Maureen K. Baldwin

The Effect of Long-Acting Reversible Contraception on Rapid Repeat Pregnancy in Adolescents: A Review

Repeat pregnancy within 2 years of a previous birth or abortion occurs in approximately 35% of recently pregnant female adolescents. The majority of these pregnancies are classified as unintended with about half ending in births and the remainder in abortions. Rapid repeat pregnancy (RRP) is associated with increased maternal and neonatal morbidity and continues a cycle of economic deprivation for young women and their families. Immediately following a pregnancy, most young women report an intention to avoid pregnancy in the near future, but many change their minds or become ambivalent within months. Lack of contraceptive use is more common among those teens that resume sexual intercourse earlier, live with a male partner, had a preterm delivery, or had an intended teen pregnancy. Adolescents who do not initiate a long-acting reversible contraceptive (LARC) method (intrauterine device or contraceptive implant) have up to a 35 times increased risk of RRP compared with their peers using LARC. Risk of RRP is decreased when LARC methods are initiated earlier after an abortion or within the postpartum period. This review will focus on the prevalence of RRP, the risk factors for RRP, and the effectiveness of strategies to reduce unintended RRP including counseling and early initiation of long-acting contraceptive methods.

Contraception during the perimenopause

Although the absolute risk of pregnancy is lower during the perimenopause due to decreased fertility and decreased coital frequency, unintended pregnancy occurs at ratios similar to those observed in young women, and pregnancies that do occur are at high risk for maternal complications and poor outcomes such as miscarriage or chromosomal abnormalities. Therefore all premenopausal women should receive counselling that includes discussion of sexual habits and contraception during routine health care encounters. The majority of US women in this age group use permanent contraception, but other methods can be safe and effective and can have non-contraceptive benefits. No contraceptive method is contraindicated based on age alone. However, estrogen-containing methods should be reserved for women without cardiovascular or thrombotic risk factors. The levonorgestrel intrauterine system (LNG-IUS, Mirena(®)) has particular benefits during perimenopause and is safe for use in nearly all women. The LNG-IUS is approved for treatment of heavy menstrual bleeding, a common concern during the perimenopause. A substantial literature supports the use of the LNG-IUS for endometrial protection during transition from contraception to hormone therapy, although this is off-label in the United States. Reliable contraception should be used until menopause is confirmed either by cessation of menses for 2 years prior to age 50, for 1 year after age 50, or by two elevated follicle-stimulating hormone (FSH) values ≥20-30IU/l while off hormonal methods for at least 2 weeks. Sterility cannot be assumed until at least age 60 because spontaneous pregnancies have been reported in women up to age 59.

Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial.

OBJECTIVE Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel. STUDY DESIGN A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement. RESULTS Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p<.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p<.001]. Satisfaction with tenaculum placement was similar for the two groups. CONCLUSION Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.

Lack of insurance and parity influence choice between long-acting reversible contraception and sterilization in women postpregnancy

BACKGROUND Disparities in postpregnancy contraception utilization exist, with low-income women disproportionately undergoing sterilization. We assessed the impact of increased intrauterine device (IUD) availability on rates of female sterilization. STUDY DESIGN Hospital billing records were used to identify women with an IUD placement or sterilization within 1 year of a pregnancy at a university hospital between Oct 2005 and Jun 2007. Demographic data were compared between women receiving either an IUD or sterilization. RESULTS There were 365 sterilizations and 223 IUD placements during the study period. IUD placements doubled over the study period from 6% to 12% of all deliveries, while sterilizations remained stable at 11% (p<.001). Demographic variables were examined for women with either public or private insurance who had financial access to both sterilization (n=253) and IUD (n=223). Women receiving sterilization were slightly older (mean age 31 years versus 30 years, p=.03), of higher parity (median three versus two, p<.01), more likely to have had cesarean delivery (69% versus 31%, p<.001) and more likely to have public insurance (77% versus 23%, p<.001) than women who received IUD. Approximately 45% of women delivering in Oregon in 2007 were publicly insured (2010 Maternal and Child Health Update: States Make Progress Towards Improving Systems of Care. National Governors Association, Table 6. Available at http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF, accessed Nov 2011). After adjusting for age, parity and type of delivery, women choosing sterilization were more likely to have public insurance than women choosing IUD (odds ratio 8.4, 95% confidence interval 4.7-14.9, p<.0001). CONCLUSIONS Women choosing sterilization are more likely to have public insurance than women choosing IUD and may represent a continued trend toward nonreversible contraception among women of lower socioeconomic status despite available long-acting reversible methods.

Intrauterine device placement at 3 versus 6 weeks postpartum: a randomized trial

OBJECTIVE To investigate whether early placement of an intrauterine device (IUD) at 3 weeks after delivery, compared to placement at 6 weeks, is associated with greater use at 3 months postpartum. STUDY DESIGN This prospective randomized, controlled trial enrolled inpatient postpartum women intending to use intrauterine contraception. Participants were assigned to an early (3 week) or standard (6 week) postpartum visit with IUD placement and were followed for 6 months. We used transvaginal ultrasonography to confirm placement and measure uterine dimensions. We measured pain with IUD insertion and satisfaction with IUD timing using 100-mm visual analog scales. Data were analyzed based on randomization and actual timing of insertion (18-24 vs. 39-45 days). RESULTS Between February 2012 and December 2013, 201 subjects were enrolled (early=101; standard=100). Most participants returned for IUD placement as scheduled; 70.1% (53/75) in the early group, 74.3% (58/78) in the standard group (p=.06). IUD use did not differ between groups at 3 months (73/100, 73.0% and 73/97, 75.3%, respectively, p=.72) or 6 months (80.3% and 82.8%, p=.71) amongst those women for whom follow-up was available. Women randomized to 6-week insertion were more likely to have resumed intercourse prior to the IUD appointment (15/64, 23.4% vs. 5/68, 7.3%, p=.01). Pain with insertion (19.9 vs. 25.1, respectively, p=.21) and satisfaction (89.6 vs. 93.4, respectively, p=.23) did not vary based on actual timing of insertion. CONCLUSION Offering IUD placement at 3 weeks postpartum compared to standard scheduling at 6 weeks does not result in increased use at 3 months. However, early IUD placement is acceptable to women and without increased pain. IMPLICATIONS This study demonstrates that IUD placement as early as 3 weeks postpartum is feasible. Larger studies are needed to evaluate risks and benefits of IUD placement at this early interval. While earlier timing does not result in increased IUD uptake, early placement should be explored as an option since many women resume intercourse before 6 weeks.

Notes from the field: expanding abortion services into the second trimester of pregnancy in Nepal (2007-2012).

In the past, abortion in Nepal was criminalized. In 2002, the government liberalized the law allowing abortion for any reason at 12 weeks and under, for rape or incest up to 18 weeks and for maternal mental or physical health or fetal health at any gestational age [1]. Despite decreasing restrictions, at least 13% ofwomenpresenting for safe abortion in 2006with eligible legal indications were turned away due to the lack of training and support to safely provide services in the second trimester [2]. Through a collaborative effort, the Nepali Ministry of Health, Family Health Division (FHD) and Ipas, a global nongovernmental organization working to end deaths and disabilities from unsafe abortion, initiated a program in 2007 to increase the availability of safe second-trimester abortion services, both dilation and evacuation (DE mifepristone-misoprostol). This structured comprehensive program has increased access to safe second-trimester abortion services in Nepal. This intervention [2] consisted of multiple steps starting with site and provider assessments including direct observation of the proficiency and competency of first-trimester vacuum aspiration skills. We designed and held workshops prior to hands-on training to sensitize providers to womens needs for and rights to safe abortion. These workshops also allowed providers to self-identify if they did not want to participate in the subsequent training. The trainings utilized adult learning

Pregnancy intention screening tools: a randomized trial to assess perceived helpfulness with communication about reproductive goals

BackgroundFederal and clinical guidelines support integration of reproductive life planning in the care of female patients to aid in the reduction of unplanned pregnancies. A multitude of tools have been created to help in the counseling component, but further research is needed regarding how and whether they facilitate patient-provider communication.ResearchWe performed a randomized controlled trial to evaluate if patients report whether a detailed or simple pregnancy intention screening tool is helpful for communication of reproductive life plans. We compared a novel reproductive counseling aid, the Family Planning Quotient (FPQ), to a simple tool based on the One Key Question® (OKQ). Providers also evaluated whether they thought the tool used at the visit was helpful. We randomized 93 patients to complete a survey including identical demographic questions and either the FPQ or OKQ reproductive counseling tool. We did not provide further instructions to either the patient or provider. Following the visits, we collected 84 subject evaluations and 79 provider evaluations. A similar proportion of subjects using either reproductive counseling tool found it helpful in communicating their reproductive life plans to their providers (approximately 66%), but there was no difference between the two tools studied. Less than half of providers reported that the FPQ tool was helpful (FPQ: 16/43, 37.2% versus OKQ: 18/36, 50%; p = 0.25).ConclusionTwo-thirds of patients reported either a detailed or simple reproductive plan screening tool was helpful to facilitate communication with their provider, but only half of providers found either tool helpful. Use of reproductive screening tools should be followed by patient-centered counseling to help patients meet their reproductive life goals.

Video compared to conversational contraceptive counseling during labor and maternity hospitalization in Colombia: A randomized trial

OBJECTIVE Assess if video-based contraceptive education could be an efficient adjunct to contraceptive counseling and attain the same contraceptive knowledge acquisition as conversation-based counseling. STUDY DESIGN This was a multicenter randomized, controlled trial examining contraceptive counseling during labor and maternity hospitalization regarding the options of immediate postpartum contraception. At two urban public hospitals, we randomized participants to a structured conversation with a trained counselor or a 14-min video providing the same information. Both groups received written materials and were invited to ask the counselor questions. Our primary outcome was to compare mean time for video-based education and conversational counseling; secondary outcomes included intended postpartum contraceptive method, pre- and postintervention contraceptive knowledge, and perceived competence in choosing a method of contraception. RESULTS We enrolled 240 participants (conversation group=119, video group=121). The average time to complete either type of counseling was similar [conversational: 16.3 min, standard deviation (SD) ±3.8 min; video: 16.8 min, SD ±4.6 min, p=.32]. Of women intending to use nonpermanent contraception, more participants intended to use a long-acting reversible contraceptive (LARC) method after conversational counseling (72/103, 70% versus 59/105, 56%, p=.041). Following counseling, mean knowledge assessment scores increased by 2 points in both groups (3/7 points to 5/7 correct). All but two participants in the video group agreed they felt equipped to choose a contraceptive method after counseling. CONCLUSIONS Compared to in-person contraceptive counseling alone, video-based intrapartum contraceptive education took a similar amount of time and resulted in similar contraceptive knowledge acquisition, though with fewer patients choosing LARC. IMPLICATIONS Video-based contraceptive education may be useful in settings with limited personnel to deliver unbiased hospital-based, contraceptive counseling for women during the antepartum period.

Health benefits of hormonal contraception

We are grateful to Dr. Nicolas Mendoza and Dr. Rafael Sanchezorrego for bringing attention to the subject of non-contraceptive enefits of hormonal contraceptives (HCs), which is not included n our recent review of contraceptive use during perimenopause 1]. Just as there is data lacking on contraceptive effectiveess of HCs for women over age 40, there is also a paucity of ata for non-contraceptive benefits in this age group, such as ecreased menstrual bleeding. We do present data particular to erimenopausal and postmenopausal women for the benefits of he levonorgestrel intrauterine system (LNG-IUS), which include eduction in total menstrual blood loss, endometrial protection, nd avoidance of hysterectomy [2,3]. We agree that research ocused on the benefits of combined HCs in this population would e helpful.

Development of a training model for estimation of uterine size in early pregnancy

Where ultrasound is not readily available to determine the gestational age of an early pregnancy, providers rely on history and clinical examination. Accurate clinical assessment can improve access to early pregnancy services, such as medical abortion—often only performed up until 9 weeks of pregnancy. Clinical assessment is usually honed with experience, but is likely improved in settings where examinations are combined with ultrasound or another “gold standard.” Providers trained in this manner are 97% accurate in detecting pregnancies of less than 9 weeks [1]. Other teaching tools are necessary in areas where ultrasound is not available. Simulation models designed from fruits or sports balls have been used for training to estimate uterine size, but have not been tested [2,3]. The present paper provides data for a novel simulation model fashioned from tape and cloth (Supplementary Material S1) and based on uterine sizes derived from the ultrasound literature (Supplementary Material S2) [4]. The accuracy of this model to represent specific uterine sizes was tested with women’s healthcare providers in August 2012 in Nepal. The study was approved by the Institutional Review Board at Oregon Health and Science University