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In-hospital placement of intrauterine devices and contraceptive implants following vaginal and cesarean delivery is increasingly popular and responds to maternal motivation for highly effective postpartum contraception. Immediate postpartum intrauterine device insertion is associated with higher expulsion than interval placement, but emerging evidence suggests that the levonorgestrel intrauterine device may have a higher expulsion rate than the copper intrauterine device.This study evaluated in-hospital provision, expulsion, and 6-month continuation of immediate postpartum copper T380 intrauterine devices, levonorgestrel intrauterine devices, and contraceptive implants.We offered enrollment in this prospective observational trial to women presenting to the University of Utah labor and delivery unit from October 2013 through February 2016 who requested an intrauterine device or implant for postpartum contraception during prenatal care or hospitalization at the time of delivery. Following informed consent, participants completed questionnaires prior to hospital discharge and at 3 and 6 months postpartum. Data on expulsions at 6 months were validated by chart abstraction.During the study period, 639 patients requested a postpartum intrauterine device or implant and 350 patients enrolled in prospective follow-up prior to discharge from the hospital. Among enrollees, 325 (93%) received their preferred contraceptive device prior to hospital discharge: 88 (27%) copper intrauterine device users, 123 (38%) levonorgestrel intrauterine device users, and 114 (35%) implant users. Participants predominantly were Hispanic (90%), were multiparous (87%), reported a household income$24,000 per year (87%), and underwent a vaginal delivery (77%). At 6 months postpartum, 289 of 325 device recipients (89%) completed follow-up. Among levonorgestrel intrauterine device users 17% reported expulsions relative to 4% of copper intrauterine device users. The adjusted hazard ratio for expulsion was 5.8 (confidence interval, 1.3-26.4). There was no statistically significant difference in expulsions by delivery type or continuation by device type. Among the 21 women who experienced intrauterine device expulsions, 14 (67%) requested a replacement long-acting reversible contraception device for contraception. The 6-month device continuation was ≥80% for all device types.An immediate postpartum long-acting reversible contraception program effectively provides women who desire highly effective reversible contraceptive devices with their method of choice prior to hospital discharge. Immediate postplacental levonorgestrel intrauterine device users have higher expulsion rates than copper intrauterine device users, but8 of 10 women initiating an intrauterine device or implant continue use at 6 months postpartum.

Case reports of pregnancies with inadvertent etonogestrel contraceptive implant exposure in the first-trimester have not demonstrated teratogenic risks or adverse pregnancy outcomes. We report the clinical observations of a 15-year-old nulligravida who continued her etonogestrel contraceptive implant throughout pregnancy and delivery, without any adverse maternal or neonatal outcomes. The patient then continued her contraceptive implant as a reliable postpartum contraceptive method. Although her favorable outcomes are consistent with available pharmacologic literature, more data is needed regarding maintenance of a contraceptive implant during a desired pregnancy.

The subdermal etonogestrel contraceptive implant has a current approved duration of 3 years. There is, however, recent and strong evidence of its effectiveness for 2 additional years during which no pregnancies were documented., Background: The subdermal etonogestrel contraceptive implant has a current approved duration of 3 years. There is, however, recent and strong evidence of its effectiveness for 2 additional years during which no pregnancies were documented. Case: We report a case of a 28-year-old woman who had an etonogestrel implant inserted 4 years earlier and wished to get pregnant. The implant was, however, deep in the triceps muscle and could not easily be removed. Her serum levels of etonogestrel remained positive even 6 years after insertion. As infertility investigation revealed endometriosis and bilateral tubal obstruction she was referred for assisted reproduction. Despite obtaining oocytes during an ovarian stimulation cycle, the endometrium was never above 4 mm, precluding embryo transfer. It was decided to remove the implant in order to improve endometrial conditions, after which the patient achieved pregnancy. Conclusion: This case report suggests that the etonogestrel implant is effective for even longer than the most recent studies have shown., info:eu-repo/semantics/publishedVersion

The first difficult contraceptive implant removals clinic in sub-Saharan Africa was started 2 years ago at New Somerset Hospital in Cape Town, South Africa, and has seen two cases of implant migration. We report these cases here. The first was a case of fascial migration and the second one of migration via the cephalic vein, both to a site just anterior to the glenohumeral joint. Both implants were removed without complications. Even with correct insertion technique, migrations can occur. Healthcare providers need to know how to manage difficult removals, and how to access and refer to difficult removals services when necessary. These services must therefore be available in all settings where implants are offered, to ensure access to rights-based family planning services for all women in southern Africa.

One of the problems being faced by Indonesia is the population explosion. The increasing population is a result of the increasing birth rate. To lower the birth rate the use of long acting contraceptive methods is being promoted. Based on data from SDKI 2012, the percentage of the the use of contraceptives in East Java is still dominated by the use of short acting contraceptive methods (80 . 99 percent). Meanwhile the long acting contraceptive methods are still lacking in use. One type of long acting contraceptive methods is implant. This study is aimed at exploring the factors that influence the use of implant s in the East Java Province based on data from SUSENAS 2015. This is a non-reactive study which used a secondary data analysis with a cross - sectional design. The sample was taken from the data of female respondents of SUSENAS 2015 who were 15–49 years old, used implant method s and lived in East Java. Chi square test and logistic regression were used to analyze the data. The results showed that women who were 30 years of age or older (OR = 3.653), had at least three children (OR = 2.563) and had previous experinces with modern contraceptives (OR = 0.109) affected the use of contraceptive implant methods in East Java. It is expected that by conducting education and socialization on the use of contraceptive implants for family planning to couples at reproductive ages, the use of contraceptive implants can be more optimized.

Author(s): Matulich, Melissa Carol; Chen, Melissa Joy; Schimmoeller, Natasha Rita; Hsia, Jennifer K; Uhm, Suji; Creinin, Mitchell D

Background: The contraceptive implant (Implanon) has been recognised as one of the most effective family planning methods and is a healthier choice for women in Africa due to its efficacy and convenience. Despite the evidence of effectiveness and safety of the implant, the actual uptake for Implanon use in the Ugu district of KwaZulu-Natal is relatively low. The aim of the study was to determine factors associated with Implanon uptake in Ugu North Sub District 2016/17.Methods: An observational cross-sectional study with an analytical component using self-administered questionnaires to collect information from 385 participants using randomised systematic sampling was conducted at family planning clinics at GJ Crookes Hospital and seven surrounding primary health care clinics. The chi-square test and multivariate logistic regression was used to determine associations.Results: Some 16% (n = 60) of the participants utilised Implanon. Despite having the correct knowledge 65.7% (n = 220) were not willing to use Implanon if it were offered. In addition, 55% of participants (n = 177) believed Implanon had more side effects. Parity ( 4 children) was found to be a statistically significant protective factor against (p 0.05) Implanon uptake.Conclusion: Implanon is a highly unattractive method of contraception for women residing in the Ugu North Sub District. Fear of side effects and invasive method of insertion were identified as the major barriers to Implanon use. Education and increased patient awareness are strategies to increase the desirability and uptake of Implanon.

Objective: Sino-implant (II) is a contraceptive implant that had a commodity price one-third of the competing products a decade ago. To make Sino-implant (II) more widely available, we conducted a trial to collect safety and efficacy data required for World Health Organization (WHO) prequalification, a quality standard allowing global donors to procure a pharmaceutical product. Study design: This was a randomized controlled trial allocating 650 participants to either Sino-implant (II) or Jadelle®. Participants were seen at 1 and 6 months, and then semiannually. The primary efficacy measure was the pregnancy Pearl Index [number of pregnancies per 100 women-years (WY) of follow-up] in the Sino-implant (II) group during up to 4 years of implant use. Results: For the primary outcome, Sino-implant (II) had a 4-year Pearl Index of 0.74 (95% confidence interval, 0.36–1.37) compared to 0.00 (95% confidence interval, 0.00–1.04) for Jadelle®. The Sino-implant (II) pregnancy rate was significantly higher in the fourth year (3.54 per 100 WY) than in the first 3 years combined (0.18 per 100 WY; p

OBJECTIVES To investigate the continuation rates of the etonogestrel subdermal contraceptive implant among well-informed women, and the reasons for early discontinuation. STUDY DESIGN Retrospective consecutive cohort design. METHODS Women who had the implant inserted between 1 January 2006 and 1 January 2010 at the Atrium Medical Centre, the Netherlands were followed up for at least three years. The dates of insertion and removal were recorded, as were the reasons for removal. Statistical analysis was performed using the independent samples t-test and the Pearson alpha correlation test. RESULTS The implant was inserted in 230 women. Follow-up was possible in 214 women, with an average age of 26.7 years. Most of them were nulliparous and the majority had used a combined oral contraceptive, Implanon®, or Mirena® previously. The mean overall continuation period was 23.5 months (95% confidence interval: 21.7-25.3), with a median of 25 months. The continuation rate after 12 months was 72%; after 24 months, 53%; and after 36 months, 25%, with all women concerned having a new implant placed. The previously used contraceptive method Implanon® was associated with the highest continuation rates. An erratic bleeding pattern was the main reason for early removal. CONCLUSIONS Despite adequate counselling before insertion, the continuation rate of the etonogestrel implant was rather low compared to those reported by other investigators. The main reason for discontinuation was an irregular bleeding pattern.

Background: A single-rod subdermal contraceptive implant containing 68 mg of etonogestrel, ImplanonNXT®, was introduced to the South African healthcare system in 2014. Initially the new device was well received but later uptake tapered off. A need was identified to determine the factors that influence women’s choices with regard to the use of ImplanonNXT® in order to improve its uptake. The aim of this study was to explore the factors that influence women’s choice of ImplanonNXT®.Method: A qualitative study was performed, using semi-structured interviews to explore patients’ knowledge, attitudes and beliefs regarding ImplanonNXT®. Ten patients were interviewed at Knysna Hospital.Findings: There was confusion amongst women about the harms and benefits of using ImplanonNXT® and it became apparent contraceptive counselling during pregnancy greatly affects the choices they make. Other factors that influenced the participants’ choice with regard to contraception included social influences, preference for familiar methods and the sideeffect profile of the various options. Perceptions of the adverse side effects of the implantable device added to confusion and fear of this method, which influenced women’s ideas about the use of ImplanonNXT®. Poor communication and reluctance from clinic staff to discuss ImplanonNXT®during antenatal visits contributed to poor knowledge about the implantable device and its side effects.Conclusion: Clearer communication during antenatal visits with pregnant women may address some of the fears and beliefs that surround its side effects, workings and efficacy. The fear of possible side effects should be a focus for counselling and education, as it predominantly contributes to women’s confusion and fear of the device. Further research is needed toaddress this as well as evaluate if interventions such as better counselling and a dedicated team approach can change the attitudes and beliefs of post-partum women towards the ImplanonNXT® device in the South African district health system.Keywords: long acting reversible contraception, barriers, post partum, perceptions, choice

Oral contraceptives are widely used hormonal contraceptives compared to other dosage forms. There are modifications of hormonal contraceptives dosage forms to reduce side effects and improve effectivity and compliance during contraceptive usage. The implantable drug delivery system is a suitable contraception technique for women who are difficult to recall the time of use, such as pills. The contraceptive implant is a small size of rod, and it is placed in the upper arm subcutaneously. Many advantages by using contraceptive implants, such as high effectivity, easy to use, free from estrogen influences, fast recovery of the normal ovulatory cycle, safe for breastfeeding women, and safer for women that have the certain medical condition. However, implant removal procedures are becoming the problem because it requires trained personnel. The unscheduled period is also one of the disadvantages of implants. Although for most women, the implant could reduce blood loss when the period, for some cases it could prolong the period of time. In this article, we reviewed implant contraceptives development due to its application increased rapidly in the last decade. The history of implants, advantages, and disadvantages, and marketed products of the implant were also described in this article. The challenges and opportunities of the contraceptive implant development were summarized based on literature. Designing in situ forming implant and polymeric implant for contraception could be the great future in contraceptive implant development. Finally, contraceptive implants are promising hormonal contraception dosage forms to develop in unintended pregnancies prevention over the world.

We present a case of a 29-year-old woman who presented to a volunteer-run primary care facility in Southern Belize. Her initial presentation was vaginal itching and white discharge; she also requested insertion of a sub-dermal contraceptive implant. During the insertion, marks suspicious for deliberate self-harm were noticed on the patient’s arm, and on further exploration she revealed she was being physically and emotionally abused by her husband. With some encouragement, she requested help in taking further action to preserve her safety; however, in Belize clinicians have no power to assist in cases involving adults. Therefore, the victim should self-present to a police station, resulting in a significant potential barrier to reporting intimate partner violence (IPV). Here we discuss this barrier further, as well as other barriers that exist to reporting IPV, and discuss possible policy changes that may improve the situation in Belize.

The case is about an 18 year-old woman who benefited of a radiopaque contraceptive implant (Nexplanon) inserted in the left arm. When she wanted to remove it, it couldn't be found by palpation, US, CT and MRI. A CXR and a thoracic CT scan were necessary to locate the implant, and the implant was removed by endovascular procedures.Significant migration of a contraceptive implant is uncommon, and only one case of migration far from the insertion limb has been reported. Using radiopaque contraceptive implants like Nexplanon could locate them easier if a migration occurs. Keywords: Migration of contraceptive implant, Foreign body

The postpartum period can be an ideal time to help a woman initiate contraception. Initiation of contraception in the immediate postpartum period is an important public health intervention. Shortened birth intervals (births spaced less than 2 years apart) are associated with significant maternal [1] and perinatal [2] morbidity. However, 33.1% of pregnancies in the USA are conceived within 18 months of a previous birth [3]. Successful initiation and continuation of postpartum contraception can decrease unintended pregnancy rates and improve maternal and child health outcomes. During pregnancy and the postpartum period, many women have access to medical care who otherwise would not. The inpatient admission for childbirth is a convenient opportunity for providers and patients to navigate contraceptive options together, particularly when the discussion has been raised in the antepartum period. There are pressing reasons to consider immediate postpartum contraception. After delivery, return to fertility can be rapid, with resumption of ovulation averaging 45 days, and occurring as early as 3 weeks postpartum in nonlactating women [4]. Delaying contraceptive initiation until several weeks postpartum places women at risk for unintended pregnancy. A range of contraceptive methods may be appropriate for women postpartum, and discussion should begin with the most effective options. Long-acting reversible contraceptive (LARC) methods, including the etonogestrel contraceptive implant and intrauterine devices, offer contraceptive efficacy and ease of user compliance. They combine cost– effectiveness with the benefit of being the most effective methods available. Immediate postpartum LARC placement has emerged as a safe and evidence-based practice. The US Medical Eligibility Criteria for Contraceptive Use supports immediate postplacental IUD insertion following cesarean section and vaginal delivery, and contraceptive implant insertion prior to hospital discharge, in lactating and nonlactating women [5]. Guidelines from the American College of Obstetricians and Gynecologists support the postpartum period as a particularly favorable time to initiate LARC [6]. And, from a public health standpoint, LARC has been found to be an important intervention to help women achieve optimal birth spacing and decrease rates of unplanned pregnancy [7–9]. Despite evidence supporting provision of immediate postpartum LARC, provider misinformation persists. A recent survey of 3000 members of the American Congress of Obstetricians and Gynecologists fellows found that only 11% of providers recognize the safety of postplacental IUD insertions [10]. Further, institutional and health policy barriers often limit immediate postpartum LARC provision. This contributes to wide variation in postpartum LARC use and availability [11]. Recognizing the potential public health impact of immediate postpartum LARC provision, several states have changed their funding practices to improve reimbursement for LARC initiation prior to hospital discharge [12]. Supporting this, despite the high initial cost associated with Contraception in the postpartum period: immediate options for long-acting success

The original inserter of the contraceptive implant, Implanon®, resulted in very deep insertion in some cases, sometimes in close proximity to neurovascular structures. This occasionally resulted in removal complications. We successfully adopted a hook-wire marker method used in breast tumor surgery to safely and simply remove these deep-lying, non-palpable implants.

Although short-acting reversible hormonal contraceptives, such as oral contraceptives and the contraceptive patch and vaginal ring, remain the most commonly used contraceptive methods in the United States, they are also associated with the highest failure rates. Long-acting reversible contraception (LARC) methods, such as intrauterine devices and contraceptive implants, offer high continuation rates and very low failure rates, and are safe for use in most women. The provision of LARC methods to adolescent, young adult and nulliparous women is a relatively new concept that offers an innovative option for these populations.

Background and methodology Information is presented on the management of women referred to a sexual health service during a 1-year period for management of a non-palpable contraceptive implant or of a palpable implant considered unsuitable for routine removal. Results Fifty-two women were referred. Thirty-four implants were non-palpable and their depth on ultrasound ranged from 2.7 to 12 mm. Seventeen were fully or partly palpable and their depth ranged from 3 mm or less (16 cases) to 5.6 mm (one case). Nine had had previous failed attempts at removal, including three with two previous failed attempts. Three implants were located at sites other than the medial aspect of the arm, and were associated with long localisation times. Forty-seven implants were removed at a one-stop clinic appointment through a 2–3 mm incision using ring forceps. The mean time for removal from making the incision to complete extraction was 4.8 minutes. Three cases judged to be of higher risk were removed under local anaesthesia in theatre through a 15 mm incision. These included the only case where removal was attempted unsuccessfully in the outpatient clinic. Seven of the implants were Nexplanon ® , including four cases seen during the last month of data collection. Conclusions Removal with the technique described is rapid, with an average time of 4–5 minutes, and less than 10 minutes in >90% of cases. Preliminary indications suggest that the introduction of Nexplanon has not resolved the problem of deep implant insertion. Based on our experience we suggest criteria for centres providing removal of deep implants.

Objective To measure infants' breast milk intake and infant growth when their mothers initiated either combined oral contraceptive (COC), levonorgestrel-releasing intrauterine system, or etonogestrel-releasing implant, or copper intrauterine device (IUD) as a reference group. Design Prospective trial. Setting University-based hospital. Patient(s) On postpartum day 42, 40 women initiated a contraceptive method according to their choice. Intervention(s) Deuterium (D 2 O; 0.5 g/kg mother's weight) was ingested by mothers on postpartum days 42, 52, and 63 as a marker of total body fluid. Main Outcome Measure(s) Infants' milk intake from 42 to 63 postpartum days was assessed by measurement of D 2 O levels in infants' saliva and infant growth by measuring their body weight, height, and tibia length. Women recorded all infant feed and changes of diapers wet with urine. Breastfeeding continuation was assessed at 6 months postpartum. Result(s) Infant mean milk intake, mean growth increase, mean number of breastfeeding episodes, daily wet diaper changes, and mean duration of exclusively breastfeeding (∼5 months) were similar in the four groups. Conclusion(s) Use of a COC, the two progestin-only contraceptives, or copper IUD did not affect the amount of infant milk intake and growth up to 9 weeks of age. The incidence of full breastfeeding and breastfeeding continuation was similar with contraceptive hormonal use and no use. Clinical Trials Registration Number NCT01388582.

Background Sino-implant (II) is a low-cost subdermal contraceptive implant containing levonorgestrel that is currently labeled for 4 years of use. Widely used in China and Indonesia, it has been little studied elsewhere. We conducted a prospective study of Sino-implant (II) use by women in Madagascar. Methods We enrolled a total of 621 women 18 or older who had Sino-implant (II) inserted on day of enrollment, some in fixed clinical sites, and some at outreach sites. Half of the women were scheduled for follow-up visits at 3 months and at 12 months postinsertion (active follow-up cohort); the other half were advised to return if they desired care for any problem, thought they were pregnant or wanted the implants removed (passive surveillance cohort). Results No insertion complications were reported. A total of 384 women returned for an earlier visit, and 351 returned for a later visit, for a total of 419 woman–years of observation. No postinsertion pregnancies or serious adverse events were observed. Twenty-eight implant removals were reported by 12 months, a cumulative removal probability of 7.3 per 100 women. Acceptability of the implants was very high, as was satisfaction with clinic services. Conclusions This is the first report on the performance of Sino-implant (II) from outside China and Indonesia and among the first in the English-language literature. These initial data from Madagascar indicate a favorable level of safety, effectiveness and acceptability during the first year of use.

The single-rod, etonogestrel-releasing, subdermal implant (ENG implant) is the most effective, long-acting reversible method of contraception available. The failure rate of the ENG implant is 0.05%, which makes it more effective than female sterilization. It is discreet, easy to insert and remove, has no effect on future fertility and is associated with a number of noncontraceptive health benefits. The ENG implant is safe and effective when used in the postpartum and postabortion setting, and in women who have contraindications to estrogen. The most common reason cited for discontinuation is irregular and unpredictable bleeding. However, structured, preinsertion counseling can increase continuation and user satisfaction.

To evaluate the impact of family planning promotion on incident pregnancy in a combined effort to address Prongs 1 and 2 of prevention of mother-to-child transmission of HIV.We conducted a factorial randomized controlled trial of 2 video-based interventions."Methods" and "Motivational" messages promoted long-term contraceptive use among 1060 couples with HIV in Lusaka, Zambia.Among couples not using contraception before randomization (n = 782), the video interventions had no impact on incident pregnancy. Among baseline contraceptive users, viewing the "Methods video" which focused on the intrauterine device and contraceptive implant was associated with a significantly lower pregnancy incidence [hazard ratio (HR) = 0.38; 95% confidence interval (CI): 0.19 to 0.75] relative to those viewing control and/or motivational videos. The effect was strongest in concordant positive couples (HR = 0.22; 95% CI: 0.08 to 0.58) and couples with HIV-positive women (HR = 0.23; 95% CI: 0.09 to 0.55).The "Methods video" intervention was previously shown to increase uptake of long-acting contraception and to prompt a shift from daily oral contraceptives to quarterly injectables and long-acting methods such as the intrauterine device and implant. Follow-up confirms sustained intervention impact on pregnancy incidence among baseline contraceptive users, in particular couples with HIV-positive women. Further work is needed to identify effective interventions to promote long-acting contraception among couples who have not yet adopted modern methods.

Repeat pregnancy within 2 years of a previous birth or abortion occurs in approximately 35% of recently pregnant female adolescents. The majority of these pregnancies are classified as unintended with about half ending in births and the remainder in abortions. Rapid repeat pregnancy (RRP) is associated with increased maternal and neonatal morbidity and continues a cycle of economic deprivation for young women and their families. Immediately following a pregnancy, most young women report an intention to avoid pregnancy in the near future, but many change their minds or become ambivalent within months. Lack of contraceptive use is more common among those teens that resume sexual intercourse earlier, live with a male partner, had a preterm delivery, or had an intended teen pregnancy. Adolescents who do not initiate a long-acting reversible contraceptive (LARC) method (intrauterine device or contraceptive implant) have up to a 35 times increased risk of RRP compared with their peers using LARC. Risk of RRP is decreased when LARC methods are initiated earlier after an abortion or within the postpartum period. This review will focus on the prevalence of RRP, the risk factors for RRP, and the effectiveness of strategies to reduce unintended RRP including counseling and early initiation of long-acting contraceptive methods.

SUMMARY Intrauterine contraceptives (IUCs) are the most widely used contraceptive method in the world, the two most common models currently in use being the TCu380A intrauterine device and the levonorgestrel-releasing intrauterine system. IUCs and subdermal implants are referred to as ‘long-acting reversible contraceptives’ because they provide contraception for at least 3 years with a single intervention. Both IUCs and the contraceptive implant have very low rates of contraceptive failure, these rates being similar in women over and under 21 years of age. They are safe, with few side effects, have a high continuation rate and can be used irrespective of age or parity. However, even now, many healthcare professionals discourage the use of these devices by adolescents, young women and nulligravidas, although the WHO makes no restrictions in this respect. IUCs represent an excellent tool for preventing unplanned pregnancy and should be considered as a first-line contraceptive choice for any woman with no me...

IUDs, contraceptive implants and hormone injections – what is available in Australia and how effective are they?

© 2016 The European Society of Contraception and Reproductive Health. Objective: Estimate symptom improvement rate of women with bleeding complaints using the etonogestrel contraceptive implant when started on continuous combined oral contraceptives (COC). Methods: We conducted a double-blinded randomised controlled trial of women reporting troublesome bleeding related to their etonogestrel contraceptive implant and desiring intervention. Participants received continuous COCs or placebo for four weeks to evaluate self-reported bleeding improvement at four weeks. Participants could continue study treatment or prescribed COCs for another eight weeks if desired. We planned to enroll 130 participants between two sites (80% power to detect a 20% effect size at a 0.05 significance level, with 10% loss to follow up). Results: We closed the study after enrolling 26 participants due to recruitment futility. All women on COCs and 75% of placebo users reported bleeding improvement at four weeks (p = 0.09), with 92% and 42%, respectively, reporting significant improvement (p = 0.03). The median number of days until bleeding stopped for at least four days in COC and placebo users was 1 day (range 1–9) and 4.5 days (range 1–28), respectively (p = 0.63). Eight (75%) COC and five (42%) placebo users opted to continue study treatment (p = 0.41). Despite bleeding improvement, women who desired implant removal at enrollment were more likely to re-request removal than those who initially considered other interventions (3 of 5 [60%] vs 1 of 17 [6%], p = 0.03). Conclusion: Although women who have troublesome bleeding while using the contraceptive implant may experience improvement with no treatment over 4 weeks, women using COCs are more likely to report significant improvement. Clinicaltrials.gov registration number: NCT01963403.

A prospective study in this journal issue compares the effects on maternal bone turnover during lactation of subdermal implant compared with copper intrauterine device (IUD) use.1 It is interesting because publications about the influence of hormonal contraceptives on the health of the lactating woman herself are rare. This study’s advantage is that bone mineral density mostly is measured using dual-energy X-ray absorptiometry or a similar modality, rather than relying on biochemical analyses of serum and urine samples.1 Its …

Purpose: To describe rates of and reasons for follow-up among adolescents and adults receiving contraceptive implants in a Federally Qualified Health Center (FQHC). Methods: Retrospective comparison of patient-initiated implant-related contacts during the 6 months postinsertion among adolescents (110) and adults (154) who had implants placed at a FQHC network. Results: Forty percent of adolescents and 26% of adults initiated follow-up ( P = .016). Bleeding changes and discussing removal were the most common reasons for follow-up for both groups. Adolescents (5.5%) and adults (9.0%) had similar removal rates ( P = .348). However, among patients who discussed implant removal, adults were more likely to have removals compared with adolescents ( P = .002). Conclusions: Other FQHCs may anticipate a similar experience to ours, where adolescents may be more likely than adults to initiate implant-related follow up, with removal rates of less than 10% at 6 months. Further study of physician decision making and patient autonomy regarding implantable contraception removal requests is warranted.

Background Long-acting reversible contraception (LARC) can assist women with birth spacing and reduce unintended pregnancies. Sub-Saharan Africa has low uptake of the two available methods of LARC, the subdermal implant and intrauterine contraception (IUC). Our primary objectives were to: 1) calculate the incidence of LARC use among postpartum Malawian women, and 2) assess if LARC knowledge and intent to use LARC were associated with LARC uptake. Methods This study was a prospective cohort study of 634 postpartum women who were recruited from the postpartum ward of Bwaila Hospital in Lilongwe, Malawi. Study participants completed a baseline survey in the postpartum ward. Follow-up telephone surveys about contraceptive use were conducted at 3, 6, and 12 months postpartum. Cox proportional hazards regression analysis was performed to evaluate if implant knowledge and intent to use implant were associated with implant uptake. Results One hundred thirty-seven implant and 10 IUC placements were reported over 12 months of follow-up; given the low rate of IUC uptake, further analysis was only done for implant uptake. The incidence rate for implant uptake was 35.6 per 100 person-years (95 % CI 30.0, 42.2). Correct implant knowledge (adjusted HR = 1.69; 95 % CI 1.06, 2.68) and intent to use implant (adjusted HR 1.95; 95 % CI 1.28, 2.98) were both associated with implant uptake. Conclusions More women reported implant use than IUC use in our study. Correct implant knowledge and intent to use implant were both associated with implant uptake, with a stronger association for intent. Interventions to increase LARC uptake should focus on improving LARC knowledge and removing barriers to LARC. Trial registration Clinical Trial Registration #: NCT01893021

ABSTRACT INTRODUCTION Subsidisation of the levonorgestrel-releasing Jadelle® contraceptive implant in 2010 resulted in a rapid uptake. Clinicians had little prior experience of client satisfaction, side effect profile, and removal rate of this contraceptive method. AIM To obtain information on satisfaction, bleeding patterns, continuation rates and reasons for removal for New Zealand women during their first year of use of a subsidised contraceptive implant, Jadelle®. METHODS Women having a Jadelle® implant inserted in New Zealand Family Planning clinics were recruited to be followed up by phone, text or email at 1, 3, 6, 9 and 12 months. They were asked about their bleeding pattern, satisfaction and their views on benefits of, or problems with, implant use. RESULTS 252 women were recruited. The three common bleeding patterns in the cohort were regular periods, amenorrhoea and irregular bleeding. Eighteen percent had their implant removed within the first year with more than half of those being unhappy with their bleeding pattern. This was usually prolonged bleeding. Otherwise satisfaction rates were high throughout the year. DISCUSSION The majority of New Zealand women using Jadelle® were satisfied with this method of contraception during their first year of use. Implant removals were most likely to be related to prolonged bleeding. However the commonest bleeding pattern was regular periods. KEYWORDS Contraceptive implant; progestin; bleeding; satisfaction; continuation rate; reducing reproductive health inequalities

BackgroundSince the internet has become an important source of contraceptive information with YouTube.com as the second most visited site, we analysed contraceptive implant YouTube videos for content and clinical accuracy.MethodsUsing the terms ‘contraceptive implant’, ‘Nexplanon’ and ‘Implanon’, the top 20 results on YouTube by relevance and view count were identified. After excluding duplicates, single-rod implant videos in English were included. Videos were classified as providing a professional or patient perspective. Views, duration and comments were noted. Videos were rated for reliability, global quality scale and whether they were positive or negative about the implant. Inter-rater agreement was measured.ResultsA total of 120 videos were retrieved; 52 were eligible for review. Less than 23% were professional videos; the majority reported patient experience (46% testimonials, 27% real-time procedure videos, 4% other). Patient videos had been posted a significantly longer duration of time than professional videos (364 vs 188 days,p=0.02), were less reliable (p≤0.0001) and were of lower global quality (pConclusionsThis study found that most of the information on YouTube pertaining to contraceptive implants is accurate, is presented from the patient's perspective, and promotes the method's use.

STUDY QUESTION Does a progestin releasing subdermal contraceptive implant affect the efficacy of medical abortion if inserted at the same visit as the progesterone receptor modulator, mifepristone, at medical abortion? SUMMARY ANSWER A etonogestrel releasing subdermal implant inserted on the day of mifepristone did not impair the efficacy of the medical abortion compared with routine insertion at 2-4 weeks after the abortion. WHAT IS ALREADY KNOWN The etonogestrel releasing subdermal implant is one of the most effective long acting reversible contraceptive methods. The effect of timing of placement on the efficacy of mifepristone and impact on prevention of subsequent unintended pregnancy is not known. STUDY DESIGN SIZE, DURATION This multicentre, randomized controlled, equivalence trial with recruitment between 13 October 2013 and 17 October 2015 included a total of 551 women with pregnancies below 64 days gestation opting for the etonogestrel releasing subdermal implant as postabortion contraception. Women were randomized to either insertion at 1 hour after mifepristone intake (immediate) or at follow-up 2-4 weeks later (delayed insertion). An equivalence design was used due to advantages for women such as fewer visits to the clinic with immediate insertion. The primary outcome was the percentage of women with complete abortion not requiring surgical intervention within 1 month. Secondary outcomes included insertion rates, pregnancy and repeat abortion rates during 6 months follow-up. Analysis was per protocol and by intention to treat. PARTICIPANTS/MATERIALS, SETTING, METHODS Women aged 18 years and older who had requested medical termination of a pregnancy up to 63 days of gestation and opted for an etonogestrel releasing contraceptive implant were recruited in outpatient family planning clinics in six hospitals in Sweden and Scotland. MAIN RESULTS AND THE ROLE OF CHANCE Efficacy of medical abortion was 259/275 (94.2%) in the immediate insertion group and 239/249 (96%) in the routine insertion group with a risk difference of 1.8% (95% CI -0.4 to 4.1%), which was within the ±5% margin of equivalence. The insertion rate was 275/277 (98.9%) in the immediate group compared to 187/261 (71.6%) women in the routine group (P < 0.001). At 6 months of follow-up significantly fewer women in the immediate group had become pregnant again (2/277, 0.8%) compared to the routine group (10/261, 3.8%) P = 0.018. LIMITATIONS, REASONS FOR CAUTION For the main outcome loss to follow-up data was minimized through access to patient records. Efforts were made to reduce loss to follow-up also for secondary outcomes. The results of the sensitivity analysis did not differ from the intention to treat or per protocol analysis. WIDER IMPLICATIONS OF THE FINDINGS Guidelines on postabortion contraception should be amended to include insertion of the etonogestrel releasing implant at the time of mifepristone intake for medical abortion up to and including a gestation of 63 days. STUDY FUNDING/COMPETING INTERESTS This study was funded by the Swedish Research Council (2012-2844), Stockholm City County and Karolinska Institutet (ALF). The contraceptive implants were provided by Merck and supplied by MSD Sweden. HKK and KGD have received honorariums for giving lectures for MSD/Merck and have participated in the national (HKK and KGD) and international (KGD) medical advisory boards for MSD/Merck. The other authors have nothing to declare. TRIAL REGISTRATION NUMBER ClinicalTrials number NCT01920022. TRIAL REGISTRATION DATE 06 August 2013. DATE OF FIRST PATIENT'S ENROLMENT 13 October 2013.

Background Remote northern communities in Ontario face unique challenges in rabies prevention and control. With large, free-roaming dog populations at high risk of exposure to rabies from wildlife, and a lack of regular access to veterinary services and vaccinations, these communities run a higher risk of human exposure to rabies than southern regions of the province. Objective To provide the baseline data on a novel approach to controlling the dog population in the Weeneebayko Area Health Authority (WAHA) in northern Ontario, implemented as part of a sustainable, humane and cost-effective pilot project to manage dog population numbers and improve public safety. Intervention In 2015, WAHA launched a large-scale two-year regional project that involved microchipping all dogs in the region to quantify and monitor population levels, vaccinating them with canine core vaccinations (including rabies) and piloting the use of an injectable ganodotropin-releasing hormone (GnRH) agonist contraceptive implant in female dogs. The Project's objectives included control of dog population numbers, reducing aggressive behaviours in community dogs, reducing the risk of rabies in communities, improving the health of community dogs and educating community members about the importance of dog population control. Outcomes In 2015, 513 dogs were microchipped and vaccinated as part of the WAHA Project: 211 females and 301 males. Seventy-six intact, free-roaming females were given the contraceptive implant, 113 females were identified as previously spayed and only 22 females were either too young or too small (toy breeds) to receive an implant. Conclusion While the final outcomes of the WAHA Project are still pending, preliminary findings, including dog population demographics and observed dynamics, support the feasibility of contraceptive implants in female dogs as a primary intervention to quickly and cost-effectively reduce dog population numbers in remote northern regions and reduce the risk of rabies transmission.

This study investigates the relationship between breastfeeding self-efficacy and LATCH scores and affecting factors in Turkish mothers.The benefits of breastfeeding for newborns and mothers are well documented. Type of birth, maternal and neonatal complications; lack of support from healthcare professionals during breastfeeding, hospital routines, time and duration of mother-newborn attachment; and insufficiency of husband and family support are the most significant factors affecting breastfeeding initiation and mothers' breastfeeding self-efficacy in early postpartum period. Therefore, it is important to determine how all these factors affect breastfeeding.This was a cross-sectional, descriptive study.The sample of the study consisted of 303 postpartum women who were recruited at the obstetrics clinic of maternity hospital in one of the three largest city of Turkey. The data were obtained using Personal Identification Form, Breastfeeding Self-Efficacy Scale-Short Form and LATCH Breastfeeding Assessment Tool to determine breastfeeding success. The mean, standard deviation, frequency, percentages, correlation analysis and Kruskal-Wallis variance analysis were used in data collection.The main finding of the study was a weak positive correlation between average LATCH scores and average Breastfeeding Self-Efficacy Scale-Short Form scores of women in the postpartum period. The women becoming pregnant four times or more got significantly higher average Breastfeeding Self-Efficacy Scale-Short Form and average LATCH scores, and the women married for 11 years or longer and the mothers starting to breastfeed their babies within 30 minutes of their birth got significantly higher average LATCH scores.The results of the present research affirm the beneficial role of high self-efficacy in successful breastfeeding.It is of great importance that midwives and obstetric nurses routinely evaluate breastfeeding self-efficacy and the capability of breastfeeding for early detection of problems related to breastfeeding.

Tuesday, May 17, 2016 8:00 AM–8:10 AM Detection of Fetal Fraction During Noninvasive Prenatal Screening (NIPS) in HIV-Infected Pregnant Women [22] Aleha Aziz, MD, MPH Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, New York, NY Anne Van Arsdale, MD, MSc, Susan Klugman, MD, and Rodney L. Wright, MD, MS INTRODUCTION: To describe the reliability of Non Invasive Prenatal Screening (NIPS) in HIV infected pregnant women. NIPS analyzes cell free fetal DNA which circulates in maternal plasma but originates from the placenta and is quantitated as “fetal fraction” (FF). Sensitivity of NIPS increases with FF. In certain populations NIPS reliability decreases, with obesity as the strongest factor negatively associated with FF. Additional variables including PAPP-A and smok- ing have been shown to affect FF. Our study aims to determine if immune system alterations such as HIV or antiretroviral medications impact FF. METHODS: A 2:1 matched case-control study was carried out comparing 15 HIV infected pregnant women to 30 without HIV undergoing NIPS. Variables such as BMI, ethnicity, medical comorbidities, toxic habits, fetal CRL, serum analytes, FF, and pregnancy outcomes were compared. Immune status and antiretro- viral medications were evaluated in correlation with FF in HIV infected patients. RESULTS: HIV infected patients receiving integrase inhibitors (INI) had lower mean FF than those without INI—4.93 (SD 2.20) versus 15.7 (SD 5.43) (P5,.01). NIPS was invalid for three HIV infected patients – all of whom were receiving INI - due to low FF. HIV infected patients with an undetectable viral load (VL) at NIPS had a significantly lower median FF compared to those with detect- able VL (P5.01). CONCLUSION/IMPLICATIONS: Integrase inhibitors may play a role in reliability of NIPS in HIV infected women, as reflected by lower FF for patients taking INI. Further study is needed to fully elucidate the mechanism for INI and decreased FF. Financial Disclosure: The authors did not report any potential conflicts of interest. 8:00 AM–8:10 AM Quality Improvement: Changing Patterns of Antibiotic Prophylaxis for Surgical Abortions [23] Olivia T. Nguyen, MS University of California Davis School of Medicine, Sacramento, CA Jade M. Shorter, MD, Alexa L. Calfee, MPH, Mitchell D. Creinin, MD, and Melody Y. Hou, MD, MPH INTRODUCTION: Patients at our institution having an abortion in the operating room are routinely prescribed prophylactic antibiotics to use the night before the procedure. After a quality assurance assessment from 4/2012–6/2013 showed poor documentation and adherence to prescribed antibiotics, we altered our procedures by pref- erentially using the clinic pharmacy for prescriptions and implement- ing a standardized preoperative template that included assessment of antibiotic adherence. METHODS: Using clinic schedules, we identified women who had abortions in the operating room from 4/2012–6/2013 and 4/2014–6/ 2015. We examined electronic medical records to confirm the abortion occurred and obtained data including demographics, prophylactic anti- biotic documentation, and patient adherence. We compared data from the two time periods to assess the impact of the interventions on anti- biotic provision and documentation. RESULTS: We identified 252 and 445 patients who had abortions during the two time periods, respectively. One patient in the latter group was excluded because she refused antibiotics. Patient character- VOL. 127, NO. 5 (SUPPLEMENT), MAY 2016 istics included mean age of 28 years, 34% white, 24% black, and 72% Medicaid-insured. Antibiotic adherence documentation improved from 69.4% (175/252) to 99.1% (440/444 P,.001). Among patients with documentation, antibiotic use the night before the procedure increased from 78.3% (137/175) to 90.0% (396/440, P,.001). Antibi- otic administration in the pre-operative area for nonadherent patients increased from 84.4% (27/32) to 97.7% (42/43, P5.036). The propor- tion of patients who received no antibiotics decreased from 2.4% (6/ 252) to 0.5% (2/444, P5.009). CONCLUSION/IMPLICATIONS: Using a standardized preopera- tive template and clinic pharmacy improves provision of prophylac- tic antibiotics for patients undergoing abortion in the operating room. Financial Disclosure: The authors did not report any potential conflicts of interest. 8:15 AM–8:25 AM A Short Course of Tamoxifen Reduces Unscheduled Bleeding in Etonogestrel Contraceptive Implant Users [24] Katharine Simmons, MD, MPH University of North Carolina, Chapel Hill, NC Alison Edelman, MD, MPH, Rochelle Fu, PhD, and Jeffrey Jensen, MD, MPH INTRODUCTION: The etonogestrel (ENG) contraceptive implant is highly effective and long-acting, but users may experience bothersome unscheduled bleeding (USB). An evidence-based strategy to reduce USB could increase continuation of the implant. The objective of this randomized trial was to determine whether a short course of tamoxifen would reduce bleeding/spotting days and increase satisfaction com- pared to placebo. METHODS: Women experiencing frequent or prolonged bleeding with the ENG implant were randomized to receive tamoxifen 10 mg or placebo twice daily for seven days, taken at the onset of an episode of bleeding. Treatment was repeated as needed every 30 days. A text message bleeding diary was completed for 180 days. A sample size of 56 was estimated to detect a difference of 6 days of bleeding per 30 days (estimated 40% reduction) with 80% power. Wilcoxian rank sum test compared bleeding/spotting days between groups. Satisfaction was assessed with visual analog scales. RESULTS: Tamoxifen subjects reported more baseline USB than placebo (median 23 vs 20 bleeding/spotting days out of 30, respectively). In the 30 days after study drug, tamoxifen users experienced significantly fewer days of bleeding/spotting than placebo (median 6 vs 12 days, P5.05). Duration of amenorrhea after therapy was longer for tamoxifen subjects than placebo (median 30 vs 8 days, P5.03). Satisfaction was higher in the tamoxifen group and side effects were similar. CONCLUSION/IMPLICATIONS: A 7-day course of tamoxifen was well tolerated and significantly reduced USB compared to placebo. Additional research is needed to determine if tamoxifen treatment can reduce discontinuation for USB. Financial Disclosure: Dr. Edelman (Professor, Obstetrics and Gynecology, Oregon Health & Science University) disclosed the following—Merck: Speaker/Honoraria includes speakers bureau, symposia, and expert witness. Dr. Jensen (Professor, Obstetrics & Gynecology, Oregon Health & Science University) disclosed the following—Abbvie: Consultant/Advisory Board, Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; Agile: Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; Bayer: Consultant/ Advisory Board, Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; Contramed: Consultant/Advisory Board, Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; Evofem: Consultant/Advisory Board; HRA phar- ma: Consultant/Advisory Board, Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; Merck: Consultant/ Advisory Board, Other Research Support includes receipt of drugs, supplies, equipment or other in-kind support; MicroChips: Consultant/Advisory Board; Teva: Consultant/Advisory Board. The other authors did not report any potential conflicts of interest. Copyright a by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. TUESDAY PAPERS 9S

Cases:\ud In addition to previously published case reports, further cases of intravascular migration of contraceptive implants have been identified from an information request to two national adverse reaction spontaneous reporting systems. We report on two new cases of insertion into the venous system with subsequent embolism to a pulmonary artery.\ud Conclusion:\ud Incorporating barium sulfate into the implant has facilitated diagnosis of these very rare adverse events with the initial diagnosis of embolism to the pulmonary arterial tree made by chest X-ray. Removal of an implant from a segmental branch of a pulmonary artery is\ud technically challenging and not without risks. Unsuccessful removal appears to be preceded by a delay in diagnosis leading to endothelialization of the implant in the pulmonary arterial wall.\ud Implications:\ud Subdermal placement of contraceptive implants over the anterior surface of the biceps rather than in the sulcus between them biceps and triceps may negate this rare but reported risk.

We were most interested to read the letter1 from Martyn Walling about the insertion technique for the etonogestrel implant. We too have adopted his technique of injecting local anaesthetic only at the site of needle puncture and not along the length of the proposed track. We also agree with Walling that after the needle has penetrated the dermis it should be withdrawn until the bevel is seen and then insertion continued after the angle of the needle has been adjusted to parallel to the skin surface. Some argue against the former on the grounds that the insertion will be more painful, but most of the pain experienced is when the skin is penetrated. We have however noticed that the last 1 cm of insertion is, for some unknown reason, often painful at the tip. We feel Walling did not make himself entirely clear about the reasons for the above techniques. …