Qiuhong Zhao

Effectiveness of Long-Acting Reversible Contraception

BACKGROUND The rate of unintended pregnancy in the United States is much higher than in other developed nations. Approximately half of unintended pregnancies are due to contraceptive failure, largely owing to inconsistent or incorrect use. METHODS We designed a large prospective cohort study to promote the use of long-acting reversible contraceptive methods as a means of reducing unintended pregnancies in our region. Participants were provided with reversible contraception of their choice at no cost. We compared the rate of failure of long-acting reversible contraception (intrauterine devices [IUDs] and implants) with other commonly prescribed contraceptive methods (oral contraceptive pills, transdermal patch, contraceptive vaginal ring, and depot medroxyprogesterone acetate [DMPA] injection) in the overall cohort and in groups stratified according to age (less than 21 years of age vs. 21 years or older). RESULTS Among the 7486 participants included in this analysis, we identified 334 unintended pregnancies. The contraceptive failure rate among participants using pills, patch, or ring was 4.55 per 100 participant-years, as compared with 0.27 among participants using long-acting reversible contraception (hazard ratio after adjustment for age, educational level, and history with respect to unintended pregnancy, 21.8; 95% confidence interval, 13.7 to 34.9). Among participants who used pills, patch, or ring, those who were less than 21 years of age had a risk of unintended pregnancy that was almost twice as high as the risk among older participants. Rates of unintended pregnancy were similarly low among participants using DMPA injection and those using an IUD or implant, regardless of age. CONCLUSIONS The effectiveness of long-acting reversible contraception is superior to that of contraceptive pills, patch, or ring and is not altered in adolescents and young women. (Funded by the Susan Thompson Buffet Foundation.).

Continuation and Satisfaction of Reversible Contraception

OBJECTIVE: To estimate 12-month satisfaction and continuation rates of intrauterine device (IUD) and implant users enrolled in the Contraceptive CHOICE Project and compare these measures with women using the oral contraceptive pills (OCPs). METHODS: We analyzed 12-month data from the first 5,087 participants enrolled in a prospective cohort study of women in the St. Louis region offered contraception at no cost for 3 years. The primary purpose of CHOICE is to promote the use of long-acting reversible contraception (IUDs and implants) and to reduce unintended pregnancies in our region. This analysis includes those participants who received their baseline contraceptive method within 3 months of enrollment and who reached the 12-month follow-up telephone survey time point (n=4,167). RESULTS: Sixty-eight percent of our participants chose a long-acting reversible contraception method (45% levonorgestrel intrauterine system, 10% copper IUD, and 13% subdermal implant), 23% chose combined hormonal methods (11% OCPs, 10% vaginal ring, and 2% transdermal patch), and 8% chose depot medroxyprogesterone acetate. Long-acting reversible contraception users had higher 12-month continuation rates (86%) than OCP users (55%). The two IUDs had the highest 12-month continuation rates: levonorgestrel intrauterine system (88%) and copper IUD (84%). Women using the implant also had very high rates of continuation at 1 year (83%). Satisfaction mirrored continuation: more than 80% of users were satisfied with the IUD compared with 54% satisfied with OCPs. CONCLUSION: IUDs and the subdermal implant have the highest rates of satisfaction and 12-month continuation. Given that long-acting reversible contraception methods have the highest contraceptive efficacy, these methods should be the first-line contraceptive methods offered to patients. LEVEL OF EVIDENCE: II

Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy

BACKGROUND The rate of teenage pregnancy in the United States is higher than in other developed nations. Teenage births result in substantial costs, including public assistance, health care costs, and income losses due to lower educational attainment and reduced earning potential. METHODS The Contraceptive CHOICE Project was a large prospective cohort study designed to promote the use of long-acting, reversible contraceptive (LARC) methods to reduce unintended pregnancy in the St. Louis region. Participants were educated about reversible contraception, with an emphasis on the benefits of LARC methods, were provided with their choice of reversible contraception at no cost, and were followed for 2 to 3 years. We analyzed pregnancy, birth, and induced-abortion rates among teenage girls and women 15 to 19 years of age in this cohort and compared them with those observed nationally among U.S. teens in the same age group. RESULTS Of the 1404 teenage girls and women enrolled in CHOICE, 72% chose an intrauterine device or implant (LARC methods); the remaining 28% chose another method. During the 2008-2013 period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1000, respectively. CONCLUSIONS Teenage girls and women who were provided contraception at no cost and educated about reversible contraception and the benefits of LARC methods had rates of pregnancy, birth, and abortion that were much lower than the national rates for sexually experienced teens. (Funded by the Susan Thompson Buffett Foundation and others.).

Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project

BACKGROUND Adolescent women have a high risk of unintended pregnancy. Currently, there are little data about their choice to initiate long-acting reversible contraception (LARC). STUDY DESIGN We evaluated the association of age and preference for a LARC vs. a non-LARC method among adolescent participants in the Contraceptive CHOICE Project, comparing those aged 14-17 years to adolescents aged 18-20 years. We then analyzed the association between age and choice of the implant vs. the intrauterine device (IUD) among adolescents. RESULTS Of the 5086 women enrolled, 70% (n=3557) of participants chose a LARC method. Among adolescents aged 14-20 years, 69% of 14-17-year-olds chose LARC, while 61% of 18-20-year-olds chose LARC (relative risk 1.16, 95% confidence interval 1.03-1.30). Among adolescents choosing a LARC method, 63% (n=93/148) of the 14-17-year-olds chose the implant, whereas 71% (n=364/510) of the 18-20-year-olds chose the IUD. CONCLUSION Long-acting reversible contraception use is clearly acceptable and common among adolescents enrolled in the Contraceptive CHOICE Project, with the younger group being most interested in the implant.

Identification of intracellular bacteria in the basal plate of the human placenta in term and preterm gestations

OBJECTIVE Bacteria have been identified in different regions of the placenta. Here, we tested the hypothesis that the maternal basal plate of the placenta harbors microbes that may be associated with adverse pregnancy outcomes. STUDY DESIGN We performed a cross-sectional study of pregnancies from a single tertiary care hospital. Maternal medical and obstetric characteristics were obtained and pregnancies followed up prospectively for outcomes and placental collection. After delivery, systematic random sampling of the placental basal plate was performed. Paraffin sections of basal plates were stained with 4 histologic stains and scored for morphological evidence of bacteria. RESULTS Of 195 total patients in the study, Gram-positive and -negative intracellular bacteria of diverse morphologies were documented in the basal plates of 27% of all placentas. Of the patients, 35% delivered preterm. No difference was noted between placental basal plates from preterm or term gestations. Intracellular bacteria were found in the placental basal plates of 54% spontaneous preterm deliveries <28 weeks, and in 26% of term spontaneous deliveries (P = .02). Intracellular bacteria were also documented in placentas without clinical or pathologic chorioamnionitis. CONCLUSION A total of 27% of placentas demonstrated intracellular bacteria in the placental basal plate using morphological techniques. Thus, the maternal basal plate is a possible source of intrauterine colonization and placental pathological examination could include examination for bacteria in this important maternal-fetal interface.

Twenty-Four–Month Continuation of Reversible Contraception

OBJECTIVE: To estimate 24-month continuation rates of all reversible contraceptive methods for women enrolled in the Contraceptive CHOICE Project. METHODS: We analyzed 24-month data from the 9,256 participants enrolled in the Contraceptive CHOICE Project, a prospective observational cohort study that provides no-cost contraception to women in the St. Louis region. The project promoted the use of long-acting reversible contraception (LARC) (intrauterine devices [IUDs] and implants) in an effort to reduce the rates of unintended pregnancy. This analysis includes participants who received their baseline contraceptive method within 3 months of enrollment and who completed a 24-month follow-up survey (N=6,153). RESULTS: Twenty-four month continuation rates for long-acting reversible contraception and non-LARC methods were 77% and 41%, respectively. Continuation rates for the levonorgestrel and the copper IUDs were similar (79% compared with 77%), whereas the implant continuation rate was significantly lower (69%, P<.001) compared with IUDs at 24 months. There was no statistically significant difference in 24-month continuation rates among the four non-LARC methods (oral contraceptive pill [OCP] 43%, patch 40%, ring 41%, depot medroxyprogesterone acetate [DMPA] 38%; P=.72). Participants who chose a LARC method at enrollment were at significantly lower risk of contraceptive method discontinuation (adjusted hazard ratio 0.29, 95% confidence interval 0.26–0.32) compared with women who selected a non-LARC method. CONCLUSION: Intrauterine devices and the implant have the highest rates of continuation at 24 months. Given their effectiveness and high continuation rates, IUDs and implants should be first-line contraceptive options and shorter-acting methods such as OCPs, patch, ring, and DMPA should be second tier. LEVEL OF EVIDENCE: II

Continuation of reversible contraception in teenagers and young women.

OBJECTIVE: To examine the effect of age on continuation rates of reversible contraceptive methods among females aged 14–19 years and women aged 20–25 years compared with women older than 25 years of age. METHODS: We analyzed data from 7,472 participants enrolled in the Contraceptive CHOICE Project, a prospective cohort study of women offered no-cost contraception. Our primary objective was to compare 12-month continuation rates between females aged 14–19, 20–25, and 26 years and older. We collected data about method continuation from telephone surveys and chart review. We used Kaplan-Meier survival curves to estimate continuation and Cox proportional hazard models to examine the risk of contraceptive method discontinuation. RESULTS: Twelve-month continuation of long-acting reversible contraceptive (LARC) methods was more than 75% for all age groups. Females aged 14–19 years using LARC methods had slightly lower continuation rates (81%) than older women (85–86%), but this did not reach statistical or clinical significance. Compared with women older than 25 years of age, females aged 14–19 years had higher discontinuation rates for non-LARC methods (53% compared with 44%; adjusted hazard ratio 1.32, 95% confidence interval [CI] 1.02–1.73). The females aged 14–19 years were less likely to be satisfied with non-LARC methods (42% compared with 51%; adjusted relative risk 0.80, 95% CI 0.65–0.98), but not with LARC methods (75% compared with 83%; relative risk 0.94, 95% CI 0.88–1.01) when compared with women older than 25 years of age; however, the differences were small. CONCLUSION: Teenagers and young women have high rates of LARC method continuation. LEVEL OF EVIDENCE: II

Contraceptive Failure Rates of Etonogestrel Subdermal Implants in Overweight and Obese Women.

OBJECTIVE: To estimate the contraceptive failure rates of the etonogestrel subdermal contraceptive implant in overweight and obese women and compare failure rates with women of normal weight and women using intrauterine devices (IUDs). METHODS: The Contraceptive CHOICE Project is a large prospective cohort study designed to promote the use of long-acting reversible contraceptive methods to reduce unintended pregnancies in the St Louis region. Participants are provided reversible contraception of their choice at no cost. We collected baseline height and weight of each participant. During each survey, participants were asked about missed menses and possible pregnancies. Any participant who suspected a pregnancy was asked to come in for urine pregnancy testing. Analysis includes the first 8,445 participants enrolled in CHOICE of which 1,168 chose the implant and 4,200 chose the IUD. Students t test, &khgr;2 test, and Kaplan-Meier survival curves were used to perform statistical analyses to estimate failure rates in overweight and obese women using the implant and IUDs. RESULTS: Of the women choosing the implant, 28% were overweight and 35% were obese. Of the women who chose an IUD, 27% were overweight and 35% were obese. The 3-year cumulative failure rates for implant and IUD users were less than one per 100 women-years and did not vary by body mass index. CONCLUSION: We found no decrease in the effectiveness of the implant in overweight or obese women. The implant may be offered as a first-line contraceptive method to any woman seeking a reversible and reliable birth control method. LEVEL OF EVIDENCE: II

Association of age and parity with intrauterine device expulsion.

OBJECTIVE: To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs). METHODS: This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan–Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion. RESULTS: A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68–3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75–5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44–0.78). CONCLUSION: IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type. LEVEL OF EVIDENCE: II

Weight Change at 12 Months in Users of Three Progestin-Only Contraceptive Methods

BACKGROUND Concerns about weight gain may influence contraceptive use. We compared the change in body weight over the first 12 months of use between women using the etonogestrel (ENG) implant, the levonorgestrel intrauterine system (LNG-IUS) or depot medroxyprogesterone acetate (DMPA) with women using the copper intrauterine device (IUD). STUDY DESIGN This was a substudy of the Contraceptive CHOICE Project, a prospective cohort study of 9256 women provided no-cost contraception. Women who had been using the ENG implant, LNG-IUS, DMPA or copper IUD continuously for at least 11 months were eligible for participation. We obtained body weight at enrollment and at 12 months and compared the weight change for each progestin-only method to the copper IUD. RESULTS We enrolled a total of 427 women: 130 ENG implant users, 130 LNG-IUS users, 67 DMPA users and 100 copper IUD users. The mean weight change (in kilograms) over 12 months was 2.1 for ENG implant users [standard deviation (SD)=6.7]; 1.0 for LNG-IUS users (SD=5.3); 2.2 for DMPA users (SD=4.9) and 0.2 for copper IUD users (SD=5.1). The range of weight change was broad across all contraceptive methods. In the unadjusted linear regression model, ENG implant and DMPA use were associated with weight gain compared to the copper IUD. However, in the adjusted model, no difference in weight gain with the ENG implant, LNG-IUS or DMPA was observed. Only Black race was associated with significant weight gain (1.3 kg, 95% confidence interval=0.2-2.4) when compared to other racial groups. CONCLUSIONS Weight change was variable among women using progestin-only contraceptives. Black race was a significant predictor of weight gain among contraceptive users.