Publications by authors named "Kathryn M Curtis"

180 Publications

Changes in U.S. Healthcare Provider Practices Related to Emergency Contraception.

Womens Health Issues 2021 Nov-Dec;31(6):560-566. Epub 2021 Sep 9.

Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia.

Introduction: Emergency contraception (EC), including EC pills (ECPs) and the copper intrauterine device, can prevent pregnancy after sexual encounters in which contraception was not used or used incorrectly. The U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), initially released in 2013, provides evidence-based clinical recommendations on the provision of EC. The objective of this analysis was to assess the percentage of health care providers reporting frequent provision of select EC practices around the time of and after the release of the U.S. SPR.

Methods: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and public-sector providers in 2013 and 2014 (n = 2,060) and 2019 (n = 1,420). We compared the percentage of providers reporting frequent provision of select EC practices by time period, overall, and by provider type.

Results: In 2019, few providers frequently provided an advance prescription for ECPs (16%), an advance supply of ECPs (7%), or the copper intrauterine device as EC (8%), although 41% frequently provided or prescribed regular contraception at the same time as providing ECPs. Providers in 2019 were more likely than providers in 2013 and 2014 to provide or prescribe contraception at the same time as providing ECPs (adjusted prevalence ratio, 1.26; 95% confidence interval, 1.001-1.59) and to provide a copper intrauterine device as EC (adjusted prevalence ratio, 3.87; 95% confidence interval 2.10-7.15); there were no other significant differences by time period.

Conclusions: Few providers report frequent implementation of recommended EC practices. Understanding the barriers faced by providers and clinics in implementing these practices may improve access to EC.
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http://dx.doi.org/10.1016/j.whi.2021.07.006DOI Listing
February 2022

COVID-19 and Sexual and Reproductive Health Care: Findings From Primary Care Providers Who Serve Adolescents.

J Adolesc Health 2021 09 21;69(3):375-382. Epub 2021 Jul 21.

Centers For Disease Control and Prevention, Division of Reproductive Health, Atlanta, Georgia.

Purpose: Among U.S. primary care physicians who delivered sexual and reproductive health (SRH) services to adolescents before the COVID-19 pandemic, we examine (1) changes in availability of in-person SRH services; (2) changes in accessibility and utilization of SRH services; and (3) use of strategies to support provision of SRH services during the pandemic.

Methods: Data were from the DocStyles provider survey administered September-October 2020. Descriptive analyses were restricted to family practitioners, internists, and pediatricians whose main work setting was outpatient and whose practice provided family planning or sexually transmitted infection services to ≥ one patient aged 15-19 years per week just before the COVID-19 pandemic (n = 791).

Results: Among physicians whose practices provided intrauterine device/implant placement/removal or clinic-based sexually transmitted infection testing before the COVID-19 pandemic, 51% and 36% indicated disruption of these services during the pandemic, respectively. Some physicians also reported reductions in walk-in hours (38%), evening/weekend hours (31%), and adolescents seeking care (43%) in the past month. At any point during the pandemic, 61% provided contraception initiation/continuation and 44% provided sexually transmitted infection services via telehealth. Among these physicians, about one-quarter reported confidentiality concerns with telehealth in the past month. There were small increases or no changes in other strategies to support contraceptive care.

Conclusions: Findings suggest disruption of certain SRH services and issues with access because of the pandemic among primary care providers who serve adolescents. There are opportunities to enhance implementation of confidential telehealth services and other service delivery strategies that could help promote adolescent SRH in the United States.
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http://dx.doi.org/10.1016/j.jadohealth.2021.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8293631PMC
September 2021

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

MMWR Morb Mortal Wkly Rep 2021 Jun 25;70(25):910-915. Epub 2021 Jun 25.

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.
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http://dx.doi.org/10.15585/mmwr.mm7025a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224864PMC
June 2021

COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians.

Prev Med 2021 09 1;150:106664. Epub 2021 Jun 1.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.
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http://dx.doi.org/10.1016/j.ypmed.2021.106664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316381PMC
September 2021

Update to U.S. Selected Practice Recommendations for Contraceptive Use: Self-Administration of Subcutaneous Depot Medroxyprogesterone Acetate.

MMWR Morb Mortal Wkly Rep 2021 May 21;70(20):739-743. Epub 2021 May 21.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), adapted by CDC from global guidance developed by the World Health Organization (WHO), provides evidence-based guidance on contraceptive use for U.S. health care providers (1). During January-February, 2021, CDC evaluated the 2019 WHO recommendation on self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) (2). CDC adopted the WHO recommendation on the basis of moderate-certainty evidence that self-administered DMPA-SC is safe and effective, and has higher continuation rates compared with provider-administered DMPA. The new U.S. SPR recommendation states that self-administered DMPA-SC should be made available as an additional approach to deliver injectable contraception. Provider-administered DMPA should remain available. Self-administered DMPA-SC is a user-controlled method that has the potential to improve contraceptive access and increase reproductive autonomy. Self-administered DMPA-SC should be offered in a noncoercive manner through a shared decision-making process between patients and their health care providers, with a focus on patient preferences and equitable access to the full range of contraceptive methods.
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http://dx.doi.org/10.15585/mmwr.mm7020a2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136426PMC
May 2021

Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey.

Contraception 2021 04 14;103(4):232-238. Epub 2021 Jan 14.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Objective(s): We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers.

Study Design: We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods.

Results: The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training.

Conclusions: Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients.

Implications: Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.
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http://dx.doi.org/10.1016/j.contraception.2021.01.004DOI Listing
April 2021

Removing Unnecessary Medical Barriers to Contraception: Celebrating a Decade of the U.S. Medical Eligibility Criteria for Contraceptive Use.

J Womens Health (Larchmt) 2021 03 23;30(3):293-300. Epub 2020 Dec 23.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

In 2010, the Centers for Disease Control and Prevention (CDC) released the U.S. Medical Eligibility Criteria for Contraceptive Use, providing recommendations for health care providers on safe use of contraception for people with certain characteristics or medical conditions. Adapted from World Health Organization guidance, the goal of the recommendations is to remove unnecessary medical barriers to contraception. Over the past decade, CDC has updated recommendations based on new evidence, collaborated with national partners to disseminate and implement the guidelines, and conducted provider surveys to assess changes in attitudes and practices around contraception safety and provision. CDC remains committed to supporting evidence-based guidelines for safe use of contraception, as the basis for improving access to contraception and high-quality family planning services, reducing unintended pregnancy, and improving reproductive health in the United States.
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http://dx.doi.org/10.1089/jwh.2020.8910DOI Listing
March 2021

Physician and clinic staff attitudes and practices during implementation of the Zika Contraception Access Network.

Contraception 2020 07 13;102(1):34-38. Epub 2020 Apr 13.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States.

Objective: The Zika Contraception Access Network (Z-CAN) provided women in Puerto Rico access to contraceptive counseling and the full range of reversible contraceptive methods, on the same day and at no cost, during the Zika virus outbreak. Because trained physicians and clinic staff were crucial to the program, we aimed to assess the implementation of and satisfaction with Z-CAN from their perspectives.

Study Design: Physicians and clinic staff in the Z-CAN program participated in an online survey on program implementation (e.g., on-site and same-day contraceptive provision), program satisfaction, and knowledge consistent with program training (e.g., contraceptive initiation and safety, client-centered contraceptive counseling, intrauterine device [IUD] and implant insertion and removal).

Results: Survey respondents included 63 physicians and 53 clinic staff members. A high proportion of physicians (>93%) reported providing IUDs, implants, pills, rings, condoms, and injections and most were very often or always able to provide same-day access to most methods. Over 90% of physicians were satisfied with the Z-CAN program, training, and ongoing support. Staff satisfaction with these program elements was similar but slightly lower. Knowledge about exams and tests needed for initiation and safety of methods varied but was generally consistent with guidelines on which physicians received training. Most physicians (>90%) reported confidence in skills on which they received training as part of the program.

Conclusions: From the perspectives of participating physicians and clinic staff, the program was generally implemented as intended and providers were largely satisfied with program strategies including training and on-going support.

Implications: Certain key components of the Z-CAN program, such as training, proctoring, and involvement of clinic staff were likely critical to Z-CAN's implementation and provider satisfaction. Results from this provider survey can inform implementation of similar efforts to increase access to contraception in both emergency and non-emergency settings.
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http://dx.doi.org/10.1016/j.contraception.2020.04.002DOI Listing
July 2020

Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Updated Recommendations for the Use of Contraception Among Women at High Risk for HIV Infection.

MMWR Morb Mortal Wkly Rep 2020 Apr 10;69(14):405-410. Epub 2020 Apr 10.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

"U.S. Medical Eligibility Criteria for Contraceptive Use" (U.S. MEC) 2016 provides evidence-based guidance for the safe use of contraceptive methods among U.S. women with certain characteristics or medical conditions (1). The U.S. MEC is adapted from global guidance from the World Health Organization (WHO) and kept up to date through continual review of published literature (1). CDC recently evaluated the evidence and the updated WHO guidance on the risk for human immunodeficiency virus (HIV) acquisition among women using hormonal contraception and intrauterine devices (IUDs) (2). After careful review, CDC adopted WHO's 2019 updated guidance for inclusion in the U.S. MEC guidance; CDC's updated guidance states that progestin-only injectable contraception (including depot medroxyprogesterone acetate [DMPA]) and IUDs (including levonorgestrel-releasing and copper-bearing) are safe for use without restriction among women at high risk for HIV infection (U.S. MEC category 1 [previously U.S. MEC category 2, advantages outweigh risks]) (Box). CDC's guidance also adds an accompanying clarification for women who wish to use IUDs, which states "Many women at a high risk for HIV infection are also at risk for other sexually transmitted diseases (STDs). For these women, refer to the recommendations in the 'U.S. Medical Eligibility Criteria for Contraceptive Use' for women with other factors related to STDs, and the 'U.S. Selected Practice Recommendations for Contraceptive Use' on STD screening before IUD insertion" (1,3). Recommendations for other hormonal contraceptive methods (including combined hormonal methods, implants, and progestin-only pills) remain the same; there is also no restriction for their use among women at high risk for HIV infection (U.S. MEC category 1). Finally, CDC clarified that the U.S. MEC recommendations for concurrent use of hormonal contraceptives or IUDs and antiretroviral use for treatment of HIV infection also apply to use of antiretrovirals for prevention of HIV acquisition (preexposure prophylaxis [PrEP]).
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http://dx.doi.org/10.15585/mmwr.mm6914a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147901PMC
April 2020

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis.

Am J Obstet Gynecol 2020 08 3;223(2):177-188. Epub 2020 Mar 3.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA.

Objectives: To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.

Data Sources: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.

Study Eligibility Criteria: We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.

Study Appraisal And Synthesis Methods: We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.

Results: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65).

Conclusion: Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.
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http://dx.doi.org/10.1016/j.ajog.2020.02.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395881PMC
August 2020

Effectiveness and safety of extending intrauterine device duration: a systematic review.

Am J Obstet Gynecol 2020 07 15;223(1):24-35.e3. Epub 2020 Jan 15.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.

Objective: To systematically review the literature to determine if extended use of intrauterine devices, including the copper or levonorgestrel intrauterine device, beyond approved durations is effective and safe for preventing pregnancy.

Study Design: We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Global Index Medicus from inception through June 2019. We considered primary studies of women using the T380A copper or currently available levonorgestrel intrauterine devices past their approved duration (extended use). The primary outcome was pregnancy. Safety outcomes included adverse events and side effects that led to discontinuation. We abstracted study data into evidence tables and assessed study quality as related to the risk of bias, precision, and external validity. For each intrauterine device type, we calculated a pooled pregnancy rate during the first 2 years of extended use using the Poisson inverse variance method.

Results: Of 4068 studies identified by our search, 4 good-to-poor-quality studies of the 52 mg levonorgestrel intrauterine device (approved for 5 years), with a total of 2098 women starting extended use, and 2 good-to-fair-quality studies of the T380A copper intrauterine device (approved for 10 years), with 245 women starting extended use, met inclusion criteria. For the levonorgestrel intrauterine device, the pooled pregnancy rate was 0.02 per 100 person-years (95% confidence interval, 0.00-0.45) in year 6, 0.03 per 100 person-years (95% confidence interval, 0.00-0.71) in year 7, and 0.02 per 100 person-years (95% confidence interval, 0.00-0.29) in years 6 and 7 combined. During this same time, annual rates of adverse events or discontinuation owing to side effects ranged from 0 to 3.7 per 100 participants. For the copper intrauterine device, the pooled pregnancy rate for years 11 and 12 was 0.0 per 100 person-years (95% confidence interval, 0.0-0.8), and annual rates of adverse events and discontinuation owing to side effects during extended use ranged from 0 to 4.6 per 100 participants.

Conclusion: The available evidence suggests that rates of pregnancy, adverse events, and discontinuation owing to side effects during the first 2 years of extended use of the 52 mg levonorgestrel intrauterine device and the T380A copper intrauterine device are low and comparable to rates during approved duration of use. Data were limited in quantity and quality, and may not be generalizable to all intrauterine device users.
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http://dx.doi.org/10.1016/j.ajog.2020.01.014DOI Listing
July 2020

Copper intrauterine device use and HIV acquisition in women: a systematic review.

BMJ Sex Reprod Health 2020 Jan;46(1):17-25

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Objectives: To review systematically copper intrauterine device (Cu-IUD) use and HIV acquisition in women.

Methods: We searched Pubmed, Embase and the Cochrane Library between database inception and 26 June 2019 for longitudinal studies comparing incident HIV infection among women using an unspecified IUD or Cu-IUD compared with non-hormonal or no contraceptive users, or hormonal contraceptive users. We extracted information from included studies, assessed study quality, and summarised study findings.

Results: From 2494 publications identified, seven met our inclusion criteria. One randomised controlled trial (RCT), judged "informative with few limitations", found no statistically significant differences in HIV risk between users of the Cu-IUD and either intramuscular depot medroxyprogesterone acetate (DMPA-IM) or levonorgestrel implant. One observational study, deemed "informative but with important limitations", found no statistically significant difference in HIV incidence among IUD users compared with women who had tubal ligation or who were not using any contraception. Another "informative but with important limitations" observational study found no difference in HIV incidence between Cu-IUD users and DMPA or norethisterone enanthate injectable, or implant users. An RCT considered "unlikely to inform the primary question" also found no difference in HIV risk between Cu-IUD and progestogen-only injectable users. Findings from the other three "unlikely to inform the primary question" cohort studies were consistent with the more robust studies suggesting no increased risk of HIV acquisition among Cu-IUD users.

Conclusion: The collective evidence, including that from a large high-quality RCT, does not indicate an increased risk of HIV acquisition among users of Cu-IUDs.
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http://dx.doi.org/10.1136/bmjsrh-2019-200512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978563PMC
January 2020

Hormonal contraception and HIV acquisition among women: an updated systematic review.

BMJ Sex Reprod Health 2020 Jan;46(1):8-16

Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.

Objective: To update a 2016 systematic review on hormonal contraception use and HIV acquisition.

Methods: We searched Pubmed and Embase between 15 January 2016 and 26 June 2019 for longitudinal studies comparing incident HIV infection among women using a hormonal contraceptive method and either non-users or users of another specific hormonal contraceptive method. We extracted information from newly identified studies, assessed study quality, and updated forest plots and meta-analyses.

Results: In addition to 31 previously included studies, five more were identified; three provided higher quality evidence. A randomised clinical trial (RCT) found no statistically significant differences in HIV risk among users of intramuscular depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel implant (LNG implant) or the copper intrauterine device (Cu-IUD). An observational study found no statistically significant differences in HIV risk among women using DMPA, norethisterone enanthate (NET-EN), implants (type not specified) or Cu-IUD. Updated results from a previously included observational study continued to find a statistically significant increased HIV risk with oral contraceptives and DMPA compared with no contraceptive use, and found no association between LNG implant and HIV risk.

Conclusions: High-quality RCT data comparing use of DMPA, LNG implant and Cu-IUD does not support previous concerns from observational studies that DMPA-IM use increases the risk of HIV acquisition. Use of other hormonal contraceptive methods (oral contraceptives, NET-EN and implants) is not associated with an increased risk of HIV acquisition.
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http://dx.doi.org/10.1136/bmjsrh-2019-200509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978562PMC
January 2020

Safety and effectiveness of hormonal contraception for women who use opioids: A systematic review.

Contraception 2019 12 1;100(6):480-483. Epub 2019 Sep 1.

Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-2, Atlanta, GA 30341, United States.

Objective: To systematically review the literature around the safety and effectiveness of hormonal contraception for women who use opioids. Our specific research questions are: 1) Among women who use opioids, do those who use hormonal contraception have increased adverse health events compared with those who do not use hormonal contraception? 2) Are there drug interactions between hormonal contraception and opioids that cause decreased effectiveness or increased toxicity from either drug?

Methods: We searched Medline, Embase, PsychInfo, CINAHL, the Cochrane Library, and clinicaltrials.gov through August 2018. We considered randomized controlled trials, cohort studies, and case-control studies, as well as pharmacokinetic and pharmacodynamic studies. We planned to use standard frameworks to assess risk of bias of included studies.

Results: The search identified 1852 articles. The full text of 66 articles was reviewed, and none met inclusion criteria.

Conclusions: Because we found no direct evidence on the safety and effectiveness of hormonal contraception for women who use opioids, we considered theoretical concerns. While women with OUD have a high prevalence of co-morbidities, such as viral hepatitis, generally women with medical conditions can safely use most contraceptive methods. When considering the pharmacokinetics and pharmacodynamics of hormonal contraception and opioids, there is little theoretical concern for interactions. Therefore, future research efforts could focus on improving access to the full range of contraceptive methods for women who use opioids, reducing unnecessary barriers to initiating and using contraception, while ensuring voluntary choice related to contraceptive use.
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http://dx.doi.org/10.1016/j.contraception.2019.08.006DOI Listing
December 2019

Changes in US health care provider attitudes related to contraceptive safety before and after the release of National Guidance.

Contraception 2019 11 29;100(5):413-419. Epub 2019 Jul 29.

Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop F-74, Chamblee, Georgia 30341-3717.

Objective: The US Medical Eligibility Criteria for Contraceptive Use (USMEC) is the first national guidance containing evidence-based recommendations for contraception. We describe provider attitudes about contraceptive safety before and after the 2010 USMEC release.

Study Design: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and Title X clinic providers before (2009-2010) and after (2013-2014) the USMEC release. We compared the proportion of providers reporting select contraceptive methods as safe for women with specific characteristics or medical conditions before and after the USMEC release and conducted multivariable logistic regression to adjust for provider characteristics.

Results: For the following select characteristics for which the USMEC classifies specific contraceptive methods as safe (Category 1 or 2), a significantly (p<.05) higher proportion of providers reported the method safe after versus before the USMEC release: intrauterine devices (IUDs) for adolescents (79.8% versus 60.2%), IUDs for women with HIV (72.4% versus 50.6%), depot medroxyprogesterone acetate (DMPA) for women with obesity (89.5% versus 76.1%), and DMPA for women with history of bariatric surgery (87.6% versus 73.9%). These differences remained significant after adjustment for provider characteristics.

Conclusions: While we observed many positive changes in health care provider attitudes related to contraception safety after the USMEC release, gaps remain. Continuing education and evidence-based training for providers, and ensuring office and health center protocols address medical eligibility for contraception for the full range of characteristics included in the USMEC might bridge remaining gaps and increase delivery of high-quality contraception care.

Implications: Gaps between evidence and provider attitudes remain that can inform future efforts to improve contraceptive service delivery.
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http://dx.doi.org/10.1016/j.contraception.2019.07.142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374697PMC
November 2019

Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive procedures.

Surg Obes Relat Dis 2019 Aug 17;15(8):1355-1361. Epub 2019 Jun 17.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness.

Objectives: To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness.

Setting: United States.

Methods: We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness.

Results: Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as "other" (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics.

Conclusions: Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.
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http://dx.doi.org/10.1016/j.soard.2019.06.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721998PMC
August 2019

Postpartum hormonal contraception use and incidence of postpartum depression: a systematic review.

Eur J Contracept Reprod Health Care 2019 Apr 28;24(2):109-116. Epub 2019 Mar 28.

c Division of Reproductive Health , Centers for Disease Control and Prevention , Atlanta , GA , USA.

Purpose: To evaluate the association between postpartum hormonal contraceptive use and postpartum depression.

Materials And Methods: We searched the literature through March 2018 on the association between postpartum hormonal contraception use and incident postpartum depression. We used the United States Preventive Services Task Force framework to assess study quality.

Results: Of 167 articles identified, four met inclusion criteria. Two studies found no differences in rates of postpartum depression between women using postpartum depot medroxyprogesterone and those not using hormonal contraception; however, a study of women receiving injectable norethisterone enanthate immediately postpartum found a 2-3-fold increased risk of depression at 6 weeks, though not at 3 months. One study compared combined hormonal contraception, progestin-only pills (POPs), etonogestrel implants and levonorgestrel intrauterine devices (LNG-IUDs) with no hormonal contraception, and found a 35-44% decreased risk of postpartum depression with POPs and LNG-IUDs, a small increased risk of postpartum antidepressant use among women using the etonogestrel implant and vaginal ring, and a decreased risk of antidepressant use with POPs.

Conclusions: Limited evidence found no consistent associations between hormonal contraceptive use and incidence of postpartum depression. Future research would be strengthened by using validated diagnostic measures, careful consideration of confounders, and ensuring adequate follow-up time.
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http://dx.doi.org/10.1080/13625187.2019.1569610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541925PMC
April 2019

Factors associated with postpartum use of long-acting reversible contraception.

Am J Obstet Gynecol 2019 07 15;221(1):43.e1-43.e11. Epub 2019 Mar 15.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Chamblee, GA.

Background: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low.

Objectives: We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception.

Study Design: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception).

Results: The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level.

Conclusion: Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.
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http://dx.doi.org/10.1016/j.ajog.2019.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592782PMC
July 2019

In Reply.

Obstet Gynecol 2019 03;133(3):582-583

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1097/AOG.0000000000003145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549716PMC
March 2019

Venous Thromboembolism Among Women Initiating Depot Medroxyprogesterone Acetate Immediately Postpartum.

Obstet Gynecol 2019 03;133(3):533-540

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, and Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee.

Objective: To estimate the absolute and relative risk of venous thromboembolism (VTE) among women who initiate depot medroxyprogesterone acetate (DMPA) immediately postpartum compared with those who do not initiate hormonal contraception.

Methods: The IBM MarketScan Commercial Claims and Encounters databases were used to identify delivery hospitalizations among women aged 15-44 years during 2005 through 2014. Diagnosis, procedure, and drug codes were used to identify contraception, VTE, and potential confounding chronic or pregnancy-related conditions. Women who initiated DMPA during days 0 through 7 postpartum were compared with women who did not initiate hormonal contraception during days 0 through 7 postpartum. Women were followed from date of delivery through 12 weeks postpartum for the occurrence of VTE, with censoring at hormonal contraception initiation or prescription, hysterectomy, sterilization, or inpatient death. The incidence rate of VTE and 95% CIs were calculated within each group and the incidence rate ratio was calculated comparing the two groups.

Results: The unadjusted VTE incidence rate through 12 weeks postpartum was 0.42/10,000 women-days in the immediate postpartum DMPA group (34 events among 11,159 women contributing 805,999 days of follow-up) and 0.15/10,000 women-days in the control group (3,107 events among 3,102,011 women contributing 206,180,811 days of follow-up). The incidence rate ratio for VTE was 2.87 (95% CI 2.05-4.03) among women in the immediate postpartum DMPA group compared with women in the control group, adjusting for age alone. After adjusting for age and pregnancy-related and chronic conditions, the adjusted incidence rate ratio for VTE was 1.94 (95% CI 1.38-2.72) among women in the immediate postpartum DMPA group compared with women in the control group.

Conclusion: Initiation of DMPA immediately postpartum is associated with a low incidence but an increased relative risk of VTE compared with nonuse of hormonal contraception.
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http://dx.doi.org/10.1097/AOG.0000000000003135DOI Listing
March 2019

Health Care Provider Attitudes about the Safety of "Quick Start" Initiation of Long-Acting Reversible Contraception for Adolescents.

J Pediatr Adolesc Gynecol 2019 Aug 4;32(4):402-408. Epub 2019 Feb 4.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.

Study Objective: To identify characteristics associated with provider attitudes on the safety of "Quick Start" initiation of long-acting reversible contraception (LARC) for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional survey of providers in public-sector health centers and office-based physicians (n = 2056) during 2013-2014.

Results: Overall, the prevalence of considering "Quick Start" initiation of LARC for adolescents as safe was 70.9% for implants and 64.5% for intrauterine devices (IUDs). Among public-sector providers, those not trained in implant or IUD insertion had lower odds of perceiving the practice safe (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.25-0.41 for implants; aOR 0.42; 95% CI, 0.32-0.55 for IUDs), whereas those practicing at health centers that did not receive Title X funding had lower odds of perceiving the practice safe for IUDs (aOR, 0.77; 95% CI, 0.61-0.98). Among office-based physicians, lack of training in LARC insertion was associated with lower odds of perceiving "Quick Start" initiation to be safe for IUDs (aOR, 0.31; 95% CI, 0.12-0.77). Those specializing in adolescent medicine had higher odds of reporting "Quick Start" initiation of LARC as safe (implants: aOR, 2.21; 95% CI, 1.23-3.98; IUDs: aOR, 3.37; 95% CI, 1.39-8.21) compared with obstetrician-gynecologists.

Conclusion: Approximately two-thirds of providers considered "Quick Start" initiation of LARC for adolescents safe; however, there were differences according to provider characteristics (eg, Title X funding, training in LARC insertion, specialty). Targeted LARC insertion training and dissemination of evidence-based family planning guidance and implementation into facility and practice-level policies might increase access to "Quick Start" initiation of LARC for adolescents.
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http://dx.doi.org/10.1016/j.jpag.2019.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717043PMC
August 2019

Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents.

J Adolesc Health 2019 02 2;64(2):211-218. Epub 2018 Nov 2.

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.

Purpose: Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents.

Methods: We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year.

Results: The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20).

Conclusions: While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.
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http://dx.doi.org/10.1016/j.jadohealth.2018.08.012DOI Listing
February 2019

Contraceptive Counseling in Clinical Settings: An Updated Systematic Review.

Am J Prev Med 2018 11;55(5):677-690

Office of Population Affairs, HHS, Rockville, Maryland.

Context: The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings.

Evidence Acquisition: Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016.

Evidence Synthesis: The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest.

Conclusions: Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective.

Theme Information: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.
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http://dx.doi.org/10.1016/j.amepre.2018.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613590PMC
November 2018

Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis.

Obstet Gynecol 2018 10;132(4):895-905

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and Emory University School of Medicine, Atlanta, Georgia.

Objective: To estimate expulsion rates among women with postpartum intrauterine device (IUD) placement by timing of insertion, IUD type, and delivery method.

Data Sources: We searched PubMed, Cochrane Library, and ClinicalTrials.gov from 1974 to May 2018.

Methods Of Study Selection: We searched databases for any published studies that examined postpartum placement of a copper IUD or levonorgestrel intrauterine system and reported counts of expulsions. We assessed study quality using the U.S. Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of IUD expulsion and estimated adjusted relative risks (RRs) for timing of postpartum placement, delivery method, and IUD type using log-binomial multivariable regression model.

Tabulation, Integration, And Results: We identified 48 level I to II-3 studies of poor to good quality. Pooled rates of expulsion varied by timing of IUD placement, ranging from 1.9% with interval placements (4 weeks postpartum or greater), 10.0% for immediate placements (10 minutes or less after placental delivery), and 29.7% for early placements (greater than 10 minutes to less than 4 weeks postpartum). Immediate and early postpartum placements were associated with increased risk of expulsion compared with interval placement (adjusted RR 7.63, 95% CI 4.31-13.51; adjusted RR 6.17, 95% CI 3.19-11.93, respectively). Postpartum placement less than 4 weeks after vaginal delivery was associated with an increased risk of expulsion compared with cesarean delivery (adjusted RR 5.19, 95% CI 3.85-6.99). Analysis of expulsion rates at less than 4 weeks postpartum also indicated that the levonorgestrel intrauterine system was associated with a higher risk of expulsion (adjusted RR 1.91, 95% CI 1.50-2.43) compared with CuT380A.

Conclusion: Postpartum IUD expulsion rates vary by timing of placement, delivery method, and IUD type. These results can aid in counseling women to make an informed choice about when to initiate their IUD and to help institutions implement postpartum contraception programs.
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http://dx.doi.org/10.1097/AOG.0000000000002822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549490PMC
October 2018

Dissemination and use of WHO family planning guidance and tools: a qualitative assessment.

Health Res Policy Syst 2018 May 22;16(1):42. Epub 2018 May 22.

World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211, Geneva 27, Switzerland.

Background: As countries continue to improve their family planning (FP) programmes, they may draw on WHO's evidence-based FP guidance and tools (i.e. materials) that support the provision of quality FP services.

Methods: To better understand the use and perceived impact of the materials and ways to strengthen their use by countries, we conducted qualitative interviews with WHO regional advisors, and with stakeholders in Ethiopia and Senegal who use WHO materials.

Results: WHO uses a multi-faceted strategy to directly and indirectly disseminate materials to country-level decision-makers. The materials are used to develop national family planning guidelines, protocols and training curricula. Participants reported that they trust the WHO materials because they are evidence based, and that they adapt materials to the country context (e.g. remove content on methods not available in the country). The main barrier to the use of national materials is resource constraints.

Conclusions: Although the system and processes for dissemination work, improvements might contribute to increased use of the materials. For example, providers may benefit from additional guidance on how to counsel women with characteristics or medical conditions where contraceptive method eligibility criteria do not clearly rule in or rule out a method.
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http://dx.doi.org/10.1186/s12961-018-0321-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964918PMC
May 2018

Hormonal Contraceptive Use Among Women of Older Reproductive Age: Considering Risks and Benefits.

J Womens Health (Larchmt) 2018 04 19;27(4):413-417. Epub 2018 Mar 19.

1 Division of Reproductive Health, Centers for Disease Control and Prevention , Atlanta, Georgia .

As women approach menopause, fertility declines but pregnancy can still occur. Maternal and infant risks are increased among women of older reproductive age compared with younger women. A high proportion of pregnancies among women of older reproductive age are unintended and these pregnancies can also be associated with negative maternal and infant consequences. However, women and their healthcare providers may have concerns about risks associated with contraceptive use, particularly combined hormonal contraceptives, among women of older reproductive age who already may be at increased risk for conditions such as cardiovascular disease and breast cancer. Nonetheless, available evidence does not suggest that hormonal contraceptive use among women of older reproductive age substantially increases age-related risks of cardiovascular events or breast cancer. CDC recommends that contraception is still needed for women older than 44 years who have not reached menopause and wish to avoid pregnancy, and that based on age alone, all contraceptive methods are considered safe or generally safe for use by women of older reproductive age.
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http://dx.doi.org/10.1089/jwh.2018.6985DOI Listing
April 2018

Health Care Provider Perceptions of the Safety of IUDs for Women with HIV.

Perspect Sex Reprod Health 2018 06 30;50(2):67-73. Epub 2018 Mar 30.

Health Scientist, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta.

Context: Women who are living with HIV use IUDs at a lower rate than the general population, and it is unclear whether health care providers' misconceptions about IUD safety contribute to this disparity.

Methods: A 2013-2014 nationwide survey of 1,998 U.S. family planning providers assessed perceptions of IUD safety for women with HIV or other medical conditions. Multivariable logistic regression was used to examine associations between provider characteristics and whether individuals believed IUDs were safe for HIV-positive women. Data from public-sector providers and office-based physicians were analyzed separately.

Results: Seven in 10 providers considered IUDs safe for women with HIV, and there were no differences by provider type. Among public-sector providers, some of the characteristics associated with believing that IUDs were unsafe for seropositive women were working at a clinic without Title X funding (odds ratio, 1.5), not being trained in IUD insertion (2.1) and not using the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for clinical guidance (1.8). Office-based physicians who did not use the guidelines also had an increased likelihood of believing that IUDs were unsafe for women with HIV (2.9), and physicians who had completed training 25 or more years ago were more likely than those who had done so less than five years ago to consider IUDs unsafe (3.3).

Conclusions: Greater use of evidence-based contraceptive guidance such as the U.S. MEC may help inform provider perceptions of IUD safety and hence contribute to increased contraceptive choice for women with HIV.
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http://dx.doi.org/10.1363/psrh.12056DOI Listing
June 2018

A systematic review and meta-analysis of venous thrombosis risk among users of combined oral contraception.

Int J Gynaecol Obstet 2018 Jun 22;141(3):287-294. Epub 2018 Feb 22.

Department of Reproductive Health and Research, WHO, Geneva, Switzerland.

Background: Combined oral contraceptives (COCs) containing various progestogens could be associated with differential risks for venous thromboembolism (VTE).

Objective: To evaluate the comparative risks of VTE associated with the use of low-dose (less than 50 μg ethinyl estradiol) COCs containing different progestogens.

Search Strategy: PubMed and the Cochrane Library were searched from database inception through September 15, 2016, by combining search terms for oral contraception and venous thrombosis.

Selection Criteria: Studies reporting VTE risk estimates among healthy users of progestogen-containing low-dose COCs were included.

Data Collection And Analysis: A random-effects model was used to generate pooled adjusted risk ratios and 95% confidence intervals; subgroup and sensitivity analyses assessed the impact of monophasic-COC use and study-level characteristics.

Main Results: There were 22 articles included in the analysis. The use of COCs containing cyproterone acetate, desogestrel, drospirenone, or gestodene was associated with a significantly increased risk of VTE compared with the use of levonorgestrel-containing COCs (pooled risk ratios 1.5-2.0). The analysis restricted to monophasic COC formulations with 30 μg of ethinyl estradiol yielded similar findings. After adjustment for study characteristics, the risk estimates were slightly attenuated.

Conclusions: Compared with the use of levonorgestrel-containing COCs, the use of COCs containing other progestogens could be associated with a small increase in risk for VTE.
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http://dx.doi.org/10.1002/ijgo.12455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5969307PMC
June 2018

Reply.

Am J Obstet Gynecol 2018 03 23;218(3):364-365. Epub 2017 Nov 23.

Prime Therapeutics, LLC, Eagan, MN.

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http://dx.doi.org/10.1016/j.ajog.2017.11.586DOI Listing
March 2018

Meeting Summary: State and Local Implementation Strategies for Increasing Access to Contraception During Zika Preparedness and Response - United States, September 2016.

MMWR Morb Mortal Wkly Rep 2017 Nov 10;66(44):1230-1235. Epub 2017 Nov 10.

Zika virus infection during pregnancy is a cause of microcephaly and other serious brain abnormalities (1). To support state and territory response to the threat of Zika, CDC's Interim Zika Response Plan outlined activities for vector control; clinical management of exposed pregnant women and infants; targeted communication about Zika virus transmission among women and men of reproductive age; and primary prevention of Zika-related adverse pregnancy and birth outcomes by prevention of unintended pregnancies through increased access to contraception.* The most highly effective, reversible contraception includes intrauterine devices and implants, known as long-acting reversible contraception (LARC). On September 28, 2016, the Association of Maternal and Child Health Programs (AMCHP) and CDC facilitated a meeting in Atlanta, Georgia, of representatives from 15 states to identify state-led efforts to implement seven CDC-published strategies aimed at increasing access to contraception in the context of Zika virus (2). Qualitative data were collected from participating jurisdictions. The number of states reporting implementation of each strategy ranged from four to 11. Participants identified numerous challenges, particularly for strategies implemented less frequently. Examples of barriers were discussed and presented with corresponding approaches to address each barrier. Addressing these barriers could facilitate increased access to contraception, which might decrease the number of unintended pregnancies affected by Zika virus.
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http://dx.doi.org/10.15585/mmwr.mm6644a6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679579PMC
November 2017
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