Lisa S. Callegari

Rethinking the Pregnancy Planning Paradigm: Unintended Conceptions or Unrepresentative Concepts?

contraceptives correctly and consistently over time. For women with ambivalent, indifferent or fl uctuating desires, highly effective contraceptives may be unappealing precisely because they negate the possibility of an unplanned (but welcome) conception. Second, planning paradigms may overlook another important facet of women’s pregnancy preferences: emotional orientations. Paradoxically, some women have highly positive emotional responses to the prospect of pregnancy even when they express an immediate, unambivalent desire to avoid conception or a clear intention not to have any more children. Moreover, these emotional responses often provide an indication of the anticipated balance both of immediate consequences of pregnancy (positive and negative) and of future life impacts of childbearing. For example, on the one hand, having a child might be diffi cult economically, and thus delaying or ending childbearing may be viewed as prudent. On the other hand, a child might bring many rewards, including personal fulfi llment, feelings of closeness to a partner, or a sense of progress or purpose in life. If the positives outweigh the negatives, or if economic or other circumstances seem unlikely to improve over time anyway, women might have favorable emotional orientations toward pregnancy and childbearing despite expressing intentions or desires to delay or avoid conception. For these women, standard timing-based defi nitions of unintended pregnancy fail to capture the trade-offs of a possible pregnancy, which, in turn, may not be well represented by the language of planning. Third, conventional planning paradigms are imbued with the normative belief that unintended pregnancies are uniformly negative events that necessarily result in adverse consequences. Yet the complexity of women’s prospective pregnancy desires and emotional orientations toward pregnancy demonstrates clearly that while some unintended pregnancies would indeed be undesired, others would be welcome. Still others would not be entirely unanticipated, and these may also be viewed positively. Emotional orientations toward pregnancy seem to offer an indication of the psychosocial stress that would likely arise should a pregnancy occur, and some studies have suggested that such orientations may be more important than timingbased intentions in predicting negative outcomes. Moreover, other studies have shown that women’s preconception desires and emotional orientations toward pregnancy may evolve after conception has occurred. Thus, a pregnancy that was not explicitly desired or whose Approximately half of pregnancies occurring each year in the United States are unintended: They either occurred too soon or were not intended at any time. This commonly cited statistic is testament to the dominance of unintended pregnancy as a public health benchmark for measuring and improving women’s reproductive health. In addition to its use as a public health metric, this timing-based defi nition of unintended pregnancy is refl ected in pregnancy planning paradigms in clinical practice. According to these paradigms, women are expected to map out their intentions regarding whether and when to conceive, and to formulate specifi c plans to follow through on their intentions.

Labor and delivery outcomes among young adolescents

OBJECTIVE We sought to determine whether young adolescents aged 11-14 years and teens aged 15-17 and 18-19 years have an increased risk of cesarean or operative delivery, as well as maternal or neonatal delivery-related morbidity, compared to young adults aged 20-24 years. STUDY DESIGN We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987 through 2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents aged 11-14 years, young teens aged 15-17 years, and older teens aged 18-19 years to young adults aged 20-24 years. The primary outcome was method of delivery. Secondary outcomes included postpartum hemorrhage, shoulder dystocia, third- and fourth-degree perineal lacerations, chorioamnionitis, prolonged maternal length of stay, gestational age at delivery, birthweight, respiratory distress syndrome, neonatal length of stay, and death. We used multivariate regression to assess associations between age and delivery outcomes. RESULTS Young adolescents aged 11-14 years had a lower risk of cesarean (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.65-0.83) and operative vaginal (RR, 0.87; 95% CI, 0.78-0.97) delivery compared to young adults aged 20-24 years. Compared to young adults, young adolescents had an increased risk of prolonged length of stay for both vaginal and cesarean delivery (RR, 1.34; 95% CI, 1.20-1.49, and RR, 1.71; 95% CI, 1.38-2.12, respectively), with no significant differences in indication for cesarean delivery or other measures of maternal morbidity. Young adolescents had an increased risk of preterm delivery (RR, 2.11; 95% CI, 1.79-2.48), low and very low birthweight (RR, 2.08; 95% CI, 1.73-2.50, and RR, 3.25; 95% CI, 2.22-4.77, respectively), and infant death (RR, 3.90; 95% CI, 2.36-6.44) compared to young adults. CONCLUSION Young adolescents have a decreased risk of cesarean and operative vaginal delivery compared to young adults; however, their neonates face higher risks of preterm delivery, low and very low birthweight, and death. This information can be used to inform clinical care for this population.

Addressing potential pitfalls of reproductive life planning with patient-centered counseling

&NA; Engaging women in discussions about reproductive goals in health care settings is increasingly recognized as an important public health strategy to reduce unintended pregnancy and improve pregnancy outcomes. “Reproductive life planning” has gained visibility as a framework for these discussions, endorsed by public health and professional organizations and integrated into practice guidelines. However, women’s health advocates and researchers have voiced the concern that aspects of the reproductive life planning framework may have the unintended consequence of alienating rather than empowering some women. This concern is based on evidence indicating that women may not hold clear intentions regarding pregnancy timing and may have complex feelings about achieving or avoiding pregnancy, which in turn may make defining a reproductive life plan challenging or less meaningful. We examine potential pitfalls of reproductive life planning counseling and, based on available evidence, offer suggestions for a patient‐centered approach to counseling, including building open and trusting relationships with patients, asking open‐ended questions, and prioritizing information delivery based on patient preferences. Research is needed to ensure that efforts to engage women in conversations about their reproductive goals are effective in both achieving public health objectives and empowering individual women to achieve the reproductive lives they desire.

Perceptions of intrauterine contraception among women seeking primary care.

BACKGROUND Intrauterine contraception (IUC) is safe, highly effective and has few medical contraindications. Primary care providers see many women with chronic conditions who might benefit from IUC. STUDY DESIGN We surveyed women aged 18-50 who visited one of four primary care clinics in Pennsylvania between October 2008 and April 2010 to investigate perceptions of IUC and to identify factors associated with accurate perceptions. Key independent variables included patient characteristics, including knowing other women who had used IUC, and having discussed IUC with a provider. Logistic regression was used to examine the association between independent variables and accurate perceptions. RESULTS The study population included 1626 eligible respondents. Only 19.5% of women knew that IUC is more effective than oral contraceptive pills, 57.4% knew that IUC does not increase the risk of sexually transmitted infections and 28.7% knew that IUC is more cost-effective than oral contraceptive pills. Among women who had never used IUC, accurate perceptions were associated with higher levels of education, knowing one or more women who had used IUC and having discussed IUC with a health care provider. CONCLUSIONS Many women seeking primary care have inaccurate perceptions of IUC and may benefit from counseling about the advantages of this approach to preventing unintended pregnancy.

Contraceptive adherence among women Veterans with mental illness and substance use disorder.

OBJECTIVE Emerging data suggest that mental illness and substance use disorder (SUD) are important risk factors for inconsistent contraceptive use. We investigated whether mental illness without or with SUD is associated with contraceptive adherence and continuation of hormonal methods among women Veterans. STUDY DESIGN We conducted a retrospective analysis of national Veterans Administration data among women aged 18-45 with a hormonal contraceptive prescription (pill/patch/ring/injectable) during the first week of fiscal year 2013. We tested associations between mental illness diagnoses (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia, adjustment disorder) without or with SUD diagnoses (drug/alcohol abuse) and 12-month contraceptive adherence (number and length of gaps ≥7 days between refills and months of contraceptive coverage) using multivariable regression models. RESULTS Among 9780 Veterans, 43.6% had mental illness alone, 9.4% comorbid mental illness and SUD, and 47.0% neither diagnosis. In adjusted analyses, compared to women with neither diagnosis, women with mental illness alone had a similar rate of gaps but increased odds of having gaps longer than 30 days [odds ratio (OR): 1.35, 95% confidence interval (CI): 1.10-1.52] and fewer months of contraceptive coverage (β_coefficient: -0.39, 95% CI: -0.56 to -0.23). Women with mental illness and SUD experienced more gaps (incidence rate ratio: 1.12, 95% CI: 1.03-1.21), increased odds of gaps longer than 30 days (OR: 1.46, 95% CI: 1.10-1.79), fewer months of contraceptive coverage (β_coefficient: -0.90, 95% CI: -1.20 to -0.62) and reduced odds of continuous 12-month coverage (adjusted OR: 0.76, 95% CI: 0.63-0.93). CONCLUSIONS Mental illness, particularly with comorbid SUD, is associated with reduced contraceptive adherence and continuation among women Veterans. Women with these risk factors could potentially benefit from use of long-acting reversible methods. IMPLICATIONS Women Veterans have a high burden of mental illness and SUD, which we found are associated with inconsistent contraceptive use. Efforts to improve adherence to hormonal contraceptives and to increase availability of long-acting reversible methods in this vulnerable population are warranted.

Associations of mental illness and substance use disorders with prescription contraception use among women veterans

OBJECTIVE To investigate whether mental illness and substance use disorder (SUD) are associated with having a prescription contraceptive method among women veterans. STUDY DESIGN We conducted a retrospective analysis of National Veterans Administration (VA) administrative and clinical data for women veterans aged 18-45 years who made at least one primary care visit in 2008. We assessed associations between mental illness (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia and adjustment disorder) and SUD (drug/alcohol use disorder) with having a prescription contraceptive method from VA (pill, patch, ring, injection, implant and intrauterine device) using multivariable logistic regression with random effects for VA facility, adjusting for confounders. RESULTS Among 94,115 reproductive aged women, 36.5% had mental illness only, 0.6% had SUD only, 5.3% had both mental illness and SUD and 57.7% had neither diagnosis. In these groups, 22.1%, 14.6%, 18.2% and 17.7% (p<0.001), respectively, had documentation in 2008 of prescription contraception. After adjusting for potential confounders, women with mental illness only were as likely as women with neither diagnosis to have a prescription method and were more likely to use a highly effective prescription method (implant or intrauterine device) if using contraception [adjusted odds ratio (aOR) 1.17, 95% confidence interval (CI) = 1.08-1.27]. Women with SUD (with or without mental illness) were significantly less likely to have a prescription method than women with neither diagnosis (aOR 0.73, 95% CI = 0.57-0.95 and aOR 0.79, 95% CI = 0.73-0.86, respectively). CONCLUSION Women veterans with SUD are less likely to have prescription contraception compared to other women, which may increase their risk of unintended pregnancy.

Evidence-Based Selection of Candidates for the Levonorgestrel Intrauterine Device (IUD)

Background: Recent evidence-based guidelines expanded the definition of appropriate candidates for the levonorgestrel-releasing intrauterine system (LNG-IUS). We investigated correlates of evidence-based selection of candidates for the LNG-IUS by physicians who offer insertion. Methods: We conducted a mixed-mode (online and mail) survey of practicing family physicians and obstetrician-gynecologists in Seattle. Results: A total of 269 physicians responded to the survey (44% response rate). Of the 217 respondents who inserted intrauterine devices, half or fewer routinely recommended the LNG-IUS to women who are nulliparous, younger than 20 years old, or have a history of sexually transmitted infections (STIs). In multivariable analyses, training/resident status was positively associated with recommending the LNG-IUS to women <20 years old (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.6–8.0) and women with history of STI (aOR, 3.7; 95% CI, 1.6–8.4). Perceived risk of infection or infertility was negatively associated with recommending the LNG-IUS to nulliparous women (aOR, 0.2; 95% CI, 0.1–0.5) and women with a history of STI (aOR, 0.3; 95% CI, 0.1–0.8). Conclusions: Many family physicians and obstetrician-gynecologists who insert the LNG-IUS are overly restrictive in selecting candidates, although those who train residents are more likely to follow evidence-based guidelines. Interventions that address negative bias and perceptions of risks, in addition to improving knowledge, are needed to promote wider use of the LNG-IUS.

Factors associated with lack of effective contraception among obese women in the United States.

OBJECTIVE To identify factors associated with contraceptive nonuse and use of less effective methods among obese women in the US. STUDY DESIGN We analyzed data from sexually active obese women (body mass index >30 kg/m²) age 20-44 using the 2006-2010 National Survey of Family Growth. We conducted multinomial logistic regression to assess associations between current contraceptive use and demographic, reproductive and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal and fertility awareness) and barrier method users (condoms) to prescription method users (pill, patch, ring, injection, implant and intrauterine device). RESULTS Of 1345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8% barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4% of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to have previously discontinued a contraceptive method due to dissatisfaction [adjusted RR (aRR), 1.93; 95% confidence interval (CI), 1.09-3.44], and nonusers were more likely to perceive difficulty becoming pregnant (aRR, 3.86; 95% CI, 2.04-7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR, 0.16; 95% CI, 0.10-0.27; behavioral methods: aRR, 0.13; 95% CI, 0.06-0.25, barrier methods: aRR, 0.15; 95% CI, 0.09-0.25) than prescription method users. CONCLUSIONS Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider. IMPLICATIONS Efforts are needed to increase contraceptive counseling for obese women, who face increased risks of morbidity from unintended pregnancy.

Preconception Care and Reproductive Planning in Primary Care

Preconception care is designed to identify and reduce biomedical, behavioral, and social risks to the health of a woman or her baby before pregnancy occurs. Few women present requesting preconception care; however, 1 in 10 US women of childbearing age will become pregnant each year. As primary care physicians (PCPs) care for reproductive-aged women before, between, and after their pregnancies, they are ideally positioned to help women address health risks before conception, including optimizing chronic conditions, to prevent adverse pregnancy and longer-term health outcomes. PCPs can help women make informed decisions both about preparing for pregnancy and about using effective contraception when pregnancy is not desired.

Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans

BACKGROUND: Significant racial/ethnic disparities in unintended pregnancy persist in the United States, with the highest rates observed among low‐income black and Hispanic women. Differences in contraceptive preferences, beliefs, and self‐efficacy may be instrumental in understanding contraceptive behaviors that underlie higher rates of unintended pregnancy among racial/ethnic minorities. OBJECTIVES: Our objective was to understand how contraceptive preferences, beliefs, and self‐efficacy vary by race and ethnicity among women veterans. STUDY DESIGN: We analyzed data from the Examining Contraceptive Use and Unmet Need Study, a national telephone survey of women veterans aged 18–44 years who had received primary care at the Veterans Administration in the prior 12 months. Participants rated the importance of various contraceptive characteristics and described their level of agreement with contraceptive beliefs using Likert scales. Contraceptive self‐efficacy was assessed by asking participants to rate their certainty that they could use contraception consistently and as indicated over time using a Likert scale. Multivariable logistic regression was used to examine associations between race/ethnicity and contraceptive attitudes, controlling for age, marital status, education, income, religion, parity, deployment history, and history of medical and mental health conditions. RESULTS: Among the 2302 women veterans who completed a survey, 52% were non‐Hispanic white, 29% were non‐Hispanic black, and 12% were Hispanic. In adjusted analyses, compared with whites, blacks had lower odds of considering contraceptive effectiveness extremely important (adjusted odds ratio; 0.55, 95% confidence interval, 0.40–0.74) and higher odds of considering the categories of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.94, 95% confidence interval, 1.56–2.41, and adjusted odds ratio; 1.99, 95% confidence interval, 1.57–2.51, respectively). Hispanics also had higher odds than whites of considering the category of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.72, 95% confidence interval, 1.29–2.28, and adjusted odds ratio, 1.63; 95% confidence interval, 1.21–2.19, respectively). Compared with whites, blacks and Hispanics had higher odds of expressing fatalistic beliefs about pregnancy (adjusted odds ratio, 1.79, 95% confidence interval, 1.35–2.39, and adjusted odds ratio, 1.48, 95% confidence interval, 1.01–2.17, respectively); higher odds of viewing contraception as primarily a woman’s responsibility (adjusted odds ratio, 1.92, 95% confidence interval, 1.45–2.55, and adjusted odds ratio, 1.77; 95% confidence interval, 1.23–2.54, respectively); and lower odds of being very sure that they could use a contraceptive method as indicated over the course of a year (adjusted odds ratio, 0.73, 95% confidence interval, 0.54–0.98, and adjusted odds ratio, 0.66, 95% confidence interval, 0.46–0.96, respectively). CONCLUSION: Women veterans’ contraceptive preferences, beliefs, and self‐efficacy varied by race/ethnicity, which may help explain observed racial/ethnic disparities in contraceptive use and unintended pregnancy. These differences underscore the need to elicit women’s individual values and preferences when providing patient‐centered contraceptive counseling.