Combination hormonal contraception and progestin-only contraception (including depot medroxyprogesterone acetate [DMPA]) are effective and convenient forms of reversible contraception that millions of women use worldwide. In recent years, observations of reduced bone mineral density in current users of these methods have led to concerns that this hormone-induced bone loss might translate into long-term increased fracture risk. Special focus has been placed on adolescent users who have not yet attained their peak bone mass as well as perimenopausal users. In 2004, the FDA added a black box warning to DMPA package labeling warning of the risk of significant bone loss and cautioning against long-term use (> 2 years). This article reviews evidence on the use of hormonal contraception and its effect on bone density in adolescent, premenopausal, and perimenopausal populations. Recommendations from reproductive healthcare organizations are reviewed and clinical recommendations are provided.

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Learning how to best meet a patient's contraceptive needs improves her chances of using her birth control consistently and is crucial to providing patient-centered care. The best contraceptive method for an individual patient is the one that is safe and that she is most comfortable using. Women's health care providers must be equipped to talk to each patient about her needs and options. The shared decision-making model in contraceptive counseling allows the patient and provider to work together in order to meet a patient's needs while remaining medically safe.

INTRODUCTION: Providers promote long-acting reversible contraception (LARC) because LARCs are highly effective at preventing pregnancy. The FDA recommends a maximum length of time for LARC use, but not a minimum. When women requesting early LARC removal perceive resistance from their providers, frustration and damaged patient-provider relationships can result. Understanding provider attitudes and practices about LARC removal is vital to patient-centered care. METHODS: Ten interviews were conducted with LARC providers and analyzed using qualitative techniques. LARC providers included physicians and mid-level providers in Ob/Gyn, pediatrics, and family medicine, in academic and community settings. Transcribed interviews were coded for themes and analyzed using a modified grounded theory approach. NVivo software was used for analysis. RESULTS: Providers defined early LARC removal as two weeks after insertion to anything prior to device expiration. Providers highlighted the importance of respecting patient autonomy when early LARC removal was requested, but many felt that patients should try LARC for a minimum amount of time to acclimate to the device or because of cost. Providers want to know why LARC removal is desired so that patient can be reassured and side effects can be treated to possibly delay or prevent removal. Many providers expressed internal conflict about early removal. They felt strongly about the benefits of LARC and disappointment or irritation with patients when LARC is removed early. CONCLUSION: Providers feel conflicted between their desire to promote effective birth control and patient requests for early LARC removal. Training around LARC provision and removal should include emphasis on the importance of patient-centered care.

Objective-This study was conducted to assess prevalence and correlates of prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan.Study design-Medically-eligible (e.g., conditions not requiring urgent medical attention, such as eclampsia, or not imminently delivering (dilation ≥8 cm)) obstetric patients admitted to three Kabul public hospitals were consecutively enrolled in this cross-sectional study. An intervieweradministered questionnaire assessed demographic information, health utilization history, including prior contraceptive use, and intent to use contraception. Correlates of prior contraceptive use were determined with logistic regression.Results-Of 4452 participants, the mean age was 25.7 years (SD±5.7 years), 66.4% repoited pregnancy prior to the presenting gestation, 88.4% had ≥1 prenatal care visit, and 82.4% reported the current pregnancy was desired. Most (67.4%) had no formal education. One-fifth (22.8%) reported using contraception prior to this pregnancy. Among women with any pregnancy prior to the current gestation (98.6% of prior users), prior contraceptive use was independently associated with having lived outside Afghanistan in the last five years (AOR=1.35, 95% CI: 1.12 -1.63), having a skilled attendant at the last birth (AOR=1.35, 95% CI: 1.07 -1.71), having a greater number of living children (AOR=1.30, 95% CI: 1.20 -1.41), longer mean birth interval (years) (AOR=1.21, 95% CI: 1.11 -1.38), and higher educational level (AOR=1.16, 95% CI: 1.09 -1.22). Immediate desire for Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access

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