Sarah Prager

Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women.

Two intrauterine devices (IUDs) are available in the United States, the levonorgestrel-bearing intrauterine system (Mirena) and the copper-bearing T380A (Paragard). These devices have very low typical-use failure rates but are used by only a minority of women. In particular, there is concern about their use in nulliparous women. We review the available data to address common concerns about using IUDs in this population and show that nulliparous women desiring effective contraception should be considered candidates for IUDs.

Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy.

BACKGROUND Women ages 35 years and older have the greatest proportion of contraceptive nonuse and unintended pregnancies ending in abortion. STUDY DESIGN We conducted a population-based case-control study among women ages 35-44 years at risk of unwanted pregnancy using the National Survey of Family Growth (NSFG) data to investigate risk factors for contraceptive nonuse. RESULTS At last intercourse, 9.8% of women reported not using any contraceptive method. Contraceptive nonusers, as compared to users, were more likely to be ages 40-44 years (OR=2.0, 95% CI 1.1-3.7), foreign-born (OR=4.3, 95% CI 1.9-9.7), black (OR=2.8, 95% CI 1.1-7.0), with household incomes 100-249% of the federal poverty level (FPL) (OR=2.5, 95% CI 1.1-5.8). Women who received contraceptive counseling in the past year had an 80% decreased risk of nonuse (95% CI 0.1-0.5). CONCLUSION Public health strategies to reduce unintended pregnancy, particularly among women ages 35 years and older, should focus on addressing disparities in contraceptive use and promoting contraceptive counseling.

The Oportunidades Conditional Cash Transfer Program: Effects on Pregnancy and Contraceptive Use among Young Rural Women in Mexico

CONTEXT Oportunidades is a large conditional cash transfer program in Mexico. It is important to examine whether the program has any direct effect on pregnancy experience and contraceptive use among young rural women, apart from those through education. METHODS Data from the 1992, 2006 and 2009 waves of a nationally representative, population-based survey were used to describe trends in pregnancy experience, contraceptive use and education among rural adolescent (15-19) and young adult (20-24) women in Mexico. To examine differences in pregnancy experience and current modern contraceptive use among young women, multivariable logistic regression analyses were conducted between matched 2006 samples of women with and without exposure to Oportunidades, predicted probabilities were calculated and indirect effects were estimated. RESULTS Over the three survey waves, the proportion of adolescent and young adult women reporting ever being pregnant stayed flat (33-36%) and contraceptive use increased steadily (from 13% in 1992 to 19% in 2009). Educational attainment rose dramatically: The proportion of women with a secondary education increased from 28% in 1992 to 46% in 2009. In multivariable analyses, exposure to Oportunidades was not associated with pregnancy experience among adolescents. Educational attainment, marital status, pregnancy experience and access to health insurance--but not exposure to Oportunidades--were positively associated with current modern contraceptive use among adolescent and young adult women. CONCLUSION Through its effect on education, Oportunidades indirectly influences fertility among adolescents. It is important for Mexico to focus on strategies to increase contraceptive use among young rural nulliparous women, regardless of whether they are enrolled in Oportunidades.

Second-trimester surgical abortion.

Surgical abortion in the second trimester became popularized in the 1970s, and now accounts for the majority of abortion procedures performed in this country. Dilation and evacuation is the most commonly used method in the second trimester, but dilation and curettage can be used with earlier gestations, and intact dilation and extraction accounts for a minority of later procedures. These various procedures will be addressed in detail. Other considerations such as preoperative and intraoperative use of ultrasound, use of uterotonics, pain management, appropriate location for second-trimester abortion provision, and routine postoperative care will also be reviewed.

Evidence-Based Selection of Candidates for the Levonorgestrel Intrauterine Device (IUD)

Background: Recent evidence-based guidelines expanded the definition of appropriate candidates for the levonorgestrel-releasing intrauterine system (LNG-IUS). We investigated correlates of evidence-based selection of candidates for the LNG-IUS by physicians who offer insertion. Methods: We conducted a mixed-mode (online and mail) survey of practicing family physicians and obstetrician-gynecologists in Seattle. Results: A total of 269 physicians responded to the survey (44% response rate). Of the 217 respondents who inserted intrauterine devices, half or fewer routinely recommended the LNG-IUS to women who are nulliparous, younger than 20 years old, or have a history of sexually transmitted infections (STIs). In multivariable analyses, training/resident status was positively associated with recommending the LNG-IUS to women <20 years old (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.6–8.0) and women with history of STI (aOR, 3.7; 95% CI, 1.6–8.4). Perceived risk of infection or infertility was negatively associated with recommending the LNG-IUS to nulliparous women (aOR, 0.2; 95% CI, 0.1–0.5) and women with a history of STI (aOR, 0.3; 95% CI, 0.1–0.8). Conclusions: Many family physicians and obstetrician-gynecologists who insert the LNG-IUS are overly restrictive in selecting candidates, although those who train residents are more likely to follow evidence-based guidelines. Interventions that address negative bias and perceptions of risks, in addition to improving knowledge, are needed to promote wider use of the LNG-IUS.

Factors associated with lack of effective contraception among obese women in the United States.

OBJECTIVE To identify factors associated with contraceptive nonuse and use of less effective methods among obese women in the US. STUDY DESIGN We analyzed data from sexually active obese women (body mass index >30 kg/m²) age 20-44 using the 2006-2010 National Survey of Family Growth. We conducted multinomial logistic regression to assess associations between current contraceptive use and demographic, reproductive and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal and fertility awareness) and barrier method users (condoms) to prescription method users (pill, patch, ring, injection, implant and intrauterine device). RESULTS Of 1345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8% barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4% of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to have previously discontinued a contraceptive method due to dissatisfaction [adjusted RR (aRR), 1.93; 95% confidence interval (CI), 1.09-3.44], and nonusers were more likely to perceive difficulty becoming pregnant (aRR, 3.86; 95% CI, 2.04-7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR, 0.16; 95% CI, 0.10-0.27; behavioral methods: aRR, 0.13; 95% CI, 0.06-0.25, barrier methods: aRR, 0.15; 95% CI, 0.09-0.25) than prescription method users. CONCLUSIONS Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider. IMPLICATIONS Efforts are needed to increase contraceptive counseling for obese women, who face increased risks of morbidity from unintended pregnancy.

Immediate versus delayed initiation of the contraceptive patch after abortion: a randomized trial.

BACKGROUND Immediate start of the contraceptive patch has not been studied in women after surgical abortion. STUDY DESIGN Women presenting for surgical abortion who had chosen the transdermal patch for contraception were randomized to either delayed start of the patch (beginning the Sunday after their abortion) or immediate start (directly observed application of the patch in the clinic). Subjects were contacted at 2 and 6 months to assess contraceptive use. RESULTS Two hundred ninety-eight women were randomized, and the follow-up rate was 71% at 2 months and 53% at 6 months. Method continuation did not differ by timing of initiation. At 2 months, 71% in the delayed-start group and 74% in the immediate-start group were using the patch [p=.6, with a difference of 3.1%, 95% confidence interval (CI)=-17.2% to +11.2%]. At 6 months, 55% in the delayed-start group and 43% in the immediate-start group were using the patch (p=.13, with a difference of 11.9%, 95% CI=-19.2% to +34%). CONCLUSION Immediate initiation of the contraceptive patch after surgical abortion was not associated with increased use of patch at 2 or 6 months.

Prospective assessment of fetal–maternal cell transfer in miscarriage and pregnancy termination

BACKGROUND Fetal cells (microchimerism) are acquired by women during pregnancy. Fetal microchimerism persists decades later and includes cells with pluripotent capacity. Persistent microchimerism has the capacity for both beneficial and detrimental maternal health consequences. Both miscarriage and termination of pregnancy can result in fetal microchimerism. We sought to determine whether cellular fetal microchimerism is acquired during management of pregnancy loss and further explored factors that could influence fetal cell transfer, including viability of fetal tissue, surgical versus medical management and gestational age. METHODS Pregnant women (n= 150 samples from 75 women) with singleton pregnancies undergoing a TOP (n= 63) or treatment for embryonic or fetal demise (miscarriage, n= 12) were enrolled. Mononuclear cells were isolated from blood samples drawn before, and 30 min after, treatment. Fetal cellular microchimerism concentrations were determined using quantitative PCR for a Y chromosome-specific sequence, expressed as genome equivalents of fetal DNA per 100 000 maternal cell equivalents (gEq/10(5)). Detection rate ratios were determined according to clinical characteristics. RESULTS Cellular fetal microchimerism was found more often in post- compared with pretreatment samples, 24 versus 5% (P= 0.004) and at higher concentrations, 0-36 versus 0-0.7 gEq/10(5) (P< 0.001). Likelihood of microchimerism was higher in surgical than medical management, detection rate ratio 24.7 (P= 0.02). The detection rate ratio for TOP versus miscarriage was 16.7 for known male fetuses (P= 0.02). Microchimerism did not vary with gestational age. CONCLUSIONS Significant fetal cell transfer occurs during miscarriage and TOP. Exploratory analyses support relationships between obstetric clinical factors and acquisition of fetal cellular microchimerism; however, our limited sample size precludes definitive analysis of these relationships, and confirmation is needed. In addition, the long-term persistence and potential consequences of fetal microchimerism on maternal health merit further investigation.

Heterosexual Anal Intercourse in the United States [6].

INTRODUCTION: More than one-third of women in the U.S. have engaged in heterosexual anal intercourse (HAI). The risk of acquiring HIV per sexual act is estimated to be 18 times higher for receptive anal intercourse than receptive vaginal intercourse; HAI is also associated with lower rates of condom use. We sought to describe frequency of HAI and condom use, HAI motivations, and HIV knowledge in the U.S. METHODS: A nationally representative sexual behavior survey of 5,162 women and men aged 18–50 year old was conducted. Data were analyzed using chi-square tests, t tests, and multivariable log-binomial regression. RESULTS: Thirty-seven percent of women have engaged in HAI. In the past three months, 12.2% have engaged in HAI, compared to 83.0% reporting vaginal intercourse. The most common motivations for HAI were self and partner pleasure and curiosity. Twice as many men as women reported ever using HAI as a method of contraception (13.5% vs 6.6%, P<.001). Condom use was lower for anal versus vaginal intercourse (9% vs 16%, P<.001). More than 70% of adults erroneously believe that HIV transmission risk is greater for vaginal intercourse than anal intercourse. CONCLUSION/IMPLICATIONS: HAI is common in the U.S. Both women and men report a wide range of motivations for both HAI and condom use with HAI. Significant knowledge gaps exist regarding HAI and HIV transmission.

“One of those areas that people avoid” a qualitative study of implementation in miscarriage management

BackgroundMiscarriage is common and often managed by specialists in the operating room despite evidence that office-based manual vacuum aspiration (MVA) is safe, effective, and saves time and money. Family Medicine residents are not routinely trained to manage miscarriages using MVA, but have the potential to increase access to this procedure. This process evaluation sought to identify barriers and facilitators to implementation of office-based MVA for miscarriage in Family Medicine residency sites in Washington State.MethodsThe Residency Training Initiative in Miscarriage Management (RTI-MM) is a theory-based, multidimensional practice change initiative. We used qualitative methods to identify barriers and facilitators to successful implementation of the RTI-MM.ResultsThirty-six RTI-MM participants completed an interview. We found that the common major barriers to implementation were low volume and a perception of miscarriage as emotional and/or like abortion, while the inclusion of support staff in training and effective champions facilitated successful implementation of MVA services.ConclusionPerceived characteristics of the innovation that may conflict with cultural fit must be explicitly addressed in dissemination strategies and support staff should be included in practice change initiatives. Questions remain about how to best support champions and influence perceptions of the innovation. Our study findings contribute programmatically (to improve the RTI-MM), and to broader theoretical knowledge about practice change and implementation in health service delivery.