Sheila K. Mody

Outreach and integration programs to promote family planning in the extended postpartum period

WHO recommends birth spacing to improve the health of the mother and child. One strategy to facilitate birth spacing is to improve the use of family planning during the first year postpartum.

Postpartum contraception utilization among low-income women seeking immunization for infants in Mumbai, India

OBJECTIVE The objective was to examine postpartum contraception utilization among Indian women seeking immunization for their infants in three low-income communities in Mumbai, India. STUDY DESIGN We conducted a cross-sectional questionnaire of low-income postpartum women seeking immunization for their infants at three large urban health centers in Mumbai. Contraceptive utilization data were collected as part of a larger study focused on the impact of postpartum domestic violence on maternal and infant health. Descriptive, bivariate and multivariate analyses were conducted to describe and identify predictors of postpartum contraceptive utilization. RESULTS Postpartum women aged 17-45 years (N=1049) completed the survey; 44.5% (n=467) reported resuming sexual relations with their husbands. Among these women, the majority (65.3%; n=305) reported not currently using contraception. In multivariate analyses, women who did not discuss postpartum family planning with their husbands, had not used contraception previous to the recent birth, and had experienced physical violence or forced sex were more likely to not use postpartum contraception (adjusted odds ratios=1.47-1.77). Among the 162 women using contraception, the most common time to initiation of contraception was 5 weeks postpartum, and the most common method used was condoms 77.8% (n=126). CONCLUSION Contraception nonuse was common among urban, low-income postpartum women in India. This study highlights the importance of developing interventions to increase use of highly effective contraceptive methods postpartum, and that spousal violence and lack of marital communication may present barriers to postpartum contraception utilization. Infant immunization may represent an opportunity for provision of contraceptives and contraceptive counseling. IMPLICATIONS This original research study is a unique contribution to the literature because it presents data regarding the nonuse of postpartum contraception among women seeking immunizations for their infants in urban centers in a developing country. It also reveals barriers to not using postpartum contraception and provides data for future interventions.

Contraceptive use in female recipients of a solid-organ transplant.

Context Women of reproductive age account for more than one-third of all solid-organ transplant recipients and are advised against becoming pregnant for 1 to 2 years after their surgeries. The risks posed to the woman, the transplanted organ, and the fetus underscore the importance of systems to ensure that patients receive counseling on family planning, including return to fertility, contraceptive use, and when pregnancy can be safely considered, and highly effective methods of contraception. Objective To investigate use of contraceptives among women after solid-organ transplant and to identify opportunities to improve care. Design A cross-sectional survey study. Setting An urban academic medical center. Patients Women 18 to 50 years old who have received a kidney, pancreas, and/or liver transplant within the past 1 to 24 months. Intervention Participants completed self-administered questionnaires regarding their menstrual pattern, pregnancy history, contraceptive use before and after transplant, and counseling on family planning issues. Main Outcome Measures Contraceptive use. Results The most common contraceptive method used in both the year preceding transplant and the year after transplant was condoms. Participants desired more counseling on highly effective contraceptive methods, such as intrauterine devices. Participants would like to receive contraceptive counseling from an obstetrician/gynecologist or transplant care team provider. Conclusion Female recipients of solid-organ transplants want more counseling on highly effective methods of contraception.

An educational intervention on drug interactions and contraceptive options for epilepsy patients: a pilot randomized controlled trial

OBJECTIVE This pilot study investigates whether an educational handout could increase short-term information retention about drug interactions between antiepileptic drugs (AEDs) and hormonal contraceptives among female epilepsy patients of reproductive age. STUDY DESIGN This is a pilot randomized controlled trial of an educational intervention among reproductive-age women with epilepsy in an academic neurology clinic. Investigators measured knowledge before and after participants received either usual care or the educational handout. The 10-question test assessed increased knowledge of which AEDs affected efficacy of certain hormonal contraceptives and was assessed by calculating the improvement in score between the pretest and posttest. The educational handout included the names of AEDs that have drug interactions with certain contraceptives and the efficacy of the contraceptives. RESULTS A total of 42 epilepsy patients participated in this study. Fourteen participants were taking AEDs that are enzyme p450 inducers and 13 participants were taking Lamotrigine. Twenty women were randomized to receive the educational handout and 22 women were randomized to usual care. We found no statistical difference in the groups with regard to age, ethnicity or level of education. We found a significantly higher improvement in quiz scores in the educational handout group (3.65 point increase) compared to the usual care group (0.68 point increase) as calculated by the Students two-sample t test (p<.001). CONCLUSIONS An educational handout on drug interactions and contraceptives resulted in increased short-term information retention on this topic among reproductive-age female epilepsy patients. IMPLICATIONS This pilot study highlights the need for further larger studies to evaluate the impact of educational interventions on improving patient knowledge about the drug interaction of AEDs and hormonal contraceptives.

Transdermal delivery of combined hormonal contraception: a review of the current literature.

The transdermal patch provides an effective and convenient option for hormonal contraception. The patch currently on the US market contains 150 µg norelgestromin and 35 µg ethinylestradiol (EE). The 20 cm2 patch is applied once weekly for 3 weeks, followed by a patch-free week, for a 21–7 cycle. Typical failure rates are similar to that of combined oral contraceptives (COCs). Transdermal delivery results in less peaks and troughs of estrogen, but a higher total estrogen exposure compared with COCs. Though studies show mixed results, the risk of developing venous thromboembolism (VTE) is about twice as high with the patch as with COCs; however, the absolute risk of VTE remains low. The side effect profile is similar to that of COCs, with slightly higher rates of breast tenderness plus a unique adverse effect of application site reactions. Two new patches have been developed, one containing gestodene and EE in Europe and another containing levonorgestrel and EE. Overall, the patch provides an alternative to COCs for women who want autonomy and the benefit of not needing to take a pill daily, with similar efficacy and tolerability.

Using the Electronic Medical Record to Assess Contraception Usage among Women Taking Category D or X Medications

BACKGROUND The aim of this study is to investigate contraceptive usage among women prescribed or currently taking a category D or X medication using the electronic medical record. METHODS This is a retrospective study assessing contraceptive usage among women prescribed category D or X medications. We obtained access to the electronic medical records of women seen in an academic Family Medicine Department between April 2011 and April 2012 who were prescribed a category D or X medication. Information was abstracted regarding the specific category D or X medication, demographics, sexual activity, sexual partner gender, and contraceptive usage. RESULTS There were a total of 610 women included in this study. Among the 610 women, 72 (11.8%) of women had documentation that they were not asked about their sexual activity. Sexual activity with men was documented in 407 of the 610 women (66.7%). Of these 407 women, 132 (32.4%) had no contraceptive method documented. Among the women using contraception, the most common method used was oral contraception. CONCLUSION According to data obtained from the electronic medical record, women who are taking a category D or X medication are not always asked about sexual activity. Contraception usage among women taking category D or X medications and who were sexually active with men was similar to the general population. Contraception usage should be better in this population given the risk of an unintended pregnancy includes fetal exposure to a potential teratogen. The electronic medical record creates an opportunity for an intervention to increase contraception utilization in this population.

Choosing a Contraceptive Method: What Matters to Women With Medical Conditions [17O]

INTRODUCTION: Factors that influence contraceptive initiation among women with complex medical conditions are unknown. METHODS: We conducted a cross-sectional study of women 18–45 years old with complex medical conditions who received contraception consultation from family planning specialists at 5 University of California Medical Centers. We asked patients about factors important in initiating a method. RESULTS: Among 97 recruited participants, medical conditions fell into these categories: neurologic (37%), endocrine (37%), cardiovascular (21%), rheumatologic (12%), oncologic (6%), and other (29%), and 10% had a history of a solid organ transplant, 7% bariatric surgery, and 6% venous thromboembolism. A majority of participants initiated long-acting, reversible contraceptive (LARC) methods including a progestin intrauterine device (IUD, 40.0%), the copper IUD (14.7%) and the contraceptive implant (17.9%). The most common reason for initiating contraception was to avoid pregnancy in the immediate future for personal reasons (45.3%). The most common reason for initiating a particular contraceptive method was safety given their medical condition (20.2%). Women commonly reported that the person with the most influence on their contraceptive method choice was the family planning specialist (37.2%) and medical condition specialist (22.3%), and less commonly the primary care provider (9.6%) and a family member or friend (12.8%). CONCLUSION: This study provides insight into contraceptive decision-making among women with medical conditions. When these women are given specialized contraceptive counseling they often choose highly effective methods.

Using the electronic medical record to refer women taking category D or X medications for teratogen and contraceptive counseling

BACKGROUND Women taking teratogens may not receive teratogen and contraceptive counseling. The objective of this study is to explore the feasibility of an electronic medical record (EMR) alert and referral system to improve teratogen and contraceptive counseling. METHODS We conducted a descriptive study in an academic outpatient setting to evaluate the feasibility of an EMR alert and referral system. Reproductive age women taking category D or X medications seen in family medicine clinics were referred by means of an EMR alert for teratogen and contraceptive counseling. A subset of these women consented to follow-up surveys assessing contraceptive usage before counseling, intended contraceptive method after counseling and satisfaction with the counseling. Participants were contacted at 1 and 3 months to assess contraceptive usage. RESULTS A total of 354 women were prescribed category D or X medications by clinicians who received the EMR alert, 170 women were referred, 59 women received counseling, and 33 participants enrolled in the study. One participant did not use any contraception. Among the 32 participants using contraception, 12 (37.5%) used oral contraceptives, 11 (34.4%) used condoms, 3 (9.4%) used withdrawal, 3 (9.4%) used intrauterine devices, 2 (6.3%) used contraceptive rings, and 1 (3.1%) used the diaphragm. After counseling, one-third of participants were considering more effective contraception. Almost all participants strongly agreed or agreed that the counseling was helpful. CONCLUSION Creating an EMR alert and referral system for women prescribed category X or D medications is feasible. Counseling on teratogen exposure and contraception may improve the acceptability of more effective contraception.