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Contraception Highlights March 2016

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

It’s all about women: creating healthy, functional markets to address the unmet global need for contraception
Denise L. Harrison, Thu Do
In 2012, dozens of organizations and hundreds of individuals met in London for a groundbreaking Summit on Family Planning to increase global access to family planning services. This visionary group of governments, civil-society members, multilateral organizations, donors and private sector groups agreed to support the research and development community to enable 120 million more women and girls in 69 developing countries to use contraceptives by the year 2020. The work of this Summit has been organized under the banner of Family Planning 2020 (FP2020) and is facilitated through the FP2020 Secretariat, headquartered at the United Nations Foundation offices in Washington, DC. This initiative represents an unprecedented step forward in improving the quality of life of women and girls worldwide.

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Reviews

Hormonal contraception among electronic cigarette users and cardiovascular risk: a systematic review
Halley E.M. Riley, Erin Berry-Bibee, Lucinda J. England, Denise J. Jamieson, Polly A. Marchbanks, Kathryn M. Curtis
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Aiming for quality in Iran’s national family planning program — two decades of sustained efforts
Mohammad Eslami, Catherine d’Arcangues
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Original Research Articles

The relationship between contraceptive use and maternal and infant health outcomes in Tajikistan
Sharifa Merali
Objective: There has been no evaluation of the association between contraceptive use and maternal and child health (MCH) in Tajikistan, though the government has made concerted efforts to improve accessibility to family planning methods. The aim of this study is to understand the relationship between current contraceptive utilization and specific MCH outcomes in Tajikistan.
Implications: Contraceptive utilization has not yet translated into beneficial MCH outcomes. Policy makers in Tajikistan might consider placing more emphasis on family planning education, while maximizing accessibility of contraceptive methods.
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Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently?
Eileen A. Yam, Jerry Okal, Helgar Musyoki, Nicholas Muraguri, Waimar Tun, Meredith Sheehy, Scott Geib
Objective: To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs).
Implications: FSWs should be encouraged to use condoms consistently, whether or not other methods are used simultaneously.
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What makes a likely abortion provider? Evidence from a nationwide survey of final-year students at Ghana’s public midwifery training colleges
Sarah D. Rominski, Jody Lori, Emmanuel Nakua, Veronica Dzomeku, Cheryl A. Moyer
Background: Even in countries where the abortion law is technically liberal, the full application of the law has been delayed due to resistance on the part of providers to offer services. Ghana has a liberal law, allowing abortions for a wide range of indications. The current study sought to investigate factors associated with midwifery students’ reported likelihood to provide abortion services.
Discussion: Midwifery students at Ghana’s public midwifery training colleges report that they are likely to provide CAC. Ensuring that midwives-in-training are well trained in abortion services, as well as encouraging empathy in these students, may increase the number of providers of safe abortion care in Ghana.
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Unplanned pregnancy and contraceptive use in Hull and East Yorkshire
Helen Bexhell, Kate Guthrie, Kelly Cleland, James Trussell
Objective: This study has two aims. The first is to assess the proportion of unplanned pregnancies among women attending antenatal clinics (ANCs) and those undergoing induced abortion (IA). The second is to assess both their previous contraceptive use and contraceptive intention, with particular focus on the use or consideration of any long-acting reversible contraceptives in Hull and East Riding in order to inform service redesign.
Implications: Opportunities to prevent unplanned pregnancies are missed when staff in primary and secondary care looking after women do not knowledgeably inform, discuss and offer contraception in a timely manner, particularly the most effective long-acting reversible contraceptive methods. Services should be deliverable where women are: this includes within pregnancy care services. Seeking patient experience is an essential component of service redesign.
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Influence of clinician referral on Nebraska women’s decision-to-abortion time
Valerie French, Renaisa Anthony, Chelsea Souder, Christine Geistkemper, Eleanor Drey, Jody Steinauer
Objective: To assess the association of clinician referral with decision-to-abortion time.
Implications: Additional research is needed to explore whether quality clinician referral improves abortion access and whether increased resources should be dedicated to improving referral patterns.
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Women's experiences with doula support during first-trimester surgical abortion: a qualitative study
Julie Chor, Phoebe Lyman, Megan Tusken, Ashlesha Patel, Melissa Gilliam
Objective: To explore how doula support influences women's experiences with first-trimester surgical abortion.
Implications: In a setting that does not allow family or friends to be present during the abortion procedure, women highly valued the presence of trained abortion doulas. This study speaks to the importance of providing support to women during abortion care. Developing a volunteer doula service is one approach to addressing this need, especially in clinics that otherwise do not permit support people in the procedure room or for women who do not have a support person and desire one.
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Efficacy and safety of a 21/7-active combined oral contraceptive with continuous low-dose ethinyl estradiol
Robin Kroll, Ronald Ackerman, Robert Feldman, Brandon Howard, Herman Weiss, Jennifer Hsieh, Nancy Ricciotti
Objective: Substituting low-dose ethinyl estradiol (EE) for the hormone-free interval in combined oral contraceptives (COCs) may enhance ovarian suppression and improve tolerability. This noncomparative phase 3 study evaluated the efficacy and safety of a 21/7-active COC regimen including 21 days of desogestrel (DSG)/EE followed by 7 days of EE.
Implications Statement: This phase 3 open-label study demonstrated that a 21/7-active COC regimen including 21 days of DSG 150 mcg/EE 20 mcg and 7 days of EE 10 mcg was efficacious and well tolerated for pregnancy prevention.
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IUD services among primary care practices in New York City
Laura Jacobson, Samantha Garbers, Hannah Helmy, Hope Roobol, Julia E. Kohn, Megan L. Kavanaugh
Objective: Intrauterine devices (IUDs) are one of the most effective forms of reversible contraception and can reduce unintended pregnancy rates. We explored practice characteristics associated with IUD services across a network of primary care practices in New York City during 2010–2013.
Implications: Much of primary care in the United States takes place in independent practices with one or two providers. Our study of a major urban area found that these types of practices are much less likely to offer IUD services than community health centers. Ensuring that small practices know where to refer women for IUD insertion and removal services is warranted to ensure women's access to IUDs.
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Relationship between etonogestrel level and BMI in women using the contraceptive implant for more than 1 year
Kathleen M. Morrell, Serge Cremers, Carolyn L. Westhoff, Anne R. Davis
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The relationship between long-acting reversible contraception and insurance coverage: a retrospective analysis
Jane Broecker, Joan Jurich, Robin Fuchs
Objective: The objective was to determine if there is a relationship between patients’ financial responsibility (out-of-pocket expenses) and placement of long-acting, reversible contraceptive (LARC) methods among girls and women living in Appalachia who expressed interest in LARC device placement.
Implications: Unintended pregnancy rates in the United States remain high, especially in Appalachia. One contributing factor is reliance on user-dependent methods which have significantly high typical use failure rates. Placement of LARC methods for more patients could decrease unintended pregnancy, but device costs may be one barrier to utilization, even for those with private insurance.
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Case Report

Arm flexion during ultrasound assists localization of an intramuscular etonogestrel contraceptive implant
Connor Biskamp, Robert P. Kauffman
Introduction: Uterine perforation is an uncommon yet well-known complication of copper intrauterine devices and the levonorgestrel intrauterine system (IUS). While initial extrauterine placement at the time of insertion is felt to be the cause of perforation in most cases, some hypothesize that delayed transmural migration and subsequent perforation can occur with slightly malpositioned or even properly placed devices.
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