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BACKGROUND: Contraception for women who are breastfeeding is a public health issue of global importance. Each year over 100 million women make decisions about beginning or resuming contraception after childbirth. These decisions include both the choice of contraceptive method and the time at which its use begins, both of which continue to be debated by experts. Choices of contraception may be limited for lactating women due to concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant, and infant growth. Ideally, the contraceptive method chosen should not interfere with lactation. Additionally, because the return of menstruation and ovulation can be unpredictable in breastfeeding women, the timing of contraception initiation is important. OBJECTIVES: To determine the effect of combined oral contraceptives and progestin-only contraceptives on lactation. The a priori hypothesis is that combined oral contraception impairs lactation, making it less appropriate than progestin-only or nonhormonal contraception for breastfeeding women. SEARCH STRATEGY: We used PUBMED, POPLINE, EMBASE, LILACS, and Cochrane Controlled Trials Register computer searches, supplemented by review articles and contact with investigators. SELECTION CRITERIA: We sought all randomized controlled trials, reported in any language, that included any form of hormonal contraception compared with another form of hormonal contraception, nonhormonal contraception, or placebo during lactation. Hormonal contraception could include combined oral or injectable contraceptives, progestin-only oral or injectable contraceptives, hormonal implants, or hormonal intrauterine devices. Study participants included breastfeeding women of any age or parity who desired contraception. DATA COLLECTION AND ANALYSIS: We evaluated the methodological quality of each report and sought to identify duplicate reporting of data from multicenter trials. We abstracted data onto data collection forms. Principal outcome measures included quantity of milk; biochemical analysis of milk composition; initiation, maintenance and duration of lactation; infant growth; efficacy of contraceptive method while breastfeeding; and timing of contraception initiation and its effects on lactation. Because the trials did not have uniform interventions, often lacked quantifiable outcomes, and had poor methodological quality, we could not aggregate the data in a meta-analyses. MAIN RESULTS: Seven reports from five randomized controlled trials met our inclusion criteria. Most of the five trials did not specify their method used to generate a random sequence, method of allocation concealment, blinding of treatments, or use of an intention-to-treat analysis. Additionally, high loss to follow-up rates invalidated at least two studies. The findings from two reports comparing oral contraceptives to placebo during lactation were conflicting. Another trial found no inhibitory effects on lactation from progestin-only contraceptives. Finally, the WHO trial found no effect of progestin-only contraceptives on lactation but a decline in breast milk volume from combination contraceptives during lactation. High loss to follow-up rates, however, undermine the credibility of the WHO trial. No significant differences in infant growth or weight appeared in any of the included trials as a result of the use of hormonal contraception during lactation. REVIEWER'S CONCLUSIONS: Evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is limited and of poor quality; results should be interpreted with caution. The existing randomized controlled trials are insufficient to establish an effect of hormonal contraception, if any, on milk quality and quantity. Evidence is inadequate to make recommendations regarding hormonal contraceptive use for lactating women. At least one properly conducted randomized controlled trial of adequate size is urgently needed to address this question.
BACKGROUND: Adequate contraceptive advice is important in women with diabetes mellitus type 1 and 2 to reduce the risk of maternal and infant morbidity and mortality in unplanned pregnancies. A wide variety of contraceptives are available for these women. However hormonal contraceptives might influence carbohydrate and lipid metabolism and increase micro- and macrovascular complications. So caution in selecting a contraceptive method is required. OBJECTIVES: To investigate whether progestogen-only, combined estrogen/progestogen or non-hormonal contraceptives differ in terms of effectiveness in preventing pregnancy, in their side effects on carbohydrate and lipid metabolism and in long-term complications such as micro- and macrovascular disease, when used in women with diabetes mellitus. SEARCH STRATEGY: The search was performed in MEDLINE, EMBASE, CENTRAL/CCTR, POPLINE, CINAHL, WorldCat, ECO, ArticleFirst, the Science Citation Index, the British Library Inside, and reference lists of relevant articles. Last search was performed in May 2005. In addition, experts in the field and pharmaceutical companies marketing contraceptives were contacted to identify published, unpublished or ongoing studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials that studied women with diabetes mellitus comparing: 1. hormonal versus non-hormonal contraceptives. 2. progestogen-only versus estrogen/progestogen contraceptives. 3. contraceptives containing <50 microg estrogen versus contraceptives containing > or = 50 microg estrogen. 4. contraceptives containing 'first'-, 'second'- and 'third'-generation progestogens, drospirenone and cyproterone acetate. Principal outcomes were contraceptive effectiveness, diabetes control, lipid metabolism and micro- and macrovascular complications. DATA COLLECTION AND ANALYSIS: Two investigators evaluated the titles and abstracts from the literature search. Quality assessment was performed independently with discrepancies resolved by discussion or consulting a third reviewer. Because the trials differed in studied contraceptives, participant characteristics and methodological quality, we could not combine the data in a meta-analysis. The trials were therefore examined on an individual basis and narrative summaries were provided. MAIN RESULTS: Three randomised controlled trials were included. Only one was of good methodological quality. It compared the influence of levonorgestrel-releasing IUD versus copper-IUD on carbohydrate metabolism in women with type 1 diabetes mellitus. No difference was found in daily insulin requirement, glycosylated hemoglobin (HbA1c) or fasting blood sugar after twelve months. The other two trials were of limited methodological quality. Both compared progestogen-only pills with different estrogen/progestogen combinations. The trials reported blood glucose levels to remain stable during treatment with most regimens. Only high-dose combined oral contraceptives were found to slightly impair glucose homeostasis. Combined oral contraceptives also appeared to have a minor adverse effect on lipid metabolism whereas progestogen-only contraceptives slightly improved lipid-metabolism. Only one study reported on micro- and macrovascular complications. No signs or symptoms of thromboembolic incidents or visual disturbances were observed. However study duration was short. Minor adverse effects were reported in one study. The trial found progestogen-only pills to cause more bleeding irregularities when compared with combined oral contraceptives. Unintended pregnancies were not observed during any of the studies. AUTHORS' CONCLUSIONS: The three included randomised controlled trials in this systematic review provided insufficient evidence to assess whether progestogen-only and combined contraceptives differ from non-hormonal contraceptives in diabetes control, lipid metabolism and complications. Two of the three studies were of limited methodological quality, sponsored by pharmaceutical companies and described surrogate outcomes. Ideally, an adequately reported, high-quality randomised controlled trial analysing both intermediate outcomes (i.e. glucose and lipid metabolism) and true clinical endpoints (micro- and macrovascular disease) in users of combined, progestogen-only and non-hormonal contraceptives should be conducted. However, due to the low incidence of micro- and macrovascular disease and accordingly the large sample size and follow-up period needed to observe differences in risk, a randomised controlled trial might not be the ideal design.
A cohort of women aged 14-29 in 1993 was identified from the General Practice Research Database and followed up for a period of 4 years. Patient files were searched for evidence of use of emergency contraception and regular contraception. Of the 95 007 women, 15 105 (16%) had received emergency contraception during the study period (an average of 5% per annum). There was a small year on year increase in uptake of emergency contraception between 1994 and 1997. Only 4% of emergency contraception users received emergency contraception more than twice in any year. More than 70% of those who had no previous record of use of regular contraception had used regular contraception within 1 year of using emergency contraception. Teenagers were more likely than other age groups to use emergency contraception, to be repeat users of emergency contraception and to fail to start regular contraception after first use of emergency contraception until later in the study period. These results disprove the notion of widespread repeated use of emergency contraception. They show that provision of an emergency contraception service does not result in failure to initiate regular contraception or abandonment of regular contraception; rather they show many women using regular contraception for the first time after use of emergency contraception.
This analysis used data, primarily from the 1997 Vietnamese Demographic and Health Survey (VN-DHS 1997), to determine the changes in contraceptive use in Vietnam. A descriptive analysis of individual, household and community characteristics was made to obtain a general description of contraceptive use. Multinomial logistic regression analyses were also performed on the currently married in (a) a sample of all women and (b) only those women who live in rural areas, to identify the strength of association that each variable has with the use of modern contraceptives. The use of any contraceptive method and the use of modern methods increased from 1988 to 1997. The primary contraceptive method utilized is the IUD and its use has increased substantially from 1988 to 1997. Younger women (aged 15-24) were less likely to use any contraceptive method. Women not desiring additional children were significantly more likely to use contraceptive methods than those desiring more children. Education has a clear impact on both contraceptive knowledge and use by women, with higher educated women being more likely to use a contraceptive method. Illiterate women with no formal education were significantly less likely to use modern methods of contraception. Differentials in contraceptive use exist regarding place of residence. Urban women are more likely than rural women to use contraception, but the difference is not large. Women living in mountainous areas are less likely to use contraception, compared with women living in the lowlands. Living standards, especially the availability of electricity in the community, have a large effect on the methods of contraception adopted by women. Religion is not strongly related to the contraceptive behaviour of women. There were significant differences in the use of contraceptives in communities with good quality of care, with increased contraceptive use corresponding to the increase in availability of family planning workers at communes, provision of counselling services at health facilities, and the volume of mass media family planning messages.
BACKGROUND: The aim of the study was to analyze the reasons for the failure of contraception and the reasons for not using any contraception among women seeking a legal abortion on social grounds. The women were also asked about their knowledge of contraception methods, including postcoital contraception. METHODS: We interviewed 200 women applying for a legal abortion within the first trimester of pregnancy about contraception, the contraceptive methods used, and the possible reasons for failure of contraception. RESULTS: Of all the women interviewed, 93% claimed to have adequate knowledge of contraception. At the time of conception 11.5% used safe methods (OCs 8%, IUDs 3.5%), 63% used less safe methods, and 26% were without contraception. Only 25% of the pill users had no explanation for the failure. 76.7% of the condom users reported that the condom was broken, had slipped off or its use had been irregular. The concern about side effects was the most common reason for not using safe contraceptives (25%). CONCLUSIONS: The women claimed to have enough information about contraceptives, and postcoital contraception was also familiar, but the knowledge on how to use them in practice was inadequate. Irregular use and breaks in contraception were common. Despite the data based on Pearl indices, pills failed twice as often as IUDs. Counseling about the proper use of contraceptives is important, although the concern about the side effects appeared to be a big, unsolved problem.
BACKGROUND: To investigate the professional activity and perceptions of intrauterine contraception among Latvian obstetrician-gynecologists. METHODS: A questionnaire was completed by 122 Latvian obstetrician-gynecologists attending an annual meeting. Statistical analysis was done with the Epi-Info 2002 statistical package. RESULTS: Every day contraceptive consulting was done by 91.8% of physicians and 98.4% reported ever having inserted intrauterine contraception. The majority of doctors reported careful selection of intrauterine contraception candidates, including screening for sexually transmitted infections before insertion. Intrauterine contraception insertion was definitely excluded in women without a stable monogamous relationship only by 9.8%. A causal relationship between intrauterine contraception and pelvic inflammatory disease was believed by 52.5%. Many doctors sometimes prescribed prophylactic antibiotics before or immediately after intrauterine contraception insertion. However, antibiotics were never prescribed before intrauterine contraception insertion by 50.8%. Younger doctors had significantly more often themselves used combined oral contraceptives than had older doctors, whereas older doctors more often had been intrauterine contraception users. Of current and former intrauterine contraception users, 93.4% were satisfied with this contraceptive method. CONCLUSIONS: Latvian obstetrician-gynecologists have wide experience in contraception counseling of intrauterine contraception, but some gaps in the theoretical knowledge of doctors about intrauterine contraception were identified. We could not find any significant differences in attitudes to and personal experience with contraceptive methods between older and younger generations, nor were there any differences between genders of obstetrician-gynecologists.
Oral contraceptives represent the most commonly employed means of contraception in the Federal Republic; they are used in 25% of all women in child-bearing age. The risk of myocardial infarction or cardiovascular death while taking oral contraceptives is determined primarily by three factors: the age of the user, the type and concentrations of estrogen and gestagen administered as well as the concomitant risk factors for coronary artery disease. With currently-used low-dose hormonal contraceptives, in young women (less than 30 years of age) who do not smoke and do not have other risk factors for coronary artery disease, there is no clear increase in the normally low risk of developing coronary artery disease or myocardial infarction. With increasing age and concomitant risk factors, users of hormonal contraceptives have an increased risk of myocardial infarction and cardiovascular death, where smoking has assumed a particularly important role. In general, the risk of cardiovascular death in users of oral contraceptives is approximately four-fold higher than in women who have never used oral contraception. A statistically-significant higher mortality has been documented in oral contraceptive users older than 35 years who smoke. In nonsmoking oral contraceptive users, the relative risk of myocardial infarction is 4.5. This increases to 23-fold for women who smoke more than 24 cigarettes daily. 75% of young women with myocardial infarction (under the age of 50 years) who use oral contraceptives, are smokers. Overall, the manifestation age of myocardial infarction is advanced four years through smoking alone, ten years through oral contraception alone and 13 years through the combination of smoking and oral contraception. The relevance of the duration of oral contraceptive use on the risk of infarction remains controversial. The number of young women with myocardial infarction and no or single-vessel coronary artery disease is significantly higher at 60% in women who have used oral contraceptives than in women of comparable age without oral contraceptive use (30%). The pathophysiological mechanism primarily responsible for myocardial infarction in oral contraceptive users and smokers appears to be thrombosis.
This report describes a pilot study conducted to determine the attitudes of men toward contraception. A questionnaire elicited responses from 436 males regarding: Personal data; contraceptive responsibility; contraceptive knowledge; use of contraception and preference for future methods. Results include attitudes toward contraceptive responsibility, assistance to pregnant partners and knowledge regarding eight common contraceptives. Usage of contraceptives in general and condoms and withdrawal specifically is reported. Preference for eight common contraceptive methods is also presented, along with data on delay of intercourse due to lack of contraceptives, partners' requests for male use of condoms/withdrawal and attitudes toward dissemination of contraceptive material to the public. Also reported are attitudes toward development of new contraceptives, use of male sterility shots or pills and the prices that men would pay for newly developed male contraceptives. The most preferred male contraceptive for future development is reported. It was concluded that the survey form and methodology were valid; that men desired to participate in family regulation; that the majority of men placed a low economic value on male contraceptives and finally that the overwhelming majority of men wanted contraceptive information to be widely disseminated in the public.