Amy K. Whitaker

Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device

BACKGROUND This study aimed to assess adolescent (aged 14-18 years) and young adult (aged 19-24 years) womens knowledge of and attitudes toward intrauterine devices (IUDs) before and after a brief educational intervention. STUDY DESIGN We administered a 43-item survey to 144 women aged 14-24 years, with half in each age category. The survey assessed knowledge of and attitudes toward IUDs, and incorporated a 3-min educational intervention about IUDs. Predictors for knowledge of and attitudes toward the IUD were examined using logistic regression. RESULTS Forty percent of participants had heard of the IUD. Having ever heard of the IUD was associated with age >18 years [adjusted odds ratio (OR)=5.7; 95% confidence interval (95% CI)=2.1-15.7], a higher level of maternal education (adjusted OR=4.5; 95% CI=1.5-13.3) and a history of voluntary sexual intercourse (adjusted OR=4.9; 95% CI=1.0-23.5). Of those who had heard of the IUD previously, 37.5% reported a positive attitude toward the IUD before the intervention. After the educational intervention, 53.5% of all participants reported a positive attitude toward the IUD, with both adolescent and young adult women having similarly positive attitudes (51.4% vs. 55.6%, p=.62). This positive attitude was associated only with a history of voluntary sexual intercourse (adjusted OR=5.2; 95% CI=1.3-21.1). The characteristics of the IUD that the participants strongly liked and disliked were rated similarly by the two age groups. However, more adolescent women considered the privacy of the IUD and the ability to use the copper IUD for 10 years as positive characteristics. CONCLUSION Most young women were unaware of IUDs but were likely to think positively about IUDs after being educated about them. Demographic and reproductive health history did not predict attitude; thus, all young women should be offered education about IUDs.

Misoprostol administered by epithelial routes: Drug absorption and uterine response.

OBJECTIVE: To quantify and compare serum levels and uterine effects following vaginal (dry), vaginal (moistened), buccal, and rectal misoprostol administration. METHODS: Forty women seeking elective abortion between 6 and 12 6/7 weeks were randomly assigned to receive 400 μg of misoprostol by one of four routes. A 2.5-mm pressure monitoring catheter was placed through the cervix to the uterine fundus to record uterine tone and activity during the 5-hour observation period. Serum levels of misoprostol acid were measured at 15 and 30 minutes, then every 30 minutes. RESULTS: The four groups were similar in age, race or ethnicity, body mass index, parity, and gestation. Serum levels after vaginal, vaginal moistened and buccal administration rose gradually, peaked between 15 and 120 minutes and fell slowly. Vaginal and vaginal moistened routes produced higher peak serum levels than buccal and rectal (445.9 and 427.1 compared with 264.8 and 202.2 pg/mL; P=.03) and higher serum concentration area under the curve at 5 hours (1,025.0 and 1279.4 compared with 519.6 and 312.5 pg-hr/mL; P<.001). Uterine tone and activity, however, were similar for buccal and the two vaginal routes. After rectal administration, serum levels peaked earlier (P<.001) then dropped more abruptly, and peak uterine tone (P<.001) and total activity (P=.04) were lower than after the other routes. CONCLUSION: Although serum levels were lower for buccal compared with the vaginal routes, the three routes produced similar uterine tone and activity. Rectal administration produced lower uterine tone and activity. Vaginal serum levels were two to three and a half times higher than those observed in prior misoprostol pharmacokinetic studies. LEVEL OF EVIDENCE: II-1

Cervical Cancer Screening, Diagnosis and Treatment Interventions for Racial and Ethnic Minorities: A Systematic Review

OBJECTIVESTo systematically review the literature to determine which interventions improve the screening, diagnosis or treatment of cervical cancer for racial and/or ethnic minorities.DATA SOURCESMedline on OVID, Cochrane Register of Controlled Trials, CINAHL, PsycINFO and Cochrane Systematic Reviews.STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONSWe searched the above databases for original articles published in English with at least one intervention designed to improve cervical cancer prevention, screening, diagnosis or treatment that linked participants to the healthcare system; that focused on US racial and/or ethnic minority populations; and that measured health outcomes. Articles were reviewed to determine the population, intervention(s), and outcomes. Articles published through August 2010 were included.STUDY APPRAISAL AND SYNTHESIS METHODSOne author rated the methodological quality of each of the included articles. The strength of evidence was assessed using the criteria developed by the GRADE Working Group.45,46RESULTSThirty-one studies were included. The strength of evidence is moderate that telephone support with navigation increases the rate of screening for cervical cancer in Spanish- and English-speaking populations; low that education delivered by lay health educators with navigation increases the rate of screening for cervical cancer for Latinas, Chinese Americans and Vietnamese Americans; low that a single visit for screening for cervical cancer and follow up of an abnormal result improves the diagnosis and treatment of premalignant disease of the cervix for Latinas; and low that telephone counseling increases the diagnosis and treatment of premalignant lesions of the cervix for African Americans.LIMITATIONSStudies that did not focus on racial and/or ethnic minority populations may have been excluded. In addition, this review excluded interventions that did not link racial and ethnic minorities to the health care system. While inclusion of these studies may have altered our findings, they were outside the scope of our review.CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGSPatient navigation with telephone support or education may be effective at improving screening, diagnosis, and treatment among racial and ethnic minorities. Research is needed to determine the applicability of the findings beyond the populations studied.

A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.

BACKGROUND The intrauterine device (IUD) is a safe, long-acting, highly effective method of birth control. Two-visit protocols for IUD insertion may represent a barrier to IUD uptake. STUDY DESIGN This study is a retrospective database review. We identified Medicaid-insured women who requested IUDs in our urban university-based clinic, which employed a two-visit protocol for IUD insertion. The number of women who returned for IUD insertion was determined. To compare women who underwent insertion to those who did not, bivariate and multivariable analyses were used. RESULTS Of the 708 women who requested IUDs at the initial visit, only 385 had an IUD inserted (54.4%). Single women were less likely to return for IUD placement compared to women who had ever been married (52.4% vs. 70.3%; p<.01). Patients who ordered IUDs at gynecologic visits were more likely to return as opposed to those who had them ordered at obstetrics-related visits (60.5% vs. 50.2%; p<.01). Women who lived >10 miles away from the clinic were less likely to return for IUD insertion than women who lived <10 miles away from the clinic (45.3% vs. 56.2%; p=.03). Race, age and type of IUD ordered were not significantly associated with probability of insertion. CONCLUSIONS Almost half of women who ordered IUDs did not return for insertion, suggesting that two-visit protocols hinder a womans ability to have an IUD placed. We must eliminate barriers to IUD insertion.

Effect of a brief educational intervention on the attitudes of young women toward the intrauterine device.

STUDY OBJECTIVE The intrauterine device (IUD) is underused by young women, who are at high risk for unintended pregnancy. We aimed to assess the impact of a brief educational intervention on the attitudes of young women toward intrauterine contraception and to assess characteristics associated with a change in attitude. DESIGN, SETTING, AND PARTICIPANTS This is a planned secondary analysis of a survey of 144 women, aged 14-24 years, which assessed attitudes toward the IUD. INTERVENTION The analysis was planned to fully examine the impact of a 3-minute educational intervention about the IUD given during administration of the survey, which included risks and benefits of IUD use, costs, side effects, and a demonstration of the IUD insertion and removal process. MAIN OUTCOME MEASURE Proportions of participants with a positive attitude toward the IUD before and after the intervention were compared using McNemars chi-square test for paired proportions. Factors associated with a change in attitude toward the IUD were evaluated using multivariable analysis. RESULTS Before the educational intervention, 14.7% (21/143) had both heard of the IUD and expressed a positive attitude toward it. After the intervention, this proportion increased to 53.8% (77/143) (P < .01). The increase in proportion with a positive attitude was consistent for all subpopulations. In multivariable analysis, the only significant predictor of a positive change in attitude toward the IUD was a history of voluntary sexual activity (adjusted odds ratio 10.3, 95% confidence interval 2.0-53.1). CONCLUSIONS A brief educational intervention significantly improves the attitude of young sexually active women toward the IUD.

Correlates of use of long-acting reversible methods of contraception among adolescent and young adult women

BACKGROUND Most pregnancies among adolescent and young adult women are unintended, and adolescent birth rates have risen. Use of long-acting reversible contraception may be an effective strategy to reduce the rate of unintended pregnancy. STUDY DESIGN We conducted a secondary data analysis of nationally representative, cross-sectional data from the 2002 National Survey of Family Growth. Our sample included 1722 sexually active women aged 15-24 years. We used multivariable logistic regression to identify correlates of ever-use of depot-medroxyprogesterone acetate (DMPA) or the intrauterine device (IUD). RESULTS One-quarter of our sample had ever used DMPA, and less than 2% had ever used the IUD. In multivariable analysis, increasing parity was associated with ever-use of DMPA (OR 2.07, 95% CI 1.55-2.77) and ever-use of the IUD (OR 4.57, 95% CI 1.60-13.03), but age and measures of socioeconomic status were not. Having ever been married (OR 5.54, 95% CI 1.23-24.82) and current cohabitation (OR 4.89, 95% CI 1.10-21.71) were associated with ever-use of the IUD. A history of an adolescent pregnancy was associated with ever-use of DMPA (OR 1.79, 95% CI 1.19-2.70) but not of the IUD. CONCLUSIONS While similarities exist between the correlates of use of DMPA and the IUD, we discovered important differences, some of which may reflect provider biases regarding IUD provision.

Contraceptive Care for Adolescents

Adolescents have a high rate of unintended pregnancy: 82% of pregnancies for women aged 15 to 19 years are unintended. The large majority of sexually active adolescent women are using some method of contraception, but few are using long-acting highly effective methods, that is, intrauterine devices and implants. Most adolescent women are relying on oral contraceptive pills and/or condoms as their most effective method, with the third most common method being depot medroxyprogesterone acetate. None of the long-acting highly effective methods are contraindicated in adolescents, and they should be considered for use and offered to young women as contraceptive options.

Awareness and Knowledge of the Intrauterine Device in Adolescents

BACKGROUND The purpose of this study was to explore intrauterine device (IUD) awareness and knowledge in a diverse, multiethnic population. METHODS We conducted a self-administered, anonymous survey addressing awareness of the IUD as a contraceptive method and knowledge about aspects of IUD use in a group of women aged 14 to 19 years. Demographic and medical information was obtained to compare awareness and knowledge between demographic groups. Chi-square, Fisher exact test, and t tests were used for analysis. Multiple logistic regression was utilized to confirm relationships. RESULTS Of the 106 respondents, 76.4% (81/106) were sexually active and 56.6% (60/106) reported a history of ever being pregnant. There were 21.1% (33/106) of respondents who had heard of the IUD as a contraceptive method. Of the subjects who had heard of the IUD, 39.4 % (13/33) were able to identify key features of the IUD. Although a history of pregnancy was predictive of having heard of the IUD, age, insurance status, education, and all other demographic factors were not associated with IUD awareness. CONCLUSION Over 70% of the adolescents had not heard of the IUD and less than half of adolescents who had heard of the IUD were able to identify key features about this contraceptive method. The lack of knowledge of this effective and safe contraceptive option is concerning given that most participants were at high risk for unintended pregnancy.

Postplacental insertion of the levonorgestrel intrauterine device after cesarean delivery vs. delayed insertion: a randomized controlled trial ☆ ☆☆ ★

OBJECTIVE This trial was designed to compare levonorgestrel intrauterine device (LNG-IUD) use at 1 year after delivery between women randomized to postplacental insertion at the time of cesarean delivery and delayed insertion 4-8 weeks after delivery. STUDY DESIGN This randomized controlled trial was conducted at two urban medical centers. Eligible pregnant women with planned cesarean deliveries were randomized to immediate postplacental insertion during cesarean or delayed insertion after 4-8 weeks. We used intention-to-treat analysis for the primary outcome of LNG-IUD use 12 months after delivery. RESULTS Forty-two women were randomized, 20 into the postplacental group and 22 in the delayed group. Although confirmed use of the LNG-IUD 12 months after delivery was higher in the postplacental group (60.0% vs. 40.9%, p=.35), this difference was not statistically significance. Expulsion was significantly more common in the postplacental group (20.0% vs. 0%, p=.04). There were significant differences between the two sites in baseline population characteristics, follow-up and expulsion. The trial did not answer the intended question as it was halted early due to slow enrollment. CONCLUSIONS Our results show higher expulsion after postplacental insertion compared to delayed insertion but suggest similar IUD use at 12 months. Moreover, it provides valuable lessons regarding a randomized controlled trial of postplacental LNG-IUD placement due to the challenges of estimating effect size and the nature of the population who might benefit from immediate insertion. IMPLICATIONS Postplacental insertion of an IUD may improve use of highly effective contraception during the postpartum period. While our results suggest higher expulsion after postplacental insertion compared to delayed insertion and similar IUD use at 12 months, our trial was insufficient to definitively test our hypothesis.

Familial, cultural and psychosocial influences of use of effective methods of contraception among Mexican-American adolescents and young adults.

STUDY OBJECTIVE To compare culturally relevant factors associated with ever having used an effective method of contraception among a cohort of predominantly Mexican American females. DESIGN Face to face interviews were conducted in either English or Spanish. The survey used was developed directly for this study based on qualitative research with this population as well as the existing literature. Women were grouped as either adolescents (ages 13-20) or young adults (ages 21-25) for study purposes. SETTING Two community-based outpatient clinics on Chicagos West Side. PARTICIPANTS Non-pregnant Latina females between 13-25 years of age. MAIN OUTCOME MEASURES Comparison of familial, cultural and psychosocial factors associated with use of effective contraception using bivariate and multivariable analyses. RESULTS Final analysis included 267 participants. Multivariable models yielded three factors found to be statistically significant predictors of effective contraception use, but only one was significant for both age groups. Number of children was a strong predictor of effective contraceptive use among both Latina adolescents and young adults (P < 0.001 for adolescents and P = 0.049 for young adults). Partner communication predicted effective contraceptive use among Latina adolescents (P = 0.001). Acculturation level strongly predicted effective contraceptive use among Latina young adults (P < 0.001). CONCLUSIONS Findings demonstrate the need to tailor messages to Latina adolescent and young adults to reduce unintended pregnancy. Interventions to improve effective contraceptive use among Latina adolescents should promote effective forms of contraception in conjunction with communication with their partners about birth control. In contrast, efforts to address unintended pregnancy among Latina young adults should be sensitive to degree of acculturation.