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Study Objective Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs. Design Secondary analysis of a cluster-randomized provider educational trial. Setting Forty US-based reproductive health centers. Participants We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care. Interventions The parent study assessed the effect of provider training on evidence-based contraceptive counseling. Main Outcome Measures We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations. Results Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98). Conclusion In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.

The recent U.S. Supreme Court decision cannot take obstetricians and gynecologists back to 1972, because abortion practice, training, and research have made 50 years of progress. During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health. Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence.

PurposeThe majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention.MethodsSexually active women aged 18-25 years receiving contraceptive counseling (n= 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering.ResultsWomen in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults toreceive LARC counseling (adjusted odds ratio [aOR]= .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR= .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR]= .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR= .57; 95% CI: .42-.79) and to select LARC (aOR= .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR= .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR= .59; 95% CI: .41-.85).ConclusionsContinued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.

Summary Background A ring-shaped, contraceptive vaginal system designed to last 1 year (13 cycles) delivers an average of 0·15 mg segesterone acetate and 0·013 mg ethinylestradiol per day. We evaluated the efficacy of this contraceptive vaginal system and return to menses or pregnancy after use. Methods In two identically designed, multicentre, open-label, single-arm, phase 3 trials (one at 15 US academic and community sites and one at 12 US and international academic and community sites), participants followed a 21-days-in, 7-days-out segesterone acetate and ethinylestradiol contraceptive vaginal system schedule for up to 13 cycles. Participants were healthy, sexually active, non-pregnant, non-sterilised women aged 18–40 years. Women were cautioned that any removals during the 21 days of cyclic use should not exceed 2 h, and used daily paper diaries to record vaginal system use. Consistent with regulatory requirements for contraceptives, we calculated the Pearl Index for women aged 35 years and younger, excluding adjunctive contraception cycles, as the primary efficacy outcome measure. We also did intention-to-treat Kaplan-Meier life table analyses and followed up women who did not use hormonal contraceptives or desired pregnancy after study completion for 6 months for return to menses or pregnancy. The trials are registered with ClinicalTrials.gov , numbers NCT00455156 and NCT00263341 . Findings Between Dec 19, 2006, and Oct 9, 2009, at the 15 US sites, and between Nov 1, 2006, and July 2, 2009, at the 12 US and international sites we enrolled 2278 women. Our overall efficacy analysis included 2265 participants (1130 in the US study and 1135 in the international study) and 1303 (57·5%) participants completed up to 13 cycles. The Pearl Index for the primary efficacy group was 2·98 (95% CI 2·13–4·06) per 100 woman-years, and was well within the range indicative of efficacy for a contraceptive under a woman's control. The Kaplan-Meier analysis revealed the contraceptive vaginal system was 97·5% effective, which provided further evidence of efficacy. Pregnancy occurrence was similar across cycles. All 290 follow-up participants reported return to menses or became pregnant (24 [63%] of 38 women who desired pregnancy) within 6 months. Interpretation The segesterone acetate and ethinylestradiol contraceptive vaginal system is an effective contraceptive for 13 consecutive cycles of use. This new product adds to the contraceptive method mix and the 1-year duration of use means that women do not need to return to the clinic or pharmacy for refills every few months. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, the US Agency for International Development, and the WHO Reproductive Health Research Department.

Objectives. We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods. Methods. We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011–2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty. Results. Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance. Conclusions. Public funding and provider training substantially improve LARC access.

Objective The objective was to evaluate amenorrhea patterns and predictors of amenorrhea during the first year after levonorgestrel 52 mg intrauterine system (IUS) placement. Study design This cohort analysis includes 1714 nulliparous and parous women who received a Liletta® levonorgestrel 52 mg IUS in a multicenter trial to evaluate efficacy and safety for up to 8 years. Participants maintained a daily diary with bleeding information. We assessed bleeding patterns in 90-day intervals; amenorrhea was defined as no bleeding or spotting in the preceding 90 days. We employed multivariable regression to identify predictors of amenorrhea at 12 months. The predictor analysis only included women not using a levonorgestrel IUS in the month prior to study enrollment. Results In the month before enrollment, 148 and 1566 women, respectively, had used and not used a levonorgestrel IUS. Prior users averaged 50±19 months of use before IUS placement; 38.4% of these women reported amenorrhea at 12 months. Amenorrhea rates for non-prior-users at 3, 6, 9 and 12 months were 0.2%, 9.1%, 17.2% and 16.9%, respectively. During the first 12 months, 29 (1.7%) women discontinued for bleeding irregularities; no women discontinued for amenorrhea. The only significant predictor of amenorrhea at 12 months was self-reported baseline duration of menstrual flow of fewer than 7 days vs. 7 or more days (18.2% vs. 5.2%, adjusted odds ratio 3.70 [1.69, 8.07]). We found no relationships between 12-month amenorrhea rates and age, parity, race, body mass index, baseline flow intensity or hormonal contraception use immediately prior to IUS placement. Conclusions Amenorrhea rates during the first year of levonorgestrel 52 mg IUS use are similar at 9 and 12 months. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow. Implications statement This information provides more data for clinicians when counseling women about amenorrhea expectations, especially since women seeking a levonorgestrel 52 mg IUS for contraception are different than women desiring treatment for heavy menstrual bleeding. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow.

In 2013, California passed Assembly Bill (A.B.) 2348, approving registered nurses (RNs) to dispense patient self-administered hormonal contraceptives and administer injections of hormonal contraceptives. The Family Planning, Access, Care and Treatment (Family PACT) program, which came into effect in 1997 to expand low-income, uninsured California resident access to contraceptives at no cost, is one program in which qualified RNs can dispense and administer contraceptives. The aims of this study were to (a) describe utilization of RN visits within California's Family PACT program and (b) evaluate the impact of RN visits on client birth control acquisition during the first 18 months after implementation of A.B. 2348 (January 1, 2013 to June 30, 2014). A descriptive observational design using administrative databases was used. Family PACT claims were retrieved for RN visits and contraception. Paid claims for contraceptive dispensing and/or administration visits by physicians, nurse practitioners, certified nurse midwives, and physician assistants were compared before and after the implementation of A.B. 2348 at practice sites where RN visits were and were not utilized. Contraceptive methods and administration procedures were identified using Healthcare Common Procedure Coding System codes, National Drug Codes, and Common Procedural Terminology codes. Claims data for healthcare facilities were abstracted by site location based on a unique combination of National Provider Identifier (NPI), NPI Owner, and NPI location number. RN visits were found mainly in Northern California and the Central Valley (73%). Sixty-eight percent of RN visits resulted in same-day dispensing and/or administration of hormonal (and/or barrier) methods. Since benefit implementation, RN visits resulted in a 10% increase in access to birth control dispensing and/or administration visits. RN visits were also associated with future birth control acquisition and other healthcare utilization within the subsequent 30 days. RN visits, though underutilized across the state, have resulted in increased access to contraception in some communities, an effect that may continue to grow with time and can serve as a model for other states. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: This article presents the extent to which providers enrolled in California's Family Planning, Access, Care, and Treatment (Family PACT) program offer contraceptive methods onsite, thus eliminating one important access barrier. Family PACT has a diverse provider network, including public-sector providers receiving Title X funding, public-sector providers not receiving Title X funding, and private-sector providers. We explored whether Title X funding enhances providers' ability to offer contraceptive methods that require specialized skills onsite. Methods: Data were derived from 1,072 survey responses to a 2010 provider-capacity survey matched by unique identifier to administrative claims data. Results: A significantly greater proportion of Title X-funded providers compared to non-Title X public and private providers offered onsite services for the following studied methods: intrauterine contraceptives (90% Title X, 51% public non-Title X, 38% private); contraceptive implants (58% Title X, 19% public non-Title X, 7% private); vasectomy (8% Title X, 4% public non-Title X, 1% private); and fertility-awareness methods (69% Title X, 55% public non-Title X, 49% private) (all p

Objectives. We examined the association of adolescent birthrates (ABRs) with access to and receipt of publicly funded family planning services in California counties provided through 2 state programs: Medi-Cal, California’s Medicaid program, and the Family Planning, Access, Care, and Treatment (Family PACT) program. Methods. Our key data sources included the California Health Interview Survey and California Women’s Health Survey, Medi-Cal and Family PACT claims data, and the Birth Statistical Master File. We constructed a linear regression analysis measuring the relationship of access to and receipt of family planning services with ABRs when controlling for counties’ select covariates. Results. The regression analysis indicated that a higher access rate to Family PACT in a county was associated with a lower ABR (B = −0.19; P Conclusions. Efforts to reduce ABRs, specifically in counties that had persistently high rates are critical to achieving a healthy future for the state and the nation. Family PACT played a crucial role in helping adolescents avoid unintended and early childbearing.

Clinical Opinion www. AJOG .org GENERAL GYNECOLOGY A statement on abortion by 100 professors of obstetrics: 40 years later One Hundred Professors of Obstetrics and Gynecology F orty years ago, leaders in obstetrics and gynecology published a com- pelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. 1 They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. 1 They wrote to ex- press their concern for women’s health in a new legal and medical era of re- productive control and to define the responsibilities of academic obstetrician- gynecologists. Since then, we have advanced the fields of reproduction and family planning. Thanks to these developments, women can now prevent pregnancy with safer and more effective forms of contracep- tion (most recently long-acting revers- ible methods), with simple and sensitive hormonal and sonographic methods to determine pregnancy status and dura- tion, and with new methods of infer- tility treatment and prenatal testing that rely on the option of terminating inten- ded pregnancies that are diagnosed as abnormal. To terminate pregnancies, cli- nicians now use misoprostol and mife- pristone for “medical abortion” (which in 2009 accounted for 16.5% of termina- tions in the United States and can be office-based) and use sonographic guid- ance of intrauterine procedures along with new methods for inducing cervical dilation and uterine contraction; patients From the 100 Professors (Appendix). Received Dec. 3, 2012; revised Jan. 23, 2013; accepted March 7, 2013. The author reports no conflict of interest. Reprints not available from the authors. a 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.03.007 In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women’s health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists. Key words: abortion, law, teaching hospital benefit from innovations in counseling and new approaches to pain control. 2-6 Studies of abortion practice and out- comes are also much more sophisticated than they were 40 years ago. 7,8 We have had 40 years of medical progress but have witnessed political regression that the 100 professors did not anticipate. In 2011 alone, 24 states passed 92 legislative restrictions on abortion. 9 Waiting periods after consent are now law in 26 states. Alabama, Arizona, Florida, Kansas, Louisiana, North Car- olina, Oklahoma and Texas require pa- tients to view ultrasound images and, in Arizona, Louisiana, Mississippi and Texas, to listen to fetal heart beats. 10 Laws in 27 states force physicians to provide deceptive counseling including false statements about risks of breast cancer, infertility and mental health. They include laws to limit second-trimester abortion under the guise of protecting the fetus from pain (Alabama, Idaho, Indiana, Kansas, Louisiana, Nebraska, and Oklahoma). 11 Laws directed specif- ically at medical education in Arizona, Kansas, and Texas prohibit abortion training in public institutions and another 7 states ban abortion in public hospitals, precluding training in them. 12 What vision of the future of legalized abortion did the 100 professors have? How accurately did they estimate the need for safe, legal abortion and antici- pate their colleagues’ willingness and commitment to meeting it? They wrote, “In view of the impending change in abortion practices generated by new state legislation and federal court de- cisions, we believe it helpful to [respond] to this increasingly liberal course of events.by contributing to the solution of an imminent problem.” 1 Forty years later, the change is not liberal. Its effects will threaten, not improve, women’s health and already obstruct physicians’ evidence-based and patient-centered practices. We review our predecessors’ 1972 statement and judge how it com- ports with what actually occurred and with legislation that has been adopted over the 40 years since their writing and the passage of Roe v Wade. The 100 professors were remarkably prescient in anticipating the need for 1 million legal abortions and today’s abortion rate of 1 in 4 pregnancies. 13,14 They predicted that teaching hospitals with specialized outpatient facilities could meet the demand and believed that abortions were the responsibility of hospitals. But today, 90% of abortions, which include the 10% that are in the second trimester, are done away from hospitals. 15 Many hospitals enforce fetal and maternal health restrictions that are not based in the law but are MONTH 2013 American Journal of Obstetrics & Gynecology FLA 5.1.0 DTD ! YMOB9193_proof ! 15 April 2013 ! 10:46 am ! ce

Clinical Opinion www. AJOG .org GENERAL GYNECOLOGY A statement on abortion by 100 professors of obstetrics: 40 years later One Hundred Professors of Obstetrics and Gynecology F orty years ago, leaders in obstetrics and gynecology published a com- pelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade (Supplementary Data available at www.AJOG.org). 1 They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. 1 They wrote to ex- press their concern for women’s health in a new legal and medical era of re- productive control and to define the responsibilities of academic obstetrician- gynecologists. Since then, we have advanced the fields of reproduction and family planning. Thanks to these developments, women can now prevent pregnancy with safer and more effective forms of contracep- tion (most recently long-acting revers- ible methods), with simple and sensitive hormonal and sonographic methods to determine pregnancy status and dura- tion, and with new methods of infer- tility treatment and prenatal testing that rely on the option of terminating inten- ded pregnancies that are diagnosed as abnormal. To terminate pregnancies, cli- nicians now use misoprostol and mife- pristone for “medical abortion” (which in 2009 accounted for 16.5% of termina- tions in the United States and can be office-based) and use sonographic guid- ance of intrauterine procedures along with new methods for inducing cervical From the 100 Professors (Appendix). Received Dec. 3, 2012; revised Jan. 23, 2013; accepted March 7, 2013. The author reports no conflict of interest. Reprints not available from the authors. a 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.03.007 In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women’s health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists. Key words: abortion, law, teaching hospital dilation and uterine contraction; patients benefit from innovations in counseling and new approaches to pain control. 2-6 Studies of abortion practice and out- comes are also much more sophisticated than they were 40 years ago. 7,8 We have had 40 years of medical progress but have witnessed political regression that the 100 professors did not anticipate. In 2011 alone, 24 states passed 92 legislative restrictions on abortion. 9 Waiting periods after consent are now law in 26 states. Alabama, Arizona, Florida, Kansas, Louisiana, North Car- olina, Oklahoma, and Texas require pa- tients to view ultrasound images and, in Arizona, Louisiana, Mississippi, and Texas, to listen to fetal heart beats. 10 Laws in 27 states force physicians to provide deceptive counseling including false statements about risks of breast cancer, infertility, and mental health. They include laws to limit second-trimester abortion under the guise of protecting the fetus from pain (Alabama, Idaho, Indiana, Kansas, Louisiana, Nebraska, and Oklahoma). 11 Laws directed specif- ically at medical education in Arizona, Kansas, and Texas prohibit abortion training in public institutions and another 7 states ban abortion in public hospitals, precluding training in them. 12 What vision of the future of legalized abortion did the 100 professors have? How accurately did they estimate the need for safe, legal abortion and antici- pate their colleagues’ willingness and commitment to meeting it? They wrote, “In view of the impending change in abortion practices generated by new state legislation and federal court de- cisions, we believe it helpful to [respond] to this increasingly liberal course of events.by contributing to the solution of an imminent problem.” 1 Forty years later, the change is not liberal. Its effects will threaten, not improve, women’s health and already obstruct physicians’ evidence-based and patient-centered practices. We review our predecessors’ 1972 statement and judge how it com- ports with what actually occurred and with legislation that has been adopted over the 40 years since their writing and the passage of Roe v Wade. The 100 professors were remarkably prescient in anticipating the need for 1 million legal abortions and today’s abortion rate of 1 in 4 pregnancies. 13,14 They predicted that teaching hospitals with specialized outpatient facilities could meet the demand and believed that abortions were the responsibility of hospitals. But today, 90% of abortions, which include the 10% that are in the second trimester, are done away from hospitals. 15 Many hospitals enforce fetal and maternal health restrictions that SEPTEMBER 2013 American Journal of Obstetrics & Gynecology

OBJECTIVE: To assess the extent to which women received contraceptive services within 90 days after birth at their first or subsequent visits and whether contraceptive provision was associated with optimal interpregnancy intervals. METHOD: We linked Californias 2008 Birth Statistical Master File with Medicaid databases to build a cohort of women aged 15-44 years who had given birth in 2008 and received publicly-funded health care services in the 18 months after their previous live birth (N=117644). We determined whether provision of contraception within 90 days after birth was associated with optimal interpregnancy intervals when controlling for covariates. RESULT: Only 41% (n=48775) of women had a contraceptive claim within 90 days after birth. To avoid short interpregnancy intervals 6 women would need to receive contraception to avoid one additional short interval (number needed to treat=6.38). Receipt of a contraceptive method receiving contraception at the first clinic visit and being seen by Medi-Cal and its family planning expansion program were significantly associated with avoidance of short interpregnancy intervals. Receiving contraception at the first postpartum clinic visit had an additional independent effect on avoiding short interpregnancy intervals when controlling for the other variables. Although foreign-born women had 47% higher odds of avoiding short interpregnancy intervals than U.S.-born women women of Asian and Pacific Islander ethnicity had 24% lower odds of avoiding short interpregnancy intervals than white women. CONCLUSION: Findings of this study suggest that closer attention to provision of postpartum contraception in publicly-funded programs has the potential to improve optimal interpregnancy intervals among low-income women. LEVEL OF EVIDENCE: : II.

In California's Medicaid family planning expansion, the Family Planning, Access, Care and Treatment (Family PACT) Program, only 1.9% of contracepting women received intrauterine contraception (IUC) in 2006. Ten skills-based IUC provider trainings were offered from 2007 to 2010.The objective was to evaluate the impact of these trainings on participant knowledge of the broad range of appropriate IUC candidates and measure changes in IUC provision following training.We evaluated changes in provider knowledge using a nine-item IUC Candidate Selection Scale on pre- and posttraining surveys. Changes in provision of IUC following the training were measured using Family PACT claims data. We compared changes in insertions posttraining to pretraining levels as well as to matched comparison sites that did not send trainees.Most participants at the training were advanced practice clinicians (70%) specializing in general primary care (77%) and practicing at community clinics (45%). Training participants increased their understanding of appropriate candidates (mean change in raw summary score=8.6, p.001), from an average of 58% correct responses to 81%. Provider sites that participated in training provided a mean of 4.6 more women with IUC following training than during baseline (p.01), an increase of 25% compared to only 7% increase among comparison sites. The impact of the training differed by practice size such that the largest and smallest clinics both changed IUC provision the most and had the largest differences over comparison sites.This study shows that skills-based training is an important strategy for the increase of IUC provision.

Objective The objective was to monitor the effectiveness of the etonogestrel implant clinical training program through a voluntary active monitoring program (AMP). Study design US health care providers underwent mandatory training by the manufacturer on etonogestrel implant insertion, localization and removal. After training, health care providers could enroll in a voluntary AMP to provide outcome data to meet a postmarketing commitment of the manufacturer with the US Food and Drug Administration (FDA). Those who volunteered completed and faxed forms to the manufacturer after implant insertion and removal detailing the procedure and device-related outcomes, including insertion-, localization- or removal-associated events. Experts reviewed outcome data quarterly, which the Sponsor then reported to the FDA. Results Among 42,337 health care providers completing the training program, 4294 (10.1%) volunteered to participate in the AMP. The 26,198 forms submitted over 6.4 years included more insertion ( n =20,497) forms than removal forms ( n =5701). The volunteers reported 646 events on 566 (2.2%) forms related to insertion ( n =197), localization ( n =34), removal ( n =357) and “other” ( n =58). Clinically important events included noninsertion ( n =4), serum etonogestrel positive but implant not found ( n =1), and possible nerve ( n =66) or vascular ( n =5) injury. The reports did not include any insertion-, localization- or removal-associated hospitalizations. Eight (0.14%) removal reports described referral for surgical implant removal. Conclusion Events related to insertion, localization or removal of the etonogestrel implant are uncommon among US providers who received mandatory training in the use of the implant. Implications This report presents results from the first mandatory US contraceptive training program. Health care providers volunteered to report information about etonogestrel implant insertion, localization and removal. Although the data do not demonstrate whether a mandatory program improves outcomes, they elucidate the utility and real-life experience that clinical training programs can provide.

Well-trained medical professionals are key to improving global reproductive health and reducing rates of unsafe abortion, but medical training often fails to prepare practitioners to provide essential family planning services. The field of medical education is currently undergoing reformation to better meet the needs of a global population, and comprehensive, integrated family planning training will be an important part of those reforms. Family planning training is not only vital to address global reproductive healthcare demand, but integrates effectively with cornerstones of current medical education reform: competency-based education, leadership development, collaboration with practitioners of all levels, and global health context. Examples of successful integration of family planning education are outlined, and recommendations for integrating family planning into medical education detailed at the 2012 FIGO World Congress are discussed.

CONTEXT: Available contraceptives are not meeting many womens needs as is evident by high levels of typical-use failure method switching and discontinuation. To improve womens satisfaction with contraceptive methods determining what features they prefer and how these preferences are satisfied by available methods and methods under development is crucial. METHODS: The importance of 18 contraceptive method features was rated by 574 women seeking abortions--a group at high risk of having unprotected intercourse and unintended pregnancies--at six clinics across the United States in 2010. For each available and potential method the number of features present was assessed and the percentage of these that were "extremely important" to women was calculated. RESULTS: The three contraceptive features deemed extremely important by the largest proportions of women were effectiveness (84%) lack of side effects (78%) and affordability (76%). For 91% of women no method had all of the features they thought were extremely important. The ring and the sponge had the highest percentage of features that women deemed extremely important (67% each). Some streamlined modes of access and new contraceptive technologies have the potential to satisfy womens preferences. For example an over-the-counter pill would have 71% of extremely important features and an over-the-counter pericoital pill 68%; currently available prescription pills have 60%. CONCLUSION: The contraceptive features women want are largely absent from currently available methods. Developing and promoting methods that are more aligned with womens preferences presumably could help increase satisfaction and thereby encourage consistent and effective use. Copyright (c) 2012 by the Guttmacher Institute.

The use of performance indicators has the potential to improve service quality and avert costs, yet such indicators have typically not been used to assess family planning and reproductive health services. An exception is California's Family PACT (Planning, Access, Care, and Treatment) Program, a statewide family planning and reproductive health services program. Our study assessed whether the behavior of providers participating in this program was influenced by performance reports that used both quality improvement and utilization management indicators. We examined three indicators in each category from 2005 to 2009 and found that change occurred in five of six indicators among private providers and in three of six indicators among public providers. Chlamydia screening rates in women age twenty-five and younger, for example, increased significantly among both private and public providers. Despite the challenges enumerated in this article, we conclude that the methodology used in the program could serve as a starting point for the development of a uniform set of provider-focused reproductive health quality and utilization reports that could be instituted by state family planning programs, state Medicaid programs and health plans, and other health care delivery systems.

Objective—The copper intrauterine device (IUD) is the most effective emergency contraceptive available but is largely ignored in clinical practice. We examined clinicians’ recommendation of the copper IUD for emergency contraception in a setting with few cost obstacles. Methods—We conducted a survey among clinicians (n=1,246; response rate 65%) in a California State family planning program, where U.S. Food and Drug Administration-approved contraceptives are available at no cost to low-income women. We used multivariable logistic regression to measure the association of intrauterine contraceptive training and evidence-based knowledge with having recommended the copper IUD for emergency contraception. Results—The large majority of clinicians (85%) never recommended the copper IUD for emergency contraception, and most (93%) required two or more visits for an IUD insertion. Multivariable analyses showed insertion skills were associated with having recommended the copper IUD for emergency contraception, but the most significant factor was evidence-based knowledge of patient selection for IUD use. Clinicians who viewed a wide range of patients as IUD candidates were twice as likely to have recommended the copper IUD for emergency contraception. While over 93% of obstetrician–gynecologists were skilled in inserting the copper IUD, they were no more likely to have recommended it for emergency contraception than other physicians or advance practice clinicians. Conclusion—Recommendation of the copper IUD for emergency contraception is rare, despite its high efficacy and long-lasting contraceptive benefits. Recommendation would require clinic flow and scheduling adjustments to allow same-day IUD insertions. Patient-centered and highquality care for emergency contraception should include a discussion of the most effective method.

Objective To estimate the number of unintended pregnancies averted through the provision of family planning services to low income women in Family PACT, California's Medicaid waiver program. Study Design We use a Markov model to estimate the number of pregnancies in the absence of Family PACT based on the contraceptive method mix used before program enrollment, and pregnancies in the presence of the program, based on method dispensing claims. Results Nearly 1 million (998,084) women were provided with contraceptives in Family PACT in 2007. Contraceptive services averted over an estimated 286,700 unintended pregnancies including 122,000 abortions, 133,000 unintended births, and over 40,000 births among teens. Conclusion This conservative measure of the effect of Family PACT on unintended pregnancies indicates the benefit of expanding access to contraceptive services, an example for other states considering expanding access to family planning services through a state plan amendment under health care reform.

Unintended pregnancy is a significant health problem in the United States, where more than three million such pregnancies occur each year.1 The burden of unintended pregnancy falls disproportionately on ethnic minority women—69% of pregnancies among blacks and 54% of those among Latinas are unintended, compared with 42% of those among white women.1 These disparities contribute to substantial differentials in abortion rates—49 abortions per 1,000 black women of reproductive age and 30 abortions per 1,000 Latina women of reproductive age, compared with 13 per 1,000 among whites.1 In addition, low-income women have higher rates of unintended pregnancy and abortion than do women with higher incomes; the largest differences are between women with incomes below 200% of the federal poverty level and those with incomes above this threshold.1 Disparities in unintended pregnancy and abortion rates are driven in part by differences in contraceptive use. Many women at risk for unintended pregnancy do not use a contraceptive method, and the proportion varies by race and ethnicity. The 2006–2008 National Survey of Family Growth (NSFG) found that among women who were sexually active and did not desire pregnancy, 9% of whites, 16% of blacks and 9% of Latinas were not using contraceptives.2 Disparities in use between blacks and whites at risk for unintended pregnancy persist in analyses that control for socioeconomic factors.3,4 Because contraceptive methods vary in their effectiveness, and because half of unintended pregnancies occur among women who are using contraceptives,1 differences by race and ethnicity in method choice may have an effect on racial and ethnic disparities in unintended pregnancy rates. Black and Latina women are more likely than whites to use the injectable and condoms, while whites are more likely than Blacks or Latinas to use oral contraceptives.2,5,6 In addition, Latinas are more likely than either white or black women to use an IUD.2 A few studies have investigated the relationship between contraceptive use and race and ethnicity while controlling for socioeconomic status. In one such study, black women were more likely than white women to have undergone tubal sterilization.7 In another, which controlled for education, income and insurance coverage, black women were less likely than whites to be using oral contraceptives, and more likely than whites to be using condoms and long-acting methods (the patch, ring, injectable, implant and IUD).6 In addition, U.S.-born Hispanics were more likely than white women to be using condoms, while foreign-born Hispanics were more likely than whites to be using long-acting methods. These findings indicate that racial and ethnic differences in use of oral contraceptives and condoms are not entirely due to socioeconomic factors, although conclusions cannot be drawn about the use of other individual methods. In 1997, recognizing that financial access may influence contraceptive use, California implemented the Family PACT (Planning, Access, Care and Treatment) program, which provides free, family planning and reproductive health services to residents with incomes up to 200% of the federal poverty level who have no other source of family planning services. Program benefits include access to all contraceptive methods that have been approved by the Food and Drug Administration (FDA), as well as to screening and treatment for STDs. Family PACT serves more than 1.5 million clients per year, including approximately two-thirds of all women in California who are eligible for services, and reaches a diverse range of economically marginalized populations with poor access to health care services.8 A higher proportion of eligible Latinas (76%) than of whites (53%), Asians (49%) and blacks (43%) participate in the program.9 In 2007, Family PACT services prevented an estimated 296,200 unintended pregnancies in California.10 The availability of the program’s claims data offers a unique opportunity for researchers to analyze contraceptive method provision by clients’ race and ethnicity in a setting where women have access, without financial barriers, to all FDA-approved methods. These data have several valuable features. Because California is the most populous state and is racially and ethnically diverse,11 analyses of its population have relevance for the nation as a whole. In addition, because Family PACT covers only low-income women, the program’s data provide information about women with the greatest need for subsidized contraceptive services. Finally, claims data provide a different perspective on contraceptive provision than self-reported data, which have been the basis for most studies on the distribution of contraceptive methods. In this article, we present characteristics of women receiving contraceptive methods in the Family PACT program in 2007 and review trends in the dispensing of contraceptives between 2001 and 2007. Examining this time period is particularly important given the arrival in 2002 of two new FDA-approved contraceptive methods: the ring and the patch. To date, information about the adoption of these methods has been limited. We will explore how contraceptive method distribution changed when these methods were introduced, as well as investigate trends by race and ethnicity in the receipt of these and other methods.

Men have a significant role in reproductive health decision making and behavior, including family planning and prevention of sexually transmitted diseases (STDs).Yet studies on reproductive health care of men are scarce. The National Survey of Family Growth 2006-2008 provided data that allowed assessment of the predisposing, enabling, and need factors associated with men’s receipt of reproductive health services in the United States. Although more than half (54%) of U.S. men received at least one health care service in the 12 months prior to the survey, far fewer had received birth control counseling/methods, including condoms (12%) and STD/HIV testing/STD treatment (12%). Men with publicly funded health insurance and men who received physical exam were more likely to receive reproductive health services when compared with men with private health insurance and men who did not receive a physical exam. Men who reported religion was somewhat important were significantly more likely to receive birth control counseling/ methods than men who stated religion was very important. The pseudo- R2 (54%), a measure of model fit improvement, suggested that enabling factors accounted for the strongest association with receiving either birth control counseling/ methods or STD/HIV testing/STD treatment.

Purpose We sought to determine the potential effect and cost-effectiveness of different means of accessing emergency contraceptive pills (ECP) on unintended pregnancy rates in sexually active women. Methods We used a computer simulation model to compare the effects of advance provision, on-demand provision, and no use of ECP on unintended pregnancies and costs of care in three hypothetical cohorts of 1 million sexually active women. Data on effectiveness of ECP from the single-use clinical trials, and costs from Medi-Cal, California's Medicaid program were used for the model. Findings Advance provision of ECP is projected to avert a greater or the same percentage of unintended pregnancies compared with on-demand provision, with the greatest percentage of pregnancies averted (66%) in low-risk women with advance provision. In the simulation model, the percentage of pregnancies averted decreases as the frequency of unprotected intercourse increases and ECP use decreases. In all scenarios, the cost-savings ratio—the number of dollars saved on averted pregnancy expenditures for each dollar spent on advance ECP—is greater than one. Conclusion Advance provision of ECP has the potential to avert unintended pregnancies and reduce medical expenditures. The most likely reason that the advance provision trials fail to demonstrate reductions in pregnancy rates is a result of a combination of small study sizes, the use of ECP in both treatment and control groups, and a failure to take into account a realistic range of rates of unprotected intercourse and imperfect ECP use.

CONTEXT: Obstetrics and gynecology residents who are trained in family planning and intend to provide abortions after residency often do not ultimately do so. The extent of the professional barriers physicians face trying to integrate abortion into their practice is unknown. METHODS: In 2006, in-depth interviews were conducted with 30 obstetrician-gynecologists who had graduated 5–10 years earlier from residency programs that included abortion training. Interviews about physicians’ experiences with abortion training and practice were coded and analyzed using a grounded theoretical approach. RESULTS: Eighteen physicians had wanted to offer elective abortions after residency, but only three were doing so at the time of the interview. The majority were unable to provide abortions because of formal and informal policies imposed by their private group practices, employers and hospitals, as well as the strain that doing so might put on relationships with superiors and coworkers. Restrictions on abortion provision sometimes were made explicit when new physicians interviewed for a job, but sometimes became apparent only after they had joined a practice or institution. Several physicians mentioned the threat of violence as an obstacle to providing abortions, but few considered this the greatest deterrent. CONCLUSIONS: The stigma and ideological contention surrounding abortion manifest themselves in professional environments as barriers to the integration of abortion into medical practice. New physicians often lack the professional support and autonomy necessary to offer abortion services.

Intrauterine progestins, progesterone receptor modulators, and antagonists have many important current and potential gynecologic applications. This article will describe the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. We will review the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, adenomyosis treatment, uterine fibroids, endometrial hyperplasia, and its concurrent use in women on hormone replacement therapy or tamoxifen.

Objective To examine the hospital and state costs of offering the option of a postpartum intrauterine device (IUD) to an underinsured population of recent immigrants to the United States with Emergency Medicaid (EM) insurance coverage only. Study Design This study is a retrospective cohort study comparing the costs of offering a reversible long-acting method of contraception (IUD) postpartum to women with EM and the current policy of covering the obstetrical delivery only. A cost–benefit analysis from the perspective of both the hospital and the state was conducted. A database of EM obstetrical patients from 2002 to 2006 was created from hospital billing records to calculate mean pregnancy costs and revenue, as well as the probability of repeat pregnancy and pregnancy outcome. Probability of IUD uptake and continuation was obtained from hospital records and the literature. Results A postpartum IUD program is not cost beneficial from the hospital's perspective, losing 70 cents per dollar spent on the program. However, the state government would save $2.94 for every dollar spent on a state-financed IUD program. Conclusion Considering only the direct costs associated with a repeat pregnancy, a program offering the option of postpartum IUD placement to underinsured women would significantly reduce state expenditures on subsequent pregnancies.

Objective To present efficacy, safety, and bleeding profile results from the clinical trials that supported the U.S. Food and Drug Administration filing for the approval of a single-rod etonogestrel (ENG) contraceptive implant (Implanon). Design Integrated analysis of 11 international clinical trials. Setting Contraceptive clinics in U.S., Chile, Asia, and Europe. Patient(s) A total of 942 healthy women, aged 18 to 40 years. Intervention(s) Insertion of an ENG implant. Most women were enrolled in studies lasting either 2 or 3 years. Main Outcomes Measure(s) Efficacy was measured by the cumulative Pearl Index in women ≤35 years old. Safety was primarily assessed by incidence of adverse events. Bleeding profiles were analyzed via reference period analyses. Result(s) No pregnancies were reported while the ENG implants were in place. Six pregnancies occurred during the first 14 days after ENG implant removal. Including these six pregnancies, the cumulative Pearl Index was 0.38 (year 1 and 2 Pearl Indexes were 0.27 and 0.30, respectively). Common drug-related adverse events were headache, weight gain, acne, breast tenderness, emotional lability, and abdominal pain. Bleeding pattern changes were observed, but no one pattern predominated. Conclusion(s) The ENG implant is an efficacious and safe method of contraception which does not require patients' consistent action.

Objectives. We examined the cost-effectiveness of contraceptive methods dispensed in 2003 to 955 000 women in Family PACT (Planning, Access, Care and Treatment), California's publicly funded family planning program. Methods. We estimated the number of pregnancies averted by each contraceptive method and compared the cost of providing each method with the savings from averted pregnancies. Results. More than half of the 178 000 averted pregnancies were attributable to oral contraceptives, one fifth to injectable methods, and one tenth each to the patch and barrier methods. The implant and intrauterine contraceptives were the most cost-effective, with cost savings of more than $7.00 for every $1.00 spent in services and supplies. Per $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contraceptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34; and emergency contraceptives, $1.43. Conclusions. All contraceptive methods were cost-effective—they saved more in public expenditures for unintended pregnancies than they cost to provide. Because no single method is clinically recommended to every woman, it is medically and fiscally advisable for public health programs to offer all contraceptive methods.

Intrauterine contraception is used by many women worldwide however it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. We conducted a survey among physicians nurse practitioners and physician assistants (n = 1246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N = 816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. Forty percent of providers did not offer intrauterine contraception to contraceptive patients and 36% infrequently provided counseling although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects including differences between hormonal and nonhormonal devices. (authors)

Background Approximately 1 out of 10 abortions in the United States occurs in the second trimester of pregnancy. This study uses survival analysis to identify the factors which delay each step of the process of obtaining an abortion. Study Design This is a secondary data analysis of a cross-sectional study investigating a sample of 398 women who presented for elective abortion at an urban hospital. Respondents completed a survey using an audio-assisted self-interviewing program and provided a timeline for their process of obtaining an abortion. Results In our analysis, we divided the abortion process into three steps ending in three distinct events (first pregnancy test, calling a clinic, getting an abortion). Factors associated with delay during the first step include obesity [hazard ratio (HR) 0.8, 95% CI 0.6–1.0], abuse of drugs or alcohol (HR 0.7, 95% CI 0.6–1.0), prior second-trimester abortion (HR 0.6, 95% CI 0.4–0.8) and being unsure of last menstrual period (HR 0.6, 95% CI 0.4–0.7) and emotional factors such as being in denial (HR 0.8, 95% CI 0.6–1.0) and fear of abortion (HR 0.7, 95% CI 0.5–1.0). Conclusion This study identified key factors associated with delay in obtaining abortion care. Interventions which seek to address these factors, especially those factors associated with later pregnancy suspicion and testing, may reduce abortion delay and facilitate women obtaining their abortions when medical risk and overall cost are lower.

OBJECTIVE: To summarize the efficacy of postabortion uterine artery embolization in cases of refractory hemorrhage. METHODS: Forty-two women were identified who had postabortion uterine artery embolization at San Francisco General Hospital between January 2000 and August 2007. Seven underwent embolization for hemorrhage caused by abnormal placentation. RESULTS: Embolization was successful in 90% (38 of 42) of cases. All failures (n4) were in patients who had confirmed abnormal placentation. However, three of seven women (43%) with probable accreta diagnosed by ultrasonography were treated successfully with uterine artery embolization. Two patients experienced complications of uterine artery embolization. These complications—one contrast reaction and one femoral artery embolus—were treated without further sequelae. CONCLUSION: Uterine artery embolization is an alternative to hysterectomy in patients with postabortion hemorrhage refractory to conservative measures, especially when hemorrhage is caused by uterine atony or cervical laceration.

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

Author(s): Darney, Philip D; Creinin, Mitchell D; Nichols, Mark; Gilliam, Melissa; Westhoff, Carolyn L

Summary Background Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. Methods We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011–13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18–25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. Findings Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8–5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3–2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34–0·85). Interpretation The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. Funding William and Flora Hewlett Foundation.

To quantify and compare serum levels and uterine effects following vaginal (dry), vaginal (moistened), buccal, and rectal misoprostol administration.Forty women seeking elective abortion between 6 and 12 6/7 weeks were randomly assigned to receive 400 mug of misoprostol by one of four routes. A 2.5-mm pressure monitoring catheter was placed through the cervix to the uterine fundus to record uterine tone and activity during the 5-hour observation period. Serum levels of misoprostol acid were measured at 15 and 30 minutes, then every 30 minutes.The four groups were similar in age, race or ethnicity, body mass index, parity, and gestation. Serum levels after vaginal, vaginal moistened and buccal administration rose gradually, peaked between 15 and 120 minutes and fell slowly. Vaginal and vaginal moistened routes produced higher peak serum levels than buccal and rectal (445.9 and 427.1 compared with 264.8 and 202.2 pg/mL; P = .03) and higher serum concentration area under the curve at 5 hours (1,025.0 and 1279.4 compared with 519.6 and 312.5 pg-hr/mL; P.001). Uterine tone and activity, however, were similar for buccal and the two vaginal routes. After rectal administration, serum levels peaked earlier (P.001) then dropped more abruptly, and peak uterine tone (P.001) and total activity (P = .04) were lower than after the other routes.Although serum levels were lower for buccal compared with the vaginal routes, the three routes produced similar uterine tone and activity. Rectal administration produced lower uterine tone and activity. Vaginal serum levels were two to three and a half times higher than those observed in prior misoprostol pharmacokinetic studies.

Objectives: The United States Food and Drug Administration cited an absence of data on young adolescents as the reason the emergency contraceptive, Plan B, could not be moved over-the-counter. This study analyzed data on young adolescents with increased access to emergency contraception. Methods: We conducted an age-stratified analysis with previously published data from a randomized, controlled trial of Plan B with a sample size of 2,117, including 964 adolescents, 90 of whom were aged younger than 16 years. Participants were randomly assigned to nonprescription pharmacy access, advance provision of 3 packs, or clinic access (control). We measured contraceptive and sexual risk behaviors at baseline and 6-month follow-up and tested for pregnancy and sexually transmitted infections. We used contingency table and logistic regression analysis to measure the effect of the intervention on risk behaviors in young adolescents ( 16 years), compared with middle adolescents (16–17 years), older adolescents (18–19 years), and adults (20–24 years). Results: Adolescents aged younger than 16 years behaved no differently in response to increased access to emergency contraception (EC) from the other age groups. As with adults, EC use was greater among adolescents in advance provision than in clinic access (44% compared with 29%; P .001), and other behaviors were unchanged by study arm, including unprotected intercourse, condom use, sexually transmitted infection acquisition, or pregnancy. Additionally, adolescents with increased access to EC did not become more vulnerable to unwanted sexual activity. Conclusion: Young adolescents with improved access to EC used the method more frequently when needed, but did not compromise their use of routine contraception nor increase their sexual risk behavior. (Obstet Gynecol 2005;106:483–491) Level of Evidence: I

OBJECTIVE To compare the efficacy and acceptability of same-day misoprostol and overnight laminaria for cervical ripening before early second-trimester surgical abortion. METHODS We performed a randomized, double-blinded, controlled trial comparing 400 microg of vaginal misoprostol, given 3-4 hours preoperatively, with overnight laminaria before early second-trimester surgical abortion among women at 13.0-16.0 weeks of gestation (n = 84). The primary outcome was procedure time, and the sample size was based on 95% power to detect a difference of 4.5 minutes between groups. Secondary outcomes included completion of the procedure on the first attempt, procedural difficulty, and patients' pain scores and preferences. RESULTS The average gestational duration was 14 weeks 6 days. Procedures performed after laminaria were significantly faster than those after misoprostol (median 3.4 versus 7.2 minutes, respectively, P = .01). Laminaria patients had significantly greater dilation than misoprostol patients at abortion (mean 43 versus 33 French, P < .001), and more misoprostol patients required additional dilation (85% versus 21%, P < .001). Physicians rated 27% of the misoprostol procedures as moderate-markedly difficult versus 5% of laminaria procedures (P = .01). Differences in efficacy were pronounced among nulliparous patients. There were no significant differences in ability to complete the procedure on the first attempt or patients' intraoperative pain scores. More women in the misoprostol group would choose their assigned method again (93% versus 62%, P < .01), and 82% of all subjects preferred a 1-day procedure. CONCLUSION Early second-trimester abortions take longer and are technically more challenging after cervical ripening with same-day misoprostol than with overnight laminaria, but patients prefer same-day misoprostol.

Objective We evaluated the tolerability of emergency contraception in adolescents. Study design In this descriptive study, 1 0.75 mg levonorgestrel tablet was administered to 52 females aged 13-16 with instructions to take the second tablet 12 hours later (unprotected intercourse was not an entry requirement). Participants kept diaries of side effects and menstrual patterns. We assessed correct use, side effects caused by treatment, and impact on menstrual cycle. Results Virtually all participants used the drug correctly, with no serious adverse events. Minor expected side effects occurred, including nausea, fatigue, and vomiting. There was no difference in reporting of side effects by age. Adolescents' mean duration of menses was comparable pre- and post-treatment (5.3 vs 5.0 days; P = .146), and onset of menses was within the expected range. Ninety percent of participants reported they would recommend emergency contraception to a friend or relative if needed. Conclusion Adolescents tolerated the medication well, experiencing transient side effects.

California is home to more than one out of eight American women of reproductive age. Because California has a large, diverse and growing population, national statistics do not necessarily describe the reproductive health of California women. This article presents risk for pregnancy and sexually transmitted infections among women in California based on the California Women’s Health Survey. Over 8900 women of reproductive age who participated in this survey between 1998 and 2001 provide estimates of access to care and use of family-planning methods in the state. We find that 49% of the female population aged 18–44 in California is at risk of unintended pregnancy. Nine percent (9%) of women at risk of an unintended pregnancy are not using any method of contraception, primarily for method-related reasons, such as a concern about side effects or a dislike of available contraceptive methods. Among women at risk for unintended pregnancy, we find disparities by race/ethnicity and education in use of contraceptive methods.