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1.  Predictors of male partner treatment for sexually transmitted infection 
Sexually transmitted diseases  2012;39(10):769-775.
Background
Patient-initiated notification is a commonly used practice for notifying sex partners of possible exposure to a sexually transmitted infection (STI), yet 46% to 75% of partners are never treated. The Contraceptive CHOICE Project (CHOICE) is a longitudinal cohort study of women that provides no-cost contraception, STI testing, treatment to participants, and free partner treatment. Our objective was to evaluate characteristics of women who tested positive for chlamydia, gonorrhea, or trichomoniasis, and their association with successful partner treatment.
Methods
We analyzed baseline survey and STI testing, notification, and treatment data from the first 5,087 participants enrolled in CHOICE. We considered “treated partners” to be men who received antibiotic treatment at the study clinic or by a prescription through the study. Independent predictors of successful partner treatment were identified using univariate analysis and multivariable analysis using Poisson regression with robust error variance.
Results
Forty-four percent of male partners were successfully treated. Women whose partners were less likely to obtain treatment were black (RRadj=0.6; 95% CI: 0.5–0.8) or reported some concern about future STI with the partner (RRadj=0.6; 95% CI: 0.4, 0.8). Women whose partners were more likely to receive treatment were living with their partner (RRadj=1.4; 95% CI: 1.1–1.8) or reported recent inconsistent condom use (RRadj=1.5; 95% CI: 1.1–2.1).
Conclusions
The male partner treatment rate resulting from female patient-initiated partner notification in our study was low. Our findings highlight the need to develop novel notification interventions that yield higher partner treatment rates and consider patient-specific factors, such as race and relationship status.
doi:10.1097/OLQ.0b013e31825ec611
PMCID: PMC3457019  PMID: 23001263
partner notification; sexually transmitted infections; treatment
2.  Contraceptive Failure Rates of Etonogestrel Subdermal Implants in Overweight and Obese Women 
Obstetrics and gynecology  2012;120(1):21-26.
Objective
To estimate the contraceptive failure rates of the etonogestrel subdermal contraceptive implant in overweight and obese women, and compare failure rates to women of normal weight and women using intrauterine devices (IUDs).
Methods
The Contraceptive CHOICE Project is a large prospective cohort study designed to promote the use of long-acting reversible contraceptive methods to reduce unintended pregnancies in the St. Louis region. Participants are provided reversible contraception of their choice at no cost. We collected baseline height and weight of each participant. During each survey, participants were asked about missed menses and possible pregnancies. Any participant who suspected a pregnancy was asked to come in for urine pregnancy testing. Analysis includes the first 8,445 participants enrolled in CHOICE of which 1,168 chose the implant and 4,200 chose the IUD. Student’s t-test, χ2 test, and Kaplan-Meier survival curves were used to perform statistical analyses to estimate failure rates in overweight and obese women using the implant and IUDs.
Results
Of the women choosing the implant, 28% were overweight and 35% were obese. Of the women who chose an IUD, 27% were overweight and 35% were obese. The 3-year cumulative failure rates for implant and IUD users were less than 1 per 100 women-years and did not vary by body mass index (BMI).
Conclusion
We found no decrease in the effectiveness of the implant in overweight or obese women. The implant may be offered as a first-line contraceptive method to any woman seeking a reversible, and reliable birth control method.
doi:10.1097/AOG.0b013e318259565a
PMCID: PMC4043143  PMID: 22678035
3.  Continuation of Reversible Contraception in Teenagers and Young Women 
Obstetrics and gynecology  2012;120(6):1298-1305.
Objective
To examine the effect of age on continuation rates of reversible contraceptive methods among teenagers and young women aged 14–19 years and women aged 20–25 years, compared to women older than 25 years of age.
Methods
We analyzed data from 7,472 participants enrolled in the Contraceptive CHOICE Project, a prospective cohort study of women offered no-cost contraception. Our primary objective was to compare 12-month continuation rates between teenagers and women aged 14–19, 20–25, and 26 years and older. We collected data about method continuation from telephone surveys and chart review. We used Kaplan-Meier survival curves to estimate continuation and Cox proportional hazard models to examine the risk of contraceptive method discontinuation.
Results
Twelve-month continuation of long-acting reversible contraceptive (LARC) methods was over 75% for all age groups. Teenagers and young women aged 14–19 years using LARC methods had slightly lower continuation rates (81%) than older women (85–86%), but this did not reach statistical or clinical significance. Compared to women older than 25 years of age, teenagers and women aged 14–19 years had lower continuation rates for non-LARC methods (44% v. 53%; HRadj1.32, 95% CI 1.02–1.73). The teenagers and young women aged 14–19 years were less likely to be satisfied with non-LARC methods (42% v. 51%; RRadj 0.80, 95% CI 0.65–0.98), but not LARC methods (75% v. 83%; RR 0.94, 95% CI 0.88–1.01) when compared to women over 25 years of age; however, the differences were small.
Conclusion
Teenagers and young women have high rates of LARC method continuation.
PMCID: PMC4037699  PMID: 23168753
4.  Knowledge of Contraceptive Effectiveness 
Objectives
To determine women's knowledge of contraceptive effectiveness.
Study Design
We performed a cross-sectional analysis of a contraceptive knowledge questionnaire completed by 4,144 women enrolled in the Contraceptive CHOICE Project prior to receiving comprehensive contraceptive counseling and choosing their method. For each contraceptive method, women were asked “what percentage would get pregnant in a year: <1%, 1-5%, 6-10%, >10%, don't know.”
Results
Overall, 86% of subjects knew the annual risk of pregnancy was >10% if no contraception is used. More than 45% of women overestimate the effectiveness of depo-medroxyprogesterone acetate, pills, patch, ring, and condoms. After adjusting for age, education and contraceptive history, women who chose the intrauterine device (IUD) [RRadj=6.9, 95% CI: 5.6-8.5] or implant [RRadj = 5.9, 95% CI 4.7-7.3] were significantly more likely to accurately identify the effectiveness of their method compared to women who chose either the pill, patch, or ring.
Conclusions
This cohort demonstrated significant knowledge gaps regarding contraceptive effectiveness and over-estimated the effectiveness of pills, patch, ring, DMPA, and condoms.
doi:10.1016/j.ajog.2012.04.012
PMCID: PMC4007217  PMID: 22521458
Contraception effectiveness; Contraception failure; Contraception knowledge
5.  Factors associated with screening for sexually transmitted infections 
Objective
To determine predictors of completion of free annual sexually transmitted infection screening among sexually active young women 25 years of age and younger.
Study Design
We analyzed survey data from 2,607 sexually active women enrolled in the Contraceptive CHOICE Project, a prospective cohort study. We evaluated demographic characteristics, sexual risk behaviors, relationship characteristics, and contraceptive method. Receipt of a home or clinic-based test kit within 56 days of the 12-month survey constituted a completed screen. A multivariable model to predict screening completion was created using Poisson regression with robust error variance.
Results
Fifty-seven percent of women completed screening. Screening completion was most strongly associated with a college education or higher (RRadj=1.2, 95% CI: 1.1, 1.3) and home-based testing (RRadj=1.3, 95% CI: 1.2, 1.5).
Conclusions
Free and home-based testing increased screening rates among young women. To meet annual testing guidelines the availability and use of home testing kits should increase.
doi:10.1016/j.ajog.2012.02.020
PMCID: PMC3319662  PMID: 22464074
Chlamydia screening; contraception; young women
6.  Preventing Unintended Pregnancies by Providing No-Cost Contraception 
Obstetrics and gynecology  2012;120(6):1291-1297.
OBJECTIVE
To promote the use of long-acting reversible contraceptive methods (LARC) (intrauterine devices and implants) and provide contraception at no cost to a large cohort of participants in an effort to reduce unintended pregnancies in our region.
METHODS
We enrolled 9,256 adolescents and women at risk for unintended pregnancy into the Contraceptive CHOICE Project, a prospective cohort study of adolescents and women desiring reversible contraceptive methods. Participants were recruited from the two abortion facilities in the St. Louis region and through provider referral, advertisements, and word of mouth. Contraceptive counseling included all reversible methods, but emphasized the superior effectiveness of LARC methods (IUDs and implants). All participants received the reversible contraceptive method of their choice at no cost. We analyzed abortion rates, the percentage of abortions that are repeat abortions, and teenage births.
RESULTS
We observed a significant reduction in the percentage of abortions that are repeat abortions in the St. Louis region compared to Kansas City and nonmetropolitan Missouri (P < 0.001). Abortion rates of the CHOICE cohort were less than half the regional and national rates (P < 0.001). The rate of teenage birth within the CHOICE cohort was 6.3 per 1,000, compared to the U.S. rate of 34.1 per 1,000.
CONCLUSION
We noted a clinically and statistically significant reduction in abortion rates, repeat abortions, and teenage birth rates. Unintended pregnancies may be reduced by providing no-cost contraception and promoting the most effective contraceptive methods.
PMCID: PMC4000282  PMID: 23168752
7.  Validity of Perceived Weight Gain in Women using Long-acting Reversible Contraception and Depot Medroxyprogesterone Acetate 
Objective
To evaluate perceived weight gain in women using contraception and determine the validity of self-reported weight gain.
Study Design
We analyzed data from new contraceptive method users who self-reported weight change at 3, 6, and 12-months after enrollment. We examined a subgroup of participants with objective weight measurements at baseline and 12-months to test the validity of self-reported weight gain.
Results
Thirty-four percent (1,407/4133) of participants perceived weight gain. Compared to copper intrauterine device users, implant users [relative risk (RR)=1.29, 95% confidence interval (CI), 1.10–1.51] and depot medroxyprogesterone acetate (DMPA) users [RR=1.37, 95% CI, 1.14–1.64] were more likely to report perceived weight gain. Women who perceived weight gain experienced mean weight gain of 10.3 pounds. The sensitivity and specificity of perceived weight gain were 74.6% and 84.4%, respectively.
Conclusions
In most women, perceived weight gain represents true weight gain. Implant and DMPA users are more likely to perceive weight gain among contraception users.
doi:10.1016/j.ajog.2012.10.876
PMCID: PMC3974101  PMID: 23103344
contraception; perceived weight gain; reproductive-age women; weight gain
8.  Baseline correlates of inconsistent and incorrect condom use among sexually active women in the Contraceptive CHOICE Project 
Sexually transmitted diseases  2011;38(11):1012-1019.
Background
To provide protection against sexually transmitted infections (STIs) and pregnancy, condoms must be used consistently and correctly. However, a significant proportion of couples in the United States fail to do so. Our objective was to determine the demographic and behavioral correlates of inconsistent and incorrect condom use among sexually active, condom-using women.
Methods
Analysis of baseline data from a prospective cohort of sexually active, condom-using women in the Contraceptive CHOICE Project (n = 2,087) using self-reported demographic and behavioral characteristics. Poisson regression was used to determine the relative risk of inconsistent and incorrect condom use after adjusting for variables significant in the univariate analysis.
Results
Inconsistent and incorrect condom use was reported by 41% (n = 847) and 36% (n = 757) of women, respectively. A greater number of unprotected acts was most strongly associated with reporting 10 or more sex acts in the past 30 days, younger age at first intercourse, less perceived partner willingness to use condoms, and lower condom use self-efficacy. Incorrect condom use was associated with reporting 10 or more sex acts in the past 30 days, greater perceived risk for future STIs, and inconsistent condom use.
Conclusions
Inconsistent and incorrect condom use is common among sexually active women. Targeted educational efforts and prevention strategies should be implemented among women at highest risk for STIs and unintended pregnancies to increase consistent and correct condom use.
doi:10.1097/OLQ.0b013e318225f8c3
PMCID: PMC3192989  PMID: 21992976
Condom use; contraception; women; self-efficacy; sexual behavior
9.  The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception 
OBJECTIVE
To introduce and promote the use of long-acting reversible methods of contraception (LARC; intrauterine contraceptives and subdermal implant) by removing financial and knowledge barriers.
STUDY DESIGN
The Contraceptive CHOICE Project is a prospective cohort study of 10,000 women 14-45 years who want to avoid pregnancy for at least one year and are initiating a new form of reversible contraception. Women screened for this study are read a script regarding LARC to increase awareness of these options. Participants choose their contraceptive method that is provided at no cost. We report the contraceptive choice and baseline characteristics of the first 2,500 women enrolled August 2007 through December 2008.
RESULTS
Sixty-seven percent of women enrolled (95% confidence interval: 65.3, 69.0) chose long-acting methods. Fifty-six percent selected intrauterine contraception and 11% selected the subdermal implant.
CONCLUSION
Once financial barriers were removed and LARC methods were introduced to all potential participants as a first-line contraceptive option, two-thirds chose LARC.
doi:10.1016/j.ajog.2010.04.017
PMCID: PMC2910826  PMID: 20541171
long-acting reversible contraception; family planning
10.  A Randomized Trial of Home versus Clinic-Based STD Screening among Men 
Sexually transmitted diseases  2012;39(11):842-847.
Background
Preventing sexually transmitted diseases (STD) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) remains a public health challenge. The U.S. Preventive Services Task Force suggests STD screening among men will likely lead to a decrease in infection rates of women. However, innovative approaches are necessary to increase the traditionally low rates of male screening. The purpose of this study is to compare the acceptability and effectiveness of home-based versus clinic-based urine screening for CT/GC in men.
Methods
We conducted a randomized clinical trial of 200 men ages 18-45 years who reside in St. Louis, Missouri. Men were enrolled via telephone and randomly assigned to receive a free urine CT/GC screening kit in-person at the research clinic or mailed to a preferred address. Participants completed questionnaires at baseline and 10-12 weeks post-enrollment. The primary outcome was whether a STD screening kit was completed.
Results
Sixty percent (120/200) completed STD screening. Men assigned to home-based screening were 60% more likely to complete screening compared to clinic-based screening (72% versus 48%, RRadj=1.6, 95% CI, 1.3, 2.00). We identified four cases of CT or GC in the home-based group compared to three cases of CT in the clinic group. Men who completed screening were significantly more likely to be white, younger, and college-educated.
Conclusions
Home-based screening for CT and GC among men is more acceptable than clinic-based screening and resulted in higher rates of screening completion. Incorporating home-based methods as adjuncts to traditional STD screening options shows promise in improving STD screening rates in men.
doi:10.1097/OLQ.0b013e3182649165
PMCID: PMC3476063  PMID: 23064532
Screening; sexually transmitted diseases; males; randomized clinical trial
11.  Structured contraceptive counseling provided by the Contraceptive CHOICE Project 
Contraception  2012;88(2):243-249.
Background
We describe the contraceptive counseling provided by the Contraceptive CHOICE Project (CHOICE) and compare contraceptive methods selected between the university research site and community partner clinics.
Study Design
We developed a structured, contraceptive counseling program. All CHOICE participants enrolling at our university research site underwent the counseling, which was evidence-based and included information about all reversible contraception. Participants enrolling at partner clinics underwent “usual” counseling. We trained 54 research team members to provide contraceptive counseling; the majority had no formal health care training. We compared the contraceptive methods chosen by participants enrolling at our university research site to participants enrolling at partner clinics who did not undergo structured contraceptive counseling.
Results
There were 6,530 (86%) women who enrolled into CHOICE at our university site and 1,107 (14%) women who enrolled at partner clinics. Uptake of long-acting reversible contraception was high at both the university site and partner clinics (72% and 78%, respectively, p<.0001). However, uptake of the intrauterine device was higher at the university site (58% compared to 43%, p<.0001) and uptake of the subdermal implant was higher at partner clinics (35% versus 14%, p<.0001). After adjusting for confounders, we found no difference in the uptake of long-acting reversible contraception between women counseled at the university site compared to partner clinics (adjusted relative risk=0.98, 95% confidence interval [0.94, 1.02]).
Conclusion
Structured contraceptive counseling can be effectively provided in a clinical research setting by staff without prior health care experience or clinical training.
doi:10.1016/j.contraception.2012.07.015
PMCID: PMC3660507  PMID: 22959396
Contraceptive counseling; Long-acting reversible contraception; Intrauterine device; Subdermal implant
12.  Continuation of the Etonogestrel Implant in Women Undergoing Immediate Postabortion Placement 
Obstetrics and gynecology  2012;120(5):1053-1059.
Objective
To estimate whether women who receive an immediate postabortion etonogestrel subdermal implant have higher discontinuation rates than women who undergo an interval insertion (insertion not associated with a recent pregnancy).
Methods
This was a secondary analysis of the Contraceptive CHOICE Project. We compared 12-month continuation rates for the subdermal implant between women undergoing immediate postabortion placement and women who underwent an interval placement. Continuation rates were compared using Kaplan-Meier estimator of survival function and Cox proportional hazard models.
Results
Over the study period, 141 women received the implant immediately postabortion and 935 women underwent an interval placement. The 12-month continuation rates were similar; 81.5% among women undergoing immediate postabortion placement and 82.8% among women undergoing interval placement (p=0.54). In the survival analysis, women who received an immediate postabortion implant were no more likely to discontinue their method than women who had an interval placement (adjusted HR 1.04, 95% CI 0.68–1.60). The most common reason given for discontinuation was frequent or irregular bleeding, which was reported by 65.4% of women discontinuing in the immediate postabortion group and 56.7% in the interval group.
Conclusion
Women who undergo immediate postabortion placement of the subdermal implant have high rates of continuation that are equivalent to women undergoing interval insertion. Immediate postabortion LARC should be available to women undergoing induced abortion to decrease the risk of repeat unplanned pregnancy.
PMCID: PMC3711380  PMID: 23090522
13.  Risk of Bacterial Vaginosis in Users of the Intrauterine Device: A Longitudinal Study 
Sexually Transmitted Diseases  2012;39(3):217-222.
BACKGROUND
Users of the intrauterine device(IUD) may be at increased risk for bacterial vaginosis (BV). Our objective was to compare the incidence of BV in women using the IUD compared to women using combined oral contraceptives (COC), the contraceptive vaginal ring, and the contraceptive patch.
METHODS
We prospectively recruited women negative for BV at baseline. Monthly, for six months, participants returned a self-obtained vaginal smear for Gram stain by mail. BV was diagnosed by a Nugent score ≥7. We performed Cox proportional hazards regression to investigate associations between demographic and behavioral characteristics, contraceptive method, and incident BV.
RESULTS
We enrolled 153 women negative for BV at baseline; 90(59%) women who chose the IUD and 63 (41%) who chose COC, ring, or patch. There were 35 women with BV at one or more time points. The incidence of BV was 37.0% among IUD users and 19.3% in COC, ring, and patch users (p=0.03). In the univariate analysis, race, IUD use, intermediate flora, and irregular vaginal bleeding were significantly associated with BV. In the adjusted model, IUD users were no more likely to acquire BV (HRadj 1.28, 95%CI 0.53–3.06)than COC, ring, and patch users. The associations between intermediate flora and irregular bleeding and BV remained significant (HRadj 3.3095% CI 1.51–7.21, and HRadj 2.54, 95% CI 1.03–6.24 respectively).
CONCLUSIONS
The association between IUD use and BV may be mediated by irregular vaginal bleeding. Intermediate flora is associated with an increased incidence of BV.
doi:10.1097/OLQ.0b013e31823e68fe
PMCID: PMC3285477  PMID: 22337109
Bacterial vaginosis; Intrauterine device; Hormonal contraception; Irregular bleeding
14.  Comparison of contraceptive method chosen by women with and without a recent history of induced abortion 
Contraception  2011;84(6):571-577.
Background
Women undergoing induced abortion may be more motivated to choose long-acting reversible contraception (LARC), including the intrauterine device (IUD) and implant, than women without a history of abortion. Our objective was to determine whether the contraceptive method chosen is influenced by a recent history of induced abortion and access to immediate postabortion contraception.
Study Design
This was a sub-analysis of the Contraceptive CHOICE Project. We compared contraception chosen by women with a recent history of abortion to women without a recent history. Participants with a recent history of abortion were divided into immediate postabortion contraception and delayed-start contraception groups.
Results
Data were available for 5083 women; 3410 women without a recent abortion history, 937 women who received immediate postabortion contraception, and 736 women who received delayed-start postabortion contraception. Women offered immediate postabortion contraception were more than 3 times as likely to choose an IUD (RRadj 3.30, 95%CI 2.67–4.85) and 50% more likely to choose the implant (RRadj 1.51, 95%CI 1.12–2.03) compared to women without a recent abortion. There was no difference in contraceptive method selected among women offered delayed-start postabortion contraception compared to women without a recent abortion.
Conclusion
Women offered immediate postabortion contraception are more likely to choose the IUD and implant than women without a recent abortion history. Increasing access to immediate postabortion LARC is essential to preventing repeat unintended pregnancies.
doi:10.1016/j.contraception.2011.03.018
PMCID: PMC3563318  PMID: 22078185
15.  Naproxen or Estradiol for Bleeding and Spotting with the Levonorgestrel Intrauterine System: A Randomized Controlled Trial 
Objective
To evaluate whether oral naproxen or transdermal estradiol decreases bleeding and spotting in women initiating the levonorgestrel-releasing intrauterine system (LNG-IUS).
Study Design
We conducted a randomized controlled trial of naproxen, estradiol, or placebo administered over the first 12 weeks of LNG-IUS use. Participants completed a written bleeding diary. We imputed missing values and performed an intention-to-treat analysis.
Results
There were 129 women randomized to naproxen (n=42), estradiol (n=44), or placebo (n=43). The naproxen group was more likely to be in the lowest quartile of bleeding and spotting days compared to placebo, 42.9% versus 16.3% (p=0.03). In the multivariable analysis, the naproxen group had a 10% reduction in bleeding and spotting days (RRadj 0.90, 95%CI 0.84–0.97) compared to placebo. More frequent bleeding and spotting was observed in the estradiol group (RRadj 1.25, 95%CI 1.17–1.34).
Conclusions
Administration of naproxen resulted in a reduction in bleeding and spotting days compared to placebo. (150 words)
doi:10.1016/j.ajog.2011.09.021
PMCID: PMC3268863  PMID: 22055339
Contraception; Treatment for irregular bleeding with hormonal contraception; Levonorgestrel intrauterine system; Progestin-only contraception
16.  Perceived racial, socioeconomic and gender discrimination and its impact on contraceptive choice 
Contraception  2011;84(3):273-279.
Background
The study was conducted to determine whether perceived racial, economic, and gender discrimination has an impact on contraception use and choice of method.
Methods
We analyzed the first 2,500 women, aged 14–45 years enrolled in the Contraceptive CHOICE Project, a prospective cohort study aimed to reduce barriers to long-acting reversible contraception. Items from the “Experiences of Discrimination” (EOD) scale measured experienced race-, gender-, and economic-based discrimination.
Results
Overall, 57% of women reported a history of discrimination. Thirty-three percent reported gender- or race-based discrimination and 24% reported discrimination attributed to socioeconomic status (SES). Prior to study enrollment, women reporting discrimination were more likely to report any contraception use (61% vs. 51%, p<0.001), but were more likely to use less effective methods (e.g., barrier methods, natural family planning or withdrawal; 41% vs. 32%, p<0.001). In adjusted analyses, gender-, race- or SES-based discrimination were associated with increased current use of less effective methods (adjusted risk ratio (aRR) 1.22, CI 1.06–1.41; aRR 1.25, CI 1.08–1.45; aRR 1.23, CI 1.06–1.43, respectively). After enrollment, 67% of women with history of experience of discrimination chose a long-acting reversible contraceptive method (intrauterine device or implantable) and 33% chose a depo-medroxyprogesterone acetate or contraceptive pill, patch or ring.
Conclusions
Discrimination negatively impacts a woman’s use of contraception. However, after financial and structural barriers to contraceptive use were eliminated, women with EOD overwhelmingly selected effective methods of contraception. Future interventions to improve access and utilization of contraception should focus on eliminating barriers and targeting interventions that encompass race-, gender-, and economic-based discrimination.
doi:10.1016/j.contraception.2011.01.004
PMCID: PMC3539813  PMID: 21843693
Discrimination; contraception; race; socioeconomic status; gender
17.  Comparison of contraceptive use between the Contraceptive CHOICE Project and state and national data 
Contraception  2010;83(5):479-485.
Background
We compared contraceptive prevalence reported in the Contraceptive CHOICE Project (CHOICE) at time of enrollment, with estimates from representative surveys, the 2006–2008 National Survey of Family Growth (NSFG) and 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS).
Study design
We calculated survey weights for CHOICE participants and compared selected demographic characteristics and prevalence estimates of current contraceptive methods being used at the time of enrollment.
Results
Compared to the NSFG, CHOICE participants at time of enrollment were less likely to be pill users (16.1% vs. 24.0%) and more likely to use condoms (23.8% vs. 13.8%). Compared to the BRFSS, CHOICE participants were more likely to use condoms (20.4% vs. 12.9%) and withdrawal (6.6% vs. 0.4%).
Conclusion
Despite differences in sampling strategies between CHOICE and state and national surveys, the contraceptive prevalence estimates were largely similar. This information combined with the high rates of long-acting reversible contraception (LARC) use after enrollment by CHOICE particiants that have been previously reported by study participants, may imply that cost and restricted access to LARC could be essential factors in the low rates of LARC use in the US.
doi:10.1016/j.contraception.2010.10.001
PMCID: PMC3074095  PMID: 21477693
Contraception; Epidemiology; Intrauterine device; Population data
18.  Understanding prescription adherence: Pharmacy claims data from the Contraceptive CHOICE Project 
Contraception  2010;83(4):340-345.
BACKGROUND
We examined prescription adherence rates by contraceptive method among women who used oral contraceptive pills (OCP), transdermal patch, or vaginal ring.
STUDY DESIGN
Women in the St. Louis area were provided their choice of OCP, patch, or ring at no cost and followed for 18 months. Time between monthly refills was obtained from pharmacy data and analyzed as a marker of adherence. Risk factors for initial nonadherence were estimated using Cox proportional hazards; predictors for repeated nonadherence were analyzed using Poisson regression with robust error variance.
RESULTS
Overall, 619 participants filled 6,435 contraceptive prescriptions with a median of 10 refills per participant. Only 30% of women (n=187) obtained all refills on time. In the time-to-failure analysis, use of vaginal ring and increased parity were predictors of early nonadherence (p<0.05). In the multivariable analysis, use of the vaginal ring and history of abortion were risk factors for repeated nonadherence (p<0.01).
CONCLUSIONS
Even with financial barriers removed, pharmacy data show that many women inconsistently refill their contraception and may be at risk for unintended pregnancy.
doi:10.1016/j.contraception.2010.08.003
PMCID: PMC3058146  PMID: 21397092
prescription adherence; vaginal ring; pharmacy claims data; unintended pregnancy
19.  Screening for STIs at Home or in the Clinic? 
Purpose of review
To assess the evidence to support home versus clinic-based screening for sexually transmitted infections.
Recent findings
Home-based screening for sexually transmitted infections has been shown to be a feasible approach for men and women from a variety of settings, including high risk, low income, and resource-poor communities. In recent studies, the testing rate with home-based screening was up to 11 times greater than the testing rate with clinic-based screening. For most individuals, self-collection and testing of urine or vaginal specimens at home was considered to be easy, acceptable, and often preferred over testing at a clinic. There is limited evidence with regard to the cost-effectiveness of home-versus clinic-based screening for sexually transmitted infections. However, a study from the U.S. concluded that home-based screening is cost saving.
Summary
Improvements in screening rates for sexually transmitted infections can be achieved with home-based screening methods. Making low-cost home test kits available may encourage at-risk young individuals with less access to clinic care, who may not otherwise be screened, to self-test for sexually transmitted infections.
doi:10.1097/QCO.0b013e32834204a8
PMCID: PMC3125396  PMID: 21124216
Sexually transmitted infections; screening; home testing; home-obtained specimen; postal specimen
20.  Women’s Knowledge About Intrauterine Contraception 
Obstetrics and gynecology  2011;117(1):48-54.
Objectives
To survey knowledge and attitudes about intrauterine contraception (IUC) among reproductive-aged women in the Saint Louis, Missouri, area.
Methods
We mailed an eight-page written survey to 12,500 randomly selected households in the St. Louis area, asking English-literate, reproductive-aged, adult women to respond. The survey asked about obstetric and contraceptive history, effectiveness of contraceptive methods, and appropriate candidates for, side effects of, and perceived risks of IUC. The results from 1,665 (13.3%) returned surveys were weighted for the analysis, which included descriptive statistics and polynomial logistic regression.
Results
Almost 8% of respondents were currently using or had previously used IUC and use was higher in women who reported discussing the method with their health care provider (adjusted odds ratio [OR] 13.4, 95% CI 6.5–27.8). Sixty-one percent of respondents underestimated the effectiveness of IUC and up to one-half of survey respondents were unable to correctly answer knowledge questions about IUC use and safety. An additional 11–36% of respondents indicated concern that IUC is associated with complications such as infection, infertility, and cancer. Current and past IUC users were more likely to be knowledgeable about IUC. Women who were currently using IUC were more likely to correctly estimate the effectiveness of IUC (adjusted OR 7.6, 95% CI 3.2–18.0).
Conclusion
Reproductive-aged women’s specific knowledge of the benefits and risks of IUC is limited. More educational interventions are needed to increase women’s knowledge about the effectiveness and benefits of IUC.
doi:10.1097/AOG.0b013e318202b4c9
PMCID: PMC3244817  PMID: 21173643
21.  The Contraceptive CHOICE Project: Recruiting Women at Highest Risk for Unintended Pregnancy and Sexually Transmitted Infection 
Journal of Women's Health  2010;19(12):2233-2238.
Abstract
Background
Unintended pregnancy disproportionately affects younger, minority, and low-income women. The purpose of this analysis is to describe our recruitment strategies and to determine if targeted efforts to reach women at greatest risk for unintended pregnancy and sexually transmitted infection (STI) were successful.
Methods
The Contraceptive CHOICE Project is a prospective cohort study providing reversible contraception at no cost to 10,000 women aged 14–45 years in the St. Louis area in order to evaluate method satisfaction and continuation and to reduce unintended pregnancies in the region. We describe four strategies for effective outreach and recruitment of high-risk women, including forming strong community partnerships. We analyze the evolution of baseline demographic and behavioral characteristics over the three waves of enrollment of the first 2,500 participants in order to assess whether our outreach efforts were successful.
Results
Overall, >60% of participants were aged ≤25 years. There was a significant increase in the percentage of minority participants enrolled throughout the first 2,500 subjects (p < 0.001). The number of women who reported trouble paying for basic necessities significantly increased over the three waves (p = 0.025). Throughout the three waves of enrollment, there was a significant increase in the number of women who tested positive for an STI at baseline (p < 0.001).
Conclusions
A multiple method approach with collaboration of key community partners led to successful recruitment of hard to reach populations at high risk for unintended pregnancy and STI.
doi:10.1089/jwh.2010.2146
PMCID: PMC3003915  PMID: 20831439
22.  Home Compared With Clinic-Based Screening for Sexually Transmitted Infections: A Randomized Controlled Trial 
Obstetrics and gynecology  2010;116(6):1311-1318.
Objective
To determine whether home-based screening for sexually transmitted infections (STIs) results in a higher STI screening rate compared to clinic-based screening in participants using long-acting reversible contraception.
Methods
We performed a randomized clinical trial of women using long-acting reversible contraception methods in the Contraceptive CHOICE Project (n = 558). Participants were randomly assigned to home-based testing (swabs mailed to the participant's home or clinic-based testing. Self-collected vaginal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae using strand displacement analysis. We estimated the relative risk of screening by group using Poisson regression with robust error variance.
Results
The randomization groups were similar at baseline, except for marital status; the clinic group had more never-married women (62.0% vs. 51.6%), and the home group had more divorced women (12.1% vs. 5.6%, p = 0.007). Women in the home group were more likely to self-report screening compared to women in the clinic group in the multivariable analysis (56.3% vs. 32.9%, RR 1.7, 95% CI 1.4 – 2.0). When analyzed by tests received or documented in medical records, similar results were obtained (56.3% vs. 25.0%, RR 2.2, 95% CI 1.7 – 2.7). Women who completed screening had higher levels of education and were more likely to receive public assistance compared to those who did not complete screening.
Conclusion
Long-acting reversible contraception users randomized to STI screening at home were more likely to complete screening than those randomized to traditional clinic-based screening. Home-based screening may be useful in women using LARC methods who may not present for regular screening.
doi:10.1097/AOG.0b013e3181fae60d
PMCID: PMC3120128  PMID: 21099596
23.  Reasons for ineffective pre-pregnancy contraception use in patients seeking abortion services 
Contraception  2009;80(6):569-574.
Background
We sought to better understand reasons for not obtaining desired contraception among women presenting for a pregnancy termination.
Study design
A survey was completed by women prior to having an abortion procedure. Reasons for lack of access were categorized as institutional, individual and compliance issues. Descriptive statistics were calculated and variables compared using chi-square tests.
Results
Participants (n=298) ranged in age from 18–48 years. One third reported contraceptive use prior to pregnancy (37%). Approximately 72% of women reported some reason for not obtaining desired contraception, while 34% reported 2 or more. The distribution of reported individual, institutional, and compliance reasons were 44%, 28%, and 24%, respectively. Report of at least one reason was associated with a 35% increase in non-use (RR=1.35, 95% CI 1.02–1.80) after adjusting for age, race, education, parity and prior abortion.
Conclusions
Many reasons for not obtaining desired contraception exist and are associated with non-use of contraception. Removing these reasons may help reduce unintended pregnancies and rates of pregnancy termination.
doi:10.1016/j.contraception.2009.05.127
PMCID: PMC3152747  PMID: 19913152
contraception; pregnancy termination; health disparities; race; women’s health; gynecology
24.  Home Screening Compared With Clinic-Based Screening for Sexually Transmitted Infections 
Obstetrics and gynecology  2010;115(4):745-752.
Objective
To estimate completion rate and acceptability of home screening for sexually transmitted infections (STIs) compared to clinic-based screening in a prospective cohort study.
Methods
The first 462 women enrolled in the Contraceptive CHOICE Project were screened at 12 months of follow-up for Chlamydia trachomatis and Neisseria gonorrhoeae using strand displacement analysis of self-collected vaginal swabs. In a telephone interview, participants were given a choice of no-cost screening with swabs mailed to the participant’s home (home-based) or screening that was available at area family planning clinics without an appointment (clinic-based). The clinic-based group also included women who elected to screen with their regular provider according to the clinician’s normal practice. We analyzed the rates of screening, including patient preference and the proportion of completed tests by testing method.
Results
Women were more likely to choose to screen for STIs at home than at a clinic or with their own medical provider (75.7% versus 16.1% versus 8.2%, p < 0.001). Women choosing clinic testing were more likely to be black than those choosing home testing. Black women comprised 42% of the clinic group compared to 28% of the home group (RR 1.63, 95% CI 1.14–2.31). The groups did not differ in other demographic characteristics, STI risk factors, or access to healthcare. Overall, 228 women (56.6%) completed screening. Women who chose home-based testing were more likely to complete a test compared to all clinic-based testers (64.6% versus 31.6%, RR 2.04, 95% CI 1.51–2.76).
Conclusion
Women overwhelmingly preferred to screen for STIs at home. Future interventions to increase screening rates in young women should consider alternative screening strategies such as home-based or patient-controlled testing.
doi:10.1097/AOG.0b013e3181d4450d
PMCID: PMC3119481  PMID: 20308834
25.  Intrauterine contraception in Saint Louis: A Survey of Obstetrician and Gynecologists’ knowledge and attitudes 
Contraception  2009;81(2):112.
Background
Many obstacles to intrauterine contraception use exist, including provider and patient misinformation, high upfront cost, and clinician practice patterns. The aim of our study was to investigate knowledge and attitudes about intrauterine contraception among obstetricians and gynecologists in the area of Saint Louis.
Study Design
We mailed a self-administered, anonymous survey to 250 clinicians who provide obstetric and gynecologic care in Saint Louis City and County which included questions about demographics, training, family planning visits, and intrauterine contraceptive knowledge and use.
Results
The overall survey response rate among eligible clinicians was 73.7%. Clinicians who had recently finished training or saw higher numbers of contraceptive patients per week were more likely to insert intrauterine contraception than clinicians who completed training prior to 1989 or saw fewer contraceptive patients. Several misconceptions among clinicians were identified, including an association between intrauterine contraceptives and an elevated risk of pelvic inflammatory disease.
Conclusions
Physician misconceptions about the risks of intrauterine contraception continue to occur. Improved clinician education is greatly needed to facilitate the use of these highly effective, long-acting, reversible methods of contraception.
doi:10.1016/j.contraception.2009.08.002
PMCID: PMC2813209  PMID: 20103447
Intrauterine contraception; intrauterine device; clinician knowledge; obstacles; survey

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