Stephanie B. Teal

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE: To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer. METHODS: Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, &khgr;2 tests, and binary logistic regression. RESULTS: The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4–6.7), recent immigrants (OR 5.7, 95% CI 2.0–16), less educated (OR 3.6, 95% CI 1.6–8.0), and uninsured (OR 3.9, 95% CI 1.6–9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1–11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1–6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0–6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0–9.4).. CONCLUSION: We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance. LEVEL OF EVIDENCE: III

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined. RESULTS Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03). CONCLUSION IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.

A Randomized Comparison of Misoprostol 6 to 8 Hours Versus 24 Hours After Mifepristone for Abortion

OBJECTIVE: To demonstrate equivalence between mifepristone 200 mg followed 6 to 8 hours later and 24 hours later by misoprostol 800 &mgr;g vaginally for abortion in women up to 63 days of gestation. METHODS: Mifepristone 200 mg was swallowed by 1,080 women after which they were randomly assigned to self-administer misoprostol intravaginally 6 to 8 hours later (group 1) or 23 to 25 hours later (group 2) at home. Participants returned for an evaluation, including transvaginal ultrasonography, 7 ± 1 days after initiating treatment. Subjects who had not aborted were offered a second dose of misoprostol. All participants returned approximately 2 weeks after receiving mifepristone. Telephone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication. RESULTS: Complete abortion rates for groups 1 and 2 were 503 of 525 (95.8%, 95% confidence interval 93.7%, 97.3%) and 521 of 531 (98.1%, 95% confidence interval 96.6%, 99.1%), respectively, which were statistically equivalent. Side effects were significantly more common after mifepristone administration for women in group 2. Nausea, vomiting, and heavy bleeding were also significantly greater for women in group 2 after misoprostol treatment. Pain and subject acceptability were similar between groups. CONCLUSION: Mifepristone 200 mg followed 6 to 8 hours later by misoprostol 800 &mgr;g vaginally is as effective for abortion and has significantly fewer side effects as compared with regimens using a 24-hour dosing interval. Women receiving mifepristone and vaginal misoprostol for abortion can have the flexibility to administer the misoprostol as soon as 6 hours after using the mifepristone. LEVEL OF EVIDENCE: I

IUD use in adolescent mothers: retention, failure and reasons for discontinuation☆☆☆

BACKGROUND Many professional organizations recommend intrauterine device (IUD) use in adolescents, but data on performance of currently available devices in US teens are scant. We describe IUD continuation, side effect and pregnancy rates in parous adolescents. STUDY DESIGN Between 2002 and 2008, a cohort of 136 young mothers from an adolescent pregnancy/postpartum program received either a CuT380A or LNG-IUS for contraception. A minimum of 2 years postplacement, IUD status was ascertained by records review and phone interviews. Discontinuation, side effect and pregnancy rates by IUD type were calculated and compared. RESULTS Mean and median survival times were 25.1 and 14.1 months, respectively, and did not differ by IUD type. Twelve-month continuation was 55%. Of the 87 removals, the most common reasons were expulsion (14.2%), pain (12.2%), bleeding (7.4%), pregnancy desire (6.8%) and pregnancy (4.7%), and rates did not differ significantly by IUD type. First-year pregnancy rates with IUD in situ was 6.2% for the CuT380A and 3.7% for the LNG-IUS (p=.5). Rates of removal for bleeding and pain were similar for both devices. CONCLUSION Over half of parous adolescents who choose IUDs keep them for at least 1 year. Expulsion rates and pregnancy rates are higher than reported in the general population.

Contraception after delivery and short interpregnancy intervals among women in the United States.

OBJECTIVE: To investigate womens patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months. METHODS: We used the 2006–2010 National Survey of Family Growth to examine womens contraceptive use after delivery and at 3, 6, 12, and 18 months after giving birth. The sample included 3,005 births that occurred within 3 years of the survey date and for which information on contraceptive use was available. We estimated multivariable-adjusted Cox regression models to assess the association between womens method use and risk of pregnancy within 18 months after delivery. We also examined the percentage of pregnancies occurring 18 months or less after the index birth that were unintended. RESULTS: Between delivery and 3 months postpartum, contraceptive use increased from 21% to 72%. At 3 months, 13% of women used permanent contraception, 6% used long-acting reversible contraceptives, 28% used other hormonal methods, and 25% relied on less-effective methods; the distribution of method use was similar in subsequent months. Among women using hormonal methods, 12.6% became pregnant within 18 months of delivery or less compared with 0.5% using permanent and long-acting contraception (adjusted hazard ratio [HR] 21.2, 95% confidence interval [CI] 6.17–72.8). Additionally, 17.8% of women using less-effective methods (HR 34.8, 95% CI 9.26–131) and 23% using no method (HR 43.2, 95% CI 12.3–152) became pregnant 18 months or less. At least 70% of pregnancies within 1 year after delivery were unintended. CONCLUSION: Few women use long-acting reversible contraceptives after delivery, and those using less-effective methods have an increased risk of unintended pregnancy. LEVEL OF EVIDENCE: II

Three-year efficacy and safety of a new 52-mg levonorgestrel-releasing intrauterine system

OBJECTIVE To assess 3-year data on the efficacy and safety of a new 52-mg levonorgestrel intrauterine contraceptive (LNG20) designed for up to 7 years use. STUDY DESIGN Nulliparous and parous women aged 16-45 years at enrollment with regular menstrual cycles and requesting contraception were enrolled in an open-label, partially randomized trial to evaluate LNG20. The primary outcome was pregnancy rate for women aged 16-35 years calculated as the Pearl Index. Women aged 36-45 years received LNG20 for safety evaluation only. All participants had in-person or phone follow-up approximately every 3 months during the study. RESULTS A total of 1600 women aged 16-35 years and 151 women aged 36-45 years agreed to LNG20 placement, including 1011 (57.7%) nulliparous and 438 (25.1%) obese women. Successful placement occurred in 1714 (97.9%) women. Six pregnancies occurred, four of which were ectopic. The Pearl Index for LNG20 was 0.15 (95% CI 0.02-0.55) through Year 1, 0.26 (95% CI 0.10-0.57) through Year 2, and 0.22 (95% CI 0.08-0.49) through Year 3. The cumulative life-table pregnancy rate was 0.55 (95% CI 0.24-1.23) through 3 years. Expulsion was reported in 62 (3.5%) participants, most (50 [80.6%]) during the first year of use. Of women who discontinued LNG20 and desired pregnancy, 86.8% conceived spontaneously within 12 months. Pelvic infection was diagnosed in 10 (0.6%) women. Only 26 (1.5%) LNG20 users discontinued due to bleeding complaints. CONCLUSION The LNG20 intrauterine system is highly effective and safe over 3 years of use in nulliparous and parous women. IMPLICATIONS STATEMENT A new 52-mg levonorgestrel-releasing intrauterine system is effective and safe for nulliparous and parous women for at least 3 years.

Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost-effective?

OBJECTIVE The objective of the study was to determine the cost-effectiveness of a hypothetical state-funded program offering immediate postpartum implant (IPI) insertion for adolescent mothers. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, n = 171) vs standard contraceptive initiation (comparison group, n = 225). Implant discontinuation, repeat pregnancies and pregnancy outcomes were determined. We compared the anticipated public expenditures for IPI recipients and comparisons at 6, 12, 24, and 36 months postpartum using the actual outcomes of this cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1000 adolescents in each arm and included 1 year of well-baby care for delivered pregnancies. RESULTS At 6 months, the expenditures of the IPI group exceed the comparison group by

Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices

73,000. However, at 12, 24, and 36 months, publicly funded IPIs would result in a savings of more than

Postpartum contraception: optimizing interpregnancy intervals.

550,000,

Medical Therapies for Chronic Menorrhagia

2.5 million, and