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Neurovascular anatomy of the adult female medial arm in relationship to potential sites for insertion of the etonogestrel contraceptive implant.
Contraception. 2019 Mar 8;OBJECTIVE: Anatomic assessment of the medial upper arm to identify potential sites for insertion of the etonogestrel (ENG) implant. STUDY DESIGN: Forty female cadaveric arms were dissected. Two rows of 1 x 2cm dissection windows were created in the inner arm overlying the triceps approximately 2-3 and 4-5cm posterior to the bicipital sulcus (sulcus). The primary window was 8-10cm proximal to the medial epicondyle and approximately 2-3cm posterior to the sulcus. Neurovascular structures within each window were identified. The entire medial upper arm was dissected to visualize underlying structures. RESULTS: Mean age (+/- SD) of cadavers at death was 72.0+/-11.0years. Arm measurements at the primary window were: circumference 28.2+/-4.8cm [range: 21-41]; skin thickness 0.6+/-0.2mm [0.3-1.0]; subcutaneous tissue thickness: 12.3+/-4.9mm [4.7-21]. The basilic vein and the medial brachial cutaneous, ulnar, and medial antebrachial cutaneous nerves were located in 40%, 58%, 40%, and 18% of the primary windows, respectively. No major neurovascular structures were located 3-5cm posterior to the sulcus. More neurovascular structures were identified overlying the biceps than triceps. Elbow flexion with the hand underneath the head displaced the ulnar nerve anteriorly towards the sulcus. CONCLUSION: As no major neurovascular structures were identified overlying the triceps 8-10cm proximal to the medial epicondyle and 3-5cm posterior to the sulcus, ENG implant insertion at this location may minimize risk of injury associated with improper deep insertion. Elbow flexion deflects the ulnar nerve away from this area and may further decrease risk of injury secondary to inadvertent deep insertion. IMPLICATIONS: Though a limited cadaver study, this anatomic assessment provides rationale for insertion of the ENG implant overlying the triceps 8-10cm proximal to the medial epicondyle and 3-5cm posterior to the sulcus. This area is theoretically safer for insertion of the ENG implant than areas of the inner arm where major neurovascular structures are commonly located. Copyright (c) 2019. Published by Elsevier Inc.
Ginekologia Polska. 2019; 90(2):61-65.OBJECTIVES: The aim of the study was to evaluate hormonal contraception use in women with epilepsy and to assess the risk of potential interactions between contraceptives and antiepileptic drugs (AEDs). MATERIAL AND METHODS: Data on hormonal contraception were obtained prospectively in women of childbearing age treated in the university epilepsy clinic. RESULTS: We evaluated 334 women with epilepsy (mean age 30.2 years). The majority of patients took one AED (193, 58%); the most commonly prescribed AEDs were: valproate, levetiracetam or lamotrigine. Hormonal contraception was used by 19 (5.7%) of all women of childbearing age. Only 7 patients (37%) of all those using hormonal contraception used prepa- rations that did not interact with AEDs; what is more 145 (46%) patients who did not use hormonal contraception were prescribed AEDs with high teratogenic potential (valproate or/and topiramate). CONCLUSIONS: A very small percentage of women with epilepsy of childbearing potential used hormonal contraception. More than a half of that group simultaneously took AEDs that may interact with oral contraceptives. A large proportion of women taking AEDs with high teratogenic potential were not using hormonal contraception. As interaction between OC and AEDs are common, nonhormonal, highly effective methods, such as IUDs, may be ideal for women with epilepsy. The results of the study indicate the need for closer cooperation between neurologist and gynecologist caring for women with epilepsy.
Resumption of sexual intercourse post partum and the utilisation of contraceptive methods in China: a cross-sectional study.
BMJ Open. 2019 Mar 12; 9(3):e026132.OBJECTIVE: This is a cross-sectional study that aimed to examine the resumption of sexual intercourse post partum, the utilisation of contraceptive methods and the influencing factors among Chinese women at a tertiary teaching hospital. DESIGN: This is a questionnaire survey by written and online interview for participants. PARTICIPANTS: Based on medical records, we sent online questionnaires about postpartum sexual intercourse and contraception plans to 550 eligible women. MAIN OUTCOME MEASURES: Potential factors affecting postpartum sexual intercourse and utilisation of contraception were determined by analysis of epidemiological and clinical factors and sexual experiences during and after pregnancy. RESULTS: Of 550 eligible participants, 406 women (73.8%) with a postpartum period of 8.5 months (range 6-10) completed the questionnaires; 146 of 406 (36.0%) resumed sexual intercourse within 3 months, and 259 of 279 (92.8%) used contraceptive methods. In univariate and multivariate analyses, sexual intercourse during pregnancy (adjusted OR 4.4, 95% CI 2.8 to 6.9) and resumption of menstruation (adjusted OR 2.5, 95% CI 1.5 to 4.3) were significant influencing factors in resumption of sexual intercourse within 3 months after childbirth. No factor was found to be associated with using contraceptive methods or the general resumption of sexual intercourse post partum. The questionnaire had good reliability and validity. CONCLUSIONS: Having sexual intercourse during pregnancy and resuming menstruation earlier were independent factors for resumption of sexual intercourse within 3 months after delivery. Almost all women who had postpartum sexual intercourse used various contraceptive methods. (c) Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Characterizing the Influence of Structural Determinants of HIV Risk on Consistent Condom Use among female sex workers in Senegal.
Journal of Acquired Immune Deficiency Syndromes. 2019 Feb 14;BACKGROUND: Female Sex Workers(FSW) are disproportionately affected by HIV even in the most generalized HIV epidemics. While structural HIV risks have been understood to affect condom negotiation among FSW globally, there remains limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic-status-and condom use among FSW across Sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSW in Senegal. METHODS: In 2015, 758 FSW >18 years of age were recruited using respondent driven sampling (RDS) in Senegal. Data on individual, community, network and structural level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants. RESULTS: The RDS-adjusted prevalence of CCU in the last ten sexual acts was 76.8% (95%CI:70.8-82.8). Structural determinants that were significantly associated with lower CCU were: physical violence (adjusted prevalence ratio [aPR]: 0.71; 95%CI:0.52-0.98); working primarily in a hotel or guest house (aPR:0.85; 95%CI:0.73-0.99); and difficultly accessing condoms (aPR:0.72; 95%CI:0.52- 0.96). High income from sex work (aPR:1.23; 95%CI:1.04-1.46) was significantly associated with higher CCU. CONCLUSION: Taken together, these data highlight the role of structural risk determinants on condom use among FSW in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSW in Senegal.
The contraceptive medroxyprogesterone acetate, unlike norethisterone, directly increases R5 HIV-1 infection in human cervical explant tissue at physiologically relevant concentrations.
Scientific Reports. 2019 Mar 13; 9(1):4334.The intramuscular progestin-only injectable contraceptive, depo-medroxyprogesterone acetate (DMPA-IM), is more widely used in Sub-Saharan Africa than another injectable contraceptive, norethisterone enanthate (NET-EN). Epidemiological data show a significant 1.4-fold increased risk of HIV-1 acquisition for DMPA-IM usage, while no such association is shown from limited data for NET-EN. We show that MPA, unlike NET, significantly increases R5-tropic but not X4-tropic HIV-1 replication ex vivo in human endocervical and ectocervical explant tissue from pre-menopausal donors, at physiologically relevant doses. Results support a mechanism whereby MPA, unlike NET, acts via the glucocorticoid receptor (GR) to increase HIV-1 replication in cervical tissue by increasing the relative frequency of CD4+ T cells and activated monocytes. We show that MPA, unlike NET, increases mRNA expression of the CD4 HIV-1 receptor and CCR5 but not CXCR4 chemokine receptors, via the GR. However, increased density of CD4 on CD3+ cells was not observed with MPA by flow cytometry of digested tissue. Results suggest that DMPA-IM may increase HIV-1 acquisition in vivo at least in part via direct effects on cervical tissue to increase founder R5-tropic HIV-1 replication. Our findings support differential biological mechanisms and disaggregation of DMPA-IM and NET-EN regarding HIV-1 acquisition risk category for use in high risk areas.
Studies in Family Planning. 2019 Mar 13;This study explores how armed conflict relates to contraceptive use in Colombia, combining data from the Uppsala Conflict Data Program and Demographic and Health Surveys 1990-2016. Our study is the first systematic effort to investigate whether and how violent conflict influences women's contraceptive use, using nationally representative data across all stages of women's reproductive careers. With fixed effects linear probability models, we adjust for location-specific cultural, social, and economic differences. The results show that although modern contraceptive use increased over time, it declined according to conflict intensity across location and time. We find no evidence that this relationship varied across socioeconomic groups. Increased fertility demand appears to explain a small portion of this relationship, potentially reflecting uncertainty about losing a partner, but conflict may also result in lack of access to contraceptive goods and services. (c) 2019 The Population Council, Inc.
[Evolution of contraceptive practices in France] Evolution des pratiques et des demandes de contraception en France.
La Revue du Praticien. 2018 Apr; 68(4):383-386.Evolution of contraceptive practices in France. In France, since the end of the 1970s, the evolution of the contraceptive landscape has been analyzed with studies conducted at regular intervals. Several phenomena have contributed to the evolution of contraceptive strategies. The profound changes in hormonal contraceptives and the development of intrauterine devices adapted to different uterine anatomies have helped to change the French contraceptive landscape. The media crisis of 2012 also strongly contributed to this evolution even if certain evolutions were already started before, against the backdrop of an overall decrease in traditional hormonal therapies in favor of so-called long-acting reversible contraceptives. The other important element affecting women's contraception is the demand to avoid hormonal contraceptives.
La Revue du Praticien. 2018 Apr; 68(4):387-391.Long-acting reversible contraception. Long-acting reversible contraception (LARC) have a long-prolonged efficacy over 3 to 5 years depending on the method. They have become in recent years a subject of major interest in contraception. Indeed, these contraceptive methods, including intrauterine devices and the subcutaneous implant, allow obtaining an optimal contraceptive effectiveness while reducing the constraints for the women. All these contraceptions require the participation of an experienced professional for their placement and withdrawal. These LARCs may usually be suitable for all women after removal of rare contraindications. For each LARC, the potential advantages and disadvantages must be taken into account in order to choose the most appropriate method for each woman. Regular monitoring is always required to allow premature withdrawal in case of side effects, incident or wish to pregnancy. Their reversibility is immediate.
[Choosing the first contraceptive: a major step] Le choix de la premiere contraception : une etape majeure.
La Revue du Praticien. 2018 Apr; 68(4):392-393.Long-acting reversible contraception. Long-acting reversible contraception (LARC) have a long-prolonged efficacy over 3 to 5 years depending on the method. They have become in recent years a subject of major interest in contraception. Indeed, these contraceptive methods, including intrauterine devices and the subcutaneous implant, allow obtaining an optimal contraceptive effectiveness while reducing the constraints for the women. All these contraceptions require the participation of an experienced professional for their placement and withdrawal. These LARCs may usually be suitable for all women after removal of rare contraindications. For each LARC, the potential advantages and disadvantages must be taken into account in order to choose the most appropriate method for each woman. Regular monitoring is always required to allow premature withdrawal in case of side effects, incident or wish to pregnancy. Their reversibility is immediate.
La Revue du Praticien. 2018 Apr; 68(4):394-400.Hormonal contraception and vascular risk. Since the early 1960, it has been well documented that combined hormonal contraceptives (CHC) increase the risk of venous thromboembolism diseases (VTE) and arterial diseases, even if it is an uncommon disease before menopause. Vascular risk is the most important determinant of the benefit/ risk profile of hormonal contraceptive. The most recent pills are associated with a higher risk of VTE than second- generation pill. CHC increase the risk of arterial disease (myocardial infarction or ischemic stroke), especially in women at high vascular risk. This increase does not depend on the generation of CHC. A meticulous research of vascular risk factors, including familial history of VTE, is recommended before prescription. It allows to adapt the contraceptive strategy for every woman according to the bene- fit/risk profile. In context of high vascular risk, low doses of both oral progestin contraceptives and intrauterine levonorgestrel could be safe with respect to VTE risk.
A Mobile Health Contraception Decision Support Intervention for Latina Adolescents: Implementation Evaluation for Use in School-Based Health Centers.
JMIR MHealth and UHealth. 2019 Mar 14; 7(3):e11163.BACKGROUND: Health care providers are a trusted and accurate source of sexual health information for most adolescents, and clinical guidelines recommend that all youth receive comprehensive, confidential sexual health information and services. However, these guidelines are followed inconsistently. Providers often lack the time, comfort, and skills to provide patient-centered comprehensive contraceptive counseling and services. There are significant disparities in the provision of sexual health services for Latino adolescents, which contribute to disproportionately higher rates of teenage pregnancy. To address this, we developed Health-E You or Salud iTu in Spanish, an evidence-informed mobile health (mHealth) app, to provide interactive, individually tailored sexual health information and contraception decision support for English and Spanish speakers. It is designed to be used in conjunction with a clinical encounter to increase access to patient-centered contraceptive information and services for adolescents at risk of pregnancy. Based on user input, the app provides tailored contraceptive recommendations and asks the youth to indicate what methods they are most interested in. This information is shared with the provider before the in-person visit. The app is designed to prepare youth for the visit and acts as a clinician extender to support the delivery of health education and enhance the quality of patient-centered sexual health care. Despite the promise of this app, there is limited research on the integration of such interventions into clinical practice. OBJECTIVE: This study described efforts used to support the successful adoption and implementation of the Health-E You app in clinical settings and described facilitators and barriers encountered to inform future efforts aimed at integrating mHealth interventions into clinical settings. METHODS: This study was part of a larger, cluster randomized control trial to evaluate the effectiveness of Health-E You on its ability to reduce health disparities in contraceptive knowledge, access to contraceptive services, and unintended pregnancies among sexually active Latina adolescents at 18 school-based health centers (SBHCs) across Los Angeles County, California. App development and implementation were informed by the theory of diffusion of innovation, the Patient-Centered Outcomes Research Institute's principles of engagement, and iterative pilot testing with adolescents and clinicians. Implementation facilitators and barriers were identified through monthly conference calls, site visits, and quarterly in-person collaborative meetings. RESULTS: Implementation approaches enhanced the development, adoption, and integration of Health-E You into SBHCs. Implementation challenges were also identified to improve the integration of mHealth interventions into clinical settings. CONCLUSIONS: This study provides important insights that can inform and improve the implementation efforts for future mHealth interventions. In particular, an implementation approach founded in a strong theoretical framework and active engagement with patient and community partners can enhance the development, adoption, and integration of mHealth technologies into clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT02847858; https://clinicaltrials.gov/ct2/show/NCT02847858 (Archived by WebCite at http://www.webcitation.org/761yVIRTp). (c)Kathleen P Tebb, Sang Leng Trieu, Rosario Rico, Robert Renteria, Felicia Rodriguez, Maryjane Puffer. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 14.03.2019.
Follow-up visits to check strings after intrauterine contraceptive placement cannot predict or prevent future expulsion.
European Journal of Contraception and Reproductive Health Care. 2019 Mar 14; 1-5.OBJECTIVES: In some settings women are advised to return to the clinic after intrauterine contraceptive (IUC) placement, for a follow-up visit to check the strings and identify any expulsions. Our objective was to evaluate whether the number of follow-up visits to check the strings at the external cervical os after IUC placement predicts or prevents future expulsions. METHODS: This was a retrospective study conducted at the University of Campinas Medical School, Brazil. We reviewed the medical records of all women who used an IUC between January 1980 and December 2017, to identify women who had experienced IUC expulsion (N = 1974). We excluded women whose IUC was expelled more than once (n = 331) or after 10 years of use (n = 31). We fitted a generalised linear model of the time between IUC placement and expulsion, adjusting for several variables at expulsion. Significance was established at p < .05. RESULTS: Most expulsions (843/1612; 52.3%) occurred within the first 6 months after IUC placement and 691/1612 (42.9%) were within the first three months after placement. The adjusted model showed that the number of visits, the woman's age, and complaints of pain and bleeding during use were not significantly associated with and had no influence on expulsion. CONCLUSIONS: Our results indicate that after IUC insertion more than one follow-up visit within the first four to six months after placement is not necessary, as additional visits to check for IUC strings do not appear to reduce or predict future expulsion.
Influence of Genetic Variants on Steady-State Etonogestrel Concentrations Among Contraceptive Implant Users.
Obstetrics and Gynecology. 2019 Mar 11;OBJECTIVE: To identify genetic variants that influence steady-state etonogestrel concentrations among contraceptive implant users. METHODS: We enrolled healthy, reproductive-age women in our pharmacogenomic study using etonogestrel implants for 12-36 months without concomitant use of hepatic enzyme inducers or inhibitors. We collected participant characteristics, measured serum etonogestrel concentrations, and genotyped each participant for 120 single nucleotide variants in 14 genes encoding proteins involved in steroid hormone (ie, estrogens, progestins) metabolism, regulation, or function. We performed generalized linear modeling to identify genetic variants associated with steady-state etonogestrel concentrations. RESULTS: We enrolled 350 women, who had a median serum etonogestrel concentration of 137.4 pg/mL (range 55.8-695.1). Our final generalized linear model contained three genetic variants associated with serum etonogestrel concentrations: NR1I2(PXR) rs2461817 (beta=13.36, P=.005), PGR rs537681 (beta=-29.77, P=.007), and CYP3A7*1C (beta=-35.06, P=.025). Variant allele frequencies were 69.4%, 84.9%, and 5.1%, respectively. Our linear model also contained two nongenetic factors associated with etonogestrel concentrations: body mass index (BMI) (beta=-3.08, P=7.0x10) and duration of implant use (beta=-1.60, P=5.8x10); R for the model =0.17. CONCLUSION: Only BMI and duration of implant use remained significantly associated with steady-state etonogestrel concentrations. Of the three novel genetic associations found, one variant associated with increased etonogestrel metabolism (CYP3A7*1C) causes adult expression of fetal CYP3A7 proteins and can consequently alter steroid hormone metabolism. Women with this variant may potentially have increased metabolism of all steroid hormones, as 27.8% (5/18) of CYP3A7*1C carriers had serum etonogestrel concentrations that fell below the threshold for consistent ovulatory suppression (less than 90 pg/mL). More pharmacogenomic investigations are needed to advance our understanding of how genetic variation can influence the effectiveness and safety of hormonal contraception, and lay the groundwork for personalized medicine approaches in women's health. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03092037.
Obstetrics and Gynecology. 2019 Mar 11;OBJECTIVE: To compare postpartum contraception use between Somali and non-Somali women. METHODS: A retrospective cohort study was performed using the Rochester Epidemiology Project. All Somali women aged 18 and older with live singleton births in Olmsted County, Minnesota, in 2009-2015 (n=317) were included, and a group of age-matched non-Somali women (n=317) were identified. Postpartum contraception was defined as the use of any method within 12 months after the first delivery within the study period. Rates of contraception use and types of contraception used were compared between groups using chi analysis. Among Somali women, an a priori list of factors was evaluated for associations with postpartum contraception use by including these factors in a multivariable logistic regression model. RESULTS: After the index birth, 33 Somali women did not present for follow-up, compared with 12 non-Somali women (10.4% vs 3.8%, difference 6.6%, 95% CI 2.3-10.9%). Somali women were less likely to use postpartum contraception than non-Somali women (69.4% vs 92.8%, odds ratio [OR] 0.18, 95% CI 0.11-0.29). Among those using postpartum contraception, both groups had comparable use of long-acting reversible contraception (LARC) (19.9% vs 23.7%, difference -3.8%, 95% CI -11.8% to 4.0%) and non-LARC hormonal contraception (39.3% vs 42.4%, difference -3.1%, 95% CI -12.7% to 6.0%). However, Somali women were more likely to use less reliable methods (40.3% vs 20.8%, difference 19.5%, 95% CI 11.0-28.5%). Among Somali women, contraception use was less likely with older maternal age (OR 0.12 for oldest vs youngest quartile, 95% CI 0.04-0.37) and more likely with prepregnancy contraception use (OR 15.46, 95% CI 5.18-46.18). CONCLUSION: Somali women were less likely to use postpartum contraception. Similar practices and beliefs may also be present in other immigrant populations. Recognition of sociocultural differences in immigrant populations and potential health care provider biases may improve patient-provider relationships and counseling practices.
Safety of levonorgestrel 52mg intrauterine system compared to copper intrauterine device: a population-based cohort study.
Contraception. 2019 Mar 11;OBJECTIVE: To compare the risk of all-cause death, hospitalizations (any cause), ectopic pregnancy, pelvic inflammatory disease or infection, uterine perforation, device removal, neuro-psychiatric drugs initiation, or new psychiatric visit(s) between levonorgestrel (LNG) 52mg intrauterine system (IUS) and copper intrauterine device (IUD) users in France. STUDY DESIGN: We identified a historical cohort of women aged 20-55years with a first dispensing of either LNG 52mg IUS or copper-IUD between January 1, 2010 and December 31, 2014, in the French National Claims database, SNDS. We used propensity score matching to balance the two groups on baseline sociodemographic and clinical characteristics to minimize confounding. We estimated Cox proportional hazards models to compare health outcomes between LNG 52mg IUS and copper-IUDs users. RESULTS: We matched 9318 LNG 52mg IUS users (mean age 36.2+/-6.8years) to 10,185 copper-IUD users (mean age 35.4+/-7.1years). After matching and age-adjustment, LNG 52mg IUS users had a slightly higher risk of anxiolytic drugs initiation (HR 1.08, 95%CI 1.01 to 1.15) and device removal (HR 1.05, 95%CI 1.01 to 1.10) compared to copper-IUD users, with no differences for other studied outcomes. CONCLUSION: French IUS users report slightly more anxiolytic treatment initiation and IUD removal compared to copper-IUD users. These results are consistent with a potential pharmacovigilance signal of anxiety-related disorders in LNG 52mg IUS users. IMPLICATIONS STATEMENT: In French LNG 52mg IUS users, there was slightly more anxiolytic treatment initiation and IUD removal compared to copper-IUD users. No risk difference was found for all-cause death, hospitalizations, ectopic pregnancy, pelvic disorders, and uterine perforation. We cannot exclude that the associations are related to differences in characteristics of women who chose each type of type of IUD. Copyright (c) 2019. Published by Elsevier Inc.
Bone turnover markers in women participating in a dose-finding trial of a contraceptive vaginal ring releasing Nestorone and estradiol.
Contraception. 2019 Mar 11;OBJECTIVE: To evaluate changes in the bone turnover markers CTx and P1NP during 6months' use of novel continuous contraceptive vaginal rings delivering Nestorone (NES) 200 mcg/day and three doses of estradiol (E2) (10, 20, and 40 mcg/day). STUDY DESIGN: This randomized trial enrolled 189 women who used two consecutive vaginal rings over 180days. Frequent blood sampling permitted analysis of NES, E2, CTx and P1NP concentrations. The bone-turnover marker analyses included only women with complete sampling and excluded women with characteristics that might interfere with accurate measurement of bone markers such as afternoon sampling, poor ring compliance or recent pregnancy. We evaluated the change from baseline to six months in CTx and P1NP, stratified by ring dose and by average circulating E2 concentrations. RESULTS: One hundred fifty-one women completed the study, and 82 women had complete data available for the bone marker analyses; the three dosage groups were balanced with regard to baseline characteristics. E2 concentrations remained low throughout treatment, regardless of which dose ring the participant used. Individual CTx changes from baseline averaged 27+/-56% (p<.01). Similarly, individual P1NP changes averaged 11+/-33% (p=.04). These increases were within the premenopausal reference ranges, and unrelated to treatment dose or to circulating E2 concentrations. CONCLUSIONS: The low E2 dose of these rings was associated with low E2 concentrations and modest increases in serum bone turnover makers. Because we have only six-month bone turnover markers and no direct evidence of bone loss or bone density change, these results must be interpreted with caution. IMPLICATIONS: Nestorone, a 19-norprogesterone derivative, leads to complete ovarian suppression, which should yield excellent contraceptive effectiveness. To prevent potential adverse effects on bone, the NES contraceptive ring should be combined with higher doses of E2 than were assessed in this study. Copyright (c) 2019. Published by Elsevier Inc.
Contraception. 2019 Mar 11;OBJECTIVE: Describe contraception availability at local health departments (LHDs) serving largely rural populations. STUDY DESIGN: We invited administrators at LHDs located in four Midwest states to participate in an online survey conducted from September 2017-April 2018. We collected data on clinic staffing, patient population, receipt of Title X funds, and services provided to assess the proportion of LHDs providing any prescription method of contraception; secondary outcomes included healthcare staff training level and other reproductive health services provided. RESULTS: Of 344 LHDs invited, 237 administrators completed the survey (68.9%). Three-quarters served rural populations. One-third (34.6%) provided short-acting hormonal contraception; however, availability varied by state (Kansas: 58.0%, 40/69; Missouri: 37.5%, 33/88; Nebraska: 16.7%, 3/18; Iowa: 9.7%, 6/62; p<.01). Only 8.4% of LHDs provided IUDs; 7.6% provided implants; and 5.9% provided both methods. LHDs in Nebraska and Kansas provided any long-acting method more frequently (Kansas: 17.4%, Nebraska: 16.7%, Iowa: 8.1%, Missouri: 4.6%; p=.04). LHDs receiving Title X funds (27.0%) were much more likely to provide any prescription contraception (85.1% vs. 14.2%, p<.01). Most LHDs relied on registered nurses (RNs) to provide medical care; 81.0% reported that RNs provided care>/=20days per month. Pregnancy testing was widely available in Missouri and Kansas (>87%) and less commonly available in Iowa and Nebraska (<18%) (p<.01). CONCLUSION: LHDs in these states are currently ill-equipped to offer comprehensive contraceptive services. Women seeking care at LHDs have limited, if any, contraceptive options. IMPLICATIONS: Local health departments in the Midwest, serving a largely rural population, rarely offer prescription contraception, especially long-acting reversible methods. Women residing in settings without broad access to publicly-funded healthcare providers may have limited access to comprehensive contraceptive services. Efforts to ensure rural access are needed. Copyright (c) 2019. Published by Elsevier Inc.
Pilot study on functional performance and acceptability of two new synthetic adhesive male condoms (Wondaleaf): a randomized cross-over trial.
Contraception. 2019 Mar 11;OBJECTIVES: This study compared the condom failure rate, safety and acceptability of two new synthetic adhesive male condoms, Wondaleaf-Cap(R) (WLC) and Wondaleaf-On-Man(R) (WLM), with a marketed latex external condom Durex(R)-Together (DT). STUDY DESIGN: We enrolled healthy married, monogamous, heterosexual condom users in a randomized controlled, cross-over, pilot trial in Malaysia. We randomized participants to six groups with different condom use-orders of the experimental WLC and WLM and control latex condom for four episodes for vaginal sex over onemonth for each condom type. We summarized the clinical and non-clinical failure rate, safety and acceptability of each condom type using descriptive statistics. We tested differences in condom failure and acceptability using generalized estimating equations and repeated measure ANOVA respectively. RESULTS: We screened 75 couples and randomized 50 eligible couples. Two couples withdrew before receiving any condom. The remaining used 576 condoms with 192 uses for each condom variant. Clinical failure rates of WLC, WLM and DT were 1.04%, 0% and 0.52%, respectively. Non-clinical failure rates of WLC, WLM and DT were 2.08%, 3.12% and 1.04%, respectively. Removal was found more painful with Wondaleaf products than the DT. Preferences of participants for WLC, WLM and DT were 33.3%, 29.2% and 25%, respectively. Overall, WLC and DT had greater acceptances among male participants than WLM. CONCLUSION: Results of this pilot study support that use of synthetic adhesive male condoms is associated with failure rates similar to those seen with existing latex, and with greater acceptability. A larger study to ascertain non-inferiority is underway. IMPLICATIONS: The availability of synthetic adhesive male condoms may increase the acceptability of condom use. However, removal pain and clinical performance requires further study. Copyright (c) 2019. Published by Elsevier Inc.
India's family planning market and opportunities for the private sector: An analysis using the total market approach.
International Journal of Health Planning and Management. 2019 Mar 15;The private (commercial) sector in India can complement public sector for family planning services, but the roadmap to engage these two sectors remains a challenge. The total market approach (TMA) offers a strategy by understanding the comparative advantage of public, commercial, and nonprofit sectors. We estimated TMA indicators using data of four rounds of the National Family Health Surveys: 1992-93, 1998-99, 2005-06, and 2015-16. The contraceptive prevalence of modern methods in India did not increase in recent years, but the number of users increased, and so did the market size for the commercial sector. In rural areas, the current market size in 2015-16 (75 million) failed to reach its potential size in 1992-93 (84 million). In urban areas, the market of modern contraceptives is mostly composed of the users from higher wealth, and a high percentage of users obtain contraceptives from subsidized sources. The family planning market of northern part of Bihar and Uttar Pradesh and of Northeast India are in the "early" stage and need more demand generation; "matured" markets are mostly concentrated in and around big metros. Subsidization in urban areas should be offered to the targeted population who need family planning products and services at low cost. (c) 2019 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.
Unmet need for family planning and its associated factor among women of reproductive age in Debre Berhan Town, Amhara, Ethiopia.
BMC Research Notes. 2019 Mar 15; 12(1):143.OBJECTIVE: Unmet need refers to fecund women who either wish to postpone the next birth (spacers) or who wish to stop childbearing (limiters) but are not using a contraceptive method. The aim of this study was to assess the unmet needs of family planning and identify associated factors in Debre Berhan town among women in reproductive age. The community-based cross-sectional study design was used among 411 study participants (women with reproductive age) at Debre Berhan town. A systematic sampling technique was used to select the households. Bivariate and multivariable analyses were done to determine the association of each independent variable with the dependent variable. RESULTS: The overall unmet need for family planning among women in reproductive age groups was found to be 30.9%. Occupational status AOR = 13.992 (1.054-185.833), from whom the respondents got information about family planning AOR = 0.018 (0.002-0.170), having a discussion with husband AOR = 16.692 (2.911-95.713) and support from husband AOR = 0.005 (0.001-0.025) was significantly associated with the outcome variable. The level of unmet need for family planning in the study area is still high compared to the target set (10%) in the national family planning guide plan for Ethiopia.
Journal of Controlled Release. 2019 Mar 12;Lack of adherence to medication dosing schedules is a significant cause of morbidity and mortality with large associated financial costs. This is especially true for contraceptive hormones, which provide almost perfect prevention of pregnancy when used correctly, but have significant failure rates in typical use, due largely to poor adherence. To increase medication acceptability and adherence, we introduce pharmaceutical jewelry, in which a transdermal patch is incorporated into jewelry worn on skin. To demonstrate the approach, we incorporated transdermal patches containing the contraceptive hormone levonorgestrel (LNG) into an earring, a ring, a necklace, and a wrist watch. Transdermal delivery of LNG from earring patches across porcine skin ex vivo achieved a steady state flux of 1.7mug/cm(2).h. Pharmacokinetic analysis in hairless rats yielded LNG delivery rates that maintained serum LNG levels near 1500pg/ml throughout the 1-week patch application period, which is well above the human contraceptive threshold concentration of 200pg/ml. When patches were applied cyclically for 16h on and 8h off to simulate earring removal at night, serum LNG concentrations dipped during off periods, but remained well above the human contraceptive threshold. Earring patches were well tolerated by the rats. We conclude that pharmaceutical jewelry can provide a novel method of drug delivery, especially for contraceptive hormones, that has the potential to improve acceptability and increase medication adherence. Copyright (c) 2019. Published by Elsevier B.V.
Contraception, Venous Thromboembolism, and Inflammatory Bowel Disease: What Clinicians (and Patients) Should Know.
Inflammatory Bowel Diseases. 2019 Mar 16;The peak incidence of the inflammatory bowel diseases (IBDs) is between the second and fourth decades of life, which coincides with prime reproductive years. Unplanned or mistimed pregnancies may account for nearly half of all pregnancies and are associated with adverse consequences such as a higher risk of delayed preconceptual care, increased risk of preterm birth, low birth weight, and adverse maternal and neonatal outcomes. Increased IBD activity during pregnancy is also associated with adverse pregnancy-related outcomes, such as miscarriage, intrauterine growth retardation, and preterm birth. Furthermore, the increased risk of venous thromboembolism (VTE) conferred by active IBD may be potentially augmented by hormonal contraceptives. Recent literature suggests that women with IBD seek counseling on contraception from gastroenterologists in preference to their primary care physicians. Meanwhile, attitudes and awareness regarding contraception counseling remain suboptimal, underpinning the importance and need for physician and patient education in this area. We discuss the association between contraception and IBD, benefits and risks associated with various contraceptive methods in women with IBD, and practical recommendations for clinicians caring for women with IBD. 10.1093/ibd/izz025_video1 izz025.video1 6014727518001 10.1093/ibd/izz025_video2 izz025.video2 6014726992001. (c) 2019 Crohn's & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com.
Community Perspectives on Contraception in the Context of the Zika Virus in the U.S. Virgin Islands: Implications for Communication and Messaging.
Women's Health Issues. 2019 Mar 13;BACKGROUND: Between January and October 2016, 575 symptomatic confirmed cases of Zika virus infection were reported in the U.S. Virgin Islands (USVI). Zika virus infection during pregnancy can cause serious birth defects. Preventing unintended pregnancy among women who choose to delay or avoid pregnancy is a primary strategy to reduce these adverse outcomes. METHODS: A rapid assessment, using one men's and five women's focus groups (N = 43), was conducted to inform communication efforts to increase awareness of contraception as a means for preventing unintended pregnancy in the context of a Zika outbreak in the USVI. RESULTS: Findings showed that people of reproductive age were aware of the relationship between Zika virus infection during pregnancy and adverse birth outcomes. However, when discussing methods for prevention, participants did not include preventing unintended pregnancy as a strategy to reduce these adverse outcomes. When asked about family planning in the USVI, participants discussed that, for some, planning pregnancies is not common. Participants wanted communications about contraception to include available methods, side effects, costs, and safety. Optimal communication channels included social media and local spokespersons. Participants identified health care providers as a trusted information source. CONCLUSIONS: Findings from this assessment informed the design of a culturally appropriate communication strategy to raise awareness of the prevention of unintended pregnancy as a primary strategy to reduce Zika-related adverse birth outcomes in the USVI. Published by Elsevier Inc.
Contraception. 2019 Mar 13;OBJECTIVES: We assessed the effect on subjective knowledge of a pilot educational comic decision aid about contraceptive methods. STUDY DESIGN: We designed four comics (www.birthcontroltales.com), each about a different contraceptive method choice. The comics employ a theoretical framework and the methods addressed were injection, intrauterine device (IUD), implant, and combined hormonal contraceptives (including pill, patch and ring). The study population included young women presenting to a college student health clinic whose preferred language is English. Participants had not used the contraceptive method described in the comic and viewed the comics in color printed copy. We assessed contraception subjective knowledge using a pre-test/posttest six-question survey with Likert scale responses before and after exposure to the comics. Surveys conducted during the participants' visit also measured participant satisfaction with the comic and participant sexual history. RESULTS: A total of 120 individual participants divided into groups of 30 each viewed one of four separate comics. Across the four groups, the difference in the pre-test/posttest scores of the six-question subjective knowledge survey indicated a 72% average increase (p-value<0.001). CONCLUSION: Comics about contraceptive methods can be a communications tool that increase subjective knowledge of contraceptive methods. Comics that model contraceptive choice decision processes can increase individual subjective knowledge of the contraceptive method mechanism, effect, usage, side effects, feasibility, and benefits. Possessing subjective knowledge of contraceptive methods can influence contraceptive initiation and use and therefore, has potential implications for changing contraceptive attitudes and behavior. IMPLICATIONS: Contraceptive method comics should be further examined in other clinic settings with broader demographic populations to glean the effect on patient decision and contraceptive behavior. Integration of the comics into a contraceptive counseling practice can be assessed in an observational trial. Additionally, studies should also consider testing long-term patient behavior, and both patient and provider satisfaction. Copyright (c) 2019. Published by Elsevier Inc.
Beyond the statistic: exploring the process of early marriage decision-making using qualitative findings from Ethiopia and India.
BMC Women's Health. 2018 Aug 24; 18(1):144.BACKGROUND: Early marriage of girls (marriage < 18 years) is a pervasive abuse of rights that compromises maternal and child health. The common conceptualization of this practice as an outcome undermines the nuanced and sometimes protracted decision-making process of whom and when to marry. METHODS: This paper uses qualitative data from semi-structured interviews with females aged 13-23 years who participated in child marriage prevention programs and either married early or cancelled/postponed early marriage, and their key marital decision-makers in Oromia, Ethiopia (n = 105) and Jharkhand, India (n = 100). RESULTS: Social norms and the loss of a parent were stressors sustaining early marriage across contexts. Participants described three stages of early marriage: initiation, negotiation and final decision-making. Girls were infrequently involved in the initiation of early marriage proposals, though their decision-making autonomy was greater in groom-initiated proposals. The negotiation phase was most open to extra-familial influences such as early marriage prevention program staff and teachers. Across settings, fathers were the most important final decision-makers. CONCLUSIONS: The breadth and number of individual and social influences involved in marital decision-making in these settings means that effective early marriage prevention efforts must involve girls, families and communities. While underlying norms need to be addressed, programs should also engage and enable the choice, voice and agency of girls. Empowerment was important in this sample, but generally required additional social resources and support to have impact. Girls with greater social vulnerability, such as those without a male caretaker, had more compromised voice, choice and agency with regards to early marriage. Understanding early marriage decision-making as a process, rather than an endpoint, will better equip programs and policies that aim to eliminate early marriage to address the underlying norms that perpetuate this practice, and is an important lens through which to support the health and human rights of women and girls globally.