This Committee Statement provides evidence-informed, person-centered guidance to optimize the identification, evaluation, management, and removal of deep and nonpalpable contraceptive implants. This guidance applies to clinicians removing the implants themselves or facilitating timely referral for removal. Appropriate referral includes a Center of Experience in the U.S. or similar tertiary experts outside the U.S. We discuss preventing the need for deep and nonpalpable implant removal by following proper subdermal placement techniques. When approaching removal of deep and nonpalpable implants, we recommend following a standardized protocol that addresses localization, positioning, marking the contraceptive implant location and measuring the depth, the necessary instruments, and removal techniques. When removing multi-rod contraceptive implants, we recommend that clinicians confirm both the number and location of the rods and adjust their removal approach accordingly. Finally, we discuss using the most appropriate diagnostic and procedural codes for deep or nonpalpable contraceptive implant removal services.
OBJECTIVE:Long-acting reversible contraceptive (LARC) methods are often grouped in contraception studies, although they differ in ways that may influence patient preferences and access. This study examines trends in IUD and implant use in Mexico, and identifies factors associated with implant use compared with IUD use. STUDY DESIGN:We used the 2009, 2014, 2018, and 2023 waves of the Mexican National Survey of Demographic Dynamics (ENADID). The sample included women aged 15-45 currently using LARC. We described the characteristics of LARC users in 2023 and estimated percentage point changes in prevalence for implant and IUD use as a proportion of all modern method use across survey periods. Multivariable logistic regression identified factors associated with implant use versus IUD (reference) among LARC users in 2023. RESULTS:The sample included 10,411 women (weighted N=4,012,772). Between 2009 and 2023, implant use increased while IUD use declined, with the largest shifts between 2018 and 2023. During this period, implant use increased by 3.48 percentage points while IUD use declined by 3 percentage points, indicating a method mix shift of implants for IUDs rather than an overall expansion of LARC use. Younger age was associated with higher odds of implant use, with odds declining with increasing age. Women with one or two children had lower odds of implant use compared with nulliparous women. CONCLUSION:Use of LARC methods in Mexico has shifted towards increased implant use and decreased IUD use, suggesting a shift between methods rather than expansion of overall LARC use. IMPLICATIONS:Increasing implant use alongside declining IUD use may reflect improved access but could also indicate constrained contraceptive choice. Ensuring availability of both methods is essential to support informed, patient-centered, and contraceptive decision-making.
OBJECTIVES:Abortion bans have been associated with decreased reproductive health care access. We examined the association between Idaho's abortion ban and postpartum contraceptive use among Medicaid beneficiaries. STUDY DESIGN:This retrospective cohort study used Medicaid claims data from Idaho and Oregon with a difference-in-differences approach. We included Medicaid-enrolled women aged 15-44 who delivered a live birth between July 1, 2021, and September 30, 2023. Idaho's abortion ban, implemented August 25, 2022, criminalized abortion from fertilization with narrow exceptions; Oregon served as the comparison state. The primary outcome was receipt of most effective contraception (implant, intrauterine device, or tubal ligation) within 90 days of delivery. Secondary outcomes included most effective contraception within 3 days of delivery, most or moderately effective contraception within 3 days and within 90 days of delivery, and postpartum visit attendance within 60 days. RESULTS:Analyzing 56,508 live births to 53,966 Medicaid beneficiaries in Idaho and Oregon, we found that Idaho's abortion ban was associated with a 1.52-percentage point decrease in receipt of the most effective contraception within 90 days postpartum (95% CI, -2.94 to -0.10; p=0.04) and a 1.41-percentage point decrease within 3 days (95% CI, -2.29 to -0.52; p=0.002). Postpartum visit attendance declined by 3.13 percentage points (95% CI, -5.59 to -0.67; p=0.01). Immediate postpartum declines coincided with decreased permanent contraception in Idaho (5.0% vs. 4.2%), while Oregon saw an increase (5.9% vs. 6.6%). CONCLUSIONS:Idaho's abortion ban was associated with significant declines in most effective postpartum contraceptive use and visit attendance among Medicaid beneficiaries, suggesting abortion restrictions may have unintended consequences for postpartum care access. IMPLICATIONS:Idaho's abortion ban was associated with reduced postpartum contraceptive use and visit attendance among Medicaid beneficiaries. Clinicians practicing in states with abortion restrictions should be aware of potential declines in postpartum care engagement and prioritize counseling and access to contraception throughout care.
OBJECTIVES:The objective of the current study was to assess whether prenatal incarceration exposure is associated with postpartum contraceptive use. STUDY DESIGN:Using pooled cross-sectional data from Phase 8 (2016-2021) of the Pregnancy Risk Assessment Monitoring System (n = 111,616) from 26 sites (25 states and New York City), we examined associations between incarceration exposure (i.e., direct or vicarious through husband/partner) in the 12 months before birth and postpartum contraceptive use. We estimated survey-weighted bivariate and multivariable logistic regression analyses to examine associations between prior incarceration and type of contraceptive use. RESULTS:Overall, 2.7% of respondents reported personal or vicarious incarceration exposure via a spouse or partner, and 82.9% of respondents reported postpartum contraceptive use. Respondents exposed to incarceration had lower odds of using any postpartum contraception compared to those without exposure (aOR = 0.69, 95% CI = 0.60-0.78). Incarceration exposure was associated with a lower odds of condom use among those using contraception (aOR = 0.84, 95% CI = 0.72-0.98) and a higher odds of abstinence (aOR = 1.61, 95% CI = 1.36-1.91). CONCLUSIONS:These findings demonstrate the need for coordinated efforts across medical, public health, and criminal justice systems to improve postpartum contraceptive support for individuals affected by incarceration.
OBJECTIVES:To compare discontinuation rates, satisfaction, and bleeding/pain outcomes over 3 years in a nulliparous population randomized to one of two copper IUDs. STUDY DESIGN:We performed secondary analyses of the nulliparous population (n = 927) in a US-based, participant-blinded, randomized trial of the NTCu380-Mini (n = 744) and the TCu380A (n = 183). We calculated overall cumulative Kaplan-Meier IUD discontinuation and reason-specific probabilities by year. At nine timepoints over three years, participants summarized IUD satisfaction (highly satisfied, satisfied, dissatisfied, or highly dissatisfied) and last menstrual bleeding patterns; we analyzed responses over time using generalized linear models and estimating equations (computing odds ratios). On first-year diaries, participants also recorded bleeding and menstrual/intermenstrual pain. RESULTS:Through one and two years, NTCu380-Mini users had lower overall discontinuation probabilities compared to TCu380A users: 24.8% vs. 32.8%, p = 0.03 and 39.6% vs. 48.0%, p = 0.02, respectively. Cumulative three-year rates were 50.1% (NTCu380-Mini) vs. 56.5% (TCu380A), p = 0.06. Through all intervals, NTCu380-Mini users had lower discontinuation rates due to bleeding and/or pain and lower expulsion rates relative to TCu380A users; cumulative three-years rate were 14.5% vs. 26.8%, p < 0.001 and 10.0% vs. 15.1%, p = 0.03, respectively. Participants reported higher satisfaction with the NTCu380-Mini (OR 1.29 [95% CI 1.01-1.64]). In the first year, median number of bleeding/spotting days in a cycle (7.0) did not differ between products, yet some prolonged bleeding outcomes and type of pain showed product differences favoring the NTCu380-Mini. CONCLUSION:Over 3 years, nulliparous NTCu380-Mini users had lower expulsion and discontinuation rates for bleeding and pain, and they reported higher satisfaction than TCu380A users. IMPLICATIONS:The NTCu380-Mini demonstrates comparative benefits in nulliparous users, with lower rates of early discontinuation due to pain and bleeding and expulsions. As copper IUDs are the only non-hormonal, long-acting reversible contraceptives available, future development should prioritize optimizing device design to minimize side effects while maintaining high contraceptive efficacy.
Access to information has been identified as a social determinant of health, influencing knowledge, attitudes, and behaviors that can shape health outcomes. Contraceptive information influences how individuals make decisions about accessing contraceptive care and method use, as well as broader reproductive health trajectories. The recent proliferation of contraceptive misinformation has led to increased research and media attention on this topic. Misinformation from all types of information sources must be understood and addressed by the sexual and reproductive health, rights, and justice field to enable people to make informed, autonomous decisions about contraception based on high-quality, high-integrity evidence. This Research Practice Support aims to guide researchers interested in studying contraceptive misinformation. First, we define key terms related to the information environment and ecosystem, including misinformation, disinformation, and other related concepts. Then, we provide actionable recommendations for each stage of the research process for studies focused on contraceptive misinformation, including study design and ethical considerations, data sources and collection, and dissemination. Scholars are encouraged to consider these recommendations to maximize the impact of their research focused on contraceptive misinformation.
Objective To describe patterns in contraceptive use and factors influencing contraceptive decision-making during the post-molar beta-hCG monitoring period. Study Design This was a mixed methods analysis of patients who received care for molar pregnancy at a regional gestational trophoblastic disease center in the South between March 1996 and February 2025. Associations between demographic factors and contraception use during monitoring were assessed using chi-square and Kruskal-Wallis tests. Semi-structured interviews were conducted from December 2024 to April 2025 until thematic saturation was reached with patients diagnosed since August 2022, to minimize recall bias. Interviews were recorded, transcribed, and analyzed for patterns using NVivo 14. Results A total of 264 patients were identified for the database. Ten completed a qualitative interview, of whom four did not use contraception during monitoring. Most identified as white (56.4% in database, 70% among those interviewed) and non-Hispanic (85.7%, 70%, respectively). Within the database, 21.6% reported no contraception use during monitoring. The most utilized methods were combined hormonal contraceptives (37.5%), barrier methods (21.6%), and medroxyprogesterone acetate injection (14.8%). Significant differences in method were identified based on age, race, county, and number of live births at molar pregnancy diagnosis. In interviews, participants discussed several key findings related to contraceptive decision-making: (1) familiarity, (2) temporary use, (3) importance of monitoring, (4) side effects, and (5) trying new things. Conclusion Despite guideline-based recommendations, more than one-fifth of patients did not use contraception during monitoring for molar pregnancy. Qualitative data demonstrate that method selection is uniquely shaped by the importance of beta-hCG monitoring and desire for expeditious return to fertility. Implications One-fifth of patients did not use contraception during molar pregnancy monitoring, highlighting an opportunity for improved contraceptive counseling and alignment with guidelines to reduce the risk of unintended pregnancy and avoid potential confounding of malignant transformation.
OBJECTIVES:To assess efficacy and adverse outcomes of misoprostol 200 mcg versus 400 mcg every three hours buccal or vaginal for medication abortion (MAb) from 24 to 27 weeks' gestation. STUDY DESIGN:This retrospective cohort study included MAbs from 24 0/7-27 0/7 weeks' gestation at Bellevue Hospital from 7/2022-6/2025. All patients received digoxin 2 mg intraamniotic injection and mifepristone 200 mg oral followed at 24-48 h by misoprostol 200 mcg or 400 mcg every three hours buccal or vaginal based on hospital policy at time of admission. The primary outcome was time from first misoprostol dose to placental expulsion. Secondary outcomes were procedural complications. Primary statistical analysis was performed with Fisher's exact and Wilcox rank-sum tests. RESULTS:Of 55 patients, 27 (49%) received 200 mcg doses of misoprostol and 28 (51%) received 400 mcg doses of misoprostol. Median time to expulsion was 13 h in the 200 mcg group versus 9.5 h in the 400 mcg group (p = 0.144). More patients in the 200 mcg group versus the 400 mcg group had blood loss ≥ 500 mL (11.1% vs 0%, p = 0.11) and retained placenta at four hours (3.7% vs 0%, p = 0.49). No patients in either group had uterine rupture. CONCLUSIONS:Misoprostol 200 mcg versus 400 mcg every three hours buccal or vaginal for MAb from 24 to 27 weeks' gestation had overall similar outcomes. Although this single site retrospective study is underpowered to significantly differentiate between the two regimens, we observe that 200 mcg dosing may be associated with higher risk of complications. Larger studies are needed to clarify optimal misoprostol dosing for 24-27 week MAb. IMPLICATIONS:For medication abortion from 24 to 27 weeks' gestation, serial doses of misoprostol 200 mcg versus 400 mcg every three hours have similar rates of complications, though there is a signal that 200 mcg dosing may be associated with longer time to expulsion, higher blood loss, and more incidences of retained placenta.
OBJECTIVES:To describe patients' decisions to replace or extend use of their 52 mg levonorgestrel (LNG) intrauterine device (IUD) or their 68 mg etonogestrel (ENG) subdermal contraceptive implant beyond the five-year or three-year FDA-approved duration, respectively, through the full known duration of efficacy. STUDY DESIGN:We recruited patients presenting for replacement of long-acting reversible contraceptive (LARC) from an obstetrics/gynecology academic clinic to participate in a semi-structured interview regarding their decision to replace or extend use of their LARC. The semi-structured interviews included questions to determine factors that impacted their decision to replace or continue the 52 mg LNG IUD or contraceptive 68 mg ENG implant at five years and three years respectively. We also asked about barriers accessing information regarding the longer duration of efficacy for pregnancy prevention. RESULTS:We interviewed 30 participants with an average age of 32 (range 21-44). Three themes emerged: 1) Central role of information and trust in clinical guidance 2) Physical and experiential factors directly motivate decisions to replace or extend LARC use 3) Desire for more information to make an informed choice. Participants in this study replaced their LARC earlier than the full duration of pregnancy prevention due to changes in symptom and efficacy concerns. The main reasons for extended use of LARC were avoidance of pain with procedures and trust in the clinician. CONCLUSIONS:This study highlights the importance of communication improvements from health systems regarding the safety and efficacy of extended use of LARC which may allow patients to make more informed decisions regarding their duration of contraceptive use. IMPLICATIONS:Qualitative study examining patients' decisions to replace or extend use of their 52 mg LNG IUD or 68 mg ENG contraceptive implant beyond FDA-approved duration, highlighted the central role of trust in clinical guidance, physical and experiential factors motivate decisions, and desire for more information to make an informed choice.
OBJECTIVE:To assess knowledge of abortion medications by mail among a sample of patients accessing abortion care at brick-and-mortar clinics. STUDY DESIGN:We analyze survey data from 359 patients at 6 abortion clinics across the United States. RESULTS:One-third of respondents knew that abortion medications could be mailed to any address in the United States. Compared to residents, a slightly lower proportion of people who traveled from out of state knew about online pills. Most respondents who knew about online pills (54%) went to a clinic because they wanted an in-person appointment. CONCLUSIONS:There is a continued need for campaigns to increase awareness of medication abortion by mail.
OBJECTIVES:To assess the availability and accessibility of an over-the-counter oral contraceptive pill (OTC OCP). STUDY DESIGN:We visited pharmacies in Michigan and observed whether the OTC OCP was available and accessible. We compared availability and accessibility by pharmacy type and evaluated associations between availability, accessibility, and neighborhood disadvantage. RESULTS:A majority of pharmacies (82 of 134, 61%) stocked the OTC OCP. Most pharmacies that stocked the pill (65%) kept it in locked security boxes or behind the counter. Local pharmacies and pharmacies in disadvantaged neighborhoods were least likely to have the pill available. CONCLUSIONS:Where one lives and shops may affect access to OTC OCPs, with those in disadvantaged areas potentially subject to increased barriers.
OBJECTIVES:Subcutaneous depot medroxyprogesterone acetate (Sayana Press; DMPA-SC 104 mg) is approved for contraception, administered by subcutaneous injection into the anterior thigh or abdomen every three months. This study aimed to compare the pharmacokinetic (PK) and pharmacodynamic (PD) profiles for a new injection site (the upper arm) to the profiles for the currently approved reference injection sites. STUDY DESIGN:We randomized 67 healthy, pre-menopausal women 18 years of age or older to one of the three injection sites (upper arm: test; abdomen or anterior thigh: reference) in this single-center, open-label relative bioavailability trial. Participants received one dose of DMPA-SC (104 mg) on Day 1. We collected serum samples for MPA concentration and hormone analyses at regular intervals starting on Day 1 (pre-dosing), determined serum PK and PD parameters and reported them using summary statistics. RESULTS:Serum MPA AUCtau (area-under-the-curve, Day 1 to Day 92) and Cmax (maximum MPA serum concentration) were 42% and 24% greater, respectively, following upper arm administration, while trough concentrations (Ctrough, Day 92) for the upper arm and combined reference injection sites were similar (Ctrough test/reference = 95.17%; 90% CI: 73.80, 122.73). No participants who were successfully injected with DMPA-SC showed serum hormone indications of ovulation starting after drug administration. We noted no new adverse safety findings in either the test or reference groups. CONCLUSIONS:The results demonstrate that upper arm injection of DMPA-SC is safe and effective and could offer another option for administration of this contraceptive injection. IMPLICATIONS:This study shows upper arm injection of DMPA-SC (104 mg) should have safety and effectiveness comparable to injection at the currently approved sites (anterior thigh, abdomen), based on MPA PK parameters and hormonal markers of ovulation and could be an acceptable option for women using this form of injectable contraception.
OBJECTIVES:To investigate the association between previous cesarean section (CS) and major complications during first- and second-trimester surgical abortion. STUDY DESIGN:We conducted a national retrospective case-control study using prospectively collected data from all MSI Australia surgical abortion facilities between 2016 and 2024. Individuals undergoing surgical abortion between 5 + 0 and 23 + 6 weeks' gestation were eligible. Cases were procedures complicated by hemorrhage ≥ 500 mL, transfusion, uterine perforation, hospital transfer, laparotomy, laparoscopy, or hysterectomy. Each case was matched to four gestation-matched controls (±3 weeks) through a blinded process. A composite severe outcome included hysterectomy, laparotomy, intensive care admission, disseminated intravascular coagulation, or massive hemorrhage (≥2000 mL). Logistic regression estimated adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS:Among 159 major-complication cases and 636 gestation-matched controls, a history of previous CS was more common among cases than controls. After adjustment for age, gestational age, parity and body mass index, previous CS remained associated with increased likelihood of being a case (aOR 2.6, 95% CI 1.7-4.0). Odds of being a case increased with increasing numbers of previous CS (aOR 2.0 per cesarean, 95% CI 1.5-2.6). Previous CS was more common among composite severe adverse outcome cases than controls (OR 9.56, 95% CI 4.34-21.04). CONCLUSION:A history of previous CS was more common among cases than controls, with the odds of being a case increasing according to the number of prior CS. These findings may assist counseling, pre-procedure assessment and perioperative planning for patients with a history of cesarean birth. IMPLICATIONS:Previous cesarean section was more common among cases than controls, including cases with severe adverse outcomes. Increasing numbers of prior cesarean sections were associated with higher odds of being a case. These findings may inform counseling and perioperative planning.
OBJECTIVES:Medication abortion is safe and effective and typically involves two medications taken sequentially: mifepristone and misoprostol. In 2023, a regulatory change removed the requirement for mifepristone to be dispensed in-person. Several states also introduced shield laws in 2023, providing certain legal protections for clinicians who provide abortion. This study uses national-level medical claims data to examine trends in mifepristone provision in 2022 and 2023, as well as workforce composition during this period of policy change. STUDY DESIGN:Using medical and prescription claims data from IQVIA, a proprietary health information company that includes data for approximately 191 million patients, we identified the number of mifepristone prescriptions and clinicians prescribing mifepristone in 2022 and 2023 in the United States that appear in this national sample. We conducted interrupted time-series analysis of mifepristone medications dispensed in-person and prescriptions from mail pharmacies from January 2022 to December 2023 and compared the proportion of clinicians providing services in 2022 versus 2023 using Pearson chi-squared tests and rate ratios. RESULTS:We identified 71,352 total mifepristone medications/prescriptions in 2022 and 95,527 in 2023. Mifepristone prescriptions via mail pharmacies increased significantly in 2023 (+305.29 per month), while medications dispensed in-person decreased (-295.6 per month). OBGYNs provided less mifepristone in 2023 compared with 2022, while family medicine physicians, nurse practitioners, and midwives provided more. CONCLUSION:Mifepristone prescriptions in mail pharmacies increased in 2023, and more advanced practice clinicians provided mifepristone in 2023 than 2022. IMPLICATIONS:Shifting abortion policies may mean shifts in who is providing that care, particularly advanced practice clinicians.
OBJECTIVES:To elucidate the patient experience with medication abortion prior to the detection of embryonic cardiac activity (ECA). We characterized the duration and intensity of bleeding and cramping, pregnancy symptoms, functional recovery, and efficacy. STUDY DESIGN:This was a prospective cohort study. A series of eight electronic surveys were administered from abortion initiation through six weeks. Chart abstraction was performed to obtain demographic and baseline clinical information and to verify follow-up data. Descriptive statistics characterized patient experience and bivariate analyses were conducted to identify potential predictors of patient experience. RESULTS:We enrolled 250 participants between July 2024 and March 2025. At baseline, 183/250 (73%) of respondents reported typically moderate menses and 185/250 (74%) reported pregnancy symptoms. At some point during the first three days, 130/207 (63.1%) reported bleeding heavier than menses and 144/201 (71.6%) reported pain or cramping heavier than menses. Nulliparity (p < 0.001) and crown rump length (CRL; p = 0.048) were significantly associated with heavier cramping vs. usual or lighter cramping than menses. Of participants who had pregnancy symptoms at baseline, 49/124 (39.5%) still had pregnancy symptoms at two weeks. The mean time to functional recovery was 5.8 days. Complication rates were low. CONCLUSIONS:Bleeding and cramping with medication abortion prior to ECA were reported as heavier than menses less frequently than previously shown for patients undergoing medication abortion later in the first trimester. Bleeding expectations discussed during counseling can therefore be adjusted and reassurance can be provided to patients who experience bleeding and cramping less than or similar to menses. IMPLICATIONS:With the implementation of abortion bans at ECA, more patients will only have access to abortion care at very early gestational duration (GD). Patient counseling on medication abortion expectations and follow-up care can be tailored to reflect the differences noted in this study.
OBJECTIVE:To evaluate the residual levonorgestrel (LNG) content in the 52-mg levonorgestrel intrauterine device (IUD; Mirena) after use beyond 8 years. STUDY DESIGN:Prospective study conducted at the University of Campinas, Campinas, SP, Brazil, from March 2014 through October 2025. We collected levonorgestrel 52 mg IUDs from participants who used the IUDs for 8 years or longer and stored them at -20°C. We recorded the dates of insertion and removal, and sociodemographic data. After thawing, we removed the levonorgestrel-containing cylinder, extracted the hormone, and quantified levonorgestrel using a validated high-performance liquid chromatography method with diode-array detection. We assessed median [IQR, 25th-75th percentiles] levonorgestrel content with use for 8, > 8-9, and > 9-10 years. We also performed levonorgestrel quantification in three non-frozen unused IUDs as a reference. RESULTS:We analyzed 42 removed levonorgestrel 52 mg IUDs with use for 8 years (n = 4), > 8-9 years (n = 26), and > 9-10 years (n = 9), plus three unused IUDs. The levonorgestrel content in the unused referenced IUDs was 52 mg. Residual levonorgestrel content after use for 8, > 8-9, and > 9-10 years was median [IQR, 25th-75th percentiles] 15.3 mg (14.3-15.6), 13.5 mg (12.1-14.5), and 11.2 mg (10.2-14.5), respectively. CONCLUSION:Residual levonorgestrel levels in the levonorgestrel 52 mg IUD at 10 years of use indicate that ∼21.5% of the initial levonorgestrel content remains within the device. Further clinical studies are needed to determine whether this residual amount is sufficient to maintain the high contraceptive efficacy of the IUD through 10 years of use. IMPLICATIONS:Residual levonorgestrel content in the levonorgestrel 52 mg IUD at 10 years of use was 11.2 mg, exceeding the reported residual content of 5.8 mg in the levonorgestrel 19.5 mg IUD at the end of its approved 5-year duration. Nevertheless, the clinical significance of this comparison remains uncertain and warrants further study.
