Melissa Gilliam

Interventions Using New Digital Media to Improve Adolescent Sexual Health: A Systematic Review

New digital media (e.g., the Internet, text messaging, and social networking sites [SNS]) have dramatically altered the communication landscape, especially for youth. These communication platforms present new tools for engaging youth in sexual health promotion and risk reduction. We searched eight public databases across multiple disciplines for all peer-reviewed studies published between January 2000 and May 2011 that empirically evaluated the impact of digital media-based interventions on the sexual health knowledge, attitudes, and/or behaviors of adolescents aged 13-24 years. Of 942 abstracts, 10 met inclusion criteria. Seven studies were conducted in the United States. Eight described Web-based interventions, one used mobile phones, and one was conducted on an SNS. Two studies significantly delayed initiation of sex, and one was successful in encouraging users of an SNS to remove sex references from their public profile. Seven interventions significantly influenced psychosocial outcomes such as condom self-efficacy and abstinence attitudes, but at times the results were in directions unexpected by the study authors. Six studies increased knowledge of HIV, sexually transmitted infections, or pregnancy. This area of research is emerging and rapidly changing. More data from controlled studies with longer (>1 year) follow-up and measurement of behavioral outcomes will provide a more robust evidence base from which to judge the effectiveness of new digital media in changing adolescent sexual behavior.

The likelihood of placenta previa with greater number of cesarean deliveries and higher parity.

OBJECTIVE To examine the relationship between prior cesarean delivery and placenta previa. METHODS A hospital‐based, case‐control study was conducted in which 316 multiparous women with placenta previa were identified. Controls consisted of 2051 multiparous women with spontaneous vaginal deliveries. Information on prior cesarean delivery was examined in three forms: as a dichotomous variable, as an ordinal variable, and as a set of three indicator variables for one, two, and three or more cesarean deliveries. Multivariable logistic regression modeling was used to obtain an adjusted estimate of this association. RESULTS Women with a prior cesarean delivery were more likely to have a placenta previa than those without (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI 1.58, 48.53). CONCLUSION This study supports the association between prior cesarean delivery and placenta previa and demonstrates that the joint effect of parity and prior cesarean delivery is greater than that of either variable alone.

Multicenter Comparison of the Contraceptive Ring and Patch A Randomized Controlled Trial

OBJECTIVE: To understand if the contraceptive ring or patch was more acceptable, as measured primarily by continuation, to women using an oral contraceptive and interested in a nondaily, combined hormonal contraceptive. METHODS: Five hundred women were randomly assigned to use the contraceptive ring (n=249) or contraceptive patch (n=251) for four consecutive menstrual cycles, starting with their next menses. Participants returned for a single follow-up visit during the fourth cycle for an evaluation, which included a questionnaire to assess acceptability and adverse effects. RESULTS: Rates of completion of three cycles were 94.6% (95% confidence interval [CI] 91.0–97.1%) and 88.2% (95% CI 83.4–92.0%) for ring and patch users, respectively (P=.03). Of these women, 71.0% (95% CI 64.8–76.6%) and 26.5% (95% CI 21.0–32.6%), respectively, planned to continue their method after the study (P<.001). Women switching to the patch were significantly more likely than women switching to the ring to experience longer periods (38% compared with 9%), increased dysmenorrhea (29% compared with 16%), frequent nausea (8% compared with 1%), frequent mood swings (14% compared with 8%), and frequent skin rash (12% compared with 2%) and were less likely to experience frequent vaginal discharge (8% compared with 17%). Ring users preferred the ring to the oral contraceptive (P<.001), and patch users preferred the oral contraceptive to the patch (P<.001). Nugent scores increased only in patch users (P=.01), although most of these women were asymptomatic. CONCLUSION: Women satisfied with combined oral contraceptives and interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269620 LEVEL OF EVIDENCE: I

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

A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.

BACKGROUND The intrauterine device (IUD) is a safe, long-acting, highly effective method of birth control. Two-visit protocols for IUD insertion may represent a barrier to IUD uptake. STUDY DESIGN This study is a retrospective database review. We identified Medicaid-insured women who requested IUDs in our urban university-based clinic, which employed a two-visit protocol for IUD insertion. The number of women who returned for IUD insertion was determined. To compare women who underwent insertion to those who did not, bivariate and multivariable analyses were used. RESULTS Of the 708 women who requested IUDs at the initial visit, only 385 had an IUD inserted (54.4%). Single women were less likely to return for IUD placement compared to women who had ever been married (52.4% vs. 70.3%; p<.01). Patients who ordered IUDs at gynecologic visits were more likely to return as opposed to those who had them ordered at obstetrics-related visits (60.5% vs. 50.2%; p<.01). Women who lived >10 miles away from the clinic were less likely to return for IUD insertion than women who lived <10 miles away from the clinic (45.3% vs. 56.2%; p=.03). Race, age and type of IUD ordered were not significantly associated with probability of insertion. CONCLUSIONS Almost half of women who ordered IUDs did not return for insertion, suggesting that two-visit protocols hinder a womans ability to have an IUD placed. We must eliminate barriers to IUD insertion.

Failure to obtain desired postpartum sterilization: risk and predictors.

OBJECTIVE: The aim of this study was to assess the rate of and risk factors for not obtaining postpartum sterilization among women who expressed a desire for sterilization during antepartum care. METHODS: In this retrospective study, we identified a cohort of women who expressed desire for postpartum sterilization at our center between March 2002 and November 2003. We compared women who did and those who did not undergo the procedure, based on demographic, antenatal, and intrapartum factors. RESULTS: Of the 712 women who expressed desire for postpartum sterilization during antepartum care, 327 (46%) did not undergo the procedure. In multivariable analysis, women who were between the ages of 21 and 25 years (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.35–0.89), were African American (OR 0.68, 95% CI 0.47–1.00), requested sterilization in the second trimester (OR 0.50, 95% CI 0.29–0.86)), and had a vaginal delivery (OR 0.21, 95% CI 0.14–0.32) rather than cesarean delivery were least likely to undergo postpartum sterilization. CONCLUSION: Despite their initial request, only 54% of women in our sample underwent sterilization. Young age, African-American race, request in the second trimester, and vaginal delivery were significantly associated with not undergoing sterilization. Our data suggest that providers should counsel all women who desire postpartum sterilization about the wide array of contraceptive methods available, with the understanding that approximately half of all women may not undergo the sterilization procedure. LEVEL OF EVIDENCE: II-2

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.

The Role of Parents and Partners in the Pregnancy Behaviors of Young Latinas.

Pregnancy among young Latinas demands attention. These teens have higher birthrates than other teen populations. Seven focus groups (N = 40) were conducted with Latinas to explore how relationships between young Latinas and their mothers, fathers, and male partners contribute to teen pregnancy. ATLAS/ti (a qualitative data analysis software program) was used to assist in coding and analysis of data. Salient themes were identified. Mothers rely on cultural values regarding sexuality and pregnancy outside of marriage and fear about birth control to dissuade their daughters from pregnancy. Fathers echo these traditional messages. Open communication about sexuality and contraception rarely occurs. Male partners increase pregnancy susceptibility given the difficulty with negotiating condom use. It is important that research and prevention programs recognize the social context in which pregnancy prevention and susceptibility occur.

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.

Minor Histocompatibility Antigens Are Expressed in Syncytiotrophoblast and Trophoblast Debris: Implications for Maternal Alloreactivity to the Fetus

The fetal semi-allograft can induce expansion and tolerance of antigen-specific maternal T and B cells through paternally inherited major histocompatibility complex and minor histocompatibility antigens (mHAgs). The effects of these antigens have important consequences on the maternal immune system both during and long after pregnancy. Herein, we investigate the possibility that the placental syncytiotrophoblast and deported trophoblastic debris serve as sources of fetal mHAgs. We mapped the expression of four mHAgs (human mHAg 1, pumilio domain-containing protein KIAA0020, B-cell lymphoma 2-related protein A1, and ribosomal protein S4, Y linked) in the placenta. Each of these proteins was expressed in several placental cell types, including the syncytiotrophoblast. These antigens and two additional Y chromosome-encoded antigens [DEAD box polypeptide 3, Y linked (DDX3Y), and lysine demethylase5D] were also identified by RT-PCR in the placenta, purified trophoblast cells, and cord blood cells. Finally, we used a proteomic approach to investigate the presence of mHAgs in the syncytiotrophoblast and trophoblast debris shed from first-trimester placenta. By this method, four antigens (DDX3Y; ribosomal protein S4, Y linked; solute carrier 1A5; and signal sequence receptor 1) were found in the syncytiotrophoblast, and one antigen (DDX3Y) was found in shed trophoblast debris. The finding of mHAgs in the placenta and in trophoblast debris provides the first direct evidence that fetal antigens are present in debris shed from the human placenta. The data, thus, suggest a mechanism by which the maternal immune system is exposed to fetal alloantigens, possibly explaining the relationship between parity and graft-versus-host disease.