Contraceptive Practices and Fertility Desires among HIV-Infected and Uninfected Women in Kenya: Results From a Nationally Representative Study

Background

Prevention of unplanned pregnancies is a critical element in the prevention of mother-to-child transmission of HIV infection, but its potential has not been fully realized. We assessed the utilization of family planning (FP) and fertility desires among women of reproductive age by HIV status.

Methods

We selected a nationally representative sample of households using a stratified 2-stage cluster design and surveyed women aged 15–49 years. We administered questionnaires and examined predictors of current use of FP and desire for children among sexually active women with known HIV infection and women who were HIV uninfected.

Results

Of 3583 respondents, 68.2% were currently using FP, and 57.7% did not desire children in the future. Among women who did not desire children in the future, 70.9% reported that they were using FP, including 68.7% of women with known HIV infection and 71.0% of women who were HIV uninfected. Women with known HIV infection had similar odds of using FP as women with no HIV infection (odds ratio, 1.12; 95% confidence interval: 0.81 to 1.54). Women with no HIV infection had significantly higher adjusted odds of desiring future children (adjusted OR, 2.27; 95% confidence interval: 1.31 to 3.93) than women with known HIV infection.

Conclusions

There is unmet need for FP for HIV-infected women, underscoring a gap in the national prevention of mother-to-child transmission of HIV strategy. Efforts to empower HIV-infected women to prevent unintended pregnancies should lead to expanded access to contraceptive methods and take into account women’s reproductive intentions.

Full article at:   http://goo.gl/oY8118

By:  Evelyn W. Ngugi, MBChB, MPH,* Andrea A. Kim, PhD, MPH,* Raymond Nyoka, MSc,* Lucy Ng’ang’a, MBChB, MPH,*Irene Mukui, MBChB,† Bernadette Ng’eno, MBChB, MMed,* and George W. Rutherford, MD, AM‡, for the KAIS Study Group

^*Division of Global HIV/AIDS, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya

^†National AIDS and Sexually Transmitted Infection (STI) Control Programme, Ministry of Health, Nairobi, Kenya

^‡Global Health Sciences, University of California, San Francisco, San Francisco, CA

Correspondence to: Evelyn W. Ngugi, MBChB, Division of Global HIV/AIDS, Center for Global Health, US Centers for Disease Control and Prevention, PO Box 606-00621, Village Market, Nairobi, Kenya

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Estimating Contraceptive Prevalence Using Logistics Data for Short-Acting Methods: Analysis Across 30 Countries

Contraceptive prevalence rate (CPR) is a vital indicator used by country governments, international donors, and other stakeholders for measuring progress in family planning programs against country targets and global initiatives as well as for estimating health outcomes. Because of the need for more frequent CPR estimates than population-based surveys currently provide, alternative approaches for estimating CPRs are being explored, including using contraceptive logistics data.

Using data from the Demographic and Health Surveys (DHS) in 30 countries, population data from the United States Census Bureau International Database, and logistics data from the Procurement Planning and Monitoring Report (PPMR) and the Pipeline Monitoring and Procurement Planning System (PipeLine), we developed and evaluated 3 models to generate country-level, public-sector contraceptive prevalence estimates for injectable contraceptives, oral contraceptives, and male condoms. Models included: direct estimation through existing couple-years of protection (CYP) conversion factors, bivariate linear regression, and multivariate linear regression. Model evaluation consisted of comparing the referent DHS prevalence rates for each short-acting method with the model-generated prevalence rate using multiple metrics, including mean absolute error and proportion of countries where the modeled prevalence rate for each method was within 1, 2, or 5 percentage points of the DHS referent value.

For the methods studied, family planning use estimates from public-sector logistics data were correlated with those from the DHS, validating the quality and accuracy of current public-sector logistics data. Logistics data for oral and injectable contraceptives were significantly associated (P<.05) with the referent DHS values for both bivariate and multivariate models. For condoms, however, that association was only significant for the bivariate model. With the exception of the CYP-based model for condoms, models were able to estimate public-sector prevalence rates for each short-acting method to within 2 percentage points in at least 85% of countries.

Public-sector contraceptive logistics data are strongly correlated with public-sector prevalence rates for short-acting methods, demonstrating the quality of current logistics data and their ability to provide relatively accurate prevalence estimates. The models provide a starting point for generating interim estimates of contraceptive use when timely survey data are unavailable. All models except the condoms CYP model performed well; the regression models were most accurate but the CYP model offers the simplest calculation method. Future work extending the research to other modern methods, relating subnational logistics data with prevalence rates, and tracking that relationship over time is needed.

Below: Public‐Sector Oral Contraceptive Prevalence Rate Estimates

Below:  Public‐Sector Male Condom Prevalence Rate Estimates

Below:  CPR Estimates for Public‐Sector Short‐Acting Methods

Below: Public‐Sector Injectables Prevalence Rate Estimates

Read more at: http://ht.ly/SAUXp

By: Cunningham M1, Bock A2, Brown N3, Sacher S1, Hatch B4, Inglis A1, Aronovich D1.

• 1John Snow, Inc., Arlington, VA, USA.
• 2John Snow, Inc., Arlington, VA, USA
• 3University of Southern California, Los Angeles, CA, USA.
• 4JSI Research & Training Institute, Inc., Arlington, VA, USA. 
  
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Barriers & Facilitators Adolescent Females Living with HIV Face in Accessing Contraceptive Services: A Qualitative Assessment of Providers' Perceptions in Western Kenya

Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.

We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.

According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.

Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

Below:  Ecologic model of barriers and facilitators for contraception use among adolescent females living with HIV

Read more at:  http://ht.ly/SuVkC 

By: Hagey JM1, Akama E2, Ayieko J2, Bukusi EA2,3, Cohen CR2,4, Patel RC5.

• 1Medical Student, School of Medicine, University of California San Francisco, San Francisco, CA, USA
• 2Family AIDS Care & Education Services, Kisumu, Kenya.
• 3Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
• 4Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA;
• 5Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.

Rural Women Are More Likely to Use Long Acting Contraceptive in Tigray Region, Northern Ethiopia: A Comparative Community-Based Cross Sectional Study

Background

In the latest report of Ethiopian Demographic and Health Survey (EDHS) 2011, the maternal mortality ratio (MMR) was estimated at 676/100,000 live births, with total fertility rate at 4.8 and contraceptive prevalence rate at 29 %. Knowledge and utilization of long acting contraceptive in the Tigray region are low. This study aims at comparing and identifying factors related to the utilization of long acting contraceptive in urban versus rural settings of Ethiopia.

Methods

A comparative community-based cross-sectional study, comprised of quantitative and qualitative methods, was conducted among 1035 married women in Wukro (urban area) and Kilteawlaelo district (rural area) in March, 2013. Stratified sampling technique was employed to approach the study participants. Data were analyzed using SPSS version 20. Multiple logistic regression analysis was used to identify the respective effect of independent predictors on utilization of long acting contraceptive.

Results

The proportion of long acting contraceptive use among the respondents was 19.9 % in the town of Wukro and 37.8 % in the district of Kilteawlaelo. Implanon was the most common type of contraceptive used in both districts, urban (75 %) and rural (94 %). The odds of using the long acting contraceptive method were three times higher among married women in the rural areas as compared with the urban women [AOR = 3. 30; 95 %, CI:2.17, 5.04]. No or limited support from male partners was an obstacle to using long acting contraceptive method [AOR = 0. 24, 95 of CI: 0.13, 0.44]. Moreover, married women whose partner did not permit them to use long acting contraceptive [AOR = 0. 47, 95 % of CI: 0.24, 0.92] and women who attended primary education [AOR = 0.24, 95 %, CI: 0.13, 0.44] were significantly associated with long acting contraceptive use.

Conclusion

Overall, the proportion of long acting contraceptive use has found to be low. Rural women were more likely to use long acting contraceptives as compared to urban women. Moreover, educational status and the partner’s permission to use contraception could influence the utilization of long acting contraceptives.

Read more at: http://ht.ly/RPOQS MT https://twitter.com/@BMC_series

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Practical Advice for Emergency IUD Contraception in Young Women

Below:  Fertility risk and window of action of different methods of emergency contraception

Below:  Illustration of the frameless GyneFix IUD anchored in the fundus of the uterus (see arrow). The anchoring knot is inserted in the fundus with a specially designed inserter

Below:  3D illuatration in two women fitted with a frameless IUD showing the disparity in width of the IUD which varies in these women between 7.14 and 31.58 mm

Too few women are aware of the very high efficacy of intrauterine copper devices (IUDs) to prevent pregnancy after unprotected intercourse. Women who frequently engage in unprotected intercourse or seek emergency contraception (EC) are at high risk of unplanned pregnancy and possible abortion. It is therefore important that these women receive precise and accurate information about intrauterine devices as they may benefit from using an IUD for EC as continuing contraception. Copper IUDs should be used as first choice options given their rapid onset of action and their long-term contraceptive action which require minimal thought or intervention on the part of the user. In the United States, there is only one copper IUD presently available which limits treatment options. There are numerous copper IUDs available for use in EC, however, their designs and size are not always optimal for use in nulliparous women or women with smaller or narrower uteruses. Utilization of frameless IUDs which do not require a larger transverse arm for uterine retention may have distinct advantages, particularly in young women, as they will be suitable for use in all women irrespective of uterine size. This paper provides practical information on EC use with emphasis on the use of the frameless IUD.

Read more at:  http://ht.ly/RmnIh HT https://twitter.com/StellenboschUni

Trends in the Contraceptive Method Mix in Low- and Middle-Income Countries: Analysis Using a New “Average Deviation” Measure

Below:  Number of Countries With Method Mix Skew According to the 50% Rule,a by Dominant Method (N = 35 Countries). Abbreviation: IUD, intrauterine device.

a Each method comprises over 50% of total contraceptive use in the country. Missing regions in the bars had no country with over 50% use of that method among contraceptive users; male sterilization, the implant, and the condom had no countries at all with over 50% use of those methods among contraceptive users.

Below:  Method Mix Among Contraceptive Users Based on Latest Surveys for 123 Countries. Abbreviation: CPR, contraceptive prevalence rate; IUD, intrauterine device.

Below:   Method Mix Among Contraceptive Users by Age

Below:   Declining Trends in Method Mix Skew Based on Average Deviation Values in 15 Selected Countries

Below:   Changes in the Method Mix Over Time, 4 Illustrative Countries.  Abbreviation: CPR, contraceptive prevalence rate; IUD, intrauterine device.

The method mix of contraceptive use is severely unbalanced in many countries, with over half of all use provided by just 1 or 2 methods. That tends to limit the range of user options and constrains the total prevalence of use, leading to unplanned pregnancies and births or abortions. Previous analyses of method mix distortions focused on countries where a single method accounted for more than half of all use (the 50% rule). We introduce a new measure that uses the average deviation (AD) of method shares around their own mean and apply that to a secondary analysis of method mix data for 8 contraceptive methods from 666 national surveys in 123 countries. A high AD value indicates a skewed method mix while a low AD value indicates a more uniform pattern across methods; the values can range from 0 to 21.9. Most AD values ranged from 6 to 19, with an interquartile range of 8.6 to 12.2. Using the AD measure, we identified 15 countries where the method mix has evolved from a distorted one to a better balanced one, with AD values declining, on average, by 35% over time. Countries show disparate paths in method gains and losses toward a balanced mix, but 4 patterns are suggested: (1) rise of one method partially offset by changes in other methods, (2) replacement of traditional with modern methods, (3) continued but declining domination by a single method, and (4) declines in dominant methods with increases in other methods toward a balanced mix. Regions differ markedly in their method mix profiles and preferences, raising the question of whether programmatic resources are best devoted to better provision of the well-accepted methods or to deploying neglected or new ones, or to a combination of both approaches.

Read more at:  http://ht.ly/R8PaZ HT @FuturesGroupGbl 

Effects of a One Year Reusable Contraceptive Vaginal Ring on Vaginal Microflora and the Risk of Vaginal Infection: An Open-Label Prospective Evaluation

Below:  Prevalence of selected vaginal microbiota by assessment window.

Visit timing: Cycle 6 (targeted at Day 144 [beginning of Cycle 6], range 2 to 251); Cycle 13 (targeted at Day 358 [12 cycles plus 21 days of use during cycle 13], range 252 to 358).

Over 1- year of use, 3.3% of subjects were clinically diagnosed with bacterial vaginosis, 15.0% with vulvovaginal candidiasis, and 0.8% with trichomoniasis. The detection rate of these three infections did not change significantly from baseline to either Cycle 6 or 13. Nugent scores remained stable. H2O2-positive Lactobacillus dominated vaginal flora with a non-significant prevalence increase from 76.7% at baseline to 82.7% at cycle 6 and 90.2% at cycle 13, and a median concentration of 107 colony forming units (cfu) per gram. Although anaerobic GNRs prevalence increased significantly, the median concentration decreased slightly (104 to 103cfu per gram). There were no significant changes in frequency or concentrations of other pathogens. High levels of agreement between vaginal and ring surface microbiota were observed.

Sustained use of the NES/EE CVR did not increase the risk of vaginal infection and was not disruptive to the vaginal ecosystem.

Read more at:  http://goo.gl/3AlcVm HT @Pop_Council 

Sexual and Contraceptive Behavior among Female University Students In Sweden - Repeated Surveys Over a 25-Year Period

RESULTS:
In 1989, age at first intercourse was 17.6 years vs. 16.7 years in 2014, number of lifetime sexual partners was 4.0 vs. 12.1 in 2014, and number of sexual partners during the previous 12 months was 1.0 vs. 2.8 in 2014. Condom use during first intercourse with the latest partner decreased from 49% to 41% (n = 172 in 2009 vs. n = 148 in 2014: p < 0.001), and experience of anal sex increased from 39% to 46% (n = 136 in 2009 vs. n = 165 in 2014: p = 0.038), and 25% (n = 41 in 2014) always used a condom during anal sex. A total of 70% (n = 251) made use of pornography, and 48% (n = 121) considered their sexual behavior affected by pornography. Eighty-nine percent (n = 291) wanted two to three children and 9% (n = 33) had thought about freezing eggs for the future. The female students' knowledge about increasing age being correlated with decreased fertility varied.

CONCLUSIONS:
Sexual behavior among female university students has gradually changed during the last 25 years and behavior appears more risky today. As this may have consequences on future reproductive health, it is vital to inform women about consistent and correct condom use and about the limitations of the fertile window.

Via:  http://ht.ly/I2NFC HT @uppsalauni

Utilization of contraceptives by persons living with HIV in Eastern Uganda

Below: Contraceptive methods used by persons living with HIV in Eastern Uganda, 2011

Approximately 62% (185/298) of persons living with HIV had used contraceptives within the three months preceding the study. Among the significant predictors, higher proportions of female respondents aged 36–49 years used injectables and male aged 50–54 years used condoms (p = 0.030 and p = 0.034, respectively). Furthermore, higher proportions of respondents with primary, secondary and tertiary education levels were more likely to use condoms (p = 0.004, p = 0.000 and p = 0.005, respectively) compared with those who never went to school. Besides, condoms were being used by Protestants (p = 0.000) compared to Catholics and Muslims. Also, more female respondents (p = 0.000) used condoms with their partners compared with the male counterparts. The main barrier to contraceptive use among non-users was desire for more children.

More efforts are needed to sensitize and provide contraceptives targeting the illiterate clients, youth, men and believers from different religious sects to increase utilization.

Via:  http://ht.ly/MWrmI  MT @WorldVisionUg

Using the Electronic Medical Record to Refer Women Taking Category D or X Medications for Teratogen and Contraceptive Counseling

Read at: http://ht.ly/Q6ysL HT @UCSDHealth 

The primary care physicians who prescribe the potential teratogens should ensure patients know about highly effective contraceptives. However, a study by Eisenberg identified that time constraint is a major barrier to adequate contraceptive counseling. Internists in the Eisenberg study believed that an electronic medical records (EMR) alert would be worthwhile. In addition, two-thirds of the internists agreed that “a referral or telephone consultation service for assistance in providing appropriate contraception for women on potential teratogens would be useful” (Eisenberg et al., 2010).

The EMR provides an opportunity to identify women taking potentially teratogenic medications and offer teratogen and contraceptive counseling. These women specifically may benefit from more counseling about longacting reversible contraception. The purpose of this study was to explore the feasibility and patient satisfaction with an EMR alert, and a referral system for teratogen and contraceptive counseling.