Quality of Information Available Online for Abortion Self-Referral.

OBJECTIVE: To assess the quality of information available online for abortion self-referral and to determine whether quality varies by region or distance to an abortion provider. METHODS: This was a cross-sectional study. We used a standard protocol to perform internet searches from August 2016 to June 2017 for abortion services in the 25 most populous U.S. cities and the 43 state capitals that were not one of the 25 most populous cities. We classified the first 10 webpage results and the first five map results and advertisements as facilitating abortion referral (local independent abortion provider, local Planned Parenthood facility, national abortion provider or organization, prochoice website, or abortion directory), not facilitating abortion referral (nonproviding physician office, nonmedical website, abortion provider greater than 50 miles from the location, news article, general directory, other), or hindering abortion referral (crisis pregnancy center or antichoice website). We used U.S. Census Bureau subregions to examine geographic differences. We made comparisons using a χ test. RESULTS: Overall, from 612 searches from 68 cities, 52.9% of webpage results, 67.3% of map results, and 34.4% of advertisements facilitated abortion referral, whereas 12.9%, 21.7%, and 29.9%, respectively, hindered abortion referral. The content of the searches differed significantly based on U.S. Census Bureau subregion (all P≤.001) and distance to an abortion provider (all P≤.02). CONCLUSION: Two thirds of map results facilitated abortion self-referral, whereas only half of webpage results did so. Advertisements were the least likely to facilitate and the most likely to hinder self-referral. Quality was lowest in areas that were farthest from abortion providers.

Continuation of copper and levonorgestrel intrauterine devices: a retrospective cohort study.

BACKGROUND: Studies conflict on whether the duration of use of the copper intrauterine device is longer than that of the levonorgestrel intrauterine device, and whether women who continue using intrauterine devices differ from those who discontinue. OBJECTIVE: We sought to assess continuation rates and performance of levonorgestrel intrauterine devices compared with copper intrauterine devices over a 5-year period. STUDY DESIGN: We performed a retrospective cohort study of 1164 individuals who underwent intrauterine device placement at an urban academic medical center. The analysis focused on a comparison of continuation rates between those using levonorgestrel intrauterine device and copper intrauterine device, factors associated with discontinuation, and intrauterine device performance. We assessed the differences in continuation at discrete time points, pregnancy, and expulsion rates using χ2 tests and calculated hazard ratios using a multivariable Cox model. RESULTS: Of 1164 women who underwent contraceptive intrauterine device insertion, 956 had follow-up data available. At 2 years, 64.9% of levonorgestrel intrauterine device users continued their device, compared with 57.7% of copper intrauterine device users (P = .11). At 4 years, continuation rates were 45.1% for levonorgestrel intrauterine device and 32.6% for copper intrauterine device (P < .01), and at 5 years continuation rates were 28.1% for levonorgestrel intrauterine device and 23.8% for copper intrauterine device (P = .33). Black race, primiparity, and age were positively associated with discontinuation; education was not. The hazard ratio for discontinuation of levonorgestrel intrauterine device compared with copper intrauterine device >4 years was 0.71 (95% confidence interval, 0.55-0.93) and >5 years was 0.82 (95% confidence interval, 0.64-1.05) after adjusting for race, age, parity, and education. Copper intrauterine device users were more likely to experience expulsion (10.2% copper intrauterine device vs 4.9% levonorgestrel intrauterine device, P < .01) over the study period and to become pregnant in the first year of use (1.6% copper intrauterine device vs 0.1% levonorgestrel intrauterine device, P < .01). CONCLUSION: We found a difference in continuation rates between levonorgestrel and copper intrauterine device users at 4 years but not at 5 years. Copper intrauterine device users were more likely to experience expulsion and pregnancy.

An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women.

OBJECTIVE AND DESIGN: Some studies suggest that specific hormonal contraceptive methods [particularly depot medroxyprogesterone acetate (DMPA)] may increase women's HIV acquisition risk. We updated a systematic review to incorporate recent epidemiological data. METHODS: We searched for articles published between 15 January 2014 and 15 January 2016 and hand-searched reference lists. We identified longitudinal studies comparing users of a specific hormonal contraceptive method against either nonusers of hormonal contraception or users of another specific hormonal contraceptive method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus non-use of hormonal contraception. RESULTS: We identified 10 new reports of which five were considered 'unlikely to inform the primary question'. We focus on the other five reports, along with nine from the previous review, which were considered 'informative but with important limitations'. The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate, and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher quality studies on DMPA (or nondisaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher quality studies of hazard ratio 1.4. CONCLUSION: Although confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely hazard ratio 1.5 or less. Data for other hormonal contraceptive methods, including norethisterone enanthate, are largely reassuring.

The safety of Sino-implant (II) for women with medical conditions or other characteristics: a systematic review.

OBJECTIVES: This study aims to systematically review evidence published on the safety of Sino-implant (II) [SI (II)] among women with medical conditions or characteristics identified by the World Health Organization for eligibility for contraceptive use. STUDY DESIGN: We searched PubMed, WEIPU, CNKI and Wanfang to identify all relevant evidence published in peer-reviewed journals from 1991 through 2014 regarding the safety of SI (II). We considered studies among women with medical conditions or other characteristics, such as age and parity, as direct evidence and studies among healthy women or a general population of women as indirect evidence. RESULTS: We identified 108 articles of which 9 met our inclusion criteria. Among women with medical conditions, no evidence was identified for the outcomes of interest, including serious adverse events or outcomes related to medical conditions. Among healthy women, evidence regarding efficacy of SI (II) for women weighing ≥70 kg was conflicting; one study showed an increased pregnancy rate and another showed no relationship. Women with menorrhagia did not experience worsened symptoms and may benefit from SI (II) use. Healthy women using SI (II) were no more likely than users of other methods to gain weight, develop elevated blood pressure, have abnormal liver or bone density tests or develop ovarian cysts or uterine myomas. CONCLUSIONS: Evidence among healthy women suggests SI (II) is safe and had health outcomes similar to those of other levonorgestrel implants. Studies were limited and conflicting regarding efficacy for women ≥70 kg. All included studies were conducted in China, limiting generalizability.

Reproductive coercion: an under-recognized challenge for primary care patients.

BACKGROUND: Reproductive coercion impacts many women of reproductive age. OBJECTIVES: We sought to explore how reproductive coercion, including pregnancy coercion and birth control sabotage, impacts women in a primary care population. METHODS: We administered a survey to women accessing care at a family medicine clinic in the Bronx, NY. Reproductive coercion was defined as a positive response to at least one of five questions adapted from previous studies. We assessed the association of reproductive and demographic characteristics with a lifetime history of reproductive coercion. RESULTS: At least one form of reproductive coercion was reported by 24% of the 97 respondents. Current lack of personal safety and a history of transactional sex for money or a place to stay were significantly associated with having experienced reproductive coercion (all P ≤ 0.02). CONCLUSIONS: Reproductive coercion was common among women of reproductive age at this urban family medicine clinic in an underserved community, and was associated with other forms of control and violence. Clinicians are advised to discuss birth control sabotage and pregnancy coercion with their patients.

Empowering adolescent girls in Sub-Saharan Africa to prevent unintended pregnancy and HIV: A critical research gap.

The need to prevent early pregnancy and HIV among adolescent girls in Sub-Saharan Africa has been recognized increasingly over recent years. Although extensive work has been done to determine appropriate interventions for girls in high-income countries, very little evidence is available to guide programmatic interventions in Sub-Saharan Africa. The available evidence has been equivocal regarding improved outcomes. While knowledge and self-reported behaviors frequently change with interventions, including those performed at the community level, educational programs, and direct contraceptive provision, downstream outcomes rarely reflect a significant effect of the interventions; however, provision of financial or other interventions to incentivize continued school enrollment are a promising development. We suggest directions for future research to fill this critical gap in the literature.

Combined hormonal contraceptive use among breastfeeding women: an updated systematic review.

BACKGROUND: Contraception is important for women who are postpartum, including those who are breastfeeding. Use of combined hormonal contraceptives (CHCs) may affect breastfeeding performance and infant health outcomes. OBJECTIVE: The objective was to identify evidence examining clinical outcomes for breastfeeding and infant health among breastfeeding women using CHCs compared to nonusers. SEARCH STRATEGY: We searched the PubMed database for all articles published from database inception through September 30, 2014. SELECTION CRITERIA: We included primary research studies that compared breastfeeding women using CHCs with breastfeeding women using nonhormonal or no contraception, or compared breastfeeding women initiating combined hormonal contraception at early versus later times postpartum. Breastfeeding outcomes of interest included duration, rate of exclusive breastfeeding and timing of supplementation. Infant outcomes of interest included growth, health and development. RESULTS: Fifteen articles describing 13 studies met inclusion criteria for this review. Studies ranged from poor to fair methodological quality and demonstrated inconsistent effects of combined oral contraceptives (COCs) on breastfeeding performance with COC initiation before or after 6 weeks postpartum; some studies demonstrated greater supplementation and decreased breastfeeding continuation among COC users compared with nonusers, and others demonstrated no effect. For infant outcomes, some studies found decreases in infant weight gain for COC users compared with nonusers when COCs were initiated at <6 weeks postpartum, while other studies found no effect. None of the studies found an effect on infant weight gain when COCs were started after 6 weeks postpartum, and no studies found an effect on other infant health outcomes regardless of time of COC initiation. CONCLUSION: Limited evidence of poor to fair quality demonstrates an inconsistent impact of COCs on breastfeeding duration and success. The evidence also demonstrated conflicting results on whether early initiation of COCs affects infant outcomes but generally found no negative impact on infant outcomes with later initiation of COCs. The body of evidence is limited by older studies using different formulations and doses of estrogen and poor methodologic quality. Given the significant limitations of this body of evidence, the importance of contraception for postpartum women and the theoretical concerns that have been raised about the use of combined hormonal contraception by women who are breastfeeding, rigorous studies examining these issues are needed. In addition, postpartum women should be counseled about the full range of safe alternative contraceptive methods, particularly during the first 6 weeks postpartum when the risk of venous thromboembolism is highest and use of estrogen may exacerbate this risk.

The safety of hormonal contraceptives for women living with HIV and their sexual partners.

BACKGROUND: Hormonal contraceptives are important for the health and well-being of some women living with HIV, so evaluation of evidence regarding their safety vis-à-vis HIV-related risks is important. METHODS: We updated two prior systematic reviews on the impact of hormonal contraception (HC) on HIV disease progression and female-to-male HIV transmission. RESULTS: One new study finds no increased risk for HIV disease progression or death associated with oral contraceptive use [adjusted (adj) hazard ratio (HR) 0.83, confidence interval [CI] 0.48-1.44] or injectables (adj HR 0.72, CI 0.53-0.98). Three new studies did not find significantly increased risks for measures of female-to-male HIV transmission with HC use. CONCLUSIONS: Hormonal contraceptive methods do not appear to accelerate HIV disease progression. More research is needed to clarify whether HC impacts HIV transmissibility.

Progestogen-only contraceptive use among breastfeeding women: a systematic review.

BACKGROUND: Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes. OBJECTIVES: We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs. SEARCH STRATEGY: We searched the PubMed database for all articles published from database inception through December 2014. SELECTION CRITERIA: We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects). RESULTS: Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association. CONCLUSION: The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence.

Conflict, displacement and sexual and reproductive health services in Mali: analysis of 2013 health resources availability mapping system (HeRAMS) survey.

OBJECTIVE: Little is known specifically about the effects of conflict and displacement on provision of sexual and reproductive health (SRH) services. We aimed to understand the association between levels of conflict and displacement and the availability of SRH services in post-conflict Mali. METHODS: A national assessment was conducted between April and May 2013 employing Health Systems Availability Mapping System (HeRAMS). Data from 1581 primary care facilities were analysed, focusing on SRH services. Descriptive analyses and multivariable logistic regression models were used to examine the availability of SRH services by different levels of conflict and displacement. FINDINGS: Of 1581 facilities, 1551 had data available to identify the details of service provision. The majority of the facilities were part of the public sector (79.1 %), identified as basic community primary care facilities (71.9 %). Overall 15.7 % of the facilities were in the zones under occupation, 40.3 % in the areas with high concentration of displaced population and 44 % in areas with low concentration of displaced populations. Between zones of low concentration of displaced populations and under occupation the likelihood of service availability varied between OR: 2.9 (95 % CI 2.0-4.4) for basic emergency obstetric care and OR: 41.7 (95 % CI 20.4-85.3) for family planning. All of the services within the three domains of SRH were more likely to be available in the low and high concentration displaced population areas compared to the facilities in the under occupation zones, after adjusting for other facility-related variables. CONCLUSION: Areas with high concentration of displaced population had less service availability, and areas formerly under occupation had the least service availability. This suggests that those living in conflict areas, and many of those who are internally displaced, have poor access to essential SRH interventions. The systematic measurement of the availability of health services, including SRH, is feasible and can contribute to recovery planning in post-conflict and humanitarian settings.

Hormonal contraceptive methods and risk of HIV acquisition in women: a systematic review of epidemiological evidence.

Whether use of various types of hormonal contraception (HC) affect risk of HIV acquisition is a critical question for women's health. For this systematic review, we identified 22 studies published by January 15, 2014 which met inclusion criteria; we classified thirteen studies as having severe methodological limitations, and nine studies as "informative but with important limitations". Overall, data do not support an association between use of oral contraceptives and increased risk of HIV acquisition. Uncertainty persists regarding whether an association exists between depot-medroxyprogesterone acetate (DMPA) use and risk of HIV acquisition. Most studies suggested no significantly increased HIV risk with norethisterone enanthate (NET-EN) use, but when assessed in the same study, point estimates for NET-EN tended to be larger than for DMPA, though 95% confidence intervals overlapped substantially. No data have suggested significantly increased risk of HIV acquisition with use of implants, though data were limited. No data are available on the relationship between use of contraceptive patches, rings, or hormonal intrauterine devices and risk of HIV acquisition. Women choosing progestin-only injectable contraceptives such as DMPA or NET-EN should be informed of the current uncertainty regarding whether use of these methods increases risk of HIV acquisition, and like all women at risk of HIV, should be empowered to access and use condoms and other HIV preventative measures. Programs, practitioners, and women urgently need guidance on how to maximize health with respect to avoiding both unintended pregnancy and HIV given inconclusive or limited data for certain HC methods.

Family planning: choices and challenges for developing countries.

While slow and uneven progress has been made on maternal health, attaining the 1994 Cairo International Conference on Population and Development (ICPD) goal for achieving universal access to reproductive health remains elusive for many developing countries. Assuring access to sexual and reproductive health services, including integrated family planning services, remains a critical strategy for improving the health and well-being of women and alleviating poverty. Family planning not only prevents maternal, infant, and child deaths, but also empowers women to engage fully in socioeconomic development and provides them with reproductive choices. This paper will discuss the current landscape of contraception in developing countries, including options available to women and couples, as well as the challenges to its provision. Finally, we review suggestions to improve access and promising strategies to ensure all people have universal access to reproductive health options.

Contraception for adolescents in low and middle income countries: needs, barriers, and access.

Substantial numbers of adolescents experience the negative health consequences of early, unprotected sexual activity - unintended pregnancy, unsafe abortions, pregnancy-related mortality and morbidity and Sexually Transmitted Infections including Human Immunodeficiency Virus; as well as its social and economic costs. Improving access to and use of contraceptives - including condoms - needs to be a key component of an overall strategy to preventing these problems. This paper contains a review of research evidence and programmatic experiences on needs, barriers, and approaches to access and use of contraception by adolescents in low and middle income countries (LMIC). Although the sexual activity of adolescents (ages 10-19) varies markedly for boys versus girls and by region, a significant number of adolescents are sexually active; and this increases steadily from mid-to-late adolescence. Sexually active adolescents - both married and unmarried - need contraception. All adolescents in LMIC - especially unmarried ones - face a number of barriers in obtaining contraception and in using them correctly and consistently. Effective interventions to improve access and use of contraception include enacting and implementing laws and policies requiring the provision of sexuality education and contraceptive services for adolescents; building community support for the provision of contraception to adolescents, providing sexuality education within and outside school settings, and increasing the access to and use of contraception by making health services adolescent-friendly, integrating contraceptive services with other health services, and providing contraception through a variety of outlets. Emerging data suggest mobile phones and social media are promising means of increasing contraceptive use among adolescents.

Hormonal contraceptive use and female-to-male HIV transmission: a systematic review of the epidemiologic evidence.

OBJECTIVE: To systematically review epidemiologic evidence assessing whether hormonal contraception alters the risk of HIV transmission from an HIV-positive woman to an HIV-negative male partner. DESIGN: Systematic review. METHODS: We included articles published or in press through December 15, 2011. We assessed studies with direct evidence on hormonal contraception use and HIV transmission, and summarized studies with indirect evidence related to genital or plasma viral load. RESULTS: : One study provided direct evidence on oral contraceptive pills (OCPs) or injectable contraception and female-to-male HIV transmission; both injectables [Cox-adjusted hazard ratio (adjHR) 1.95, 95% confidence interval (CI) 1.06-3.58; marginal structural model (MSM) adjusted odds ratio (adjOR) 3.01, 95% CI 1.47-6.16] and OCPs (Cox adjHR 2.09, 95% CI 0.75-5.84; MSM adjOR 2.35, 95% CI 0.79-6.95) generated elevated point estimates, but only estimates for injectables were significant. Findings from 11 indirect studies assessing various hormonal contraception methods and viral genital shedding or setpoint were mixed, and seven of eight studies indicated no adverse effect of various hormonal contraception methods on plasma viral load. CONCLUSION: The only direct study on OCPs or injectable contraception and female-to-male HIV transmission suggests increased risk with the use of injectables. Given the potential for confounding in observational data, the paucity of direct evidence on this subject, and mixed indirect evidence, additional evidence is needed.

Effect of hormonal contraceptive methods on HIV disease progression: a systematic review.

OBJECTIVE: Systematically assess from the literature whether women living with HIV who use hormonal contraception are at increased risk of HIV-disease progression compared with those who do not use hormonal contraception. METHODS: We searched PUBMED and EMBASE for articles published in peer-reviewed journals through December 15, 2011 for evidence relevant to all hormonal contraceptive methods and HIV-disease progression. RESULTS: Twelve reports of 11 studies met inclusion criteria. One randomized controlled trial (RCT) found increased risk for the composite outcome of a reduced CD4 cell count or death among hormonal contraceptive users when compared with copper intrauterine device (IUD) users. Ten cohort studies reported no increased risk for HIV disease progression (as measured by mortality, time to a CD4 cell count below 200, time to initiation of antiretroviral therapy, an increase in HIV-RNA viral load, or a decrease in CD4 count) among women who used hormonal contraception compared with those who did not. CONCLUSION: The preponderance of evidence indicates that HIV-positive women can use hormonal contraceptive methods without concerns related to HIV-disease progression. Cohort studies consistently found no association between hormonal contraceptive use and HIV-disease progression compared with nonuse of hormonal contraceptives. One RCT found that hormonal contraceptive use was associated with increased risk of HIV-disease progression when compared with IUD use, but this study had important methodological shortcomings. Prevention of unintended pregnancy among women living with HIV remains a public health priority to safeguard women's and infants' health and to prevent vertical transmission of HIV.

Detecting alcohol problems in HIV-infected patients: use of the CAGE questionnaire.

The HIV epidemic has been consistently associated with injection drug use and crack cocaine, but alcohol problems in HIV-infected persons are less well described. Our objectives were 2-fold: (1) to assess the prevalence of alcohol problems in HIV-infected patients initiating medical care; and (2) to determine the positive predictive value of the CAGE questionnaire for alcohol abuse or dependence in HIV-infected patients. Between July 1997 and October 2000, we assessed a consecutive series of patients who were establishing primary care for HIV infection (clinic sample), using an established alcohol screening test, the CAGE questionnaire. In addition, we enrolled other HIV-infected patients, including some of the clinic sample, who had two or more positive responses to the CAGE questionnaire into a longitudinal cohort (cohort sample), performed a diagnostic interview for lifetime history of alcohol abuse and dependence, and determined the positive predictive value of CAGE for alcohol diagnoses. In the clinic sample (n = 664), 42% (276 of 664) had two or more positive responses to the four CAGE questions. In the cohort sample (n = 141), 95% (134 of 141) met DSM-IV criteria for diagnosis of lifetime alcohol abuse or dependence. For patients initiating HIV primary care, a history of alcohol problems is very common. The CAGE questionnaire identifies a lifetime history of alcohol abuse or dependence in HIV-infected patients. Routine screening for alcohol problems should be performed in all patients entering HIV medical care and the CAGE questions are useful in this setting.