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Contraception Journal
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Contraception Highlights December 2014

Thinking (Re)Productively
Expert analysis on pressing issues from the Association of Reproductive Health Professionals

Counseling for emergency contraception: time for a tiered approach

Typical counseling for emergency contraception (EC) does not take into account the relative effectiveness of the methods or client characteristics; new data and lessons from contraceptive counseling research suggest that it is time for this approach to change. The number of EC options available in the United States has grown in the last decade and now includes levonorgestrel (LNG) pills, ulipristal acetate (UPA) pills and a copper intrauterine device (IUD). Understanding of the relative effectiveness of EC options has also grown and is the subject of ongoing research. Similar to other contraceptive methods, there is a range of effectiveness for ECs, and user adherence impacts effectiveness.

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Commentary

Notes from the field: expanding abortion services into the second trimester of pregnancy in Nepal (2007–2012)
In the past, abortion in Nepal was criminalized. In 2002, the government liberalized the law allowing abortion for any reason at 12 weeks and under, for rape or incest up to 18 weeks and for maternal mental or physical health or fetal health at any gestational age. Despite decreasing restrictions, at least 13% of women presenting for safe abortion in 2006 with eligible legal indications were turned away due to the lack of training and support to safely provide services in the second trimester. Through a collaborative effort, the Nepali Ministry of Health, Family Health Division (FHD) and Ipas, a global nongovernmental organization working to end deaths and disabilities from unsafe abortion, initiated a program in 2007 to increase the availability of safe second-trimester abortion services, both dilation and evacuation (D&E) and medical abortion (MA; mifepristone-misoprostol).
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Review Articles

Mortality of induced abortion, other outpatient surgical procedures and common activities in the United States
Elizabeth G. Raymond, Daniel Grossman, Mark A. Weaver, Stephanie Toti, Beverly Winikoff
Objective: The recent surge of new legislation regulating induced abortion in the United States is ostensibly motivated by the desire to protect women's health. To provide context for interpreting the risk of abortion, we compared abortion-related mortality to mortality associated with other outpatient surgical procedures and selected nonmedical activities.
Conclusions: The safety of induced abortion as practiced in the United States for the past decade met or exceeded expectations for outpatient surgical procedures and compared favorably to that of two common nonmedical voluntary activities. The new legislation restricting abortion is unnecessary; indeed, by reducing the geographic distribution of abortion providers and requiring women to travel farther for the procedure, these laws are potentially detrimental to women's health.
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The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review
Dana Schonberg, Lin-Fan Wang, Ariana H. Bennett, Marji Gold, Emily Jackson
Objective: We sought to evaluate the accuracy of assessing gestational age (GA) prior to first trimester medication abortion using last menstrual period (LMP) compared to ultrasound (U/S).
Conclusion: Our results support that LMP can be used to assess GA prior to medication abortion at GA <63 days. Further research looking at patient outcomes and identifying women eligible for medication abortion by LMP but ineligible by U/S is needed to confirm the safety and effectiveness of providing medication abortion using LMP alone to determine GA.
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Original Research Articles

A randomized study on pharmacodynamic effects of vaginal rings delivering the progesterone receptor modulator ulipristal acetate: research for a novel estrogen-free, method of contraception
YongMei Huang, Jeffrey T. Jensen, Vivian Brache, Leila Cochon, Alistair Williams, Maria-José Miranda, Horacio Croxatto, Narender Kumar, Heather Sussman, Elena Hoskin, Marlena Plagianos, Kevin Roberts, Ruth Merkatz, Diana Blithe, Regine Sitruk-Ware
Objective: To determine whether a 3-month contraceptive vaginal ring (CVR) delivering ulipristal acetate (UPA) can inhibit ovulation in 90% of cycles.
Implications: The 3-month CVR delivering UPA 2500 μg/day can become an effective user-controlled estrogen-free contraceptive method. Benign PAEC during treatment returns to normal after discontinuation. The prevention of occasional excessive withdrawal bleeding, either by a progestin or by using higher UPA levels to increase follicle suppression may permit prolonged treatment.
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We should really keep in touch: predictors of the ability to maintain contact with contraception clinical trial participants over 12 months
Leah N. Torres, David K. Turok, Jessica N. Sanders, Janet C. Jacobson, Amna I. Dermish, Katherine Ward
Objectives: This study assesses the ability to maintain contact with participants enrolled in an emergency contraception (EC) trial with 12 months of follow-up based on the modes of contact they provided at enrollment.
Implications: Understanding how best to reduce loss to follow-up is an essential component of conducting a contraceptive clinical trial. Improved participant retention maximizes internal validity and allows for important clinical outcomes, such as pregnancy, to be assessed.
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Abortion providers, stigma and professional quality of life
Lisa A. Martin, Michelle Debbink, Jane Hassinger, Emily Youatt, Lisa H. Harris
Objectives: The Providers Share Workshop (PSW) provides abortion providers safe space to discuss their work experiences. Our objectives were to assess changes in abortion stigma over time and explore how stigma is related to aspects of professional quality of life, including compassion satisfaction, burnout and compassion fatigue for providers participating in the workshops.
Implications: Stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue among abortion care providers. Therefore, strengthening human resources for abortion care requires stigma reduction efforts. Participants in the PSWs show reductions in stigma over time.
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Patient and provider perspectives on Bedsider.org, an online contraceptive information tool, in a low income, racially diverse clinic population
Gregory M. Gressel, Lisbet S. Lundsberg, Jessica L. Illuzzi, Cheryl M. Danton, Sangini S. Sheth, Xiao Xu, Aileen Gariepy
Objective: To explore patient and provider perspectives regarding a new Web-based contraceptive support tool.
Implications Statement: This study identifies a contrast between how patients and providers in an urban clinic setting perceive a Web-based contraceptive tool. Given a potential patient–provider discrepancy in preferred methods and approaches to contraceptive counseling, additional research is needed to enhance this important arena of women's health care.
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Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial
Rebecca J. Mercier, Abigail Liberty
Objective: To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo.
Implications: Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.
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Crisis pregnancy center websites: Information, misinformation and disinformation
Amy G. Bryant, Subasri Narasimhan, Katelyn Bryant-Comstock, Erika E. Levi
Objective: Most states with 24-h waiting periods prior to abortion provide state resource directories to women seeking abortion. Our objective was to evaluate the information on abortion provided on the websites of crisis pregnancy centers listed in these resource directories.
Conclusion: Most crisis pregnancy centers listed in state resource directories for pregnant women provide misleading or false information regarding the risks of abortion. States should not list agencies that provide inaccurate information as resources in their directories.
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Removal of a Nexplanon® implant located in the biceps muscle using a combination of ultrasound and fluoroscopy guidance
Maryam Guiahi, Kristina Tocce, Stephanie Teal, Tyler Green, Paul Rochon
Abstract: Despite modifications to avoid deep insertions, clinical experience with Nexplanon® demonstrates that deep insertions still occur. We present a case of a Nexplanon® found in the biceps muscle that was successfully removed with a small incision using a combination of ultrasound and fluoroscopy guidance by interventional radiologists.
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Same-day and delayed reports of pain intensity in second-trimester medical termination of pregnancy: a brief report
M. Mentula, E. Kalso, O. Heikinheimo
Objective: To assess same-day and delayed reports of pain intensity during and after second-trimester medical termination of pregnancy (MTOP).
Implications: Adequate, properly timed pain management during second-trimester MTOP is crucial.
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Obstetrician-gynecologists’ beliefs on the importance of pelvic examinations in assessing hormonal contraception eligibility
Jean M. Yu, Jillian T. Henderson, Cynthia C. Harper, George F. Sawaya
Objective: To describe obstetrician-gynecologists’ beliefs regarding the importance of pelvic examination (including external genitalia inspection, speculum examination, bimanual examination) in assessing hormonal contraception eligibility.
Conclusions: Despite guidelines stating that pelvic examinations are unnecessary in assessing hormonal contraception eligibility, most obstetrician-gynecologists believe that they are of some importance. These attitudes may pose a barrier to contraception provision.
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Letters to the Editor

Hypothesis: amenorrhea-inducing contraception may reduce HIV acquisition risk
G. Justus Hofmeyr, Mandisa Singata-Madliki, Theresa A. Lawrie, Marleen Temmerman
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Medicaid reimbursement for immediate post-abortion provision of long-acting reversible contraception reduces both unintended pregnancies and health care expenditures
Tsu-Yu Tsao, Cristina Yunzal-Butler, Judith Sackoff, Deborah Kaplan
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Response to letter to the editor titled "Medicaid reimbursement for immediate post-abortion provision of long-acting reversible contraception reduces both unintended pregnancies and health care expenditures"
Aileen Langston
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The INAS-OC study
Øjvind Lidegaard
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Reply to letter to the editor: "The INAS-OC study"
Jürgen Dinger
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Response to Mitchell D. Creinin’s letter regarding "Extended use of the intrauterine device: a literature review and recommendations for clinical practice"
Justine Wu, Sarah Pickle
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