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Objective To model the impacts of out-of-pocket cost of an over-the-counter (OTC) progestin-only pill on use and associated unintended pregnancy among U.S. women. Study Design Using data from a 2015 nationally representative survey of 2,539 U.S. women aged 15 to 44 assessing interest in using an OTC progestin-only pill, we used discrete survival analysis and a Markov model to analyze women's likelihood of using of an OTC pill at different price points and by sociodemographic characteristics. We modeled the impact of product price on the potential total number of U.S. users and on unintended pregnancies in 1 year among adult women at risk of unintended pregnancy. Results In a model assuming no out-of-pocket costs, more than 12.5 million adults and 1.75 million teens reported likely use of an OTC progestin-only pill if available. Among adults, this resulted in an estimated 8% decrease in unintended pregnancy in 1 year. Adult and teen women on average were willing to pay $15 and $10, respectively, resulting in 7.1 million adult and 1.3 million teen users and an estimated 5% decrease in unintended pregnancy among adults. Conclusions At low and no out-of-pocket cost, a large population of women in the United States might likely use an OTC progestin-only pill. A low retail price and insurance coverage are necessary to provide equitable access to this method for low-income populations across the United States, fill current gaps in contraceptive access, and potentially decrease unintended pregnancy.

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

Objectives This study describes women's reasons for seeking ulipristal acetate (UPA) for emergency contraception (EC) through the only authorized online retailer for UPA EC in the US. Study design Women aged 14 to 59 years, living in states that allow prescription medications to be shipped from out-of-state, accessed the KwikMed online pharmacy between January 2011 and December 2015. After completing a medical eligibility screener, women answered optional multiple-choice questions. To obtain UPA through KwikMed, individuals must be female, 50 years of age or younger, not currently pregnant or breastfeeding and not attempting to order UPA more than once within 30 days or more than four times per year. Results Over the 5-year period, KwikMed provided 8019 prescriptions for UPA, and the number of women using this service more than tripled over time. Among women who responded to the survey questions ( n =7133; response rate=89%), most sought EC because of a condom failure (45.3%) or because they did not use regular contraception (41.2%). More than half (53.5%) of women reported that they chose UPA because of its effectiveness compared to levonorgestrel EC pills, and 58.9% preferred ordering UPA online because they found it easier than getting it from a doctor, clinic or pharmacy. Conclusions This study documents the importance of providing confidential services for acquiring EC online. Benefits of online access include convenience, less embarrassment, avoiding situations in which a provider might refuse to provide EC because of their own ideological belief and more reliable availability for this time-sensitive contraceptive. Implications Though physical, logistical and societal barriers can restrict women's access to EC, this study demonstrates that providing access to UPA online empowers women to obtain EC when they need it.

To compare use of contraceptive methods at last heterosexual intercourse among 15-44year-old women and men at risk of unintended pregnancy in the United States.We employed data from the National Survey of Family Growth 2006-2013. We considered women and men to be at risk of unintended pregnancy if they had intercourse in the last month, regardless of contraceptive use, and if they or their partner had the ability to get pregnant and was not trying to become pregnant. We categorized multiple method use according to the most effective method reported. To explore the contributions of age and relationship status to differences in reporting between women and men, we conducted sensitivity analyses, limiting age to 25-44years and union status to married and cohabiting.Distributions of methods used at last intercourse differed for women and men. A positive difference reflects higher reporting among women, while a negative difference reflects higher reporting among men. Percentage-point differences were largest for reported use of no method (-7.6) and female sterilization (+7.4), each p.001. These differences persisted even when the sample was restricted by age and relationship status.Estimates of men's contraceptive use may be subject to underreporting of their partners' method use, particularly when their female partner is sterilized. Neither older age nor married and cohabiting relationship status accounted for the observed differences. Further research is needed to explore the factors underlying reporting differences between women and men with respect to female sterilization and use of no method. IMPLICATIONS (50): Characterizing the determinants of contraceptive use among men and the relationship of men's pregnancy intentions, feelings and desires to contraceptive use are important future research goals. To ensure valid results, researchers must be aware of the potential for underreporting of method use among men, particularly with respect to female sterilization.

CONTEXT Contraceptive failure rates measure a woman's probability of becoming pregnant while using a contraceptive. Information about these rates enables couples to make informed contraceptive choices. Failure rates were last estimated for 2002, and social and economic changes that have occurred since then necessitate a reestimation. METHODS To estimate failure rates for the most commonly used reversible methods in the United States, data from the 2006–2010 National Survey of Family Growth were used; some 15,728 contraceptive use intervals, contributed by 6,683 women, were analyzed. Data from the Guttmacher Institute's 2008 Abortion Patient Survey were used to adjust for abortion underreporting. Kaplan-Meier methods were used to estimate the associated single-decrement probability of failure by duration of use. Failure rates were compared with those from 1995 and 2002. RESULTS Long-acting reversible contraceptives (the IUD and the implant) had the lowest failure rates of all methods (1%), while condoms and withdrawal carried the highest probabilities of failure (13% and 20%, respectively). However, the failure rate for the condom had declined significantly since 1995 (from 18%), as had the failure rate for all hormonal methods combined (from 8% to 6%). The failure rate for all reversible methods combined declined from 12% in 2002 to 10% in 2006–2010. CONCLUSIONS These broad-based declines in failure rates reverse a long-term pattern of minimal change. Future research should explore what lies behind these trends, as well as possibilities for further improvements.

IntroductionOral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time.Methods and analysisBridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626–737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio.Ethics and disseminationEthical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations.Trial registration numberISRCTN70616901.

Objective: The aim of the study was to compare the effect of previously used contraceptive methods on women's short- and long-term fecundity. Use of hormonal contraception (HC) was compared with the use of a contraceptive mobile application (app). Methods: This real-life prospective observational study comprised 2874 women who were attempting to become pregnant using the Natural Cycles mobile app to monitor their fertility. The women registered to use the app between August 2014 and June 2016 with the intention of planning a pregnancy and had previously either used the same app to prevent pregnancy or had recently discontinued HC use. We calculated the average time to pregnancy (TTP) for all women who became pregnant during the study and performed Kaplan-Meier life-table analysis to examine the cumulative probabilities of pregnancy for all women in the study. Results: The average TTP was 2.3 (95% confidence interval [CI] 2.1, 2.4) and 3.7 (95% CI 3.4, 3.9) cycles for women who had previously used Natural Cycles and HC, respectively. The time to reach 30% pregnancy probability for women previously on HC was 1.6 (95% CI 1.5, 1.8) times longer than for women previously using Natural Cycles. There was no significant difference in the 13 cycle cumulated pregnancy probability between the two groups. Conclusion: The results show that fertility awareness-based methods of contraception increase short-term pregnancy rates relative to HC, but have no effect on long-term pregnancy rates.

Objectives Mandatory employer-based insurance coverage of contraception in the US has been a controversial component of the Affordable Care Act (ACA). Prior research has examined the cost‐effectiveness of contraception in general; however, no studies have developed a formal decision model in the context of the new ACA provisions. As such, this study aims to estimate the relative cost‐effectiveness of insurance coverage of contraception under employer-sponsored insurance coverage taking into consideration newer regulations allowing for religious exemptions. Study design A decision model was developed from the employer perspective to simulate pregnancy costs and outcomes associated with insurance coverage. Method-specific estimates of contraception failure rates, outcomes and costs were derived from the literature. Uptake by marital status and age was drawn from a nationally representative database. Results Providing no contraception coverage resulted in 33 more unintended pregnancies per 1000 women (95% confidence range: 22.4; 44.0). This subsequently significantly increased the number of unintended births and terminations. Total costs were higher among uninsured women owing to higher costs of pregnancy outcomes. The effect of no insurance was greatest on unmarried women 20–29 years old. Conclusions Denying female employees' full coverage of contraceptives increases total costs from the employer perspective, as well as the total number of terminations. Implications Insurance coverage was found to be significantly associated with women's choice of contraceptive method in a large nationally representative sample. Using a decision model to extrapolate to pregnancy outcomes, we found a large and statistically significant difference in unintended pregnancy and terminations. Denying women contraception coverage may have significant consequences for pregnancy outcomes.

CONTEXT Unintended pregnancy is a universal benchmark for reproductive health, but whether variations reflect differences in measurement and how well measures predict pregnancy outcomes warrant further examination. U.S. and British measures of unintended and unplanned pregnancy offer a useful comparison. METHODS Some 220 women seeking pregnancy testing at the Columbia University Medical Center in 2005 responded to three pregnancy measures: a binary timing-based measure of unintended pregnancy (TMUP); a multi-item measure of timing-based intentions and planning behaviors, the London Measure of Unplanned Pregnancy (LMUP); and a measure combining intentions (from the TMUP) and how women would feel about a positive pregnancy test. Six-month pregnancy status was assessed among 159 respondents. Estimates of unintended and unplanned pregnancy were calculated using the TMUP and the LMUP, and receiver operating characteristic (ROC) curves were generated to assess congruence. RESULTS According to the TMUP, 76% of pregnancies were unintended; by contrast, LMUP scores categorized 39% as unplanned. The ROC curve indicated that expanding the range of scores for classifying pregnancies as unplanned on the LMUP would achieve greater congruence between these measures. At six months, the proportion of pregnancies that had ended in abortion was 42% of those classified as unintended using the TMUP, 60% of those classified as unplanned using the LMUP and 71% of those that women said they had not intended and were very upset about. CONCLUSIONS U.S. and British measures of unintended pregnancy are not directly comparable, and a measure combining intentions and feelings may better predict pregnancy outcomes.

This study examined differences in women's anticipated emotional orientations toward unintended pregnancy by relationship status and race and ethnicity. Data from a prospective survey of 437 women aged 18 to 44 years who intended no more children for at least 2 years were analyzed along with 27 in-depth interviews among a diverse subsample. Cohabiting women and women in romantic relationships not living together were less likely to profess happiness (odds ratio = 0.42, p

To evaluate whether a public program providing long-acting reversible contraceptive (LARC) methods free of charge increases the LARC initiation rate and reduces the unintended pregnancy rate in the general population.Since 2013, all women in Vantaa, Finland, have been entitled to 1 LARC method free of charge. With time-series analysis between 2000 and 2015, we assessed whether this public program was associated with changes in steady-state mean rates of LARC initiation and abortions.The initiation rate of LARCs (1/1000 women) increased 2.2-fold from 1.9 to 4.2 after the intervention (P .001). Concomitantly, the abortion rate (1/1000 women) declined by 16% from 1.1 to 0.9 in the total sample (P .001), by 36% from 1.3 to 0.8 among those aged 15 to 19 years (P .001), and by 14% from 2.0 to 1.7 among those aged 20 to 24 years (P = .01).The LARC program was associated with increased uptake of LARC methods and fewer abortions in the population. Public Health Implications. Entitling the population to LARC methods free of charge is an effective means to reduce the unmet need of contraception and the need for abortion, especially among women younger than 25 years.

Objective Unintended pregnancies (UPs) are associated with a significant cost burden, but the full cost burden in Canada is not known. The objectives of this study were to quantify the direct cost of UPs in Canada, the proportion of cost attributable to UPs and imperfect contraceptive adherence and the potential cost savings with increased uptake of long-acting reversible contraceptives (LARCs). Methods A cost model was constructed to estimate the annual number and direct costs of UP in women aged 18 to 44years. Adherence-associated UP rates were estimated using perfect-and typical-use contraceptive failure rates. Change in annual number of UPs and impact on cost burden were projected in three scenarios of increased LARC usage. One-way sensitivity analyses were conducted to assess the impact of key variables on scenarios of increased LARC use. Results There are more than 180 700 UPs annually in Canada. The associated direct cost was over $320 million. Fifty-eight percent (58%) of UPs occurred in women aged 20 to 29years at an annual cost of $175 million; 82% of this cost ($143 million) was attributable to contraceptive non-adherence. Increased LARC uptake produced cost savings of over $34 million in all three switching scenarios; the largest savings ($35 million) occurred when 10% of oral contraceptive users switched to LARCs. The minimum duration of LARC usage required before cost savings was realized was 12months. Conclusion The cost of UPs in Canada is significant and much of it can be attributed to imperfect contraceptive adherence. Increased LARC uptake may reduce contraceptive non-adherence, thereby reducing rates of UP and generating significant cost savings, particularly in women aged 20 to 29.

Emergency contraception (EC) prevents pregnancy after unprotected sex or contraceptive failure. Use of EC has increased markedly in countries where a product is available over the counter, yet barriers to availability and use remain. Although effective in clinical trials, it has not yet been possible to show a public health benefit of EC in terms of reduction of unintended pregnancy rates. Selective progesterone receptor modulators developed as emergency contraceptives offer better effectiveness than levonorgestrel, but still EC is less effective than use of ongoing regular contraception. Methods which inhibit ovulation whenever they are taken or which act after ovulation to prevent implantation and strategies to increase the uptake of effective ongoing contraception after EC use would prevent more pregnancies.

With the rapid emergence of Zika virus throughout Latin America and its association with microcephaly, requests for access to abortion medications through online telemedicine have increased in countries where access to safe abortion is not universally available.

Objective This study has two aims. The first is to assess the proportion of unplanned pregnancies among women attending antenatal clinics (ANCs) and those undergoing induced abortion (IA). The second is to assess both their previous contraceptive use and contraceptive intention, with particular focus on the use or consideration of any long-acting reversible contraceptives in Hull and East Riding in order to inform service redesign. Study design Consecutive women attending their first ANC appointment and women attending a gynecology clinic undergoing IA were asked to complete a two-page questionnaire that contained a validated pregnancy intendedness questionnaire [the London Measure of Unplanned Pregnancy (LMUP)] and questions to establish contraceptive use and access prior to this index pregnancy. Results The overall response rate was 69%. We received 648 evaluable questionnaires for women undergoing IA. Of these pregnancies, 75.8% [95% confidence interval (CI), 72.3%–79.0%] were unplanned (LMUP, score 0–3). We received 1001 evaluable questionnaires from women booking at ANCs. Of these pregnancies, 5.5% (95% CI, 4.2%–7.0%) were unplanned. Among those with unplanned pregnancies who were not using contraception, 31% reported that they were unable to obtain the method they wanted. Among those using a method immediately prior to the index unplanned pregnancy, 33% stated that it was not the method they wanted; of these, 75% would have preferred sterilization, the implant, injectable or intrauterine contraceptive. Conclusion Unplanned pregnancies in this population are common among women undergoing IA but are uncommon among women attending an ANC. About a third of women not using contraception reported that they were unable to obtain the method they wanted, and about a third of women using contraception stated that they were not using the method they would have preferred. Implications Opportunities to prevent unplanned pregnancies are missed when staff in primary and secondary care looking after women do not knowledgeably inform, discuss and offer contraception in a timely manner, particularly the most effective long-acting reversible contraceptive methods. Services should be deliverable where women are: this includes within pregnancy care services. Seeking patient experience is an essential component of service redesign.

Objective We modeled the potential impact of novel male contraceptive methods on averting unintended pregnancies in the United States, South Africa, and Nigeria. Study design We used an established methodology for calculating the number of couple-years of protection provided by a given contraceptive method mix. We compared a “current scenario” (reflecting current use of existing methods in each country) against “future scenarios,” (reflecting whether a male oral pill or a reversible vas occlusion was introduced) in order to estimate the impact on unintended pregnancies averted. Where possible, we based our assumptions on acceptability data from studies on uptake of novel male contraceptive methods. Results Assuming that only 10% of interested men would take up a novel male method and that users would comprise both switchers (from existing methods) and brand-new users of contraception, the model estimated that introducing the male pill or reversible vas occlusion would decrease unintended pregnancies by 3.5% to 5.2% in the United States, by 3.2% to 5% in South Africa, and by 30.4% to 38% in Nigeria. Alternative model scenarios are presented assuming uptake as high as 15% and as low as 5% in each location. Model results were sensitive to assumptions regarding novel method uptake and proportion of switchers vs. new users. Conclusion Even under conservative assumptions, the introduction of a male pill or temporary vas occlusion could meaningfully contribute to averting unintended pregnancies in a variety of contexts, especially in settings where current use of contraception is low. Implications Novel male contraceptives could play a meaningful role in averting unintended pregnancies in a variety of contexts. The potential impact is especially great in settings where current use of contraception is low and if novel methods can attract new contraceptive users.

Objective To examine reasons for seeking abortion services outside the formal healthcare system in Great Britain, where abortion is legally available. Study design We conducted a mixed-methods study among women resident in England, Scotland, and Wales who requested at-home medication abortion through online telemedicine initiative Women on Web (WoW) between November 22, 2016, and March 22, 2017. We examined the demographics and circumstances of all women requesting early medication abortion and conducted a content analysis of a sample of their anonymized emails to the service to explore their reasons for seeking help. Results Over a 4-month period, 519 women contacted WoW seeking medication abortion. These women were diverse with respect to age, parity, and circumstance. One hundred eighty women reported 209 reasons for seeking abortion outside the formal healthcare setting. Among all reasons, 49% were access barriers, including long waiting times, distance to clinic, work or childcare commitments, lack of eligibility for free NHS services, and prior negative experiences of abortion care; 30% were privacy concerns, including lack of confidentiality of services, perceived or experienced stigma, and preferring the privacy and comfort of using pills at home; and 18% were controlling circumstances, including partner violence and partner/family control. Conclusion Despite the presence of abortion services in Great Britain, a diverse group of women still experiences logistical and personal barriers to accessing care through the formal healthcare system, or prefer the privacy of conducting their abortions in their own homes. Health services commissioning bodies could address existing barriers if supported by policy frameworks. Implications The presence of multiple barriers to accessing abortion care in Great Britain highlights the need for future guidelines to recommend a more woman-centered approach to service provision. Reducing the number of clinic visits and designing services to meet the needs of those living in controlling circumstances are particularly important goals.

BACKGROUND: Caretakers/parents/caregivers/guardians play important roles in improving Sexual and Reproductive Health (SRH) of adolescents. Caretaker-adolescent sexual communication suggested to influence young peoples sexual behaviours. Despite this significance the communication is believed to be low in Unguja due to the increase of risky sexual behaviours among adolescents. This study assessed the pattern of such communication using IMB model as a framework. METHODS: This is a cross-sectional study targeted caretakers of adolescents aged 15-19. One thousand caretakers of adolescents were interviewed using structured questionnaire. Comparison between male and female caretakers on discussing different SRH topics to both sexes of adolescents was made. The mean-score difference of overall communication was examined using Univariate analysis of variance (ANOVA). Bivariate correlation and simple path analysis via regression was conducted to determine the association of IMB variables in relation to communication practice. RESULTS: This study finds 40.7% of caretakers had ever communicated with their adolescents on SRH matters and 9.2% reported to have had communicated in the past 30 days. The weighted topic measure revealed only 26.5% of caretakers communicated with their adolescents. Both caretakers communicated more with their female adolescents. The communication was more common between same sex and between caretakers and their biological adolescents (p < 0.000). Both male and female caretakers mostly discussed sexual abstinence to female adolescents while to male adolescents HIV/STIs was mostly discussed by female caretakers and pregnancy by male caretakers. The least discussed topics to both sexes are safer sex and other contraceptives use. The bivariate correlations suggested that IMB constructs were inter-related and associated with communication practice. CONCLUSION: Caretakers-adolescents communication on SRH in Unguja is low and it is not comprehensive. Caretakers fail to communicate with their adolescents on sensitive issues but do so on less sensitive ones. The pattern of communication found to vary across gender of caretaker and that of adolescent and depends on the nature of relationship between caretaker and adolescent. There is gender differences in selecting SRH topics of discussion. Interventions programmes have to include strategies that enhance caretakers information motivation and skills so as to improve SRH communication between caretakers and adolescent.

BackgroundIncorporating thorough contraception counselling into an abortion consultation is challenging. We compared contraceptive choices and methods received between two counselling models: (1) telephone counselling separate from the abortion consultation and (2) face-to-face counselling integrated into the consultation.MethodsWe obtained de-identified data on demographic characteristics and contraceptive methods that had been chosen and received by women who had an abortion at British Pregnancy Advisory Service between 2011 and 2014 and had a choice of counselling models. We compared the characteristics of women who chose each model of counselling and the contraceptive methods they chose and received using Fisher’s exact test, and used logistic regression to explore associations between counselling model and choice and receipt of Tier 1 contraceptive methods (intrauterine contraception, implant, sterilisation), controlling for covariates.ResultsThe sample included 18 573 women. Women choosing telephone counselling were more likely to be non-White (34% vs 22%, PDiscussionTelephone-based contraception counselling separate from the abortion consultation may serve some women better than integrated counselling, particularly those reporting past difficulty obtaining contraception.

Objectives To assess self reported outcomes and adverse events after self sourced medical abortion through online telemedicine. Design Population based study. Setting Republic of Ireland and Northern Ireland, where abortion is unavailable through the formal healthcare system except in a few restricted circumstances. Population 1000 women who underwent self sourced medical abortion through Women on Web (WoW), an online telemedicine service, between 1 January 2010 and 31 December 2012. Main outcome measures Successful medical abortion: the proportion of women who reported ending their pregnancy without surgical intervention. Rates of adverse events: the proportion who reported treatment for adverse events, including receipt of antibiotics and blood transfusion, and deaths reported by family members, friends, or the authorities. Care seeking for symptoms of potential complications: the frequency with which women reported experiencing symptoms of a potentially serious complication and the proportion who reported seeking medical attention as advised. Results In 2010-12, abortion medications (mifepristone and misoprostol) were sent to 1636 women and follow-up information was obtained for 1158 (71%). Among these, 1023 women confirmed use of the medications, and follow-up information was available for 1000. At the time women requested help from WoW, 781 (78%) were

Objectives The Natural Cycles application is a fertility awareness-based contraceptive method that uses dates of menstruation and basal body temperature to inform couples whether protected intercourse is needed to prevent pregnancies. Our purpose with this study is to investigate the contraceptive efficacy of the mobile application by evaluating the perfect- and typical-use Pearl Index. Study design In this prospective observational study, 22,785 users of the application logged a total of 18,548 woman-years of data into the application. We used these data to calculate typical- and perfect-use Pearl Indexes, as well as 13-cycle pregnancy rates using life-table analysis. Results We found a typical-use Pearl Index of 6.9 pregnancies per 100 woman-years [95% confidence interval (CI): 6.5–7.2], corrected to 6.8 (95% CI: 6.4–7.2) when truncating users after 12 months. We estimated a 13-cycle typical-use failure rate of 8.3% (95% CI: 7.8–8.9). We found that the perfect-use Pearl Index was 1.0 pregnancy per 100 woman-years (95% CI: 0.5–1.5). Finally, we estimated that the rate of pregnancies from cycles where the application erroneously flagged a fertile day as infertile was 0.5 (95% CI: 0.4–0.7) per 100 woman-years. We estimated a discontinuation rate over 12 months of 54%. Conclusions This study shows that the efficacy of a contraceptive mobile application is higher than usually reported for traditional fertility awareness-based methods. The application may contribute to reducing the unmet need for contraception. Implications The measured typical- and perfect-use efficacies of the mobile application Natural Cycles are important parameters for women considering their contraceptive options as well as for the clinicians advising them. The large available data set in this paper allows for future studies on acceptability, for example, by studying the efficacy for different cohorts and geographic regions.

Objectives The objective of this study was to quantify the cost burden of unintended pregnancies (UPs) in Norway, and to estimate the proportion of costs due to imperfect contraceptive adherence. Potential cost savings that could arise from increased uptake of long-acting reversible contraception (LARC) were also investigated. Methods An economic model was constructed to estimate the total number of UPs and associated costs in women aged 15–24 years. Adherence-related UP was estimated using ‘perfect use’ and ‘typical use’ contraceptive failure rates. Potential savings from increased use of LARC were projected by comparing current costs to projected costs following a 5% increase in LARC uptake. Results Total costs from UP in women aged 15–24 years were estimated to be 164 million Norwegian Kroner (NOK), of which 81.7% were projected to be due to imperfect contraceptive adherence. A 5% increase in LARC uptake was estimated to generate cost savings of NOK 7.2 million in this group. Conclusions The cost of UP in Norway is substantial, with a large proportion of this cost arising from imperfect contraceptive adherence. Increased LARC uptake may reduce the UP incidence and generate cost savings for both the health care payer and contraceptive user.

Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile, and availability. The most effective emergency contraceptive is the copper intrauterine device (IUD), followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, whereas ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.

Aim To discover whether a hand-out explaining the benefits of intrauterine contraceptives (IUCs) and implants could increase their uptake in Hull, UK. Methods We developed a simple double-sided A4 hand-out. On one side was a script with pictures of copper and levonorgestrel IUCs next to a 20 pence coin and of an implant beside a hairgrip. On the other side was the three-tiered effectiveness chart published in the textbook Contraceptive Technology . We implemented the project in family planning (FP), abortion and antenatal clinics and general practitioner (GP) surgeries. The plan was that the receptionist would give the hand-out to every woman and ask her to read it before seeing a clinician. We evaluated the hand-out in FP clinics and GP practices because routine electronic monitoring reports were available only for these locations. Results There was no impact in GP practices. There was no overall impact in FP clinics, with the exception of the service hub, in which there was an increase in the proportion of women receiving IUCs or implants of 15.0% between the periods October 2011–April 2012 and May 2012–November 2012 ( p =0.0002). This clinic is open 6 days per week and has permanent sexual health staff on the reception desk. The proportion of women receiving IUCs or implants returned to baseline in December 2012–November 2013, when a change in clinic procedure to reduce waiting times caused staff to stop dispensing hand-outs. Conclusions This was not a formal study, so there was no research coordinator to monitor the project. We think that there was no impact among GPs because the project was not implemented by them. The project was poorly implemented at the four satellite FP clinics. Only the service hub implemented the project, where it had a clear impact. We conclude that when implemented as intended, this simple, very low-cost long-acting reversible contraception intervention was highly effective and also extremely cost effective.

ObjectiveTo examine the impact of subject characteristics on efficacy as measured by the Pearl Index (PI) in clinical trials and to make study populations similar by matching.MethodsOur analysis used US data from four large Phase III studies. We compared results from one fertility control patch study with pooled data from three studies with virtually identical design on oral hormonal contraceptives. First, we identified three characteristics that had the most impact on the PI. Second, we used these three variables and matched subjects from the patch study with those from the oral contraceptive (OC) studies. Finally, we calculated the PIs for matched and unmatched subjects from both the patch study and the OC studies.ResultsA total of 3706 subjects were included in our analysis. The variables ‘Hispanic ethnicity’, ‘previous pregnancy’ and ‘previous use of hormonal contraceptives’ had the most impact on the PI. The PIs for the matched patch cohort and the matched OC cohort were 2.97 and 2.48, respectively. Those for the unmatched patch cohort and the unmatched OC cohort were 10.17 and 0.90, respectively.ConclusionSubject characteristics strongly influence the PI in clinical studies of hormonal contraceptives. In particular, Hispanic ethnicity, previous pregnancies and no previous use of hormonal contraceptives result in a higher PI.ImplicationsPIs from different clinical trials cannot be meaningfully compared unless subject characteristics that have most impact on the PI are similar or are made to be similar statistically as we did here by matching.

Objective To evaluate pregnancy complication rates and related charges in users of 84/7, 21/7 and 24/4 combined oral contraceptives (COCs). Study design Data were obtained from the i3 InVision Data Mart™ retrospective claims database. Subjects were aged 15–40 years, first prescribed a COC between 1/1/2006 and 4/1/2011 and continuously insured for ≥ 1 year. 84/7 users were matched 1:1 to 21/7 and 24/4 users. Results Pregnancy-related complication rates and associated charges were significantly lower with 84/7 vs. 21/7 and 24/4 regimens. Conclusion Preliminary data suggest 84/7 regimens may be associated with fewer pregnancy complications and lower related charges.

We investigate trends in contraceptive behaviors in France and how they may have contributed to fluctuations in unintended pregnancy rates over time and across subgroups of the population between 2000 and 2010.Data are drawn from three national surveys in France, comprising 4714 women ages 15 to 49 in 2000, 8613 in 2005 and 5260 in 2010. We used multinomial and simple logistic regression models to explore trends in contraceptive behaviors over time. We estimated trends in unintended pregnancy rates in relation to population shifts in contraceptive behaviors between 2000 and 2010.A third of women were not using contraception at the time of the surveys. However, only 2.4% in 2000, 3.2% in 2005 and 2.4% in 2010 had an unmet need for contraception (p=.002). Among contraceptive users, user-dependent hormonal methods decreased from 59% in 2000 to 52% in 2010 (p.0001), while long-acting reversible methods increased from 22% to 24% (p=.04). Changes in contraceptive behaviors resulted in fluctuations in unintended pregnancy rates estimated to have risen from 3.16% to 3.49% between 2000 and 2005, and to have decreased to 3.26% in 2010. Small changes in unmet need for contraception exerted the largest effects.This study indicates that changes in contraceptive behaviors over the past decade in France have potentially resulted in significant fluctuations in unintended pregnancy rates. Our results also demonstrate that a simple algorithm combining contraceptive behaviors and typical-use failure rates may be an acceptable proxy for monitoring trends in unintended pregnancies.This study offers a framework towards assessing trends in unintended pregnancies, when data on abortions and unintended births are not available. In the context of high contraceptive coverage, gaps of use undermine efforts to improve contraceptive effectiveness, as small fluctuations in unmet need contribute significantly to trends in unintended pregnancy rates.

Background From 2001 to March 2006 Planned Parenthood health centers throughout the United States provided medical abortion by a regimen of oral mifepristone followed 24–48 h later by vaginal misoprostol. In response to concerns about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration to buccal and required either routine antibiotic coverage or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine antibiotic coverage for all medical abortions. Methods We performed a retrospective analysis of Planned Parenthood cases assessing the rates of mortality caused by infection following medical abortion during a time period when misoprostol was administered vaginally (2001 through March 2006), as compared with the rate from April 2006 to the end of 2012 after a change to buccal administration of misoprostol and after initiation of new infection-reduction strategies. Results The mortality rate dropped significantly in the 81-month period after the joint change to (1) buccal misoprostol replacing vaginal misoprostol and (2) either sexually transmitted infection (STI) screening or routine preventative antibiotic coverage (15 month period) or universal routine preventative antibiotic coverage as part of the medical abortion (66-month period), from 1.37/100,000 to 0.00/100,000, P= .013 (difference=1.37/100,000, 95% CI 0.47–4.03 per 100,000). Conclusion The infection-caused mortality rate following medical abortion declined by 100% following a change from vaginal to buccal administration of misoprostol combined with screen-and-treat or, far more commonly, routine antibiotic coverage. Significance Deaths from infection following medical abortion declined to zero after a change in the regimen.

Introduction The worldwide expansion of the Internet offers an important modality of disseminating medically accurate information about medication abortion. We chronicle the story of www.medicationabortion.com , an English-, Spanish-, Arabic- and French-language website dedicated to three early abortion regimens. Methods We evaluated the website use patterns from 2005 through 2009. We also conducted a content and thematic analysis of 1910 emails submitted during this period. Results The website experienced steady growth in use. In 2009, it received 35,000 visits each month from more than 20,000 unique visitors and was accessed by users in 208 countries and territories. More than half of all users accessed the website from a country in which abortion is legally restricted. Users from more than 40 countries sent emails with individual questions. Women often wrote in extraordinary detail about the circumstances of their pregnancies and attempts to obtain an abortion. These emails also reflect considerable demand for information about the use of misoprostol for self-induction. Conclusion The use patterns of www.medicationabortion.com indicate that there is significant demand for online information about abortion, and the findings suggest future priorities for research, collaboration and educational outreach.

Objectives Unintended pregnancies (UPs) in adolescents significantlyimpact young women, their families/children, and society, however the full cost burden is currently not known. The objectives were to quantify the direct cost of UPs in Canadian adolescents, the proportion of UPs and cost attributable to imperfect contraceptive adherence, and estimate the potential cost savings with increased uptake of long-acting reversible contraceptives (LARCs) among adolescents. Methods A cost model was constructed to estimate the annual number and direct costs of UPs in adolescent women aged 15-19years.Adherence-associated UP rates were estimated using perfect- and typical-use failure rates. Change in annual number of UPs and impact on cost burden were projected in three scenarios of increased LARC use. One-way sensitivity analyses were conducted to assess impact of key variables on scenarios of increased LARC use. Results Among Canadian adolescents, there are more than 39,000 UPs annually. The associated direct cost was over $60 million; 61% of this cost ($37 million) was attributable to contraceptive non-adherence. Increased LARC uptake produced cost savings of over $3million in all three switching scenarios; the largest savings ($3.6 million) occurred when 10% of females using either a SARC or no method switched to LARCs. Minimum duration of LARC usage required before realizing cost savings was 6.8 months. Conclusions The cost of UPs in Canadian adolescents is significant and largely attributed to imperfect contraceptive adherence. Increased LARC uptake in adolescents may improve ongoing contraceptive adherence, thereby reducing rates of adolescent UP and generating significant cost savings in this age group.

ObjectiveTo investigate the association between contraceptive effectiveness of Natural Cycles and users’ previous choice of contraceptive, and to evaluate the impact of shifting from other methods to Natural Cycles on the risk of unintended pregnancy.SettingNatural Cycles mobile application.Participants16 331 Natural Cycles users in Sweden for the prevention of pregnancy.Outcome measuresRisk of unintended pregnancy.Study designReal world evidence was collected from Natural Cycles users regarding contraceptive use prior to using Natural Cycles and sexual activity while using Natural Cycles. We calculated the typical use 1-year Pearl Index (PI) and 13-cycle failure rate of Natural Cycles for each cohort. The PI was compared with the population PI of their stated previous methods.ResultsFor women who had used condoms before, the PI of Natural Cycles was the lowest at 3.5±0.5. For women who had used the pill before, the PI of Natural Cycles was the highest at 8.1±0.6. The frequency of unprotected sex on fertile days partially explained some of the observed variation in PI between cohorts. 89% of users switched to Natural Cycles from methods with higher or similar reported PIs.ConclusionThe effectiveness of Natural Cycles is influenced by previous contraceptive choice and this should be considered when evaluating the suitability of the method for the individual. We estimate that Natural Cycles usage can reduce the overall likelihood of having an unintended pregnancy by shifting usage from less effective methods.

We prospectively examined the influence of young women's depression and stress symptoms on their weekly consistency of contraceptive method use.Women ages 18-20 years (n = 689) participating in a longitudinal cohort study completed weekly journals assessing reproductive, relationship and health characteristics. We used data through 12 months of follow-up (n = 8877 journals) to examine relationships between baseline depression (CES-D) and stress (PSS-10) symptoms and consistency of contraceptive methods use with sexual activity each week. We analyzed data with random effects multivarible logistic regression.Consistent contraceptive use (72% of weeks) was 10-15 percentage points lower among women with moderate/severe baseline depression and stress symptoms than those without symptoms (p.001). Controlling for covariates, women with depression and stress symptoms had 47% and 69% reduced odds of contraceptive consistency each week than those without symptoms, respectively (OR 0.53, CI 0.31-0.91 and OR 0.31, CI 0.18-0.52). Stress predicted inconsistent use of oral contraceptives (OR 0.27, CI 0.12-0.58), condoms (OR 0.40, CI 0.23-0.69) and withdrawal (OR 0.12, CI 0.03-0.50).Women with depression and stress symptoms appear to be at increased risk for user-related contraceptive failures, especially for the most commonly used methods.Our study has shown that young women with elevated depression and stress symptoms appear to be at risk for inconsistent contraceptive use patterns, especially for the most common methods that require greater user effort and diligence. Based upon these findings, clinicians should consider women's psychological and emotional status when helping patients with contraceptive decision-making and management. User-dependent contraceptive method efficacy is important to address in education and counseling sessions, and women with stress or depression may be ideal candidates for long-acting reversible methods, which offer highly effective options with less user-related burden. Ongoing research will provide a greater understanding of how young women's dynamic mental health symptoms impact family planning behaviors and outcomes over time.

Background This study evaluated the total costs of unintended pregnancy (UP) in the United States (US) from a third-party health care payer perspective and explored the potential role for long-acting reversible contraception (LARC) in reducing UP and resulting health care expenditure. Study Design An economic model was constructed to estimate direct costs of UP as well as the proportion of UP costs that could be attributed to imperfect contraceptive adherence. The model considered all women requiring reversible contraception in the US: the pattern of contraceptive use and the rates of UP were derived from published sources. The costs of UP in the United States and the proportion of total cost that might be avoided by improved adherence through increased use of LARC were estimated. Results Annual medical costs of UP in the United States were estimated to be $4.6 billion, and 53% of these were attributed to imperfect contraceptive adherence. If 10% of women aged 20–29 years switched from oral contraception to LARC, total costs would be reduced by $288 million per year. Conclusions Imperfect contraceptive adherence leads to substantial UP and high, avoidable costs. Improved uptake of LARC may generate health care cost savings by reducing contraceptive non-adherence.

vagina cannot be directly confirmed. Diaphragms and caps are designed to obstruct the cervical canal, but demonstration of the security of this obstruction is lacking. And pregnancy is certainly not rare in users of these methods. Therefore, verification of the contraceptive efficacy of these methods requires direct evidence of a reduction in pregnancy risk. In this paper, we describe and evaluate the evidence that exists regarding vaginal spermicides, and we consider the implications of these data for both the presentation of existing products to the public and the development and regulatory approval of new products.

We used this only as an example to show the variations in the total blood volume but not as the basis of what to be expected as the norm. We would like to reference Table 2 in our study, 1 where the total blood volume and 5, 10, and 15% volumes were calculated for different body surface area quintiles. That was the main purpose of this arti- cle. This was also the reason for not including blood transfusions. Our future direction would be to validate this with quantified blood loss and assess clinical changes at different percentages of total blood volume lost and blood transfusions. We did group all our pregnant patients together; how- ever, this should not have changed our outcome, because the measurements were all taken on admission and would have been reflective of the patient’s cur- rent gestational period. We agree with the authors regarding the existence of multiple confounding factors such as multiple gestation, which was the reason we did not include that group in our study. Financial Disclosure: The authors did not report any potential conflicts of interest. Radha Burtch, MD Chantal Scott, MD Departments of Obstetrics and Gynecology, John H. Stroger Jr. Hospital of Cook County and Northwestern University, Feinberg School of Medicine, Chicago, Illinois Lindsay Zimmerman, MPH Department of Obstetrics and Gynecology, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois Ashlesha Patel, MD Departments of Obstetrics and Gynecology, John H. Stroger Jr. Hospital of Cook County and Northwestern University, Feinberg School of Medicine, Chicago, Illinois REFERENCES 1. Burtch R, Scott C, Zimmerman L, Patel A. Blood loss as a function of body sur- face area: redefining parameters of obstet- ric blood loss. Obstet Gynecol 2016;128: 2. Feldschuh J, Enson Y. Prediction of the normal blood volume. Relation of blood Letters volume to body habitus. Circulation 1977;56(4 pt 1):605–12. 3. Baker RJ, Kozoll DD, Meyer KA. The use of surface area as a basis for establish- ing normal blood volume. Surg Gynecol Obstet 1957;104:183-9. 4. Nadler SB, Hidalgo JU, Bloch T. Predic- tion of blood volume in normal human adults. Surgery 1962;51:224–32. 5. Milosevic N, Popovic J, Grujic Z, Rapaic M. One-compartmental biometric blood loss calculation after cesarean section. Eur J Drug Metab Pharmacokinet 2011; 6. Wang Y, Moss J, Thisted R. Predictors of body surface area. J Clin Anesth 1992;4: Interpregnancy Interval After Termination of Pregnancy and the Risks of Adverse Outcomes in Subsequent Birth We thank the authors for their report 1 but are concerned that the analysis was too simplified to truly understand the association of interpregnancy interval and subsequent preterm birth. When evaluating the demographic categories, gestational age was grouped as 12 weeks or less compared with more than 12 weeks. This type of categoriza- tion fails to allow an analysis reflecting when abortions are performed and to use this analysis, if correct, to properly counsel patients. Approximately 53% of all abortions in the United States are performed at 7 weeks of gestation or less. 2 Grouping together women who undergo abortion at 10 weeks with those who undergo abortion at 6 weeks is potentially inappropriate statistically. For this analysis to have the ability to guide clinical practice, gestational age categories cannot simply be conve- niently packaged into bivariate groups. The authors need to present analyses with clinically applicable ges- tational age ranges such as 7 weeks or less, 8–10 weeks, and 11–14 weeks (all first trimester) as well as 15–20 and 21–24 weeks or more in the second trimester. Because the primary out- come was preterm birth, gestational age at the time of abortion (as well as type of abortion, especially in the sec- ond trimester) is potentially the most important confounder and needs the utmost attention during analysis. If the authors do not have sufficient numbers in each group to perform such analyses, this very significant limitation needs to be recognized before the information is used clini- cally for patient counseling, espe- cially given the overly weak adjusted association. Financial Disclosure: Dr. Creinin is a consul- tant for Danco Laboratories. The other author did not report any potential conflicts of interest. Mitchell D. Creinin, MD Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California James Trussell, PhD Office of Population Research, Princeton University, Princeton, New Jersey REFERENCES 1. Mannisto J, Bloigu A, Gissler M, Heikinheimo O, Niinimaki M. Inter- pregnancy interval after termination of pregnancy and the risks of adverse outcomes in subsequent birth. Obstet Gynecol 2017;129:347–54. 2. Jatlaoui TC, Ewing A, Mandel MG, Sim- mons KB, Suchdev DB, Jamieson DJ, et al. Abortion surveillance—United States, 2013. MMWR Surveill Summ 2016;65:1–44. In Reply: We thank Mitchell D. Creinin and James Trussell for their interest in our work. 1 In the analyses presented in our article, the gestational age at termination of pregnancy and the method of termination (medical com- pared with surgical) were used to adjust for the confounders and to ensure the comparability of the dif- ferent termination-to-subsequent conception interval groups. Thus, these variables were included in the models, but the results were not pre- sented according to them. After Drs. Creinin and Trussell raised a concern about the categorization of gesta- tional age at termination of preg- nancy, we re-analyzed our data by using a new division of gestational age at termination: 7 weeks or less, 8–12 weeks, 13–20 weeks, and 21– 24 weeks. The first two groups repre- sent the first-trimester terminations, and the latter two groups represent the second-trimester terminations. The new categorization of gestational OBSTETRICS & GYNECOLOGY Copyright a by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Objective To analyze rates of significant adverse events and outcomes in women having a medical abortion at Planned Parenthood health centers in 2009 and 2010 and to identify changes in the rates of adverse events and outcomes between the 2 years. Methods In this database review we analyzed data from Planned Parenthood affiliates that provided medical abortion in 2009 and 2010 almost exclusively using an evidence-based buccal misoprostol regimen. We evaluated the incidence of six clinically significant adverse events (hospital admission, blood transfusion, emergency department treatment, intravenous antibiotics administration, infection, and death) and two significant outcomes (ongoing pregnancy and ectopic pregnancy diagnosed after medical abortion treatment was initiated). We calculated an overall rate as well as rates for each event and identified changes between the 2 years. Results Among 233,805 medical abortions provided in 2009 and 2010, significant adverse events or outcomes were reported in 1,530 cases (0.65%). There was no statistically significant difference in overall rates between years. The most common significant outcome was ongoing intrauterine pregnancy (0.50%); significant adverse events occurred in 0.16% of cases. One patient death occurred as a result of an undiagnosed ectopic pregnancy. Only rates for emergency department treatment and blood transfusion differed by year and were slightly higher in 2010. Conclusion Review of this large data set reinforces the safety of the evidence-based medical abortion regimen. Level of evidence III.

Objective To examine the characteristics and experiences of women in Ireland and Northern Ireland seeking at-home medical termination of pregnancy (TOP) using online telemedicine. Design Population-based study. Setting Ireland and Northern Ireland. Population Between 1 January 2010 and 31 December 2015, 5650 women requested at-home medical TOP through online telemedicine initiative Women on Web. Methods We examined the demographics and circumstances of women requesting medical TOP and examined the experiences of the 1023 women who completed TOP between January 2010 and December 2012. We conducted a content analysis of women's evaluations and used logistic regression to examine factors associated with lack of emotional support during and after TOP Main outcome measures Satisfaction with TOP; feelings before and after TOP; emotional support during TOP. Results Women requesting TOP were diverse with respect to age, pregnancy circumstances and reasons for seeking TOP. Among those completing TOP, 97% felt they made the right choice and 98% would recommend it to others in a similar situation. Women commonly reported serious mental stress caused by their pregnancies and their inability to afford travel abroad to access TOP. The feelings women most commonly reported after completing TOP were ‘relieved’ (70%) and ‘satisfied’ (36%). Women with financial hardship had twice the risk of lacking emotional support (odds ratio = 2.0, P < 0.001). Conclusions The vast majority of women who completed at-home medical TOP through Women on Web had a positive experience. These demonstrated benefits to health and wellbeing contribute new evidence to the debate surrounding abortion laws in Ireland and Northern Ireland. Tweetable abstract Irish and Northern Irish women completing at-home medical TOP report benefits for health, wellbeing and autonomy.

Objective To examine contraceptive choices among women seeking termination of pregnancy (TOP) and the provision of the chosen methods. Design Population-based study. Setting British Pregnancy Advisory Service (BPAS) clinics in England and Wales. Population Between 1 January 2011 and 31 December 2014, 211 215 women had a TOP at BPAS, were offered contraceptive counselling, and were eligible to obtain contraception at no cost. Methods We examined electronic records from BPAS and assessed the proportions of women who accepted contraceptive counselling and chose a contraceptive method, as well as the distributions of methods chosen, analysed by provider and by TOP type. We calculated the proportions receiving their chosen method and the methods chosen by women using no method at conception. We used logistic regression to examine the factors associated with choice of an intrauterine contraceptive (IUC) or implant. Main outcome measures Post-TOP contraceptive method choice. Receipt of chosen method post-TOP. Results Eighty-five per cent of women accepted contraceptive counselling and 51% chose to obtain a method from BPAS rather than from a GP or contraception and sexual health clinic post-TOP. [correction added on 25 November 2016 after first online publication: 51% has been inserted in the preceding sentence.] Among those who wanted to receive contraception from BPAS, 51% chose an IUC or implant and 19% chose oral contraceptives. Ninety-one per cent of women who obtained contraception from BPAS received their chosen method. Women were more likely to choose an IUC or implant if they obtained contraception from BPAS, had a surgical TOP, were parous, young, white, or had one or more previous TOPs. Conclusions The standards set for patient-centred TOP care should emphasise the need for a full range of contraceptive options to be offered and provided post-TOP. Tweetable abstract Uptake targets for long-acting reversible methods do not reflect women's post-TOP contraceptive preferences.

Background Progestin-only contraceptives (POCs) are appropriate for many women who cannot or should not take estrogen. POCs include injectables, intrauterine contraception, implants, and oral contraceptives. Many POCs are long-acting, cost-effective methods of preventing pregnancy. However, concern about weight gain can deter the initiation of contraceptives and cause early discontinuation among users. Objectives The primary objective was to evaluate the association between progestin-only contraceptive use and changes in body weight. Search methods Until 4 August 2016, we searched MEDLINE, CENTRAL, POPLINE, LILACS, ClinicalTrials.gov, and ICTRP. For the initial review, we contacted investigators to identify other trials. Selection criteria We considered comparative studies that examined a POC versus another contraceptive method or no contraceptive. The primary outcome was mean change in body weight or mean change in body composition. We also considered the dichotomous outcome of loss or gain of a specified amount of weight. Data collection and analysis Two authors extracted the data. Non-randomized studies (NRS) need to control for confounding factors. We used adjusted measures for the primary effects in NRS or the results of matched analysis from paired samples. If the report did not provide adjusted measures for the primary analysis, we used unadjusted outcomes. For RCTs and NRS without adjusted measures, we computed the mean difference (MD) with 95% confidence interval (CI) for continuous variables. For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% CI. Main results We found 22 eligible studies that included a total of 11,450 women. With 6 NRS added to this update, the review includes 17 NRS and 5 RCTs. By contraceptive method, the review has 16 studies of depot medroxyprogesterone acetate (DMPA), 4 of levonorgestrel-releasing intrauterine contraception (LNG-IUC), 5 for implants, and 2 for progestin-only pills. Comparison groups did not differ significantly for weight change or other body composition measure in 15 studies. Five studies with moderate or low quality evidence showed differences between study arms. Two studies of a six-rod implant also indicated some differences, but the evidence was low quality. Three studies showed differences for DMPA users compared with women not using a hormonal method. In a retrospective study, weight gain (kg) was greater for DMPA versus copper (Cu) IUC in years one (MD 2.28, 95% CI 1.79 to 2.77), two (MD 2.71, 95% CI 2.12 to 3.30), and three (MD 3.17, 95% CI 2.51 to 3.83). A prospective study showed adolescents using DMPA had a greater increase in body fat (%) compared with a group not using a hormonal method (MD 11.00, 95% CI 2.64 to 19.36). The DMPA group also had a greater decrease in lean body mass (%) (MD -4.00, 95% CI -6.93 to -1.07). A more recent retrospective study reported greater mean increases with use of DMPA versus Cu IUC for weight (kg) at years 1 (1.3 vs 0.2), 4 (3.5 vs 1.9), and 10 (6.6 vs 4.9). Two studies reported a greater mean increase in body fat mass (%) for POC users versus women not using a hormonal method. The method was LNG-IUC in two studies (reported means 2.5 versus -1.3; P = 0.029); (MD 1.60, 95% CI 0.45 to 2.75). One also studied a desogestrel-containing pill (MD 3.30, 95% CI 2.08 to 4.52). Both studies showed a greater decrease in lean body mass among POC users. Authors' conclusions We considered the overall quality of evidence to be low; more than half of the studies had low quality evidence. The main reasons for downgrading were lack of randomizations (NRS) and high loss to follow-up or early discontinuation. These 22 studies showed limited evidence of change in weight or body composition with use of POCs. Mean weight gain at 6 or 12 months was less than 2 kg (4.4 lb) for most studies. Those with multiyear data showed mean weight change was approximately twice as much at two to four years than at one year, but generally the study groups did not differ significantly. Appropriate counseling about typical weight gain may help reduce discontinuation of contraceptives due to perceptions of weight gain.

INTRODUCTION: Although antiretroviral therapy (ART) reduces individual tuberculosis (TB) risk by two-thirds the population-level impact remains uncertain. Cape Town reports high TB notification rates associated with endemic HIV. We examined population trends in TB notification rates during a 10-year period of expanding ART. METHODS: Annual Cape Town TB notifications were used as numerators and mid-year Cape Town populations as denominators. HIV-stratified population was calculated using overall HIV prevalence estimates from the Actuarial Society of South Africa AIDS and Demographic model. ART provision numbers from Western Cape government reports were used to calculate overall ART coverage. We calculated rates per 100000 population over time overall and stratified by HIV status. Rates per 100000 total population were also calculated by ART use at treatment initiation. Absolute numbers of notifications were compared by age and sub-district. Changes over time were described related to ART provision in the city as a whole (ART coverage) and by sub-district (numbers on ART). RESULTS: From 2003 to 2013 Cape Towns population grew from 3.1 to 3.7 million inhabitants and estimated HIV prevalence increased from 3.6 to 5.2%. ART coverage increased from 0 to 63% in 2013. TB notification rates declined by 16% (95% confidence interval (CI) 14-17%) from a 2008 peak (851/100000) to a 2013 nadir (713/100000). Decreases were higher among the HIV-positive (21% (95% CI 19-23%)) than the HIV-negative (9% (95% CI 7-11%)) population. The number of HIV-positive TB notifications decreased mainly among 0- to 4- and 20- to 34-year-olds. Total population rates on ART at TB treatment initiation increased over time but levelled off in 2013. Overall median CD4 counts increased from 146 cells/microl (interquartile range (IQR) 66 264) to 178 cells/microl (IQR 75 330; p