Trends in the use of hormonal contraception in Estonia 2005-2019 and the risk of arterial and venous thromboembolism: a population-based study.

PURPOSE: To describe trends in hormonal contraceptive use, incidence of thromboembolism and presence of risk factors for thromboembolism among the users in Estonia. MATERIAL AND METHODS: Data of 223 312 female patients aged 15-49 years in 2005-2019 from national health insurance databases was derived. Annual prevalence rates of hormonal contraceptive users, incidence rates of thromboembolism and prevalence rates of risk factors were calculated. RESULTS: Between 2005-2019 usage of progestogen-only contraceptives (POCs) increased steadily (from 24 to 135 users per 1000 population), whereas combined hormonal contraceptive (CHC) use declined (from 209 in 2012 to 161 users per 1000 population in 2019). During the study period, 390 cases of venous thromboembolism and 108 arterial thromboembolism coincided with hormonal contraceptive use. Incidence rate for venous thromboembolism was 5.0 (95% CI 4.5-5.5) and for arterial thromboembolism 1.4 per 10 000 person-years (95% CI 1.1-1.7) among hormonal contraceptive users. Age adjusted incidence of venous thromboembolism among CHC users was 5.8 (95% CI 4.1-8.2) times higher than in POC users. Among CHC users, 10.3% had more than one risk factor for thrombosis. CONCLUSIONS: In regards to the risk of thromboembolism, wider use of POCs and declining prevalence of CHCs in Estonia is positive trend. Still, women with history of thrombosis receiving CHC is a serious concern.

Characteristics of women who use hormonal contraceptives and their population-level impacts on HIV infection in a cohort of South African women (2002-2016).

PURPOSE: Women's choice of contraceptive can have broader implications and may play a significant role in shaping their sexual practices. We aim to identify the characteristics of women who use hormonal injectables and those at high-risk of HIV infection. We also quantify the population-level impact of their shared characteristics on HIV incidence rates. MATERIALS AND METHODS: Data from 9948 women who enrolled in six-HIV prevention trials conducted in South Africa (2002-2016) were included. We used logistic and Cox regression models and estimated the population-level impact of the use of injectables on HIV incidence in the multifactorial-model setting. RESULTS: Using hormonal injectables were associated with increased risk of HIV infection (adjusted Hazard ratio (aHR):1.51, 95% CI:1.22, 1.86). At the population level less than 20% of the infections were associated with injectable contraceptives among younger women (i.e., less than 35 years of age). Factors including being single/not-cohabiting, using condoms at last sex, partner-related factors, and STI diagnosis were all identified as shared characteristics of women who preferred using hormonal injectables and those at high-risk of HIV infection. At the population level, these factors were associated with more than 50% of the infections among women younger than 35 years of age. CONCLUSIONS: Our analysis presented evidence for the overlapping characteristics of the women who used hormonal injectables and those at high-risk of HIV infection. These findings reinforce the importance of comprehensive contraceptive counselling to women about the importance of dual protection, such as male condoms and hormonal contraceptives use.

Student knowledge and confidence with prescribing hormonal contraception.

INTRODUCTION: Pharmacists' scope of practice has expanded in several states to include independently prescribing and dispensing hormonal contraceptive products. The objective of this research was to assess student knowledge and confidence with prescribing hormonal contraception following a simulated patient case activity. METHODS: This was a descriptive, exploratory, nonexperimental study utilizing educational assessments and survey data from second professional year students during the 2017 to 2018 and 2018 to 2019 academic years. Student performance was assessed using a five-question readiness assurance test at the beginning of class, documented patient assessment and plan, and five-question post-activity quiz. Student confidence with interpreting legal regulations and following protocol instructions, performing a patient assessment, prescribing an appropriate contraceptive product, and providing verbal and written communication to patients and providers was assessed using a nine-question survey at the end of class. RESULTS: Average student performance was consistent on the readiness assurance test between the two years. Students scored an average of 84.2% and 91.6% on the documented assessment and plan and 96.4% and 91.2% on the post-activity quiz for each year, respectively. Students felt most confident with navigating and interpreting a prescription drug formulary, providing the patient with written documentation, and communicating with the patient's prescriber. Students were less confident with selecting an appropriate product based on patient-specific factors and providing education on missed doses. CONCLUSIONS: This case-based activity demonstrated student knowledge and confidence with prescribing hormonal contraceptives.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans.

BACKGROUND: Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. OBJECTIVES: The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. STUDY DESIGN: Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. RESULTS: Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. CONCLUSION: Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

The influence of health care utilization on the association between hormonal contraception initiation and subsequent depression diagnosis and antidepressant use.

OBJECTIVE: Assess the influence of healthcare utilization on previously reported associations between contraception initiation, diagnosis of depression, and dispensing of antidepressant medications. STUDY DESIGN: Retrospective cohort analysis of insurance records from 272,693 women ages 12-34 years old enrolled in the United States Military Healthcare System in September 2014 and followed for 12 months. We compared outcomes of women who initiated hormonal contraception with all women eligible for care and then with women who accessed care during the study month using Kaplan-Meier and Cox proportional hazards analyses. RESULTS: Women age 12-34 who initiated hormonal contraception experienced a higher risk of depression diagnosis and antidepressant use when compared to all enrolled women but not when compared to women who accessed care. Among those who accessed care, some progestins (i.e., levonorgestrel, Hazard Ratio (HR) = 1.46, and norelgestromin, HR = 1.93) were associated with an increased rate of depression diagnosis but not antidepressant use; norethindrone (HR = 0.21) was associated with a decreased rate of depression diagnosis. CONCLUSION: When compared to women utilizing their health insurance, associations between initiating hormonal contraception and depression diagnosis and antidepressant use decreased or disappeared. This suggests that healthcare utilization may have confounded previous reports of an association between hormonal contraception use and depression and antidepressant use.

Breaking down barriers to birth control access: An assessment of online platforms prescribing birth control in the USA.

INTRODUCTION: In the USA, the requirement that individuals obtain a prescription for hormonal contraception is a significant barrier for women who lack the time, finances, insurance coverage or means of transportation to visit a provider. The emergence of telemedicine services has removed some of these barriers by providing women with the opportunity to conveniently obtain birth control prescriptions through their computer or smartphone. METHODS: In this article, we compare the prescribing processes and policies of online platforms that prescribe hormonal contraceptives to women in the USA, and use the recommendations of the 2016 US medical eligibility criteria for contraceptive use to evaluate whether online prescribers are providing evidence-based care. RESULTS: As of February 2018, nine online platforms prescribed hormonal birth control to women across various states in the USA. These platforms varied in regard to their prescribing processes, range of methods offered, locations of operation, fees for services, and policies regarding age restrictions. DISCUSSION: An assessment of each platform's online health questionnaire reveals that these telemedicine services are adequately screening for contraindications and safely providing birth control methods to patients, although efforts could be made to strengthen the rigour of online health questionnaires to ensure they adequately screen for all contraindications.

Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies.

In 2013, California passed legislation to expand the scope of pharmacist practice, including authorizing pharmacists to prescribe hormonal contraception. Pharmacist-prescribed contraception was largely unavailable across the state in 2017. This study aimed to identify barriers and facilitators to offering this service in California independent pharmacies. To do so, we thematically analyzed qualitative data from structured interviews with 36 pharmacists working in independent pharmacies in 2016-17. We found that pharmacists anticipated general benefits from expanding their roles to prescribe contraception, including increasing health care access and decreasing costs. In contrast, described barriers were concrete, including lack of financial incentives and business risks for independent pharmacies. Specific barriers to prescribing hormonal contraception included time required to screen and counsel women about contraception and concerns that pharmacist-prescribed contraception would increase liability and lead to patients seeking health care less frequently. This study suggests that incentives and barriers identified by the respondents are likely to have varied and unequal impacts, with immediate barriers being potentially prohibitive for pharmacists to prescribe contraception. For independent pharmacies, perceived business risks and lack of insurance reimbursement may outweigh professional support for prescribing contraception, limiting the public health impact of legislation that should increase contraceptive access.

Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives.

Background Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use. METHODS: Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'. RESULTS: In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04). CONCLUSION: Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

Cervical Cancer Identification with Synthetic Minority Oversampling Technique and PCA Analysis using Random Forest Classifier.

Cervical cancer is the fourth most communal malignant disease amongst women worldwide. In maximum circumstances, cervical cancer indications are not perceptible at its initial stages. There are a proportion of features that intensify the threat of emerging cervical cancer like human papilloma virus, sexual transmitted diseases, and smoking. Ascertaining those features and constructing a classification model to categorize, if the cases are cervical cancer or not is an existing challenging research. This learning intentions at using cervical cancer risk features to build classification model using Random Forest (RF) classification technique with the synthetic minority oversampling technique (SMOTE) and two feature reduction techniques recursive feature elimination and principle component analysis (PCA). Utmost medical data sets are frequently imbalanced since the number of patients is considerably fewer than the number of non-patients. For the imbalance of the used data set, SMOTE is cast-off to solve this problem. The data set comprises of 32 risk factors and four objective variables: Hinselmann, Schiller, Cytology and Biopsy. Accuracy, Sensitivity, Specificity, PPA and NPA of the four variables remains accurate after SMOTE when compared with values obtained before SMOTE. An RSOnto ontology has been created to visualize the progress in classification performance.

Determining factors for the prevalence of anemia in women of reproductive age in Nepal: Evidence from recent national survey data.

Anemia is a condition in which the number of red blood cells is not sufficient to meet the physiological need of the body. Women of reproductive age and pregnant women are at a high risk of anemia, which in turn may contribute to maternal morbidity and mortality. We aimed to describe the prevalence of anemia and the factors associated with the risk of developing anemia in women of reproductive age in Nepal. Additionally, we examined the association of women's decision-making autonomy regarding healthcare and experience of intimate partner violence (IPV) with anemia. Data from the 2016 Nepal Demographic and Health Survey (NDHS) were used in this study. The data were adjusted for sampling weight, stratification, and cluster sampling design. A battery-operated portable HemoCue was used to measure hemoglobin and detect anemia. Using complex sample logistic regression, the association between dependent and independent variables were examined; crude and adjusted odds ratio were reported. The mean (± SD) hemoglobin concentration was 12.13 g/dL (± 1.48). Overall, about 41% (95% CI 38.6-43.0%) of women aged 15-49 years were anemic. Women in households with wells as the source of drinking water (aOR 1.93; 95% CI 1.58-2.37) were significantly associated with an increased risk of developing anemia. While women who were currently using hormonal contraceptives (aOR 0.63, 95% CI 0.52-0.76) were significantly less likely to be anemic. After adjusting for background characteristics among women who were married at the time of the survey, decision-making autonomy regarding healthcare, and experience of IPV did not have a significant association with anemia. The high prevalence of anemia suggests the need for substantial improvement in the nutritional status of women. The increased disease burden compared with the past survey highlights the needs to reconsider the existing nutritional policy in Nepal.

[Use of contraception with only progestogens in primary care: Study GESTAGAP]. / Uso de la anticoncepción con solo gestágenos en atención primaria: estudio GESTAGAP.

AIM: To estimate the prevalence of use of progestin-only contraceptive among women who request reversible contraception in Primary Care (PC). DESIGN: Multicentre cross-sectional study. SETTING: Primary Care Health Care Centres (Madrid). PARTICIPANTS: Women aged 16-50 years old, users of reversible contraception, who speak Spanish, and had attended the Primary Care Centre in the last year. MAIN MEASUREMENTS: Primary outcome: contraceptive method used: Contraception with progestins-only (yes/no). Age, parity, country of origin, type of contraceptive method used, reason for choice, source of information, satisfaction with the contraceptive method. Telephone survey. RESULTS: A total of 417 women were interviewed. The median age was 30.3years (SD: 7.7). Spanish 69%, and 82% of participants had secondary or university studies. More than half (57%) were nulliparous. The type of contraceptive used included: progestins only: 14%, combined hormonal contraceptive: 74%, copper IUD: 2%, and condom 10%. The prevalence of use of "progestins-only" was 13.9% (95%CI: 10.6-17.2). Medroxyprogesterone acetate injection was the most progestin-only method used (4.6%), desogestrel oral pill (4.1%), IUD-levonorgestrel IUD (3.9%), and etonogestrel subdermal implant (1.9%). The family doctor was the prescriber in 71% of the women. Satisfaction: high (range 9-10). Using only progestogens was associated with older age, being non-Spanish, breastfeeding, and having a medical contraindication for combined contraception (P<0.05). CONCLUSIONS: The prevalence of use for progestins was 14%, satisfaction was very high for all contraceptive methods. The user profile for the only progestins-only corresponds to older, and non-Spanish women with conditions such as breastfeeding or contraindications for other contraceptives.

Characterizing pharmacist-prescribed hormonal contraception services and users in California and Oregon pharmacies.

OBJECTIVES: This study describes hormonal contraception services provided by pharmacists and characterizes patient populations utilizing the service at one supermarket-based pharmacy chain in California and Oregon. STUDY DESIGN: This is a descriptive study of 391 pharmacies in California and Oregon within a supermarket-based pharmacy chain providing hormonal contraception services and the patients who utilized those services in a 6.5-month period between August 2016 and February 2017. Data were extracted from pharmacy prescription records and available visit documentation forms to describe services provided and patient characteristics. RESULTS: During the study period, 381 trained pharmacists from the pharmacy chain provided hormonal contraception services in 391 pharmacy locations in Oregon and California. A total of 2117 visits were completed and 1970 hormonal contraception prescriptions were issued and dispensed during the study period. Researchers were able to access documentation for 676 visits (32%). Patients from various age groups (range 13-55 years old) and geographical locations (22 states total) utilized the service. Most had health insurance (74%), had seen a primary care provider in the past year (89%) and were previous hormonal contraception users (91%). Contraceptive methods prescribed include pill (n=1886, 95.7%), patch (n=31, 1.6%), vaginal ring (n=51, 2.6%) and injectable (n=2, 0.1%). CONCLUSION: Following scope of practice expansion, pharmacists in a community-based pharmacy setting are serving as an access point for women to obtain hormonal contraception services and supplies. IMPLICATIONS: This study provides an initial look at California's and Oregon's expansion of hormonal contraception prescribing authority to pharmacists. The service was available across all pharmacy locations of a supermarket-based chain in California and select locations in Oregon and utilized by diverse populations of patients. Pharmacists effectively provided hormonal contraception services and supplies to most patients seeking hormonal contraception.

HIV prevalence and incidence in a cohort of women at higher risk for HIV acquisition in Chókwè, southern Mozambique

Reliable HIV incidence estimates for Mozambique are limited. We conducted a prospective HIV incidence study as part of a clinical research site development initiative in Chókwè district, Gaza Province, southern Mozambique. Methods: Between June 2010 and October 2012, we recruited women at sites where women at higher risk of HIV infection would likely be found. We enrolled and tested 1,429 sexually active women in the screening phase and 479 uninfected women in the prospective phase. Participants were scheduled for 12+ months follow-up, when they underwent face-to-face interviews, HIV counseling and testing, and pregnancy testing. We observed a total of 373.1 woman-years (WY) of follow-up, with mean (median) of 9.4 (9.7) women-months per participant. Results: The prevalence of HIV was 29.4% (95% confidence interval [CI]: 27.0-31.8%). In multivariable logistic regression analysis, factors that remained significantly associated with prevalent HIV were: older age (OR: 0.6; 95% CI: 0.4-0.7), lower educational level (OR: 0.4; 95% CI: 0.3-0.7), and using hormonal contraception (OR: 0.6; 95% CI: 0.4-0.7) or condoms (OR: 0.5; 95% CI: 0.3-0.7). We observed an HIV incidence rate of 4.6 per 100 WY (95% CI: 2.7, 7.3). The HIV incidence was 4.8 per 100 WY (95% CI: 2.5, 8.3) in women aged 18-24 years, 4.5 per 100 WY (95% CI: 1.2, 11.4) in women aged 25-29 years and 3.2 per 100 WY (95% CI: 0.1, 18.0) in the 30-35 years stratum. None of the demographic factors or time-varying behavioral factors examined was significantly associated with incident HIV infection in bivariable analysis at p ≤ 0.10. Conclusions: We found a high HIV incidence among sexually active young women in Chókwè, Mozambique. HIV prevention programs should be strengthened in the area, with more comprehensive reproductive health services, regular HIV testing, condom promotion, and messaging about multiple sexual partners.