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February 9, 2010
Courses Course Schedule
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James Trussell's ResearchHealth and WellbeingJames Trussell and Kelly Cleland continue their collaborative work with the Association of Reproductive Health Professionals (ARHP) on increasing public awareness of and access to emergency contraception. ARHP and the Office of Population Research sponsor the Emergency Contraception Hotline (1-888-NOT-2-LATE) and the Emergency Contraception Website not-2-late.com. The Hotline provides detailed information about emergency contraception, as well as the phone numbers of five nearby clinicians who will provide emergency contraceptives in the United States. The Website contains more detailed information and the complete listing of providers. The Hotline is available in English and in Spanish. The website is available in English, Spanish, French, and Arabic. Since it was launched on February 14, 1996, the Hotline has received more than 700 thousand calls. The Website has received more than 5 million visitors since it was launched in October 1994; there are currently about 125,000 visitors per month. The Website was completely redesigned and relaunched in September, 2006.
Lisa Wynn (Macquarie University), Angel Foster (Ibis Reproductive Health) and James Trussell analyzed emails sent to the Emergency Contraception Website to identify sexual and reproductive health misconceptions. From July 1, 2003 through June 30, 2004, 1,134 English-language questions were e-mailed to ec.princeton.edu. They performed content analysis on these e-mails and grouped misconceptions into thematic categories. Of the questions sent during the study period, 27% (n=303) evinced underlying misconceptions about sexual and reproductive health issues. Content analysis revealed five major thematic categories of misconceptions: sexual acts that can lead to pregnancy; definitions of "protected" sex; timing of pregnancy and pregnancy testing; dangers that emergency contraceptives pose to women and fetuses; and confusion between emergency contraception and abortion. These misconceptions have several possible sources: abstinence-only sexual education programs in the U.S., the proliferation of medically inaccurate websites, terminology used in public health campaigns, non-evidence based medical protocols, and confusion between emergency contraception and medication abortion in the media.
Using data from a population-based cohort on contraception and abortion in France (Cocon survey), Caroline Moreau, Nathalie Bojos, and Jean Bouyer (INSERM), James Trussell, and Germán Rodríguez estimated method-specific probabilities of discontinuing contraceptive use among women in France. Probabilities of contraceptive discontinuation for method-related reasons varied widely by method: IUDs were associated with the lowest probabilities of discontinuation (9% within 12 months, 28% within 4 years), followed by the pill (21% and 47%, respectively). Discontinuation risks were significantly higher for all other methods (condoms, withdrawal, fertility awareness methods and spermicides). They found no differences in discontinuation rates by type of IUD (levonorgestrel-IUD versus copper-IUD) and increasing rates of pill discontinuation with decreasing dosage in estrogen.
Ellen Wiebe (University of British Columbia) and James Trussell conducted a retrospective chart survey in two urban free-standing abortion clinics to estimate the menstrual cycle day of conception in women presenting for abortion. There were 913 charts reviewed of women presenting for an abortion at less than 63 days gestation as determined by endovaginal ultrasound who were "sure" of the date of their last normal menstrual period. The estimated mean cycle day of conception was 14.6. There were 26/99 (26.3%) of women using cyclic hormonal contraception who conceived before day 10 of their cycle compared to 100/679 (14.7%) using all other forms of contraception, including "none". (p=.005). There were no other differences in day of ovulation with respect to age, ethnicity, or obesity. These data suggest that there is an important subset of women who ovulate early and therefore the usual pattern of hormonal contraception may have a higher failure rate for these women.
James Trussell and colleagues from the Guttmacher Institute provided updated estimates of contraceptive discontinuation, contraceptive failure, and resumption of contraceptive use for the most commonly used reversible methods in the United States. Estimates were obtained using the 2002 National Survey of Family Growth and the 2001 Abortion Patient Survey to correct for underreporting of abortion in the NSFG. Altogether, 12.4% of all episodes of contraceptive use ended with a failure within 12 months after initiation of use. Injectable and oral contraceptives remain the most effective reversible methods used by women in the United States, with probabilities of failure during the first 12 months of use of 7% and 9%, respectively. The probabilities of failure for withdrawal (18%) and the condom (17%) are similar. Reliance on fertility-awareness-based methods results in the highest probability of failure (25%). There was no clear improvement in contraceptive effectiveness between 1995 and 2002. Altogether, 47% of all reversible methods used were discontinued for method-related reasons by the end of 12 months. However, they found that only 20.9% of reversible method use is discontinued in the first year if they eliminate change of method as a reason for discontinuation. The male condom was the method most likely to be discontinued (57.1%). By comparison, similar levels of method-related reasons for discontinuation in the first year of use were found for withdrawal (54.2%) and fertility-awareness-based methods (53.2%). Lower levels of discontinuation for method-related reasons were found for the pill (32.7%) and for Depo Provera (44.0%). By the end of the first year, 80.3% of periods of nonuse following discontinuation of use of a contraceptive method had ended with resumption of use of some type of contraceptive. A very high proportion of resumption occurs in the first month that a woman is exposed to risk of unintended pregnancy after discontinuation. Overall, 71.5% of nonuse intervals had already ended in resumption of use in less than one month.
The UK Medical Eligibility Criteria (UK MEC) were adapted from the WHO Medical Eligibility Criteria to reflect evidenced-based practice in the United Kingdom. One significant change concerns combined hormonal contraceptive (CHC) use and body mass index (BMI). In the UK MEC use of CHC by women with a BMI of 35-39 has been rated UK MEC 3, and for women with a BMI ≥40, use of CHC has been rated UK MEC 4. This change was prompted by concerns about the effect of CHC use on the risk of venous thromboembolism (VTE). James Trussell, Kate Guthrie (Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire), and Bimla Schwarz (University of Pittsburgh) reviewed the evidence for that change and examined the consistency of this recommendation with recommendations with respect to age and smoking. They examined five large recent studies of the effect of combined oral contraceptives (COCs) and BMI on VTE. They found that all evidence was expressed as relative risks. When they instead estimate absolute or attributable risks, they conclude that the UK MEC recommendations with respect to CHU use and obesity are inconsistent with those for age and smoking, that use of CHCs among women with a BMI of 35-39 is generally safe and should be changed from a UK MEC 3 to a UK MEC 2, and that there are no data on the safety of use of CHCs among women with a BMI ≥40.
We know little about the sexual, social, and emotional dynamics at work in pregnancy ambivalence, especially compared to the research on HIV risk. Few researchers have explored how the eroticization of closeness or pregnancy risk could lead to the abandonment of contraception in the heat of the sexual moment, even when a child is not wholly intended. Jenny Higgins, Jennifer Hirsh (Columbia University), and James Trussell analyzed qualitative data from in-depth sexual and reproductive history interviews with 24 women and 12 men from the Southeastern U.S. Exactly half of the respondents (50%, N=18) had experienced at least one lifetime unintended pregnancy. Respondents described three categories of pleasure related to pregnancy ambivalence: 1) active eroticization of risk, in which pregnancy fantasies heightened the charge of the sexual encounter; 2) a passive romanticization of pregnancy, in which people neither actively sought nor prevented conception; and 3) an escapist pleasure in imagining that a pregnancy would sweep one away from hardship. All three categories contributed to misuse or non-use of coitus-dependent methods. Their analysis suggests that for some individuals, the perceived emotional and sexual benefits of conception may outweigh the goal of averting conception, even when a child is not wholly intended. Future behavioral studies should collect more nuanced data on pregnancy-related pleasures. Clinicians and patients would benefit from clearer guidelines for assessing ambivalence and for linking ambivalent clients with longer-acting methods that are not coitus-dependent.
Jenny Higgins and James Trussell analyzed data from a cross-sectional sexuality survey of university students from two college campuses, one Midwestern and one Southern (N=1504). Out of 16 possible sexual combinations of four sexual activities (masturbation, oral sex, vaginal sex, and anal sex), only four categories contained more than 5% of respondents: masturbation, oral, and vaginal sex only (37%); oral and vaginal sex only (20%); all four activities (14%); and none of these activities (8%). One in five respondents (20%) had ever engaged in anal sex. Although women were significantly less likely than men to have ever masturbated, those who had started at relatively young ages and had masturbated frequently in the past year. Findings also illustrated challenges to young people's sexual health, including lack of contraceptive use, lack of verbal sexual consent, and alcohol use proximal to sex. Anal sex is increasingly normative among young people, and safer sex efforts should encourage condom use during vaginal and anal sex. However, very few college students appear to be substituting oral or anal sex for vaginal sex. The investigators conclude that masturbation, which is very common among young adults (although less so among young women), should be encouraged as an essential aspect of sexual wellbeing. Finally, condom promotion alone will fail unless young people are helped to develop sexual communication skills and sexual fluency.
Teenage pregnancy statistics published by the UK Office for National Statistics (ONS) are too out-of-date and not geographically detailed enough to be used for effective monitoring of local Teenage Pregnancy Strategies. James Trussell, Kate Guthrie (Sexual and Reproductive Healthcare Partnership, Hull and East Yorkshire) and Kelly Cleland decided in Hull to produce more timely statistics using locally generated data. In October 2007, they extracted data on births and induced abortions that occurred from 2001 through September 2007 and data on pregnancies ongoing on September 30 from the information from the latest antenatal visit, for antenatal bookings that occurred from January through September 2007. Overall, they were able clearly to establish that while local efforts may have averted a rise in teenage pregnancy, they certainly have not in fact reduced the overall number of pregnancies; nor was progress seen in any postcode. Were they relying on ONS data, monitoring would by necessity have ceased in the calendar year 2005. By using locally generated statistics, they were able to conduct a more relevant and timely assessment of teen pregnancy trends, with statistics that are a year and a half more current than the ONS data. Since publication of these results, ONS decided to adopt their model by adding booking data to antenatal clinics to produce much more timely estimates.
In a paper published in the New England Journal of Medicine, Mary Fjerstad (Planned Parenthood Federation of America [PPFA]), James Trussell, Irving Sivin (Population Council) Steve Lichtenberg (Northwestern) and Vanessa Cullins (PPFA) sought to determine the rates of serious infection following medical abortion and also to evaluate the association between different infection-reduction measures and changes in the rates of serious infection. From 2001 to March 2006 Planned Parenthood health centers throughout the United States provided medical abortion principally by a regimen of oral mifepristone followed 24 to 48 hours later by vaginal misoprostol. In response to concerns about serious infections, in early 2006 Planned Parenthood changed the route of misoprostol administration to buccal and required either routine antibiotic coverage or universal screening and treatment for chlamydia; in July 2007, Planned Parenthood began requiring routine antibiotic coverage for all medical abortions. Rates of serious infection dropped significantly after the joint change to 1) buccal misoprostol replacing vaginal misoprostol and 2) either sexually transmitted infection (STI) testing or routine antibiotic coverage as part of the medical abortion regimen (73% decline from 93/100,000 to 25/100,000, p<0.001). The subsequent change to routine antibiotic coverage led to a further significant reduction in the rate of serious infection (76% decline from 25/100,000 to 6/100,000, p=0.03). Together, medical abortion with buccal misoprostol combined with routine antibiotic coverage brought the serious infection rate down by 93%, from 93 to 7 per 100,000 (absolute reduction 86/100,000 (95% CI 64-112, p<0.001).
Mary Fjerstad and Vanessa Cullins (PPFA), Irving Sivin (Population Council) Steve Lichtenberg (Northwestern), James Trussell, and Kelly Cleland sought to evaluate the effectiveness of the buccal medical abortion regimen and examine correlates of its success during routine service delivery. Audits at 10 large urban service points were conducted in 2006 to estimate success rates of the buccal regimen. Success was defined as medical abortion without vacuum aspiration. These audits also permitted an estimate of success rates with oral misoprostol following mifepristone in a subset in which 98% of the subjects stemmed from 2 sites. Effectiveness of the buccal misoprostol-mifepristone regimen was 98.3% for women with gestational ages below 60 days. The oral misoprostol-mifepristone regimen, used by 278 women with a gestational age below 50 days, had a success rate of 96.8%. The investigators conclude that in conjunction with 200mg of mifepristone, buccal use of 800μg of misoprostol up to 59 days of gestation is as effective as vaginal use of 800μg of misoprostol up to 63 days of gestation.
Julia Potter, Jean Bouyer and Caroline Moreau (INSERM) and James Trussell explored the experience of reproductive-age women in the French population with premenstrual syndrome (PMS) by estimating perceived symptom prevalence, identifying risk factors, and quantifying the burden of symptoms. This study also assesses the stability of the PMS diagnosis over a 1-year period of follow-up. The prevalence of reported PMS was estimated from a population-based cohort of 2863 French women interviewed in 2003 and 2004. Multivariate logistic regressions were used to identify risk factors associated with PMS. PMS fluctuation was studied by comparing women's responses in 2003 and 2004. Results show that 4.1% of women qualified for severe PMS (six symptoms) and 8.1% qualified for moderate PMS (one to five symptoms), resulting in 12.2% of women who reported PMS symptoms that impacted their daily lives. Risk factors for PMS fell into three categories: hormonal, psychosocial, and physiological, with life stressors and exogenous hormonal exposure exerting the most substantial impact. Results also indicate a high level of intraindividual variation in PMS status over time; among women who qualified for PMS during 1 or both years of the study, 72% demonstrated fluctuation in their PMS status. The investigators conclude that more women report suffering from distressing premenstrual symptoms than are captured by strict premenstrual dysphoric disorder (PMDD) diagnostic criteria. The impact of PMS symptoms on women appears to fluctuate over time, however, producing greater variability in the syndrome than previously recognized. Clinicians should be mindful of high intraindividual variability in the syndrome when advising patients about long-term management. View All Research on Health and Wellbeing Source: OPR Annual Reports.
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