1. Managing bleeding irregularities with contraceptive implants
- Management of Bleeding Irregularities during Contraceptive Implant Use: A Systematic Review in Contraception
Contraceptive implants are highly effective and safe for most patients, but unscheduled bleeding remains a leading reason for early discontinuation. This systematic review synthesized 21 studies evaluating treatments for bothersome bleeding, including NSAIDs, tranexamic acid, doxycycline, hormonal regimens, progesterone receptor modulators, and vitamin E. Certainty of evidence ranged from high to very low. Overall, celecoxib, mefenamic acid, tamoxifen, and ulipristal acetate showed the most consistent improvement in bleeding patterns during,and sometimes after, treatment; hormonal treatments, TXA, and mifepristone with ethinyl estradiol or doxycycline appeared to improve bleeding during treatment but not after. The authors recommend that providers who provide contraceptive implants provide anticipatory counseling to patients about likely irregular bleeding patterns and consider offering a trial of treatment for patients bothered by such bleeding.
2. Interest in 12-month supply of contraceptives
- Patient interest in and availability of a 12-month supply of contraception: A cross-sectional analysis in Contraception
Extended dispensing of oral contraceptives (e.g., a 12-month supply of pill packs) is associated with fewer gaps in use and improved continuation, but access often breaks down between prescribing, coverage, and pharmacy fulfillment. While many states (23) require insurers to cover pharmacies dispensing an extended or 12-month supply of oral contraception, patients may not receive this amount due to insurance restrictions, provider prescriptions issues, or pharmacy stocking. In this cross-sectional study of ~500 oral contraceptive users living in a state with an extended-supply coverage requirement, nearly three-quarters (72.9%) wanted a 12-month supply, citing convenience and avoiding pharmacy trips and lapses in contraception. Despite that interest, only 17% reported being offered a 12-month supply by a clinician, and even among those prescribed a 12 month supply, only 64.9% of these patients were actually able to fill the 12-month prescription at the pharmacy. Patients with public insurance were less likely to have been offered a 12-month supply. The authors advocate for an increase in state-level policies to cover dispensing extended supplies, and for efforts to increase both provider and patient awareness in states with existing policies mandating such coverage.
3. Misoprostol routes for cervical priming
- Sublingual or Oral Versus Vaginal Misoprostol for Cervical Priming Prior to First-Trimester Surgical Abortion: A Systematic Review and Meta-Analysis in American Journal of Obstetrics and Gynecology
Procedural (surgical) abortion is an extremely safe method of pregnancy termination, and is typically completed in a single clinical visit for patients in the first trimester or early second trimester of pregnancy. For certain gestational durations or clinical histories, misoprostol may be used for cervical priming to reduce procedure time, blood loss, and risk of cervical or uterine injury. Misoprostol can be administered through several routes, including oral, sublingual, and vaginal, and it has not been clear which of these routes is superior. In this systematic review and meta-analysis of 21 randomized controlled trials (4,000+ patients undergoing first-trimester procedural abortion with premedication with misoprostol), the authors found comparable outcomes across oral, sublingual, and vaginal routes. There were no significant clinical differences in preoperative cervical dilation, duration of procedure, or blood loss; while there was a statistically significant difference in procedural duration between sublingual and vaginal misoprostol, this was not clinically significant (less than a minute shorter duration with sublingual misoprostol). Given these findings, the authors suggest that oral or sublingual administration of misoprostol may be simpler to administer and more acceptable for patients, without compromising clinical outcomes.
4. Clinician beliefs about self-managed abortion reporting
- Beliefs about reporting self-managed abortion to government authorities among health professionals registering for a professional education webinar in Contraception
Self-managed abortion (SMA) is safe and effective, and is increasingly common as abortion restrictions become more widespread around the United States. No state currently requires healthcare providers to report SMA to law enforcement, but for pregnant people who choose SMA, legal risk frequently comes from healthcare providers who report them to the authorities, whether or not they understand this to be mandatory. For this study, the investigators surveyed almost 600 participants, including social workers, nurses, physicians and public health employees, on their beliefs around reporting both SMA and other child welfare concerns. The majority of participants, 81%, did not support mandatory reporting of SMA, and beliefs about SMA reporting were related to, but distinct from, beliefs about child welfare reporting, underscoring how easily these frameworks can be conflated. There were, however, significant differences by profession, with more social workers and nurses supporting mandatory reporting. This study reveals an ongoing need for training and education around SMA reporting.
5. Emotional intimate partner violence and postpartum contraception
- Association Between Emotional Intimate Partner Violence Around the Time of Pregnancy and Postpartum Contraceptive Use: Results from the Pregnancy Risk Assessment Monitoring System 2016-2021 in Violence Against Women
Intimate partner violence (IPV) around the time of pregnancy has long been associated with adverse perinatal outcomes. Emotional IPV, in which abusers use verbal or non-verbal methods to harm or control their victims, during the perinatal period is under-recognized compared with physical violence, yet it can meaningfully constrain reproductive autonomy. Although emotionally abusive partners may seek to influence patients’ decisions around contraceptive use, little is known about the associations between emotional IPV and postpartum contraception uptake. Using Pregnancy Risk Assessment Monitoring System (PRAMS) data of 30,000+ respondents, the authors found emotional IPV was associated with lower odds of postpartum contraceptive use. Notably, screening for IPV during prenatal care was associated with higher odds of postpartum contraceptive uptake, suggesting that identification and support may help patients access desired care after delivery. The initial findings of this study highlight a necessity to identify and address emotional IPV in pregnant people, thereby potentially helping them access desired care. Furthermore, IPV counseling may have an important role to play in empowering survivors to seek postpartum contraception.
6. Young adult patients’ experiences of contraceptive counseling
- Adolescent and young adult women’s experiences of contraceptive coercion in healthcare interactions in the southern United States in Contraception
Contraception counseling is an essential part of reproductive healthcare and is provided in a variety of clinical settings and by a wide range of providers. This counseling needs to center the patient’s priorities and autonomous decision-making, including for adolescents and young adults. In this mixed-methods study of 46 patients aged 16-24 years old, the authors analyzed patients’ experiences of contraception counseling within the healthcare system. Patients reported their providers often presented the oral contraceptive pill as the “best” option, discussed a limited range of birth control options, and actively tried to dissuade patients interested in non-hormonal contraception away from copper IUD use. Participants who wanted a copper IUD reported needing persistent self-advocacy to access their preferred method. The authors emphasize that a reproductive justice–informed, patient-centered approach requires presenting a full range of options, respecting individual patients’ preferences and concerns and avoiding introducing their own biases when counseling young patients seeking contraception.
7. Measuring patient-centered contraceptive counseling skills
- Development of a novel scale to measure health care professionals’ patient-centered contraceptive counseling competency in Contraception
Healthcare providers have a unique role to play when counseling patients about contraception. Historically, contraceptive counseling has been influenced by coercion, racism and socioeconomic bias, among other influences. A patient-centered approach, which allows patients to freely express their priorities, concerns and needs, has been shown to significantly improve the experiences and outcomes of patients seeking reproductive healthcare. Currently, however, there are few available tools for providers to assess their own comfort and ability in patient-centered contraceptive counseling. This study, part of a statewide contraceptive access program in Massachusetts, describes development and validation of a 25-item scale to assess clinicians’ competency in patient-centered contraceptive counseling across three domains: patient-centered counseling practices, cultural/structural competency, and alignment with reproductive justice principles. The goal of this initial study was to validate the scale in three phases: first, a small group of reproductive health experts evaluated the initial scale items. Next, 103 healthcare professionals tested the scale, and their responses were analyzed. Finally, these results were used to create a final, validated scale that contains 25 separate questions covering three spheres: patient-centered counseling, cultural and structural competency when working with diverse patient populations, and agreement with reproductive justice principles. Now that the scale has been rigorously validated, it can be further developed for widespread implementation.
8. Implementing contraception screening in primary care
- Implementing SINC (Self-Identified Need for Contraception) Screening: A Mixed Methods Case Study in Contraception
Self-identified need for contraception (SINC) screening is a clinical tool that can be used to provide patient-centered contraceptive counseling in a wide range of practice settings. By asking “Do you want to talk about pregnancy prevention or contraception today?”healthcare professionals are able to offer appropriate counseling and/or resources. The implementation of SINC screening has not been widely studied, and its success in real-world settings is not well understood. In order to improve SINC screening in the primary care setting, the authors of this paper analyzed its implementation across four clinics. They decided to focus specifically on individuals who were assigned male at birth (AMAB), a group commonly excluded from contraception screening studies. This mixed methods study included data from the electronic health record and staff interviews. The authors found that SINC implementation required substantial up-front time and coordination, but became manageable after staff training and was acceptable to AMAB patients. This research aims to provide support for the expansion of SINC screening with an overall goal of increased access to patient-centered contraceptive services throughout primary care.