Adolescent and young women's experience with the vaginal ring and oral contraceptive pills.

STUDY OBJECTIVE: To compare acceptability of the vaginal contraceptive ring to that of oral contraceptive pills. DESIGN: Randomized, cross-over, 6-month study. SETTING: Urban family planning clinic for young low-income patients. PARTICIPANTS: Sexually active females aged 15-21 years (n = 130). INTERVENTIONS: Participants were randomly assigned to use the vaginal ring or oral contraceptive pills for an initial study interval of three 28-day cycles, followed by three cycles of the alternate method. MAIN OUTCOME MEASURES: Participants completed surveys about method use, acceptability, and side effects at baseline, after three cycles, and after six cycles. We analyzed study data using ANOVA models for cross-over designs. RESULTS: We did not detect higher compliance with the ring as compared to oral contraceptive pills (P = 0.176), although overall approval of the ring was significantly higher on several items measured, including liked using method (P = 0.015), would recommend it to friends (P = 0.012), and not as hard to remember to use method correctly (P < or = 0.000). Participants were less worried about health risks while using the ring (P = 0.006), but reported that the ring was more likely to interfere with sex than the pill (P < or = 0.001) and that sex partners liked the pill (P = 0.034). Most women did not report bothersome side effects with either method. CONCLUSIONS: Adolescent and young women showed favorable acceptability of the vaginal contraceptive ring compared to oral contraceptive pills.

Beyond access: acceptability, use and nonuse of emergency contraception among young women.

OBJECTIVE: This study was undertaken to assess the acceptability of levonorgestrel emergency contraception (EC). STUDY DESIGN: We examined attitudes and use patterns among 1950 women in a randomized trial evaluating access to EC through advance provision, pharmacies, or clinics. RESULTS: Most women considered EC to be safe (92%) and effective (98%). Compared with women with clinic access, women with direct pharmacy access were no more likely to use EC within 24 hours (odds ratio [OR] = 1.65, 95% CI = 0.82-3.30) or to report it very convenient (OR = 1.41, 95% CI = 0.77-2.56). However, women with advance provisions were more likely to use EC promptly (OR = 2.43, 95% CI = 1.24-4.80) and report high convenience (OR = 4.25, 95% CI = 2.32-7.76). Advance provision increased use by all women, whereas pharmacy access increased use only among condom users. Inconvenience and fear of side effects were common reasons for nonuse. CONCLUSION: Women viewed EC favorably. Advance provision improved promptness and convenience of use overall, while pharmacy access benefited specific populations.

Safety of mifepristone abortions in clinical use.

OBJECTIVES: Extensive data from clinical trials document mifepristone's safety and efficacy for induced abortion, but less information is available about its safety in routine clinical use. METHODS: Data on mifepristone abortion use from the Planned Parenthood Federation of America, the largest provider of mifepristone abortion in the United States, from 2001 through the first quarter of 2004 were collected using a centralized reporting system. Over the study period, 95,163 mifepristone abortions were provided. Reportable events are complications requiring inpatient or outpatient hospital treatment. RESULTS: Overall, 2.2 per 1000 women (95% CI 1.9-2.5) experienced a complication, most commonly, heavy bleeding. Mifepristone abortion mortality is estimated to be 1.1 per 100,000 based on one death (95% CI 0.3-5.9). CONCLUSIONS: The safety of mifepristone is high; few serious medical complications occur in routine clinical use.

Cervical cancer screening continues to limit provision of contraception.

PURPOSE: Balancing needs for contraception and cervical cancer screening is challenging for clinicians. We assessed US obstetrician/gynecologists' practices regarding requirement of Pap testing before prescribing oral contraceptive or emergency contraceptive pills. METHODS: Questionnaires structured as clinical vignettes describing women desiring contraception with different risks of cervical dysplasia were mailed to a national sample of 355 obstetrician/gynecologists. RESULTS: A minority (3%) of the 185 obstetrician/gynecologists who responded would refill 12 months of oral contraceptives without requiring Pap testing. However, most would provide a limited supply of oral contraceptives until Pap testing could be performed. A substantial proportion (11-16%) would refuse to prescribe emergency contraception to women who they felt required Pap testing. Younger physicians, those practicing in academic settings and those who follow American Cancer Society guidelines were more willing to prescribe contraceptives without Pap testing. CONCLUSIONS: Cervical cancer screening continues to limit prescription of routine and emergency contraception by many US obstetrician/gynecologists.

Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial.

OBJECTIVE: To compare bleeding profiles and satisfaction among women using a norelgestromin/ethinyl estradiol (E2) transdermal contraceptive patch in an extended regimen to those among women using a traditional 28-day patch regimen. METHODS: Healthy, regularly menstruating women (N = 239) were randomly assigned (2:1 ratio) to receive the norelgestromin/ethinyl E2 transdermal patch in an extended regimen (weekly application for 12 consecutive weeks, 1 patch-free week, and 3 more consecutive weekly applications, n = 158) or a cyclic regimen (4 consecutive cycles of 3 weekly applications and 1 patch-free week, n = 81). Subjects recorded bleeding data daily and completed satisfaction questionnaires. Subjects and investigators provided overall assessments of the regimens. RESULTS: Extended use of the norelgestromin/ethinyl E2 transdermal patch resulted in fewer median bleeding days (6 compared with 14, P < .001), bleeding episodes (1 compared with 3, P < .001), and bleeding or spotting episodes (2 compared with 3, P < .001) compared with cyclic use during days 1-84; median numbers of bleeding or spotting days were similar between regimens (14 compared with 16, P = .407) during this time. Extended use delayed median time to first bleeding to 54 days compared with 25 days with cyclic (P < .001). Subjects were highly satisfied with both regimens. Although not statistically significant, slightly more adverse events were reported with the extended than with the 28-day regimen. CONCLUSION: Compared with cyclic use, extended use of the norelgestromin/ethinyl E2 transdermal patch delayed menses and resulted in fewer bleeding days. This regimen may represent a useful alternative for women who prefer fewer episodes of withdrawal bleeding.

A qualitative study of insurers' coverage for mifepristone-induced abortion.

In this qualitative evaluation of 14 U.S. health insurers' coverage policies concerning mifepristone-induced medical abortion, the findings suggest that a significant proportion of health plans do not include evidence-based clinical information obtained from recent research, data, and practice. This omission may hinder the adoption of new, evidence-based protocols for medical abortion by physicians. A model coverage policy that contains comprehensive clinical information regarding appropriate clinical regimens for mifepristone is provided as an example for insurers and others in the field.

Willing and able? Provision of medication for abortion by future internists.

INTRODUCTION AND BACKGROUND: The development of medications such as mifepristone (RU486) has created the opportunity to introduce medication abortion as a component of office practice. METHODS: Two hundred twelve residents training in internal medicine, family practice, and gynecology at 11 residency programs completed anonymous surveys assessing willingness to provide medication for abortion and perceived barriers to future provision of mifepristone. RESULTS: Residents training in internal medicine knew less about mifepristone and preabortion screening than other primary care trainees. Forty-two percent of internists, 84% of family practitioners, and 83% of gynecologists were willing to prescribe mifepristone (p < .001). Many internists were concerned about lacking adequate "backup" access to vacuum aspiration services (84% of internists, 74% of family practitioners, 35% of gynecologists; p < .001). In multivariable analysis, the training-related factors most predictive of whether an internist was willing to provide medication for abortion were feeling that mifepristone is very safe, abortion services are needed by the patients served, knowing to check an ultrasound before inducing abortion, and having no concern of how to manage bleeding or of lacking adequate backup should vacuum aspiration be needed. CONCLUSIONS AND DISCUSSION: Many (42%) future internists are willing to provide mifepristone, but most lack adequate knowledge of mifepristone and preabortion screening. As access to abortion services is limited in many U.S. counties, internists who are willing to provide mifepristone should be offered the necessary training to do so safely.

Knowledge of emergency contraception among women aged 18 to 44 in California.

OBJECTIVE: The State of California has taken several steps to make emergency contraceptives (ECs) available to women in the state. By using data from the 1999-2001 California Women's Health Survey, we estimated the knowledge of emergency contraception among adult women of reproductive age at risk of pregnancy (n=6209). STUDY DESIGN: This study is based on 3 years of data (1999-2001) from the California Women's Health Survey (CWHS), an annual population-based survey of more than 4000 randomly selected adult women (aged 18 years and older) in California. A total of 6198 women aged 18 to 44 responded to the 2 emergency contraception questions: "To the best of your knowledge, if a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy?" and "What can she do?" RESULTS: We find that 38% of California women were able to correctly identify emergency contraception. Most importantly, the women who are most likely to need emergency contraception-those who are at risk of an unintended pregnancy but not using any method of contraception-have among the lowest levels of knowledge (only 29% identified a method of ECs). CONCLUSION: Results show that family planning providers may be reaching their clients, but broader outreach to the public has not yet achieved sufficiently high information levels among women in greatest need of the method.

Expanded state-funded family planning services: estimating pregnancies averted by the Family PACT Program in California, 1997-1998.

OBJECTIVES: The California Family Planning, Access, Care, and Treatment Program was implemented in 1997 to provide family planning services for uninsured, low-income women and men. We estimated the impact on fertility of providing 500 000 women with contraceptives. METHODS: Paid claims and medical record review data were used to estimate pregnancies averted. Pregnancies women experienced while enrolled in the program and pregnancies they would have experienced given methods used before enrollment were modeled as a Markov process. RESULTS: One year of Family Planning, Access, Care, and Treatment services averted an estimated 108 000 unintended pregnancies that would have resulted in 50 000 unintended births and 41 000 induced abortions. CONCLUSIONS: Providing contraceptives to low income, medically indigent women significantly reduced the number of unintended pregnancies in California.