Understanding the impact of COVID-19 on women's access to and experiences of contraceptive services in England: a qualitative study.

BACKGROUND: The COVID-19 pandemic response prompted rapid changes to how contraceptive services were delivered in England. Our aim was to examine women's experiences of accessing contraceptive services since March 2020 and to understand any inequalities of access. METHODS: We conducted telephone interviews with 31 women aged 17-54 years who had accessed contraceptive services in England since March 2020. The sample was skewed to include participants with lower educational attainment and higher deprivation. Interview transcripts were thematically analysed using inductive and deductive approaches. RESULTS: Few differences were found regarding educational attainment. Participants using contraceptive injections (all living in areas in the most deprived quintile) reported the greatest access challenges. Some switched method or stopped using contraception as a result. More general barriers reported by participants included service closures, unclear booking processes, and lack of appointment availability. Many participants welcomed the flexibility and convenience of remote contraceptive services. However, telephone appointments posed challenges for those at school or living with parents, and some described them as rushed and inconducive to asking questions or raising concerns. Those accessing contraception for the first time or nearing menopause felt they were unable to access sufficient support and guidance during the pandemic. Some participants voiced concerns around the lasting effects of COVID-19 on appointment availability and inadequate service delivery. CONCLUSIONS: Women's experiences of accessing contraceptive services in England since March 2020 are diverse. While remote services were suitable for some, COVID-19 restrictions unequally impacted women depending on their method of contraception and life stage.

Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis.

INTRODUCTION: The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women. METHODS: We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4. RESULTS: Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment. CONCLUSIONS: Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.

Contraceptive Behavior in Appalachia: Exploring Use, Nonuse, and Contraceptive Attitudes.

Very little is known about contraceptive behavior in Appalachia, a large geographic region in the eastern United States where even basic prevalence estimates of contraceptive use/nonuse are lacking. This study characterizes contraceptive behavior among Appalachians, including contraceptive use, reasons for use, and methods used; contraceptive nonuse and reasons for nonuse; and attitudes about contraception, including acceptability. This is a secondary analysis of a subsample of survey data collected on sexual and reproductive health attitudes, behaviors, and needs among reproductive-age women (18-49 years) living in the Appalachian region (n = 332). Results identify rates of contraceptive use (66.6%) and nonuse (33.1%) among Appalachian residents. Methods used most frequently included those that did not require prescription (i.e., external condoms and natural family planning methods) though many reported the use of intrauterine devices (IUDs). Among nonusers, fear of side effects from contraception and ambivalence towards pregnancy were most commonly selected as the most important reason for not using contraception. Contraception was considered acceptable by this sample overall, and these acceptability attitudes were significantly associated with contraceptive behavior.

Contraceptive counseling and choices in pregnancies with maternal cardiac disease.

OBJECTIVE: Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy. METHODS: All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score. RESULTS: Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options. CONCLUSION: Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.

Associations of Urban Residence and Wealth Index With Various Sources of Contraceptives Among Young Women Aged 15-24 Years in 25 Sub-Saharan African Countries.

PURPOSE: Appreciating user differences in contraceptive sources is essential for improving contraceptive access and safeguarding an equitable and sustainable future. Therefore, this study explored whether urban residence and individual wealth are associated with where women access contraception (e.g., government, private, or nongovernmental organization provider) and assessed whether these associations are modified by the income level in the respondents' country of residence. METHODS: We analyzed the cross-sectional data of Demographic Health Surveys conducted between 2009 and 2020 in 25 countries. The final data set included 25,081 young women aged between 15 and 24 years who are using contraceptives. Multinomial logistic regression models were established to assess the associations of our outcome variable, namely, various contraceptive sources, with our main independent variables, namely, urban residence and wealth index. We also assessed the potential effect modification by country income level on the above associations. RESULTS: We observed obvious urban-rural and rich-poor disparities in odds of using contraceptive sources. Generally, living in urban residences and being wealthy were positively associated with all sources of contraceptives. However, these associations were mostly modified by country income level. People living in urban residences utilized more private sources, especially in low-income (beta coefficient, B = 0.973) and upper-middle-income countries (B = 1.361). Young women in urban areas across all analyzed countries were also more likely to use contraceptives from other sources (B = 0.267). In addition, women from poor households were less likely to use private sources (B = -1.166) and other sources (B = -0.547). DISCUSSION: Even though young women may prefer private sources of contraceptives due to their confidentiality and flexible hours, these sources carry more benefits for rich and urban young women than for poor and rural women. The differential accessibility and affordability may account for the observed urban-rural and rich-poor disparities in using contraceptive sources, respectively, and the income level of a country is likely to modify such disparities.

Evaluation of the psychometric properties of the Reproductive Autonomy Scale for use in the UK.

BACKGROUND: Reproductive autonomy-control over outcomes including contraceptive use and childbearing-is a human right and vital to women's empowerment. Those whose reproductive autonomy is threatened by the structures and relationships in their lives are at risk of coercion and unplanned pregnancy and could benefit from additional services. The Reproductive Autonomy Scale (RAS) was developed in the USA to assess women's reproductive autonomy; this study evaluates the RAS for use in the UK. METHODS: After testing, the RAS was incorporated into an online survey of women of reproductive age. Those who were sexually active were asked to complete the RAS, which was evaluated according to classical test theory. Reliability was assessed via internal consistency and a 3-month test-retest. Construct validity was assessed using hypothesis testing and confirmatory factor analysis. RESULTS: For 826 women the RAS was highly acceptable, with a response rate of >97.7%. Almost the whole range of reproductive autonomy scores were captured. Internal consistency was good, with a Cronbach's α of 0.75. Test-retest reliability was fair-good with an intraclass correlation coefficient of 0.67. Construct validity analysis found the scale to be valid based on our hypothesis that among women who want to avoid pregnancy, those with higher reproductive autonomy will be more likely to use contraception. The three-factor structure of the scale was confirmed on confirmatory factor analysis. CONCLUSION: The RAS is valid and reliable for use in the UK. This tool holds potential utility across research, clinical practice, health interventions and policy development.

Understanding women's views of and preferences for accessing postpartum contraception: a qualitative evidence synthesis.

BACKGROUND: Nearly half of women experience unintended pregnancies. These are associated with increased risk of poor maternal physical and psychosocial health outcomes. Many pregnancies in the first year postpartum are unintended, further increasing risks of poor outcomes and complications. We undertook a qualitative evidence synthesis to evaluate qualitative research on women's views and preferences for accessing postpartum contraception, and identify evidence gaps and opportunities for postpartum contraception provision. METHODS: Five databases were searched to identify relevant qualitative studies. Included studies focused on views of, and preferences for, accessing postpartum contraception for women of reproductive age in high-income countries. RESULTS: Of 1854 studies identified, 28 full texts were assessed and 19 studies included. These were critically appraised using Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) and analysed using thematic synthesis. Included studies indicated the majority of women desire postpartum contraception, but face a range of financial, health system and personal barriers. Women felt unclear about the ideal interpregnancy interval (IPI) and the rationale for this. Women preferred contraceptive counselling at varying times both antenatally and postnatally, and commonly preferred to receive contraception in the immediate postpartum period before hospital discharge. Women commonly saw their obstetrician or general practitioner for contraceptive counselling, but welcomed midwifery involvement. CONCLUSIONS: Most women were interested in postpartum contraception and pregnancy spacing, but felt unclear about the optimal IPI, highlighting the need for further education and support around this issue. Contraceptive counselling was viewed as valuable antenatally and postnatally, and by varying maternal health providers, as was the provision of immediate postpartum contraception.

Self-reported contraceptive use and satisfaction among women accessing telemedicine medical abortion at the onset of the COVID-19 pandemic at 3-6-month follow-up.

BACKGROUND: Changes in legislation due to COVID-19 led to the introduction of telemedicine for early medical abortion (EMA) at home in Scotland. The opportunity to provide contraception at presentation may be more limited with this model of care. We compared contraceptive use immediately post-abortion with 3-6 months later to determine if contraceptive needs were being met. METHODS: We contacted 579 women by telephone call or text message who agreed to be involved in a service evaluation of telemedicine EMA in NHS Lothian at 3-6 months post-abortion. A research nurse administered a questionnaire on the women's current contraception use. The research nurses also offered women support in switching or initiating contraception via the abortion service if desired. RESULTS: The response rate to the contact was 57% (331/579). Under a third of the women (30%, 98/331) were using the progestogen-only pill (POP) at 3-6 month follow-up, a significant decrease (p<0.00) compared with 65% (215/331) who were provided with POP at the time of abortion. Thirty-nine women (12%) were provided with contraception through this telephone contact, leading to a significant increase in the proportion using subdermal implants, the progestogen injectable or intrauterine contraception. CONCLUSIONS: This study shows that there was a decrease in the use of the POP 3-6 months after telemedicine EMA during the COVID-19 pandemic. Telephone contact at 3-6 months to facilitate obtaining contraception may be a promising strategy to improve access to effective methods with this model of abortion care.

A systematic review of randomised controlled trials of the effects of digital health interventions on postpartum contraception use.

BACKGROUND: Digital health interventions (DHI) have been used to enhance the uptake of postpartum contraception and reduce unmet contraception needs. We conducted a systematic review of the effectiveness of DHI on postpartum contraceptive use and repeated pregnancy. METHOD: We searched MEDLINE, Embase, Global Health, CINAHL and Cochrane CENTRAL (January 1990-July 2020). Randomised controlled trials (RCTs) of DHI promoting contraception among pregnant or postpartum women were included. Two researchers screened articles and extracted data. We assessed the risk of bias, certainty of evidence (CoE) and conducted meta-analyses following Cochrane guidance. RESULTS: Twelve trials with 5527 women were included. Interventions were delivered by video (four trials), mobile phone counselling (three trials), short message services (SMS) (four trials) and computer (one trial). During pregnancy or the postpartum period, mobile phone counselling had an uncertain effect on the use of postpartum contraception (risk ratio (RR) 1.37, 95% CI 0.82 to 2.29, very low CoE); video-based education may moderately improve contraception use (RR 1.48, 95% CI 1.01 to 2.17, low CoE); while SMS education probably modestly increased contraception use (RR 1.12, 95% CI 1.01 to 1.23, moderate CoE). Mobile phone counselling probably increased long-acting reversible contraception (LARC) use (RR 4.23, 95% CI 3.01 to 5.93, moderate CoE). Both mobile phone counselling (RR 0.27, 95% CI 0.01 to 5.77, very low CoE) and videos (RR 1.25, 95% CI 0.24 to 6.53, very low CoE) had uncertain effects on repeated pregnancy. CONCLUSIONS: During pregnancy or in the postpartum period, videos may moderately increase postpartum contraception use and SMS probably modestly increase postpartum contraception use. The effects of DHI on repeated pregnancy are uncertain. Further well-conducted RCTs of DHI would strengthen the evidence of effects on contraception use and pregnancy.

User interest in a new non-hormonal long-acting reversible contraceptive: what impact does mechanism of action have on past and future contraceptive decision-making?

BACKGROUND: We are in the process of developing a new non-hormonal long-acting reversible method of contraception (LARC) in recognition of the fact that a significant minority of users are unhappy with their current method. Our method has a novel (post-fertilisation) mechanism of action (MOA), but little is known about the value users place on this. METHODS: Using in-depth interviews, we explored 30 Australian end-users' experiences of contraception, recruited via social media. A thematic approach was taken to examine the influence the MOA has on choice and factors affecting willingness to try current methods and a novel non-hormonal LARC with a post-fertilisation effect. RESULTS: We identified two themes that were the most salient across all interviews: that contraceptive decision-making involves a trade-off of priorities, influenced by contraceptive properties (including MOA) and the context in which contraception is used; and views on novel methods of contraception were influenced by willingness to trial new products and interest in non-hormonal options. Side effects, efficacy, and the financial burden of contraceptives were all considered more important than MOA during decision-making. Participants were willing to try a new method if endorsed by trusted sources, including friends and medical practitioners, and were enthusiastic to try a novel LARC with no hormones. CONCLUSION: This study found that the MOA had minimal impact on participants' choice of contraception. Rather, avoidance of hormones and side effects influenced willingness to try a novel method over any unacceptable aspects of a post-fertilisation MOA.

Feasibility of e-commerce pharmacy provision and acceptability of levonorgestrel 1.5 mg for pericoital use in urban and peri-urban settings in Kenya: a prospective cohort study.

INTRODUCTION: An 'on-demand' contraceptive pill may suit women having infrequent sex. We assessed the feasibility of e-commerce pharmacy provision and acceptability of levonorgestrel (LNG) 1.5 mg for pericoital use in Kenya. METHODS: A 12-month prospective, single-arm, open-label, interventional study conducted from August 2020 to August 2021. A total of 897 women aged 18-49 years at risk of pregnancy and having infrequent sex (ie, six times or fewer coital frequency/month) were screened and enrolled. We undertook univariate and bivariate analysis on multiple data points: enrolment dataset, bimonthly surveys, extended survey around 6-month follow-up, and e-commerce pharmacy sales log. RESULTS: A total of 2291 pericoital LNG 1.5 mg pill doses were dispensed to 300 women over a 12-month period mainly via the USSD (Unstructured Supplementary Service Data) platform. Of the 266 women who obtained the pill and completed the survey, most (83%) were satisfied/very satisfied with e-commerce platform services, citing convenience and ease of use. The pill was also acceptable. Of the 266 women who used it at least once, 94% were satisfied/very satisfied, likely to continue using and would recommend it to others; 86% used it within 24 hours before/after sex as recommended and most of the time they had sex; and 147 (55%) experienced side effects, mainly nausea, headache, changes in menstrual pattern, cramps and dizziness that were mild and tolerable. CONCLUSIONS: E-commerce pharmacy provision of LNG 1.5 mg for pericoital use is feasible. In addition, a pericoital LNG 1.5 mg pill is acceptable among women having infrequent sex and could potentially address their unmet family planning needs.

Integrating pre-exposure prophylaxis of HIV infection into family planning services: a scoping review.

INTRODUCTION: The aim of this review was to map evidence of integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning services. A comprehensive package, using a combination of PrEP and contraceptive delivery, could reduce the number of new HIV infections and/or unintended pregnancies for at-risk women and adolescent girls. METHODS: A scoping literature search was conducted between August 2020 and October 2020. After developing the review question, electronic databases (MEDLINE, Embase, Cochrane Library, Global Health, Web of Science) were systematically reviewed. All types of articles published from 2012 to August 2020 in English were included. The intended outcome was to identify barriers and enablers of integrating services at the client-level and provider-level. RESULTS: 38 articles met inclusion criteria, with 16 from low-and middle-income countries and 22 from high-income countries. Barriers at the client-level included a lack of risk perception associated with low uptake and continuation of PrEP and pill burden; and at the provider-level, barriers included a lack of studies on cost-effectiveness of integrating services and provider training and knowledge. Facilitators included the initiation of PrEP and contraception at the same time and by the same provider or HIV self-testing. CONCLUSION: Mapping and synthesising current evidence, this review identified key barriers and facilitators for the integration of PrEP into family planning services for women and adolescent girls. In order to address these factors, more implementation research in a variety of settings is needed to meet women's sexual and reproductive health needs globally.

A cross-sectional study of factors associated with immediate postpartum uptake of contraceptive implants in Papua New Guinea.

OBJECTIVES: In 2016 the Port Moresby General Hospital in Papua New Guinea introduced a midwife led postpartum contraception service to educate patients and provide contraceptive implants. This study examines the factors that were associated with immediate postpartum uptake of the implants. STUDY DESIGN: We conducted a cross-sectional study of patients on the hospital postnatal ward who gave birth between March 2017 and January 2018. Patients aged 16-45 who had a vaginal birth with a singleton, live baby not requiring admission to the special care nursery were eligible for inclusion and invited to complete a survey prior to discharge. RESULTS: Of 2082 patients approached, all consented to participate in the survey. Of those completing the survey, 531 (25.5%) chose to have the contraceptive implant provided immediately postpartum. Excluding patients who chose tubal ligation (n = 330), in multivariable analysis, higher odds of implant uptake was associated with no prior contraception use compared to prior use (aOR 1.38; 95% CI 1.07 -1.77), unplanned pregnancy compared to planned (aOR 1.37, 95% CI 1.07-1.79), and having received antenatal education about the implant compared to no information (AOR 1.65, 95% CI 1.23-2.10). CONCLUSIONS: Antenatal education about the contraceptive implant impacted on likelihood of immediate postpartum method uptake. Patients who had no prior use of contraception and those with unplanned pregnancies were also more likely to request the implants, suggesting that the midwife-led postpartum service is successfully reaching patients with a previous unmet need for contraception. IMPLICATIONS: This study demonstrates successful delivery of a postpartum implant program in a setting where community access to contraception is limited. Antenatal information and education can support implant uptake and that the program provides the opportunity for birth spacing and limiting in patients with a previous unmet need.

Concern that contraception affects future fertility: How common is this concern among young people and does it stop them from using contraception?

Objectives: This study examines the concern that contraception affects future fertility among community college students and its association with contraceptive use. Study design: We used baseline data from a randomized controlled trial with 2060 community college students assigned female at birth. We used mixed-effects multivariate logistic regression adjusted for clustered data to assess sociodemographic factors associated with concerns about contraception affecting future fertility and to test the association between this concern and contraceptive use. Results: Most participants (69%) worried about contraception affecting their future fertility. Multivariable results indicated that first-generation college students (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.01-1.55) and non-English speakers at home (aOR, 1.30; 95% CI, 1.04-1.64) were more concerned. Racial and ethnic differences were significant, with Black non-Hispanic (aOR, 2.83; 95% CI, 1.70-4.70), Asian/Pacific Islander non-Hispanic (aOR, 2.12; 95% CI, 1.43-3.14), and Hispanic (aOR, 1.54; 95% CI, 1.17-2.02) participants more likely to be concerned than White non-Hispanic counterparts. Participants who received contraceptive services in the past year had lower odds of this concern (aOR, 0.72; 95% CI 0.59-0.88). Furthermore, participants with this concern had lower odds of using contraception (aOR, 0.67; 95% CI, 0.49-0.91), especially hormonal contraception (aOR, 0.77; 95% CI, 0.61-0.97). Conclusions: Most students feared contraception's impact on fertility, and this fear was associated with not using contraception. Disparities in this concern may be tied to discrimination, reproductive coercion, and limited reproductive health care access. Addressing concerns about contraception affecting future fertility is crucial to person-centered contraceptive counseling. Implications: This study examines the concern that contraception affects future fertility among sexually active female community college students and its impact on contraceptive use. Most participants expressed concerns about contraception affecting future fertility. Addressing future fertility concerns in patient-centered contraceptive counseling is crucial for reaching young people.

Designing illustrative social media stories to promote adolescent peer support and healthy sexual behaviors.

Objective: Adolescent females in the United States continue to have unmet sexual and reproductive healthcare needs. Research shows that interventions incorporating peer support can augment perceived self-efficacy and reinforce healthy behaviors. Yet, few user-centered digital sexual health interventions incorporate peer support, and aim to change perceptions of peer norms and model social skills. The objective of this study was to design and demonstrate the receptivity of adolescent females to illustrated digital social media stories that promote healthy sexual behaviors and peer social support. Methods: We conducted a three-phase study approved by our Institutional Review Board. In Phase 1, we presented sexually active adolescent female emergency department patients aged 14-19 with eight sexual health scenarios via a survey study. Participants wrote three text messages addressed to the protagonist of each scenario which motivated and encouraged her to consider the use of contraceptives. Messages were scored based on the construct of peer support (emotional, tangible, informational, and belonging). In Phase 2, we worked with a professional artist and screenwriter to design digital sexual health comics using the gathered messages. In Phase 3, we gathered feedback on the comics from adolescent female emergency department patients. Results: Females (n = 22) provided 352 messages. Using top rated messages, we designed five digital visualizations in a running story called Mari tells it like it is. Each story incorporated 5-12 peer-authored quotes. We inserted the final images into Instagram®. Additional females (n = 39) found the images "relatable," "super-realistic," and "educational." Conclusion: Collecting peer-authored texts from our local adolescent community led to the creation of well-received sexual health visualizations. This novel method of design incorporated adolescent voices to promote peer support and healthy behaviors.

Potential candidate for oral pericoital contraception: evaluating ulipristal acetate plus cyclo-oxygenase-2 inhibitor for ovulation disruption.

BACKGROUND: There remains considerable global unmet contraceptive need, with almost 200 million women reporting desire to limit or space childbearing without contraceptive use. Researchers have documented worldwide interest in an oral, on-demand contraceptive option were it available. Candidates for use include ulipristal acetate (UA), levonorgestrel and cyclo-oxygenase-2 (COX-2) inhibitors alone or in combination. METHODS: We performed an exploratory, prospective study of matched menstrual cycles: one baseline cycle and one treatment cycle of UA 30 mg plus meloxicam 30 mg just prior to ovulation. The primary outcome was ovulation disruption, defined as unruptured dominant follicle for 5 days. Secondary outcomes included comparing cycle length, endometrial stripe thickness, and side effects. RESULTS: Nine participants completed all study procedures in both cycles. Ovulatory disruption occurred in 66.7% (n=6) of treatment cycles and all but one demonstrated features of ovulatory dysfunction. Cycle length (mean±SD) was longer in the treatment cycle (31.9±4.0 vs 28.6±3.5 days, p<0.01). Secondary outcomes did not differ between the two cycles. CONCLUSIONS: UA plus the COX-2 inhibitor meloxicam disrupts ovulation at peak luteal surge and is a promising candidate for evaluation as a pericoital oral contraceptive. TRIAL REGISTRATION NUMBER: NCT03354117.