Immediate vs delayed postpartum insertion of long-acting reversible contraception methods: meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to conduct a meta-analysis of randomized trials comparing the immediate vs delayed provision of long-acting reversible contraceptives in postpartum subjects, focusing on short-interval pregnancies, utilization rates, and adverse events. DATA SOURCES: Cochrane Central, Embase, PubMed, and ClinicalTrials.gov were systematically searched from inception up to December 19, 2023, without filters or language limitation. STUDY ELIGIBILITY CRITERIA: We selected randomized controlled trials assessing the immediate insertion of long-acting reversible contraceptives in women during postpartum period in comparison with the delayed provision. STUDY APPRAISAL AND SYNTHESIS METHODS: We calculated relative risks with 95% confidence intervals to analyze the primary outcome of utilization rates and secondary endpoints, including initiation rates, pregnancy, any breastfeeding, exclusive breastfeeding, and serious adverse events. A random-effects model was employed in the R software. Moreover, we assessed the risk of bias of selected randomized controlled trials using version 2 of the Cochrane Risk of Bias Assessment Tool. RESULTS: We included 24 randomized trials comprising 2507 participants, of whom 1293 (51.6%) were randomized to the immediate insertion. Postpartum women in the immediate group had lower risk of pregnancy (relative risk 0.16; 95% confidence interval 0.04-0.71; P=.02) compared with delayed group, and higher rates of long-acting reversible contraceptives at 6 months of follow-up (relative risk 1.23; 95% confidence interval 1.09-1.37; P<.01). CONCLUSION: Inserting long-acting reversible contraceptives before hospital discharge was associated with a reduction in the risk of pregnancy, and increased rates of its utilization at 6 months of follow-up. This intervention may be an effective contraception strategy for postpartum women.

Reasons for satisfaction with the use of the 52-mg levonorgestrel intrauterine system.

OBJECTIVES: To assess the reasons to use, reasons they liked, satisfaction with, and possibilities of recommendation to other women of the levonorgestrel 52-mg intrauterine system (LNG-IUS) by users. MATERIALS AND METHODS: A cross-sectional study was conducted at the University of Campinas, Campinas, Brazil from January to July 2021. We enrolled users who came to the clinic, and we applied a pre-tested structured questionnaire with open-ended questions. We performed descriptive analyses of the variables, assessing the level of satisfaction with, and the reasons regarding the possibility of continuing to use, the IUS. RESULTS: Of the 517 enrolled women, 251 (48%) were aged 35 years or older (mean age 33.9 ± 9.0 years), 276 (53%) were white, 14 (3%) were adolescents, 155 (30%) were nulligravidas, and 307 (59.4%) reported experiencing amenorrhea in the last 90 days. Common reasons why women liked to use the LNG-IUS included both the reduction of menstrual bleeding (419 women; 81%) and dysmenorrhea (290 women; 56.1%). Nine out of 10 users (517 women; 91%) were satisfied with the method, and the majority would recommend it to other women. CONCLUSION: We found a high satisfaction rate among LNG-IUS users mainly due to the reduction of both menstrual bleeding and dysmenorrhea.

Delivery of home-based post-partum contraception in rural Guatemalan women: feasibility, recruitment and retention in a cluster-randomized trial.

BACKGROUND: Few cluster-randomized trials have been performed in rural Guatemala. Our objective was to describe the feasibility, recruitment and retention in our cluster-randomized trial. METHODS: In our cluster-randomized trial, a range of contraceptives were brought to mothers' homes in rural Guatemala. RESULTS: Of 173 women approached, 33 were excluded. Of the 140 eligible women, 127 (91%) consented to participate. Of the 87 women who should have been assessed for the primary outcome, three were lost to follow-up, which represents a retention rate of 97%. CONCLUSIONS: Nurses who are both clinical providers and study staff can feasibly conduct research, which leads to high enrollment and retention rates.

Juventude, gênero e justiça reprodutiva: iniquidades em saúde no planejamento reprodutivo no Sistema Único de Saúde / Youth, gender and reproductive justice: health inequities in family planning in Brazil's Unified Health System

Resumo Iniciação sexual é um processo gradual de experimentação e aprendizado do repertório cultural sobre gênero, reprodução, contracepção, violência sexual, entre outros temas que circundam a sociabilidade juvenil. Ao contrário da perspectiva da abstinência sexual como panaceia para redução da "gravidez precoce" no Brasil, postula-se a abordagem da justiça reprodutiva como framework para enfrentar iniquidades em saúde no planejamento reprodutivo. Discutem-se desafios às políticas públicas de saúde para amparar adolescentes e jovens em suas trajetórias sexuais e reprodutivas, privilegiando a dimensão da interseccionalidade. O foco recai nas iniciativas institucionais públicas de oferta de métodos contraceptivos hormonais reversíveis de longa duração (LARC) no Sistema Único de Saúde, na última década. Do ponto de vista metodológico, tal reflexão se apoia em material empírico oriundo de pesquisa antropológica documental sobre tecnologias contraceptivas, no intuito de problematizar o que chamamos de "oferta seletiva" de tais dispositivos e seu viés discriminatório e estigmatizante. A defesa da ampliação da oferta contraceptiva no SUS, com acesso universal de todas as mulheres à LARC, distancia-se do que designamos como "coerção contraceptiva" em determinados grupos sociais.

Abstract Sexual initiation is a gradual process of experimentation and learning the cultural repertoire of gender, reproduction, contraception, sexual violence and other topics surrounding youth sociability. Unlike sexual abstinence-based approaches promoted as a panacea for reducing "early pregnancy" in Brazil, reproductive justice is posited as a framework for addressing health inequities in family planning. This article discusses the challenges faced by public health policies in supporting adolescents and young people in their sexual and reproductive trajectories, drawing on the concept of intersectionality. We focus on public institutional initiatives providing long-acting reversible contraceptives (LARC) on the Brazilian Unified Health System (SUS) implemented over the last decade. We conducted a documentary anthropological study drawing on empirical data on contraceptive technologies in order to problematize what we call the "selective provision" of these devices and discriminatory and stigmatizing practices. Advocating the expansion of the provision of contraception on the SUS, with universal access to LARC for all women, distances itself from what we call "contraceptive coercion" among specific social groups.

Contraceptive practices in women with chronic medical conditions.

Contraception in women with severe medical conditions is a potential measure to reduce maternal mortality. We sought to determine the contraceptive use in women with medical conditions at the University Hospital of the West Indies (UHWI) in Jamaica to determine if there is room for improvement in contraceptive use. Participants were identified from the medical out-patient departments and questionnaires administered. Two hundred and sixty females between 18 and 44 years with varied chronic medical conditions were included. Those included were systemic lupus erythematosus (SLE), diabetes, hypertension (HTN), thyroid disease, cardiac and renal disease. The total current use of contraception was 58.4%, while 41.6% were not on contraceptives. The use of barrier methods and long-acting reversible contraceptives (LARCs) was 71% and 10%, respectively. The current use of contraception in patients with sickle cell disease (SCD) was 84% (p=.004) and in rheumatoid arthritis (RA), 14% (p=.028). Fifty-eight (58, 24.2%) of the women were using two or more methods of contraception. There is a role for improving contraceptive use among women with medical conditions as they are at increased risk of pregnancy complications.IMPACT STATEMENTWhat is already known on this subject? Women with medical comorbidities significantly contribute to both direct and indirect causes of maternal mortality. Contraception may play an integral role in reducing the risk of dying in chronically ill women; however, the use of contraception in this group is often suboptimal.What the results of this study add? This study adds to the literature that in this high-risk group, there is an underuse of long-acting reversible contraceptives, which is ideal for this population.What the implications are of these findings for clinical practice or further research? The results will provide evidence that this high-risk group of women should be targeted and counselled regarding their risk of morbidity and mortality in pregnancy as well as contraception use while their condition is optimised. From this evidence, services may be put in place in institutions, especially in low-resource settings.

Delivery of home-based postpartum contraception in rural Guatemalan women: a cluster-randomized trial protocol.

BACKGROUND: Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth. METHODS: This study is a cluster-randomized trial of communities in rural Guatemala where women receive ante- and postnatal care through a community-based nursing program. When nurses visit women for their postpartum visit in the intervention clusters, instead of providing only routine care that includes postpartum contraceptive education and counseling, the nurses will also bring a range of barrier, short-acting, and long-acting contraceptives that will be offered and administered in the home setting, after routine clinical care is provided. DISCUSSION: A barrier to postpartum contraception is access to medications and devices. Our study removes some access barriers (distance, time, cost) by providing contraception in the home. We also trained community nurses to place implants, which are a type of long-acting reversible contraceptive method that was previously only available in the closest town which is about an hour away by vehicular travel. Therefore, our study examines how home-based delivery of routinely available contraceptives and the less routinely available implant may be associated with increased uptake of postpartum contraception within 3 months of childbirth. The potential implications of this study include that nurses may be able to be trained to safely provide contraceptives, including placing implants, in the home setting, and provision of home-based contraception may be an effective way of delivering an evidence-based intervention for preventing unintended and closely spaced pregnancies in the postpartum period. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04005391. Retrospectively registered on 1 July 2019.

Millennials and contraception: why do they forget? An international survey exploring the impact of lifestyles and stress levels on adherence to a daily contraceptive regimen.

BACKGROUND: Rates of unintended pregnancies are particularly high in young women, a finding that may be associated with their tendency not to use contraceptives correctly and/or consistently. For millennial women, busy lifestyles and associated stress may impact on daily activities including taking an oral contraceptive pill. METHODS: Contraceptive pill users aged 21-29 years ('millennial' women; N = 4500) from nine countries in Europe and North and South America completed an online questionnaire on their daily habits and activities, disruptions to their routine and associated stress levels. RESULTS: Thirty-nine percent of surveyed participants had forgotten to take their contraceptive pill at least once in the past month; 39% also admitted not taking it at the same time each day. On average, participants had experienced two major disruptions to their daily lives in the past year, with three quarters (74%) believing these disruptions increased their stress levels. Of those who had missed at least one pill in the past year, 40% attributed it to a busy schedule and 21% to stress, among other reasons. Over half of respondents (55%) reported they were more likely to forget their pill when preoccupied. CONCLUSIONS: Times of stress may make it more likely for millennial women to forget to take their pill. Health care providers should be aware of typical contraceptive adherence rates among young women and ensure that contraceptive counselling sessions include discussion of lifestyle issues and potential barriers to adherence. Every woman should be counselled on all available methods, so that she can make an informed choice on what best suits her.

The use of long-acting reversible contraceptives in Latin America and the Caribbean: current landscape and recommendations.

STUDY QUESTION: Can the high rate and associated burden of unintended pregnancy (UP) and adolescent pregnancy in Latin America and the Caribbean (LAC) be reduced through wider access to and use of long-acting reversible contraceptive (LARC) methods? SUMMARY ANSWER: Studies show that impoved access to and use of LARC methods is an effective tool for reducing the high rates of UP, unsafe abortion and abortion-related complications, and maternal deaths (as well as reducing their social and financial burden), and we have provided recommendations to help achieve this in LAC. WHAT IS KNOWN ALREADY: LAC comprises 46 countries with 650 million inhabitants, and shows large disparities in socioeconomic development, access to health services and attention to sexual and reproductive health rights. The exercise of these rights and universal access to sexual and reproductive health (SRH) programmes is a key strategy for improving maternal health by reducing the number of UPs, the rate of women's and child mortality and morbidity, and the number of unsafe abortions. The implementation of SRH programmes in the region has contributed to a decrease in pregnancy rates of more than 50% over 40 years. However, despite this progress, the numbers of UP and adolescent pregnancies are still among the highest worldwide, which can be attributed in large part to the low prevalence of use of LARC methods. STUDY DESIGN SIZE DURATION: This is a position paper with the objective of reviewing the magnitude and burden of UP in LAC, as well as available LARC methods and barriers to their access, with the goal of increasing knowledge and awareness among healthcare professionals (HCP), policymakers and the general public about the potential to reduce UP rates through the increased use of LARC. PARTICIPANTS/MATERIALS SETTING METHOD: We searched the electronic databases of PubMed and EMBASE to identify studies published up to May 2017. We also searched for websites regarding LAC, LARC methods, and UP including, for example, those from the United Nations, the World Health Organization, Pan American Health Organization, the Alan Guttmacher Institute and the United States Agency for International Development. Studies were included if they investigated mainly UP and their consequences as well as the use of LARC methods in the region. During 3 days of meetings, the importance of the studies identified and the appropriateness of inclusion were discussed. MAIN RESULTS AND THE ROLE OF CHANCE: LAC is not one unit and shows great ethnic diversity as well as economic and cultural differences among the various countries. These differences must be taken into account when developing policies related to disseminating information and combatting misinformation regarding the use of LARC among different audiences, such as adolescents and young women, nulligravidas, indigenous populations and women with disabilities. Furthermore, only some governments have made efforts to increase accessibility to LARC methods, and there is a need to implement training programmes for HCPs, launch education campaigns for the general public, increase access and review the cost-benefit analyses specific to LARC, which have already demonstrated that the upfront cost of LARC is less than the cummulative expense of short-term contraceptives. Recommendations to achieve these goals are presented. LIMITATIONS REASONS FOR CAUTION: Knowledge and awareness of the contraceptive method itself and of the mix of individual countries in the region is essential to the development of specific strategies and actions, tailored to each particular country situation, aimed at increasing access to modern contraceptive methods, especially LARC. WIDER IMPLICATIONS OF THE FINDINGS: Healthcare systems in LAC should consider LARC as a primary option for decreasing UP and adolescent pregnancy. Disseminating information, increasing awareness of their efficacy, removing barriers and improving access to LARC methods are the urgent actions recommended for government, academia, professional organizations, insurance companies and policymakers in order to address this major public health problem in LAC. STUDY FUNDING/COMPETING INTERESTS: This manuscript was supported by a grant from the Americas Health Foundation (AHF), a 501(c)3 nonprofit organization dedicated to improving healthcare throughout the Latin American Region. LB and IM received additional support from the São Paulo Research Foundation (FAPESP) award # 2015/20504-9. The authors declare no conflict of interest.

Legal termination of pregnancy as an opportunity for expanding postabortion contraception: Experience at the Pereira Rossell Hospital, Montevideo, Uruguay.

OBJECTIVE: To determine to what extent women adopted highly effective contraceptive methods after a legal abortion. METHODS: The data available during a period before and another period after liberalization of the abortion law were reviewed. The data gathering was incomplete and reliable only during certain periods, which were used in the study. RESULTS: There was an increase in the proportion of women who returned for contraception and in the proportion who used any method and long-acting methods; however, no contraception was administered immediately after abortion and only 16% of all women treated started to use a long-acting method during the period after the law was liberalized. CONCLUSION: The proposed objective was not being achieved, the recommended guidelines were not being followed, and data gathering was incomplete. Good intentions are not enough and it is always necessary to evaluate the performance of a program. The results indicate that immediate reforms are necessary in postabortion contraception services.

The Use of Long Acting Reversible Contraceptives and the Relationship between Discontinuation Rates due to Menopause and to Female and Male Sterilizations / Uso de contraceptivos reversíveis de longa duração e a relação entre taxas de descontinuidade devido à menopausa e à esterilização de homens e mulheres

Abstract Introduction Women require effective contraception until they reach menopause. The long acting reversible contraceptives (LARC) and the depot-medroxyprogesterone acetate (DMPA, Depo-Provera(r), Pfizer, Puurs, Belgium) are great options and can replace possible sterilizations. Purpose To assess the relationship between the use of LARCs and DMPA and terminations ascribed to menopause and sterilizations in a Brazilian clinic. Methods We reviewed the records of women between 12 and 50 years of age attending the clinic that chose to use a LARC method or DMPA. Cumulative termination rates due to sterilization or because the woman had reached menopause were computed using single decrement life-table analysis over 32 years. We also examined all records of surgical sterilization at our hospital between the years 1980-2012. Results Three hundred thirty-two women had continuously used the same contraceptive until menopause, and 555 women had discontinued the method because they or their partners underwent sterilization. From year 20 to year 30 of use, levonorgestrel intrauterine-releasing system (LNG-IUS - Mirena(r), Bayer Oy, Turku, Finland; available since 1980), copper intrauterine device (IUD - available since 1980) and DMPA users showed a trend of cumulative higher discontinuation rates due to menopause when compared with the discontinuation rates due to sterilization. Over the study period, a steep decline in the use of sterilization occurred. Conclusion Over the past 15 years of research we have observed a trend: women usually preferred to continue using LARC methods or DMPA until menopause rather than decide for sterilization, be it their own, or their partners'. The annual number of sterilizations dropped in the same period. The use of LARC methods and DMPA until menopause is an important option to avoid sterilization, which requires a surgical procedure with potential complications.

Resumo Introdução Mulheres necessitam de contracepção até atingirem a menopausa. Os contraceptivos reversíveis de longa duração e o acetato de medroxiprogesterona de depósito (AMPD) são ótimas opções para substituir possíveis esterilizações. Objetivo Avaliar a relação entre o uso de contraceptivos reversíveis de longa duração (LARCs) e AMPD com terminações atribuídas à menopausa e a esterilizações em uma clínica brasileira. Métodos Revisamos os registros de mulheres entre 12 e 50 anos de idade atendidas em clínica e que escolheram usar LARC ou AMPD. Índices de terminação acumulada devido à esterilização ou à menopausa foram computados usando análise de tabela de vida durante 32 anos. Também examinamos todos os registros de cirurgias de esterilização em nosso hospital no período de 1980 a 2012. Resultados Trezentas e trinta e duas mulheres usaram continuamente o mesmo contraceptivo até a menopausa, e 555 mulheres não deram continuidade ao método pelo fato de elas ou seus parceiros terem se submetido à esterilização. De 20 a 30 anos de uso, usuários de sistema intrauterino de levonorgestrel, dispositivo intrauterino de cobre e AMPD apresentaram tendência de maiores índices de descontinuidade devido à menopausa quando comparados a índices de descontinuidade devido à esterilização. No período de estudo, ocorreu um declínio acentuado no uso de esterilização. Conclusão Nos últimos 15 anos do estudo, foi observada uma tendência na qual mulheres optaram mais por continuar usando LARC ou AMPD até a menopausa do que pela esterilização própria ou de seus parceiros. O número anual de esterilizações caiu no mesmo período. O uso de LARC e AMPD até a menopausa é uma opção importante para evitar a esterilização, que exige um procedimento cirúrgico com potenciais complicações.

Legal termination of pregnancy as an opportunity for expanding postabortion contraception: Experience at the Pereira Rossell Hospital, Montevideo, Uruguay.

OBJECTIVE: To determine to what extent women adopted highly effective contraceptive methods after a legal abortion. METHODS: The data available during a period before and another period after liberalization of the abortion law were reviewed. The data gathering was incomplete and reliable only during certain periods, which were used in the study. RESULTS: There was an increase in the proportion of women who returned for contraception and in the proportion who used any method and long-acting methods; however, no contraception was administered immediately after abortion and only 16% of all women treated started to use a long-acting method during the period after the law was liberalized. CONCLUSION: The proposed objective was not being achieved, the recommended guidelines were not being followed, and data gathering was incomplete. Good intentions are not enough and it is always necessary to evaluate the performance of a program. The results indicate that immediate reforms are necessary in postabortion contraception services.

Estimated disability-adjusted life years averted by long-term provision of long acting contraceptive methods in a Brazilian clinic.

STUDY QUESTION: What is the contribution of the provision, at no cost for users, of long acting reversible contraceptive methods (LARC; copper intrauterine device [IUD], the levonorgestrel-releasing intrauterine system [LNG-IUS], contraceptive implants and depot-medroxyprogesterone [DMPA] injection) towards the disability-adjusted life years (DALY) averted through a Brazilian university-based clinic established over 30 years ago. SUMMARY ANSWER: Over the last 10 years of evaluation, provision of LARC methods and DMPA by the clinic are estimated to have contributed to DALY averted by between 37 and 60 maternal deaths, 315-424 child mortalities, 634-853 combined maternal morbidity and mortality and child mortality, and 1056-1412 unsafe abortions averted. WHAT IS KNOWN ALREADY: LARC methods are associated with a high contraceptive effectiveness when compared with contraceptive methods which need frequent attention; perhaps because LARC methods are independent of individual or couple compliance. However, in general previous studies have evaluated contraceptive methods during clinical studies over a short period of time, or not more than 10 years. Furthermore, information regarding the estimation of the DALY averted is scarce. STUDY DESIGN, SIZE AND DURATION: We reviewed 50 004 medical charts from women who consulted for the first time looking for a contraceptive method over the period from 2 January 1980 through 31 December 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who consulted at the Department of Obstetrics and Gynaecology, University of Campinas, Brazil were new users and users switching contraceptive, including the copper IUD (n = 13 826), the LNG-IUS (n = 1525), implants (n = 277) and DMPA (n = 9387). Estimation of the DALY averted included maternal morbidity and mortality, child mortality and unsafe abortions averted. MAIN RESULTS AND THE ROLE OF CHANCE: We obtained 29 416 contraceptive segments of use including 25 009 contraceptive segments of use from 20 821 new users or switchers to any LARC method or DMPA with at least 1 year of follow-up. The mean (± SD) age of the women at first consultation ranged from 25.3 ± 5.7 (range 12-47) years in the 1980s, to 31.9 ± 7.4 (range 16-50) years in 2010-2011. The most common contraceptive chosen at the first consultation was copper IUD (48.3, 74.5 and 64.7% in the 1980s, 1990s and 2000s, respectively). For an evaluation over 20 years, the cumulative pregnancy rates (SEM) were 0.4 (0.2), 2.8 (2.1), 4.0 (0.4) and 1.3 (0.4) for the LNG-IUS, the implants, copper IUD and DMPA, respectively and cumulative continuation rates (SEM) were 15.1 (3.7), 3.9 (1.4), 14.1 (0.6) and 7.3 (1.7) for the LNG-IUS, implants, copper IUD and DMPA, respectively (P < 0.001). Over the last 10 years of evaluation, the estimation of the contribution of the clinic through the provision of LARC methods and DMPA to DALY averted was 37-60 maternal deaths; between 315 and 424 child mortalities; combined maternal morbidity and mortality and child mortality of between 634 and 853, and 1056-1412 unsafe abortions averted. LIMITATIONS, REASONS FOR CAUTION: The main limitations are the number of women who never returned to the clinic (overall 14% among the four methods under evaluation); consequently the pregnancy rate could be different. Other limitations include the analysis of two kinds of copper IUD and two kinds of contraceptive implants as the same IUD or implant, and the low number of users of implants. In addition, the DALY calculation relies on a number of estimates, which may vary in different parts of the world. WIDER IMPLICATIONS OF THE FINDINGS: LARC methods and DMPA are highly effective and women who were well-counselled used these methods for a long time. The benefit of averting maternal morbidity and mortality, child mortality, and unsafe abortions is an example to health policy makers to implement more family planning programmes and to offer contraceptive methods, mainly LARC and DMPA, at no cost or at affordable cost for the underprivileged population. STUDY FUNDING/COMPETING INTERESTS: This study received partial financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant # 2012/12810-4 and from the National Research Council (CNPq), grant #573747/2008-3. B.F.B., M.P.G., and V.M.C. were fellows from the scientific initiation programme from FAPESP. Since the year 2001, all the TCu380A IUD were donated by Injeflex, São Paulo, Brazil, and from the year 2006 all the LNG-IUS were donated by the International Contraceptive Access Foundation (ICA), Turku, Finland. Both donations are as unrestricted grants. The authors declare that there are no conflicts of interest associated with this study.