Long-acting Reversible Methods Research Articles

Contextual influences on the choice of long-acting reversible and permanent contraception in Ethiopia: A multilevel analysis.

BackgroundLong acting reversible and permanent contraception (LARPs) offer promising opportunities for addressing the high and growing unmet need for modern contraception and helps to reduce unintended pregnancies and abortion rates in sub-Saharan Africa (SSA). This study examines the contextual factors that influence the use of long acting reversible and permanent contraception among married and fecund women in Ethiopia.MethodWe use data from the 2016 Ethiopian Demographic and Health Survey to examine the contextual factors that influence choice of long acting reversible and permanent contraception among married, non-pregnant and fecund women. The DHS collects detailed information on individual and household characteristics, contraception, and related reproductive behaviors from women of reproductive age. In addition, we created cluster level variables by aggregating individual level data to the cluster level. Analysis was done using a two-level multilevel logistic regression with data from 6994 married (weighted = 7352) women residing in 642 clusters (communities).ResultsIn 2016, 12% of married, non-pregnant and ‘fecund’ women were using long-acting reversible and permanent methods of contraception in Ethiopia. A higher proportion of women with secondary and above education (17.6%), urban residents (19.7%), in the richest wealth quintile (18.3%) and in paid employment (18.3%) were using LARP methods compared to their counterparts. Regression analysis showed that community level variables such as women’s empowerment, access to family planning information and services, region of residence and knowledge of methods were significantly associated with use of LARP methods. Age, wealth status, employment status and women’s fertility preferences were among the individual and household level variables associated with choice of LARP methods. With regards to age, the odds of using LARP methods was significantly lower among adolescents (OR, 0.53; 95% CI, 0.32–0.85) and women over the age of 40 (OR, 0.63; 95% CI, 0.44–0.90) compared to women in their 20’s.ConclusionThe findings of this study indicate that the demand for long-acting reversible and permanent contraception is influenced not only by women’s individual and household characteristics but also by the community’s level of women’s empowerment, socio-economic development, as well as access and exposure to family planning information and services. Thus, improving knowledge of long-acting reversible and permanent methods, improving women’s decision making autonomy and upgrading the capacity and skills of health workers particularly the midlevel providers and community health extension workers on the provision of LARP methods and rights-based approach is important to improve the uptake of LARP methods.

BARRIERS TO UTILIZATION OF LONG ACTING REVERSIBLE AND PERMANENT CONTRACEPTIVE METHODS IN ETHIOPIA: SYSTEMATIC REVIEW

ABSTRACT BACKGROUND Globally the use of Long-Acting Reversible and Permanent Methods (LARPMs) has been recommended as the first-line, highly effective options for pregnancy prevention. They have greater efficacy than short acting contraceptive methods and are associated with lower rates of unwanted pregnancy. Ethiopia has made significant progress in family planning (FP); however, one fourth of married women still have unmet need for FP and nearly three-fourth of family planning users depend on short acting injectable contraceptives. The aim of this study was to review existing researches to identify barriers to long acting reversible and permanent contraceptive use in emerging regions of Ethiopia.METHOD: Published and unpublished literatures were searched using major search engines and different search terms related to the topic. Literature search was carried out from March to May 2016. Six selection criteria were prepared to summarize the findings using PRISMA protocol. A checklist of eight-item quality assessment criteria was used to rate the quality of studies independently by two investigators, and the third investigator cross checked and decided on agreements. The studies were critically appraised, and thematic analysis was used to synthesize the data.RESULTS: Using the screening criteria, 69 eligible full-text articles and reports were reviewed; of which 34 articles and 8 policy/strategy documents were considered for data synthesis. The review has included policy related, individual, socio-cultural and health facility related barriers/factors affecting LARPMs use in emerging regions. Lack of strategies to reach the mobile population of emerging regions, facility readiness to provide LARPMs and quality of care were major policy and health care factors contributing for the low utilization of LARPMs. Low knowledge of LARPMs, health concerns, fear of side effects, and lower education were among individual level barriers identified through the review. Moreover, the review showed that men’s (partner’s) objection, desire for more children (especially by the male partner), absence of male involvement, lack of women’s decision-making power and lack of discussion with partners were gender related barriers.CONCLUSION: The regional disparity in LARPM use, particularly in emerging regions, requires targeted policy and strategic direction to address the prevailing inequality in family planning use and method mix. To improve the utilization of LARPMs, efforts should be made to address the key demand and supply side barriers. More context specific research evidences should be generated to understand barriers that are specific to these regions. (Ethiopian Journal of Reproductive Health 2018; 10; 3: 1-24)

Predictors of contraceptive switching and discontinuation within the first 6 months of use among Highly Effective Reversible Contraceptive Initiative Salt Lake study participants

Nearly half of women will switch or discontinue using their selected contraceptive method in the first year. Research on early switching or discontinuation provides important clinical and public health insights, although few studies have assessed associated factors, particularly among longitudinal cohorts. The current study explores attributes associated with early contraceptive method switching or discontinuation (<6 months of initiation) among participants enrolled in the intervention cohorts of the Highly Effective Reversible Contraceptive Initiative Salt Lake Contraceptive Initiative (Utah, United States). Highly Effective Reversible Contraceptive Initiative Salt Lake participants have access to no-cost contraception for 3 years. This includes both the initial selection and the ability to switch or to discontinue methods without cost. Methods available included the following: nonhormonal behavioral methods (male/female condoms, withdrawal, diaphragms, cervical caps, and fertility awareness); short-acting methods (pill, patch, ring, and injectable); and long-acting methods (intrauterine devices and contraceptive implants). Participants completed surveys at baseline and at 1, 3, and 6 months. We collected data on participant demographics, contraceptive continuation, switching, and discontinuation, as well as factors associated with these changes, including established measures of pregnancy intention and ambivalence and reasons for switching or discontinuing. We conducted descriptive statistics, univariable, and multivariable Poisson regression analyses to assess predictors of both discontinuation and switching. We also conducted χ2 analyses to compare reported reasons for stopping between switchers and discontinuers. At 6 months, 2,583 women (70.0%) reported continuation of their baseline method, 367 (10%) reported at least 1 period of discontinuation, 459 (12.4%) reported switching to a different method, and 279 (7.6%) did not provide 6-month follow-up. Factors associated with discontinuation included selection of a short-acting method (incidence rate ratio [IRR], 2.49; 95% confidence interval [CI], 1.97, 3.12), report of Hispanic ethnicity (IRR, 1.45; 95% CI, 1.12, 1.89) and nonwhite race (IRR, 1.48; 95% CI, 1.08, 2.02), and having any future pregnancy plans, even years out. Participants with some college education were less likely to report discontinuation (IRR, 0.73; 95% CI, 0.57, 0.94). Selecting a short-acting method at baseline was also associated with increased likelihood of method switching (IRR, 2.29, 95% CI, 1.87, 2.80), as was having 2 or more children (IRR, 1.37; 95% CI, 1.08, 1.74). Women were less likely to switch if they were on their parents' insurance (IRR, 0.74; 95% CI, 0.56, 0.99). Among participants who switched methods, 36.9% switched to a long-acting reversible method, 31.7% switched to a short-acting hormonal method, and 31.1% switched to a nonhormonal behavioral method, such as condom use. Of participants providing a reason for stopping, 454 women (73.2%) reported side effects as 1 reason for switching or discontinuing their initial method. Early contraceptive method switching and discontinuation are frequent outcomes of contraceptive use. These changes are common even with removal of contraceptive access barriers.

Do women want to talk about birth control at the time of a first-trimester abortion?

ObjectiveTo investigate if women desire talking to a counselor or physician about contraception when seeking first-trimester medical or surgical abortion. Study designWe conducted a cross-sectional study by distributing self-administered anonymous surveys to women at three clinics in Sacramento, California; Chicago, Illinois; and Cleveland, Ohio, from October 2014 to February 2015. Participants completed surveys after registration and before any in-office counseling. We asked whether women want to discuss contraception, specific topics they want to discuss, reasons why they may not want to talk about contraception and whether they want to receive contraception services as part of their abortion care. We conducted regression analyses to assess associations between patient characteristics and the desire for counseling. ResultsAmong 3041 eligible women, 1959 (64.4%) completed surveys. Overall, 1208 (61.7%) did not want to discuss contraception prior to having an abortion, primarily citing that they already know which method they want. We found no association between the desire to discuss contraception and age, race, planned abortion method, clinic site and number of unplanned pregnancies. Among those who desired to talk about contraception, subjects preferred to discuss which contraceptive methods are easier to use and more effective as compared to previously used methods. Regardless of their desire for a discussion about contraception, 1386 (70.8%) of subjects wanted to leave the clinic with a specific method, including a long-acting reversible method [intrauterine device or implant (190, 13.7%)] or other hormonal method [pills, patch, ring or injectable (680, 49.1%)]. ConclusionsThe majority of women seeking first-trimester abortion do not come to the clinic wanting to discuss contraception, most commonly because they have a preferred method in mind. ImplicationsProviders should ask women presenting for abortion if they want to discuss contraception and not assume that they need or desire such information. Focused discussions, starting with the preferred method if known, may better satisfy women's preferences. Providers should account for such desires when allocating resources for contraception services during abortion care.

Pharmacy access to medical abortion from trained providers and post-abortion contraception in Nepal.

To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies was associated with reduced post-abortion contraceptive use in Nepal. The present prospective observational study compared contraceptive use among women aged 16-45years and up to 63days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression. Of 605 participants, 600 completed follow-up at 14-21days; 474 (79.0%) were using a contraceptive method, most commonly pills (180 [30.0%]) and injectables (175 [29.2%]), followed by condoms (82 [13.7%]), long-acting reversible methods (33 [5.5%]), and sterilization (4 [0.7%]). Receipt of care from a private pharmacy was not associated with a difference in the use of hormonal or long-acting methods (adjusted odd ratio 0.89, 95% confidence interval 0.60-1.33). Medical abortion provision from pharmacies by qualified providers can provide women with necessary induced-abortion care while not compromising longer-term pregnancy prevention.

Contraceptive Method Use and Chlamydia Positivity Among California Family Planning Clients: The Case for New Multipurpose Prevention Technologies.

Adolescent girls and young women experience high rates of sexually transmitted infection (STI) with currently available contraceptive methods, yet few studies examine the burden of chlamydial infection by contraceptive method used. In this cross-sectional analysis, we linked July 2012-June 2013 claims from a publicly-funded family planning program in California to chlamydia laboratory test results. Female clients were classified by the most effective contraceptive method reported by providers during the year: tier 1 (high-efficacy permanent or long-acting reversible methods), tier 2 (shorter-acting hormonal methods), or tier 3 (barrier methods, emergency contraception, or natural family planning). In addition, we identified clients who received condoms from providers. We used log-binomial models to estimate adjusted prevalence ratios comparing chlamydia positivity by contraceptive method(s). Of 74,636 female clients of ages 15-29 years with chlamydia test results, 5.1% had at least one positive test during the year. Chlamydia positivity was highest among tier 2 users (5.3%) compared with 4.5% and 4.9% among tiers 1 and 3 users, respectively (p < 0.001). Positivity was higher among clients who received condoms from providers than those who did not (6.3% vs. 4.3%, p < 0.001). In adjusted analyses, there were no significant differences in positivity by contraceptive tier. However, clients who received condoms had 1.32 (95% confidence interval: 1.24-1.40) times the positivity of those who did not. We found high chlamydia positivity among young female family planning clients regardless of contraceptive method. The development and provision of additional Multipurpose Prevention Technologies that confer protection against both pregnancy and STIs may help to address unmet need for STI prevention.

Reported contraceptive use in the month of becoming pregnant among U.S. abortion patients in 2000 and 2014

ObjectivesThe objective was to determine whether types of contraceptive methods used by abortion patients in the month they became pregnant changed between 2000 and 2014. Study designWe used secondary data from the 2000 (n=10,015) and 2014 (8177) Abortion Patient Surveys. Patients were asked which contraceptive methods they had last used and when they had stopped or if they were still using them. The main outcome variable was type of contraceptive method used in the month the pregnancy began. We used bivariate logistic regressions to assess changes in the demographic and contraceptive use profiles of abortion patients. ResultsIn both years, slightly more than half of patients reported that they had used a contraceptive method in the month they became pregnant, though the decline from 54% in 2000 to 51% in 2014 was statistically significant (p=.011). The methods most commonly reported to have been used in the month the pregnancy began were condoms (28% and 24% in 2000 and 2014, p<.001) followed by the pill (14% and 13%, p=.12). There was a statistically significant increase in the proportion of abortion patients who reported using long-acting reversible methods in the month they got pregnant (0.1% in 2000 vs. 1% in 2014, p<.001), and the estimated number of abortions attributed to these users was greater in 2014 than in 2000 (9500 vs. 1800). ConclusionsContraceptive use patterns of abortion patients were similar in both time periods, and changes in method use mirrored changes in contraceptive use among the larger population of women. ImplicationsPostabortion contraception counseling has the potential to help nonusers find methods that meet their preferences and to help women better use their current methods.

A review of clinical experience with progesterone-only injectable contraceptives at OAUTHC, Ile-Ife

Background: Progestogen-only injectable contraceptives (POICs) remain the most popular contraceptive method in Nigeria. Considering how widely used POICs are worldwide, there is little published evidence of their safety and effectiveness. There is also a paucity of research to determine associations between the influence of age and parity and the preferred choice of POICs in women. Aim: This study was to determine the use prevalence and the influence of age and parity on the preferred choice of POIC, and also the reasons for discontinuation among users of POICs at the family planning clinics of OAUTHC, Ile-Ife. Materials and Methods: A retrospective record of 324 women who chose POICs out of a total of 1,029 clients seen at the family planning units of the hospital was collected for the period between January and December 2015. Information relevant to this study objectives was extracted using a purpose-designed proforma. Data were analyzed with SPSS version 16, and results were presented as frequencies and percentages. Pearson Chi-square test was used as test of significance where applicable and a P value Results: The prevalence of POIC during the study period was 31.49%. Depo-Provera (depot medroxyprogesterone acetate [DMPA]) was the most popular injectable preferred by the women. Age and parity had significant effects on the preferred injectable contraception with P values of 0.032 (CI 0.088-0.099) and 0.002 (CI 0.009-0.013), respectively, as younger clients with lower parity preferred Noristerat while preference for DMPA increased with age and parity. Majority (67%) did not experience any side effect; secondary amenorrhea was the most common side effect experienced by 27% of the clients. Only 34% continued with the method for the duration of study while 66% discontinued for different reasons. Conclusion: POICs are very effective and safe long-acting reversible method of contraception. While DMPA may be the more popular overall choice, norethisterone enanthate (NET-EN) is preferable in younger women of low parity.

Lessons learnt from the introduction of the contraceptive implant in South Africa

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologies elsewhere and applies these to the SA context. Drawing on the World Health Organization’s conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed.

Using contraceptives to delay first birth: a qualitative study of individual, community and health provider perceptions in southern Tanzania

BackgroundYoung adolescents and unmarried women in low and middle income countries face challenges in accessing family planning services. One factor likely to limit contraceptive use is the attitude and opinion of local stakeholders such as community leaders and health workers. Much of the existing evidence on this topic focuses on women who have already started childbearing. Using primary qualitative data, we explored individual, community and health provider’s perceptions about using modern contraceptives to delay the first birth in a high fertility setting.MethodsA descriptive qualitative study was conducted in Tandahimba district in southern Tanzania between December 2014 and March 2015. We conducted 8 focus group discussions with men and women and 25 in-depth interviews (18 with women, 4 with family planning service providers and 3 with district-level staff). Participants were purposively sampled. Data transcripts were managed and coded using Nvivo 11 software and we employed a thematic framework analysis.ResultsThree main themes emerged about using modern contraceptives to delay first birth: (1) the social and biological status of the woman (2) the type of contraceptive and (3) non-alignment among national policies for adolescents. Use of modern contraceptives to delay first birth was widely acceptable for women who were students, young, unmarried and women in unstable marriage. But long-acting reversible methods such as implants and intrauterine devices were perceived as inappropriate methods for delaying first birth, partly because of fears around delayed return to fecundity, discontinuation once woman’s marital status changes and permanently limiting future fertility. The support for use of modern contraceptives to delay a first pregnancy was not unanimous. A small number of participants from both rural and urban areas did not approve the use of contraceptive methods before the birth of a first baby at all, not even for students. There was lack of clarity and consistency on the definition of ‘young’ and that had direct implications for access, autonomy in decision-making, confidentiality and consent for young people.ConclusionsWomen who wish to delay their first birth face challenges related to restrictions by age and method imposed by stakeholders in accessing and provision of modern contraceptives. There is a need for a clearly communicated policy on minimum age and appropriate method choice for delayers of first birth.

Contraception After Surgical and Medical Abortion: A Review.

To prevent subsequent unintended pregnancy, contraception should be initiated soon after surgical and medical abortion. Evidence regarding the safety of postabortion contraception, especially for longacting reversible methods, has accumulated in recent years. This review seeks to provide up-to-date recommendations about the provision and timing of contraception after surgical and medical abortion. Recommendations are based on the US Medical Eligibility Criteria (MEC) or on the authors' review of the current literature for topics that the MEC does not address. Contraceptive counseling at the time of abortion should be collaborative. All reversible contraceptive methods are safe to begin immediately after surgical abortion, barring concern for surgical complications or underlying medical contraindications. After medical abortion, the implant may be initiated immediately, combined hormonal contraception may be initiated shortly thereafter, and the intrauterine device may be placed once the abortion is complete. Further research is needed to determine the optimal timing of depot medroxyprogesterone acetate initiation after medical abortion. Abortion is an important opportunity for contraceptive counseling and provision. Clinic policies and insurance coverage should maximize access to all contraceptive methods, including long-acting reversible methods.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

BackgroundPreventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.MethodsTwo hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.ResultsSeventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant “while using FP”: all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.ConclusionsWLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.Trial registrationIntegra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862.

Increasing Access to Family Planning Choices Through Public-Sector Social Franchising: The Experience of Marie Stopes International in Mali.

Mali has one of the world's lowest contraceptive use rates and a high rate of unmet need for family planning. In order to increase access to and choice of quality family planning services, Marie Stopes International (MSI) Mali introduced social franchising in public-sector community health centers (referred to as CSCOMs in Mali) in 3 regions under the MSI brand BlueStar. Potential franchisees are generally identified from CSCOMs who have worked with MSI outreach teams; once accredited as franchisees, CSCOMs receive training, supervision, family planning consumables and commodities, and support for awareness raising and demand creation. To ensure availability and affordability of services, franchisees are committed to providing a wide range of contraceptive methods at low fixed prices. The performance of the BlueStar network from inception in March 2012 until December 2015 was examined using information from routine monitoring data, clinical quality audits, and client exit interviews. During this period, the network grew from 70 to 135 franchisees; an estimated 123,428 clients received voluntary family planning services, most commonly long-acting reversible methods of contraception. Franchisee efficiency and clinical quality of services increased over time, and client satisfaction with services remained high. One-quarter of clients in 2015 were under 20 years old, and three-quarters were adopters of family planning (that is, they had not been using a modern method during the 3 months prior to their visit). Applying a social franchising support package, originally developed for for-profit private-sector providers, to public-sector facilities in Mali has increased access, choice, and use of family planning in 3 regions of Mali. The experience of BlueStar Mali suggests that interventions that support quality supply of services, while simultaneously addressing demand-side barriers such as service pricing, can successfully create demand for a broad range of family planning services, even in settings with low contraceptive prevalence.

Long-Acting Reversible Contraception.

Unwanted pregnancy is a major public health problem both in developed and developing countries. Although the reduction in the rates of these pregnancies requires multifactorial approaches, increasing access to long-acting contraceptive methods can contribute significantly to change this scenario. In Brazil, gynecologists and obstetricians play a key role in contraceptive counseling, being decisive in the choice of long-acting reversible methods, characterized by intrauterine devices (IUDs) and the contraceptive implant. The vast scope due to the reduced number of situations to indicate long-acting methods should be emphasized in routine contraceptive counseling. On the other hand, gynecologists and obstetricians should adapt the techniques of insertion of long-acting methods, and engage in facilitating conditions to access these contraceptives through public and private health systems in Brazil. This study is part of a project called Diretrizes e Recomendações FEBRASGO (Guidelines and Recommendations of the FEBRASGO - Brazilian Federation of Gynecology and Obstetrics Associations from the Portuguese acronym). It aims to review the main characteristics of long-acting contraceptives and critically consider the current situation and future prospects to improve access to these methods, proposing practical recommendations of interest in the routine of gynecologists and obstetricians.

Trends in Repeat Births and Use of Postpartum Contraception Among Teens - United States, 2004-2015.

Teen* childbearing (one or more live births before age 20 years) can have negative health, social, and economic consequences for mothers and their children (1). Repeat teen births (two or more live births before age 20 years) can constrain the mother's ability to take advantage of educational and workforce opportunities (2), and are more likely to be preterm or of low birthweight than first teen births (3). Despite the historic decline in the U.S. teen birth rate during 1991-2015, from 61.8 to 22.3 births per 1,000 females aged 15-19 years (4), many teens continue to have repeat births (3). The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend that clinicians counsel women (including teens) during prenatal care about birth spacing and postpartum contraceptive use (5), including the safety and effectiveness of long-acting reversible methods that can be initiated immediately postpartum. To expand upon prior research assessing patterns and trends in repeat childbearing and postpartum contraceptive use among teens with a recent live birth (i.e., 2-6 months after delivery) (3), CDC analyzed data from the National Vital Statistics System natality files (2004 and 2015) and the Pregnancy Risk Assessment Monitoring System (PRAMS; 2004-2013). The number and proportion of teen births that were repeat births decreased from 2004 (82,997; 20.1%) to 2015 (38,324; 16.7%); in 2015, the percentage of teen births that were repeat births varied by state from 10.6% to 21.4%. Among sexually active teens with a recent live birth, postpartum use of the most effective contraceptive methods (intrauterine devices and contraceptive implants) increased from 5.3% in 2004 to 25.3% in 2013; however, in 2013, approximately one in three reported using either a least effective method (15.7%) or no method (17.2%). Strategies that comprehensively address the social and health care needs of teen parents can facilitate access to and use of effective methods of contraception and help prevent repeat teen births.

Prospects for Fertility Decline in Africa

Prospects for Fertility Decline in Africa

Contraceptive use in the Nordic countries.

The aim was to compare contraceptive use in the Nordic countries and to assess compliance with recommendations from the European Medicines Agency regarding the use of combined oral contraception containing low-dose estrogen and levonorgestrel, norethisterone or norgestimate. Data on hormonal contraceptive prescriptions and sales figures for copper intrauterine devices were obtained from national databases and manufacturers in Denmark, Finland, Iceland, Norway and Sweden in 2010-2013. Contraceptive use was highest in Denmark (42%) and Sweden (41%), followed by Finland (40%). Combined oral contraception was the most used method in all countries, with the highest use in Denmark (26%). The second most used method was the levonorgestrel-releasing intrauterine system, with the highest use in Finland (15%) and ≈10% in the other countries. Copper intrauterine devices (7%) and the progestin-only pill (7%) were most often used in Sweden. Combined oral contraception use decreased with increasing age and levonorgestrel-releasing intrauterine system and progestin-only pills use increased. The use of long-acting reversible methods of contraception (=levonorgestrel-releasing intrauterine system, copper intrauterine devices, and implants) increased with time and was highest in Sweden (20%) and Finland (18%). The highest use of European Medicines Agency recommended combined oral contraception was in Denmark, increasing from 13 to 50% between 2010 and 2013. In Finland, recommended combined oral contraception remained below 1%. Contraceptive use was highest in Denmark and Sweden, levonorgestrel-releasing intrauterine system use was highest in Finland and all long-acting methods were most common in Sweden. The use of combined oral contraception recommended by the European Medicines Agency was highest in Denmark.

Contraceptive method preferences and provision after termination of pregnancy: a population-based analysis of women obtaining care with the British Pregnancy Advisory Service.

To examine contraceptive choices among women seeking termination of pregnancy (TOP) and the provision of the chosen methods. Population-based study. British Pregnancy Advisory Service (BPAS) clinics in England and Wales. Between 1 January 2011 and 31 December 2014, 211215 women had a TOP at BPAS, were offered contraceptive counselling, and were eligible to obtain contraception at no cost. We examined electronic records from BPAS and assessed the proportions of women who accepted contraceptive counselling and chose a contraceptive method, as well as the distributions of methods chosen, analysed by provider and by TOP type. We calculated the proportions receiving their chosen method and the methods chosen by women using no method at conception. We used logistic regression to examine the factors associated with choice of an intrauterine contraceptive (IUC) or implant. Post-TOP contraceptive method choice. Receipt of chosen method post-TOP. Eighty-five percent of women accepted contraceptive counselling and 51% chose to obtain a method from BPAS rather than from a GP or contraception and sexual health clinic post-TOP. [correction added on 25 November 2016 after first online publication: 51% has been inserted in the preceding sentence.] Among those who wanted to receive contraception from BPAS, 51% chose an IUC or implant and 19% chose oral contraceptives. Ninety-one percent of women who obtained contraception from BPAS received their chosen method. Women were more likely to choose an IUC or implant if they obtained contraception from BPAS, had a surgical TOP, were parous, young, white, or had one or more previous TOPs. The standards set for patient-centred TOP care should emphasise the need for a full range of contraceptive options to be offered and provided post-TOP. Uptake targets for long-acting reversible methods do not reflect women's post-TOP contraceptive preferences.

Patient-provider conversations about sterilization: A qualitative analysis

ObjectivesAlthough female sterilization is the second most commonly used contraceptive method in the US, research suggests that providers may serve as barriers to desired sterilization. Study designWe conducted a modified grounded theory analysis of audio-recorded contraceptive counseling visits with 52 women who specified on a previsit survey that they wanted no future children and a supplemental analysis of visits with 14 women who wanted or were unsure about future children in which sterilization was mentioned. ResultsSterilization was discussed in only 19 of the 52 visits, primarily with patients who were older women with children. Although some framed sterilization positively, many clinicians discouraged patients from pursuing sterilization, encouraging them instead to use long-acting reversible methods and framing the permanence of sterilization as undesirable. In the 33 remaining sessions, sterilization was not mentioned, and clinicians largely failed to solicit patients' future reproductive intentions. We found no clear patterns regarding discussion of sterilization in the 14 supplemental cases. ConclusionClinicians did not discuss sterilization with all patients for whom it might have been appropriate and thus missed opportunities to discuss sterilization as part of the full range of appropriate methods. When they did discuss sterilization, they only infrequently presented the method in positive ways and more commonly encouraged patients to choose a long-acting reversible method instead. Clinicians may want to reflect on their counseling practices around sterilization to ensure that counseling is centered on patient preferences, rather than driven by their own assumptions about the desirability of reversibility. ImplicationsClinicians often fail to discuss sterilization as a contraceptive option with potentially appropriate candidates and, when they do, often discourage its selection. Clinicians should consider assessing reproductive intentions to ensure that potentially relevant methods are included in counseling.

New developments in long-acting reversible contraception: the promise of intrauterine devices and implants to improve family planning services.

After decades of having the developed world's highest rates of unintended pregnancy, the United States finally shows signs of improvement. This progress is likely due in large part to increased use of highly effective long-acting reversible methods of contraception. These methods can be placed and do not require any maintenance to provide years of contraception as effective as sterilization. Upon removal, fertility returns to baseline rates. This article addresses advances in both software-improved use and elimination of barriers to provide these methods; and hardware-novel delivery systems and devices.