User preferences for a contraceptive microarray patch in India and Nigeria: Qualitative research on what women want.

BACKGROUND: A new contraceptive microarray patch (MAP) for women is in development. Input on this method from potential end-users early in the product development process is important to guide design decisions. This paper presents the qualitative component of a broader study exploring initial acceptability of the MAP and selected product features. The qualitative research was intended to identify product features that are most salient to end-users and to contextualize preferences around them with subsequent research planned to assess quantitatively the relative importance of those features. METHODS: We conducted 16 focus group discussions and 20 in-depth interviews with women and 20 IDIs with family planning providers in New Delhi, India, and Ibadan, Nigeria. Input from the MAP developer served to identify plausible features of the MAP to include in the focus group discussions and in-depth interviews. Interviews were audio-recorded, transcribed into English, coded, and analyzed to examine key dimensions of MAP features. RESULTS: Many participants viewed the MAP as potentially easy to use. Interest in self-application after learning correct use was high, especially in India. Participants favored formulations affording protection from pregnancy for three or six months, if not longer. Interest in a shorter-acting MAP was particularly low in Nigeria. Non-desirable MAP features included a potential localized skin rash and pain at application. Views on patch size and location of application were related to the potential for rash and pain, with a desire to permit discreet use and minimize pain. Results indicate that the side effect profile, effectiveness, and pricing are also important factors for acceptability and uptake of a future product. CONCLUSION: Study findings indicate that a contraceptive MAP is of potential interest to women and that specific MAP attributes will be important to acceptability.

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X-Funded Facilities in 2016.

CONTEXT: As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS: A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS: Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out. CONCLUSION: Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.

Projections and opinions from 100 experts in long-acting reversible contraception.

OBJECTIVE: This survey of published researchers of long-acting reversible contraceptives (LARCs) examines their opinions about important barriers to LARC use in the United States (US), projections for LARC use in the absence of barriers and attitudes toward incentives for clinicians to provide and women to use LARC methods. STUDY DESIGN: We identified 182 authors of 59 peer-reviewed papers on LARC use published since 2013. A total of 104 completed an internet survey. We used descriptive and multivariate analyses to assess LARC use barriers and respondent characteristics associated with LARC projections and opinions. RESULTS: The most commonly identified barrier was the cost of the device (63%), followed by women's knowledge of safety, method acceptability and expectations about use. A shortage of trained providers was a commonly cited barrier, primarily of primary care providers (49%). Median and modal projections of LARC use in the absence of these barriers were 25-29% of contracepting women. There was limited support for provider incentives and almost no support for incentives for women to use LARC methods, primarily out of concern about coercion. CONCLUSIONS: Clinical and social science LARC experts project at least a doubling of the current US rate of LARC use if barriers to method provision and adoption are removed. While LARC experts recognize the promise of LARC methods to better meet women's contraceptive needs, they anticipate that the majority of US women will not choose LARC methods. Reducing unintended pregnancy rates will depend on knowledge, availability and use of a wider range of methods of contraception to meet women's individual needs. IMPLICATIONS: Efforts to increase LARC use need to meet the dual goals of increasing access to LARC methods and protecting women's reproductive autonomy. To accomplish this, we need reasonable expectations for use, provider training, low-cost devices and noncoercive counseling, rather than incentives for provision or use.

Current challenges in contraception in adolescents and young women.

PURPOSE OF REVIEW: Although developing countries have made much progress in expanding the availability and use of family planning services, the need for effective contraception is large, and growing because the largest cohorts in human history are entering their reproductive years. Not only regarding developing countries but also in developed countries, where the usual contraceptive methods, such as the oral contraceptives, intrauterine devices (IUDs) and condoms, have been available for decades, there have been many new advances in contraceptive technology in the last several years. New formulations of oral contraceptives, extended and continuous use of oral contraceptives and long-acting reversible contraceptives (LARC) may have a wider role in contraception and their increased implementation could help to reduce unintended pregnancy. RECENT FINDINGS: Today's oral contraceptive regimens are safer and more tolerable, with equal or improved efficacy as compared to early formulations. Incremental decreases in the estrogen dosage have helped to alleviate some of the unwanted estrogenic side effects of combined hormonal contraceptives. Progestogens have also been controversial in connection with findings of increased venous thromboembolism risks but they have evolved over time, and, in general, newer generations of progestins have minimal side effects. Currently available 'LARC' methods, such as IUDs, the intrauterine system, injectable contraceptives and implants require administration less than once per cycle or month. They are more cost effective than the combined oral contraceptive pill even at 1 year of use. Increasing the access and availability of new formulations of oral contraceptives and LARC methods will reduce the number of unintended pregnancies. SUMMARY: Evidence-based guidelines about the safety of contraceptive methods among women with comorbid medical conditions can help guide providers in determining the best method of contraception for each woman, depending on whether they are in their adolescent, postpartum or perimenopause years. As most patients can safely use highly effective methods of contraception, health providers should promote their use in order to further efforts to reduce unintended pregnancy. This promotion should be done by enabling women to make an informed choice among all contraceptive options.

Estudio sobre la accesibilidad y tolerabilidad del uso de implantes hormonales subdérmicos en una población de exclusión social en Sevilla / Accesibility and tolerability on the use of subcutaneous hormone implants in a socially excluded population

Objetivo: Conocer la aceptabilidad y la tolerabilidad del uso del implante subcutáneo en una población de exclusión social (población del Vacie).Diseño:Estudio de cohortes prospectivo con estudio de seguimiento. Emplazamiento: Centro de salud de Pino Montano B, en Sevilla.Participantes:66 mujeres en entre 15-49 años a las que se les insertó el implante subcutáneo, de las cuales el 44,6% son del Vacie, y 55,4% no son del Vacie. Intervención: Cuestionario preimplante, colocación del implante y seguimiento con cuestionario a los 3 meses post-implante. Mediciones: Estudio de variables sociodemográficas con tablas de N frecuencias. Contraste de la variable tolerabilidad con la variable procedencia: Vacie/no Vacie mediante ji cuadrado y la aceptabilidad con tablas N de frecuencias. Resultados: No existe relación estadísticamente significativa entre la tolerabilidad del método entre poblaciones (p=0,618) con un RR 1,33 (0,430-4,134) de que las mujeres que no son del Vacie fueron menos tolerantes que las del Vacie. Un 93,1% del Vacie y 88,9% de las que no son del Vacie se volverían a implantar el método pasados los 3 años de caducidad. En el Vacie un 84,7% y en las que no son del Vacie un 82,4% consideraron que el método es sobresaliente. Conclusiones: El implante podría considerarse seguro, tolerable y aceptado como método anticonceptivo sin diferencias entre culturas(AU)

Objective: To determine the aceptability and tolerability of subcutaneous implants used in a socially excluded population from El Vacie, Seville. Design: Prospective cohort study with follow-up. Setting: Pino Montano B Outpatient Department in Seville, Spain. Participants: A total of 66 females between 15-49 years who had a subcutaneous implant inserted, of whom 44.6% were from El Vacie (a shantytown outside Seville, Spain). Interventions: Pre-implant questionnaire, placing of the implant and a post-implant questionnaire 3 months later. Main measurements: A study of the sociodemographic variables with frequency tables. Comparison of the tolerability with the place of residence variable (from El Vacie/not from El Vacie) using the Chi squared statistic, and the acceptability with frequency tables. Results: There were no statistically significant differences between the tolerability variables studied (P=.618), with a (relative risk) RR of 1.33 (0.430-4.134). The women not from El Vacie were less tolerant than the women from El Vacie. The great majority of women (93.1% El Vacie women and 88.9% non-El Vacie women) would come back to use this contraceptive method again after it expires in 3 years, and 84.7% of El Vacie women and 82.4% of those not from El Vacie considered the method as excellent. Conclusions: Subcutaneous hormone implants were a safe, tolerable and acepted method with no cultural differences(AU)

Perceived and insurance-related barriers to the provision of contraceptive services in U.S. abortion care settings.

BACKGROUND: Abortion facilities represent a potentially convenient setting for providing contraception to women experiencing unintended pregnancies. This analysis examines a range of factors that may act as barriers to integrating contraceptive and abortion services and documents abortion providers' perspectives on their role in their patients' contraceptive care. METHODS: Administrators from 173 large, nonhospital facilities that provide abortions in the United States responded to a structured survey between May and September 2009. We used chi-square tests to assess differences in categorical outcomes. RESULTS: Although the majority of U.S. abortion facilities offer a range of contraceptive methods on site, facility staff identified multiple barriers to full integration of the two services, in particular, insurance, patient, and cost barriers. Few of these perceived barriers, however, were associated with differences in the actual provision of most contraceptive methods. Specialized abortion clinics that do not accept health insurance were less likely to have highly effective methods, such as intrauterine devices and implants, on site. Facilities located in Medicaid states were more likely to accept both public and private health insurance for contraceptive services. CONCLUSION: Increased access to contraceptive services during abortion care is one strategy for reducing repeat unintended pregnancy, and stakeholders at all levels--including abortion providers, insurance companies, and policy makers--have a role to play in achieving this goal.

New contraceptive choices.

Family planning users and providers have been calling for more choices. They want contraceptive methods that provide highly effective protection and at the same time cause fewer side effects, cost less, and are easier to use. In response, researchers are improving existing contraceptives and developing new ways to deliver hormones. Offering a wide range of safe, effective, and convenient family planning methods encourages more people to use contraception. Having more choices helps ensure that users are satisfied with their family planning method. Most new methods reaching the market today result from investments made years ago. Virtually all methods undergo a long process of research and rigorous testing for safety and effectiveness and must obtain regulatory approvals before becoming available.

Paying for family planning.

PIP: Both houses of the US Congress have passed bills to require that all health plans for federal employees which pay for prescription medications also cover prescription contraceptives approved by the US Food and Drug Administration (USFDA). Of these, the five most commonly prescribed are contraceptive pills, implantable levonorgestrel (Norplant), long-acting injectable medroxyprogesterone acetate (Depo-provera), IUDs, and the diaphragm. Differences between the two bills are now being worked out by a joint House-Senate committee and passage seems almost certain. If a compromise joint bill is passed by both houses, it would cover plans which insure more than 1 million reproductive age women. However, the Equity in Prescription and Contraceptive Coverage (EPICC) Act requiring all US private health plans to cover contraceptive prescriptions is less certain to eventually become legislation. Currently, only 49% of traditional indemnity plans and 39% of health maintenance organizations cover the five most commonly prescribed reversible methods of contraception, while many health plans cover no form of contraception, other than sterilization. The passage of EPICC would expand contraceptive choice for another 45 million US women of childbearing age. Opposition to both bills has come mainly from health insurance and business groups, as well as conservative groups which oppose funding for family planning. Supporters of legislation to expand contraceptive choice for US women should understand that the right to reproductive health and contraceptive services extends beyond US borders, and pressure Congress to bolster US financial support for international population control programs.^ieng

Sex discrimination and insurance for contraception.

Unintended pregnancy is a serious problem in the United States. Most private insurance plans do not pay for contraception even though they pay for other prescription drugs and devices. This Article argues that this pattern constitutes sex discrimination and is prohibited by Title VII of the Civil Rights Act of 1964, as amended by the Pregnancy Discrimination Act. It discusses the reasons this issue has been neglected and suggests ways federal and state officials might remedy this common form of gender discrimination.

Medical care cost savings from adolescent contraceptive use.

An analysis of the economic benefits of adolescent contraceptive use utilizes information from a national private payer database and from the California Medicaid program to compare private- and public-sector costs and savings. The study estimates the costs of acquiring and using 11 contraceptive methods appropriate for adolescents, treating associated side effects, providing medical care related to an unintended pregnancy during method use and treating sexually transmitted diseases (STDs) and compares them with the costs of using no method. The average annual cost per adolescent at risk of unintended pregnancy who uses no method is $1,267 ($1,079 for unintended pregnancy and $188 for STDs) in the private sector and $677 ($541 for unintended pregnancy and $137 for STDs) in the public sector under the most conservative assumptions. At one year of use, private-sector savings from adolescent contraceptive use range from $308 for the implant to $946 for the male condom; public-sector savings rise from $60 for the implant to $525 for the male condom. Both the use of male condoms with another method and the advance provision of backup emergency contraceptive pills provide additional savings.

PIP: Six previous studies have demonstrated that contraceptive use saves substantial health care dollars in both private and public settings in the US. The present study was the first to focus on the costs and savings of contraceptive use among US adolescent women 15-19 years of age. Through use of data from a national third-party private payer database and from the California Medicaid program, the costs of acquiring and using 11 contraceptive methods appropriate for adolescents, treating associated side effects, providing medical care related to an unintended pregnancy during method use, and treating sexually transmitted diseases (STDs) were calculated and compared with the costs of using no method. Under the most conservative of the three scenarios considered (which included the cost of STDs and lowered the cost of unintended birth to reflect the reported proportions of unwanted and mistimed births), the average annual cost per adolescent at risk of unintended pregnancy who used no method was US$1267 (including $188 for STDs) in the private sector and $677 ($137 for STDs) in the public sector. At 1 year of use, cost savings from adolescent contraceptive use were lowest for the implant ($60 in the public sector and $308 in the private sector) and highest for the male condom ($525 and $946, respectively). Additional savings were conferred both by the use of male condoms with another method and the advance provision of backup emergency contraceptive pills. Policies that reduce the occurrence of adolescent pregnancy and STDs are important for their social and reproductive health benefits. These findings indicate that--in addition--the provision of health insurance coverage for contraception, without substantial out-of-pocket expenditures or deductibles, is highly cost-effective.

The fertility impact of alternative family planning distribution channels in Indonesia.

Clinic-based distribution of contraceptive commodities is expensive per unit distributed. This situation has fueled the search for alternative means of delivery. Comparing the performance of alternatives is straightforward if the output measure is a count of commodities distributed, but comparing actual fertility impacts is another matter. I use data from the 1991 Indonesia Demographic and Health Survey to assess the extent of difference among the eventual fertility outcomes of users supplied with similar commodities through varying sources. When the "modern" methods of pill, IUD, and injection are grouped together, the fertility of users supplied with these commodities differs markedly according to their source of supply. I find little evidence for self-selecting of users into supply channels. This result implies that fertility differentials by source are likely due to characteristics of the distribution channels.

Still waiting for the contraceptive revolution.

PIP: There was considerable anticipation in the mid-1960s with the marketing and uptake of the oral contraceptive pill and the IUD that many other new forms of contraception would be available to the general public before the turn of the century. Much of that enthusiasm about contraceptive advances has since waned. Only three new contraceptive methods received US Food and Drug Administration approval during the 1990s, none as soon as advocates had expected, while the only other important changes were the gradual adjustment of pill formulations to expose users to a smaller total dosage of hormones and the introduction of new hormones already widely used in Europe. The lack of decisive advances is not the result of a paucity of candidate methods. In 1993, for example, an estimated 100 experimental contraceptive methods were being studied around the world. Many of those methods had, however, been in the works for years, while others were only slight modifications of products already on the market. Regulatory and legal issues, public opinion and politics, and financial issues have been identified as key obstacles to why the contraceptive reality has failed to match 1960s expectations. The author explains who sponsors contraceptive research and describes the ongoing development of spermicides and barrier methods, injectables, vaginal rings, implants, IUDs, methods for men, vaccines, and menses induction.^ieng

Contraception update: implantable and injectable methods.

There are currently more options available to pediatricians caring for sexually active adolescents who wish to prevent pregnancy. The two progestin-only methods, levonorgestrel subdermal implants and DMPA injections, minimize or entirely remove the obstacle of patient compliance from contraceptive efficacy. Adolescents considering a progestin-only method of contraception should be counseled explicitly about the likelihood of menstrual irregularity with use. Perhaps more importantly, adolescents should be reminded that hormonal methods of contraception do not provide protection from sexually transmitted disease. Thus, male condom use should not only be recommended, but also concrete discussion and instruction on appropriate use should be given.

PIP: Two new progestin-only contraceptive methods--levonorgestrel subdermal implants and Depo-Provera injection--have the potential to overcome adolescents' traditional poor compliance with family planning methods. Both methods provide safe, highly effective, reversible fertility control, but require virtually no ongoing patient compliance. The levonorgestrel implants provide continuous contraception for up to five years and have a failure rate under 1%. The primary side effect is an alteration in menstrual patterns: prolonged bleeding in 40%, irregular bleeding in 38%, intermenstrual spotting in 32%, more frequent bleeding in 16%, and amenorrhea in 12%. An average weight gain of five pounds over the five-year period of use is expectable given the appetite stimulation associated with progestins. Depo-Provera, injected every three months, has a failure rate of 0.1-0.7% in the first year of use. Amenorrhea is the most commonly reported menstrual side effect. Although both methods are highly effective in preventing pregnancy, they confer no protection against sexually transmitted diseases; thus, adolescent acceptors should be counseled to use condoms concomitantly.

Cost-effectiveness of levonorgestrel subdermal implants. Comparison with other contraceptive methods available in the United States.

The objective of this analysis was to evaluate and compare the cost-effectiveness of eight contraceptive methods: condoms, diaphragms, oral contraceptives, intrauterine devices, medroxyprogesterone acetate suspension, levonorgestrel subdermal implants, tubal ligation and vasectomy. Based on a comprehensive review of the literature and various additional data sources, this analysis identified, measured and compared direct costs of the methods, physician visits, treatment of adverse effects and cost of failure (i.e., mean cost for all types of deliveries or first-trimester abortion). Medical benefits (if any) resulting from each contraceptive method were calculated and considered in the analysis as cost savings. The cost of method failure proved to be the greatest influence on cost-effectiveness. Sterilization was identified as the most cost-effective method overall. Of the reversible methods, the intrauterine device was found to be the most cost-effective, followed by levonorgestrel implants.

PIP: Cost is an important factor which can influence the choice of a particular contraceptive method. Costs affect not only patients, but the ability of social service systems to provide access to contraception. Levonorgestrel implants were approved by the Food and Drug Administration in December 1990 as the first available contraceptive subdermal implant. They have since been inserted in 780,000 women in the US. The authors developed a cost-effectiveness model to evaluate and compare the cost-effectiveness of these implants against those of condoms, diaphragms, oral contraceptives, IUDs, medroxyprogesterone acetate suspension, tubal ligation, and vasectomy. The model identifies, measures, and compares direct costs of the methods, physician visits, the treatment of adverse effects, and cost of failure, thus calculating an expected cost per year for each method. Medical benefits, if any, resulting from the use of each method were calculated and considered in the analysis as cost savings. A sensitivity analysis was performed using cost parameters and failure rates, both independently and in combination. Data for the analysis were drawn from a comprehensive literature review, physician surveys, manufacturer package inserts, 1992 diagnosis-related group hospital reimbursement rates from Medicaid, and physician interviews. The cost of method failure had the greatest influence upon cost-effectiveness, with sterilization identified as the most cost-effective method overall. Of the reversible methods, the IUD was found to be the most cost-effective, followed by levonorgestrel implants.

Practical problems which women encounter with available contraception in Australia.

Australian women face major difficulties with contraception because of the limited range of choices, the need for meticulous attention to compliance with most available methods and because of cost limitations for a significant minority of the population. The most commonly used methods are oral contraceptive pills and barrier methods, and each has substantial compliance problems which can be minimized with care and counselling. There is an urgent need for a wider range of options in Australia and for good information and publicity about them. Present progress in this direction gives some hope for the near future.

PIP: Australian women face compliance, availability, and cost problems with contraceptives. In reality, oral contraceptives (OCs) have a high failure rate. An abortion survey in New South Wales in 1992 found that 14.4% of women were using OCs at the time of conception. Complete compliance with OCs is uncommon (28-40%). Abrupt cessation of OC use and forgetting to use pills at either end of the pill cycle are major reasons for noncompliance. Leading reasons for abrupt cessation of OCs are concerns about OCs, poor cycle control, weight gain, and headaches. Some ways to improve OC compliance are improved packaging, uniform missed pill instructions, clearer and more readable package inserts, improved verbal and written counseling, and detailed instructions on how to take the pills and what to do when one misses a pill. The abortion survey found that 22% of women seeking an abortion were using condoms at the time of conception. Many report a broken or slipped condom, both of which are generally caused by incorrect usage. Women who use the diaphragm only when they have intercourse have a higher failure rate than those who keep it in place for 24 hours, even though the latter do not use spermicides. Women are less likely to use their contraceptive method if the instructions are difficult and complicated. The vaginal ring has potential because it does not require action every day and can be left in place. The mass media and attitudes of providers influence women's choice of contraceptives. In New South Wales, only 50% of general practitioners discuss IUDs when they talk to women about contraception. 11% of women in the abortion survey could not obtain postcoital contraception from their physicians. A postcoital contraceptive and low dose OCs should be readily available in Australia. Contraceptives are expensive in Australia. Some contraceptives which are unavailable in Australia are OCs with gestodene, postcoital contraceptives, the levonorgestrel-releasing IUD, Norplant, the vaginal sponge, the female condom, and RU-486.

Evaluation of the effect of contraceptive prices on demand in eight Western European countries.

Wide differences exist among European countries as regards national reimbursement schemes and the resulting individual expenditure on contraception. In this current research project annual expenditure and costs in the first year of use were calculated, taking into account existing reimbursement levels, for oral contraceptives, intrauterine devices, condoms, and sterilization in eight Western European countries: Italy, France, United Kingdom, Spain, West Germany, Austria, Sweden and Denmark. The costs were expressed in Swiss francs. For users of oral contraceptives it emerged that the annual expenditure on contraception ranged from nil in the United Kingdom to 172.32 Swiss francs in Austria. In the case of condoms, the cost to users was lowest in the United Kingdom (57.44 Swiss francs) and highest in Spain (105.95 Swiss francs). Expenditure on the use of an intrauterine device in the first year ranged from nil in the United Kingdom and Sweden to 449.87 Swiss francs in Austria, while sterilization was carried out free of charge in France, West Germany and Denmark, as compared with a cost of 677.57 Swiss francs in Italy. The variation in expenditure was largely explained by the extent to which contraception costs are reimbursed in the respective countries. Correlation of the calculated expenditure on a method and its use did not show any statistically significant trend. This suggests that the wide differences in the choice of contraceptive methods between countries are not related to differences in national reimbursement schemes and resulting costs to users, and that other factors must be involved.

La calidad de atención en el mercadeo comercial y social de los programas de planificación familiar en América Latina y el Caribe / La calidad de atención en el mercadeo comercial y social de los programas de planificación familiar en América Latina y el Caribe / Quality of family planning services programs in the Latin American business and social markets

Este artículo revisa la situación de la calidad de atención en el contexto del mercadeo comercial de los productos y servicios de planifiación familiar, con especial enfoque en el desarrollo de programas de mercadeo social de anticonceptivos (MSA) en América Latina y el Caribe (ALC). Se observan los mecanismos comunes a todos los programas de mercadeo del sector comercial, en términos de lo adecuado de su respuesta a las inquietudes sobre la calidad de atención ofrecida por los programas de MSA al proporcionar productos y servicios de planificación familiar