Community Understanding of Contraception During the Zika Virus Outbreak in Puerto Rico.

In response to the Zika virus outbreak in Puerto Rico (2015-2016), the Zika Contraception Access Network (Z-CAN) was established to provide same-day access to the full range of reversible contraception at no cost to women. Formative research was conducted to inform the development of a communication campaign about Z-CAN. Ten focus groups with women and men, aged 18 to 49 years, in Puerto Rico were conducted to collect data on contraception awareness, use, and decision making during the Zika outbreak, as well as culturally appropriate messaging and outreach strategies. Thematic analysis was conducted using the constant comparative method. Data showed that there was community awareness regarding Zika in Puerto Rico. However, it was not a motivating factor in contraception decision making; instead, economic factors were the major drivers. Most participants preferred to receive information on contraception, potential side effects, and where to access contraceptive services via Internet-based channels and health care providers. Based on these findings, the Ante La Duda, Pregunta [When in Doubt, Ask] campaign was launched to promote awareness of Z-CAN services among those who chose to prevent pregnancy during the Zika outbreak. Our results underscore the importance of conducting formative research to develop communication initiatives, while also demonstrating that it is feasible to perform these activities as part of an emergency response.

Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines.

LGBT clients have unique healthcare needs but experience a wide range of quality in the care that they receive. This study provides a summary of clinical guideline recommendations related to the provision of primary care and family planning services for LGBT clients. In addition, we identify gaps in current guidelines, and inform future recommendations and guidance for clinical practice and research. PubMed, Cochrane, and Agency for Healthcare Research and Quality electronic bibliographic databases, and relevant professional organizations' websites, were searched to identify clinical guidelines related to the provision of primary care and family planning services for LGBT clients. Information obtained from a technical expert panel was used to inform the review. Clinical guidelines meeting the inclusion criteria were assessed to determine their alignment with Institute of Medicine (IOM) standards for the development of clinical practice guidelines and content relevant to the identified themes. The search parameters identified 2,006 clinical practice guidelines. Seventeen clinical guidelines met the inclusion criteria. Two of the guidelines met all eight IOM criteria. However, many recommendations were consistent regarding provision of services to LGBT clients within the following themes: clinic environment, provider cultural sensitivity and awareness, communication, confidentiality, coordination of care, general clinical principles, mental health considerations, and reproductive health. Guidelines for the primary and family planning care of LGBT clients are evolving. The themes identified in this review may guide professional organizations during guideline development, clinicians when providing care, and researchers conducting LGBT-related studies.

The Zika Contraception Access Network: a feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreak.

BACKGROUND: Prevention of unintended pregnancy is a primary strategy to reduce adverse pregnancy and birth outcomes related to Zika virus infection. The Zika Contraception Access Network (Z-CAN) aimed to build a network of health-care providers offering client-centred contraceptive counselling and the full range of reversible contraception at no cost to women in Puerto Rico who chose to prevent pregnancy during the 2016-17 Zika virus outbreak. Here, we describe the Z-CAN programme design, implementation activities, and baseline characteristics of the first 21 124 participants. METHODS: Z-CAN was developed by establishing partnerships between federal agencies, territorial health agencies, private corporations, and domestic philanthropic and non-profit organisations in the continental USA and Puerto Rico. Private donations to the National Foundation for the Centers for Disease Control and Prevention (CDCF) secured a supply of reversible contraceptive methods (including long-acting reversible contraception), made available to non-sterilised women of reproductive age at no cost through provider reimbursements and infrastructure supported by the CDCF. To build capacity in contraception service provision, doctors and clinic staff from all public health regions and nearly all municipalities in Puerto Rico were recruited into the programme. All providers completed 1 day of comprehensive training in contraception knowledge, counselling, and initiation and management, including the insertion and removal of long-acting reversible contraceptives (LARCs). Z-CAN was announced through health-care providers, word of mouth, and a health education campaign. Descriptive characteristics of programme providers and participants were recorded, and we estimated the factors associated with choosing and receiving a LARC method. As part of a Z-CAN programme monitoring plan, participants were invited to complete a patient satisfaction survey about whether they had obtained free, same-day access to their chosen contraceptive method after receiving comprehensive counselling, their perception of the quality of care they had received, and their satisfaction with their chosen method and services. FINDINGS: Between May 4, 2016, and Aug 15, 2017, 153 providers in the Z-CAN programme provided services to 21 124 women. 20 110 (95%) women received same-day provision of a reversible contraceptive method. Whereas only 767 (4%) women had used a LARC method before Z-CAN, 14 259 (68%) chose and received a LARC method at their initial visit. Of the women who received a LARC method, 10 808 (76%) women had used no method or a least effective method of contraception (ie, condoms or withdrawal) before their Z-CAN visit. Of the 3489 women who participated in a patient satisfaction survey, 3068 (93%) of 3294 women were very satisfied with the services received, and 3216 (93%) of 3478 women reported receiving the method that they were most interested in after receiving counselling. 2382 (78%) of 3040 women rated their care as excellent or very good. INTERPRETATION: Z-CAN was designed as a short-term response for rapid implementation of reversible contraceptive services in a complex emergency setting in Puerto Rico and has served more than 21 000 women. This model could be replicated or adapted as part of future emergency preparedness and response efforts. FUNDING: National Foundation for the Centers for Disease Control and Prevention.

Providing quality family planning services to LGBTQIA individuals: a systematic review.

OBJECTIVE: Lesbian, gay, bisexual, transgender, queer/questioning, intersex and asexual (LGBTQIA) individuals have unique sexual and reproductive health needs; however, facilitators and barriers to optimal care are largely understudied. The objective of this study was to synthesize findings from a systematic review of the literature regarding the provision of quality family planning services to LGBTQIA clients to inform clinical and research strategies. STUDY DESIGN: Sixteen electronic bibliographic databases (e.g., PubMed, PSYCinfo) were searched to identify articles published from January 1985 to April 2016 relevant to the analytic framework. RESULTS: The search parameters identified 7193 abstracts; 19 descriptive studies met inclusion criteria. No studies assessed the impact of an intervention serving LGBTQIA clients on client experience, behavior or health outcomes. Two included studies focused on the perspectives of health care providers towards LGBTQIA clients. Of the 17 studies that documented client perspectives, 12 elucidated factors facilitating a client's ability to enter into care, and 13 examined client experience during care. Facilitators to care included access to a welcoming environment, clinicians knowledgeable about LGBTQIA needs and medical confidentiality. CONCLUSIONS: This systematic review found a paucity of evidence on provision of quality family planning services to LGBTQIA clients. However, multiple contextual facilitators and barriers to family planning service provision were identified. Further research is needed to assess interventions designed to assist LGBTQIA clients in clinical settings, and to gain a better understanding of effective education for providers, needs of specific subgroups (e.g., asexual individuals) and the role of the client's partner during receipt of care.

Drug interactions between hormonal contraceptives and psychotropic drugs: a systematic review.

OBJECTIVE: To examine whether the co-administration of hormonal contraceptives (HC) and psychotropic drugs commonly used to treat anxiety and/or depression results in safety or efficacy concerns for either drug. METHODS: We searched PubMed and Cochrane libraries for clinical or pharmacokinetic (PK) studies that examined co-administration of any HC with psychotropic drugs [selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), oral benzodiazepines, bupropion, mirtazapine, trazadone, buspirone, hydroxyzine, monoamine oxidase inhibitors (MAOIs), or atypical antipsychotics] in reproductive aged women. RESULTS: Of 555 articles identified, 22 articles (18 studies) met inclusion criteria. We identified 5 studies on SSRIs, four on TCAs, one on bupropion, three on atypical antipsychotics and five on oral benzodiazepines. No articles met inclusion criteria for SNRIs, mirtazapine, trazadone, buspirone, hydroxyzine or MAOIs. Overall, clinical studies did not demonstrate differences in unintended pregnancy rates when HCs were administered with and without psychotropic drugs or in psychotropic drug treatment outcomes when psychotropic drugs were administered with and without HCs. PK studies did not demonstrate changes in drug exposure related to contraceptive safety, contraceptive effectiveness or psychotropic drug effectiveness for most classes of psychotropic drugs. However, limited PK data raise concern for HCs increasing systemic exposure of amitriptyline and imipramine (both TCAs), theoretically posing safety concerns. CONCLUSION: Limited quality and quantity evidence on use of psychotropic drugs and HCs suggests low concern for clinically significant interactions, though no data exist specifically for non-oral formulations of HC. Given the high frequency of use for both HCs and psychotropic drugs among reproductive-age women in the US, this review highlights a need for further research in this area.

Co-administration of St. John's wort and hormonal contraceptives: a systematic review.

OBJECTIVES: St. John's wort (SJW) is a known strong inducer of the cytochrome P450 (CYP) 3 A4 enzyme, and both the ethinyl estradiol and progestin components of hormonal contraceptives are substrates of CYP3A4. This systematic review examined whether the co-administration of SJW and hormonal contraceptives leads to significant safety or efficacy concerns. STUDY DESIGN: Systematic review. METHODS: PubMed and Cochrane Library databases were searched for articles of any comparative study design (clinical or pharmacokinetic) that examined potential interactions between SJW and hormonal contraceptives in women of reproductive age. RESULTS: Of the 48 identified articles, four studies met inclusion criteria and compared use of combined oral contraceptives (COCs) alone to the use of COCs co-administered with SJW. Two studies demonstrated no change in markers of ovulation, but one study demonstrated increased follicular growth and probable ovulation when COCs were co-administered with SJW. Three studies demonstrated an increased risk of breakthrough bleeding with COCs and SJW. Three studies showed changes in at least one pharmacokinetic parameter that suggested a significantly decreased exposure to hormone concentrations when COCs were co-administered with SJW. The only study that did not demonstrate any significant pharmacokinetic differences examined a SJW product containing a low amount of hypericin. CONCLUSION: Limited evidence showing increased risk of ovulation and breakthrough bleeding raises concern for decreased contraceptive efficacy when COCs are co-administered with SJW. The pharmacokinetic evidence is mixed but suggests that SJW administration may be associated with weak to moderate induction of the metabolism of COCs.

Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review.

BACKGROUND: Women with depressive or bipolar disorders are at an increased risk for unintended pregnancy. OBJECTIVE: To examine the safety of hormonal contraception among women with depressive and bipolar disorders. METHODS: We searched for articles published through January 2016 on the safety of using any hormonal contraceptive method among women with depressive or bipolar disorders, including those who had been diagnosed clinically or scored above threshold levels on a validated screening instrument. Outcomes included changes in symptoms, hospitalization, suicide and modifications in medication regimens such as increase or decrease in dosage or changes in type of drug. RESULTS: Of 2376 articles, 6 met the inclusion criteria. Of three studies that examined women clinically diagnosed with depressive or bipolar disorder, one found that oral contraceptives (OCs) did not significantly change mood across the menstrual cycle among women with bipolar disorder, whereas mood did significantly change across the menstrual cycle among women not using OCs; one found no significant differences in the frequency of psychiatric hospitalizations among women with bipolar disorder who used depot medroxyprogesterone acetate (DMPA), intrauterine devices (IUDs) or sterilization; and one found no increase in depression scale scores among women with depression using and not using OCs, for both those treated with fluoxetine and those receiving placebo. Of three studies that examined women who met a threshold for depression on a screening instrument, one found that adolescent girls using combined OCs (COCs) had significantly improved depression scores after 3 months compared with placebo, one found that OC users had similar odds of no longer being depressed at follow-up compared with nonusers, and one found that COC users were less frequently classified as depressed over 11 months than IUD users. CONCLUSIONS: Limited evidence from six studies found that OC, levonorgestrel-releasing IUD and DMPA use among women with depressive or bipolar disorders was not associated with worse clinical course of disease compared with no hormonal method use.

The safety of intrauterine devices in breastfeeding women: a systematic review.

OBJECTIVES: To investigate levonorgestrel (LNG)-releasing and copper-bearing (Cu) intrauterine device (IUD) safety among breastfeeding women and, for Cu-IUD use, breastfeeding performance and infant health. STUDY DESIGN: Systematic review. METHODS: We searched PubMed, Embase, Cochrane Library and clinicaltrials.gov for articles through January 2016. We included studies of Cu-IUD or LNG-IUD users comparing IUD-specific (perforation, expulsion) and other contraceptive-related (infection, removal/cessation due to bleeding/pain and other adverse events) outcomes for breastfeeding vs. non-breastfeeding women. We also included studies of breastfeeding women comparing contraceptive-related outcome for IUD-users vs. other contraceptive-method users. Finally, we included studies comparing breastfeeding outcomes among Cu-IUD users to users of other nonhormonal contraceptives or no contraception. RESULTS: Of 548 articles identified, 23 (16 studies) met the inclusion criteria. Two studies suggested that the risk of IUD perforation was 6-10 times higher among breastfeeding vs. non-breastfeeding women. Seven studies suggested that risks for other adverse events were similar or lower among breastfeeding vs. non-breastfeeding women. Three studies among breastfeeding women found no increased risk of adverse events in IUD users vs. nonusers. Breastfeeding performance and infant growth were similar for Cu-IUD users and users of other nonhormonal methods or no contraception. CONCLUSION: Overall, risks for adverse events among IUD users, including expulsion, pain and removals, were similar or lower for breastfeeding women vs. non-breastfeeding women. Uterine perforation with IUDs, while rare, appeared more frequent among breastfeeding women. No evidence indicated that Cu-IUD use in breastfeeding women influences breastfeeding performance or infant growth.