Peggy Goedken

Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial.

BACKGROUND Barriers to intrauterine device (IUD) use in nulliparous women include fear of pain with insertion and provider perception of difficulty with insertion. The goal of this study was to evaluate whether misoprostol prior to IUD insertion in nulliparous women eased insertion and decreased pain. STUDY DESIGN This was a double-blinded, randomized, controlled trial. Nulliparous women requesting an IUD were randomized to buccal placement of 400-mcg misoprostol or placebo. Provider ease of insertion and patient-reported pain were measured using a 100-mm visual analogue scale. RESULTS Seventy-three subjects completed the study. Baseline characteristics were similar between groups. Provider perception of ease of insertion was not different between study and control groups (28.97 mm, 22.33 mm, p=.18). Pain immediately prior to IUD insertion (10.84 vs. 2.11; p=.003) and after IUD insertion (46.50 vs. 35.14; p=.040) was higher for those in the study group compared to the control group. CONCLUSION This study demonstrates that it is not helpful to provide misoprostol for cervical ripening prior to insertion of IUDs as it does not improve ease of insertion for provider or decrease reported pain for the woman, and it may increase womens pain experience with insertion. IMPLICATION STATEMENT Our study demonstrates that providers do not perceive nulliparous IUD insertion as difficult; women do experience pain with insertion but find the experience acceptable. The addition of misoprostol for cervical ripening prior to insertion does not ease insertion for providers and increases the pain level experienced by women.

Reproductive Healthcare Needs and Desires in a Cohort of HIV-Positive Women

Background. The aim of this study was to determine current contraceptive use, contraceptive desires and knowledge, future fertility desires, and sterilization regret in a cohort of HIV-positive women. Study Design. 127 HIV-positive women receiving care at an urban infectious disease clinic completed a survey addressing their contraceptive and reproductive histories as well as their future contraceptive and fertility desires. Results. The most common forms of contraception used were sterilization (44.4%) and condoms (41.3%). Less than 1% used a long-term reversible method of contraception (LARC) despite these being the methods that best fit their desired attributes of a contraceptive method. Overall, 29.4% desired future fertility. Only 50.6% of those sexually active had spoken with a provider within the last year regarding their contraceptive plans. There was a high degree of sterilization regret (36.4%), and 18.2% of sterilized women desired future fertility. Multivariate analysis found women in a monogamous relationship had a statistically increased rate of regret compared to women who were not sexually active (OR 13.8, 95% CI 1.6–119, P = 0.17). Conclusion. Given the diversity in contraceptive and fertility desires, coupled with a higher rate of sterilization regret than is seen in the general population, integration of comprehensive family planning services into HIV care via increased contraceptive education and access is imperative.

Postplacental intrauterine device insertion at a teaching hospital.

OBJECTIVE To determine whether postplacental intrauterine device (IUD) insertion can be safely and effectively performed within a teaching program. STUDY DESIGN This was a prospective cohort of 177 subjects planning vaginal delivery enrolled antenatally who desired postplacental IUD insertion of either the copper T380A IUD or levonorgestrel IUS. Insertions were performed primarily by resident physicians following a training session. Follow-up included a 4- to 8-week visit and telephone calls at 3 and 6 months. RESULTS Ninety-nine subjects underwent successful postplacental IUD insertion of 100 attempts. Seventeen expulsions (17%) were noted: 10 complete and 7 partial. The study identified no differences in outcome by training level; however, the study lacked statistical power to evaluate anything other than large differences. CONCLUSION Postplacental IUD insertions can be safely and effectively performed within a training program. IMPLICATIONS A training protocol may safely and feasibly be initiated among physicians, advanced practice clinicians or trainees with no prior experience with postplacental IUD insertion. By initiating this practice, access to highly effective contraception may increase for patients who have difficulty returning for a visit or otherwise receiving effective methods.

Family planning knowledge, attitudes and practices among bariatric healthcare providers.

OBJECTIVE This survey aimed to identify the family planning knowledge, attitudes and practices of bariatric providers in the perioperative period. STUDY DESIGN We developed a quantitative survey based on semistructured interviews with six bariatric providers. We mailed the survey to the American Society of Metabolic and Bariatric Surgery members with plans to use data from the first 275 responders to assess knowledge, attitudes and practices regarding family planning. RESULTS Over 70% of 272 respondents recommended that women avoid pregnancy for 12-24months after bariatric procedures. Most (73.0%) considered female reproductive health discussions very important, and most feel comfortable (70.4%) with these discussions. The majority considered the most effective contraceptive methods to be safe for women after gastric bypass; only a minority (35.3%) provided contraceptive services or referrals, and few (4.9%) have accurate knowledge of contraceptive effectiveness. Respondents most frequently preferred the patients own gynecologist (80.9%) or bariatric surgeon (71.0%) discuss contraception. Discussing contraception was associated with provider age 40-49years, training region in southeast or midwest and degrees of physician assistant or nurse practitioner with adjusted odds ratios exceeding 2.0. CONCLUSION Bariatric providers consider reproductive health very important, and while most are comfortable having these conversations, few have accurate knowledge of contraceptive safety and effectiveness. Most would prefer patients see their gynecologists to discuss contraception. These findings suggest an opportunity for gynecologists to educate themselves and bariatric colleagues about contraception recommendations after bariatric surgery and collaborate with bariatric centers in their area to meet the needs of these patients. IMPLICATIONS Gynecologists must become educated and involved in the care of female bariatric patients to discuss reproductive health concerns and to counsel effectively regarding contraception after bariatric surgery.

Use of Dual Methods for Protection from Unintended Pregnancy and Sexually Transmitted Diseases in Adolescent African American Women

STUDY OBJECTIVE To characterize factors associated with dual method contraceptive use in a sample of adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional survey of sexually active African American women aged 14-19 years who attended an urban Title X clinic in Georgia in 2012 (N = 350). Participants completed a computerized survey to assess contraceptive and condom use during the past 2 sexual encounters with their most recent partner. Dual method use was defined as use of a hormonal contraceptive or intrauterine device and a condom. We applied multinomial logistic regression, using generalized estimating equations, to examine the adjusted association between dual method use (vs use of no methods or less effective methods alone; eg, withdrawal) and select characteristics. RESULTS Dual methods were used by 20.6% of participants at last sexual intercourse and 23.6% at next to last sexual intercourse. Having a previous sexually transmitted disease (adjusted odds ratio [aOR], 2.30; 95% confidence interval [CI], 1.26-4.18), negative attitude toward pregnancy (aOR, 2.25; 95% CI, 1.19-4.28), and a mother who gave birth as a teen (aOR, 2.34; 95% CI, 1.21-4.52) were associated with higher odds of dual method use. Having no health insurance (aOR, 0.39; 95% CI, 0.18-0.82), 4 or more lifetime sexual partners (aOR, 0.42; 95% CI, 0.22-0.78), sex at least weekly (aOR, 0.54; 95% CI, 0.29-0.99), and agreeing to monogamy with the most recent partner (aOR, 0.40; 95% CI, 0.16-0.96) were associated with decreased odds of dual method use. CONCLUSION Dual method use was uncommon in our sample. Efforts to increase use of dual methods should address individual and relationship factors.

Sexually Transmitted Disease Partner Notification among African-American, Adolescent Women

Objective. To better understand preferences and practices regarding partner notification of sexually transmitted infection (STI) among female, African-American adolescents. Methods. Participants completed a questionnaire and STI testing at baseline. Those diagnosed with Chlamydia or gonorrhea were recruited for a follow-up study, involving another questionnaire and repeat STI testing after three months. Results. At baseline, most participants (85.1%) preferred to tell their partner about an STI diagnosis themselves instead of having a health care provider inform him, and 71.0% preferred to bring their partner for clinic treatment instead of giving him pills or a prescription. Two-thirds of participants were classified as having high self-efficacy for partner notification of a positive STI diagnosis. In the multivariable analysis, older participants and those with fewer lifetime sexual partners were more likely to have high self-efficacy. Ninety-three participants (26.6%) had Chlamydia or gonorrhea and, of this subset, 55 participated in the follow-up study. Most adolescents in the follow-up study (76.4%) notified their partner about their infection. Conclusion. Although participants were willing to use most methods of partner notification, most preferred to tell partners themselves and few preferred expedited partner therapy. Traditional methods for partner notification and treatment may not be adequate for all adolescents in this population.

Knowledge and use of and opportunities for emergency contraception in Northern Haiti.

To evaluate the knowledge and experience of, and desire for, emergency contraception (EC) in postpartum women in Haiti, and to determine the knowledge and practices of EC providers.

Using a checklist to assess pregnancy in teenagers and young women.

OBJECTIVE: Health care providers should assess pregnancy in women seeking contraceptive services. Although urine pregnancy tests are available in most U.S. settings, their accuracy varies based on timing relative to missed menses, recent intercourse, or recent pregnancy. We examined the performance of a checklist based on criteria recommended in family planning guidance documents to assist health care providers in assessing pregnancy in a sample of U.S. teenagers and young women. METHODS: Study participants were a convenience sample of sexually active black females aged 14–19 years seeking care in an urban family planning clinic. Each participant provided a urine sample for pregnancy testing and was then administered the checklist in two formats, audio computer-assisted self-interview and in-person interview. We estimated measures of the checklist performance compared with urine pregnancy test as the reference standard, including negative predictive value, sensitivity, specificity, and positive predictive value. RESULTS: Of 350 participants, 31 (8.9%) had a positive urine pregnancy test. The audio computer-assisted self-interview checklist indicated pregnancy was unlikely for 250 participants, of whom 241 had a negative urine pregnancy test (negative predictive value=96.4%). The sensitivity of the audio computer-assisted self-interview checklist was 71%, the specificity was 75.6%, and the positive predictive value was 22%. The in-person checklist yielded similar results. CONCLUSION: The checklist may be a valuable tool to assist in assessing pregnancy in teenagers and young women. Appropriate use of the checklist by family planning providers in combination with discussion and clinically indicated use of urine pregnancy tests may reduce unnecessary barriers to contraception in this population. LEVEL OF EVIDENCE: II

Family Planning Knowledge Attitudes and Practices Among Bariatric Health Care Providers [205].

INTRODUCTION: More than 100,000 bariatric procedures are performed yearly in the United States. Women account for the majority of cases. Guidelines cosponsored by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society of Metabolic and Bariatric Surgery recommend women avoid pregnancy preoperatively and 12–18 months after surgery. This survey aims to identify the family planning knowledge, attitudes, and practices of bariatric providers in the perioperative period. METHODS: We developed a quantitative survey from qualitative data of semistructured health care provider interviews and mailed it to American Society of Metabolic and Bariatric Surgery members. We collected data from a convenience sample of the first 275 responders to perform a descriptive analysis. RESULTS: A total of 272 participants consented to the study. More than 70% of respondents recommend women avoid pregnancy for 12–24 months after bariatric procedures. The majority considers the most effective contraceptive methods to be safe for women after gastric bypass; however, the minority (35.3%) provides contraceptive services or referrals. Although most (73.0%) consider female reproductive health discussions very important, the majority (70.4%) never or almost never feels comfortable with these discussions. Respondents most frequently prefer the patients own gynecologist (80.9%) and the bariatric surgeon (71.0%) discuss contraception. CONCLUSION: Bariatric providers consider reproductive health very important; however, most are not comfortable having these conversations and would prefer patients see their gynecologists to discuss contraception. This is an opportunity for gynecologists to educate themselves and colleagues about contraception recommendations after bariatric surgery and collaborate with bariatric centers in their area to meet the needs of these patients.

O508 Postpartum family planning needs assessment in Cap Haitien, Haiti

Background: Haiti is the poorest country in the Western Hemisphere, with a maternal mortality ratio of 680/100,000. Census data from Haiti shows 25% of sexually active women using contraception, and 60% not using contraception express a desire to do so. Objectives: This study aims to evaluate the knowledge of and desire for contraception in postpartum women who have delivered at a large public hospital in Haiti, and to determine the level of knowledge and practices patterns of the providers in the realm of family planning (FP). Methods: We conducted 6 focus groups with immediately postpartum patients (n = 33) and 3 focus groups with maternity service providers (n = 22), and administered a structured questionnaire to immediately postpartum patients (n = 250). Results: 98% of women expressed a desire for FP counseling prior to discharge from the postpartum ward, and 80% of women want to choose a method prior to hospital discharge, yet only 6% of women received FP counseling during their hospitalization. Most women expressed a desire to either space or limit their pregnancies, including women with one live birth and women in the youngest age group. Providers reported a lack of FP counseling and method provision for postpartum women, yet there was uniform concern for the volume of induced abortions and maternal mortalities seen, which many felt could be averted by improving postpartum FP services. No providers had experience with initiating methods immediately postpartum. Conclusion: Efforts to design a comprehensive FP program that can be integrated into the postpartum care services would help both patients and providers reach their goals.