Reproductive Choice

Question 1

Family Planning

Overview

Answer 1

Educational, comprehensive medical, or societal activities which enable individuals to determine freely the number and spacing of their children, and selected the means by which this may be achieved.

One of the 10 great public health achievements of the 20^th century

Question 2

Intended Pregnancy

Answer 2

• Affluent society ⇒ less fertility
• Improved maternal well-being
  
  • Earlier initiation of prenatal care
  • Less depression
  • Higher rates of breastfeeding
  • More likely to complete high school/education
• Improved child health
  
  • Less likely to have low birth weight
  • Better mental and physical health

Question 3

Unintended Pregnancy

Answer 3

• Teenage pregnancy
  
  • U.S. teenage pregnancy rates 2x vs UK, Wales, Canada, and 8x vs Japan and Netherlands
  • Main reason is access to care
  • Public cost of unwanted pregnancies was ~$21 billion in 2010
• Disparities in unintended pregnancies
  
  • ~45% of pregnancies in U.S. in 2011 were unintended
  • Black women > Hispanic or white woman
  • Women with lower family income
  • Unmarried women

Question 4

Contraception

Efficacy

Answer 4

• General efficacy
  
  • # of unplanned pregnancies that occur during a specified period of exposure and use
• Pearl Index
  
  • # failures per 100 woman-years
  • (# preg. x 12 months) / (# women studied x # months) x 100 = Pearl Index
  • Assumes a constant failure rate over time
• Life-table analysis
  
  • Failure rate for each month of use
  • Allows cumulative failure rate to be deduced

Question 5

Natural Family Planning

Answer 5

• Fertility awareness, periodic abstinence, or rhythm method
• Indicators such as cervical mucus and basal body temperature used to delineate fertile window
• Helps couples conceive as well as avoid pregnancy
• Typical failure rate during first year of use is 25.3%

Question 6

Withdrawal Method

Answer 6

• Use is probably underreported
• No protection from STIs
• Typical failure rate for one year is 18.4%

Question 7

Spermicide Alone

Answer 7

• Nonoxynol-9, benzalkonium chloride
• Requires application 10-30 minutes prior to intercourse
• Postcoital douches do not work

Question 8

Diaphragm/Cap/Sponge

Answer 8

• A way to hold spermicide against the cervix
• Low-cost, non-hormonal, woman-controlled
• Must be placed before intercourse, and left in place 6 hours after intercourse
  
  • Effectiveness depends on fit (must be fitted by Gyn)
• Typical use failure rate during first year is 16-32%
• Affected by parity

Question 9

Condoms

Answer 9

• Only contraceptive method effective in prevention of HIV transmission
• Must give instructions for effective use
• Slippage, spillage, and breakage are concerns
• Male condom (17.4% failure)
• Female condom (27% failure)

Question 10

Hormonal Contraceptives

Answer 10

• Combined Oral Contraception (“The pill”)
• Intravaginal Ring
• Patch
• Progestin-only Pills (“The mini-pill”)
• Nexplanon/etonorgestrel implant
• Depo-medroxy progesterone

Question 11

Non-hormonal IUD

Answer 11

• Devices:
  
  • Paragard TCu 380-A
• Mechanism:
  
  • Sterile inflammatory response ⇒ ⊗ sperm capacitation, penetration, and survival
• Slightly ↑ blood loss and menstrual pain

Question 12

Hormonal IUD

Answer 12

• Devices:
  
  • Mirena 52 mg LNG
  • Lilette 52 mg LNG
  • Kyleena 19.5 mg LNG
  • Skyla 13.5 mg LNG
• Mechanism:
  
  • Sterile inflammatory response ⇒ ⊗ sperm capacitation, penetration, and survival
  • Progestin effects on endometrium
• ↓ Blood loss; tx of hyperplasia, endometriosis, and dysmenorrhea

Question 13

IUD Overall Efficacy

Answer 13

• Failure rate in first year of use 0.2-0.8%
• Expulsion rate 10%
• Removal rate 15%
• PID risk: 6x during first 20 days after insertion, but then normalizes

Question 14

Sterilization

Answer 14

• Male: vasectomy
  
  • Same-day procedure under local anesthesia
  • Reversible
  • Failure rate is 0.2%
• Female: tubal ligation or salpingectomy
  
  • ⊗ Transport of egg to uterus
  • Performed during or immediately after delivery; or interval (general or regional anesthesia)
  • Benefits: non-hormonal, permanent
  • Risks: those of surgery, regret
  • Regret can approach 25% is certain populations
  • Failure rate is 0.7%

Question 15

Abortion

Methods

Answer 15

• First trimester
  
  • Medical – mifepristone plus misoprostol
  • Procedural – dilation and evacuation
• Second trimester
  
  • Dilation and evacuation (curettage)
• Benefits: unwanted pregnancy carries adverse effects for mom and child
• Risks: bleeding, infection, uterine perforation