The impact of oral contraceptive initiation on young women's condom use in 3 American cities: missed opportunities for intervention.

PURPOSE: To describe women's condom use and assess predictors of consistent condom use and dual method use in the 6 months after the initiation of oral contraception (OC). METHODS: We conducted a planned secondary cohort analysis among women less than 25 years of age initiating oral contraceptives at public family planning clinics in Atlanta, Dallas and New York City, USA, as part of a randomized trial. These clinics provide care to predominantly African American or Hispanic women of low socioeconomic status. Participants completed interviews at enrollment and at 6 months after OC start. We used multivariate logistic regression to assess factors associated with consistent condom and dual method use at 6 months. RESULTS: 1281 participants met the inclusion criteria for this analysis. At enrollment prior to OC start, 28% were consistent condom users. In the six months after initiation of oral contraception, only 14% always used a condom and 4% always used dual methods. In multivariate analysis, receiving basic advice to always use a condom after OC initiation from a provider during the baseline clinic consultation was associated with a 50% increase in the odds of using condoms consistently. Only 28% of participants were given this condom use advice. CONCLUSIONS: This study documents a decline in women's condom consistent use subsequent to initiation of the oral contraceptive and suggests that opportunities for positive intervention around condom use among women starting hormonal methods are being missed. Basic condom use advice, which is neither time consuming nor resource dependent, was associated with increased consistent use and should be immediately implemented in all family planning services.

Smoking and oral contraceptive continuation.

BACKGROUND: Smoking may be related to early discontinuation of oral contraceptives (OC). STUDY DESIGN: This was a planned secondary analysis of a randomized clinical trial. Women aged less than 25 initiating OC at three inner-city publicly funded family planning clinics enrolled in the study. Subjects reported smoking status at enrollment; 3- and 6-month interviews assessed OC continuation. RESULTS: One hundred eighty-nine (12%) of 1598 participants were current smokers. Smokers were more often lost to follow-up than nonsmokers (P<.01). Among participants with a 6-month interview, only 26% of smokers and 46% of nonsmokers were continuing OC (P<.001). After adjustment for confounding factors, smokers were still somewhat less likely to be continuing OC (adjusted OR 0.6, 95% CI 0.4-1.0). This association was unrelated to number of cigarettes smoked per day. CONCLUSIONS: These data suggest that young smokers may be more likely to discontinue OC within 6 months than nonsmokers. Smoking may be a marker for risk-taking behavior that extends to the premature discontinuation of OC.

Prior pill experiences and current continuation among pill restarters.

CONTEXT: Discontinuation of oral contraceptives often puts women at risk for unintended pregnancies. Understanding why a woman discontinued pill use can provide insight into her risk of discontinuation if she restarts use. METHODS: Women younger than 25 obtaining oral contraceptives at three university health centers in 2003-2005 were recruited to participate in a randomized trial; 628 former users were interviewed about their previous experience with the method, and were followed up three months after restarting use. Bivariate and multinomial logistic regression analyses were used to assess the relationship between prior reasons for stopping pill use and method continuation. RESULTS: Women who had discontinued using oral contraceptives because of side effects were less likely to be very sure about restarting the pill at baseline (73%) than were those who had stopped for logistical or fertility-related reasons (88-94%). They also were less likely to have been satisfied with the pill in the last use interval (49% vs. 95-98%) and less likely to be satisfied with it in the three months after restarting (76% vs. 89-93%). These women were more likely to report a short duration of use than an intermediate duration or continuous use during follow-up (odds ratios, 2.5 and 4.5). CONCLUSIONS: When counseling women who are restarting pill use, providers should ask about their experiences with the method and reasons for discontinuation; counseling for women who discontinued because of side effects should address their risk factors for early discontinuation and informing them about other contraceptive choices.

A high cholecystectomy rate in a cohort of Mexican American women who are postpartum at the time of oral contraceptive pill initiation.

BACKGROUND: Opinions regarding the association between gallbladder disease and oral contraceptive (OCs) differ. The objective of this article is to quantify cholecystectomy rate among women initiating OCs. STUDY DESIGN: Women under the age of 25 years were enrolled at four sites in a randomized trial evaluating initiation of OCs. Hospitalizations while enrolled were elicited during follow-up interviews, and medical records of women who underwent cholecystectomy were reviewed. RESULTS: Of 757 women enrolled at University of Texas Southwestern Medical Center (UTSW), 8 underwent cholecystectomy, a rate of 25.3/1000 woman-years (95% CI=8.1, 42.5). All eight were Mexican American and postpartum when they initiated OCs. The expected rate is 4.2/1000 woman-years for U.S. women aged 15-44. CONCLUSIONS: Women enrolled at the UTSW site had an increased rate of cholecystectomy and were more likely to be postpartum and Mexican American than women enrolled at the other sites.

Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial.

OBJECTIVE: To estimate whether young women taking the first pill on the day of prescription had higher continuation rates and lower pregnancy rates than women who waited until menses to start the oral contraceptive pill (OCP). METHODS: We recruited 1,716 women aged younger than 25 years seeking to initiate the oral contraceptive at three publicly funded family planning clinics, and randomly assigned them to conventional initiation of the pill (conventional start) or immediate, directly observed ingestion of the first pill (quick start) during the clinic visit. Women underwent follow-up interviews at 3 and 6 months. RESULTS: Sixty percent of participants discontinued the pill, and 8% became pregnant during follow-up. Women who took the first pill in the clinic were more likely to continue to the second OCP pack (odds ratio 1.5, 95% confidence interval 1.0-2.1.); however, the Quick Start approach did not improve OCP continuation rates at 3 and 6 months. Those assigned to Quick Start were slightly less likely to become pregnant within 6 months from the time they started the pill (hazard ratio 0.90, 95% confidence interval 0.64-1.25). Eighty-one percent of women rated the Quick Start approach as acceptable or preferable to waiting. Rates of serious adverse events were low and similar in the two groups. CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068848

Oral contraceptive discontinuation: do side effects matter?

OBJECTIVE: The purpose of this study was to assess self-reported side effects in women after they received the oral contraceptive (OC) and to compare discontinuation rates, according to presence or absence of side effects. STUDY DESIGN: The study comprised 1716 women aged <25 years who initiated the OC at 3 publicly funded family planning clinics and completed structured interviews after 3 and 6 months. RESULTS: Nearly 60% of subjects discontinued the OC by 6 months. Most subjects reported no changes in headaches, weight, moodiness, and sexual satisfaction during the first 3 months of OC use. Subjects with any complaints, especially women with increased headaches or moodiness, were more likely to discontinue the OC prematurely. Nonetheless, most discontinuation occurred for reasons that were unrelated to side effects. CONCLUSION: Side effects are absent or mild among most OC users, but women with complaints are more likely to discontinue. Side effects are less important reasons for discontinuation than widely believed.

Vaginal speculum lubrication and its effects on cervical cytology and microbiology.

The prevailing approach to Papanicolaou (Pap) and endocervical Gen-Probe(R) screening is to use an unlubricated vaginal speculum because of concerns that gel lubricant interferes with Pap smear adequacy and cervical microbiology. This study tests the hypothesis that lubrication of metal specula with a bacteriostatic gel does not increase unsatisfactory cervical cytology or decrease detection rates of endocervical Chlamydia trachomatis or Neisseria gonorrhoeae. At a publicly funded family planning clinic site, each of eight consecutive months was randomly designated by computer as an exclusively gel-lubricated or water-moistened specula use month. The assigned vaginal speculum intervention was used on all patients receiving a Pap smear and/or combination DNA probe assay for endocervical C. trachomatis and N. gonorrhoeae. From July 2003 through February 2004, 3460 Pap smears and 5535 combination probe assays for C. trachomatis and N. gonorrhoeae were collected from 6538 patients. During the 4 months of gel lubricant use, the rate of unsatisfactory cytology was 1.1% compared to 1.5% during the 4 months of water lubrication [odds ratio (OR) 0.74; 95% confidence interval (CI) 0.41-1.35]. During the 4 months of gel lubricant use, the detection rate for endocervical C. trachomatis was 1.5% compared to 1.5% (OR 1.05; 95% CI 0.67-1.62) in water lubricant months. The study population N. gonorrhoeae infection rate was too low to statistically analyze. The use of a small amount of gel lubricant on metal vaginal specula did not increase unsatisfactory cytology or decrease endocervical C. trachomatis detection rates when compared to water lubricant.

Obstetric antecedents for postpartum pelvic floor dysfunction.

OBJECTIVE: The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth. STUDY DESIGN: All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated. RESULTS: During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01). CONCLUSION: The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

Reductions in stress and depressive symptoms in mothers of substance-exposed infants, participating in a psychosocial program.

OBJECTIVE: Depression profoundly impairs psychosocial functioning. Depression can have disruptive effects on a person's family, with significant impact on the psychosocial development of the children. Recent research suggests that a mother's depressive symptoms may increase parenting stress and that parenting stress may, in turn, increase depressive symptoms, with a possible negative cycle to this process. Little is known about how these two factors interact in drug-involved mothers. This study examines how the NEW CONNECTIONS intervention (a parental education and support program for drug-involved parents) acts on parental stress and symptoms of depression. METHODS: The study site was the NEW CONNECTIONS Infant Intervention Program. The Beck Depression Inventory-II (BDI-II) and the Parenting Stress Index (PSI) were administered to drug- and alcohol-involved mothers (N = 120) at baseline and after the intervention (Week 12). RESULTS: Four of the seven PSI domains of parenting stress showed a significant reduction (Demandingness, Competence, Isolation, and Role Restriction). Changes in four domains were significantly correlated with reductions in depressive symptoms (Competence, Isolation, Attachment, and Role Restriction). There was a significant reduction in depressive symptoms as measured by the BDI-II. CONCLUSION: Reduction in some aspects of parenting stress is associated with reduction in depressive symptoms in mothers of substance-exposed infants who participated in the NEW CONNECTIONS psychosocial intervention targeting the parent-child relationship.

Legal implications of sterilization of the mentally retarded.

For more than 50 years, sterilization of mentally retarded persons was an accepted practice in many states as a way to reduce the number of persons born with mental defects. In recent years, the practice has come under heavy challenge, both medically and legally. At present, only 19 states have statutes that allow sterilizations for eugenic reasons. This article examines important court decisions regarding eugenic sterilization laws and the legal status of sterilization of mentally retarded adults and minors, as well as the consequent legal implications for physicians. Federal funding restrictions on sterilization of mentally impaired persons are discussed. The requirement of voluntary, informed consent is considered in light of an increasing emphasis on the rights of mentally retarded persons as well as greater awareness of the psychological effects of involuntary sterilization.