Karen Pazol

Condoms for Dual Protection: Patterns of Use with Highly Effective Contraceptive Methods

Objectives. U.S. women experience high rates of unplanned pregnancy and sexually transmitted infections (STIs), yet they seldom combine condoms with highly effective contraceptives for optimal protection. Because oral contraceptives (OCs) have been the predominant form of highly effective contraception in the U.S., it is unknown whether condom use is similarly low with increasingly promoted user-independent methods. Methods. We used weighted data from the National Survey of Family Growth to assess condom use odds among women relying on OCs vs. user-independent methods (i.e., injectibles, intrauterine devices, and implants). We also estimated the expected reduction in unplanned pregnancies and abortions if half or all of the women currently using a single highly effective method also used condoms. Results. Across every demographic subgroup based on age, partner status, race/ethnicity, household income, and education, condom use prevalence was lower for women relying on user-independent methods vs. OCs. Multivariable models for adult women also revealed a significant reduction within most demographic subgroups in the odds of condom use among women relying on user-independent methods vs. OCs. Population estimates suggested that if half of all women using highly effective methods alone also used condoms, approximately 40% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 393,000 unplanned pregnancies and nearly 76,000 abortions. If all highly effective method users also used condoms, approximately 80% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 786,000 unplanned pregnancies and nearly 152,000 abortions. Conclusions. Adding condoms to other methods should be considered seriously as the first line of defense against unplanned pregnancy and STIs. This analysis can serve to target interventions where dual-method promotion is needed most.

Seasonal variation in feeding behavior, competition and female social relationships in a forest dwelling guenon, the blue monkey (Cercopithecus mitis stuhlmanni), in the Kakamega Forest, Kenya

Socioecological models relate differences in feeding strategies to variation in the nature of female social relationships. Among the African forest guenons, females consume large quantities of fruit and other plant reproductive parts, resources which are thought to promote contest competition, yet these monkeys have been characterized as having agonistically undifferentiated relationships in which rank, if discernible at all, does not correlate with fitness benefits. To determine whether female relationships become more hierarchical under relevant ecological conditions, we monitored the adult females of two blue monkey groups (Cercopithecus mitis stuhlmanni) over a complete annual cycle in the Kakamega Forest, Kenya. Females competed aggressively for plant reproductive parts more often than any other resource type, and in both groups we detected linear dominance hierarchies. Nonetheless, agonism rates remained low throughout our study, and did not vary with changes in ecological conditions. Rather, when plant reproductive parts were scarce, subordinate females spent more time feeding and less time resting in an apparent attempt to compensate for a reduced efficiency of food intake. The effects of rank and food abundance were not reflected, however, in the distribution of grooming. The use of alternative feeding strategies appeared to blunt competition – females of all ranks were unlikely to be near others while feeding and spent more time consuming alternative resources when plant reproductive parts were scarce. The diverse diet of this species may allow females to avoid conflict so that dominance has only subtle effects that are difficult to detect. While socioecological models often simplify the connection between resources and female interactions, our results emphasize that the behavior of animals consuming particular resources, and not the resources themselves, are critical predictors of social patterns.

Abortion-Related Mortality in the United States: 1998-2010.

OBJECTIVE: To examine characteristics and causes of legal induced abortion–related deaths in the United States between 1998 and 2010. METHODS: Abortion-related deaths were identified through the national Pregnancy Mortality Surveillance System with enhanced case-finding. We calculated the abortion mortality rate by race, maternal age, and gestational age and the distribution of causes of death by gestational age and procedure. RESULTS: During the period from 1998–2010, of approximately 16.1 million abortion procedures, 108 women died, for a mortality rate of 0.7 deaths per 100,000 procedures overall, 0.4 deaths for non-Hispanic white women, 0.5 deaths for Hispanic women, and 1.1 deaths for black women. The mortality rate increased with gestational age, from 0.3 to 6.7 deaths for procedures performed at 8 weeks or less and at 18 weeks or greater, respectively. A majority of abortion-related deaths at 13 weeks of gestation or less were associated with anesthesia complications and infection, whereas a majority of abortion-related deaths at more than 13 weeks of gestation were associated with infection and hemorrhage. In 20 of the 108 cases, the abortion was performed as a result of a severe medical condition where continuation of the pregnancy threatened the womans life. CONCLUSION: Deaths associated with legal induced abortion continue to be rare events—less than 1 per 100,000 procedures. Primary prevention of unintended pregnancy, including those in women with serious pre-existing medical conditions, and increased access to abortion services at early gestational ages may help to further decrease abortion-related mortality in the United States. LEVEL OF EVIDENCE: III

Gonadal steroid modulation of the limbic-hypothalamic-pituitary-adrenal (LHPA) axis is influenced by social status in female rhesus monkeys

Chronic stress can have a deleterious effect on the reproductive axis that, for females, is manifested in an increased incidence of infertility. However, gonadal steroids may, in turn, affect a female’s response to stress as measured by activity within the limbic-hypothalamic-pituitary-adrenal (LHPA) axis. What is not clear is whether a history of exposure to stress modifies the effect of gonadal steroids on LHPA responsivity. Rhesus monkeys present a unique opportunity to assess LHPA responsivity when housed socially in groups. Under these situations, monkeys exhibit a rich network of affiliation and have established social status hierarchies. Previous work indicates that socially subordinate macaque females are hypercortisolemic due to diminished glucocorticoid negative feedback. The present study tested the hypothesis that estradiol (E2) would decrease glucocorticoid negative feedback, assessed from a dexamethasone (DEX) suppression test, and increase the response to corticotropin releasing factor (CRF) and that these effects would be attenuated by co-treatment with P4. In addition, we also determined whether E2 and P4 would differentially affect LHPA responsiveness to pharmacological challenge in socially dominant compared with subordinate females. Endogenous gonadal hormone secretion in female rhesus monkeys (n=7) was suppressed by continuous treatment with a sustained release formulation of the GnRH analog leuprolide acetate (Lupron Depot). The response to a combined DEX suppression-CRF stimulation test was assessed using a counterbalanced design during a placebo (control) treatment condition and during E2, P4, and E2 + P4 replacement therapy. Females who were members of a large breeding group of 140 adults and juveniles of both sexes, were classified as dominant (n=4) or subordinate (n=3) based on the relative social dominance positions within the group. Plasma levels of cortisol were significantly higher during E2 replacement compared to the other treatment conditions following DEX suppression and stimulation with CRF. Escape from glucocorticoid negative feedback, assessed as the increase in cortisol following maximum suppression by DEX and prior to stimulation by CRF, was enhanced by E2. Plasma ACTH was also significantly higher during E2 replacement following DEX suppression, an effect that was attenuated by co-treatment with P4. The evaluation of the influence of social status indicated that the decrease in glucocorticoid negative feedback on cortisol and ACTH release induced by E2 was exacerbated in socially subordinate females. Overall, cortisol and ACTH decreased less in response to DEX and increased more in response to CRF in socially subordinate females compared with dominant females. Taken together, these data indicate that E2 increases the responsiveness of the LHPA axis in female rhesus monkeys and this response in enhanced by social subordination.

Development, theoretical framework, and lessons learned from implementation of a school-based influenza vaccination intervention.

The Advisory Committee on Immunization Practices (ACIP) recently recommended that all children 6 months to 18 years old be vaccinated annually against influenza. School-based influenza vaccination interventions may potentially increase influenza vaccination rates among hard-to-reach populations, particularly rural adolescents. This article describes the theoretical framework, intervention development, and lessons learned from 1st-year implementation of a multicomponent intervention aimed to promote influenza vaccine acceptance among multiethnic (predominantly African American) adolescents attending middle and high school in rural Georgia. Adolescents, parents, and school administrators were active participants in the development and implementation of the intervention. The educational intervention, which consisted of a brochure and a school skit/ presentation, was guided by constructs from the Health Belief Model and social norms. Process evaluation results indicated that our intervention development methods were successful in creating a low-cost, theory-based educational intervention that garnered community investment and met the cultural relevance and literacy needs of our target audience. To our knowledge, this study is the first to extensively engage middle- and high-school students and parents in the design and implementation of key educational components of a theory-based influenza vaccination intervention.

Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014

Teen childbearing can have negative health, economic, and social consequences for mothers and their children (1) and costs the United States approximately

Psychosocial correlates of intention to receive an influenza vaccination among rural adolescents

9.4 billion annually (2). During 1991-2014, the birth rate among teens aged 15-19 years in the United States declined 61%, from 61.8 to 24.2 births per 1,000, the lowest rate ever recorded (3). Nonetheless, in 2014, the teen birth rate remained approximately twice as high for Hispanic and non-Hispanic black (black) teens compared with non-Hispanic white (white) teens (3), and geographic and socioeconomic disparities remain (3,4), irrespective of race/ethnicity. Social determinants associated with teen childbearing (e.g., low parental educational attainment and limited opportunities for education and employment) are more common in communities with higher proportions of racial and ethnic minorities (4), contributing to the challenge of further reducing disparities in teen births. To examine trends in births for teens aged 15-19 years by race/ethnicity and geography, CDC analyzed National Vital Statistics System (NVSS) data at the national (2006-2014), state (2006-2007 and 2013-2014), and county (2013-2014) levels. To describe socioeconomic indicators previously associated with teen births, CDC analyzed data from the American Community Survey (ACS) (2010-2014). Nationally, from 2006 to 2014, the teen birth rate declined 41% overall with the largest decline occurring among Hispanics (51%), followed by blacks (44%), and whites (35%). The birth rate ratio for Hispanic teens and black teens compared with white teens declined from 2.9 to 2.2 and from 2.3 to 2.0, respectively. From 2006-2007 to 2013-2014, significant declines in teen birth rates and birth rate ratios were noted nationally and in many states. At the county level, teen birth rates for 2013-2014 ranged from 3.1 to 119.0 per 1,000 females aged 15-19 years; ACS data indicated unemployment was higher, and education attainment and family income were lower in counties with higher teen birth rates. State and county data can be used to understand disparities in teen births and implement community-level interventions that address the social and structural conditions associated with high teen birth rates.

Progesterone and medroxyprogesterone acetate differentially regulate α4 subunit expression of GABAA receptors in the CA1 hippocampus of female rats.

The Centers for Disease Control and Preventions Advisory Committee on Immunization Practices recently expanded annual influenza vaccination recommendations to include all children 6 months through 18 years of age. Adolescent attitudes toward influenza vaccination may play a key role in reaching this newly added age group. This study examined the association between attitudes toward influenza vaccination and intention to be vaccinated among rural adolescents. Data were collected from baseline surveys distributed to adolescents in September/October 2008, prior to the H1N1 influenza pandemic, in two counties participating in a school-based influenza vaccination intervention trial in rural Georgia (N = 337). Survey items were based on constructs from the Health Belief Model and the Integrated Behavioral Model. Approximately one-third of participants (33.8%) intended to receive an influenza vaccination, 33.5% did not intend to be vaccinated and 28.8% were unsure. Controlling for background factors, intention to receive an influenza vaccination was associated with low perceived barriers [odds ratio (OR) = 0.77, P < 0.001], injunctive norms (OR = 1.23, P = 0.002) and receipt of influenza vaccination in the past year (OR =6.21, P < 0.001). Findings suggest that perceived barriers and injunctive social norms may influence vaccination acceptance among rural adolescents. Future influenza vaccination efforts geared toward rural middle and high school students may benefit from addressing adolescent attitudes toward influenza vaccination.

Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011–2013 and 2015

The Womens Health Initiative trials - in which more extreme adverse outcomes were observed in the medroxyprogesterone acetate (MPA) + conjugated equine estrogen (CEE) arm, as compared to the CEE only arm - suggest that the addition of MPA to estrogen treatment has undesirable consequences. An important question raised by these results is whether the adverse outcomes observed in the progestin arm can be attributed to effects that are unique to MPA or are common to all progestins. In this study we explored the potential for MPA and progesterone (P4) to differentially impact neuroendocrine function by comparing their effects on mRNA expression for the alpha4 subunit of GABA(a) receptors in the CA1 hippocampus of female rats. Prior research has shown that P4, acting through its reduced metabolite allopregnanolone (AP), can mediate alpha4 subunit expression, thereby altering GABA(A) receptor gated currents. By contrast, MPA competitively inhibits the enzymes necessary for the synthesis of AP. In this study, ovariectomized females were primed with estradiol benzoate and then treated with P4, MPA, or vehicle. Subjects were sacrificed 12 h or 24 h later and in situ hybridization was used to measure alpha4 mRNA in the CA1 hippocampus. At 12 h but not 24 h, alpha4 mRNA was reduced in the P4 group as compared to the MPA group, and as compared to the vehicle group. These results suggest that MPA, while progestational in terms of its effects in the uterus, is not a simple substitute for P4 in other systems. The relative impact of these two progestins on neuroendocrine function must be carefully explored.

Impact of Contraceptive Education on Contraceptive Knowledge and Decision Making: A Systematic Review.

Zika virus infection during pregnancy can cause congenital microcephaly and brain abnormalities (1,2). Since 2015, Zika virus has been spreading through much of the World Health Organizations Region of the Americas, including U.S. territories. Zika virus is spread through the bite of Aedes aegypti or Aedes albopictus mosquitoes, by sex with an infected partner, or from a pregnant woman to her fetus during pregnancy.* CDC estimates that 41 states are in the potential range of Aedes aegypti or Aedes albopictus mosquitoes (3), and on July 29, 2016, the Florida Department of Health identified an area in one neighborhood of Miami where Zika virus infections in multiple persons are being spread by bites of local mosquitoes. These are the first known cases of local mosquito-borne Zika virus transmission in the continental United States.(†) CDC prevention efforts include mosquito surveillance and control, targeted education about Zika virus and condom use to prevent sexual transmission, and guidance for providers on contraceptive counseling to reduce unintended pregnancy. To estimate the prevalence of contraceptive use among nonpregnant and postpartum women at risk for unintended pregnancy and sexually active female high school students living in the 41 states where mosquito-borne transmission might be possible, CDC used 2011-2013 and 2015 survey data from four state-based surveillance systems: the Behavioral Risk Factor Surveillance System (BRFSS, 2011-2013), which surveys adult women; the Pregnancy Risk Assessment Monitoring System (PRAMS, 2013) and the Maternal and Infant Health Assessment (MIHA, 2013), which surveys women with a recent live birth; and the Youth Risk Behavior Survey (YRBS, 2015), which surveys students in grades 9-12. CDC defines an unintended pregnancy as one that is either unwanted (i.e., the pregnancy occurred when no children, or no more children, were desired) or mistimed (i.e., the pregnancy occurred earlier than desired). The proportion of women at risk for unintended pregnancy who used a highly effective reversible method, known as long-acting reversible contraception (LARC), ranged from 5.5% to 18.9% for BRFSS-surveyed women and 6.9% to 30.5% for PRAMS/MIHA-surveyed women. The proportion of women not using any contraception ranged from 12.3% to 34.3% (BRFSS) and from 3.5% to 15.3% (PRAMS/MIHA). YRBS data indicated that among sexually active female high school students, use of LARC at last intercourse ranged from 1.7% to 8.4%, and use of no contraception ranged from 7.3% to 22.8%. In the context of Zika preparedness, the full range of contraceptive methods approved by the Food and Drug Administration (FDA), including LARC, should be readily available and accessible for women who want to avoid or delay pregnancy. Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available.