory analysis of associations between eating disordered symptoms, perceived weight changes, and oral contraceptive discontinuation among young minority women.

PURPOSE: To explore associations between eating-disordered (ED) symptoms, perceived oral contraceptive (OC)-related weight changes, and OC discontinuation among young minority women. METHODS: We conducted a prospective substudy of a randomized controlled trial evaluating the impact of a pill pack supply (3 vs. 7 months) on OC continuation among young urban women presenting to a university-affiliated community-based family planning clinic for OC management. Participants (n = 354) were adolescent (n = 173) and young adult (n = 181) women aged 13-24 years, predominantly underinsured and largely Hispanic (92%). We conducted a structured baseline interview that included an ED screening instrument. At the 6-month follow-up, we conducted a telephone interview to determine OC continuation and dimensions of perceived OC-related weight changes during the study period. RESULTS: At baseline, 24% of the subjects fulfilled the moderate/severe ED symptom screen criteria (n = 60). By 6 months, 57% of the subjects (n = 200) reported weight changes and 62% (n = 218) had discontinued OC use. Unadjusted discontinuation rates were similar across age- and ED symptom groups. In multivariate analysis, both ED symptoms (odds ratio = .49, 95% confidence interval = .25-.96, p = .04) and perceived weight changes (odds ratio = .60, 95% confidence interval = .38-.94, p = .03) were negatively associated with OC continuation. CONCLUSIONS: ED symptoms and perceived weight changes were associated with an increased likelihood of OC discontinuation among these young women. Reproductive health practitioners should consider psychological symptoms when managing OC.

Influence of depressed mood and psychological stress symptoms on perceived oral contraceptive side effects and discontinuation in young minority women.

BACKGROUND: We examined the influence of depressed mood and psychological stress on oral contraceptive (OC) side effects and discontinuation. STUDY DESIGN: We administered standard psychological instruments to 354 young women (13-24 years old) beginning a 6-month OC continuation intervention trial and questions on OC side effects and use at 6 months. Logisitic regression determined the relationships between psychological conditions, perceived OC side effects and continuation rates. RESULTS: Baseline depressed mood (21%) and stress (19%) and 6-month mood (25%) and weight changes (57%) were relatively common. Only 38% continued OCs at 6 months. Depressed mood [odds ratio (OR) 2.27, confidence interval (CI) 1.25-4.15, p=.007] and stress (OR 2.07, CI 1.12-3.82, p=.02) were associated with perceived OC-related moodiness; depressed mood was associated with perceived weight loss (OR 1.89, CI 1.01-3.55, p=.05). Depressed mood (OR 0.54, CI 0.29-0.99, p=.04), stress (OR 0.48, CI 0.25-0.91, p=.03) and perceived weight change (OR 0.60, CI 0.38-0.94, p=.03) all reduced the likelihood of OC continuation. CONCLUSION: Young women with adverse psychological symptoms are at risk for perceived OC side effects and discontinuation.

The effect of pack supply on oral contraceptive pill continuation: a randomized controlled trial.

OBJECTIVE: The often small number of oral contraceptive pill (OCP) cycles provided may contribute to high rates of discontinuation. We examined the effect of an increased OCP supply on 6-month continuation rates. METHODS: This was a randomized trial of women initiating OCP use at an urban family-planning clinic (n=700). All participants were randomized to receive three or seven cycles of OCPs. Participants younger than age 18 years or uninsured received their entire supply as packs; those older than age 18 years with insurance were additionally randomized to receive either packs or a prescription for refills. We contacted participants by telephone 6 months after enrollment to assess OCP continuation and adverse events. RESULTS: We obtained follow-up information from 76% of participants (260 of 342 in the three-pack group, 244 of 319 in the seven-pack group). Participants who received seven packs had higher 6-month continuation than participants who received three packs (51% compared with 35%, P<.001). The treatment effect was greater among participants younger than 18 years of age (49% compared with 12%, P<.001) than among those aged 18 years and older (52% compared with 40%, P=.018). Participants who received a prescription were less likely to continue OCP use than those who received packs (42% compared with 21%, P=.027). Adverse events in the study were rare and not associated with receiving more OCP packs. CONCLUSION: A greater OCP supply at the time of initiation can improve continuation rates, especially among women younger than 18 years of age. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00677742. LEVEL OF EVIDENCE: I.

Studying the use of oral contraception: a review of measurement approaches.

BACKGROUND: Although oral contraception (OC) misuse is presumed to play an important role in unwanted pregnancy, research findings have often been equivocal, perhaps reflecting unaddressed inconsistencies in methodological approaches. METHODS: Using established databases, we performed a systematic review of measurement methods for OC use using primary research reports published from January 1965 to December 2009. RESULTS: Terminology used to describe OC use, which included "continuation," "compliance," and "adherence," differed across studies and was rarely defined. The majority of studies (n = 27 of 38, 71%) relied solely on self-report measures of OC use. Only two reports described survey or interview questions, and reliability and validity data were seldom described. More rigorous measurement methods, such as pill counts (electronic or manual), serum and urinary biomarkers, and pharmacy records, were infrequently employed. Nineteen studies simultaneously used more than one method, but only three studies compared direct and indirect methods. CONCLUSIONS: The lack of a consistent, well-defined measurement of OC use limits our understanding of contraceptive misuse and related negative outcomes. Future research should clarify terminology, develop standardized measures, incorporate multimethod approaches with innovative methods, and publish details of measurement methods.