Tina R. Raine

Emergency contraception: advance provision in a young, high-risk clinic population.

Objective To assess whether advance provision of emergency contraception increases its use and whether it has secondary effects on regular contraceptive use. Methods We conducted a controlled trial of female clients, aged 16–24 years, who attended a publicly funded family planning clinic. Women were systematically assigned to receive an advance provision of emergency contraception and education (treatment) or education only (control). Among 263 participants enrolled (133 treatment, 130 control), follow-up was completed in 213 (111 treatment, 102 control). The main outcome measures were emergency contraception knowledge and use, frequency of unprotected sex, and pattern of contraceptive use in the past 4 months. Results Participants were aware of emergency contraception at follow-up, but the treatment group was three times as likely to use it (P = .006). Although the treatment group did not report higher frequencies of unprotected sex than the control group, women in the treatment group (28%) were more likely than those in the control group (17%) to report using less effective contraception at follow-up compared with enrollment (P = .05). The proportion of women in both groups who reported consistent pill use increased from enrollment to follow-up (34% versus 45%); however, the control group (58%) was more likely than the treatment group (32%) to report consistent pill use at follow-up (P = .03). Conclusion Use of emergency contraception was increased by providing it in advance, but not by education alone. Changes to less effective contraceptive methods and patterns of pill use were potentially negative effects that need to be explored in relation to observed benefits.

The Effect of Increased Access to Emergency Contraception Among Young Adolescents

Objectives: The United States Food and Drug Administration cited an absence of data on young adolescents as the reason the emergency contraceptive, Plan B, could not be moved over-the-counter. This study analyzed data on young adolescents with increased access to emergency contraception. Methods: We conducted an age-stratified analysis with previously published data from a randomized, controlled trial of Plan B with a sample size of 2,117, including 964 adolescents, 90 of whom were aged younger than 16 years. Participants were randomly assigned to nonprescription pharmacy access, advance provision of 3 packs, or clinic access (control). We measured contraceptive and sexual risk behaviors at baseline and 6-month follow-up and tested for pregnancy and sexually transmitted infections. We used contingency table and logistic regression analysis to measure the effect of the intervention on risk behaviors in young adolescents (< 16 years), compared with middle adolescents (16–17 years), older adolescents (18–19 years), and adults (20–24 years). Results: Adolescents aged younger than 16 years behaved no differently in response to increased access to emergency contraception (EC) from the other age groups. As with adults, EC use was greater among adolescents in advance provision than in clinic access (44% compared with 29%; P ≤ .001), and other behaviors were unchanged by study arm, including unprotected intercourse, condom use, sexually transmitted infection acquisition, or pregnancy. Additionally, adolescents with increased access to EC did not become more vulnerable to unwanted sexual activity. Conclusion: Young adolescents with improved access to EC used the method more frequently when needed, but did not compromise their use of routine contraception nor increase their sexual risk behavior. Level of Evidence: I

Attitudes and beliefs about the intrauterine device among teenagers and young women

BACKGROUND Little is known about attitudes and beliefs among teenagers and young women about the intrauterine device (IUD). STUDY DESIGN We surveyed 252 women, ages 14-27 years, presenting for appointments at an urban family planning clinic about demographics, sexual and birth control history, and opinions about the IUD. RESULTS Fifty-five percent had not heard of the IUD. Participants who were parous were 4.4 times more likely to be interested in the IUD than nulliparous participants. Independent of parity, participants who had heard of the IUD from a health care provider were 2.7 times more likely to be interested in using the method. The study population was at high risk for sexually transmitted infections (STIs); however, 82% of participants predicted that they would increase or experience no change in their condom use with an IUD in place. CONCLUSIONS Health care providers should be encouraged to talk to teenagers and young women who are at high risk for unintended pregnancy, both parous and nulliparous, about using the IUD.

Determinants of contraceptive method among young women at risk for unintended pregnancy and sexually transmitted infections

The objective of this study was to examine the relationship between contraceptive method choice, sexual risk and various demographic and social factors. Data were collected on 378, 15- to 24-year-old women, recruited from health clinics and through community outreach in Northern California. Logistic regression analysis was used to estimate the association of predictors with contraceptive method used at last sex. Asian and Latina women were less likely to use any method. Women who were raised with a religion, or thought they were infertile, were also less likely to use any method. Women with multiple partners were generally less likely to use any method, but were more likely to use barrier methods when they did use one. Few women (7%) were dual method users. Women appear to act in a rational fashion within their own social context and may use no methods at all or use methods that are less effective for pregnancy prevention but offer more protection from sexually transmitted infections.

One-Year Contraceptive Continuation and Pregnancy in Adolescent Girls and Women Initiating Hormonal Contraceptives

OBJECTIVE: To assess contraceptive discontinuation, switching, factors associated with method discontinuation, and pregnancy among women initiating hormonal contraceptives. METHODS: This was a 12-month longitudinal cohort study of adolescent girls and women (n=1,387) aged 15 to 24 years attending public family planning clinics who did not desire pregnancy for at least 1 year and selected to initiate the patch, ring, depot medroxyprogesterone acetate, or pills. Participants completed follow-up assessments at 3, 6, and 12 months after baseline. Life table analysis was used to estimate survival rates for contraceptive continuation. Cox proportional hazards models were used to estimate factors associated with method discontinuation. RESULTS: The continuation rate (per 100 person-years) at 12 months was low for all methods; however, it was lowest for patch and depot medroxyprogesterone acetate initiators, 10.9 and 12.1 per 100 person years, respectively (P≤.003); continuation among ring initiators was comparable to pill initiators, 29.4 and 32.7 per 100 person-years, respectively (P=.06). Discontinuation was independently associated with method initiated and younger age. The only factors associated with lower risk of discontinuation were greater intent to use the method and being in school or working. The pregnancy rate (per 100 person-years) was highest for patch and ring initiators (30.1 and 30.5) and comparable for pill and depot medroxyprogesterone acetate initiators (16.5 and 16.1; P<.001). CONCLUSION: The patch and the ring may not be better options than the pill or depot medroxyprogesterone acetate for women at high risk for unintended pregnancy. This study highlights the need for counseling interventions to improve contraceptive continuation, education about longer-acting methods, and developing new contraceptives that women may be more likely to continue. LEVEL OF EVIDENCE: II

Hormonal contraceptive method choice among young, low-income women: how important is the provider?

OBJECTIVES Several new methods are available, but we know little about successful integration of contraceptive technologies into services. We investigated provider factors associated with the initiation of new hormonal methods among women at high risk of unintended pregnancy. METHODS This cohort study enrolled 1387 women aged 15-24 starting hormonal contraception (vaginal ring, transdermal patch, oral contraceptive, or injectable) at four family planning clinics in low-income communities. We measured provider factors associated with method choice, using multinomial logistic regression. RESULTS Ring and patch initiators were more likely than women starting oral contraceptives to report that they chose their method due to provider counseling (p<0.001). Contraceptive knowledge in general was low, but initiation of a new method, the ring, was associated with higher knowledge about all methods after seeing the provider (p<0.001). Method initiated varied with provider site (p<0.001). These associations remained significant, controlling for demographics and factors describing the provider-patient relationship, including trust in provider and continuity of care. CONCLUSION Womens reports of provider counseling and of their own contraceptive knowledge after the visit was significantly associated with hormonal method initiated. PRACTICE IMPLICATIONS More extensive counseling and patient education should be expected for successful integration of new hormonal methods into clinical practice.

Contraceptive decision-making in sexual relationships: young men's experiences, attitudes and values

Much attention has been focused on efforts to reduce unintended pregnancy by improving contraceptive use among high-risk women; however, there is limited information to guide interventions to engage young men in contraceptive decision-making. We conducted focus groups of young men, aged 19–26, from diverse racial backgrounds from low-income communities in the San Francisco Bay Area to examine social norms about sexual relationships and how they impact on contraceptive use. The data were analysed using content analysis. A range of relationships were described, however casual relationships predominated. While young men expressed strong desires to avoid pregnancy in casual relationships, the unpredictable nature of relationships, together with low communication and regard for the women involved, made stressing consistent contraceptive use among partners unlikely. The themes expressed by these young men about sex and behaviour in different relationships illustrate a spectrum of decision-making dilemmas and illustrate the inherent difficulty in fully engaging young men in contraceptive decision-making. A strategy is needed to address relationship values, dynamics and condom use beyond STI-prevention frameworks and young womens ability to make appropriate contraceptive choices in light of the inherent difficulties and uncertainty associated with casual relationships.

Race, adolescent contraceptive choice, and pregnancy at presentation to a family planning clinic.

OBJECTIVE To assess racial/ethnic differences in pregnancy and contraceptive choice among adolescent family planning patients. METHODS The charts of 605 female adolescents presenting to a teen family planning clinic for an initial visit were retrospectively reviewed for demographic and reproductive health information, sexual risk behaviors, pregnancy, and current and dispensed contraceptive method. Logistic and multinomial logistic regression analysis were used to estimate the association of these factors with pregnancy and contraceptive choice. RESULTS Black adolescents were three times more likely than white adolescents to be pregnant at presentation to the clinic (P = .05). Ninety‐one percent of adolescents did not want to be pregnant; pregnancy desire was highly correlated with current contraceptive method. None of the adolescents who reported being unsure or wanting to be pregnant used hormonal methods. Black adolescents were more likely to rely on barrier methods than hormonal methods (P = .04); choice of barrier methods over hormonal methods was not correlated with risk for sexually transmitted diseases. There were no differences, however, in method dispensed by race. Black and white adolescents were equally likely to choose hormonal methods at the end of the visit, but adolescents who used hormonal methods at presentation—who were more likely to be white—were significantly more likely to leave the clinic with hormonal methods. CONCLUSION Black race/ethnicity was an independent risk factor for use of less effective barrier contraceptive methods and pregnancy at presentation to the clinic. Understanding how black adolescents make contraceptive choices is essential to helping them avoid unintended pregnancies.

Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners

OBJECTIVE Nurse practitioners (NPs) provide frontline care in womens health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants. METHOD A US nationally representative sample of nurse practitioners in primary care and womens health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. RESULTS Two-thirds of womens health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in womens health and 10% in primary care. Half of NPs desired training in these methods. CONCLUSION Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Contraceptive discontinuation and repeat unintended pregnancy within 1 year after an abortion.

BACKGROUND We examined 12-month hormonal contraceptive continuation and pregnancy rates by abortion history. STUDY DESIGN Women who wanted to avoid pregnancy for at least 1 year were recruited at four San Francisco Bay area family planning clinics on regular service days and on abortion care days. Participants completed baseline and follow-up questionnaires. Multivariable Cox models assessed the factors associated with method discontinuation and pregnancy. RESULTS Women who were enrolled into the study on the day of their abortion were 20% more likely to discontinue their contraceptive method than women who never had an abortion [adjusted hazard ratio (AHR)=1.21, 95% confidence interval (CI)=1.03-1.42]. Women who had a recent abortion or previous abortion were 60% more likely to have a pregnancy during follow-up than women who never had an abortion (AHR=1.63, 95% CI =1.21-2.20, and AHR=1.66, 95% CI=1.18-2.33, respectively). CONCLUSION The experience of having an unintended pregnancy and abortion does not lead to behavioral changes that protect against another unintended pregnancy.