Long-acting Reversible Methods Research Articles

Barriers to Preferred Contraception Use in Mississippi.

Introduction: Many Americans are not using the contraceptive method they prefer, but there has been limited study of how this may be related to health system barriers. We evaluated how such barriers to contraceptive care are related to unmet contraceptive preference in Mississippi and which contraceptive methods are preferred by those who report an unmet preference. Materials and Methods: Between September 2020 and February 2021, we used social media advertisements to recruit Mississippi residents 18-45 years of age, who were assigned female at birth, for an online survey. We asked respondents if they wanted to use a different contraceptive method or start using one, and if so, which method they preferred. We assessed barriers in the reproductive healthcare services environment (e.g., long wait for appointments, unaffordability or lack of insurance acceptance). We used multivariable-adjusted Poisson regression models to test the relationship between experiencing one or more barriers to reproductive healthcare and having an unmet contraceptive preference. Results: Among 462 eligible respondents, 37% had an unmet contraceptive preference. Most respondents (83%) reported one or more barriers to accessing office-based reproductive healthcare. Respondents who experienced a barrier had almost twice the prevalence of unmet preference as people who experienced no barrier (prevalence ratio 1.81, 95% confidence interval: 1.14-2.86). Among respondents with unmet preference, short-acting hormonal, long-acting reversible, and permanent methods were most desired. Conclusion: We find that nearly two-fifths of reproductive-aged Mississippians with capacity for pregnancy are not using their preferred contraceptive method. Structural barriers to care are very common and are significantly associated with experiencing unmet contraceptive preference, undermining reproductive autonomy.

Transplantation and Pregnancy

Transplantation is becoming increasingly widespread worldwide as a life-saving treatment for patients with end-stage organ failure. While the woman's quality of life improves rapidly after transplantation, the improvement of the endocrine system helps to regain fertility. The success of conception and successful pregnancy rates are quite low compared to the general population. Particular attention should be paid to obstetric complications such as hypertension, preeclampsia, fetal growth restriction, and preterm delivery during pregnancy. Ideally, preconception counseling should begin in the period before transplantation. Initiating contraception immediately after transplantation is ideal and long-acting reversible methods such as intrauterine devices and subcutaneous implants may be preferable. Factors that influence pregnancy outcomes in women undergoing organ transplantation include good general health within two years of transplantation, no evidence of organ rejection in the last year, stable graft conditions, absence of acute infections affecting the fetus, and adequate doses of immunosuppression drugs. However, factors that may adversely affect pregnancy include the etiology of the disease requiring transplantation, chronic allograft dysfunction, renal failure, cardiopulmonary diseases, hypertension, diabetes, obesity, and infections such as hepatitis B, hepatitis C, and Cytomegalovirus (CMV). Postponing pregnancy for at least 1 year after transplantation is very important to optimize pregnancy outcomes. Pregnancy in the early post-transplant period increases the risk of acute rejection, infection risk, and graft-related problems. In general, transplanted women can have successful pregnancies and live birth rates are above 70% on average. Although perinatal morbidity and mortality rates are high, most newborns are healthy and develop normally. Specific criteria such as pre-pregnancy serum creatinine levels and blood pressure control, as well as adherence to immunosuppressive therapy, significantly influence pregnancy success in transplant patients. In this review, optimizing pregnancy outcomes often involves addressing maternal and fetal risks, regular graft monitoring to detect potential complications such as organ rejection, and regulation of transplant medications to ensure safety and efficacy during pregnancy. Successful management relies on a multidisciplinary approach with contributions from obstetricians, neonatologists, nephrologists, hepatologists, and transplant surgeons.

Uso de métodos contraceptivos de longa ação e principais preocupações de suas usuárias

Abstract Objectives: to assess factors associated with the use of long-acting reversible methods (LARC) and women’s concerns about them. Methods: this is a cross-sectional study conducted in a digital environment from April to June 2021, with the use of a structured instrument disseminated through social networks. The study included women of reproductive age (18 to 49 years old), who were not pregnant, not hysterectomized, not sterilized and whose partners were not vasectomized. Data were analyzed using logistic and multinomial regression. Results: the study population consisted of 1596 women aged 18 to 49 living in all regions of the country, 22% of whom were using LARC. Aspects associated with LARC use were younger age, having health insurance, being in a relationship and not wanting to get pregnant. Half of LARC users reported having some kind of concern about the method, the most frequent being the risk of becoming pregnant (36.2%). The aspects associated with having concerns about using LARC were the type of method, not being in a relationship and not wanting to get pregnant. Conclusions: LARC users are not a homogeneous group. Current experience of using LARC is lived with concerns, including some about its efficacy.

Brief report: Influence of mandatory contraceptive education emphasizing long-acting reversible methods on continuation rates among military recruits

ObjectivesDetermine if the replacement of patient-initiated, individual contraceptive education with mandatory group contraceptive education, during US Navy basic training, was associated with decreased LARC continuation. Study designSecondary analysis of administrative billing data from female military recruits who began basic training between September 2012 and February 2020. ResultsServicewomen who started LARC method during rather than after basic training had higher continuation rates. Servicewomen who started training before the implementation of mandatory group education had higher IUD continuation than those trained after. ConclusionsImplementation of mandatory group contraceptive education during basic training was not associated with a decline in LARC continuation.

Role of community-level emergency contraceptive pills awareness and possibilities of long-acting reversible or permanent methods in reducing unwanted births in Bangladesh: evidence from a nationwide cross-sectional survey

ObjectiveThis study aims to investigate the role of community-level emergency contraceptive pill (ECP) awareness in reducing unwanted births (UWBs) in Bangladesh and explore the regional variation in women’s appropriateness to...

Disruptions to youth contraceptive use during COVID-19: Mixed-methods results from Nairobi, Kenya.

Ensuring access to sexual and reproductive health (SRH) services for adolescents is a global priority, given the detrimental health and economic impact of unintended pregnancies. To examine whether and how COVID-19 affected access to SRH services, we use mixed-methods data from young men and women in Nairobi, Kenya to identify those at greatest risk of contraceptive disruptions during COVID-19 restrictions. Analyses utilize cross-sectional data collected from August to October 2020 from an existing cohort of youth aged 16-26. Unadjusted and adjusted logistic regression examined sociodemographic, contraceptive, and COVID-19-related correlates of contraceptive disruption among users of contraception. Qualitative data were collected concurrently via focus group discussions (n = 64, 8 groups) and in-depth interviews (n = 20), with matrices synthesizing emergent challenges to obtaining contraception by gender. Among those using contraception, both young men (40.4%) and young women (34.6%) faced difficulties obtaining contraception during COVID-19. Among young men, difficulty was observed particularly for those unable to meet their basic needs (aOR = 1.60; p = 0.05). Among young women, risk centered around those with multiple partners (aOR = 1.91; p = 0.01), or who procured their method from a hospital (aOR = 1.71; p = 0.04) or clinic (aOR = 2.14; p = 0.03). Qualitative data highlight economic barriers to obtaining contraceptives, namely job loss and limited supply of free methods previously available. Universal access to a variety of contraceptive methods during global health emergencies, including long-acting reversible methods, is an essential priority to help youth avert unintended pregnancies and withstand periods of disruptions to services. Non-judgmental, youth-friendly services must remain accessible throughout the pandemic into the post-COVID-19 period.

Learning from success cases: ecological analysis of potential pathways to universal access to family planning care in low- and middle-income countries.

Background Universal access to family planning services is a well-recognized human right and several countries and organizations are committed to this goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabled those advances. Methods Analyses were based on data from publicly available national health surveys carried out since 1986 in Egypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women’s education, and women’s age. We also explored contextual differences in terms of women’s empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review. Results Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced an important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women’s education and women’s age. All countries managed to increase coverage over recent years, especially among women from the more disadvantaged groups. Conclusions Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most disadvantaged in recent years. Policies involving primary health care services, provision of various methods, and high quality training of health providers are crucial to increase coverage.

Pregnancy Outcumes and Contraceptive Use in Women with Rheumatoid Arthritis: A Comparative Study

Background. Rheumatoid arthritis (RA) is a common chronic autoimmune disorder that has a female predominance and commonly affects women of childbearing age. It is shown to remit during pregnancy in most studies and improve in about half of the patients when assessed with objective disease activity measures.Objective — to assess the pregnancy outcomes in women with RA prior and after the diagnosis and compare them with those in women with no chronic illness, to evaluate contraceptive practices and contraceptive method efficacy with the use of concomitant rheumatic medications (methotrexate, leflunomide).Patients and Methods. Female patients diagnosed with RA according to ACR/EULAR 2010 classification criteria were compared with apparently healthy female controls matching in age in this case-control study. Data were collected by questionnaires and interviews. The questionnaires included demographic data and pregnancy outcomes, mode of delivery, contraceptive methods used by patients against the background of methotrexate and leflunomide therapy.Results and discussion. One hundred patients with RA were included. The mean age of the patients and controls was 38.4±5.1 and 36.7±4.5 years, respectively. The live births significantly decreased in female patients with RA compared to the controls and the period before the diagnosis (p=0.01, p=0.002, respectively). Caesarean section frequency was higher in the control group compared to patients with RA (p=0.001). But in patients with RA, frequency of caesarean section increased after the diagnosis (p=0.021). Frequency of unplanned pregnancy significantly decreased after the diagnosis of RA compared to the period before the diagnosis (p<0.001). About 75.4% of patients had the desired number of children in their family before the diagnosis, and 24.6% feared the effect of RA on themselves and their children. 81% of 100 women with RA used methotrexate, 43.2% of them received rheumatological consultation regarding the contraceptive methods, and 56.8% did not. 30.86% of patients treated with methotrexate used ineffective contraceptive methods, 27.16% — long-acting reversible methods, 14.81% — effective contraceptive methods, and 24.69% did not use any contraceptive methods. 19% of RA patients used leflunomide, and 73.7% of them received rheumatological consultation regarding the type of contraceptive methods, 36.84% used effective methods of contraception, 31.58% — long-acting reversible methods, 15.79% — ineffective contraceptive methods and 15.79% did not use any contraceptive methods.Conclusion. There is a decrease in live births and an increase in preterm birth frequency as well as caesarean sections in Iraqi female patients with RA. There is lack of knowledge about the importance of contraceptive methods efficacy in relation to teratogenic medications (methotrexate, and leflunomide).

User interest in a new non-hormonal long-acting reversible contraceptive: what impact does mechanism of action have on past and future contraceptive decision-making?

BackgroundWe are in the process of developing a new non-hormonal long-acting reversible method of contraception (LARC) in recognition of the fact that a significant minority of users are unhappy with...

Service delivery at Title X sites in Texas during the COVID-19 pandemic.

The important role of Title X sites in supporting publicly funded reproductive healthcare was elevated during the COVID-19 pandemic, as many people experienced economic uncertainty and changed their fertility preferences. In this study, we assessed changes in service delivery during the first year of the COVID-19 pandemic at Title X-supported sites in Texas, a large state with a high uninsured rate and a diverse Title X network. Using surveys of Title X-funded organizations in Texas from April and November 2020, we examined the percentage of organizations reporting service modifications. With administrative data on 507,947 client encounters between March 2019 and March 2021, we assessed change in client volume at the onset of the pandemic and evaluated the association between regional COVID-19 case rates and the provision of key Title X services. In April 2020, most organizations (78%) limited in-person operations while implementing telehealth (74%) and contactless contraception (67%). Network-wide encounter volume declined by 26% at pandemic onset (incidence rate ratio [IRR]=0.74, 95% confidence interval [CI]=0.65, 0.84). Health departments experienced the steepest declines in encounter volume (IRR=0.43, 95% CI=0.36-0.50). Weekly encounters, particularly for long-acting reversible method placement/removal and sexually transmitted infection testing, decreased as COVID-19 rates increased. Investment in public health infrastructure, including providing robust support to health departments as well as rebuilding and expanding the Title X network, is essential to safeguarding access to publicly funded reproductive healthcare during and after the pandemic.

Learning from success cases: ecological analysis of pathways to universal access to family planning care in low- and middle-income countries.

Background Universal access to family planning services is a well-recognized human right and several countries and organizations are committed tothis goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabledthose advances. Methods Analyses were based on data from publicly available national health surveys carried out since 1986 inEgypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women's education, and women's age. We also explored contextual differences in terms of women's empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review. Results Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women's education and women's age. All countries managed to increase coverage over recentyears, especially among women from the more vulnerable groups. Conclusions Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most vulnerable in recent years. Policies involving primary health care services, provision of variousmethods, and high quality training of health providers are crucial to increase coverage.

Adapting High Impact Practices in Family Planning During the COVID-19 Pandemic: Experiences From Kenya, Nigeria, and Zimbabwe.

We describe how High Impact Practices (HIPs) in family planning (FP) were adapted across Kenya, Nigeria, and Zimbabwe to maintain access to services in response to the coronavirus disease (COVID-19) pandemic. Using a qualitative data collection tool structured around 3 HIP categories (service delivery, demand creation, and enabling environment), adaptations in FP programs during the pandemic were documented. We describe adaptations made to 3 specific HIPs: mobile outreach, community health workers, and digital health for social and behavior change. In Zimbabwe, the Mhuri/Imuli project adapted its mobile outreach model integrating community-based outreach with facility-based outreach. The number of outreach clients served per week peaked at 1,759 (July 2020) from a low of 203 (May 2020). Clients choosing long-acting reversible methods increased from 22% to 59% during the 3 months before and after lockdown, respectively.In Kenya, a program addressed youth's hesitation to visit health facilities through youth community health volunteers, who provided counseling, community dialogues, contraceptive pills, and condoms. Over 6 months, the program reached 1,048 youth with community dialogues, and 4,656 youth received FP services. In Nigeria, peer mobilizers provided services through a socially distanced community-based program to help adolescent girls access contraceptive self-injection when movement restrictions limited youth's ability to travel to facilities.In Nigeria, Adolescents 360 adapted sexual and reproductive health information programs for virtual delivery through WhatsApp. A contraceptive education Facebook campaign gained more than 80,000 followers, reached 5.9 million adolescents, and linked 330 adolescents to program-supported facilities from January to March 2021. In Kenya, the Kibera-based project used WhatsApp to reach youth with discussion groups and health workers with skills strengthening. Monitoring how projects adapt HIPs to ensure continuity of care during the COVID-19 pandemic can help inform the implementation of successful adaptations in the face of present and future challenges.

Determinants of Long-Acting Reversible Contraceptive Methods Utilization Among Married Women of Reproductive Age Group In Ambo Town, Oromia Region, West Ethiopia, 2016: A Case Control Study

Background: The contraceptive utilization rate in Ethiopia is approximately 29%. In contrast, only 3.7% of married women in Ethiopia use the most effective and convenient methods, i.e., long-acting contraceptive methods. This rate is approximately 3.2% in the Oromia region, the most populous region in Ethiopia. In regard to this, the current study aimed to identify determinants of long-acting reversible contraceptive method utilization among married women in Ambo town, Ethiopia. Objective: To identify determinants of long-acting reversible contraceptive method utilization among married women of reproductive age in Ambo town, 2016 Methods: A community-based unmatched case-control study was carried out in Ambo town on 420 married women of reproductive age who were randomly selected. The study population comprised users [case group; n=140] and nonusers [control group; n=280] of one of the longacting reversible methods. Multivariable logistic regression analysis was performed to determine independent predictors. Adjusted odds ratios together with their corresponding 95% CIs were calculated to assess the strength of association and declare statistical significance. Result: A total of 418 married women participated in the study, with a response rate of 99.45%. Moderate level of knowledge on long-acting reversible contraceptive methods [AOR= 8.73, 95%CI: 3.08 - 24.77], good level of knowledge [AOR=13.99, 95%CI:4.93-39.71], spousal discussion on long-acting reversible contraceptive methods [AOR=2.88, 95%CI:1.3-6.36], positive attitude toward long-acting reversible contraceptive methods [AOR=7.07, 95% CI: 3.77-13.24], women from households in the poorest wealth quintile [AOR= 6.83, 95%CI: 2.68- 17.38], women from households in the medium wealth quintile [AOR=5.83, 95%CI: 2.23- 15.23] were positive determinants, whereas intention to give birth in the future [AOR=0.09, 95% CI: 0.02- 0.36] and women’s expectations of restriction to methods use [AOR=0.2, 95% CI: 0.08- 0.48] were negative determinants of long-acting reversible contraceptive method utilization. Conclusion: Good knowledge, moderate knowledge, positive attitude, wealth index and spousal discussion were positive determinants, whereas intention to give birth in the future and woman’s expectation of restriction to method use were negative determinants of long-acting reversible contraceptive method utilization. Stakeholders should emphasize behavioral change communication to increase knowledge on long-acting reversible contraceptive methods, strengthen inter-spousal discussion and bring a positive attitude towards long-acting reversible contraceptive methods.

Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020.

Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).

Learning from success cases: ecological analysis of pathways to universal access to reproductive health care in low- and middle-income countries.

Background Universal access to family planning services is a well-recognized human right and several countries and organizations are committed tothis goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabledthose advances. Methods Analyses were based on data from publicly available national health surveys carried out since 1986 inEgypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women's education, and women's age. We also explored contextual differences in terms of women's empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review. Results Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women's education and women's age. All countries managed to increase coverage over recentyears, especially among women from the more vulnerable groups. Conclusions Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most vulnerable in recent years. Policies involving primary health care services, provision of variousmethods, and high quality training of health providers are crucial to increase coverage.

Did COVID-19 Impact Contraceptive Uptake? Evidence from Senegal.

This study assessed the impact of the COVID‐19 pandemic on the number of new contraceptive acceptors in Senegal overall and by method. Monthly service data from March 2019 to December 2020 were extracted for the number of new contraceptive users of IUDs, implants, injectables, and oral contraceptive pills (OCPs). Data were analyzed using descriptive statistics and interrupted time series analysis for trend analyses overall and by the contraceptive method. Following the announcement of the first COVID‐19 case in Senegal in March 2020, there was an immediate significant decrease in the number of new acceptors overall, and for new users of implants and injectables. From March–December 2020, the trend in monthly new family planning acceptors increased overall, mainly driven by significant increases in new IUD and implant acceptors. Compared to the period before the onset of COVID‐19, there was a statistically significant shift from shorter‐acting methods (OCPs, injectables) to long‐acting reversible methods (IUDs, implants). Despite the immediate adverse impact of COVID‐19‐related restrictions, the number of new acceptors rebounded, trends in the number of new monthly acceptors significantly increased, and there was a significant shift to longer‐acting methods.

Modern contraceptive use among women in need of family planning in India: an analysis of the inequalities related to the mix of methods used

ObjectiveTo evaluate the type of contraceptives used by women in need of family planning in India and the inequalities associated with that use according to women's age, education, wealth, subnational region of residence and empowerment level.MethodsUsing data from the Indian National Family and Health Survey-4 (2015–2016), we evaluated the proportion of partnered women aged 15–49 years with demand for family planning satisfied (DFPS) with modern contraceptive methods. We also explored the share of each type of contraception [short- (e.g., condom, pill) and long-acting (i.e., IUD) reversible contraceptives and permanent methods] and related inequalities.ResultsThe majority (71.8%; 95% CI 71.4–72.2) of women in need of contraception were using a modern method, most (76.1%) in the form of female sterilization. Condom and contraceptive pill were the second and third most frequently used methods (11.8% and 8.5%, respectively); only 3.2% reported IUD. There was a nearly linear exchange from short-acting to permanent contraceptive methods as women aged. Women in the poorest wealth quintile had DFPS with modern methods at least 10 percentage points lower than other women. We observed wide geographic variation in DFPS with modern contraceptives, ranging from 23.6% (95% CI 22.1–25.2) in Manipur to 93.6% (95% CI 92.8–94.3) in Andhra Pradesh. Women with more accepting attitudes towards domestic violence and lower levels of social independence had higher DFPS with modern methods but also had higher reliance on permanent methods. Among sterilized women, 43.2% (95% CI 42.7–43.7) were sterilized before age 25, 61.5% (95% CI 61.0–62.1) received monetary compensation for sterilization, and 20.8% (95% CI 20.3–21.3) were not informed that sterilization prevented future pregnancies.ConclusionIndian family planning policy should prioritize women-centered care, making reversible contraceptive methods widely available and promoted.

P–743 The fertility paradox: the need for contraception after in vitro fertilisation

Abstract Study question What are a woman’s contraceptive needs after successful in vitro fertilisation (IVF) pregnancy? and how should services respond to help prevent unintended pregnancies? Summary answer Women who have IVF pregnancies require tailored, postnatal contraception counselling. Services must provide evidence-based information about the risks of spontaneous conception to engage them effectively. What is known already Women undergoing IVF are an increasingly heterogeneous group with a wide range of causative subfertility factors. Furthermore, increasingly, women are accessing treatment primarily for reasons other than subfertility. The evidence relating to rates of spontaneous conception post assisted conception varies widely according to population, cause of subfertility, type and outcome of fertility treatment and length of follow-up. A recent large retrospective UK cohort study estimated the treatment-independent live birth rate after IVF live birth over 5 year follow up as 15% [https://doi.org/10.1093/humrep/dez099]. We aim to explore the experiences and views about contraception among this diverse group of women. Study design, size, duration A qualitative study of the views of women who have had spontaneous pregnancies after successful IVF was conducted in September/October 2020. A qualitative approach of in-depth interviews was chosen to allow exploration of individual experiences in an area not much studied previously. The sample consisted of twenty interviewees from around the UK. Participants/materials, setting, methods Purposive and snowballing sampling methods were used with eligible participants recruited from a range of sources including social media and peer networks. The sample included a wide range of spontaneous pregnancy outcomes after successful IVF, including single and multiple livebirths, miscarriage, ectopic pregnancy and termination of pregnancy. The framework method was used for analysis using NVivo12 software. Main results and the role of chance Contraceptive choices were subject to a complex and dynamic interaction of influencing factors including i) beliefs regarding their own subfertility, ii) desire for more children and iii) their views on contraception. After IVF pregnancy, the majority of women (n = 15) used no contraception or ineffective methods (inconsistent condom use or withdrawal) before their next pregnancy with only two women using hormonal methods (progesterone-only pill). Spontaneous pregnancy was not universally welcomed in this group and the inter-pregnancy intervals were often short (n = 15, less than 18 months) or very short (n = 6, less than 12 months). After subsequent spontaneous pregnancy, use of contraception and the most effective (long-acting reversible) methods remained low. Women held persistent beliefs regarding their subfertility despite subsequent spontaneous pregnancy (or pregnancies). Women associated aspects of the IVF process (e.g. need for multiple cycles, low numbers of eggs collected etc.) with a sense of personal failure, despite an ultimately “successful” outcome resulting in livebirth. This may contribute to or reinforce their self-belief in subfertility. Other specific barriers to contraception use, in women having IVF, included lack of knowledge of the likelihood of spontaneous pregnancy, lack of contraceptive experience and inherent incentives towards shorter inter-pregnancy intervals. Limitations, reasons for caution There is potential recall bias with some women recalling experiences associated with IVF treatment more than ten years ago. However our sample included women who were currently pregnant as well as women who were further towards the end of their reproductive life to capture a range of experiences. Wider implications of the findings: The contraceptive needs of women having IVF pregnancies are being overlooked. Fertility services should take responsibility for providing accurate information on the risks of subsequent spontaneous pregnancy in this population. Maternity and community healthcare professionals must address women’s perceptions of their fertility in order to engage them in contraception counselling. Trial registration number N/A

Need for Contraceptive Services Among Women of Reproductive Age - 45 Jurisdictions, United States, 2017-2019.

Ensuring access to contraceptive services is an important strategy for preventing unintended pregnancies, which account for nearly one half of all U.S. pregnancies (1) and are associated with adverse maternal and infant health outcomes (2). Equitable, person-centered contraceptive access is also important to ensure reproductive autonomy (3). Behavioral Risk Factor Surveillance System (BRFSS) data collected during 2017-2019 were used to estimate the proportion of women aged 18-49 years who were at risk for unintended pregnancy* and had ongoing or potential need for contraceptive services.† During 2017-2019, in the 45 jurisdictions§ from which data were collected, 76.2% of women aged 18-49 years were considered to be at risk for unintended pregnancy, ranging from 67.0% (Alaska) to 84.6% (Georgia); 60.7% of women had ongoing or potential need for contraceptive services, ranging from 45.3% (Puerto Rico) to 73.7% (New York). For all jurisdictions combined, the proportion of women who were at risk for unintended pregnancy and had ongoing or potential need for contraceptive services varied significantly by age group, race/ethnicity, and urban-rural status. Among women with ongoing or potential need for contraceptive services, 15.2% used a long-acting reversible method (intrauterine device or contraceptive implant), 25.0% used a short-acting reversible method (injectable, pill, transdermal patch, or vaginal ring), and 29.5% used a barrier or other reversible method (diaphragm, condom, withdrawal, cervical cap, sponge, spermicide, fertility-awareness-based method, or emergency contraception). In addition, 30.3% of women with ongoing or potential need were not using any method of contraception. Data in this report can be used to help guide jurisdictional planning to deliver contraceptive services, reduce unintended pregnancies, ensure that the contraceptive needs of women and their partners are met, and evaluate efforts to increase access to contraception.

Measuring quality of care at the community level using the contraceptive method information index plus and client reported experience metrics in Bangladesh.

BackgroundLow rates of contraceptive continuation in Bangladesh are a symptom of poor quality family planning (FP) counseling. Improving family planning counseling by the country’s community health care workers (CHWs) could improve contraceptive continuation. This study explores client experiences of care from CHWs, as measured by the method information index plus (MII+) and communication quality metric.MethodsConducted in a peri-urban sub-district with low contraceptive use rates, this mixed methods study explores FP client experiences with community-based counseling and referrals by Family Welfare Assistants (FWAs), a CHW cadre providing FP services. Client- and patient-reported experience with community FP services was measured by the MII+ and communication quality metric. A quantitative post-service exit survey was coupled with observations of the interactions between 62 FWAs and 692 female clients to measure FWA and client FP knowledge, FWA capacities, attitudes, quality of FP communication, FP referrals, and contraceptive uptake.ResultsSummary MII+ scores suggest that only 20% of clients reported adequate provision of information for informed decisions. Observations and self-reporting alike suggest moderate to high quality of communication during FWA and client interactions. Despite FWAs’ theoretical knowledge of long-acting reversible and permanent FP methods, few clients were referred to facilities for them; 81% of clients who preferred a pill received it, while only 34% of clients seeking long-acting methods received needed referrals.ConclusionsQuality community-based FP counseling could help address rising contraceptive discontinuation rates in Bangladesh. While MII and MII+ scores in this study were low, and FWA evinced numerous misconceptions, FWAs demonstrated strong communication skills that facilitate rapport and trust with their clients and communities. Bangladesh’s policy and programs should capitalize upon these relationships and enhance CHWs’ knowledge of all method types, and side effects management, with updated job aids, refresher training, and supervision.