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Purpose Among U.S. primary care physicians who delivered sexual and reproductive health (SRH) services to adolescents before the COVID-19 pandemic, we examine (1) changes in availability of in-person SRH services; (2) changes in accessibility and utilization of SRH services; and (3) use of strategies to support provision of SRH services during the pandemic. Methods Data were from the DocStyles provider survey administered September–October 2020. Descriptive analyses were restricted to family practitioners, internists, and pediatricians whose main work setting was outpatient and whose practice provided family planning or sexually transmitted infection services to ≥ one patient aged 15–19 years per week just before the COVID-19 pandemic (n = 791). Results Among physicians whose practices provided intrauterine device/implant placement/removal or clinic-based sexually transmitted infection testing before the COVID-19 pandemic, 51% and 36% indicated disruption of these services during the pandemic, respectively. Some physicians also reported reductions in walk-in hours (38%), evening/weekend hours (31%), and adolescents seeking care (43%) in the past month. At any point during the pandemic, 61% provided contraception initiation/continuation and 44% provided sexually transmitted infection services via telehealth. Among these physicians, about one-quarter reported confidentiality concerns with telehealth in the past month. There were small increases or no changes in other strategies to support contraceptive care. Conclusions Findings suggest disruption of certain SRH services and issues with access because of the pandemic among primary care providers who serve adolescents. There are opportunities to enhance implementation of confidential telehealth services and other service delivery strategies that could help promote adolescent SRH in the United States.

In 2010, the Centers for Disease Control and Prevention (CDC) released the U.S. Medical Eligibility Criteria for Contraceptive Use, providing recommendations for health care providers on safe use of contraception for people with certain characteristics or medical conditions. Adapted from World Health Organization guidance, the goal of the recommendations is to remove unnecessary medical barriers to contraception. Over the past decade, CDC has updated recommendations based on new evidence, collaborated with national partners to disseminate and implement the guidelines, and conducted provider surveys to assess changes in attitudes and practices around contraception safety and provision. CDC remains committed to supporting evidence-based guidelines for safe use of contraception, as the basis for improving access to contraception and high-quality family planning services, reducing unintended pregnancy, and improving reproductive health in the United States.

Objective The Zika Contraception Access Network (Z-CAN) provided women in Puerto Rico access to contraceptive counseling and the full range of reversible contraceptive methods, on the same day and at no cost, during the Zika virus outbreak. Because trained physicians and clinic staff were crucial to the program, we aimed to assess the implementation of and satisfaction with Z-CAN from their perspectives. Study design Physicians and clinic staff in the Z-CAN program participated in an online survey on program implementation (e.g., on-site and same-day contraceptive provision), program satisfaction, and knowledge consistent with program training (e.g., contraceptive initiation and safety, client-centered contraceptive counseling, intrauterine device [IUD] and implant insertion and removal). Results Survey respondents included 63 physicians and 53 clinic staff members. A high proportion of physicians (>93%) reported providing IUDs, implants, pills, rings, condoms, and injections and most were very often or always able to provide same-day access to most methods. Over 90% of physicians were satisfied with the Z-CAN program, training, and ongoing support. Staff satisfaction with these program elements was similar but slightly lower. Knowledge about exams and tests needed for initiation and safety of methods varied but was generally consistent with guidelines on which physicians received training. Most physicians (>90%) reported confidence in skills on which they received training as part of the program. Conclusions From the perspectives of participating physicians and clinic staff, the program was generally implemented as intended and providers were largely satisfied with program strategies including training and on-going support. Implications Certain key components of the Z-CAN program, such as training, proctoring, and involvement of clinic staff were likely critical to Z-CAN’s implementation and provider satisfaction. Results from this provider survey can inform implementation of similar efforts to increase access to contraception in both emergency and non-emergency settings.

Study Objective To identify characteristics associated with provider attitudes on the safety of “Quick Start” initiation of long-acting reversible contraception (LARC) for adolescents. Design, Setting, Participants, Interventions, and Main Outcome Measures We conducted a cross-sectional survey of providers in public-sector health centers and office-based physicians (n = 2056) during 2013-2014. Results Overall, the prevalence of considering “Quick Start” initiation of LARC for adolescents as safe was 70.9% for implants and 64.5% for intrauterine devices (IUDs). Among public-sector providers, those not trained in implant or IUD insertion had lower odds of perceiving the practice safe (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.25-0.41 for implants; aOR 0.42; 95% CI, 0.32-0.55 for IUDs), whereas those practicing at health centers that did not receive Title X funding had lower odds of perceiving the practice safe for IUDs (aOR, 0.77; 95% CI, 0.61-0.98). Among office-based physicians, lack of training in LARC insertion was associated with lower odds of perceiving “Quick Start” initiation to be safe for IUDs (aOR, 0.31; 95% CI, 0.12-0.77). Those specializing in adolescent medicine had higher odds of reporting “Quick Start” initiation of LARC as safe (implants: aOR, 2.21; 95% CI, 1.23-3.98; IUDs: aOR, 3.37; 95% CI, 1.39-8.21) compared with obstetrician-gynecologists. Conclusion Approximately two-thirds of providers considered “Quick Start” initiation of LARC for adolescents safe; however, there were differences according to provider characteristics (eg, Title X funding, training in LARC insertion, specialty). Targeted LARC insertion training and dissemination of evidence-based family planning guidance and implementation into facility and practice-level policies might increase access to “Quick Start” initiation of LARC for adolescents.

Context The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings. Evidence acquisition Multiple databases, including PubMed, were searched during 2016–2017 for articles published from March 1, 2011, to November 30, 2016. Evidence synthesis The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest. Conclusions Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective. Theme information This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.

Objective(s) We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers. Study Design We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods. Results The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training. Conclusions Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients. Implications Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.

CONTEXT Women who are living with HIV use IUDs at a lower rate than the general population, and it is unclear whether health care providers' misconceptions about IUD safety contribute to this disparity. METHODS A 2013-2014 nationwide survey of 1,998 U.S. family planning providers assessed perceptions of IUD safety for women with HIV or other medical conditions. Multivariable logistic regression was used to examine associations between provider characteristics and whether individuals believed IUDs were safe for HIV-positive women. Data from public-sector providers and office-based physicians were analyzed separately. RESULTS Seven in 10 providers considered IUDs safe for women with HIV, and there were no differences by provider type. Among public-sector providers, some of the characteristics associated with believing that IUDs were unsafe for seropositive women were working at a clinic without Title X funding (odds ratio, 1.5), not being trained in IUD insertion (2.1) and not using the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for clinical guidance (1.8). Office-based physicians who did not use the guidelines also had an increased likelihood of believing that IUDs were unsafe for women with HIV (2.9), and physicians who had completed training 25 or more years ago were more likely than those who had done so less than five years ago to consider IUDs unsafe (3.3). CONCLUSIONS Greater use of evidence-based contraceptive guidance such as the U.S. MEC may help inform provider perceptions of IUD safety and hence contribute to increased contraceptive choice for women with HIV.

CDC's U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) (first published in 2010 and updated in 2016) provides evidence-based guidance for the safe use of contraceptive methods among U.S. women with certain characteristics or medical conditions (1), and is adapted from global guidance from the World Health Organization (WHO) and kept up to date based on continual review of published literature (2).* CDC recently evaluated the evidence and the updated WHO guidance on the risk for human immunodeficiency virus (HIV) acquisition among women using hormonal contraception.† After careful review, CDC adopted the updated WHO guidance for inclusion in the U.S. MEC guidance; this guidance states that the advantages of progestin-only injectable contraceptive use (including depot medroxyprogesterone acetate [DMPA]) by women at high risk for HIV infection outweigh the theoretical or proven risks (U.S. MEC category 2). The guidance also includes an accompanying updated clarification, which states that "there continues to be evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. Uncertainty exists about whether this is due to methodological issues with the evidence or a real biological effect. In many settings, unintended pregnancies and/or pregnancy-related morbidity and mortality are common, and progestin-only injectables are among the few types of methods widely available. Women should not be denied the use of progestin-only injectables because of concerns about the possible increased risk. Women considering progestin-only injectables should be advised about these concerns, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV." Recommendations for other hormonal contraceptive methods (including combined hormonal methods, implants, and progestin-only pills) remain the same; there is no restriction for their use among women at high risk for HIV infection (U.S. MEC category 1).

Family planning is essential for any comprehensive treatment plan for women of reproductive age with multiple sclerosis (MS), including counseling on using effective contraception to optimally time desired and prevent unintended pregnancies. This topical review summarizes the first evidence-based recommendations on contraception safety for women with MS. In 2016, evidence-based recommendations for contraceptive use by women with MS were included in US Medical Eligibility Criteria for Contraceptive Use. They were developed after review of published scientific evidence on contraception safety and consultation with experts. We summarize and expand on the main conclusions of the Centers for Disease Control and Prevention guidance. Most contraceptive methods appear based on current evidence to be safe for women with MS. The only restriction is use of combined hormonal contraceptives among women with MS with prolonged immobility because of concerns about possible venous thromboembolism. Disease-modifying therapies (DMTs) do not appear to decrease the effectiveness of hormonal contraception although formal drug–drug interaction studies are limited. Neurologists can help women with MS make contraceptive choices that factor their level of disability, immobility, and medication use. For women with MS taking potentially teratogenic medications, highly effective methods that are long-acting (e.g. intrauterine devices, implants) might be the best option.

Key Clinical PointsLong-Acting Reversible Contraception Intrauterine devices (IUDs) and hormonal implants are the most effective reversible methods of contraception — approximately 20 times as effective as pills, patches, and rings; couples should be counseled and informed about the superior effectiveness of long-acting reversible contraception (LARC) methods. IUDs and hormonal implants are safe for almost all women, including adolescents, as well as women in the postpartum or postabortion period. The main side effect of IUDs and hormonal implants is a change in bleeding patterns; anticipatory counseling about expected changes in bleeding may increase rates of continuation. Barriers to access to IUDs and hormonal implants remain, including those related to education, provider training, cost, and logistics; successful interventions have been shown to minimize these barriers. Adolescents and adult women should be counseled about contraception and should have access to the full range of contraceptive methods...

Objective The objective was to assess risk of pelvic inflammatory disease (PID) among women with current asymptomatic undiagnosed cervical infection or who are at high risk of sexually transmitted infections (STIs), comparing those who have a copper-bearing (Cu-) or levonorgestrel (LNG-) intrauterine device (IUD) placed with women who do not. Study design We searched PubMed and Cochrane Library for articles from January 1984 through January 2016 addressing our objective. We assessed study quality using the United States Preventive Services Task Force evidence grading system. Results Our search strategy yielded 2220 articles, of which 10 met inclusion criteria. Two studies provided direct evidence of PID rates in women with undiagnosed gonococcal or chlamydial (GC/CT) infection or at high risk for STIs initiating IUDs versus other contraceptive methods (level II-2, fair to poor), and neither study found a difference. Eight studies provided indirect evidence (II-2 to II-3, fair to poor). One study found no difference in PID rates between initiators of Cu- versus LNG-IUDs. Five studies compared algorithms based on patient factors with laboratory GC/CT screening to predict cervical infection. Based on likelihood ratios, none of these algorithms adequately identified women at high risk of asymptomatic cervical infection who should not undergo IUD placement. Two studies compared IUD placement on the same day as STI screening with delayed placement after screening and found no difference in PID rates. Conclusion Limited evidence suggests that IUD placement does not increase the risk of PID compared with no IUD placement among women with asymptomatic undiagnosed cervical infection or at high risk of STIs. Algorithms based on patient characteristics to identify women with asymptomatic GC/CT may be overly restrictive, leading to missed opportunities for IUD initiation. Historical concerns about higher PID risk among women at risk for STIs who use IUDs may not be relevant with modern devices and STI screening and treatment practices.

OBJECTIVE: This study aims to determine whether emergency contraceptive pills (ECPs) are less safe and effective for women with obesity compared with those without obesity. STUDY DESIGN: We searched PubMed for articles through November 2015 regarding the safety and effectiveness of ECPs [ulipristal acetate (UPA), levonorgestrel (LNG) and combined estrogen and progestin] among obese users. We assessed study quality using the United States Preventive Services Task Force evidence grading system. RESULTS: We identified four pooled secondary analyses (quality: poor to fair), two of which examined UPA and three examined LNG formulations. Three analyses pooled overlapping data from a total of three primary studies and demonstrated significant associations between obesity and risk of pregnancy after ECP use. One analysis reported a 4-fold increased risk of pregnancy among women with obesity (BMI≥30 kg/m(2)) compared with women within normal/underweight categories (BMI

We are grateful to Sharon Achilles for her thoughtful input related to describing potential biological mechanisms, and to all study investigators who provided additional information about their analyses. WHO provided support for the writing of this systmatic review and for the writing group to attend a working meeting in Geneva, Switzerland in October 2015. D.J.W. was partially funded by NIH DP2-HD-08-4070. The review was conducted independently of the WHO guidance development process; and conclusions represent the independent opinions of the authors. The findings and conclusions in this article do not necessarily reflect the positions and policies of the donor. Role of authors: The World Health Organization (J.N.K. and P.S.S.) initiated the idea to conduct this systematic review update. C.B.P. led the conduct of the systematic review, including conducting the systematic literature search and drafting the manuscript. C.B.P., K.M.C., and P.C.H. screened titles, abstracts, and full-text manuscripts to determine study inclusion. S.J.P. conducted the statistical meta-analysis. All coauthors (C.B.P., K.M.C., P.C.H., S.J.P., T.C., J.N.K., D.J.W., and P.S.S.) participated in framing the study question, developing the quality criteria, abstracting study information and assessing study quality, interpreting the data, and contributing to the writing and editing of the manuscript. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official positions of the Guttmacher Institute, the Centers for Disease Control and Prevention, the World Health Organization, the National Institutes of Health, or other institutions with which the authors are affiliated.

Background Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness. Objectives To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness. Setting United States. Methods We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness. Results Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as “other” (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics. Conclusions Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

Identify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents.We analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year.Although most providers (95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30-0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28-0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27-0.91) and family medicine (aOR 0.21, 95% CI 0.09-0.47) versus adolescent medicine, completing training ≥15 versus5 years ago (aOR 0.27, 95% CI 0.09-0.83), and reporting that 0-24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09-0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method.While most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception.Although95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.

BackgroundContraception is important for women who are postpartum, including those who are breastfeeding. Use of combined hormonal contraceptives (CHCs) may affect breastfeeding performance and infant health outcomes.ObjectiveThe objective was to identify evidence examining clinical outcomes for breastfeeding and infant health among breastfeeding women using CHCs compared to nonusers.Search strategyWe searched the PubMed database for all articles published from database inception through September 30, 2014.Selection criteriaWe included primary research studies that compared breastfeeding women using CHCs with breastfeeding women using nonhormonal or no contraception, or compared breastfeeding women initiating combined hormonal contraception at early versus later times postpartum. Breastfeeding outcomes of interest included duration, rate of exclusive breastfeeding and timing of supplementation. Infant outcomes of interest included growth, health and development.ResultsFifteen articles describing 13 studies met inclusion criteria for this review. Studies ranged from poor to fair methodological quality and demonstrated inconsistent effects of combined oral contraceptives (COCs) on breastfeeding performance with COC initiation before or after 6 weeks postpartum; some studies demonstrated greater supplementation and decreased breastfeeding continuation among COC users compared with nonusers, and others demonstrated no effect. For infant outcomes, some studies found decreases in infant weight gain for COC users compared with nonusers when COCs were initiated at

Background Postpartum women need effective contraception. Concerns have been raised that use of progestogen-only contraceptives (POCs) may affect breastfeeding performance and infant health outcomes. Objectives We investigated the clinical outcomes of breastfeeding duration, initiation of supplemental feeding and weaning, as well as infant outcomes including infant growth, health and development among breastfeeding women using POCs compared with breastfeeding women not using POCs. Search strategy We searched the PubMed database for all articles published from database inception through December 2014. Selection criteria We included primary research studies of breastfeeding women of any age or parity who received POCs, including progestogen-only pills, injectables, implants or hormonal intrauterine devices (IUDs). The main outcomes were breastfeeding performance (as measured by initiation, continuation, frequency and exclusivity of breastfeeding) and infant health (as measured by growth, development or adverse health effects). Results Forty-nine articles reporting on 47 different studies were identified that investigated the use of POCs in breastfeeding women and reported clinically relevant outcomes of infant growth, health or breastfeeding performance. Studies ranged from poor to fair methodological quality and generally failed to show negative effects of the use of POCs on breastfeeding outcomes or on infant growth or development. One randomized controlled trial (RCT) raises concerns that immediate insertion of the levonorgestrel IUD postpartum may be associated with poorer breastfeeding performance when compared with delayed insertion, although two other RCTs evaluating early etonogestrel implants compared with delayed initiation of implants or depot medroxyprogesterone acetate failed to find such an association. Conclusion The preponderance of evidence fails to demonstrate adverse breastfeeding outcomes or negative health outcomes in infants such as restricted growth, health problems or impaired development. Evidence newly added to this review was largely consistent with previous evidence.

The 2016 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a select group of common, yet sometimes controversial or complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26-28, 2015. The information in this report updates the 2013 U.S. SPR (CDC. U.S. selected practice recommendations for contraceptive use, 2013. MMWR 2013;62[No. RR-5]). Major updates include 1) revised recommendations for starting regular contraception after the use of emergency contraceptive pills and 2) new recommendations for the use of medications to ease insertion of intrauterine devices. The recommendations in this report are intended to serve as a source of clinical guidance for health care providers and provide evidence-based guidance to reduce medical barriers to contraception access and use. Health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.

Objectives: The significant improvement in the contraceptive prevalence rate in Kaduna State, Nigeria, from 8.4% in 2008 to 18.5% in 2013 is a notable achievement. This article analyses the role of midwives as drivers of reproductive health commodity security (RHCS) and their impact on contraceptive use in Kaduna State. Methods: The United Nations Population Fund (UNFPA) supported the bimonthly review resupply meetings facilitated by midwives at State and local government area (LGA) levels. The midwives deliver contraception to the LGAs for onward distribution to 6974 of the 25,000 health facilities across the country according to usage data from the previous 2 months. They also collect requisition, issue and resupply form data from the previous 2 months. Results: The active participation of midwives at the bimonthly meetings improved data timeliness by 23% and data completeness by 50% in 1 year. Only one health facility ran out of intrauterine devices and only 17% reported running out of female condoms. The total number of contraceptives issued increased from 31,866 in 2012 to 177,828 in 2013, resulting in a couple–year protection increase from 3408 in 2012 to 102,207 in 2013. Conclusions: Creation of increased demand and engagement of midwives in providing family planning services, especially long-acting contraceptive methods, coupled with the removal of cost to the user and the strengthening of the supply chain have been major factors in more than doubling the contraceptive prevalence rate.

Background Hormonal contraceptives are important for the health and well-being of some women living with HIV, so evaluation of evidence regarding their safety vis-a-vis HIV-related risks is important. Methods We updated two prior systematic reviews on the impact of hormonal contraception (HC) on HIV disease progression and female-to-male HIV transmission. Results One new study finds no increased risk for HIV disease progression or death associated with oral contraceptive use [adjusted (adj) hazard ratio (HR) 0.83, confidence interval [CI] 0.48–1.44] or injectables (adj HR 0.72, CI 0.53–0.98). Three new studies did not find significantly increased risks for measures of female-to-male HIV transmission with HC use. Conclusions Hormonal contraceptive methods do not appear to accelerate HIV disease progression. More research is needed to clarify whether HC impacts HIV transmissibility.

OBJECTIVE: To examine contraceptive use among women with selected medical conditions. METHODS: We used a nationwide health care claims database to identify women aged 15-44 years continuously enrolled in private insurance during 2004-2011 with and without selected medical conditions. We assessed current permanent and reversible prescription contraceptive use during October 1 2010 to September 30 2011 with diagnosis procedure and pharmacy codes and calculated prevalence by age and condition. We used polytomous logistic regression to calculate odds of female sterilization or reversible prescription methods compared with neither. Among users of reversible methods we used logistic regression to calculate odds of using long-acting reversible contraceptives compared with shorter acting methods. RESULTS: A low proportion of women with medical conditions were using sterilization or reversible prescription methods (45% and 30% of women aged 15-34 and 35-44 years respectively) and this proportion was consistently lower among the older age group across all medical conditions. Across both age groups sterilization and long-acting reversible contraceptives were used less frequently than shorter acting methods (injectable pill patch or ring). The odds of sterilization were higher among women with any compared with no condition for women aged 15-34 years (odds ratio [OR] 4.9 95% confidence interval [CI] 4.5-5.3) and 35-44 years (OR 1.2 95% CI 1.1-1.2). Among women using reversible prescription methods the odds of using long-acting reversible contraceptives were increased among those with any compared with no condition for women aged 15-34 years (OR 2.2 95% CI 2.1-2.5) and 35-44 years (OR 1.1 95% CI 1.1-1.2). CONCLUSION: Despite the potential for serious maternal and fetal pregnancy-associated risks contraceptive use was not optimal among women with medical conditions. LEVEL OF EVIDENCE: III.

Whether use of various types of hormonal contraception (HC) affect risk of HIV acquisition is a critical question for women's health. For this systematic review, we identified 22 studies published by January 15, 2014 which met inclusion criteria; we classified thirteen studies as having severe methodological limitations, and nine studies as "informative but with important limitations". Overall, data do not support an association between use of oral contraceptives and increased risk of HIV acquisition. Uncertainty persists regarding whether an association exists between depot-medroxyprogesterone acetate (DMPA) use and risk of HIV acquisition. Most studies suggested no significantly increased HIV risk with norethisterone enanthate (NET-EN) use, but when assessed in the same study, point estimates for NET-EN tended to be larger than for DMPA, though 95% confidence intervals overlapped substantially. No data have suggested significantly increased risk of HIV acquisition with use of implants, though data were limited. No data are available on the relationship between use of contraceptive patches, rings, or hormonal intrauterine devices and risk of HIV acquisition. Women choosing progestin-only injectable contraceptives such as DMPA or NET-EN should be informed of the current uncertainty regarding whether use of these methods increases risk of HIV acquisition, and like all women at risk of HIV, should be empowered to access and use condoms and other HIV preventative measures. Programs, practitioners, and women urgently need guidance on how to maximize health with respect to avoiding both unintended pregnancy and HIV given inconclusive or limited data for certain HC methods.

BACKGROUND: Whether providers who regularly provide family planning services consider contraceptive methods as unsafe for women with obesity is unknown. METHODS: We analyzed questionnaire responses received from December 2009 to March 2010 from 635 office-based physicians and 1323 Title X clinic providers delivering family planning services, who were randomly sampled (response rate 65%) before the release of national evidence-based contraception guidelines. We examined provider and clinical setting characteristics and clinic patient demographics for association with provider misconceptions about safety of combined oral contraceptives (COCs), depot medroxyprogesterone acetate (DMPA), or intrauterine devices (IUDs) for women with obesity. If providers considered methods as unsafe or do not know, we categorized those responses as misconceptions. We used multivariable logistic regression to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: A substantial proportion of respondents had misconceptions about the safety of COCs (31%), DMPA (24%), copper (Cu) (18%), and levonorgestrel (LNG)-IUDs (16%) for women with obesity. Provider type was associated with increased odds of misconceptions for all four methods compared with office-based obstetrician/gynecologists. Not having the method available onsite was associated with safety misconceptions of DMPA (aOR 1.90, 95% CI 1.07–3.36), Cu-IUD (aOR 4.19, 95% CI 1.51–11.61), and LNG-IUD (aOR 5.25, 95% CI 1.67–16.49). CONCLUSION: While the majority of providers considered all four contraceptive methods safe for women with obesity, substantial proportions had misconceptions about safety of COCs, DMPA, and IUDs. Provider education, particularly among certain specialties, is needed to increase knowledge regarding moderate and highly effective contraceptive methods among this patient population.

OBJECTIVE: Health care providers should assess pregnancy in women seeking contraceptive services. Although urine pregnancy tests are available in most U.S. settings their accuracy varies based on timing relative to missed menses recent intercourse or recent pregnancy. We examined the performance of a checklist based on criteria recommended in family planning guidance documents to assist health care providers in assessing pregnancy in a sample of U.S. teenagers and young women. METHODS: Study participants were a convenience sample of sexually active black females aged 14-19 years seeking care in an urban family planning clinic. Each participant provided a urine sample for pregnancy testing and was then administered the checklist in two formats audio computer-assisted self-interview and in-person interview. We estimated measures of the checklist performance compared with urine pregnancy test as the reference standard including negative predictive value sensitivity specificity and positive predictive value. RESULTS: Of 350 participants 31 (8.9%) had a positive urine pregnancy test. The audio computer-assisted self-interview checklist indicated pregnancy was unlikely for 250 participants of whom 241 had a negative urine pregnancy test (negative predictive value=96.4%). The sensitivity of the audio computer-assisted self-interview checklist was 71% the specificity was 75.6% and the positive predictive value was 22%. The in-person checklist yielded similar results. CONCLUSION: The checklist may be a valuable tool to assist in assessing pregnancy in teenagers and young women. Appropriate use of the checklist by family planning providers in combination with discussion and clinically indicated use of urine pregnancy tests may reduce unnecessary barriers to contraception in this population.

Purpose To estimate the prevalence of and factors associated with dual method use (i.e., condom with hormonal contraception or an intrauterine device) among adolescents and young women in the United States. Methods We used 2006–2010 National Survey of Family Growth data from 2,093 unmarried females aged 15–24 years and at risk for unintended pregnancy. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the associations between dual method use at last sex and sociodemographic, behavioral, reproductive history, and sexual behavior factors. Results At last sex, 20.7% of adolescents and young women used dual methods, 34.4% used condoms alone, 29.1% used hormonal contraception or an intrauterine device alone, and 15.8% used another method or no method. Factors associated with decreased odds of dual method use versus dual method nonuse included having a previous pregnancy (aOR = .44, 95% CI .27–.69), not having health insurance coverage over the past 12 months (aOR = .41, 95% CI .19–.91), and having sex prior to age 16 (aOR = .49, 95% CI .30–.78). Conclusions The prevalence of dual method use is low among adolescents and young women. Adolescents and young women who may have a higher risk of pregnancy and sexually transmitted infections (e.g., those with a previous pregnancy) were less likely to use dual methods at last sex. Interventions are needed to increase the correct and consistent use of dual methods among adolescents and young women who may be at greater risk for unintended pregnancy and sexually transmitted infections.

Unintended pregnancy rates remain high in the United States and these pregnancies may carry increased risks for negative health outcomes. Lack of contraceptive use and inconsistent use are important contributors to the high rate of unintended pregnancies. Women may face certain barriers to starting contraception and using it effectively. The Centers for Disease Control and Prevention has recently developed the U.S. Selected Practice Recommendations for Contraceptive Use, 2013, which provides guidance for common yet sometimes complex issues in contraceptive management. This guidance aims to reduce barriers to contraceptive use by providing clear recommendations for providers to assist women in initiating and using contraceptive methods to maximize effectiveness and decrease risk of unintended pregnancy.

Immediate postpartum intrauterine devices (IUDs) have been underutilized in the United States despite their known safety. Understanding how providers' attitudes contribute to underutilization is important in improving access. Our objective was to examine healthcare providers' perceptions of the safety of immediate postpartum IUDs before publication of United States contraceptive guidelines.We analyzed survey data collected from December 2009 to March 2010 from 635 office-based physicians and 1368 Title X clinic providers (overall response rate of 64.8%). Providers were asked how safe they thought copper and levonorgestrel (LNG) IUDs were in postpartum women (very safe, safe, unsafe, very unsafe, and unsure). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for characteristics associated with considering immediate and delayed postpartum IUDs to be safe.Less than 40% of respondents considered immediate or delayed IUD insertion to be safe. Providers with1 day of family planning training had decreased odds of considering immediate postpartum IUD insertion to be safe compared with unsafe/unsure (aOR 0.18, 95% CI 0.04-0.84 for copper IUD and aOR 0.17, 95% CI 0.04-0.81 for LNG-IUD). Providers without training in postpartum or interval copper IUD insertion had decreased odds of considering immediate postpartum copper IUD insertion (aOR 0.40, 95% CI 0.16-0.79) and delayed postpartum insertion for both IUD types to be safe (aOR 0.34, 95% CI 0.18-0.66 for copper IUD and aOR 0.41, 95% CI 0.21-0.77 for LNG-IUD).Before United States contraceptive guidelines, a majority of providers perceived immediate postpartum IUDs to be unsafe.

Progress has been made in efforts to reduce unintended pregnancy; however, unintended pregnancy remains a public health issue in the United States. A key component of reducing unintended pregnancy is to increase correct and consistent use of contraception by reducing barriers to access and use. The CDC has recently updated its guidance for the safe and effective use of contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), 2016, and U.S. Selected Practice Recommendations for Contraceptive Use (US SPR), 2016, are intended for healthcare providers to help patients choose a method that is safe and can be used effectively. The recommendations aim to reduce certain barriers to contraception and thus help women, men, and couples to control timing of pregnancies.

Summary Whether or not the use of hormonal contraception affects risk of HIV acquisition is an important question for public health. We did a systematic review, searching PubMed and Embase, aiming to explore the possibility of an association between various forms of hormonal contraception and risk of HIV acquisition. We identified 20 relevant prospective studies, eight of which met our minimum quality criteria. Of these eight, all reported findings for progestin-only injectables, and seven also reported findings for oral contraceptive pills. Most of the studies that assessed the use of oral contraceptive pills showed no significant association with HIV acquisition. None of the three studies that assessed the use of injectable norethisterone enanthate showed a significant association with HIV acquisition. Studies that assessed the use of depot-medroxyprogesterone acetate (DMPA) or non-specified injectable contraceptives had heterogeneous methods and mixed results, with some investigators noting a 1·5–2·2 times increased risk of HIV acquisition, and others reporting no association. Thus, some, but not all, observational data raise concern about a potential association between use of DMPA and risk of HIV acquisition. More definitive evidence for the existence and size of any potential effect could inform appropriate counselling and policy responses in countries with varied profiles of HIV risk, maternal mortality, and access to contraceptive services.

This paper seeks to address the gaps in research regarding recommendations for contraceptive use. There are three primary questions to be answered question the patient and provider understanding of adherence instructions to contraceptives prevention of bleeding irregularities among women using hormonal and intrauterine contraception and the long term effectiveness of hysteroscopic sterilization. Although this paper does discuss findings that answer these questions the purpose of the paper is to facilitate more research in these areas. Lastly the paper calls for more research in this field focusing on sensitive subgroups in the population that are likely to react differently to contraceptives. Copyright © 2013 Elsevier Inc. All rights reserved.

Background Unscheduled uterine bleeding is common among women who choose extended or continuous combined hormonal contraception and may subsequently lead to method discontinuation. This systematic review evaluates the evidence on treatments for unscheduled bleeding for women using continuous or extended combined hormonal contraception. Study design We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through January 2012 and were relevant to therapeutic or prophylactic treatments for unscheduled uterine bleeding during extended or continuous combined hormonal contraception use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. Results Four articles met the inclusion criteria. Evidence from two randomized controlled trials, both of fair quality, suggested that a short hormone-free interval of 3 or 4 days improved a current unscheduled bleeding episode. Evidence from one randomized controlled trial of fair quality suggested that oral doxycycline (100 mg twice daily) did not improve a current unscheduled bleeding episode. One good quality randomized controlled trial suggested that prophylactic treatment with a daily low dose of oral doxycycline (40 mg) caused earlier onset of amenorrhea in new extended combined oral contraceptive users. Conclusions Limited evidence suggests that introducing a short hormone-free interval when unscheduled bleeding occurs during continuous or extended hormonal contraceptive use may reduce unscheduled bleeding days; one study suggests that twice-daily oral doxycycline initiated at the time of unscheduled bleeding is an ineffective treatment. Limited data suggest that prophylactic low-dose daily oral doxycycline may induce earlier amenorrhea among new extended combined hormonal contraceptive users.

We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use.We searched the PubMed database for all peer-reviewed articles in any language published from database inception through May 2012 that examined the effect of a structured follow-up schedule of visits or contacts on contraceptive use. We included studies that compared women who initiated a method of contraception with a certain follow-up schedule compared to women with a different follow-up schedule or no follow-up at all. To be included, studies must have compared groups on a measure of contraceptive use (e.g., pregnancy, correct use, consistent use, method discontinuation including expulsion). Though not ideally suited to answer our review question, studies in which women used a variety of contraceptive methods but results were not stratified by method type were included.Four studies met our inclusion criteria (Level I, poor to II-2, poor). Two studies examined the effect of a specific follow-up visit schedule on intrauterine device (IUD) continuation: one examining frequency of visits and one examining the timing of the first follow-up visit. Women with more frequent follow-up visits did not have a statistically significant difference in proportion of removals for medical reasons compared with women who had fewer follow-up visits; among women who had their IUDs removed for medical reasons, those who had more frequent follow-up visits had a longer mean time of use prior to removal. The other study found more removals and shorter continuation among women with a follow-up visit at 1 week compared to women with a follow-up visit at 1 month after IUD insertion (no statistical tests reported). Two studies examined the effect of follow-up phone calls compared to no follow-up phone calls after an initial family planning visit among adolescents initiating a variety of contraceptive methods. Neither of the two studies found any differences in method continuation or correct use between study groups.It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates.

Background Nausea and vomiting are side effects of emergency contraception pill (ECP) use. Different ECP regimens and the use of antinausea drugs may prevent these side effects. Methods We conducted two searches to identify data pertaining to the prevention of nausea and vomiting with ECP use and management of emesis with ECP use. Both searches queried the PubMed and Cochrane databases for peer-reviewed articles, in any language, published on January 1966–February 2012. Types of ECP included in our searches were levonorgestrel (LNG), Yuzpe regimens or ulipristal acetate (UA). Our search strategy for data on management of emesis with ECP use also included the gray literature. The gray literature includes materials such as reports, patent claims, prescribing information and package labels that are not published commercially. Results Eleven articles met the inclusion criteria. Split dose or two doses of LNG caused less nausea than UA and standard two-dose Yuzpe regimen in one study. Four studies demonstrated no difference between split-dose versus single-dose LNG. In two trials, meclizine and metoclopramide, given before Yuzpe ECPs, reduced nausea, but only meclizine reduced vomiting. Conclusion The evidence does not support routine use of antiemetics with ECP use. Data to guide management of emesis with ECP are limited to expert opinion and package labeling.

Background Certain contraceptive methods may increase the risk of adverse events for women with certain medical conditions, including some women with diabetes, hyperlipidemia, liver disease, cervical cancer, sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). This review was conducted to evaluate the evidence regarding health outcomes among women with and without laboratory testing to identify certain medical conditions prior to initiating contraceptives. Study Design The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language evaluating health outcomes among women who initiated certain contraceptive methods and who had or had not received glucose, lipid, liver enzyme, cervical cytology, STI or HIV screening. Results The systematic review did not identify any relevant direct evidence. Conclusions While certain methods of hormonal contraception may not be safe for use by some women with diabetes, hyperlipidemia or liver disease, there is little value in screening for these conditions in asymptomatic women prior to initiation of contraceptive methods due to the low prevalence of these conditions among women of reproductive age. Although intrauterine devices (IUDs) and cervical caps should not be initiated in women with cervical cancer, the high rates of cervical screening and low incidence of cervical cancer in the United States make this scenario unlikely. Although some women at risk for, or infected with, STIs or HIV should not undergo IUD insertion, if women have been screened for STIs or HIV according to guidelines, additional screening at the time of IUD insertion is not warranted. Requiring unnecessary laboratory screening prior to initiation of contraceptive methods may impose barriers to contraceptive access, and efforts to remove such barriers are critical in reducing unintended pregnancy.

Background Bleeding irregularities, such as intermenstrual spotting or heavy or prolonged menstrual bleeding, are common among copper-containing intrauterine device (Cu-IUD) users and are one of the leading reasons for method discontinuation. This review evaluates the evidence for effective therapeutic and preventive treatments for bleeding irregularities during Cu-IUD use. Study Design We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through March 2012 and were relevant to treatments for irregular bleeding during Cu-IUD use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. Results From 1470 articles, we identified 17 articles that met our inclusion criteria. Evidence from two studies of poor quality demonstrated that antifibrinolytic agents or nonsteroidal anti-inflammatory drugs (NSAIDs) have been used for intermenstrual bleeding or spotting among a small number of Cu-IUD users with mixed results. Evidence from 10 studies of fair to poor quality suggested that some NSAIDs may significantly reduce menstrual blood loss or bleeding duration among Cu-IUD users with heavy or prolonged menstrual bleeding. Antifibrinolytic drugs or antidiuretics may also help reduce blood loss. High-dose aspirin was shown to increase blood loss among those with baseline menorrhagia. Evidence from five studies of fair to poor quality suggested that bleeding irregularities among new Cu-IUD users may be prevented with NSAIDs, although one large study of good quality suggested that prophylactic treatment with ibuprofen does not affect continuation of Cu-IUD use. Evidence from two studies of fair to poor quality suggested that antifibrinolytic agents might be helpful in preventing heavy or prolonged menstrual bleeding among new Cu-IUD users. Conclusions Limited evidence suggests that NSAIDs may be effective treatments for bleeding irregularities associated with Cu-IUD use; antifibrinolytic agents and antidiuretics have also been studied as possible treatments in a small number of subjects, but their safety has not been well documented. NSAIDs and antifibrinolytics may also prevent bleeding irregularities among new CU-IUD users. Preventive NSAID use, however, does not impact Cu-IUD continuation.

Background Instructions on what to do after pills are missed are critical to reducing unintended pregnancies resulting from patient non-adherence to oral contraceptive (OC) regimens. Missed pill instructions have previously been criticized for being too complex, lacking a definition of what is meant by “missed pills,” and for being confusing to women who may not know the estrogen content of their formulation. To help inform the development of missed pill guidance to be included in the forthcoming US Selected Practice Recommendations, the objective of this systematic review was to evaluate the evidence on patient understanding of missed pill instructions. Study design We searched the PubMed database for peer-reviewed articles that examined patient understanding of OC pill instructions that were published in any language from inception of the database through March 2012. We included studies that examined women's knowledge and understanding of missed pill instructions after exposure to some written material (e.g., patient package insert, brochure), as well as studies that compared different types of missed pill instructions on women's comprehension. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. Results From 1620 articles, nine studies met our inclusion criteria. Evidence from one randomized controlled trial (RCT) and two descriptive studies found that more women knew what to do after missing 1 pill than after missing 2 or 3 pills (Level I, good, to Level II-3, poor), and two descriptive studies found that more women knew what to do after missing 2 pills than after missing 3 pills (Level II-3, fair). Data from two descriptive studies documented the difficulty women have understanding missed pill instructions contained in patient package inserts (Level II-3, poor), and evidence from two RCTs found that providing written brochures with information on missed pill instructions in addition to contraceptive counseling significantly improved knowledge of how to manage missed pills for up to three months compared to contraceptive counseling alone (Level I, fair). Evidence from one RCT found that graphic-based missed pill instructions were better than text-only instructions (Level I, good), and data from two RCTs found that less information resulted in improved comprehension (Level I, good to fair). Evidence from one descriptive study found that many women missing pills did not intend to follow recommended actions per missed pill instructions despite understanding the guidance (Level II-3, poor). Conclusions There is wide variability in the percent of women having correct knowledge on what to do when pills are missed after exposure to written missed pills instructions, with more women knowing what to do after missing 1 pill than after missing 2 or 3 pills. Women have difficulty understanding missed pill instructions contained in patient package inserts. Providing written brochures with information on missed pill instructions in addition to contraceptive counseling may improve knowledge of how to manage missed pills. Graphic-based missed pill instructions and those containing less information may result in improved comprehension. Even with clear instructions, many women missing pills may choose not to follow the recommended actions.

Objective: Systematically assess from the literature whether women living with HIV who use hormonal contraception are at increased risk of HIV-disease progression compared with those who do not use hormonal contraception. Methods: We searched PUBMED and EMBASE for articles published in peer-reviewed journals through December 15, 2011 for evidence relevant to all hormonal contraceptive methods and HIV-disease progression. Results: Twelve reports of 11 studies met inclusion criteria. One randomized controlled trial (RCT) found increased risk for the composite outcome of a reduced CD4 cell count or death among hormonal contraceptive users when compared with copper intrauterine device (IUD) users. Ten cohort studies reported no increased risk for HIV disease progression (as measured by mortality, time to a CD4 cell count below 200, time to initiation of antiretroviral therapy, an increase in HIV-RNA viral load, or a decrease in CD4 count) among women who used hormonal contraception compared with those who did not. Conclusion: The preponderance of evidence indicates that HIV-positive women can use hormonal contraceptive methods without concerns related to HIV-disease progression. Cohort studies consistently found no association between hormonal contraceptive use and HIV-disease progression compared with nonuse of hormonal contraceptives. One RCT found that hormonal contraceptive use was associated with increased risk of HIV-disease progression when compared with IUD use, but this study had important methodological shortcomings. Prevention of unintended pregnancy among women living with HIV remains a public health priority to safeguard women’s and infants’ health and to prevent vertical transmission of HIV. 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2013, 27:787–794

Objective: To systematically review epidemiologic evidence assessing whether hormonal contraception alters the risk of HIV transmission from an HIV-positive woman to an HIV-negative male partner. Design: Systematic review. Methods: We included articles published or in press through December 15, 2011. We assessed studies with direct evidence on hormonal contraception use and HIV transmission, and summarized studies with indirect evidence related to genital or plasma viral load. Results: One study provided direct evidence on oral contraceptive pills (OCPs) or injectable contraception and female-to-male HIV transmission; both injectables [Coxadjusted hazard ratio (adjHR) 1.95, 95% confidence interval (CI) 1.06‐3.58; marginal structuralmodel(MSM)adjustedoddsratio (adjOR)3.01,95% CI1.47‐6.16]and OCPs (Cox adjHR 2.09, 95% CI 0.75‐5.84; MSM adjOR 2.35, 95% CI 0.79‐6.95) generated elevated point estimates, but only estimates for injectables were significant. Findings from 11 indirect studies assessing various hormonal contraception methods and viral genitalsheddingorsetpoint weremixed, andsevenofeightstudies indicatednoadverse effect of various hormonal contraception methods on plasma viral load. Conclusion: The only direct study on OCPs or injectable contraception and female-tomale HIV transmission suggests increased risk with the use of injectables. Given the potential for confounding in observational data, the paucity of direct evidence on this subject, and mixed indirect evidence, additional evidence is needed. 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2013, 27:493‐505

Objective To evaluate from the literature whether combined hormonal contraception (CHC), including combined oral contraception pills (COCs), transdermal patch, vaginal ring or combined injectables, have different effectiveness or failure rates by body weight or body mass index (BMI). Study design We searched PubMed and the Cochrane Library databases for all articles in all languages published between inception and February 2016, for evidence relevant to body weight or BMI, CHC use and contraceptive effectiveness. The quality of each individual study was assessed using the system for evaluating evidence developed by the United States Preventive Services Task Force. Results From 2874 articles, we identified 15 reports for inclusion, all of fair to poor quality. Fourteen studies measured the association of obesity status and contraceptive failure among COC users. Three fair quality and one poor quality study reported increased COC failure among a heterogeneous population of overweight and obese women compared with normal weight women, while eight fair quality and two poor quality studies did not find an association. Two fair quality studies reported on contraceptive transdermal patches. One pooled analysis described a higher proportion of pregnancies among women using the patch who weighed ≥90 kg; another secondary analysis suggested BMI>30 was associated with increased failure. No studies directly compared contraceptive effectiveness using the combined vaginal ring or combined injectable. Conclusion Current available evidence addressing the risk of CHC failure in obese compared to normal weight women is limited to fair and poor quality studies. Studies of COCs show mixed results, though absolute differences in COC failure by body weight and BMI are small. Based on limited evidence, it appears that increasing body weight and BMI may contribute to decreasing contraceptive patch effectiveness.

Background Contraception is an important consideration for women with multiple sclerosis (MS); however, little is known about the possible effects of hormonal contraception on disease progression or other adverse outcomes (e.g., thrombosis, low bone mineral density). Objective To evaluate the evidence on the safety of contraceptive use among women with MS. Search strategy We searched the PubMed database for peer-reviewed articles published in any language from database inception through July 2015. Selection criteria We included studies that examined health outcomes among women diagnosed with MS initiating or continuing a contraceptive method. We excluded case reports and case series but included all other study designs. Results From 111 articles, we identified four studies (from 5 articles) that met our inclusion criteria. Evidence from one randomized controlled trial, two retrospective cohort studies, and one cross-sectional study suggests that use of combined oral contraceptives (COCs) or oral contraceptives (OCs) (type not specified) among women with MS does not worsen the clinical course of disease, defined as disability level , disease severity or progression , relapse or number of new brain lesions on magnetic resonance imaging (body of evidence grading Level I, fair to Level II-3, poor). No studies were identified that examined the safety of other contraceptive methods or examined other outcomes of interest (venous thromboembolism, changes in bone mineral density) related to contraceptive use among women with MS. Conclusions Limited evidence suggests that COC or OC use after MS onset does not worsen the clinical course of disease.

Objective The objective was to determine the association between use of intrauterine devices (IUDs) by young women and risk of adverse outcomes. Methods We searched Pubmed, CINAHL, Embase, Popline and the Cochrane Library for articles from inception of database through December 2015. For outcomes specific to IUD use (IUD expulsion and perforation), we examined effect measures for IUD users generally aged 25 years or younger compared with older IUD users. For outcomes of pregnancy, infection, pelvic inflammatory disease (PID), and heavy bleeding or anemia, we examined young IUD users compared with young users of other contraceptive methods or no method. Results We identified 3169 articles of which 16 articles from 14 studies met our inclusion criteria. Six studies (Level II-2, good to poor) reported increased risk of expulsion among younger age groups compared with older age groups using copper-bearing (Cu-) IUDs. Two studies (Level II-2, fair) examined risks of expulsion among younger compared with older women using levonorgestrel-releasing (LNG-) IUDs; one reported no difference in expulsion, while the other reported increased odds for younger women. Four studies (Level II-2, good to poor) examined risk of expulsion among Cu- and LNG-IUD users combined and reported no significant differences between younger and older women. For perforation, four studies (Level II-2, fair to poor) found very low perforation rates (range, 0%-0.1%), with no significant differences between younger and older women. Pregnancies were generally rare among young IUD users in nine studies (Level I to II-2, fair to poor), and no differences were reported for young IUD users compared with young combined oral contraceptive (COC) or etonogestrel (ENG) implant users. PID was rare among young IUD users; one study reported no cases among COC or IUD users, and one reported no difference in PID among LNG-IUD users compared with ENG implant users from nationwide insurance claims data (Level I to II-2, fair). One study reported decreased odds of bleeding with LNG-IUD compared with COC use among young women, while one study of young women reported decreased odds of removal for bleeding with LNG-IUD compared with ENG implant (Level I to II-2, fair). Conclusion Overall evidence suggests that the risk of adverse outcomes related to pregnancy, perforation, infection, heavy bleeding or removals for bleeding among young IUD users is low and may not be clinically meaningful. However, the risk of expulsion, especially for Cu-IUDs, is higher for younger women compared with older women. If IUD expulsion occurs, a young woman is exposed to an increased risk of unintended pregnancy if replacement contraception is not initiated. IUDs are safe for young women and provide highly effective reversible contraception.

Objectives To investigate levonorgestrel (LNG)-releasing and copper-bearing (Cu) intrauterine device (IUD) safety among breastfeeding women and, for Cu-IUD use, breastfeeding performance and infant health. Study design Systematic review. Methods We searched PubMed, Embase, Cochrane Library and clinicaltrials.gov for articles through January 2016. We included studies of Cu-IUD or LNG-IUD users comparing IUD-specific (perforation, expulsion) and other contraceptive-related (infection, removal/cessation due to bleeding/pain and other adverse events) outcomes for breastfeeding vs. non-breastfeeding women. We also included studies of breastfeeding women comparing contraceptive-related outcome for IUD-users vs. other contraceptive-method users. Finally, we included studies comparing breastfeeding outcomes among Cu-IUD users to users of other nonhormonal contraceptives or no contraception. Results Of 548 articles identified, 23 (16 studies) met the inclusion criteria. Two studies suggested that the risk of IUD perforation was 6–10 times higher among breastfeeding vs. non-breastfeeding women. Seven studies suggested that risks for other adverse events were similar or lower among breastfeeding vs. non-breastfeeding women. Three studies among breastfeeding women found no increased risk of adverse events in IUD users vs. nonusers. Breastfeeding performance and infant growth were similar for Cu-IUD users and users of other nonhormonal methods or no contraception. Conclusion Overall, risks for adverse events among IUD users, including expulsion, pain and removals, were similar or lower for breastfeeding women vs. non-breastfeeding women. Uterine perforation with IUDs, while rare, appeared more frequent among breastfeeding women. No evidence indicated that Cu-IUD use in breastfeeding women influences breastfeeding performance or infant growth.

Background With dramatic improvements in life expectancy for cystic fibrosis (CF) patients, contraception for women with CF has become an important issue. There are theoretical concerns that hormonal contraceptive use among women with CF may impact disease severity or risk for other adverse health outcomes, including thrombosis and poor bone health, as well as concerns that malabsorption or altered drug metabolism might impact contraceptive effectiveness. Objective To evaluate evidence on the safety and effectiveness of contraceptive methods among women with CF. Search Strategy We searched the PubMed database for all articles published from database inception through October 2015. Selection Criteria We included studies that examined measures of disease severity, other health outcomes or indicators of contraceptive effectiveness among women with CF initiating or continuing a contraceptive method. Results Seven studies met our inclusion criteria. Three observational studies of fair to poor quality suggest that use of oral contraceptives (OCs) does not negatively impact CF disease severity, defined as changes in pulmonary function, number of exacerbations or need for intravenous antibiotics. Three small studies of poor quality reported on contraceptive failure among women with CF using combined hormonal contraceptives (combined OCs, patch or ring). One pregnancy was reported in a patch user out of 43 hormonal contraceptive users across all studies. One pharmacokinetic study reported that women with CF achieve steroid hormone plasma concentrations similar to healthy women after ingestion of combined OCs. Conclusions Limited evidence suggests that hormonal contraceptive use does not negatively impact disease severity among women with CF and that hormonal contraceptive effectiveness is not impaired by CF. Studies were limited by small sample sizes and short duration of follow-up. No studies examined the effect of hormonal contraception on thrombosis or bone health among women with CF.

Background Women with sickle cell disease have an increased risk of pregnancy-related complications and need safe, effective contraceptive methods to prevent unintended pregnancy. Study Design We conducted a systematic review to examine the safety of hormonal and intrauterine contraceptive use among women with sickle cell disease. Results Eight articles met the inclusion criteria. The evidence was of fair to poor quality and suggested that progestin-only and combined hormonal contraception had no effect on frequency of sickle crises or other adverse events and no effect on hematologic parameters associated with sickle crises. No studies examined the risk of thromboembolism in combined hormonal contraceptive users with sickle cell disease. There was insufficient evidence to comment on the safety of intrauterine contraception. Conclusion While data are limited, there is no evidence to suggest that hormonal contraceptive use among women with sickle cell disease is associated with an increased risk of clinical complications.

To examine predictors of health care providers perceiving intrauterine devices (IUDs) as unsafe for nulliparous women and of infrequent provision of IUDs to nulliparous women.We analyzed questionnaire data obtained during December 2009 to March 2010 from 635 office-based providers (physicians) and 1,323 Title X clinic providers (physicians, physician assistants, certified nurse midwives, nurse practitioners, and nurses). Using multivariable logistic regression, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between patient, health care provider, and clinic and practice variables and provider misconceptions about the safety of IUDs for nulliparous women and with infrequent IUD provision.Approximately 30% of respondents had misconceptions about the safety of IUDs for nulliparous women. Factors associated with increased odds of misconceptions about the copper IUD and levonorgestrel-releasing IUD included: being an office-based family medicine physician (copper IUD adjusted OR 3.20, 95% CI 1.73-5.89; levonorgestrel-releasing IUD adjusted OR 2.03, 95% CI 1.10-3.76); not being trained in IUD insertion (copper IUD adjusted OR 4.72, 95% CI 2.32-9.61; levonorgestrel-releasing IUD adjusted OR 2.64, 95% CI 1.34-5.22); and nonavailability of IUDs on-site at their practice or clinic (copper IUD adjusted OR 2.18, 95% CI 1.20-3.95; levonorgestrel-releasing IUD adjusted OR 3.45, 95% CI 1.95-6.08). More than 60% of providers infrequently provided IUDs to nulliparous women. Nonavailability of IUDs on-site (copper IUD adjusted OR 1.78, 95% CI 1.01-3.14; levonorgestrel-releasing IUD adjusted OR 2.10, 95% CI 1.22-3.62) and provider misconceptions about safety (copper IUD adjusted OR 6.04, 95% CI 2.00-18.31; levonorgestrel-releasing IUD adjusted OR 6.91, 95% CI 3.01-15.85) were associated with infrequent IUD provision.Health care provider misconceptions about the safety of IUDs for nulliparous women are prevalent and are associated with infrequent provision. Improved health care provider education and IUD availability are needed to increase IUD use among nulliparous women.III.

Background While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ. Methods We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs. Results Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions. Conclusion Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks.