Amy Neustadt

Adherence and acceptability of the contraceptive ring compared with the pill among students: a randomized controlled trial.

OBJECTIVES: To compare satisfaction with and adherence to the contraceptive vaginal ring and a daily low-dose oral contraceptive pill (OCP) among college and graduate students using a novel method of electronic data collection. METHODS: We randomly assigned 273 women to the contraceptive vaginal ring (n=136) or OCP (n=137) for three consecutive menstrual cycles. Participants completed daily Internet-based, online diaries regarding method adherence and satisfaction during cycles of use. At 3 months, they completed an online survey regarding intention to continue their method and overall acceptability. At 6 months, we surveyed participants to see whether they continued using contraception and, if so, which method. RESULTS: Rates of loss to follow-up were similar between groups. Contraceptive vaginal ring users reported more perfect use in the first 2 months (P=.05). After the 3-month study period, 52 (43%) of 121 contraceptive vaginal ring users and 65 (52%) of 126 OCP users reported plans to continue their method (P=.16). However, at 6 months, only 31 (26%) of 117 contraceptive vaginal ring users and 36 (29%) of 123 OCP users had continued their assigned study method (P=.61). Almost 50% of both groups were using condoms or no method. CONCLUSION: Contraceptive vaginal ring users were more likely to report perfect use during the 3-month trial period than were OCP users. Despite randomization, participants were equally satisfied with their assigned hormonal contraceptive method. At 6 months, less than 30% of participants were still using their assigned method. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00635570. LEVEL OF EVIDENCE: I

Intrauterine contraception for adolescents aged 14-18 years: a multicenter randomized pilot study of levonorgestrel-releasing intrauterine system compared to the Copper T 380A.

BACKGROUND Intrauterine contraception can provide adolescents with effective, long-term contraception as well as with other health benefits. In adult populations, intrauterine contraception rates highly in patient satisfaction and safety. It is rarely prescribed to adolescents because of limited data. STUDY DESIGN Multicenter, randomized, controlled, participant-blinded pilot study of 14-18-year-old females assigned to the Copper T 380A intrauterine device or the Levonorgestrel Intrauterine System. Participants were followed up for 6 months following insertion. RESULTS We enrolled 23 participants; 12 received the Levonorgestrel Intrauterine System, and 11 received the Copper T 380A. At 6 months, the continuation rates were 75% for the Levonorgestrel Intrauterine System users and 45% for the Copper T 380A users (p=.15). Two Copper T 380A users experienced partial expulsion. Heavy bleeding and pelvic pain were the most commonly reported side effects. Participants rated both methods favorably. CONCLUSIONS This study shows that at 6 months, though not statistically significant, adolescent continuation rates trended towards being greater with the Levonorgestrel Intrauterine System compared to the Copper T 380A. These pilot data will be helpful in the design of a larger trial of intrauterine contraception use among adolescents.

Pharmacokinetics of the etonogestrel contraceptive implant in obese women.

OBJECTIVE We sought to examine the pharmacokinetics and acceptability of the etonogestrel contraceptive implant in obese women. STUDY DESIGN We developed and validated a plasma etonogestrel concentration assay and enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve. RESULTS All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women. CONCLUSION Obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion. These findings should not be interpreted as decreased contraceptive effectiveness without additional considerations.

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.

Use of withdrawal and unintended pregnancy among females 15-24 years of age.

OBJECTIVE: To examine the prevalence of withdrawal (coitus interruptus) use among a cohort of U.S. females aged 15–24 years, to describe characteristics of withdrawal users, and to evaluate whether withdrawal users exhibit a higher risk of unintended pregnancy. METHODS: We analyzed the 2006–2008 National Survey of Family Growth, estimating with a Cox proportional hazards model the risk of an unintended pregnancy over and up to a 47-month retrospective period among females aged 15–24 years who used withdrawal relative to females who used only other methods of contraception. We also examined correlates of withdrawal use using a logit model. RESULTS: During the study period, 31.0% of females in our cohort used withdrawal. Of withdrawal users, 21.4% experienced an unintended pregnancy compared with 13.2% of females who used only other contraceptive methods (adjusted hazard ratio 1.75, 95% confidence interval [CI] 1.23–2.49). Withdrawal users were also 7.5% more likely to have used emergency contraception (adjusted odds ratio [OR] 1.57, 95% CI 1.13–2.20). Married females were 14.8% less likely than single females to use withdrawal (adjusted OR 0.58, 95% CI 0.35–0.96). CONCLUSION: Use of withdrawal as contraception is common and might place females at higher risk of unintended pregnancy. Health care providers should be aware that many patients may use withdrawal, should consider the need for emergency contraception among these females, and should encourage them to use more effective methods of contraception. LEVEL OF EVIDENCE: II

Daily context matters: predictors of missed oral contraceptive pills among college and graduate students

OBJECTIVE The purpose of this study was to understand the relationship between daily contextual factors and oral contraceptive (OC) adherence among students who attend college or graduate school. STUDY DESIGN Data on OC adherence, demographics, contextual factors, and side-effects were collected as part of the acceptability of the NuvaRing (Merck & Co, Whitehouse Station, NJ) vs OC study, in which students were assigned randomly to the contraceptive vaginal ring or to a low-dose OC. We performed bivariate and multivariable analyses to create an explanatory model for nonperfect OC adherence (missed at least 1 pill during 3 months of use). RESULTS In a multivariable predictive model, missing a pill was associated positively with high perceived stress (odds ratio [OR], 3.16; P = .007), having ≥10 hours per week of paid employment (OR, 2.13; P = .075), and living with a partner (OR, 9.92; P = .040). CONCLUSION Stressful and hectic lives contribute to poor OC adherence. When counseling women about contraception, clinicians should consider the influence of daily life on contraceptive adherence.

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.

Sexual, relationship, contraceptive and personal factors influencing emergency contraception use: a qualitative study ☆

BACKGROUND Emergency contraception (EC) has not achieved its abortion reduction potential in the United States in part due to nonuse. Understanding use behaviors may increase EC promotion. STUDY DESIGN Interviews were conducted with 30 EC users aged 18-35 years. Interviews were analyzed for salient themes using ATLAS/ti. We used an analytical framework including personal context (life circumstances motivating pregnancy prevention), contraceptive context (knowledge, attitudes and experience), sexual context (planned/unplanned intercourse) and relationship context. RESULTS Our sample was primarily college-educated, nulliparous, single women. EC users were motivated to prevent pregnancy, but unwilling or unable to use contraceptive methods due to ambivalence, fear, limited access or difficulty with use. Favorable attitudes toward EC, desire to defer pregnancy, infrequent intercourse, partner support of EC and relationship instability facilitated EC use. CONCLUSIONS EC fills an important gap in preventing pregnancy for motivated women who struggle with contraceptive use. Contextual factors informed womens EC behaviors.

Perceived Benefits and Barriers to Family Planning Education among Third Year Medical Students

Abstract Purpose: The purpose of the current study is to explore third- year medical students’ interest in learning about family planning, exposure to family planning (contraception and abortion) and perceived barriers and benefits to family planning education in their obstetrics and gynecology rotation. Method: We conducted four focus groups with 27 third-year medical students near the end of their rotation in obstetrics and gynecology. Results: Students desired education in family planning but perceived limited exposure during their rotation. Most students were aware of abortion but lacked factual information and abortion procedural skills. They felt systemic and faculty-related barriers contributed to limited exposure. Students discussed issues such as lack of time for coverage of contraception and abortion in the curricula and rotation itself. Perceived benefits of clinical instruction in family planning included increased knowledge of contraceptive management and abortion the ability to care for and relate to patients, opportunity for values clarification, and positive changes in attitudes towards family planning. Conclusions: Medical students who desire full education in family planning during their obstetrics and gynecology rotation may face barriers to obtaining that education. Given that many medical students will eventually care for reproductive-age women, greater promotion of opportunities for exposure to family planning within obstetrics and gynecology rotations is warranted.