Evaluation of a computerized contraceptive decision aid: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of a contraceptive decision aid in reducing decisional conflict among women seeking reversible contraception. STUDY DESIGN: We conducted a randomized trial of a computer-based decision aid compared to a control group for women presenting for reversible contraception at two clinics affiliated with an academic medical center. The primary outcome was change in decisional conflict, measured before and after the healthcare visit using the validated Decisional Conflict Scale. We hypothesized the decision aid would reduce the decisional conflict score by 10 points on a 100-point scale (0 = no conflict, 100 = high conflict) compared to the control group. Secondary outcomes included contraceptive method chosen and satisfaction with the healthcare visit. RESULTS: We enrolled and randomized 253 women, and 241 had complete data for our primary outcome. Overall, pre-visit decisional conflict scores were low, reflecting low levels of decisional conflict in our sample; median score 15 (range 0-80) in the decision aid and 10 (0-85) in the control group (p = 0.45). Both groups had a similar reduction in median decisional conflict after the healthcare visit: -10 (-80 to 25) and -10 (-60 to 5) in the decision aid and control groups respectively (p = 0.99). Choice of contraception (p = 0.23) and satisfaction with healthcare provider (p = 0.79) also did not differ by study group. CONCLUSIONS: Decisional conflict around contraception was low in both groups at baseline. Use of a computerized contraceptive decision aid did not reduce decisional conflict, alter method choice, or impact satisfaction compared to the control group among women choosing reversible contraception. IMPLICATIONS: Use of a computerized contraceptive decision aid did not reduce decisional conflict or alter method choice compared to the control group among women choosing reversible contraception. Future studies could focus on testing the decision aid in different clinical settings, especially where barriers to providing comprehensive contraceptive counseling exist.

Medicaid savings from the Contraceptive CHOICE Project: a cost-savings analysis.

BACKGROUND: Forty-five percent of births in the United States are unintended, and the costs of unintended pregnancy and birth are substantial. Clinical and policy interventions that increase access to the most effective reversible contraceptive methods (intrauterine devices and contraceptive implants) have potential to generate significant cost savings. Evidence of cost savings for these interventions is needed. OBJECTIVE: The purpose of this study was to conduct a cost-savings analysis of the Contraceptive CHOICE Project, which provided counseling and no-cost contraception, to demonstrate the value of investment in enhanced contraceptive care to the Missouri Medicaid program. STUDY DESIGN: The Contraceptive CHOICE Project was a prospective cohort study of 9256 reproductive-age women who were enrolled between 2007 and 2011. Study follow-up was completed October 2013. This analysis includes 5061 Contraceptive CHOICE Project participants who were current Missouri Medicaid beneficiaries or were uninsured and reported household incomes <201% of the federal poverty line. We created a simulated comparison group of women who were receiving care through the Missouri Title X program and modeled the contraception and pregnancy outcomes that would have occurred in the absence of the Contraceptive CHOICE Project. Data about contraceptive use for the comparison group (N=5061) were obtained from the Missouri Title X program and adjusted based on age, race, ethnicity, and income. To make an accurate comparison that would account for the difference in the 2 populations, we used our simulation model to estimate total Contraceptive CHOICE Project costs and total comparison group costs. We reported all costs in 2013 dollars to account for inflation. RESULTS: Among the Contraceptive CHOICE Project participants who were included, the uptake of intrauterine devices and implants was 76.1% compared with 4.8% among the comparison group. The estimated contraceptive cost for the simulated Contraceptive CHOICE Project group was $4.0 million vs $2.3 million for the comparison group. The estimated numbers of unintended pregnancies and births averted among the simulated Contraceptive CHOICE Project group compared with the comparison group were 927 and 483, respectively, which represented a savings in pregnancy and maternity care of $6.7 million. We estimated that the total cost savings for the state of Missouri attributable to the Contraceptive CHOICE Project was $5.0 million (40.7%) over the project duration. CONCLUSION: A program providing counseling and no-cost contraception yields substantial cost savings because of the increased uptake of highly effective contraception and consequent averted unintended pregnancy and birth.

Differences in Contraceptive Discontinuation Among Black and White Women: Evidence from the Contraceptive CHOICE Project.

OBJECTIVE: We sought to evaluate whether differences in rates of contraceptive discontinuation exist among black and white women receiving contraceptive counseling and no-cost contraception among users of long-acting reversible contraceptive (LARC; intrauterine devices or subdermal implant) and non-LARC (oral contraceptive pills, contraceptive vaginal ring, patch, or injection) methods. MATERIALS AND METHODS: We analyzed data from a prospective cohort study of 7546 non-Hispanic black and white women who participated in the Contraceptive CHOICE Project. Among women who initiated their method within 12 weeks of enrollment, discontinuation was defined as any break in use longer than 1 month. Using Cox proportional hazards regression analysis, we estimated discontinuation stratified by use of LARC methods. RESULTS: There were no statistically significant differences in contraceptive discontinuation between black and white women at 12, 24, or 36 months among both LARC [12-month adjusted hazard ratio (HRadj-12M) 1.01 (95% confidence interval or 95% CI 0.86-1.18); HRadj-24M 1.10 (95% CI 0.97-1.24); and HRadj-36M 1.10 (95% CI 0.98-1.23)] and non-LARC users [HRadj-12M 1.08 (95% CI 0.92, 1.26); HRadj-24M 1.07 (95% CI 0.94, 1.23); and HRadj-36M 1.08 (95% CI 0.95, 1.23)] adjusting for confounders. Secondary analyses found no significant differences in discontinuation of LARC and non-LARC methods among black and white women at highest risk of pregnancy or those receiving public assistance at baseline. CONCLUSIONS: At 12, 24, and 36 months there were no differences in contraceptive discontinuation of both LARC methods and non-LARC methods when comparing white and black women.

From research to practice: dissemination of the Contraceptive CHOICE Project.

Unintended pregnancy is a public health problem with societal consequences. The Contraceptive CHOICE Project (CHOICE) demonstrated a reduction in teen pregnancy and abortion by removing barriers to effective contraception. The purpose of the study was to describe the dissemination approach used to create awareness of and promote desire to adopt the CHOICE model among selected audiences. We used a 4-stage approach and detail the work completed in the first 2 stages. We describe stakeholder involvement in the first stage and the process of undertaking core strategies in the second stage. We examine insights gained throughout the process. Through our dissemination approach, we reached an estimated 300,000 targeted individuals, not including the population reached through media. We were contacted by 141 entities for technical assistance. The completion and reporting of dissemination processes is an important component of research. There is a need to fully document and disseminate strategies that can help facilitate practice change.

Risk of unintended pregnancy based on intended compared to actual contraceptive use.

BACKGROUND: After initiating a new contraceptive method, the provider has little control of how or whether that method is used. OBJECTIVE: We sought to compare unintended pregnancy rates by the initial chosen contraceptive method after counseling to traditional contraceptive effectiveness in the same study population. STUDY DESIGN: The Contraceptive CHOICE Project provided reversible contraception to 9252 women at no cost during 2-3 years of follow-up. We performed 2 analyses of contraceptive efficacy in this prospective cohort: (1) intent-to-use (ITU), grouping participants based on their chosen method at enrollment; and (2) as-used, categorizing participant time according to the method used. In ITU analysis, switching of methods and method continuation were not considered, as we wanted to assess outcomes based on the method chosen at baseline. We used Cox proportional hazards models to compare rates of unintended pregnancy. RESULTS: During 20,017 person-years, we identified 615 unintended pregnancies. In ITU analysis, pregnancy rates were 5.3, 5.5, 2.0, 1.7, and 1.9 per 100 person-years for women initiating oral, injectable, implantable, copper, and hormonal intrauterine contraception (IUC) at baseline, respectively. The adjusted hazard ratio for injectable contraception compared to hormonal IUC was 2.4 (95% confidence interval, 1.8-3.3). Delaying initiation of IUC or implantable contraception increased unintended pregnancies by 60% (adjusted hazard ratio, 1.6; 95% confidence interval, 1.2-2.0). In as-used analysis, pregnancy rates were 6.7, 1.6, 0.2, 0.6, and 0.2 per 100 person-years for women using oral, injectable, implantable, copper, and hormonal IUC, respectively. CONCLUSION: Although highly effective in the as-used analysis, women initially choosing injectable contraception had pregnancy rates similar to oral contraception and significantly worse than IUC or implantable contraception. Despite switching and discontinuation, women choosing an IUC or implantable contraception at baseline were much less likely to have an unintended pregnancy compared to those selecting other methods.

Three-year continuation of reversible contraception.

OBJECTIVE: The objective of this analysis was to estimate the 3-year continuation rates of long-acting reversible contraceptive (LARC) methods and to compare these rates to non-LARC methods. STUDY DESIGN: The Contraceptive CHOICE Project (CHOICE) was a prospective cohort study that followed 9256 participants with telephone surveys at 3 and 6 months, then every 6 months for 2-3 years. We estimated 3-year continuation rates of baseline methods that were chosen at enrollment. The LARC methods include the 52-mg levonorgestrel intrauterine device; the copper intrauterine device, and the subdermal implant). These were then compared to rates to non-LARC hormonal methods (depot medroxyprogesterone acetate, oral contraceptive pills, contraceptive patch, and vaginal ring). Eligibility criteria for this analysis included participants who started their baseline chosen method by the 3-month survey. Participants who discontinued their method to attempt conception were censored. We used a Cox proportional hazard model to adjust for confounding and to estimate the hazard ratio for risk of discontinuation. RESULTS: Our analytic sample consisted of 4708 CHOICE participants who met inclusion criteria. Three-year continuation rates were 69.8% for users of the levonorgestrel intrauterine device, 69.7% for copper intrauterine device users, and 56.2% for implant users. At 3 years, continuation was 67.2% among LARC users and 31.0% among non-LARC users (P < .001). After adjustment for age, race, education, socioeconomic status, parity, and history of sexually transmitted infection, the hazard ratio for risk of discontinuation was 3-fold higher among non-LARC method users than LARC users (adjusted hazard ratio, 3.08; 95% confidence interval, 2.80-3.39). CONCLUSION: Three-year continuation of the 2 intrauterine devices approached 70%. Continuation of LARC methods was significantly higher than non-LARC methods.

Risk-based screening for Chlamydia trachomatis and Neisseria gonorrhoeae prior to intrauterine device insertion.

OBJECTIVE: The objective was to compare three strategies for Chlamydia trachomatis and Neisseria gonorrhoeae screening prior to intrauterine device (IUD) insertion. STUDY DESIGN: This was a secondary analysis of the Contraceptive CHOICE Project. We measured the prevalence of C. trachomatis and/or N. gonorrhoeae at the time of IUD insertion. We then compared sensitivity, specificity, negative and positive predictive values, and likelihood ratios for three screening strategies for C. trachomatis and N. gonorrhoeae prior to IUD insertion: (a) "age-based" ­ age ≤25 years alone; (b) "age/partner-based" ­ age ≤25 and/or multiple sexual partners; and (c) "risk-based" ­ age ≤25, multiple sexual partners, inconsistent condom use and/or history of prior sexually transmitted infection (STI). RESULTS: Among 5087 IUD users, 140 (2.8%) tested positive for C. trachomatis, 16 (0.3%) tested positive for N. gonorrhoeae, and 6 (0.1%) were positive for both at the time of IUD insertion. The "risk-based" screening strategy had the highest sensitivity (99.3%) compared to "age-based" and "age/partner-based" screening (80.7% and 84.7%, respectively.) Only one (0.7%) woman with a chlamydia or gonorrhea infection would not have been screened using "risk-based" screening. CONCLUSION: A risk-based strategy to screen for C. trachomatis and N. gonorrhoeae prior to IUD insertion has higher sensitivity than screening based on age alone or age and multiple sexual partners. IMPLICATIONS: Using a risk-based screening strategy (age≤25, multiple sexual partners, inconsistent condom use and/or history of an STI) to determine who should be screened for C. trachomatis and N. gonorrhoeae prior to IUD insertion will miss very few cases of infection and obviates the need for universal screening.

Pharmacy claims data versus patient self-report to measure contraceptive method continuation.

OBJECTIVE: To compare self-reported 12-month continuation of oral contraceptive pills (OCPs), patch, and ring versus continuation by pharmacy claims data. STUDY DESIGN: Women in the Contraceptive CHOICE Project who chose OCPs, the patch, or the ring as their initial method were included. Continuation was assessed by periodic telephone survey and by obtaining prescription claims data. Continuation was defined as no gap of more than 30 days. Kaplan-Meier survival functions were used to estimate continuation rates and cumulative unintended pregnancy rates. Kappa statistic assessed the level of agreement between self-report and claims data. RESULTS: We analyzed 1510 women who initiated use by 3 months and provided information on discontinuation. Of OCP users, 59% continued their method at 12 months by self-report versus 38% by pharmacy claims. Patch and ring users had self-reported/pharmacy continuation of 45%/28% and 57%/37%, respectively. Kappa coefficients and their 95% confidence intervals between the two measurements were 0.46 (0.40, 0.52), 0.54 (0.39, 0.68), and 0.54 (0.47, 0.61) for OCP, patch, and ring, respectively. Among women who self-reported continuation, unintended pregnancy rates were 0.4% in those who continued by pharmacy claims versus 4.9% in those who discontinued according to claims data. CONCLUSION: Contraceptive continuation rates differ by self-report versus pharmacy claims with women overestimating their continuation by self-report. IMPLICATIONS: This article directly compares contraception continuation rates by self-report and by pharmacy claims data. The study suggests that previously reported continuation rates from survey data overestimate specific method use.

Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review.

The Contraceptive CHOICE Project (CHOICE) sought to reduce unintended pregnancies in the St. Louis Region by removing cost, education, and access barriers to highly effective contraception. CHOICE was a prospective cohort study of over 9,000 women 14-45 years of age who received tiered contraceptive counseling to increase awareness of all reversible methods available, particularly long-acting reversible contraceptive (LARC) methods. Participants were provided with contraception of their choice at no cost for 2-3 years. We studied contraceptive method choice, continuation, and population outcomes of repeat abortion and teen pregnancy. Seventy-five percent of study participants chose one of the three LARC methods (46% levonorgestrel intrauterine system, 12% copper intrauterine device, and 17% subdermal implant). LARC users reported greater continuation than non-LARC users at 12 months (87% versus 57%) and 24 months (77% versus 41%). In our cohort, LARC methods were 20 times more effective than non-LARC methods. As a result, we observed a reduction in the percent of repeat abortions from 2006 to 2010 in St. Louis compared with Kansas City and nonmetropolitan Missouri and found substantial reductions in teen pregnancy, birth, and abortion (34.0, 19.4, and 9.7 per 1000 teens, respectively) compared with national rates among sexually experienced teens (158.5, 94.0, and 41.5 per 1000, respectively). Improved access to LARC methods can result in fewer unintended pregnancies and abortions and considerable cost savings to the health care system.

Positive Testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the Risk of Pelvic Inflammatory Disease in IUD Users.

BACKGROUND: Unintended pregnancies are a major public health problem in the United States, and intrauterine devices (IUDs) are among the most effective reversible birth control methods available. Historically, there have been concerns about IUD use and infection among young and/or high-risk women that may increase the risk of pelvic inflammatory disease (PID) and subsequent infertility. METHODS: The Contraceptive CHOICE Project (CHOICE) was a prospective cohort study of over 9,000 women 14-45 years of age residing in the St. Louis area who were interested in initiating a new form of reversible contraception. At enrollment, participants were counseled regarding long-acting contraceptive methods with the goal of increasing awareness of all reversible methods available. Participants were also tested for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) during enrollment and were provided with contraception at no cost for 2-3 years. RESULTS: We estimate the frequency of self-reported PID in new IUD users compared with women using other contraceptive methods. Among both new IUD users who tested positive for GC and/or CT and those who tested negative, the PID rate was 1% or below. CONCLUSIONS: Our results demonstrate that IUD use is safe for all women, including women at high risk for sexually transmitted infections.

The role of contraceptive attributes in women's contraceptive decision making.

OBJECTIVE: Contraceptive methods have differing attributes. Women's preferences for these attributes may influence contraceptive decision making. Our objective was to identify women's contraceptive preferences among women initiating a new contraceptive method. STUDY DESIGN: We conducted a cross-sectional, self-administered survey of women's contraceptive preferences at the time of enrollment into the Contraceptive CHOICE Project. Participants were asked to rank the importance of 15 contraceptive attributes on a 3-point scale (1 = not at all important, 2 = somewhat important, and 3 = very important) and then to rank the 3 attributes that were the most important when choosing a contraceptive method. The survey also contained questions about prior contraceptive experience and barriers to contraceptive use. Information about demographic and reproductive characteristics was collected through the CHOICE Project baseline survey. RESULTS: There were 2590 women who completed the survey. Our sample was racially and socioeconomically diverse. Method attributes with the highest importance score (mean score [SD]) were effectiveness (2.97 [0.18]), safety (2.96 [0.22]), affordability (2.61 [0.61]), whether the method is long lasting (2.58 [0.61]), and whether the method is "forgettable" (2.54 [0.66]). The attributes most likely to be ranked by respondents among the top 3 attributes included effectiveness (84.2%), safety (67.8%), and side effects of the method (44.6%). CONCLUSION: Multiple contraceptive attributes influence decision making and no single attribute drives most women's decisions. Tailoring communication and helping women make complex tradeoffs between attributes can better support their contraceptive decisions and may assist them in making value-consistent choices. This process could improve continuation and satisfaction.

Performance of a checklist to exclude pregnancy at the time of contraceptive initiation among women with a negative urine pregnancy test.

OBJECTIVE: Our objective was to measure the sensitivity and specificity of a six-item "pregnancy checklist" at excluding early- or luteal-phase pregnancy among women with a negative urine pregnancy test who were initiating contraception. STUDY DESIGN: This was a secondary analysis of the Contraceptive CHOICE Project, a prospective cohort study of 9256 women in the St. Louis region. Women who had a negative urine pregnancy test on the day of enrollment were included in this analysis. Women with a positive urine pregnancy test or without urine pregnancy testing were excluded. We identified all luteal-phase pregnancies that occurred among women with a negative urine pregnancy test. We calculated the sensitivity, specificity, positive predictive value and negative predictive value (NPV) and likelihood ratios of the pregnancy checklist for excluding luteal-phase pregnancies. RESULTS: There were 6929 women included in this analysis; 69% of these women met at least one checklist criterion to exclude pregnancy ("negative screen"). There were 36 luteal-phase pregnancies (0.5%) subsequently diagnosed among women with a negative urine pregnancy test. The sensitivity and specificity of the checklist were 77.7% and 69.1%, respectively. The NPV of the checklist was 99.8% and the positive predictive value was 1.3%. CONCLUSION: Among women with a negative urine pregnancy test, the pregnancy checklist can be used to safely exclude more than 99% of early pregnancies at the time of contraceptive initiation. IMPLICATIONS: In patients with a negative urine pregnancy test, a pregnancy checklist using six criteria based on patient history has high NPV in excluding early pregnancy. This checklist can be used to facilitate same-day initiation of contraceptive methods, including long-acting reversible contraception. Although the checklist had a high false positive rate, initiation of contraception should not be delayed in women with a "positive screen." Rather women who desire an intrauterine device or implant can be "bridged" with a shorter-acting method until pregnancy can be excluded.

Contraceptive continuation in Hispanic women.

OBJECTIVE: The purpose of this study was to examine the effect of Hispanic ethnicity on the continuation and satisfaction of reversible contraceptive methods. STUDY DESIGN: We analyzed 12 months of data that were collected from 7913 participants in the Contraceptive CHOICE Project. Kaplan-Meier survival curves were used to estimate continuation, and Cox proportional hazard models were used to estimate the risk of discontinuation. RESULTS: Hispanic women were more likely to choose a long-acting reversible contraceptive (LARC) method compared with non-Hispanic black and non-Hispanic white women (80%, 73%, and 75%, respectively; P < .05). The 12-month continuation rates were higher for LARC methods than combined hormonal methods for all race/ethnicity (Hispanic women, 87% vs 40%; non-Hispanic black women, 85% vs 46%; non-Hispanic white women, 87% vs 56%). There was no statistical difference in discontinuation of LARC methods at 12 months. Eighty percent of LARC users reported high satisfaction levels at 12 months, regardless of race/ethnicity. CONCLUSION: Hispanic women in the Contraceptive CHOICE Project experienced high continuation and satisfaction for LARC methods, similar to women of other ethnicities.

Provision of no-cost, long-acting contraception and teenage pregnancy.

BACKGROUND: The rate of teenage pregnancy in the United States is higher than in other developed nations. Teenage births result in substantial costs, including public assistance, health care costs, and income losses due to lower educational attainment and reduced earning potential. METHODS: The Contraceptive CHOICE Project was a large prospective cohort study designed to promote the use of long-acting, reversible contraceptive (LARC) methods to reduce unintended pregnancy in the St. Louis region. Participants were educated about reversible contraception, with an emphasis on the benefits of LARC methods, were provided with their choice of reversible contraception at no cost, and were followed for 2 to 3 years. We analyzed pregnancy, birth, and induced-abortion rates among teenage girls and women 15 to 19 years of age in this cohort and compared them with those observed nationally among U.S. teens in the same age group. RESULTS: Of the 1404 teenage girls and women enrolled in CHOICE, 72% chose an intrauterine device or implant (LARC methods); the remaining 28% chose another method. During the 2008-2013 period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1000, respectively. CONCLUSIONS: Teenage girls and women who were provided contraception at no cost and educated about reversible contraception and the benefits of LARC methods had rates of pregnancy, birth, and abortion that were much lower than the national rates for sexually experienced teens. (Funded by the Susan Thompson Buffett Foundation and others.).

Association of age and parity with intrauterine device expulsion.

OBJECTIVE: To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs). METHODS: This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion. RESULTS: A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78). CONCLUSION: IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type. LEVEL OF EVIDENCE: : II.

Change in sexual behavior with provision of no-cost contraception.

OBJECTIVE: To estimate whether providing no-cost contraception is associated with the number of sexual partners and frequency of intercourse over time. METHODS: This was an analysis of the Contraceptive CHOICE Project, a prospective cohort study of 9,256 adolescents and women at risk for unintended pregnancy. Participants were provided reversible contraception of their choice at no cost and were followed-up with telephone interviews at 6 and 12 months. We examined the number of male sexual partners and coital frequency reported during the previous 30 days at baseline compared with 6-month and 12-month time points. RESULTS: From our total cohort, 7,751 (84%) women and adolescents completed both 6-month and 12-month surveys and were included in this analysis. We observed a statistically significant decrease in the fraction of women and adolescents who reported more than one sexual partner during the past 30 days from baseline to 12 months (5.2% to 3.3%; P<.01). Most participants (70-71%) reported no change in their number of sexual partners at 6 and 12 months, whereas 13% reported a decrease and 16% reported an increase (P<.01). More than 80% of participants who reported an increase in the number of partners experienced an increase from zero to one partner. Frequency of intercourse increased during the past 30 days from baseline (median, 4) to 6 and 12 months (median, 6; P<.01). However, greater coital frequency did not result in greater sexually transmitted infection incidence at 12 months. CONCLUSION: We found little evidence to support concerns of increased sexual risk-taking behavior subsequent to greater access to no-cost contraception.

Medical contraindications in women seeking combined hormonal contraception.

OBJECTIVE: The objective of the study was to evaluate the prevalence of medical contraindications in a large group of women seeking combined hormonal contraception (CHC). STUDY DESIGN: The Contraceptive CHOICE Project is a prospective cohort study designed to promote the use of long-acting reversible contraceptive methods to reduce unintended pregnancies in the St Louis region. During baseline enrollment, participants were asked about their desired methods of contraception and medical history. Potential medical contraindications were defined as self-reported history of hypertension, myocardial infarction, cerebral vascular accidents, migraines with aura, any migraine and age 35 years or older, smoking in women older than 35 years, venous thromboembolism, or liver disease. We reviewed all research charts of women with self-reported medical contraindications to verify all conditions. Binomial 95% confidence intervals (CIs) were calculated around percentages. RESULTS: Between August 2007 and December 2009, 5087 women who enrolled in the CHOICE Project provided information about their medical history and 1010 women (19.9%) desired CHC at baseline. Seventy women (6.93%; 95% CI, 5.44-8.68%) were defined as having a potential medical contraindication to CHC at baseline. After chart review, only 24 of 1010 participants desiring CHC (2.38%; 95% CI, 1.53-3.52%) were found to have true medical contraindications to CHC including 17 with hypertension, 2 with migraines with aura, 2 with a history of venous thromboembolism, and 3 smokers aged 35 years or older. CONCLUSION: The prevalence of medical contraindications to CHC was very low in this large sample of reproductive-aged women. This low prevalence supports provision of CHC without a prescription.

Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use.

OBJECTIVE: To measure discontinuation within 6 months among users of the levonorgestrel intrauterine system, copper intrauterine device (IUD), and etonogestrel implant and identify baseline characteristics associated with early discontinuation. METHODS: This was an analysis of the Contraceptive CHOICE Project, a cohort study of 9,256 participants provided with no-cost contraception and followed with telephone interviews at 3 and 6 months. We used logistic regression to investigate characteristics associated with early discontinuation of the two IUDs and implant and described reasons for discontinuation. RESULTS: A total of 6,167 participants were eligible for this analysis. Follow-up data were available for 5,928 participants; 5,495 (93%) were using their method at 6 months and 433 (7%) had discontinued. Discontinuation rates were 7.3%, 8.0%, and 6.9% for the levonorgestrel intrauterine system, copper IUD, and implant, respectively. After adjusting for age, race, marital status, low socioeconomic status, and history of sexually transmitted infection, we found that unmarried women were slightly more likely to discontinue compared with married women (adjusted odds ratio [OR] 1.26, 95% confidence interval [CI] 1.01-1.59 and adjusted OR 1.62, 95% CI 1.11-2.37, respectively). No other baseline characteristics, including younger age (14-19 years), were associated with early discontinuation. The most common reason given for discontinuation was cramping among IUD users and irregular or frequent bleeding among implant users. CONCLUSION: Rates of discontinuation of long-acting reversible contraception at 6 months is low and not increased in adolescents and young women. Intrauterine devices and the implant should be considered as first-line contraceptive options among all women to reduce unintended pregnancy. LEVEL OF EVIDENCE: : II.

Sexually transmitted infection prevalence in a population seeking no-cost contraception.

BACKGROUND: We used universal screening to determine the prevalence rates of Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) in 9256 women enrolling into a contraceptive study. METHODS: We offered screening using nucleic acid amplification or culture to all participants enrolling into the Contraceptive CHOICE Project. Demographic characteristics were collected through staff-administered questionnaires. Univariate and multivariable analyses were performed to assess the risk of sexually transmitted infection at baseline and to compare risk profiles of CT and TV. RESULTS: Results were available for 8347 consenting women with satisfactory results; 656 (7.9%) were tested positive for 1 or more infections. Approximately one third of participants were older than 26 years, and half were identified as African American. There were 35 cases of GC for a prevalence of 0.4% (95% confidence interval [CI], 0.3-0.6), 260 cases of CT for a prevalence of 3.1% (95% CI, 2.8-3.5), and 410 cases of TV for a prevalence of 4.9% (95% CI, 4.4-5.4). Black women were more likely to be tested positive (odds ratio, 3.95; 95% CI, 3.08-5.06) compared with white women and accounted for 81.3% of cases. T. vaginalis was more prevalent in black women (8.9%) compared with white women (0.9%). Older age was a risk factor for TV, whereas younger age was associated with CT. Of the 656 positive cases, 106 (16%) were diagnosed in women older than 25 years, falling outside traditional screening guidelines. CONCLUSION: We found GC, CT, and TV to be more prevalent than current national statistics, with TV being the most prevalent. Current screening recommendations would have missed 16% of infected women.