Use of reproductive health services among women using long- or short-acting contraceptive methods - a register-based cohort study from Finland.

BACKGROUND: Long-acting reversible contraceptives (LARCs) have superior contraceptive efficacy compared to short-acting reversible contraceptives (SARCs) and choosing LARCs over SARC methods reduces the need for abortion care. However, little is known how initiating these methods associates with the subsequent overall need of reproductive health services including family planning services, and visits for gynecological reasons in primary and specialized care. METHODS: We followed altogether 5839 non-sterilized women aged 15-44 years initiating free-of-charge LARC methods (n = 1689), initiating or switching SARC methods (n = 1524), or continuing with the same SARC method (n = 2626) at primary care family planning clinics in the City of Vantaa, Finland, 2013-2014 for 2 years using Finnish national health registers. We assessed the use of reproductive health services, namely attending public primary or specialized health care for gynecological reasons or attending the family planning clinics by applying unadjusted and adjusted negative binomial regression models on visit counts. RESULTS: A total of 11,290 visits accumulated during the two-year follow-up: 7260 (64.3%) at family planning clinics, 3385 (30.0%) for gynecological reasons in primary, and 645 (5.7%) in specialized health care. Altogether 3804 (52.4%) visits at the family planning clinics were for routine checkup, and 3456 (47.6%) for other reasons. Women initiating LARC methods used reproductive health services for reasons other than routine checkups similarly as women initiating or switching SARC methods (adjusted incidence rate ratio 0.93, 95% CI 0.82-1.05), while women continuing with SARC methods used the services less frequently (0.65, 0.59-0.72). Women initiating free-of-charge LARC and those continuing with the same SARC method used services less for abortion care than women initiating or switching SARC (adjusted incidence rate ratios 0.05, 95% CI 0.03-0.08 and 0.16, 95% CI 0.11-0.24, respectively). CONCLUSIONS: While women initiating LARC methods have lower need for abortion care compared to women initiating SARC methods, women initiating both LARC and SARC methods have similar overall need for reproductive health services. In contrast, women continuing with their SARC method need reproductive health services less than women initiating LARC or a new SARC method. These service needs should be acknowledged when planning and organizing family planning services, and when promoting long-acting reversible contraception.

Use of universally offered family planning services - a cohort study in the city of Vantaa, Helsinki metropolitan area, Finland.

Aims: Knowledge about the women reached by public family planning services is scarce. The means for provision of these services that are pivotal for women's health and empowerment varies globally. In Finland, family planning services are offered free of charge, but often separately for different age groups. City of Vantaa offers these services for all female residents without age limit. The aim of this study was to describe the characteristics of the women using public family planning services. Methods: We assessed the sociodemographic and reproductive characteristics of women aged 15-44 using (n = 11,790) and not using (n = 42,931) these services in 2013-2014. We obtained adjusted odds ratios (AORs) and 95% confidence intervals (95%CIs) for service use by multivariate logistic regression. Results: Women under 35 years of age had higher odds of service use compared with those over 35 (AORs ranging from 2.79 [95%CI 2.54-3.07] for 15-19 year-olds to 1.81 [95%CI 1.69-1.95] for 30-34 year-olds). Women speaking a foreign native language used services less when aged under 30 and more when aged 35-44 compared with women speaking the national languages. Women with a history of delivery, induced abortion or sexually transmitted infections, or with a lower socioeconomic or educational status were more likely to use the services. Conclusions: Young women in general were more likely to use free-of-charge family planning services. In contrast, young women speaking a foreign native language were underrepresented among service users. It is important to recognise and actively reach underrepresented groups, such as young women with a foreign background, to optimise equal access to family planning services.

Contraceptive priorities among women seeking family planning services in Finland in 2017-2019.

OBJECTIVE: To assess how women's reproductive history, contraceptive experience and need of abortion care are associated with priorities for contraception. STUDY DESIGN: In this cross-sectional survey study, we gathered information on women's history of births and abortions, previous use and satisfaction with contraceptive methods, and features of contraceptive methods they value most. Women were recruited at public family planning and outpatient abortion clinics in the capital region of Helsinki, Finland. RESULTS: Of the 1006 women responding, 502 were recruited during visits for abortion care and 504 for contraceptive counseling. Women seeking abortion care more often had a history of abortion than women seeking contraceptive counseling (44% vs 11%), presented with a higher mean number of different contraceptive methods used (69% vs 55% with more than 2 previous methods), and were less often satisfied with the methods used (36% vs 60% satisfied with 2 out of 3 methods), p < 0.001 for all. In addition, women seeking abortion care had lower odds of prioritizing effectiveness (aOR 0.3, 95% CI 0.2-0.5), and higher odds of prioritizing lower hormonal levels or non-hormonal alternatives (aOR 2.0, 95% CI 1.3-3.2). There was no difference between the groups regarding priorities of lesser pelvic pain (aOR 0.7, 95% CI 0.5-1.1), regular period (aOR 01.2, 95% CI 0.8-1.9), or the method being easy to use (aOR 1.2, 95% CI 0.8-1.8). CONCLUSIONS: There is a contrast between guidelines emphasizing effectiveness in postabortion contraception, and many women's contraceptive priorities. IMPLICATION STATEMENT: Clinicians providing contraceptive counseling must be mindful of each individual's personal contraceptive priorities.

Municipal contraceptive services, socioeconomic status and teenage pregnancy in Finland: a longitudinal study.

OBJECTIVES: Declining teenage pregnancy rates have been linked to improved access to youth-friendly contraceptive services, but information on the combined association of these services and socioeconomic factors with teenage pregnancy is lacking. DESIGN AND SETTING: This retrospective longitudinal register-based study covers the annual teenage childbirth and induced abortion rates in the 100 largest municipalities in Finland in 2000-2018. We investigated the combined association of regional, socioeconomic (ie, education level and need for social assistance) and adolescent contraceptive service variables (ie, free-of-charge contraception, an adolescent-only clinic and availability of over-the-counter emergency contraception (OTC EC)) with teenage childbirth and induced abortion rates at the municipality level by using Poisson mixed-effects model. PRIMARY OUTCOME MEASURES: Annual teenage childbirth and induced abortion rates as numbers per 1000 teenage girls aged 15-19 years old in the 100 largest municipalities in Finland from 2000 to 2018. RESULTS: The following variables were significantly associated with both lower teenage childbirth and induced abortion rates when adjusted for all the other variables used in the model: providing free-of-charge contraception (rate ratio (RR) 0.82 (95% CI 0.73 to 0.92) and RR 0.87 (95% CI 0.79 to 0.96), respectively), availability of OTC EC without age limit (RR 0.70 (95% CI 0.67 to 0.75) and RR 0.74 (95% CI 0.71 to 0.78), respectively), and high education level of the municipality (RR 0.94 (95% CI 0.94 to 0.95) and RR 0.94 (95% CI 0.93 to 0.94), respectively). CONCLUSION: Providing free-of-charge contraception and availability of OTC EC without age limit are associated with lower teenage pregnancy rates. These services combined with proper counselling are thus important contents of youth-friendly contraceptive services that should be provided equally for all teenagers in order to further reduce teenage pregnancy rates.

Free-of-charge long-acting reversible contraception: two-year discontinuation, its risk factors, and reasons.

BACKGROUND: Since 2013, the residents of the city of Vantaa, Finland, have been offered their first long-acting reversible contraceptive method (levonorgestrel-releasing intrauterine system, implant, and copper intrauterine device) free of charge. OBJECTIVE: The primary aim of this study was to assess the 2-year cumulative discontinuation rates of long-acting reversible contraceptive methods when provided free of charge for first-time users in a real-world setting. Additional aims were to describe factors associated with discontinuation and to evaluate the reasons for discontinuation. STUDY DESIGN: This is a retrospective register-based cohort study of 2026 nonsterilized women aged 15 to 44 years, who initiated a free-of-charge long-acting contraceptive method in 2013-2014 in the city of Vantaa. Removals within 2 years after method initiation and reasons for discontinuation were obtained from electronic health records and from national registers. We calculated the 2-year cumulative incidence rates of discontinuation with 95% confidence intervals for each method. Furthermore, we assessed crude and adjusted incidence rate ratios of discontinuation with 95% confidence interval by Poisson regression models comparing implants and copper intrauterine device with levonorgestrel-releasing intrauterine systems. RESULTS: During the 2 -year follow-up, 514 women discontinued, yielding a cumulative discontinuation rate of 28.3 per 100 women-years (95% confidence interval, 26.2-30.4). Among the 1199 women who initiated the levonorgestrel-releasing intrauterine system, the cumulative discontinuation rate was 24.2 per 100 women-years (95% confidence interval, 21.7-26.9); among the 642 implant users, 33.3 per 100 women-years (95% confidence interval, 29.5-37.4); and among the 185 copper intrauterine device users, 37.8 per 100 women-years (95% confidence interval, 31.0-45.7). Compared with women aged 30 to 44 years, women aged 15 to 19 years (adjusted incidence rate ratio, 1.58; 95% confidence interval, 1.17-2.14) and 20 to 29 years (adjusted incidence rate ratio, 1.35; 95% confidence interval, 1.11-1.63) were more likely to discontinue. We observed a higher discontinuation rate in women who had given birth within the previous year (adjusted incidence rate ratio, 1.36; 95% confidence interval, 1.13-1.65), spoke a native language other than Finnish or Swedish (adjusted incidence rate ratio, 1.31; 95% confidence interval, 1.06-1.63), and had a history of a sexually transmitted infection (adjusted incidence rate ratio, 1.62; 95% confidence interval, 1.07-2.46). No association was found in marital status, overall parity, history of induced abortion, socioeconomic status, education level, or smoking status. The most common reason for discontinuation was bleeding disturbances, reported by 21% of women who discontinued the levonorgestrel-releasing intrauterine system, by 71% who discontinued the implant, and by 41% who discontinued the copper intrauterine device. One in 4 women who discontinued the copper intrauterine device reported heavy menstrual bleeding, whereas only 1% who discontinued the levonorgestrel-releasing intrauterine system and none who discontinued implants reported this reason. Abdominal pain was the reported reason for discontinuation in 20% of both intrauterine device users and in only 2% who discontinued implants. CONCLUSION: At 2 years, the use of implants and copper intrauterine devices was more likely to be discontinued than that of the levonorgestrel-releasing intrauterine system. Women younger than 30 years and those who gave birth in the preceding year, spoke a native language other than Finnish or Swedish, or had a history of sexually transmitted infections were more likely to discontinue. The levonorgestrel-releasing intrauterine system was least likely to be removed owing to bleeding disturbances.

Predictors of choosing long-acting reversible contraceptive methods when provided free-of-charge - A prospective cohort study in Finland.

OBJECTIVE: To identify factors associated with choosing long-acting reversible contraception (LARC) (intrauterine device or contraceptive implant), when provided free-of-charge. STUDY DESIGN: This register-based cohort study comprises all women living in the city of Vantaa in the Helsinki metropolitan area during 2013-2014, with information on LARC initiations retrieved from electronic health records. Since January 2013, women in Vantaa can receive their first LARC method free-of-charge at public contraceptive clinics. We performed multivariable regression to assess seven predictors based on literature and four predictors based on gynecological history for association with choosing LARC in this population. RESULTS: In 2013-2014, 9669 women entitled to a free-of-charge method visited a public clinic and 2035 (21.0%) women initiated LARC. Factors most associated with LARC initiation included history of delivery (odds ratio [OR] 5.4, 95% confidence intervals [CI] 4.7-6.2) and induced abortion (OR 1.4, 95%CI 1.2-1.6), and no previous visit at the clinic (OR 1.3, 95%CI 1.2-1.5). Previous delivery was associated with LARC initiation in all age-groups (OR, 95%CI by age-group; 15-19 years: 10.8, 5.1-23.4; 20-24 years: 6.4, 4.9-8.3; 25-29 years: 6.7, 5.2-8.6; 30-44 years: 3.6, 2.9-4.6). CONCLUSION: History of delivery and induced abortion were strongly associated with choosing a LARC method, even though all women in the population were entitled to their first free-of-charge LARC method. The association was particularly strong among women less than 25 years of age. IMPLICATIONS STATEMENT: Untargeted provision of free-of-charge LARC in public contraceptive services reached women with previous delivery or abortion well during the programs first years. However, as LARCs are recommended to all women, future research should focus on how uptake evolves and how to reach all women in need of long-term, effective contraception.

Induced Abortion in a Population Entitled to Free-of-Charge Long-Acting Reversible Contraception.

OBJECTIVE: To study the rate of induced abortion in a population in whom long-acting reversible contraceptive (LARC) methods are offered free of charge as part of primary health care services. METHODS: We conducted a register-based cohort study on females aged 15-44 years in the city of Vantaa, Finland. We assessed the rate of abortion among females entitled to LARC methods free of charge by survival analysis in four cohorts: those visiting public family planning clinics and initiating free-of-charge LARC methods during 2013-2014 (LARC cohort, n=2,035); those visiting public family planning clinics not choosing LARC methods (no LARC cohort, n=7,634); and three age-matched control participants for every LARC and no LARC participant from the general population not using the services (nonservice users, n=5,981 and 22,748). The patients were followed up by means of Finnish national registers until February 28, 2016. RESULTS: During the 78,500 woman-years accumulated, altogether 996 patients in Vantaa underwent an abortion (12.3 abortions/1,000 woman-years, 95% CI 11.6-13.1). Of these, 16 abortions occurred in the LARC cohort (3.9/1,000, 95% CI 2.4-6.0), 243 in the no LARC cohort (15.3/1,000, 95% CI 13.5-17.2), and 737 (12.6/1,000, 95% CI 11.7-13.5) among matched nonservice users. The adjusted abortion rate in the LARC cohort was 80% lower than in the no LARC cohort (risk ratio [RR] 0.20, 95% CI 0.11-0.32) and 74% lower than among their matched control participants (RR 0.26, 95% CI 0.15-0.43). In contrast, there was no difference in the abortion rate between the no LARC cohort and the control participants (adjusted RR 1.01, 95% CI 0.87-1.18). CONCLUSION: When providing a population with free-of-charge LARC methods, the abortion rate was markedly lower among patients initiating free-of-charge LARC compared with patients using the services but not initiating a LARC method. Programs of this kind could be of major importance in populations with high rates of unintended pregnancy.

Long-Acting Reversible Contraception Free of Charge, Method Initiation, and Abortion Rates in Finland.

OBJECTIVES: To evaluate whether a public program providing long-acting reversible contraceptive (LARC) methods free of charge increases the LARC initiation rate and reduces the unintended pregnancy rate in the general population. METHODS: Since 2013, all women in Vantaa, Finland, have been entitled to 1 LARC method free of charge. With time-series analysis between 2000 and 2015, we assessed whether this public program was associated with changes in steady-state mean rates of LARC initiation and abortions. RESULTS: The initiation rate of LARCs (1/1000 women) increased 2.2-fold from 1.9 to 4.2 after the intervention (P < .001). Concomitantly, the abortion rate (1/1000 women) declined by 16% from 1.1 to 0.9 in the total sample (P < .001), by 36% from 1.3 to 0.8 among those aged 15 to 19 years (P < .001), and by 14% from 2.0 to 1.7 among those aged 20 to 24 years (P = .01). CONCLUSIONS: The LARC program was associated with increased uptake of LARC methods and fewer abortions in the population. Public Health Implications. Entitling the population to LARC methods free of charge is an effective means to reduce the unmet need of contraception and the need for abortion, especially among women younger than 25 years.