A theoretical model of contraceptive decision-making and behaviour in diabetes: A qualitative application of the Health Belief Model.

AIM: People with diabetes have contraceptive needs that have been inadequately addressed. The aim of this qualitative study was to develop a theoretical model that reflects contraceptive decision-making and behaviour in the setting of diabetes mellitus. METHODS: We conducted semi-structured, qualitative interviews of 17 women with type 1 or type 2 diabetes from Michigan, USA. Participants were recruited from a diabetes registry and local clinics. We adapted domains from the Health Belief Model (HBM) and applied reproductive justice principles to inform the qualitative data collection and analysis. Using an iterative coding template, we advanced from descriptive to theoretical codes, compared codes across characteristics of interest (e.g. diabetes type), and synthesized the theoretical codes and their relationships in an explanatory model. RESULTS: The final model included the following constructs and themes: perceived barriers and benefits to contraceptive use (effects on blood sugar, risk of diabetes-related complications, improved quality of life); perceived seriousness of pregnancy (harm to self, harm to foetus or baby); perceived susceptibility to pregnancy risks (diabetes is a 'high risk' state); external cues to action (one-size-fits-all/anxiety-provoking counselling vs. personalized/trust-based counselling); internal cues to action (self-perceived 'sickness'); self-efficacy (reproductive self-efficacy, contraceptive self-efficacy); and modifying factors (perceptions of biased counselling based upon one's age, race or severity of disease). CONCLUSIONS: This novel adaptation of the HBM highlights the need for condition-specific and person-centred contraceptive counselling for those with diabetes.

Unmet/met need for contraception and self-reported abortion in Ghana.

BACKGROUND: Unmet need for contraception in several sub-Saharan African countries, including Ghana, remains high, with implications for unintended pregnancies and unsafe abortion, associated maternal morbidity and mortality. In this paper, we analysed for any associations between unmet/met need for contraception and the prevalence of abortion. METHODS: The paper utilizes the 2014 Ghana Demographic Health Survey dataset. Applying descriptive statistics initially, and later, a binary logistic regression, we estimate two different models, taking into account, unmet/met need for contraception (Model 1) and a multivariable one comprising socioeconomic, spatial, cultural and demographic behaviour variables (Model 2) to test the associations between unmet/met need for contraception in Ghana. RESULTS: One-fourth (25%) of sampled women in 2014 had ever had an abortion. The bivariate results showed that women who reported "no unmet" considerably tended to report abortion more than the reference category - not married and no sex in the last 30days. The elevated odds among respondents who indicated "no unmet need" persisted even after controlling for all the relevant confounders. Relatedly, unlike women with an unmet need for spacing, women who desired to limit childbearing had a slightly higher tendency to report an abortion. CONCLUSION: The linkage between unmet need for contraception appears more complex, particularly when the connections are explored post-abortion. Thus, while an abortion episode is most likely due to unintended pregnancy, contraception may still not be used, after an abortion, probably because of failure, side effects or simply, a dislike for any method.

2016 Updates to US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use: Highlights for Adolescent Patients.

The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.

Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety.

OBJECTIVE: To assess the effectiveness and safety of task shifting for the delivery of injectable contraceptives, contraceptive implants, intrauterine devices (IUDs), tubal ligation and vasectomy in low- and middle-income countries. METHODS: Multiple electronic databases were searched up to 25 May 2012 for studies which had assessed the delivery of contraceptives by health workers with lower levels of training, compared to delivery by health workers usually assigned this role, or compared to no organized provision of contraceptives. We included randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. Data were extracted using a standard form and the certainty of the evidence found was assessed using GRADE. RESULTS: We identified six randomized controlled trials published between 1977 and 1995 that assessed the safety and effectiveness of task shifting for the delivery of long-term contraceptives. Two studies assessed IUD insertion by nurses compared to doctors, two assessed IUD insertion by auxiliary nurse-midwives compared to doctors, one assessed tubal ligation by midwives compared to doctors, and one assessed the delivery of vasectomy by medical students compared to doctors. In general, little or no difference was found in contraceptive outcomes between cadres. Study design limitations and the low number of eligible studies, however, allow only limited conclusions to be drawn. CONCLUSIONS: The findings indicate that task shifting for the delivery of long-term contraceptives may be a safe and effective approach to increasing access to contraception. Further research is needed because the certainty of the evidence identified is variable.

Quality of care in contraceptive services provided to young people in two Ugandan districts: a simulated client study.

BACKGROUND: Low and inconsistent use of contraceptives by young people contributes to unintended pregnancies. This study assessed quality of contraceptive services for young people aged 15-24 in two rural districts in Uganda. METHODS: Five female and two male simulated clients (SCs) interacted with 128 providers at public, private not-for-profit (PNFP), and private for profit (PFP) health facilities. After consultations, SCs were interviewed using a structured questionnaire. Six aspects of quality of care (client's needs, choice of contraceptive methods, information given to users, client-provider interpersonal relations, constellation of services, and continuity mechanisms) were assessed. Descriptive statistics and factor analysis were performed. RESULTS: Means and categorized quality scores for all aspects of quality were low in both public and private facilities. The lowest quality scores were observed in PFP, and medium scores in PNFP facilities. The choice of contraceptive methods and interpersonal relations quality scores were slightly higher in public facilities. Needs assessment scores were highest in PNFP facilities. All facilities were classified as having low scores for appropriate constellation of services. Information given to users was suboptimal and providers promoted specific contraceptive methods. Minority of providers offered preferred method of choice and showed respect for privacy. CONCLUSIONS: The quality of contraceptive services provided to young people was low. Concurrent quality improvements and strengthening of health systems are needed.

Estradiol valerate and dienogest: a novel four-phasic oral contraceptive pill effective for pregnancy prevention and treatment of heavy menstrual bleeding.

Estradiol valerate and dienogest have been combined to create a novel four-phasic oral contraceptive pill effective for both pregnancy prevention and treatment of heavy menstrual bleeding. This formulation represents the only oral contraceptive pill available in the USA containing an estrogen component that is biologically active as the endogenous estrogen 17ß-estradiol. This medication was developed out of efforts to replace the most common estrogen in contraceptive pills, ethinyl estradiol, which is known to be a potent inducer of hepatic protein synthesis. Estradiol valerate has been available since the 1970s in oral and injectable forms indicated for the treatment of menopausal climacteric symptoms. Dienogest has been used in other oral contraceptive pills for over 10 years. Previous attempts to develop an oral contraceptive pill with natural estradiol or estradiol valerate were unsuccessful due to poor cycle control. A novel dynamic-dosing regimen was devised to improve the bleeding pattern. This medication has been shown in several clinical trials to have good contraceptive efficacy and cycle control. Recent studies have also demonstrated that this medication is effective for the treatment of heavy menstrual bleeding. However, compared with other oral contraceptive pills, this medication is associated with a higher frequency of absent withdrawal bleeding. Furthermore, the dynamic dosing regimen requires relatively complex instructions for users who miss pills.

Review of issues concerning the use of reproductive inhibitors, with particular emphasis on resolving human-wildlife conflicts in North America.

This manuscript provides an overview of past wildlife contraception efforts and discusses the current state of research. Two fertility control agents, an avian reproductive inhibitor containing the active ingredient nicarbazin and an immunocontraceptive vaccine, have received regulatory approval with the Environmental Protection Agency and are commercially available in the USA. OvoControl G Contraceptive Bait for Canada Geese and Ovo Control for pigeons are delivered as oral baits. An injectable immunocontraceptive vaccine (GonaCon Immunocontraceptive Vaccine) was registered with the Environmental Protection Agency for use in female white-tailed deer in September 2009. An injectable product (GonaCon Immunocontraceptive Vaccine) is registered for use in female white-tailed deer. Both products are labeled for use in urban/suburban areas where these species are overabundant. Several other compounds are currently being tested for use in wildlife in the USA, Europe, Australia and New Zealand that could have promise in the future. The development and use of reproductive inhibitors for resolving human-wildlife conflicts will depend on a number of factors, including meeting the requirements of regulatory agencies for use in the environment and on the biological and economical feasibility of their use. Use will also be dependent on health and safety issues and on public acceptance of the techniques.

Estrogens and epilepsy: why are we so excited?

Estrogens are essential for normal brain function throughout life. The source of estrogens is not only from the periphery, but local production has also been demonstrated in the CNS. Actions of estrogens involve a variety of effects, which include modulation of gene expression, regulation of neurotransmitter release, or direct inter-actions with neurotransmitter receptors. By these effects, estrogens affect neuronal excitability and thus may play an important role in seizure disorders. Although the original clinical as well as animal studies suggest that estrogens have exclusively proconvulsant properties, it has now become clear that estrogens also produce anticonvulsant effects. These opposite effects of estrogens on seizures may depend on treatment duration, latency prior to seizure testing, mode of administration, estrogen dose and hormonal status, estrogenic species, the region/neurotransmitter system involved, seizure type/model used, and sex. Animal data also suggest that estrogens, specifically beta-estradiol, have neuroprotective effects on seizure-induced hippocampal damage. Further studies are necessary to understand the role of estrogens in seizure disorders. Such under-standing is important, especially for women with epilepsy, to make qualified decisions regarding administration of contraceptives and hormonal replacement therapy as well as for the design of new therapeutic strategies for better seizure control and prevention of seizure-induced neuronal damage.

Biological safety testing of polymers.

The extent of testing polymer-containing medical devices is subject to a range of considerations and needs to be determined on a case-by-case basis. This article reports on recent areas of concern for device materials including biodegradation and immunogenicity potential.

In vitro study of drug-loaded bioresorbable films and support structures.

Bioresorbable films can serve simultaneously as anatomic support structures and as drug delivery platforms. In the present study, bioresorbable poly(L-lactic acid) (PLLA) films containing dexamethasone were prepared by solution processing methods. Their in vitro studies focused on the mechanical properties with respect to morphology and degradation and erosion processes. Novel expandable support devices (stents) developed from these films were studied. Such a stent would support conduits, such as the neonatal trachea to treat tracheal malacia, until the airway matures, and would then be totally resorbed, obviating the need for a removal operation. The PLLA films showed good initial mechanical properties. They can accommodate drug incorporation on the film surface and also in the bulk. Water incubation of the films results in a decrease in their tensile mechanical properties, due to chain scission and morphological changes. These changes can vary from degradation and small changes in morphological features to erosion, leading to a microporous structure, depending on the polymer. The cumulative release of dexamethasone from the films is linear. The rate of release is determined by the film's structure (drug location/dispersion). The stents demonstrated good mechanical properties. The initial radial compression strength of the stent is determined mainly by the polymer structure. Drug incorporation has a minor effect on the initial stent strength. Exposure to radial compression stress results in elastic reversible deformation or a sudden brittle fracture, depending on the polymer. A 20-week in vitro study of the stents showed that they are applicable for supporting body conduits, such as the trachea.