Contributions of side effects to contraceptive discontinuation and method switch among Kenyan women: a prospective cohort study.

OBJECTIVE: To determine the contribution of specific contraceptive side effects to method switch and modern-method discontinuation among Kenyan women. DESIGN: A prospective cohort study. SETTING: Five counties in Western Kenya. PARTICIPANTS: Women aged ≥18 years old and emancipated female minors ≥14 years old using modern, reversible contraception were recruited while attending 10 public health facilities. METHODS: Patient-reported adverse effect symptoms, method switch and discontinuation were reported through weekly text message-based surveys for 24 weeks. MAIN OUTCOME MEASUREMENTS: Prevalence, hazards ratio (HR). RESULTS: Among 825 women, 44% were using implants, 43% injectables, 7% an intrauterine device and 6% oral contraceptive pills at enrolment. Most (61%) women were continuing a method used in the previous month. During the 24-week follow up, incidence of contraceptive switch was 61.3 per 100 person-years (95% confidence interval [CI] 52.4-71.8) and incidence of discontinuation was 38.5 per 100 person-years (95% CI 31.6-47.0). On average, one-quarter (prevalence [Pr] 0.24, 95% CI 0.22-0.26) of participants reported side effects or method problems weekly, with sexual side effects the most prevalent symptom (Pr 0.15, 95% CI 0.13-0.16). Lack of expected bleeding was associated with higher risk of method switch (adjusted hazard ratio [aHR] 2.36, 95% CI 1.22-4.57). Risk of all-modern method discontinuation was higher among women experiencing irregular bleeding (aHR 2.39, 95% CI 1.20-4.77), weight changes (aHR 2.72, 95% CI 1.47-4.68) and sexual side effects (aHR 2.42, 95% CI 1.40-4.20). CONCLUSIONS: Addressing irregular bleeding, weight changes and sexual side effects through development of new products that minimise these specific side effects and anticipatory counseling may reduce method-related discontinuation. TWEETABLE ABSTRACT: Bleeding, weight changes, sexual problems associated with discontinuation of #contraception, but many continue despite side effects.

Primary cesarean section and adverse delivery outcomes among women of very advanced maternal age.

OBJECTIVE: To assess associations between primary cesarean delivery and adverse delivery outcomes with very advanced maternal age. STUDY DESIGN: We conducted a population-based cohort study including 78,880 births to mothers 25 years and older with singleton births from 2003 to 2012 using Washington State birth certificates and hospital discharge data, excluding births to women with a prior cesarean section. The primary outcome was mode of delivery. Secondary outcomes included maternal transfusion, chorioamnionitis, severe perineal lacerations and prolonged length of stay. Outcomes of births to women of advanced maternal age (35 to 39, 40 to 44) and very advanced maternal age (45 to 49, ⩾50) were compared with referent births among women aged 25 to 34 years. General linear models with a log-link function were used to calculate unadjusted and adjusted relative risks and 95% confidence intervals (CIs). RESULT: Proportions and risks of primary cesarean section increased with age (25 to 34 years, referent: 20.0%; 35 to 39 years: 25.9%, relative risk (RR)=1.25 (95% CI=1.20 to 1.29); 40 to 44 years: 30.9%, RR=1.45 (95% CI=1.40 to 1.50); 45 to 49 years: 35.7%, RR=1.59 (95% CI=1.45 to 1.75); and ⩾50 years: 60.7%, RR=2.44 (95% CI=1.95 to 3.05); P-trend <0.001). Associations did not differ between primiparous and multiparous women. No differences were noted for measures of maternal morbidity, except there was a trend of increasing risk of prolonged length of stay among births to older women (P-trend <0.001). CONCLUSION: Primary cesarean delivery risk continues to increase above age 35 regardless of prior vaginal birth, with the highest risk among women aged 50 years and older.

Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception.

OBJECTIVES: The availability of long-acting hormonal birth control methods has created new contraceptive options for adolescents. The purpose of this study was to determine whether teens initiating these methods use condoms less frequently than teens using oral contraceptive pills or condoms alone and may therefore be at an increased risk of acquiring sexually transmitted infections. STUDY DESIGN: To investigate ongoing condom behavior in teens using levonorgestrel (Norplant) contraceptive implants, oral contraceptives, and condoms alone, we examined data from a 2-year prospective cohort study of 399 urban teens. The study consisted of 3 clinic-based cohorts of adolescent female contraceptive users: Norplant contraceptive implants (n = 200), oral contraceptives (n = 100), and condoms alone (n = 99). Data were collected at an admission interview and at 1- and 2-year follow-up from method continuers. RESULTS: Norplant contraceptive implant users were less likely than oral contraceptive or condom users to report condom use at last sex or consistent condom use at 1- and 2-year follow-up. The implant group showed a significant decrease in condom use from admission to 2 years after method initiation. The proportion of implant users self-reporting new sexually transmitted infections at 2-year follow-up, however, was not significantly greater than that of oral contraceptive or condom users. CONCLUSIONS: Our findings indicate that teen users of Norplant contraceptive implants are less likely to use condoms than teens who choose oral contraceptives but, probably because of differences in sexual behavior, are no more likely to self-report sexually transmitted infections. Our findings also indicate that teens who choose oral contraceptives and condoms do not use them consistently enough to avoid pregnancies or sexually transmitted infections.

PIP: Ongoing condom behavior was examined among teens using Norplant contraceptive implants, oral contraceptives, and condoms alone. Data were examined from a 2-year prospective cohort study of 399 urban teens in San Francisco, California; 200 female adolescents used Norplant, 100 used oral contraceptives, and 99 used only condoms. Norplant users were less likely than oral contraceptive or condom users to report condom use at most recent sexual intercourse or consistent condom use at the 1- and 2-year follow-ups. However, while Norplant users had a significant decrease in condom use from admission to 2 years after method initiation, the proportion of implant users self-reporting new sexually transmitted infections at the 2-year follow-up was not significantly higher than that of oral contraceptive or condom users.