Megan L. Kavanaugh

Changes in use of long-acting contraceptive methods in the United States, 2007–2009

OBJECTIVE To examine trends in the use of long-acting reversible contraceptive (LARC) methods-the intrauterine device (IUD) and implant--and the extent to which these methods have replaced permanent sterilization and less effective short-acting methods. DESIGN We tabulated data from female survey respondents overall and by demographic subgroups. We performed t-tests of the differences in the proportions of female contraceptors using LARC in 2007 and 2009. We also looked at use of LARC, sterilization, other methods, and no method among women at risk of unintended pregnancy. SETTING In-home survey. PATIENT(S) All female respondents to the surveys. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Current use of LARC methods in 2009, and change in use from 2007. RESULT(S) The proportion of contraceptors using LARC increased significantly from 2.4% in 2002 to 3.7% in 2007 and 8.5% in 2009. The increase occurred among women in almost every age, race, education, and income group. Among women at risk of unintended pregnancy, increases in LARC use more than offset decreases in sterilization. CONCLUSION(S) LARC methods (primarily IUDs) are contributing to an increase in contraceptive effectiveness in the United States.

Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences

Stigmatization is a deeply contextual, dynamic social process; stigma from abortion is the discrediting of individuals as a result of their association with abortion. Abortion stigma is under-researched and under-theorized, and the few existing studies focus only on women who have had abortions. We build on this work, drawing from the social science literature to describe three groups whom we posit are affected by abortion stigma: Women who have had abortions, individuals who work in facilities that provide abortion, and supporters of women who have had abortions, including partners, family, and friends, as well as abortion researchers and advocates. Although these groups are not homogeneous, some common experiences within the groups--and differences between the groups--help to illuminate how people manage abortion stigma and begin to reveal the roots of this stigma itself. We discuss five reasons why abortion is stigmatized, beginning with the rationale identified by Kumar, Hessini, and Mitchell: The violation of female ideals of sexuality and motherhood. We then suggest additional causes of abortion stigma, including attributing personhood to the fetus, legal restrictions, the idea that abortion is dirty or unhealthy, and the use of stigma as a tool for anti-abortion efforts. Although not exhaustive, these causes of abortion stigma illustrate how it is made manifest for affected groups. Understanding abortion stigma will inform strategies to reduce it, which has direct implications for improving access to care and better health for those whom stigma affects.

Changes in Abortion Rates Between 2000 and 2008 and Lifetime Incidence of Abortion

OBJECTIVE: To estimate abortion rates among subpopulations of women in 2008, assess changes in subpopulation abortion rates since 2000, and estimate the lifetime incidence of abortion. METHODS: We combined secondary data from several sources, including the 2008 Abortion Patient Survey, the Current Population Surveys for 2008 and 2009, and the 2006–2008 National Survey of Family Growth, to estimate abortion rates by subgroup and lifetime incidence of abortion for U.S. women of reproductive age. RESULTS: The abortion rate declined 8.0% between 2000 and 2008, from 21.3 abortions per 1,000 women aged 15–44 to 19.6 per 1,000. Decreases in abortion were experienced by most subgroups of women. One notable exception was poor women; this group accounted for 42.4% of abortions in 2008, and their abortion rate increased 17.5% between 2000 and 2008 from 44.4 to 52.2 abortions per 1,000. In addition to poor women, abortion rates were highest for women who were cohabiting (52.0 per 1,000), aged 20–24 (39.9 per 1,000), or non-Hispanic African American (40.2 per 1,000). If the 2008 abortion rate prevails, 30.0% of women will have an abortion by age 45. CONCLUSION: Abortion is becoming increasingly concentrated among poor women, and restrictions on abortion disproportionately affect this population. LEVEL OF EVIDENCE: III

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009-2012

OBJECTIVE: To examine current levels, current correlates of, and changes in long-acting reversible contraceptive (LARC) use, including intrauterine devices and implants, among females aged 15–44 years using contraception between 2008–2010 and 2011–2013 with specific attention to associations between race, income, and age and their LARC use. METHODS: We analyzed data from two rounds of the National Survey of Family Growth, nationally representative samples of females aged 15–44 years, consisting of 6,428 females in 2008–2010 and 5,601 females in 2011–2013. We conducted simple and multivariable logistic regression analyses with adjustments for the sampling design to identify demographic characteristics predictive of LARC use and changes in these patterns between the two time periods. In this cross-sectional, descriptive study, our primary outcome of interest was current prevalence of LARC use among all contraceptive users at the time of the interview. RESULTS: The prevalence of LARC use among contracepting U.S. females increased from 8.5% in 2009 to 11.6% in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5% to 15.1%), those with private insurance (7.1–11.1%), those with fewer than two sexual partners in the previous year (9.2–12.4%), and those who were nulliparous (2.1–5.9%) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3–5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35–44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women. CONCLUSION: During the most recent time period surveyed, use of LARC methods, particularly intrauterine devices, increased almost uniformly across the population of users. LEVEL OF EVIDENCE: III

Meeting the Contraceptive Needs of Teens and Young Adults: Youth-Friendly and Long-Acting Reversible Contraceptive Services in U.S. Family Planning Facilities

PURPOSE Increased use of contraceptive services, including long-acting reversible contraceptives (LARCs), among sexually active teens and young adults could significantly reduce unintended pregnancy. Objectives were to describe youth-friendly contraceptive services (including LARC) available to teens and young adults at U.S. publicly funded family planning facilities. METHODS Between April and September 2011, center directors at a nationally representative sample of 1,196 U.S. publicly funded family planning facilities were surveyed to assess accessibility and provision of contraceptive services for teens and young adults; 584 (52%) responded. RESULTS Facilities were accessible to young clients in several ways, including not requiring scheduled appointments for method refills (67%) and having flexible hours (64%). Most facilities provided outreach and/or education to young people (70%), and 27% used social network media to do this. Most facilities took steps to ensure confidentiality for young clients. These youth-friendly practices were more common at Planned Parenthood, Title X, and reproductive health focused facilities than at other facilities. Long-acting reversible contraceptive methods were regularly discussed with younger clients at less than half the facilities. Youth-friendly sites had increased rates of LARC provision among younger clients. The most common challenges to providing contraceptive and LARC services to younger clients were the costs of LARC methods (60%), inconvenient clinic hours (51%), staff concerns about intrauterine device (IUD) use among teens (47%), and limited training on implant insertion (47%). CONCLUSIONS Improving the ability of family planning facilities to provide youth-friendly contraceptive and LARC-specific methods to younger clients may increase the use of highly effective contraception in this population.

Characteristics of women in the United States who use long-acting reversible contraceptive methods.

OBJECTIVE: To examine characteristics of U.S. women that are associated with use of long-acting reversible contraception and changes in these characteristics between 2002 and 2006–2008. METHODS: We analyzed data from two nationally representative samples of women aged 15–44 in the National Survey of Family Growth, including 7,643 women in 2002 and 7,356 women in 2006–2008. We conducted simple and multinomial logistic regression analyses to identify demographic and reproductive health characteristics associated with use of long-acting reversible contraception. RESULTS: Long-acting reversible contraception (intrauterine devices and subdermal implants) use among U.S. women using contraception increased from 2.4% in 2002 to 5.6% in 2006–2008. The largest increases in long-acting reversible contraception use during this time occurred among the youngest and oldest age groups, non-Hispanic white and non-Hispanic African American women, foreign-born women, and those in the highest income group. High prevalence of long-acting reversible contraception use in 2006–2008 was seen among women who had given birth once or twice (10%), foreign-born women (8.8%), and Hispanic women (8.4%). After adjusting for key demographic and reproductive health characteristics, in comparison with users of other contraceptive methods and with those not using contraception who were at risk for unintended pregnancy, foreign-born women and women who experienced coitarche before age 18 were approximately twice as likely to be using long-acting reversible contraception as women without those characteristics. CONCLUSION: A more diverse population of women used long-acting reversible contraception in 2006–2008 compared with 2002. However, there is likely more potential for increased uptake, especially among populations historically not considered to be candidates for these methods. LEVEL OF EVIDENCE: III

Prospective assessment of pregnancy intentions using a single- versus a multi-item measure.

CONTEXT Traditional measures of pregnancy intentions that are dichotomous and retrospective do not fully capture the complexity surrounding womens plans to become pregnant. METHODS During January-June 2008, 249 women aged 15-44 awaiting pregnancy test results at family planning clinics in Pittsburgh completed a survey containing both single- and multi-item measures of pregnancy intentions. Chi-square analyses were used to assess differences between subgroups of women. RESULTS Few women were trying to become or planning for pregnancy (11% on the single-item measure; 20% on the multi-item measure), while approximately one-third of the sample were not trying to become or planning for pregnancy (31% on the single-item and 36% on the multi-item measure). The single-item measure categorized more women as ambivalent about pregnancy (58%) than did the multi-item measure (44%). Of women categorized as ambivalent by the single-item measure, 62% were also categorized as ambivalent by the multi-item measure. Overall, 68% of responses to the two measures were concordant. With both measures, women who were not planning or trying for pregnancy were more likely than those who were planning for pregnancy or who were ambivalent to indicate that they planned to have an abortion if their test was positive (27-29% vs. 0-2%). CONCLUSIONS Prospective assessment of pregnancy intention with either a single- or a multi-item measure may allow for a more nuanced assessment of pregnancy intention than current measures. The multi-item measure may reduce the number of women categorized as ambivalent and aid the development of targeted contraceptive and preconception counseling interventions.

Interest in Intrauterine Contraception Among Seekers of Emergency Contraception and Pregnancy Testing

OBJECTIVE: To estimate the interest in using intrauterine contraception among women and adolescent girls seeking emergency contraception or walk-in pregnancy testing. METHODS: We surveyed 412 women and adolescent girls who requested emergency contraception or pregnancy testing at four family planning clinics in Pittsburgh, Pennsylvania. The 41-item survey assessed knowledge of, attitudes toward, and interest in using an intrauterine device (IUD). Data were analyzed using &khgr;2 and Fisher exact tests and multivariable logistic regression methods. RESULTS: The response rate was 85%. Twelve percent (95% confidence interval [CI] 9–15) of women and adolescent girls surveyed expressed interest in same-day insertion of an IUD, and 22% (95% CI 18–26) wanted more information about IUDs. Interest in same-day IUD insertion increased with higher education level, prior unwanted pregnancy, and experience with barriers to use of contraception. CONCLUSION: Same-day IUD insertion may be a reasonable way to increase the use of highly-effective contraception among women and adolescent girls seeking emergency contraception or walk-in pregnancy testing. LEVEL OF EVIDENCE: II

Patients' attitudes and experiences related to receiving contraception during abortion care

BACKGROUND High risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC). STUDY DESIGN Structured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey. RESULTS Among abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest. CONCLUSION Many women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.

Counseling about and use of emergency contraception in the United States.

CONTEXT Few nationally representative studies have examined the prevalence and predictors of emergency contraception use or of receipt of counseling about the method. The impact of the U.S. Food and Drug Administrations 2006 approval of behind-the-counter sales of the method to women aged 18 and older remains to be seen; therefore, understanding patterns of use and counseling before the 2006 policy change is necessary to assess its impact. METHODS Data collected from 7,643 women aged 15-44 participating in the 2002 National Survey of Family Growth were analyzed using multivariable logistic regression to assess predictors of receipt of counseling and use of emergency contraception. RESULTS Overall, 3% of women reported that a clinician had discussed emergency contraception with them in the past year, and 4% of those who had ever had sex with a man reported having used the method. Only 4% of those who had seen a gynecologist in the past year reported having received counseling. Womens likelihood of having received counseling was reduced if they were 30 or older (odds ratio, 0.2), and was elevated if they were Hispanic (4.1), black (2.6) or ever-married (2.4). Receipt of counseling in the last 12 months was the strongest predictor of ever-use (11.7). CONCLUSIONS Clinicians can play a pivotal role in ensuring that women have accurate information about how to access and use emergency contraception. However, efforts are needed to explore other ways to deliver this counseling.