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Contraception Journal
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Contraception Highlights January 2015

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

Referral-making in the current landscape of abortion access
Melanie Zurek, Jenny O’Donnell, Rebecca Hart, Deborah Rogow
2014 brought a number of abortion facility closures in the United States, often as a result of targeted legislation aimed at limiting the provision of abortion. As these closures decrease the availability of already limited services, women will require greater assistance locating and accessing abortion care. In this context, abortion referral-making—defined here as a process of connecting a woman in need of abortion care with a facility that provides services—may be a critical, yet for many years overlooked, component of access.
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Original Research Articles

Can women determine the success of early medical termination of pregnancy themselves?
S.T. Cameron, A. Glasier, A. Johnstone, H. Dewart, A. Campbell
Objective: To determine the outcome of early medical termination of pregnancy (TOP) among women who choose a “self assessment” follow up comprising a self-performed low sensitivity urine pregnancy test with instructions on signs/symptoms that mandate contacting the TOP service.
Implications Statement: If women are given clear instructions on how and when to conduct a urine pregnancy test and on signs/symptoms that mandate contacting the TOP service, then they can confirm the success of early medical TOP themselves. Late presentation due to failure to recognize an ongoing pregnancy is rare.
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Late termination of pregnancy for lethal fetal anomalies: a national survey of maternal–fetal medicine specialists
Adam R. Jacobs, Gillian Dean, Erika J. Wasenda, Lauren M. Porsch, Erin L. Moshier, David A. Luthy, Maureen E. Paul
Objectives: The objective was to ascertain the practices and opinions of US maternal–fetal medicine specialists regarding termination of pregnancy as a management option following late diagnosis of lethal fetal anomalies.
Implications: This national survey supports the need for improved services for pregnant women who desire later termination of pregnancy following diagnosis of serious fetal anomalies. Helpful efforts might include educating physicians about the laws and regulations governing late termination of pregnancy, forging more consistent standards of care, and improving collaboration between MFM specialists and family planning providers to enhance access to care.
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What happens when we routinely give doxycycline to medical abortion patients?
Laura J. Frye, Erica Chong, Beverly Winikoff, NCT01799252 Trial Investigators
Objectives: Routine provision of antibiotics following medical abortion is common yet practitioners and professional societies differ on its utility. Our study compares the side effects experienced by women who were prescribed doxycycline following medical abortion to those who were not and assesses the adherence to one prescribed regimen.
Implications: In the absence of robust evidence that prescribing 7 days of doxycycline following medical abortion is effective at reducing serious infections, these data can assist the public health community with deciding whether routine provision is the most appropriate strategy.
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Mifepristone (RU486) in Australian pharmacies: the ethical and practical challenges
Rebekah Yeaun Lee, Rebekah Moles, Betty Chaar
Objective: The recent legalization of mifepristone has given women in Australia a new option for termination of pregnancy. Pharmacists are well positioned to provide information and supply mifepristone for patients. However, there are ethical and legal concerns in Australia regarding the supply of mifepristone, as pharmacists may choose to conscientiously object to supplying mifepristone and are subject to differing abortion laws between states and territories in Australia. The objective of this study was to explore attitudes and knowledge of Australian pharmacists about mifepristone.
Implications: To ensure patient safety, well-being and autonomy, there is an imperative need for pharmacist-specific training and guidelines to be made available and open discussion to be initiated within the profession to raise awareness, in particular regarding professional accountability for full patient care.
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Unmet contraceptive need among married Nigerian women: an examination of trends and drivers
Anne Austin
Objective: The aim of this study is to examine trends in and drivers of unmet need for contraceptives among married Nigerian women between 2003 and 2013.
Implications: Nigeria has set a goal of a 36% contraceptive prevalence rate by 2018. With a current contraceptive prevalence rate of 15% reaching the additional 16% of women, who have articulated a demand for contraception, will almost reach that goal. Contraceptive use directly reduces maternal risk; implementing interventions to increase demand for contraception and meeting articulated demands for contraception would not only support women's (and men's) ability to realize their reproductive rights but also, ultimately, may reduce the burden of maternal deaths in Nigeria.
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HIV status and postpartum contraceptive use in an antenatal population in Durban, South Africa
Heather M. Marlow, Suzanne Maman, Dhayendre Moodley, Siân Curtis, Luz McNaughton Reyes
Objective: We examined contraceptive use and dual protection in the postpartum period in a Prevention of Mother to Child Transmission population and whether it varied by HIV status.
Conclusion: HIV status may be an important motivating behavioral factor for women to use contraceptives and dual protection in the postpartum period.
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Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update
Adam Sonfield, Athena Tapales, Rachel K. Jones, Lawrence B. Finer
Background: The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013.
Implications: This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.
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Achieving cost-neutrality with long-acting reversible contraceptive methods
James Trussell, Fareen Hassan, Julia Lowin, Amy Law, Anna Filonenko
Objectives: This analysis aimed to estimate the average annual cost of available reversible contraceptive methods in the United States. In line with literature suggesting long-acting reversible contraceptive (LARC) methods become increasingly cost-saving with extended duration of use, it aimed to also quantify minimum duration of use required for LARC methods to achieve cost-neutrality relative to other reversible contraceptive methods while taking into consideration discontinuation
Implications: Previous economic arguments in support of using LARC methods have been criticized for not considering that LARC methods are not always used for their full duration of efficacy. This study calculated that cost-savings from LARC methods relative to SARC methods, with discontinuation rates considered, can be realized within 3 years.
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Stopping and switching contraceptive methods: findings from Contessa, a prospective longitudinal study of women of reproductive age in England
Kaye Wellings, Nataliya Brima, Katharine Sadler, Andrew J. Copas, Lisa McDaid, Catherine H. Mercer, Sally McManus, Judith Stephenson, Anna Glasier
Objective: Discontinuation of, and change in, use of contraceptive methods contributes to high unplanned pregnancy rates. The aims of the Contessa study were to estimate the prevalence of and reasons for discontinuation and change and to assess the implications for preventive intervention.
Interpretation: Effective strategies to aid contraceptive adherence have proved elusive but, if found, could reduce unplanned pregnancy rates appreciably. Understanding of the factors contributing to successful contraceptive practice is essential to prevention of unintended pregnancy.
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Postpartum glucose tolerance in women with gestational diabetes using levonorgestrel intrauterine contraception
Jessica W. Kiley, Cassing Hammond, Charlotte Niznik, Alfred Rademaker, Dachao Liu, Lee P. Shulman
Objective: Postpartum contraception is critical in women with gestational diabetes mellitus (GDM). We evaluated the effect of the levonorgestrel intrauterine system (LNG-IUS) on glucose tolerance in postpartum women with GDM.
Implications: Use of levonorgestrel intrauterine contraception does not appear to negatively affect glucose tolerance in postpartum women with a history of gestational diabetes. Additional appropriately powered clinical studies are needed to confirm these results.
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Increased exposure of norethindrone in HIV+ women treated with ritonavir-boosted atazanavir therapy
Barent N. DuBois, Jessica Atrio, Frank Z. Stanczyk, Ganesh Cherala
Objective: Pharmacokinetics of norethindrone in combination oral contraceptive regimen are well described among HIV+ women treated with ritonavir-boosted protease inhibitor therapies; however, such characterization is lacking in women using progestin-only contraception. Our objective is to characterize pharmacokinetics of norethindrone in HIV+ women using ritonavir-boosted atazanavir treatment during progestin-only contraceptive regimens.
Implications: Norethindrone-based progestin-only contraceptives, unlike combination oral contraceptives, exhibit greater drug exposure when co-administered with ritonavir-boosted atazanavir regimen and thus may not warrant a category 3 designation by the World Health Organization. Prospective studies are needed to confirm whether pharmacokinetic interaction results in favorable clinical outcomes.
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“Get It and Forget It:” online evaluation of a theory-based IUD educational video in English and Spanish
Samantha Garbers, Mary Ann Chiasson, Rachel Baum, Natalie Tobier, Alicia Ventura, Sabina Hirshfield
Objectives: Get It & Forget It, an educational video about intrauterine devices (IUDs), was developed and evaluated.
Conclusion: An online theory-driven video intervention can reach young women seeking information about long-acting contraception.
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Performance of a checklist to exclude pregnancy at the time of contraceptive initiation among women with a negative urine pregnancy test
Jaspur Min, Christina Buckel, Gina M. Secura, Jeffrey F. Peipert, Tessa Madden
Objective: Our objective was to measure the sensitivity and specificity of a six-item “pregnancy checklist” at excluding early- or luteal-phase pregnancy among women with a negative urine pregnancy test who were initiating contraception.
Implications: In patients with a negative urine pregnancy test, a pregnancy checklist using six criteria based on patient history has high NPV in excluding early pregnancy. This checklist can be used to facilitate same-day initiation of contraceptive methods, including long-acting reversible contraception. Although the checklist had a high false positive rate, initiation of contraception should not be delayed in women with a “positive screen.” Rather women who desire an intrauterine device or implant can be “bridged” with a shorter-acting method until pregnancy can be excluded.
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The female condom learning curve: patterns of female condom failure over 2 uses
Mags Beksinska, Jenni Smit, Ross Greener, Gilda Piaggio, Carol Joanis
Background: Male and female condom (FC) functional performance failure declines with user experience. With the recent availability of a wider range of FCs, it is important to know if women with experience in using one type of FC are more proficient in using another type, even if the FC design is quite different.
Implications: FC failure rates decrease over 20 uses, regardless of FC condom type used. The decrease is higher at the beginning of use, indicating that improvement is greatest after the first five uses.
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Case Report

Delayed-type hypersensitivity reaction against Nexplanon®
Maurizio Serati, Giorgio Bogani, Sanjeev Kumar, Antonella Cromi, Fabio Ghezzi
Abstract: Nexplanon® is an etonogestrel implant with a long-acting contraceptive effect. Although several studies underlined its safety profile, its implant can rarely lead to moderate or severe adverse event. Here, we presented a case of delayed-type hypersensitivity reaction against Nexplanon® that resolved after its removal.
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