A Nurse Is Reviewing Contraception Options for Four Clients
Am J Nurs. Author manuscript; available in PMC 2020 Oct 4.
Published in concluding edited form as:
PMCID: PMC7533104
NIHMSID: NIHMS1628733
An Prove-Based Update on Contraception
A detailed review of hormonal and nonhormonal methods.
Laura E. Britton, PhD, RN, Amy Alspaugh, MSN, RN, CNM, Madelyne Z. Greene, PhD, RN, and Monica R. McLemore, PhD, MPH, RN, FAAN
Abstract
Contraception is widely used in the United States, and nurses in all settings may run into patients who are using or want to use contraceptives. Nurses may exist called on to anticipate how family unit planning intersects with other health care services and provide patients with data based on the most current evidence. This article describes cardinal characteristics of nonpermanent contraceptive methods, including mechanism of activity, correct use, failure rates with perfect and typical use, contraindications, benefits, side effects, discontinuation procedures, and innovations in the field. We too hash out how contraceptive care is related to nursing ethics and health inequities.
Keywords: birth control, contraception, family planning, reproductive health
Contraception is widely used in the United States, with an estimated 88.2% of all women ages 15 to 44 years using at least one form of contraception during their lifetime.1 Among women who could become pregnant but don't wish to do and then, 90% use some form of contraception.2 Thus, nurses in diverse settings are probable to run across patients who are using contraception while presenting for a vast range of health care needs. Nurses will take many opportunities to support such patients past analogous contraceptive use with other treatments, such as past identifying medications that interact with contraceptives or are teratogenic. Some patients, coming together with a nurse on an unrelated affair, may even seize the moment to ask questions most contraception.
Patients are best prepared to brand informed decisions well-nigh contraceptive utilise when they have bear witness-based information; nurses tin meliorate support patients' reproductive goals past cultivating their own knowledge base. This article will fix nurses at diverse practice levels and practice settings to meet the needs of patients who are current or potential contraceptive users. It describes the major categories of nonpermanent contraceptive methods and provides evidence-based updates. Nosotros as well discuss inequities in contraceptive intendance that nurses can accost using their electric current clinical knowledge and a reproductive justice arroyo.
Contraception in context.
In its position argument on reproductive health, the American Nurses Association (ANA) has asserted that clients have the correct to make reproductive health decisions "based on full information and without coercion," and that nursing professionals must be prepared to discuss "all relevant information about health choices that are legal."3 Similarly, the American Academy of Nursing has issued policy recommendations that back up "admission to safe, quality sexual and reproductive health care and reproductive health intendance providers."iv Aligning with these policies means that, across settings and in accordance with their scope of practice, nurses should be prepared to provide contraceptive counseling, services, and referrals.
Moreover, adopting a reproductive justice approach to intendance delivery can potentially improve the quality and equity of reproductive health care and outcomes significantly.five Reproductive justice is a homo rights framework that aligns with the ANA'south Lawmaking of Ideals for Nurses with Interpretive Statements,6, seven and functions simultaneously every bit a theory, a practice, and a strategy. For more details, run across Reproductive Justice.five, 7 Understanding contraception and contraceptive care in the context of both nursing ideals and reproductive justice will assist nurses be best prepared for providing optimal care.
CONTRACEPTIVE METHODS: Fundamental CONSIDERATIONS
Three main considerations unremarkably arise in discussions of contraceptive methods: method safety and contraindications, failure rates, and return to fertility.
An important source for data about method safety comes from the Centers for Affliction Control and Prevention (CDC): the U.South. Medical Eligibility Criteria for Contraceptive Employ (U.S. MEC),8 which categorizes the safety of contraceptive methods in accordance with the specific health concerns of patients (encounter Table 1 viii). In this article nosotros'll highlight the mutual contraindications and drug interactions categorized as U.S. MEC 4: "A condition that represents an unacceptable health risk if the contraceptive method is used."8 We recommend that readers familiarize themselves with the U.S. MEC, which includes a comprehensive listing of such weather condition; it's available costless online (www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf) and as an app.
Table ane.
U.Due south. Medical Eligibility Criteria for Contraceptive Employ (U.S. MEC): Categorization of Safety for Specific Health Conditions8
| Category | Condition | Safe Recommendation |
|---|---|---|
| U.Due south. MEC 1 | A condition for which there is no restriction for the use of the contraceptive method. | Can utilize the method. |
| U.S. MEC 2 | A condition for which the advantages of the contraceptive method generally outweigh the theoretical or proven risks. | Tin use the method. |
| U.S. MEC 3 | A condition for which the theoretical or proven risks of the contraceptive method more often than not outweigh its advantages. | Should not apply the method unless no other method is appropriate and acceptable. |
| U.s.a.MEC4 | A condition for which the contraceptive method poses an unacceptable health risk. | Should not apply the method. |
Failure rates represent a style to appraise the efficacy of various contraceptive methods. For a given method, the failure rate is the percentage of users who have an unintended pregnancy during the first yr of use; a lower failure rate indicates higher efficacy. For context, consider that upwards to 85% of women who accept unprotected intercourse will experience an unintended pregnancy inside a year.9 Failure rates for perfect and typical use of a given contraceptive method are also distinguished. Perfect use reflects method use when instructions are followed exactly and consistently; typical use reflects existent-life use, when the method may not be used consistently or perfectly.
Many people have questions almost the timing of return to fertility subsequently stopping contraceptive use. The return to fertility is relatively rapid afterward cessation of almost all hormonal and nonhormonal methods, with the exception of depot medroxyprogesterone acetate (DMPA). For example, in one report among women who discontinued combined hormonal contraception, pregnancy rates were 57% at three months and 81% at 12 months after cessation.10 Conversely, ovulation may not resume for 15 to 49 weeks afterwards 1's final DMPA injection, according to i systematic review.ten
Method safety, efficacy, and return to fertility are non the only considerations that influence contraceptive selection. It's important for nurses and other providers to empathise that individuals will value different features of various contraceptive methods. Personal preferences (such every bit for a hormonal or nonhormonal method, ease and condolement with mode of use, partner credence, furnishings on the sexual experience, forcefulness of desire to avoid pregnancy, and religious or spiritual behavior and practices), medical considerations (such as whether the method protects against sexually transmitted infections [STIs], potential side effects), and structural factors (such as immediate and ongoing costs, ability to begin or stop use without needing access to health care)—all of these elements play a function.11–14 Seeing the whole picture will better equip nurses to assist patients choose a method virtually aligned with their preferences and needs.
In this commodity, nosotros depict the about mutual nonpermanent contraceptive methods; summarize their efficacy, mechanisms of action, uses, common adverse effects, and contraindications; and review the modes of administration of each blazon. Emergency contraception lies across the telescopic of this article and is not addressed.
HORMONAL CONTRACEPTIVES
Combined hormonal contraceptives
(CHCs) are among the nigh commonly prescribed and well-researched types of medication in use.1, xv Synthetic estrogen and progestin revolutionized modern family planning when this combination start came on the market in pill form in 1960. Today CHCs tin exist delivered through a pill, patch, or vaginal ring with similar failure rates: less than 1% with perfect use and 7% to nine% with typical use.ix, sixteen, 17
In CHCs, both progestins and estrogen inhibit the hypothalamic–pituitary–ovarian centrality, which controls the reproductive cycle (see Effigy 1).eighteen Progestins prevent pregnancy by inhibiting the luteinizing hormone (LH) surge, thus suppressing ovulation, thickening the cervical mucus, lowering fallopian tube motility, and causing the endometrium to become atrophic.18 Estrogens prevent pregnancy by suppressing follicle-stimulating hormone (FSH) product, which prevents the development of a dominant follicle.xviii Progestin is responsible for the bulk of both contraceptive action and side effects; the addition of estrogen helps forestall irregular or unscheduled bleeding.nine
The Hormonal Regulation of Ovulation
At left: the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to secrete the gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH stimulate the growth and maturation of the ovarian follicles. The mature follicle secretes estrogen, inhibiting the hypothalamus from further GnRH production (until the next reproductive wheel). At right: after ovulation, blood levels of LH and FSH fall, and the ruptured follicle, now a corpus luteum, secretes estrogen and progesterone to prepare the uterine lining for fertilization and implantation. Adjusted with permission from Encyclopædia Britannica, © 2013 by Encyclopædia Britannica, Inc.
Traditionally, users have CHCs for three weeks, then placebo pills or zippo for 1 week. The hormone-costless week prompts "withdrawal bleeding," caused by withdrawal from active CHC ingredients, that mimics the menstrual cycle and may provide balls that the user isn't pregnant.18 Nurses can educate their patients that withdrawal haemorrhage is non bodily menses and isn't clinically necessary.eighteen, 19
Common side effects of CHCs include lighter, shorter periods (40% to l% reduction in menstrual catamenia); irregular bleeding (breakthrough bleeding or spotting); amenorrhea; nausea; chest tenderness; emotional lability; headaches; and reduced premenstrual syndrome symptoms (such as bloating, cramping, and acne).18 CHCs are besides associated with reduced gamble of ovarian, endometrial, and colon cancer, and are essential in treating polycystic ovarian syndrome.18 As with other methods, information technology's difficult to predict which individuals will experience which side effects and how severe these volition be. Certain side furnishings, especially amenorrhea, may be considered benign by some people but unacceptable by others.20 These may be referred to equally "noncontraceptive benefits" of these methods.
CHC contraindications (U.S. MEC four–category conditions) include beingness historic period 35 years or older and smoking 15 or more cigarettes per twenty-four hours; being less than 21 days postpartum; having a systolic blood pressure level of 160 mmHg or greater, or a diastolic blood pressure of 100 mmHg or greater; having had major surgery with prolonged immobilization; experiencing migraine with aura; and being at elevated risk for recurrent deep vein thrombosis or pulmonary embolism.viii
CHCs are however effective when taken concurrently with many medications, including about commonly used antibiotics. But concurrent use of sure medications—including rifampin (Rifadin) or rifabutin (Mycobutin) therapy, the antiretroviral drug fosamprenavir (Lexiva), and certain anticonvulsants—can reduce CHC effectiveness.8 In such cases, use of a nonhormonal backup contraceptive method is recommended.
CHC pills.
Numerous CHC pills are currently available on the market place. Typically, pills contain a ombination of 10 to 35 mcg ethinyl estradiol and one of the four generations of progestins. Different formulations take different side effect profiles, so patients may need to endeavor some other formulation if an undesirable side effect occurs.
Pills should exist taken at about the aforementioned time every day to maintain ovulation suppression. This frequent dosing is one of the major drawbacks of pill use, and missing a pill is mutual, regardless of historic period.16 In general, nurses should counsel patients that a missed pill should be taken as soon as information technology is remembered. Ovulation suppression is not guaranteed if more than than 48 hours have elapsed since the terminal pill was taken. Missing a unmarried pill will have little result on effectiveness, but if ii pills are missed, the most recent pill should exist taken as before long as possible, and a fill-in method (such as condoms) should exist used for seven days.18
Pills tin be initiated at whatsoever time. A "Lord's day start" has been popular in the by considering it typically ensures that the withdrawal bleed does not occur on weekend days. Recently, a "quick start,"starting the pill on the day of visit, has become more popular because, at least initially, it'southward associated with improve adherence, and there is no increment in the incidence of irregular bleeding.21
Extended and continuous use are increasingly popular dosing regimens. Extended use involves using the CHC for longer than the typical month-long cycle, thereby giving the user an extended time between withdrawal bleeds. This can be achieved by taking pills specifically designed for such regimens or by simply skipping the placebo pills in a 28-day pill pack (though users will run out of pills more quickly). Continuous employ involves taking CHCs without intermission for an indefinite time. Extended and continuous use regimens have been associated with improved ovulation suppression, increased medication adherence, high user acceptability, decreases in scheduled bleeding, and less breakthrough bleeding over time.19, 22 Moreover, decreasing or eliminating periods can be preferable for patients who accept period-related mood changes, headaches, painful cramping, heavy menstruum, or other estrogen-related changes. While extended and continuous use regimens accept primarily been studied regarding CHC pills, in that location is bear witness of similar efficacy among CHC patch and vaginal band users.23
CHC transdermal patch.
The CHC transdermal patch (Xulane), a thin square about 2 inches across, contains 150 mcg norelgestromin and 35 mcg ethinyl estradiol (meet Figure 2). Information technology can be placed on the stomach, upper arm, buttock, or back, and must be completely attached to the skin to be effective. The patch is replaced every calendar week for iii weeks; during the fourth week no patch is worn and a withdrawal drain occurs. Weekly application is highly-seasoned for those who don't want the burden of daily pill taking. In 2014, the patch became available as a generic product.
While contraindications for CHCs utilize to all commitment methods, there are some additional concerns with the patch. Findings from early research suggested at that place was an increased risk of venous thromboembolism (VTE) with the patch compared to CHC pills, only later on research has yielded conflicting results.24, 25 The U.S. Nutrient and Drug Administration (FDA) recommends that the same guidelines regarding VTE exist practical to both methods: CHC pills and the patch should be avoided in patients at high adventure for clots, such as those who take a history of or current VTE or surgery requiring immobilization.24, 26 The patch besides causes skin irritation in most 20% of users, though only about 3% discontinue the method for this reason.17
CHC vaginal ring.
The band (NuvaRing) is a clear, flexible ring almost two inches in diameter that is placed in the vagina for 21 days and removed for seven days to permit for withdrawal haemorrhage; information technology's replaced monthly (see Figure 3). It releases 15 mcg/twenty-four hour period of ethinyl estradiol and 120 mcg/day of etonogestrel. Users can simply place the band in the vaginal canal themselves. As with the patch, the less frequent applications can be appealing and can lead to increased adherence.17 The ring'southward internal placement ensures the steady delivery of hormones, which allows for lower serum concentrations than occur with either the patch or pills. As a result, the ring generally has milder side furnishings than are seen with other CHC commitment methods.17 Some users may feel increased vaginal irritation and discharge.17 There is also some evidence of reduced vaginal dryness, which may appeal to perimenopausal women and others who tend to experience such dryness.
Ring users may have concerns near their risk for pregnancy if the band is removed intentionally or accidentally. The ring can be removed for up to 3 hours without diminishing its contraceptive upshot. This gives users the selection of removing it during sex if they prefer. The manufacturer recommends rinsing the device in cool or lukewarm h2o prior to reinsertion.27 If the ring is out for more than than three hours, users should have extra steps to protect confronting pregnancy. Equally with whatsoever device, users should consult the package insert for more specific instructions.
Progestin-only methods
include pills, injections, implants, and intrauterine devices (IUDs). Without concomitant estrogen, progestin-but methods pose less risk of VTE than CHCs.28 While the safe of the CHC pill, patch, and ring are addressed collectively in the U.Due south. MEC, the progestin-only methods are given separate safe profiles. Like CHCs, progestin-only methods require a prescription.
Progestin-only pills (POPs).
POPs are generally made with first-generation progestins, and dosage amounts are substantially lower than those plant in whatsoever CHC. Like CHCs, POPs should be taken at the same time of day. They are used continuously, with no hormone-gratuitous interval. Despite their pharmacokinetic differences, failure rates are oft reported together: Hatcher and colleagues report that for both types of pills, the failure rate is less than ane% with perfect utilise and 7% with typical use.9 That said, POPs take a higher failure rate when non taken at the same time every 24-hour interval, because constructive drug levels are maintained in the bloodstream for merely 22 hours.9 Nurses should caution patients that they must be vigilant about adhering to the dosing schedule. The almost common side effects of POPs are unscheduled bleeding and spotting, likely due to the shorter daily window of efficacy and the absence of estrogen.18
POPs are considered safe in many clinical scenarios wherein CHCs are contraindicated (as noted above). As with CHCs, patients should use a nonhormonal fill-in method when taking sure medications, including rifampin or rifabutin therapy, the antiretroviral drug fosamprenavir, and sure anticonvulsants.eight
DMPA injection.
DMPA (Depo-Provera) is available equally a 150 mg/mL intramuscular injection or a 104 mg/mL subcutaneous injection given every 12 to 13 weeks.eighteen, 29 Injections must be administered past a provider. The failure rate is less than ane% with perfect utilize and 4% with typical use.9 In addition to the aforementioned progestin mechanisms of action, DMPA likewise affects the hypothalamic–pituitary–ovarian axis at the hypothalamus, inhibiting ovulation through suppression of gonadotropin-releasing hormone.xviii
Irregular periods are a common side effect. Ane systematic review found that, after a year of regular employ, merely 12% of DMPA users had regular periods and 46% had amenorrhea.30 Although personal preferences vary, amenorrhea may be seen as beneficial past patients with anemia, endometriosis, fibroids, dysmenorrhea, or menorrhagia.9 Other potential side effects include weight gain, impaired glucose metabolism, os mineral density loss, headache, and mood changes (specifically low).18 Because DMPA is 1 of the more than detached methods available, it may appeal to people wishing to proceed their contraception private.
DMPA has few contraindications and nearly no drug interactions. Additional benefits include decreased risk of endometrial cancer and pelvic inflammatory illness, reduced incidence of epileptic seizures, and reduced frequency of sickle cell crises.9, 29
Implants.
Implants and IUDs containing progestin, equally well as IUDs without hormones, are collectively referred to as long-acting reversible contraception (LARC). LARC insertions and removals are within the telescopic of practice of advanced practice clinicians, including NPs and certified nurse midwives. Once inserted, LARCs involve little user effort to maintain contraceptive efficacy.
The unmarried-rod implant (Implanon, Nexplanon), which is about the size of a matchstick, is inserted in the upper arm and can remain in place for up to 3 years (see Figure four). The implant contains 68 mg of etonogestrel that is released incrementally at slowly diminishing rates, from 60 to 70 mcg/day initially to 25 to 30 mcg/24-hour interval by the terminate of the third year.31 Failure rates with both typical and perfect use are below 1%.9 The well-nigh unremarkably reported reasons for discontinuation include irregular bleeding (x%), emotional lability (2%), and weight gain (2%).32 The implant method tin can appeal to people who want a long-term, reversible, highly effective method merely are uncomfortable with having devices in the vagina or uterus or with insertion procedures at those sites.18 The implant is prophylactic for the vast majority of people, though in that location are contraindications for some specific conditions, such as active breast cancer.8
IUDs with progestin (also chosen intrauterine systems [IUSs]).
With both typical and perfect employ, IUDs have failure rates beneath 1%.9 Those with progestin alter the cervical mucus such that sperm cannot pass through the cervix to access the upper reproductive tract.
Four levonorgestrel (LNG) IUDs are bachelor on the U.Due south. market, with similar effectiveness but varying doses, elapsing, and side effects.33 The naming convention uses a number to indicate the boilerplate number of micrograms of LNG released per day. The LNG-IUS 20 (Mirena) and LNG-IUS 12 (Kyleena) can be used up to five years. The LNG-IUS 20 (Liletta, designed as a lower-cost version of Mirena) can be used up to 4 years, and the LNG-IUS viii (Skyla) up to iii years. The LNG-IUS 12 and LNG-IUS 8 are smaller in size, which makes insertion easier. Amenorrhea occurs in 20% of LNG-IUS 20 users afterward one twelvemonth, in 12% of LNG-IUS 12 users after one year, and in 12% of LNG-IUS 8 users after three years.
Contraindications to IUD use include current purulent cervicitis, chlamydia infection, gonorrhea infection, or pelvic inflammatory disease at the time of insertion.21 If pelvic inflammatory affliction develops afterwards insertion, a course of antibiotics may be prescribed, and removal may be warranted.
Despite their condom and efficacy, IUD use in the The states is lower than in other parts of the industrialized world.34 IUDs have a fraught history, the legacy of which may affect patient and provider attitudes (encounter Are IUDs Safe? 8, ix, 35–40). This is slowly starting to alter, and recent substantial declines in unintended pregnancies are attributed, in function, to an increase in the use of LARCs.41
NONHORMONAL METHODS
Nonhormonal methods include the copper IUD, barrier methods with and without spermicides, and behavioral methods. Nonhormonal methods mostly accept fewer risks and side effects considering, by definition, they don't involve exposure to exogenous or constructed hormones. As with hormonal methods, the effectiveness, rubber, and ease of employ of various nonhormonal methods are important user considerations and will strongly influence individual choices.
Copper IUD.
The most constructive reversible nonhormonal method is the copper IUD (Paragard), which has a failure rate beneath 1% with both typical and perfect use; the device tin be used for up to 10 years, and must be inserted by a skilled provider.9, 42 Copper ions are spermicidal. The copper IUD does not bear on ovulation or timing of the menstrual cycle, just information technology is associated with heavier menstrual bleeding and cramping.43 In a three-yr Australian study among 211 users, of the 59 women who discontinued employ though still requiring contraception, 28 did so because of heavy bleeding.44 This side effect may be felt more acutely by users switching from a hormonal method that lessened their normal menstruum; anticipatory guidance from nurses tin help set up such users for this possibility.
The copper IUD may be an appealing option for those who are limited by contraindications to CHCs or progestin-only methods. In addition to the same contraindications for progestin-containing IUDs, copper IUDs are contraindicated for women with copper allergies, uterine infections, or uterine cancer.eight
Bulwark methods (with or without spermicides)
include condoms and diaphragms used at the time of intercourse. Efficacy is highly dependent on user beliefs, and failure rates with typical and perfect utilize vary widely. For the male condom, failure rates with typical and perfect use are 13% and 2%, respectively; for the female prophylactic, 21% and v%, respectively; and for the diaphragm, 17% and 16%, respectively.9
Condoms are bachelor over the counter. Those fabricated from polyurethane or latex preclude the manual of STIs, including HIV infection. Nonlatex condoms fabricated of lambskin are available for individuals with latex sensitivity, only don't protect against STIs.
Diaphragms are inserted into the vaginal canal such that they cake the cervical os and tin be placed up to an hour before intercourse. They require a prescription, and have traditionally come up in multiple sizes, thus requiring plumbing equipment by a provider. Diaphragms are used with a spermicide to increment their effectiveness. In the United States, all commercially available spermicides contain nononoyl-9 (North-9) and are sold over the counter. N-9 may cause irritation or allergic reactions, and increases the hazard of urinary tract infections.eight The irritation can crusade genital lesions, which may increase the take chances of HIV acquisition. For women with HIV, N-9 irritation is suspected of increasing viral shedding, which increases the likelihood of manual to partners. Thus, spermicide use is contraindicated in people at high risk for contracting HIV and is non recommended for people who have HIV.8
Behavioral methods
include withdrawal, lactational amenorrhea (LAM), and fertility awareness-based methods (FABMs). Withdrawal (often called "pulling out") involves removal of the penis from the vaginal culvert during intercourse but before ejaculation. The failure rates are 20% with typical use and 4% with perfect apply.ix Withdrawal requires good advice and mutual agreement, besides as acceptable physical control past the ejaculating partner. Research indicates that just a very small proportion of individuals utilize withdrawal as their primary contraceptive method; just because it'due south also ordinarily used in conjunction with other methods and might non be considered a "existent" method, its use may exist underreported.45 Withdrawal may be an pick for people who don't want to use other contraceptive methods for religious or cultural reasons.
LAM relies on the natural suppression of the LH surge that occurs during exclusive breastfeeding. Information technology's highly constructive when infants are exclusively fed chest milk on need, when infants are under 6 months of age, and when the woman has not yet resumed menses.eighteen If breastfeeding is nonexclusive or the baby is older than six months, efficacy drops.
FABMs involve fugitive unprotected intercourse during an estimated fertile window, which is determined through a variety of strategies of varying effectiveness. There are limited data about failure rates for each approach46; only collectively, the FABMs appear to have failure rates of 15% with typical utilize and from 0.4% to 5% with perfect use.9 These methods may involve tracking the menstrual cycle, basal torso temperature, cervical mucus, or LH levels in guild to calculate the likely fertile period. Midcycle, the LH surge preceding ovulation is followed by an increase in progesterone, causing a modest just measurable increment in basal trunk temperature. The timing of ovulation varies, even among women with similar cycle lengths.47 Some FABM users might not fully embrace how the method works,48 and nurses can help them attain a ameliorate understanding of their menstrual cycle.
Although FABMs have traditionally been a depression-tech contraceptive method, several mobile apps that support FABMs are now available. An app user inputs the relevant data, and the app uses an algorithm to generate fertility window predictions. Apps algorithms vary, as does the accuracy of their predictions.49, 50 Nurses should explain to patients that most wellness apps aren't regulated by the FDA, and very few have been evaluated in peer-reviewed scientific studies.51 In one study, almost twenty% of FABM apps independent erroneous medical information.50 Moreover, in that location is evidence that some app companies' advertising overstates their product's efficacy.52
For recent developments in contraception, see Innovations in Hormonal and Nonhormonal Methods.53–62
DISPARITIES IN Access AND Use
Considering of economic hardship and institutionalized racism, homophobia, and transphobia, many people have compromised access to the full spectrum of contraceptive options. Studies indicate that such socioeconomic factors play a role in the higher rates of unintended and unwanted pregnancies observed among Blackness and Latina women compared with white women in the United States, as well as influencing user preferences.xiv, 63 Blackness and Latina women tend to report lower rates of overall contraceptive use and prescription contraceptive use, but higher rates of rubber apply and tubal ligation or sterilization.64, 65
Disparate patterns of contraceptive use and options are too related to bias and discrimination within the health intendance system. Barriers to high-quality contraceptive care may emerge in the forms of limited noesis well-nigh contraceptive options, express access to health care generally, receiving biased care from providers, and reproductive coercion. For instance, there is evidence to suggest that providers are more probable to recommend IUDs to Blackness and Latina women with low socioeconomic status than to white women with such condition.66 Explanations for this pattern include that some providers subconsciously run into certain women (that is, women of color or low socioeconomic status) as "not needing" more children, needing a lower-maintenance method, or needing more assistance to finer prevent pregnancy.67 Simply pressuring certain patients into using LARCs undermines their reproductive autonomy and risks continuing historically coercive and racist U.South. contraception policies. Every bit frontline providers, nurses can address these disparities by engaging in reflexive nursing practices and working to disengage institutionalized racism.68
Members of sexual and gender minorities—including those who identify equally lesbian, gay, bisexual, queer, transgender, or gender nonbinary—as well require access to contraceptive services. But they often have limited access to safe, affirming health care of all types. Members of these minorities accept pregnancy and childbearing histories, plans, and desires equally diverse equally those of any other population. Many nonheterosexual women take been pregnant and given birth, and many have a want to do so.69 Others regularly have sex that could atomic number 82 to pregnancy, and need and want reliable and consequent contraception.70, 71 Nevertheless others may rarely or never have penile–vaginal intercourse, and use contraception mainly for its noncontraceptive benefits, such every bit menstrual regulation, or acne or endometriosis treatment.72
Many transgender or nonbinary individuals who have a uterus and ovaries are capable of becoming pregnant through penile–vaginal intercourse.73 Testosterone therapy in transgender men is not a reliable contraceptive method, though this misconception is common.74 Access to constructive contraception may be especially critical for transgender men or transmasculine people, since many desire menses suppression.75, 76 Clinical and anecdotal show likewise suggest that period and pregnancy may trigger or heighten feelings of gender dysphoria or may put condom at risk past "outing" i as transgender or transmasculine.77, 78 Some members of these minorities may accomplish amenorrhea and pregnancy prevention with sterilization. Others may want to end menstruating but retain the possibility of becoming pregnant afterward in life. Nurses can let such patients know that this may be possible with progestin-merely IUDs. Estrogen-containing contraceptives may cause amenorrhea but are contraindicated in people on masculinizing hormone therapy.
An essential component of patient-centered nursing do is the delivery of individualized care; this includes avoiding assumptions about a patient'due south reproductive health priorities and needs based on membership in a detail group. Individuals from any marginalized or stigmatized group who have experienced bias and discrimination in health care might have learned to look the same from time to come encounters. It's of import for nurses in all clinical settings to empathise how such history can affect patients' current experiences and the nurse–patient human relationship. By applying nursing skills such equally taking thorough health histories, listening actively to patients' reproductive health priorities, and referring patients to appropriate wellness care services, nurses may exist able to meliorate these relationships and clinical outcomes.
CONCLUSION
It'southward vital that nurses in all settings and specialties stay current on the latest prove regarding contraception. Outset, this is essential to fulfilling the World Health Organisation's recommendation to provide comprehensive contraceptive patient education79 and the ANA'south ethical mandate to support the reproductive cocky-conclusion of all patients.six Second, nurses can provide amend patient-centered care if they can competently address patients' family planning concerns and questions with electric current and testify-based knowledge. We recognize that this is challenging, as new types of contraception, hormonal formulations, commitment systems, and indications for employ are ever being developed. For a listing of resources that will help nurses stay upwards to date, see Resources for Nurses. Lastly, actively addressing the concerns of patients from stigmatized groups will ultimately contribute to efforts to resolve disparities in contraceptive care and work toward reproductive justice for all.▼
Footnotes
The authors and planners have disclosed no potential conflicts of involvement, financial or otherwise.
A podcast with the authors is bachelor at www.ajnonline.com.
For four additional continuing nursing education activities on the topic of contraception, go to www.nursingcenter.com/ce.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533104/
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