Contraception: X最新文献

Objective

In 2017, New Mexico approved an amendment allowing pharmacists to prescribe and dispense hormonal contraception. We interviewed rural New Mexico women to determine their perceptions of pharmacy access to hormonal contraception.

Study design

We conducted semi-structured telephone interviews with women recruited from rural New Mexico communities. The interview guide explained the amendment followed by questions about the advantages and disadvantages of pharmacy access to hormonal contraception within rural communities.

Results

Between November 2017 and May 2018, we recruited 32 women to participate. Participants were young (26/32 18–29 years old), gravid (27/31), employed (30/32), white (22/32) and Hispanic (26/31). The majority used Medicaid as their primary insurance (16/28). Most participants were supportive of pharmacy access to hormonal contraception. Participants saw their rural communities as facing health care barriers, some of which could be alleviated by pharmacy access. Perceived benefits of pharmacy access included convenience of pharmacy hours, shorter wait times, and no need for an appointment. Participants expressed concerns about lack of privacy in their pharmacies. Many expressed trust in their pharmacist to review side effects and explain usage of contraception- a role that was considered separate from that of a primary care provider who offers regular medical visits for routine screening and nuanced or complex discussions about contraception. Some participants expressed that pharmacy access could be especially beneficial for teens.

Conclusions

Rural New Mexico women were supportive of pharmacy access to contraception and accept pharmacists as trusted members of the health care team.

Implications

Rural New Mexico women find benefit in pharmacy access to hormonal contraception, citing improved access to contraceptives in their communities.

Objective

Assess oral sedation versus placebo for pain control with cervical dilator placement.

Study design

We randomized participants presenting for dilation and evacuation to lorazepam 1 mg/oxycodone 5 mg or placebo 45 min before cervical dilator placement. Our primary outcome was median visual analog scale (VAS) pain score after dilator placement using a 100-mm VAS. We used our outcome data to calculate median pain score changes from baseline to better reflect pain score differences between study groups. Planned sample size was 30 participants per group, for a total of 60.

Results

We randomized 27 participants; 9 received sedation and 11 placebo. Median pain score increase from baseline to last dilator placement was 20 [interquartile range (IQR) 8–29] and 31 (IQR 15–81) in the oral sedation and placebo groups, p = .16.

Conclusion

We were unable to enroll our desired sample size, and our sample is underpowered to make any conclusions. Our results suggest that oral sedation may provide some benefit for pain relief with dilator insertion and indicate that further research might be worthwhile especially in settings that do not routinely provide these analgesics.

Implications

We had difficulty with study recruitment because many patients desired oral sedation for pain management for cervical dilator placement and declined randomization. Randomized trials of pain management with a placebo arm may find recruitment challenging especially if default clinical care already includes a pain management option that patients would have to opt out of.

Objectives

To describe changes in use and receipt of emergency contraceptive (EC) pills among women in the United States during a period of key EC policy changes, from 2008 to 2015.

Study design

Using data from the 2006 to 2010 and 2013 to 2017 National Surveys of Family Growth, we present changes in the percent of women who ever used EC between 2008 and 2015 by select sociodemographic and sexual and reproductive health characteristics, and we examine multivariable relationships of these characteristics with EC ever use in 2015. We also examine changes in repeat EC use, receipt of EC counseling, reasons for EC use and source of EC between the time periods.

Results

Among sexually experienced women ages 15 to 44, EC ever use increased from 11% in 2008 to 23% in 2015 overall and among nearly all groups of women. In 2015, age 20 to 29, non-Hispanic other or Hispanic race, at least a high school education, working part-time, income at least 100% of the federal poverty level, ever having been married, and having received EC counseling in the prior year all represent characteristics associated with higher odds of having ever used EC. In 2015, a smaller share of women last obtained EC with a prescription or at a health facility than in 2008.

Conclusions

Increases in EC use occurred as access to EC was broadened through regulatory changes that moved some forms of EC from behind-the-counter to fully over-the-counter between 2008 and 2015.

Implications

Over-the-counter provision of many forms of EC pills may have increased access and introduced more flexibility in how EC is obtained, but these changes may have come with tradeoffs, both in the form of cost barriers and decreased opportunities for clinicians to discuss EC with their patients. Despite improved access to contraception more broadly through the Affordable Care Act, EC remains a necessary component of the overall contraceptive method mix, and clinicians can play a key role in discussing EC as one option among many during contraceptive counseling sessions.

Objective

To examine the rate of ovulatory disruption when intramuscular depot medroxyprogesterone acetate (DMPA) is administered across graded stages of dominant follicle development.

Study design

We assigned enrolled participants to one of three preassigned dominant follicle size groups: 12-14 mm, 15–17 mm and ≥ 18 mm. We followed dominant follicles via serial transvaginal ultrasound (TVUS) until the follicles reached their assigned size, at which time we administered DMPA. For 5 consecutive days thereafter, we followed the follicles via TVUS to observe follicle rupture and obtained serum luteinizing hormone (LH), estradiol, and progesterone concentrations. In the following 2 weeks, we collected serum progesterone concentrations twice weekly to detect possible ovulatory delay or dysfunction. We also collected serum medroxyprogesterone acetate (MPA) concentrations at 1 and 24 h after DMPA administration to examine against ovulatory outcomes.

Results

Twenty-six of 29 enrolled women completed the study. DMPA suppressed ovulation in 17/26 (65%) and caused ovulatory dysfunction in 1/26 (4%) participants. Larger follicles were more likely to rupture despite DMPA (12–14 mm: 0/10 (0%); 15–17 mm: 3/10 (30%); ≥ 18 mm: 6/6 (100%); p < .01). Pre-DMPA LH concentrations ranged from 13.8 to 93.7 IU/L (mean 49.0 IU/L) in cases of follicle rupture. We observed no cases of follicle rupture when DMPA was administered through cycle day 12. All 24-h MPA concentrations exceeded those needed for ovulation suppression.

Conclusion

DMPA suppressed and additionally disrupted ovulation in 65% and 4% of observed cycles, respectively. DMPA may provide effective emergency contraception as well as ongoing contraception if administered prior to an expected ovulation and specifically before the LH surge.

Implications

DMPA may be an alternative form of emergency contraception that can also self-bridge to ongoing contraception. As ovulation was not observed among any follicles when DMPA was given through cycle day 12, women who initiate DMPA up through cycle day 12 may not require backup contraception.

Objective

To assess the availability of oral emergency contraception in southwestern Pennsylvania pharmacies.

Study design

We conducted a simulated patient study to assess on-the-shelf availability of levonorgestrel emergency contraception and immediate availability of ulipristal acetate emergency contraception.

Results

Only 44% of pharmacies stocked levonorgestrel on-the-shelf and only 5% of pharmacies had ulipristal acetate immediately available.

Conclusions

We found significant barriers to obtaining timely oral emergency contraception in southwestern Pennsylvania.

Implications statement

Timely access to emergency contraception is important for people's ability to determine if, when, how, and under what circumstances to have children. Pharmacies in southwestern Pennsylvania need to expand access to oral emergency contraception.

Objective

Barriers to removal of long-acting reversible contraception (LARC) threaten reproductive self-determination, but their influence on contraceptive behaviors is not well understood. We describe perspectives of women in Western Kenya concerning LARC removal barriers.

Study design

We used a qualitative descriptive approach with conventional content analysis to analyze transcripts for content and themes from eight focus group discussions (n = 55 participants) and one client journey mapping workshop (n = 9 participants) with women ages 18–49 in Western Kenya who were currently using or had formerly used contraceptives.

Findings

Our primary themes concerned women's experience of LARC removal barriers and the impact on their behaviors and attitudes towards contraception. Women described providers being unwilling to remove LARC, regardless of rationale (including expiration, seeking pregnancy, or experiencing intolerable side effects) or demanding unaffordable fees. Women were reluctant to try LARC for fear of having to use the method for its entire lifespan even if they did not like it. Women saw LARC removal barriers as increasing their risk of unintended pregnancy through non-replacement of expired devices and fostering distrust in the health system.

Conclusion

Barriers to LARC removal may discourage utilization of LARC and contraceptive services generally, which can undermine women's efforts to achieve reproductive self-determination.

Implications

Our findings affirm the importance of timely LARC removal to ensure that family planning programs uphold women's reproductive autonomy.

Objectives: To identify the lowest dose of Depo-Provera that, when administered off-label subcutaneously, suppressed ovulation and had a pharmacokinetic profile consistent with a 4-month contraceptive effect.

Study Design: We conducted a randomized, multicenter, parallel-group study to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of medroxyprogesterone acetate (MPA) after subcutaneous injection of three different doses of Depo-Provera. We randomized sixty women between 18 and 40 years of age at low risk of pregnancy with confirmed ovulation and body mass index of 18 to 35 kg/m² to receive a single injection of 45, 75 or 105 mg of Depo-Provera, or a single injection of Depo-subQ provera 104 as a reference drug (15 women per group) and followed them for 7.5 months. We evaluated suppression of ovulation as the primary outcome, and MPA concentrations, pharmacokinetic parameters, safety, and local tolerability as secondary outcomes.

Results: Five women ovulated within four months of treatment initiation (three in the 45 mg group and two in the 75 mg group). MPA levels associated with ovulation were in general low, largely ≤ 0.2 ng/mL (the presumed contraceptive threshold). No women in either the 105 mg group or the Depo-subQ provera 104 group ovulated within four months. The PK parameters including C_max, C₁₁₉, and AUC₀₋₁₁₉ for these 2 groups were similar but not equivalent.

Conclusion: A dose of 105 mg of Depo-Provera injected subcutaneously was the lowest tested dose that consistently suppressed ovulation and maintained serum MPA levels consistent with contraceptive effect for at least 4 months. The PK and PD results for the 105 mg dose were similar to Depo-subQ provera 104 over this period.

Objective

To estimate differences in emergency contraception (EC) use, access, and counseling by rural-urban residence among reproductive age women in the United States.

Study design

We examined respondent data (2006–2017) from the National Survey of Family Growth for women ages 15-44 (n = 28,448) to estimate EC use, access, and counseling by rural-urban county of residence. Rural-urban prevalence ratios for EC outcome measures were estimated using predicted margins from logistic regression models, which were adjusted for demographic differences and current contraceptive method use. Changes in ever-use of EC over time were estimated for rural and urban respondents, separately, using Chi-square tests and trends were estimated using inverse variance weighted linear regression models.

Results

During 2006 to 2017, 10% of rural and 19% of urban women who had ever had sex reported ever using EC pills. Among rural women, ever-use increased from 6% in 2006-2008 to 15% in 2015-2017 (Chi-square p < 0.01; trend p-value < 0.01); among urban women, ever-use increased from 11% to 27% (Chi-square p < 0.01; trend p-value < 0.01). Rural and urban women were similarly likely to have obtained EC without a prescription and from a drug store. Rural women were less likely to have received EC counseling than urban women; however, counseling rates were low among all women.

Conclusion

We observed differences in EC ever-use and receipt of EC counseling by rural-urban residence among US women ages 15 to 44, adding to the evidence that rural-urban residence is an important factor in reproductive health. More research is needed to explore factors contributing to rural-urban differences in EC use.

Implications

Our key finding that EC use varied by rural-urban county residence offers additional evidence that rural-urban residence should be considered in reproductive health practice and policy. We discuss areas for future research into potential barriers to EC use in rural populations.

Objectives

Comprehensive sexual education plays an essential role in adolescent sexual and reproductive health and rights (SRHR). The study aim was to investigate Kenyan secondary school teachers’ attitudes toward girls associated with contraceptive use and abortion.

Study design

We conducted a cross-sectional study in January 2018 among school teachers (n = 144) at 4 religiously affiliated suburban secondary schools in Kenya and used 2 validated Likert Scales (1–5) to capture contraception and abortion stigma.

Results

Overall, 122 teachers responded (85%) (females, 57%; males 43%; age, 21–70 years [mean, 36]). Respondents associated contraceptive use with a promiscuous lifestyle (43%) that will encourage peers to do the same (51%). Respondents indicated that married women were more deserving of contraception than unmarried women (57%), a girl could not herself decide to use contraceptives (50%), and contraceptive use could impair future fertility (57%). Abortion was considered a sin (74%), shameful for the family (48%), a habit (34%), and a behavior that might encourage peers to do the same (51%). Many believed an abortion will lead to worse health (73%). Male and female teachers gave similarly distributed responses. Younger teachers were more likely to find abortion shameful (<29, 64%; 30–39, 39%; ≥40, 39%; p = 0.046). Contraception stigma and abortion stigma were highly correlated (r = 0.355, p < 0.001).

Conclusions

Stigmatizing attitudes associated with contraceptive use and/or abortion were common among teachers in Western Kenya.

Implications

Stigma may hinder the sexual and reproductive health and rights of students. Contraceptive use and abortion stigma need to be addressed in teacher education to ultimately improve health outcomes among adolescents.