Contraception最新文献

Objective: To evaluate reasons for non-fulfillment and ongoing contraceptive plans of patients who desired but did not receive inpatient postpartum permanent contraception (PC).

Study design: Multi-site retrospective cohort study of 1254 patients with unfulfilled inpatient postpartum PC. We analyzed the reason for PC non-fulfillment, documented contraceptive plan, and method prescription or provision at hospital discharge, six-weeks, and one-year postpartum.

Results: In our cohort, 44.3% of patients with unfulfilled inpatient PC did not receive any highly- or moderately-effective contraception within one year postpartum.

Conclusions: Removing barriers to PC fulfillment as well as contraceptive counseling that acknowledges these barriers is imperative.

Objective: To evaluate the impact of length of the Medicaid sterilization waiting period and postpartum permanent contraception fulfillment.

Study design: Simulations from a retrospective cohort study estimating the potential increase in permanent contraception within 365 days of delivery.

Results: In our sample of 2076 patients, 61% achieved permanent contraception with the current waiting period of 30 days. With the waiting period hypothetically reduced to 15, 3, 1, and 0 days, 62.9%, 63.7%, 64.5%, and 75% patients, respectively, would have achieved permanent contraception.

Conclusions: As potential Medicaid sterilization policy revisions are considered, understanding the impact on fulfillment rates is critical.

Objective: To evaluate the method of immediate postpartum IUD (ppIUD) insertion (manual versus ring forceps) and expulsion rate within 6-week postpartum.

Study design: We performed a retrospective cohort study of patients who had a singleton vaginal delivery and an immediate ppIUD inserted at Rush University from January 2014 to September 2023. The primary outcome was rate of expulsion within 6-week postpartum. We compared the rate of expulsion by method of insertion, either using a manual technique versus using ring forceps. We performed univariable analysis for the association between baseline maternal characteristics and the primary outcome and we performed multivariable logistic regression to determine the independent association of the method of insertion and the primary outcome.

Results: Two hundred nineteen patients met eligibility with 117 immediate ppIUDs inserted manually and 102 inserted with ring forceps. Baseline maternal demographics were similar across study groups. After adjusting for factors selected a priori (estimated blood loss, body mass index, gestational age at delivery, nulliparity, type of IUD), use of ring forceps was more likely to result in expulsion compared to manual insertion (30.4% vs 16.2% respectively; adjusted OR 2.49, 95% confidence interval 1.28-4.90).

Conclusion: In this retrospective analysis, insertion of immediate ppIUD with ring forceps was independently associated with an increased rate of expulsion within 6 weeks postpartum when compared to manual insertion.

Implications: In this setting, ring forceps was associated with high rates of immediate postpartum IUD expulsion compared to manual technique. Studies disagree, suggesting need for additional work.

Objectives: To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States.

Study design: We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from the current literature and calculated the number needed to treat (NNT) and number needed to screen to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44% to 100%.

Results: The annual savings to health care payers in the United States of foregoing RhD testing and RhIg administration with bleeding events at <12 weeks are $5.5 million/100,000 total pregnancies, assuming the sensitization risk is 0%. In sensitivity analyses with a sensitization risk of 1.5% and subsequent pregnancy rate of 84.3% foregoing Rh testing and RhIg administration would save $2.8 million/100,000 pregnancies, with a NNT of 7322 and a number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is most economical.

Conclusions: There is an opportunity to save as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy.

Implications: Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By deimplementing this low-value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.

Objectives: Family planning researchers have not critically engaged with topics of race, racism, and associated concepts like ethnicity. This lack of engagement contributes to the reproduction of research that reifies racial hierarchies rather than illuminate and interrupt the processes by which racism affects health. This Research Practice Support paper lays out considerations and best practices for addressing race and racism in quantitative family planning research.

Study design: We are scholars with racialized identities and expertise in racial health equity in family planning research. We draw from scholarship and guidance across disciplines to examine common shortcomings in the use and analysis of race and racism and propose practices for rigorous use of these concepts in quantitative family planning research.

Results: We recommend articulating the role of race and racism in the development of the research question, authorship and positionality, study design, data collection, analytic approach, and interpretation of analyses. Definitions of relevant concepts and additional resources are provided.

Conclusions: Family planning and racism are inextricably linked. Failing to name and analyze the pathways through which structural racism affects family planning, and the people who need or want to plan if, when, or how to become pregnant or parent may reproduce harmful and incorrect beliefs about the causes of health inequities and the attributes of Black, Indigenous, and other people racialized as non-White. Family planning researchers should critically study racism and race with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

Implications: Family planning research can better contribute to efforts to eliminate racialized health inequities and avoid perpetuating harmful beliefs and conceptualizations of race by ensuring that they study race and racism with procedures grounded in appropriate and articulated theory, evidence, and analytic approaches.

Objectives: The COVID-19 pandemic brought multiple simultaneous consequences, with high potential to change fertility-related behaviors. We use nationally representative sex and contraceptive use event history calendar measures to demonstrate person-specific changes in contraceptive use after the pandemic, showing differences across demographic subgroups.

Study design: We use data from the first nationally representative web survey of U.S. fertility, fielded in 2020-2022: the American Family Health Study (AFHS). Using responses from 1,357 female-identifying respondents ages 18-49, we analyze 26,274 person-months of sex and contraceptive use data spanning directly before and after the beginning of the pandemic to detect change.

Results: Individual-level hazard models of starting and stopping contraception revealed no pandemic-related changes in starting contraception, but significant reductions in the rate of stopping contraception for specific subgroups. Hispanic females reduced their rates of stopping contraceptive use during the pandemic (lowering their odds of stopping use by 71%), ultimately behaving more similarly to individuals from other racial or ethnic subgroups. Additionally, those aged 41 and older significantly reduced their rates of stopping contraceptive use (lowering their odds of stopping use by 78%) relative to other age groups.

Conclusions: Sudden large-scale health policy changes can produce significant changes in contraceptive use behaviors. The COVID-19 changes interacted with race, ethnicity, and age to produce different changes in contraceptive behaviors among different subgroups of the U.S.

Population:

Objective: To evaluate feasibility of levonorgestrel 52mg intrauterine device (IUD) placement without uterine sounding.

Study design: We performed a three-phase feasibility study from February 2023-May 2024. In phase one, participants had levonorgestrel 52mg IUD placement with sounding. In the experimental phases, placement occurred without sounding and with (phase two) or without (phase three) concurrent transabdominal sonography and participants had 3-month follow-up. We defined feasibility as successful IUD placement without uterine sounding based on ultrasound confirmation immediately following placement. We measured total instrumentation time from the sound or inserter touching the cervix to inserter removal. Participants reported maximal pain experienced using a 100-mm Visual Analogue Scale when the inserter was removed. Physicians rated procedures as easy, moderate, or difficult. We calculated a sample size of 30 per phase so that if there was one failed placement, the lower 95% confidence interval of the successful placement rate would be no less than 90.0%.

Results: Successful placement without sounding occurred in 30(100%) participants in phase two and 28(93.3%) in phase three. Median instrumentation was longest in phase one (49.5 [IQR 42.3-55.0] seconds) compared to phases two (16.0 [IQR12.0-28.0] seconds, p<0.0001) and three (25.0 [IQR 18.5-32.2] seconds, p<0.0001). Participants' median placement pain was 21.0 (IQR 10.3-32.8) mm in phase one with no difference in phase two (25.5 [IQR 14.3-47.0] mm, p=0.35), but was higher in phase three (36.0 [IQR 22.8, 61.0] mm, p=0.01).Physicians rated IUD placement "easy" most often in phase two (n=29[96.7%]) compared to phases one (n=22[73.3%], p=0.03) or three (n=22[73.3%], p=0.03). Participants experienced one perforation and one expulsion, both in phase three.

Conclusion: Levonorgestrel 52mg IUD placement without sounding is feasible with concurrent sonography. Placement without sounding results in shorter instrumentation time but does not decrease maximum placement pain.

Objectives: To compare performance characteristics of etonogestrel bioanalytical assays across laboratories.

Study design: We conducted a blinded, six laboratory study: five academic laboratories and one contracted commercial laboratory (reference). Etonogestrel was quantitated at each laboratory in both prepared serum and/or plasma samples of six known etonogestrel concentrations, and in 60 clinical samples from participants using etonogestrel-containing contraceptive methods. Per regulatory guidance, laboratory accuracy (percent bias) and precision (coefficient of variation; CV) were defined as ±15% of the nominal prepared concentration. We compared inter- and intra-laboratory agreement using a Kendall's Tau-B and Passing-Bablok regression.

Results: For prepared samples, six laboratories analyzed serum and three laboratories analyzed plasma. All etonogestrel results were within ±15% for accuracy across all concentrations at four labs, including the reference laboratory. All labs demonstrated high precision, with only one occurrence of CV >15%. We found a positive association between prepared plasma and serum etonogestrel results (Kendall's Tau-B 0.80-0.88). For clinical samples, five laboratories analyzed serum and three laboratories analyzed plasma. Compared to the reference laboratory, inter-laboratory serum etonogestrel concentrations were positively correlated (Kendall's Tau-B 0.76-0.95). Proportional bias was observed, meaning individual lab etonogestrel results were consistently higher (slope estimates 0.78-0.95) or lower (slope estimates 1.05-1.10) than the reference laboratory. In clinical samples, intra-laboratory results were well associated between plasma and serum (Kendall's Tau-B 0.92-0.96).

Conclusion: There was good intra-laboratory agreement, irrespective of sample matrix; however, there was inter-laboratory variability in etonogestrel results. Differences between laboratory results should be considered when comparing etonogestrel pharmacokinetics across studies.

Objective: To understand immediate postpartum long-acting reversible contraception (IPP LARC) desire and utilization trends among publicly insured patients delivering at one academic hospital in a state with healthcare barriers and high short-interval birth rates.

Methods: We conducted a retrospective cohort study of electronic delivery records between March 2018-June 2023 for publicly insured patients. Patient demographics, IPP LARC desire and utilization trends were compared using chi-square or Fisher's exact tests. Binary logistic regression explored the relationship between IPP LARC utilization and demographics. Multivariable logistic regression was performed on all statistically significant variables.

Results: Analysis included 10,472 delivery encounters; 2,459 (23.5%) requested IPP LARC on admission and 464 (4.4%) changed contraception to IPP LARC after admission. Among those obtaining IPP LARC (n=2,523, 24.1%), 1,224 (48.5%) selected arm implants and 1,299 selected IUDs. Patients who self-reported as non-Hispanic Black and non-Hispanic Other or multiple races utilized IPP LARC less (aOR=0.84, 95% CI: 0.72-0.98, aOR=0.68, CI 95%: 0.48-0.97, respectively). Patients with cesarean delivery (aOR=1.45, 95% CI: 1.31-1.61) or inadequate prenatal care (aOR=1.54, CI 95%: 1.35-1.75) were more likely to utilize IPP LARC. Maternal age and years of education were inversely associated with utilization. Primiparous patients were less likely to utilize IPP LARC.

Conclusion: LARC utilization was 24.1% during the immediate postpartum period; higher than the 11% nationally reported interval LARC use among publicly insured patients. Understanding the demographics of those desiring IPP LARC could highlight accessibility gaps. The impact of IPP LARC utilization on rates of short-interval birth is being evaluated.

Funding source: Organon IIS #60719 IMPLICATIONS STATEMENT: Understanding the demographics of IPP LARC utilizers may contribute to understanding accessibility gaps and facilitate discernment of factors impacting patient initiation. Evidence suggests that comprehensive contraception access during delivery admission is feasible, patient-desired, and essential.

Objectives: To describe contraceptive use for pregnancy prevention among transgender men and gender diverse (TGD) individuals assigned female or intersex at birth (AFIAB) and explore whether contraceptive use differs by testosterone use.

Study design: We analyzed data from a cross-sectional, online survey of N=1,694 TGD individuals AFIAB recruited in 2019 through a community-facing website and a national community-engaged cohort study of sexual and/or gender minority (SGM) adults in the US. Descriptive and regression analyses characterized the current and ever use of contraceptive methods for pregnancy prevention, stratified by testosterone use, and described reasons for contraceptive use/non-use.

Results: Most respondents (71.0%) had used contraception before with 49.4% using it for pregnancy prevention. The methods for pregnancy prevention that were most frequently ever used for pregnancy prevention included: external condoms (91.8%), combined hormonal contraceptive pills (63.0%), and withdrawal (45.9%). The methods most frequently currently used for pregnancy prevention included: external condoms (35.4%), hormonal IUD (24.8%), and abstinence (19.2%). Some reported formerly (n=55, 6.6%) or currently (n=30, 3.6%) relying on testosterone for pregnancy prevention. Only 4 of the 33 reasons for contraceptive use and non-use differed by testosterone use group. The most reported reasons for never using contraception were not engaging in penis-in-vagina sex (5.7%) or no sex with individuals who produce sperm (4.8%).

Conclusions: Most TGD individuals AFIAB have used contraception, and almost half for pregnancy prevention. The most used methods require minimal and/or non-invasive healthcare system interaction. Some respondents relied on testosterone as birth control, despite a lack of efficacy evidence.