Section Faculty Co-Edit New Book on Contraception

Section chief Melissa Gilliam, MD, MPH, and Section faculty Amy Whitaker, MD, MSc, have co-edited the book Contraception for Adolescent and Young Adult Women. Published by Springer, the book provides evidence-based and up-to-date information for clinicians, as well as resources to pass on to patients. Dr. Gilliam is also Founder and Director of Ci3 (the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health).

From the Springer website:

Now more than ever there is a need for youth to learn about and use contraception consistently and effectively. Contraception for Adolescent and Young Adult Women is a valuable resource for gynecologists and primary care practitioners who are on the front lines when it comes to discussing, recommending, and prescribing contraceptive options to adolescent and young adult women … This book serves as an excellent reference for family physicians, adolescent medicine physicians, gynecologists, and anyone who wishes to learn and implement best contraceptive counseling and provision practices.

Contraception for Adolescent and Young Adult Women will be available in softcover and ebook on May 31. Preorder here.

Research: Immediate vs delayed IUD insertion after a cesarean delivery

Section of Family Planning and Contraceptive Research faculty Dr. Amy Whitaker and Section chief Dr. Melissa Gilliam co-authored an article e-published in December 2013 in the journal Contraception that discusses their randomized controlled trial (RCT) designed to compare levonorgestrel intrauterine device (LNG-IUD) use at one year after delivery between women who received the device at the time of cesarean delivery and those who underwent delayed insertion 4-8 weeks after delivery.

Long-acting reversible contraceptives are excellent methods for postpartum use because they allow adequate time between births and do not require repeat visits to a physician or pharmacy. Postplacental IUD insertion refers to the practice of inserting the IUD within 10 minutes of delivery of the placenta, which can occur through the uterine incision during cesarean delivery. Placement immediately after delivery may help to overcome some of the many barriers to insertion which occur during other time periods, and ensures that women receive the IUD even if they do not return for the postpartum visit.

Our trial showed that after twelve months, 60% of women who had the LNG-IUD inserted immediately after their cesarean delivery were still using the device, while 41% of the women who underwent delayed insertion were still using theirs. This difference, however, is not statistically significant. The women in the postplacental arm experienced significantly higher rates of expulsion (20% vs. 0%).

Future researchers can learn from the challenges of conducting a randomized controlled trial in this population. Due to slow enrollment and high losses to follow-up, the trial was stopped early. The fundamental challenge of conducting this type of research stems from the difficulties in studying an intervention that is most likely to benefit women who do not follow- up for a postpartum visit. However, those women may also be less likely to participate in an RCT. Thus, in our study and in similar trials, more women followed up for insertion in the delayed group than would be expected from the observational literature or clinical experience, making comparisons difficult.

Nonetheless, this trial does provide valuable insights for further study in this area. Immediate insertion of an IUD during a cesarean delivery may improve use of highly effective contraception during the postpartum period. Our results show higher expulsion rates after postplacental insertion compared to delayed insertion, but suggest similar IUD use at 12 months.

“Beyond Safe and Legal” – Lack of Access to Abortion as a Form of Gendered Violence

For Day 13 of the 16 Days of Activism, guest blogger Claire McKinney writes about abortion restrictions as gendered violence.

The past two years have been witness to a prodigious amount of new and pernicious abortion restrictions across the United States. According to the Guttmacher Institute, over 162 restrictions have been enacted over the past two and a half years. Many of these restrictions have taken the form of Targeted Regulation of Abortion Providers, or TRAP laws. These laws operate under the guise of making abortions safer for women by creating more stringent requirements for abortion providers, including upgrading facilities to the level of ambulatory surgical centers, requiring doctors who perform abortions to have hospital privileges, and by prohibiting telemedicine, or the provision of medical services over the internet, of use for many rural residents. The regulations have shuttered dozens of clinics across the United States, eliminating access to abortion for countless women, especially poor women in non-urban settings.

This past summer, the Texas legislature’s attempt to pass several of these restrictions in a single bill reached national attention when Wendy Davis, a representative from Fort Worth, filibustered the bill in the closing days of a special session which had been called for the express purpose of passing incredibly restrictive abortion laws that would close the doors of all but five of Texas’ abortion clinics, forcing some women in rural areas to drive anywhere up to 500 miles to reach a provider. Because the filibuster rules of the Texas legislature require that all speaking must be germane to the bill in question, all 10 hours of Davis’ filibuster worked as justifications to reject the abortion restrictions being proposed.

Wendy Davis

Wendy Davis. (Image: huffingtonpost.com)

The testimony Davis introduced, from members of various medical communities as well as from Texas constituents who were barred from testifying during the public hearings on the bills, displayed the full range of justifications for having full access to abortion providers. From a women’s health perspective, what is troubling about these new restrictions is the co-option of the language of women’s health to justify new restrictions. Opponents of abortion have learned to speak that language of science and women’s health without any concern for the validity of their claims. They claim that these laws are necessary to guarantee the safety of abortion, readily ignoring that abortion is safer than childbirth in terms of complications and risk of mortality. When those who object to new restrictions demand evidence for the need for hospital privileges or clinic standards that are only necessary for complicated surgeries demand to see evidence to support these restrictions, the only response is silence. And yet the bad faith co-option of women’s health continues to ensure that women will be refused the care that is medically necessary and socially desirable.

Concerns for women’s health, for women’s citizenship status, and for unjustified interference in medical practice repeatedly echoed through many parts of the testimony. What is striking that often is not present in thinking through the need for access to abortion is how lack of access contributes to gendered violence and is itself a form of economic violence.

In 2012, Karuna Chibber of the Bixby Center for Global Reproductive Health at the University of California San Francisco found that women who were denied abortions were significantly more likely to experience intimate partner violence than women who had safely procured an abortion. It would be easy to speculate how coerced parenthood places women into vulnerable positions in relation to partners such that they could not leave such partnerships, even if they turn violent. Chibber’s work provides a new way of understanding access to abortion to be an issue not only of a choice of one’s life goals but also a crucial resource for women to avoid situations of intimate partner violence. The right to abortion is also the right to be free from violence.

Roe v. Wade anniversary

Image: salon.com

The economic violence associated with lack of access to abortion is more well established and has been a thread of concern for establishing a right to access to abortion since the movements of the 1960s. Many women who seek abortions do so because they know an additional child will place an unsustainable economic strain on themselves and their family. Women lose opportunities such as the time and resources to attend school and to advance or even hold employment when they cannot afford childcare, ensuring that a cycle of poverty will either begin or persist for these women and their families. Furthermore, women in poverty are those who are mostly likely to lose access to abortion providers by the increased restrictions on abortion. Women with financial needs can travel long distances with relative ease, while these restrictions work to create an economic underclass, whose rights are less than those of the wealthy. The differential health results are themselves a form of violence against women that demands that access to abortion remains part of the activist agenda for women’s empowerment.

Davis’ filibuster delayed the passage of the abortion restrictions in Texas, but only by a couple of weeks. Since their passage, they have been held as constitutional by the Texas Court of Appeals and the Supreme Court has refused to hear the constitutional challenge against such laws. Relying on legislative and judicial forums to protect access to abortion has proven to be less than effective. Instead, protecting and expanding access to abortion requires organizations and individuals to articulate demands not only in the language of health which has become too susceptible to cooption, but also in the language of women’s citizenship and right to be free from violence.

Claire McKinney is a PhD candidate in Political Science at The University of Chicago. Her dissertation develops a concept of medicalized citizenship and the centrality of the language of health in the history of and in present day abortion politics. 

Contraception as Preventive Medicine

Updates in Clinical Care provided by The Ryan Center at the University of Chicago

An Ounce of Prevention 
Given the current climate of change and controversy surrounding contraceptive access, we should once again examine the importance of contraception as a tool for preventive medicine.

Contraception is the key to prevention.
More than half of all US women will experience an unintended pregnancy at some point in their lives, and nearly one-third will have an abortion (1, 2). Unfortunately, the rate of unintended pregnancy in the United States has seen no improvement in recent years, and there was a slight increase from 2001 to 2006, from 50 to 52 per 1,000 reproductive-aged women. Poor and low-income women are at even higher risk of unintended pregnancy: the rate for women at or below the poverty limit is 66 per 1,000 women, compared to 10 per 1,000 women who are at >200% of the poverty limit (1).

Although incorrect and inconsistent use of contraception account for some unintended pregnancies, the majority (52%) occur among the small percentage of women (16%) who are not using any contraception (3).

On a note of positive change, we have seen teen pregnancy in the United States decline significantly since the mid-1990s. Although abstinence has played a role, several analyses have confirmed that contraception is responsible for the majority of the decline in teen pregnancies (4, 5). To review some of the latest research in the area of contraception, see recent studies highlighted on our Reproductive Health & Justice Research blog.

Increasing access to contraception, especially highly effective methods of contraception, is a vital public health issue.

1.  Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, 84(5):478–485.
2.  Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Gynecology, 2011, 117(6):1358–1366.
3.  Gold RB et al., Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
4.  Santelli J, et al. Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use, Am J Public Health, 2007, 97:150–156.
   5.  Teen Births at Record Low Thanks to Improvements in Contraceptive Use, New York: Guttmacher Institute, April 11, 2012, available at: http://www.guttmacher.org/media/inthenews/2012/04/11/index.html.

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The Ryan Center & Contraceptive Care
We are pleased to announce two new exciting programs offered by the Ryan Center.

Carol’s Contraceptive Access Project (CCAP)
Due to a generous donation, we are now able to provide contraception for patients at the Ryan Center, regardless of insurance or ability to pay. We have low-cost options and financial assistance for:

  • Immediate insertion of intrauterine devices and implantable contraception (e.g. Implanon®)
  • Same-day injections of Depo-Provera®
  • Combined hormonal contraceptives (the pill, patch, and ring)

Center for Contraceptive Management
We offer the full range of contraceptive options, including, but not limited to:

  • Intrauterine device (IUD) and Implanon®/Nexplanon® insertion
  • Depo-Provera injections
  • Surgical and “no-cut” Essure® tubal sterilization
  • Prescriptions for: oral contraceptive pills, the contraceptive vaginal ring (NuvaRing®), the contraceptive patch (Ortho Evra®), and emergency contraception

      *We specialize in contraception for medically complicated patients.

Contact us at 773-702-6118 to make an appointment.

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IUD Clinical Trial
Are you or your patient interested in receiving an investigational IUD for long-term birth control? Participants will be compensated up to $900 over the course of 5 years. Click here for more information. UPDATE: This study is now closed.

Disparities in Reproductive Care Among Urban and Rural Women

In Primary Care Physician’s Perceptions of Barriers To Preventive Reproductive Health Care in Rural Communities [PDF], published in Perspectives on Sexual and Reproductive Health, authors Cynthia H. Chuang, et al, sought to investigate the disparities in reproductive health care between urban and rural women.

Findings suggest that expanding access to preventive reproductive health services in rural areas may not be sufficient to improve use of contraceptive services and preconception care.  Raising public awareness of the importance of pregnancy planning and good preconception health is needed.

In 2010, authors conducted semistructured interviews with 19 rural primary care physicians in central Pennsylvania regarding their experiences in two domains of preventive reproductive health—contraceptive care and preconception care. Physicians perceived that they had a greater role in providing contraceptive care than did nonrural physicians and that contraceptives were widely accessible to patients in their communities; however, the scope of contraceptive services that were provided by each individual provider varied greatly.  Physicians also perceived rural community norms of unintended pregnancies, large families, and indifference toward career and educational goals for young women as the biggest barriers to both contraceptive and preconception care, as these issues predicted a lack of interest in family planning.

Study findings point to the importance of encouraging primary care physicians to take a more proactive role in promoting preventive reproductive health care.  This could be accomplished through continuing education programs and skills-building workshops to increase both provider knowledge about client self-efficacy for reproductive health counseling.

HIV Testing in Variety of Clinical Settings

In Supporting the Integration of HIV Testing into Primary Care Settings, published in The American Journal of Public Health, authors Janet J. Myers, et al, examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings.

Authors utilized quantitative process data from 8 regional AETCs from 2008 and 2009, along with qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of being able to diagnosis an infection as early as possible and providing treatment.

When compared with other AETC training, results indicated that HIV testing training was generally longer and utilized a broader variety of strategies to educate more providers per training.  It was also found that educational trainings did provide a platform for providers to master comprehension of their primary care responsibility to address public health concerns through HIV testing.  These AETC efforts illustrate not only how integration of the principles of primary care and public health can be promoted through professional training, but how integral these skills are to comprehensive and well-rounded clinical care practice.

How Educated are Medical Providers on Medical Abortion?

In Knowledge of Medication Abortion Among Adolescent Medical Providers, published in The Journal of Adolescent Health, authors Mandy S. Coles, et al, sought to understand whether providers caring for adolescents have the knowledge to counsel accurately on medication abortion, a suitable option for many teenagers seeking to terminate a pregnancy.

An online survey related to medication abortion was administered to U.S. providers in the Society for Adolescent Health and Medicine.  Authors evaluated the knowledge of medication abortion by reported adolescent medicine fellowship training, and to compare responses to specific knowledge questions by medication abortion counseling.  They also examined the relationship between providers’ self-assessed and actual knowledge.

Authors surveyed 797 total providers.  About 25% of respondents incorrectly believed that medication abortion was not very safe, 40% misidentified that it was < 95% effective, and 32% did not select the correct maximum recommended gestational age (7–9 weeks).  However, providers had difficulty identifying that serious complications of medication abortion are rare, and those who counseled on medication abortion had more accurate information in all knowledge categories, except for expected outcomes.  Medication abortion knowledge did not differ by adolescent medicine fellowship completion. In total, only thirty two percent of those surveyed were identified as having “very good knowledge.”

The authors concluded that knowledge regarding medication abortion safety, effectiveness, expected outcomes, and complications is suboptimal even among adolescent medicine fellowship trained physicians.  In order to ensure pregnant teenagers receive accurate counseling on all options, adolescent medicine providers need better education on medication abortion.

Minors Express Mainly Negative Opinions about Parental Notification Laws

In Abortion-Seeking Minors’ Views on the Illinois Parental Notification Law: A Qualitative Study, published in Perspectives on Sexual and Reproductive Health, author Erin K. Kavanagh and other researchers from the Section of Family Planning and Contraceptive research analyze abortion-seeking minors’ thoughts on mandatory parental involvement laws and the potential impact such a law might have on a minor’s decision and level of access to abortion services. 

In-depth interviews were conducted with 30 minors presenting for an abortion at one of three Chicago-area clinics in 2010. Interviewers described the Illinois parental notification law (which was passed in 1995 but is not in effect because of legal challenges) and a corresponding judicial bypass option to the minors and asked their opinions about them. Interviews were coded and analyzed using content analysis and grounded theory methods.

The participants believed this law would diminish minors’ reproductive autonomy and potentially expose them to unwanted pressure or interference in their abortion decision. At the same time, many felt that voluntarily seeking support from a trusted adult, but not necessarily a parent, could benefit minors. The authors suggest that policymakers might better understand the impact of parental notification laws on minors’ ability to make reproductive health decisions if teens’ voices were heard in the debates concerning these laws and question whether parental notification laws best serve the reproductive well-being of minors.

Obese Women Using Implanon May Have Lower Levels of Active Hormone

In Pharmacokinetics of the etonogestrel contraceptive implant in obese women, new research published in the American Journal of Obstetrics and Gynecology, author Sarah Momar and Section researchers examined serum levels of etonogestrel, the active hormone in Implanon, in a small cohort of obese women (BMI>30).

Researchers enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve.

All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women.

Although  this study finds that obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion, authors comment that more research is needed to determine if this translates to decreased contraceptive effectiveness.

New Study Examines Association between DMPA (Depo shot) and STI Risk among Adolescents

In the article Depot Medroxyprogesterone Acetate Use is Not Associated with Risk of Incident Sexually Transmitted Infections Among Adolescent Women, published in the Journal of Adolescent Health, author Amy Romer and other researchers from the Section of Family Planning and Contraceptive Research investigated whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of sexually transmitted infections (STIs) in a group of healthy adolescents. The authors found no evidence that DMPA use increased risk of STIs, and the only factor significantly associated with increased risk was a greater number of sexual partners (odds ratio, range = 1.91-2.62)

Adolescent women aged 14–17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed.

In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period.

The authors conclude that in this U.S.-based cohort of adolescent women, no evidence was found that DMPA use is associated with increased STI risk. Authors recommend that efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.