contraceptive methods literature review

• Introduction
• Conclusions
• Article Information

This algorithm has not been validated for clinical use. IUD indicates intrauterine device; PATH, Pregnancy Attitudes, Timing, and How important is pregnancy prevention.

This algorithm has not been validated for clinical use. BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); MEC, Medical Eligibility Criteria for Contraceptive Use.

• Selection, Effectiveness, and Adverse Effects of Contraception—Reply JAMA Comment & Response April 19, 2022 Stephanie Teal, MD, MPH; Alison Edelman, MD, MPH
• Selection, Effectiveness, and Adverse Effects of Contraception JAMA Comment & Response April 19, 2022 Ekaterina Skaritanov, BS; Gianna Wilkie, MD; Lara C. Kovell, MD
• Contraception in Women With Cardiovascular Disease JAMA JAMA Insights August 9, 2022 This JAMA Insights in Women’s Health series summarizes the prevalence of cardiovascular disease among women of childbearing age, the most effective forms of contraception based on the patient’s medical condition and preference, and the risks and adverse effects associated with contraindicated forms of contraception. Kathryn J. Lindley, MD; Stephanie B. Teal, MD, MPH
• Patient Information: Long-Acting Reversible Contraception JAMA JAMA Patient Page October 4, 2022 This JAMA Patient Page describes types of long-acting reversible contraception, how they are placed and removed, and their potential side effects. Elisabeth L. Stark, MD; Aileen M. Gariepy, MD, MPH, MHS; Moeun Son, MD, MSCI
• Patient Information: Medication Abortion JAMA JAMA Patient Page November 1, 2022 This JAMA Patient Page describes medication abortion and its risks and effectiveness. Rebecca H. Cohen, MD, MPH; Stephanie B. Teal, MD, MPH

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Teal S , Edelman A. Contraception Selection, Effectiveness, and Adverse Effects : A Review . JAMA. 2021;326(24):2507–2518. doi:10.1001/jama.2021.21392

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Contraception Selection, Effectiveness, and Adverse Effects : A Review

• 1 Department of OB/GYN, University Hospitals Medical Center and Case Western Reserve University, Cleveland, Ohio
• 2 Department of OB/GYN, Oregon Health & Science University, Portland
• Comment & Response Selection, Effectiveness, and Adverse Effects of Contraception—Reply Stephanie Teal, MD, MPH; Alison Edelman, MD, MPH JAMA
• Comment & Response Selection, Effectiveness, and Adverse Effects of Contraception Ekaterina Skaritanov, BS; Gianna Wilkie, MD; Lara C. Kovell, MD JAMA
• JAMA Insights Contraception in Women With Cardiovascular Disease Kathryn J. Lindley, MD; Stephanie B. Teal, MD, MPH JAMA
• JAMA Patient Page Patient Information: Long-Acting Reversible Contraception Elisabeth L. Stark, MD; Aileen M. Gariepy, MD, MPH, MHS; Moeun Son, MD, MSCI JAMA
• JAMA Patient Page Patient Information: Medication Abortion Rebecca H. Cohen, MD, MPH; Stephanie B. Teal, MD, MPH JAMA

Importance   Many women spend a substantial proportion of their lives preventing or planning for pregnancy, and approximately 87% of US women use contraception during their lifetime.

Observations   Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. In the US, oral contraceptive pills are the most commonly used reversible method of contraception and comprise 21.9% of all contraception in current use. Pregnancy rates of women using oral contraceptives are 4% to 7% per year. Use of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis from 2 to 10 venous thrombotic events per 10 000 women-years to 7 to 10 venous thrombotic events per 10 000 women-years, whereas progestin-only and nonhormonal methods, such as implants and condoms, are associated with rare serious risks. Hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder. Optimal contraceptive selection requires patient and clinician discussion of the patient’s tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences.

Conclusions and Relevance   Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Contraception is defined as an intervention that reduces the chance of pregnancy after sexual intercourse. According to a report from 2013, an estimated 99% of women who have ever had sexual intercourse used at least 1 contraceptive method in their lifetime. 1 Approximately 88% of sexually active women not seeking pregnancy report using contraception at any given time. 2 All nonbarrier contraceptive methods require a prescription or initiation by a clinician. Therefore, contraception is a common reason women 15 to 50 years of age seek health care. 3 This review summarizes current evidence regarding efficacy, adverse effects, and optimal selection of reversible contraceptives. This review uses the terms women and men when the biological expectation for the individual is ovulation or sperm production, respectively.

A search of OVID Medline All, Embase.com, and Ovid Evidence-Based Medicine Reviews–Cochrane Central Register of Controlled Trials for English-language studies was conducted for articles published between January 1, 2000, and June 28, 2021, to identify randomized clinical trials, systematic reviews, and practice guidelines related to contraception or contraceptives. After excluding duplicates and articles not relevant to this review, 2188 articles were identified as potentially relevant via title or abstract content. Thirty-seven articles, consisting of 13 randomized clinical trials, 22 systematic reviews, and 2 guidelines were included. Evidence-based guidelines that used GRADE and systematic reviews were selected for inclusion over individual studies. Clinical practice guidelines from the Society of Family Planning, the World Health Organization, and the American College of Obstetricians and Gynecologists on selected topic areas were reviewed to identify additional key evidence.

The mean age of first sexual intercourse among females in the US is 17 years. 4 Many women typically use contraceptives for approximately 3 decades. 2 The choice of contraceptive is determined by patient preferences, tolerance for contraceptive failure, and adverse effects. Clinicians should elicit patient preferences, identify possible contraindications to specific contraceptives, and facilitate contraceptive initiation and continuation. Clinicians should also be prepared to address misperceptions ( Box ). Some experts recommend screening for contraceptive need at each visit. Two validated screening options, with toolkits available online, are One Key Question and the PATH questions (Pregnancy Attitudes, Timing, and How important is pregnancy prevention). 5 , 6

Commonly Asked Questions About Contraception

What options are available for male contraception? There are currently no Food and Drug Administration–approved contraceptive options for men except condoms. Current male contraceptive methods under evaluation attempt to suppress sperm count to <1 million/mL and include a testosterone plus progestin topical gel.

Are contraceptives associated with increased rates of cancer? Combined hormonal contraceptives, such as combined oral contraceptive pills, protect against endometrial and ovarian cancer. They are associated with an increased risk of early breast cancer diagnosis in current or recent users (ie, within the past 6 mo). The incidence is 68 cases per 100 000 person-years compared with 55 cases per 100 000 nonuser-years. There are no associations of past contraceptive use with increased rates of cancer and there is no association of past contraceptive use and mortality.

Can teenagers use intrauterine devices (IUDs)? Prior guidance suggested restricted use of IUDs by teenagers, nonmonogamous or unmarried, and nulliparous women, but there is no high-quality evidence to support this recommendation. None of these characteristics are true contraindications.

Should all women use the most effective form of contraception? The choice of contraceptive is determined by patient preferences and tolerance for failure. Patients may value other attributes of a method (such as route of administration or bleeding patterns) more highly than effectiveness, and may prefer to have a slightly higher risk of unplanned pregnancy to avoid other adverse effects.

Is the pill as effective for individuals with obesity? Obesity adversely influences contraceptive steroid levels but determining whether this affects contraceptive effectiveness is difficult. The primary reason for contraceptive failure is suboptimal adherence. The use of any method for individuals no matter their weight will prevent more pregnancies than not using a method.

Why are pills not available over the counter (OTC)? Combined hormonal contraceptives are unlikely to be available OTC in the US due to concerns regarding increased rates of thrombosis. Efforts to bring progestin-only pills OTC are progressing.

Quiz Ref ID Reversible contraceptive methods are typically grouped as hormonal (such as progestin-only pills or estrogen-progestin patches) or nonhormonal (condoms, diaphragms) and long-acting (such as intrauterine devices [IUDs]) or short-acting (such as pills). Reversible contraceptive methods can also be grouped by level of effectiveness for pregnancy prevention. Except for behavioral methods, condoms, and spermicide, contraceptive methods are only available by prescription in the US.

Progestins and estrogens are steroid or lipid hormones. Hormonal contraception contains a progestin with or without an estrogen. Progesterone is the only naturally occurring progestin; most contraceptive progestins, such as levonorgestrel and norethindrone, are synthesized from testosterone. Progestins provide a contraceptive effect by suppressing gonadotropin-releasing hormone from the hypothalamus, which lowers luteinizing hormone from the pituitary, which in turn prevents ovulation. 7 , 8 In addition, progestins have direct negative effects on cervical mucus permeability. Progestins reduce endometrial receptivity and sperm survival and transport to the fallopian tube. 9 - 11 Estrogens enhance contraceptive effectiveness by suppressing gonadotropins and follicle-stimulating hormone, preventing the development of a dominant follicle. However, the most important contribution of estrogens to progestin-based contraceptives is the reduction of irregular bleeding. The estrogen component in most combined hormonal contraceptives is ethinylestradiol.

A variety of progestin-only contraceptive methods exists ( Table 1 ). Their effectiveness varies based on dose, potency, and half-life of the progestin as well as user-dependent factors, such as adherence to the prescription schedule. 12 , 13

Progestin-only pills include norethindrone- and drospirenone-containing formulations, which differ in their ability to suppress ovulation. Norethindrone pills contain 300 µg of norethindrone compared with 1000 µg in a typical combined contraceptive pill. The lower amount of progestin in norethindrone pills results in less consistent ovulation suppression and more potential for breakthrough bleeding. The contraceptive efficacy is maintained by other progestin-mediated effects. Drospirenone-only pills contain slightly more progestin than an estrogen and progestin combined hormonal contraception, which aids in ovulation suppression. In one study in which participants delayed their drospirenone-containing pill intake by 24 hours, mimicking a missed dose, ovulation suppression was maintained with only 1 participant of 127 having evidence of ovulation. 14 The benefits of progestin-only contraceptive pills include ease of initiation and discontinuation, fertility return within 1 cycle, safety profile, and minimal effect on hemostatic parameters. 15

Quiz Ref ID Depot medroxyprogesterone acetate (DMPA) is an injectable progestin available in intramuscular (150 mg) and subcutaneous (104 mg) formulations, which are administered at 12- to 14-week intervals. While DMPA is associated with irregular uterine bleeding, this pattern improves with longer duration of use. A systematic review of DMPA-related bleeding patterns (13 studies with 1610 patients using DMPA) found that 46% of those using DMPA were amenorrheic in the 90 days following the fourth dose. 16 DMPA is the only contraceptive method that can delay return to fertility. The contraceptive effect and cycle irregularity can persist for up to 12 months after the last dose, 17 likely due to persistence in adipose tissue and its effectiveness in suppressing the hypothalamic-pituitary-ovarian (HPO) axis. DMPA may be best suited for those who benefit from amenorrhea (eg, patients with developmental disabilities, bleeding diatheses) but not by those who want to conceive quickly after discontinuation. Typical effectiveness of DMPA and progestin-only contraceptive pills is 4 to 7 pregnancies per 100 women in a year. 12 , 18

Quiz Ref ID Progestin-only long-acting methods, such as the levonorgestrel (LNG) IUD and the subdermal implant, have typical effectiveness rates of less than 1 pregnancy per 100 women per year similar to permanent methods, such as tubal ligation or vasectomy ( Table 2 ). 12 , 18 These methods are also associated with return to fertility within 1 cycle after discontinuation. The LNG IUD maintains efficacy for at least 7 years, with amenorrhea rates of up to 20% at 12 months and 40% at 24 months. 19 However, initiation requires an in-person visit with a clinician trained in IUD placement. The etonogestrel subdermal implant is effective for up to 5 years 20 and is easily placed or removed. Initiation and discontinuation also require in-person visits. The bleeding profile of the implant is less predictable and up to 11% of users remove it in the first year due to irregular bleeding. 21 An analysis of 11 studies (923 participants) from Europe, Asia, South America, and the US found that the bleeding pattern in the first 3 months (such as prolonged, frequent, or irregular episodes) is consistent with future bleeding patterns. 21 However, those with frequent or prolonged bleeding in the first 3 months have a 50% chance of improvement in the subsequent 3 months. 21

Combined hormonal methods that contain both estrogen and progestin include the daily oral pill, monthly vaginal ring, and weekly transdermal patch. With full adherence, effectiveness of these methods is 2 pregnancies per 100 users per year. However, typical effectiveness is 4 to 7 pregnancies per 100 women per year, with variability in effectiveness related to the user’s adherence. 12 , 18 The importance of patient adherence to hormonal contraception was recently demonstrated by a cohort study of approximately 10 000 individuals in the US. Pregnancy rates were 4.55 per 100 participant-years for short-acting methods (pills, patch, ring) compared with 0.27 for long-acting reversible methods (IUD, implant). 13 Women younger than 21 years using short-acting methods had higher pregnancy risk as women 21 or older (adjusted hazard ratio, 1.9 [95% CI, 1.2-2.8]). 13 No risk differences by age were observed for the long-acting reversible methods of IUD or implant. Absolute rates were not reported by age stratum.

Combined hormonal contraceptives prevent pregnancy through the same mechanisms as progestin-only methods. Their greatest advantage over progestin-only methods is their ability to produce a consistent, regular bleeding pattern. In a study that compared bleeding diaries from 5257 women using 9 different methods of contraception (nonhormonal, combined hormonal contraception, and progestin-only), approximately 90% of combined hormonal contraception pill users (n = 1003) over a 90-day standard reference period reported regular scheduled withdrawal bleeds while no one experienced amenorrhea. 22 Occasionally, patients do not have a withdrawal bleed during the placebo week. A pregnancy test can be performed if the patient or clinician is concerned about the possibility of pregnancy as the reason for not bleeding. If pregnancy is ruled out, the lack of withdrawal bleeding is due to HPO axis suppression and patients can be reassured that lack of withdrawal bleeding does not indicate a health problem or reduced fertility.

Regardless of the route of delivery, ethinylestradiol and other estrogens are metabolized by the liver and activate the hemostatic system. The most significant risk of combined hormonal contraception is estrogen-mediated increases in venous thrombotic events. 23 - 25 Large international cohort studies have identified the risk of deep vein thrombosis at baseline in reproductive-aged women to be approximately 2 to 10 per 10 000 women-years. The risk associated with combined hormonal contraception is approximately 7 to 10 venous thrombotic events per 10 000 women-years. 26 - 28 The risk of venous thromboembolism is substantially greater in pregnancy. One UK study of 972 683 reproductive-aged women with 5 361 949 person-years of follow-up found a risk of deep vein thrombosis of 20 per 100 000 in women who were not pregnant. This rate increased to 114 per 100 000 women-years in the third trimester of pregnancy and to 421 per 100 000 in the first 3 weeks postpartum. 29 The absolute risk of ischemic stroke in reproductive-aged women not taking combined hormonal contraception is 5 per 100 000 women-years. 25 Combined hormonal contraception is associated with an additional absolute risk of approximately 2 per 100 000 (ie, overall risk of 7 per 100 000). 25 This study did not exclude women who smoked cigarettes or had hypertension. 25

Clinicians who prescribe combined hormonal contraception should counsel women regarding signs and symptoms of arterial and venous thrombosis, especially for women with multiple additional risk factors, including body mass index (calculated as weight in kilograms divided by height in meters squared) at or over 30, smoking, and age older than 35 years. While progestins are not associated with an increase in thromboembolic risks, 30 , 31 US Food and Drug Administration package inserts for these methods contain “class labeling” or the same risks as estrogen and progestin combined hormonal contraceptive methods. Patients at increased risk of thrombosis can be provided a progestin-only, nonestrogen-containing method because this method of contraception does not increase risk of venous thromboembolism. 32

Behavioral contraceptive methods include penile withdrawal before ejaculation and fertility awareness–based methods. Imprecise terms, such as natural family planning , the rhythm method , or other euphemisms may be used by patients when referring to these methods. The effectiveness of withdrawal and fertility awareness depends on patient education, cycle regularity, patient commitment to daily evaluation of symptoms (first morning temperature, cervical mucus consistency), and the patient’s ability to avoid intercourse or ejaculation during the time of peak fertility. Data on pregnancy rates are frequently of poor quality and highly dependent on study design. 33 A meta-analysis of higher-quality prospective studies of women at risk for undesired pregnancy reported failure rates of 22 pregnancies per 100 women-years for fertility awareness methods. 34

Other nonhormonal methods prevent sperm from entering the upper reproductive tract through a physical barrier (condoms and diaphragms) or through agents that kill sperm or impair their motility (spermicides and pH modulators). First-year typical use effectiveness for these methods is 13 pregnancies per 100 women in a year. 12 , 18

The copper-bearing IUD is a highly effective nonhormonal reversible method. 12 , 18 Typical use pregnancy rates are 1% per year. 12 , 18 There is no effect on a user’s HPO axis and thus ovulation and menstrual cyclicity continues. The primary mechanism of action is spermicidal, through direct effects of copper salts and endometrial inflammatory changes. 35 The major challenge with the copper IUD is that it can increase the amount, duration, and discomfort of menses mostly during the first 3 to 6 months of use. 36 IUD use does not increase later risk of tubal infertility. 37 If sexually transmitted infection (STI) testing is indicated, testing can be performed concurrently with IUD placement. 38 - 40 This expedited process of testing for STIs at the time of IUD placement does not increase the risk of pelvic inflammatory disease. The absolute risk of pelvic inflammatory disease after IUD insertion is low in those with (0%-5%) or without (0%-2%) existing gonorrhea or chlamydial infection. 41

Emergency contraception (EC) reduces pregnancy risk when used after unprotected intercourse. The most effective method of EC is a copper IUD, which reduces pregnancy risk to 0.1% when placed within 5 days of unprotected intercourse. 42 A copper IUD also has the added advantage of providing patients with ongoing contraception. LNG IUDs were not previously considered an option for EC. However, in a recent randomized noninferiority trial, women requesting EC who had at least 1 episode of unprotected intercourse within the prior 5 days were randomized to receive a copper IUD (n = 356) or a 52-mg LNG IUD (n = 355). 43 LNG IUD was noninferior to copper IUD (between-group absolute difference, 0.3% [95% CI, −0.9% to 1.8%]). However, the proportion of study participants who had unprotected intercourse midcycle (and therefore were at risk of pregnancy) was not reported. If a patient needs EC and wishes to initiate a 52-mg LNG IUD, it is reasonable to immediately place the IUD plus give an oral EC, 44 given the limited and indirect evidence supporting the LNG IUD alone for EC.

Quiz Ref ID Oral EC consists of a single dose of either a progestin (LNG, 1.5 mg) or an antiprogestin (ulipristal acetate, 30 mg). Both of these agents work by blocking or delaying ovulation. Neither is abortifacient. LNG EC is available over-the-counter; a prescription is needed for ulipristal acetate. The medication should be taken as soon as possible after unprotected intercourse for maximum efficacy but can be taken up to 5 days afterward for ulipristal acetate. 45 - 47 LNG efficacy is diminished after 3 days. Efficacy appears similar between the 2 agents when ingested within the first 72 hours after intercourse (ulipristal acetate EC: 15 pregnancies of 844, LNG EC: 22 pregnancies of 852; reduction in pregnancy without EC use estimated to be 90% less) but pharmacodynamic and clinical studies demonstrated that the ulipristal acetate treatment effect persists up to 120 hours with no pregnancies (0/97). 46 Actual use studies of EC that included 3893 individuals found lower pregnancy prevention rates than expected, which appears to be related to multiple acts of unprotected intercourse both before and after the EC use. 48 , 49 If further acts of unprotected intercourse occur 24 hours after EC use and a regular method of contraception has not been started, EC needs to be taken again. 49 Repeat use of LNG EC results in no serious adverse events; repeat dosing for ulipristal acetate EC has not been specifically studied. 50 Clinicians should review the options for EC with all patients starting a user-controlled method, such as condoms. These patients may be prescribed oral EC to keep at home for immediate use if needed.

Two evidence-based guidelines are available to assist clinicians in evaluating the safety of contraception initiation and use. 32 , 42 These guidelines were developed by the US Centers for Disease Control and Prevention, are updated regularly, and are freely available online and in smartphone apps.

The first is the US Medical Eligibility Criteria for Contraceptive Use 32 (US MEC), which provides information on the safe use of contraceptive methods for women with various medical conditions (eg, diabetes, seizure disorder) and other characteristics (eg, elevated body mass index, tobacco use disorder, postpartum). The US MEC uses a 4-tiered system to categorize level of risk for each disease/contraceptive method combination. 32 The risk tiers are (1) no restrictions exist for use of the contraceptive, (2) advantages generally outweigh theoretical or proven risks although careful follow-up might be required, (3) theoretical or proven risks outweigh advantages of the method and the method usually is not recommended unless other more appropriate methods are not available or acceptable, and (4) the condition represents an unacceptable health risk if the method is used. 32

All clinicians, including advanced practice clinicians, should be familiar with prescribing within US MEC categories 1 and 2 (no restrictions or benefits outweigh risks). For women with underlying health conditions who want to use a category 3 method, such as a woman with a history of breast cancer choosing combined hormonal contraceptives, primary care physicians or specialists should review the detailed evidence listed in the US MEC to advise their patients. Subspecialists in complex family planning who have completed extra fellowship training may provide helpful consultation for patients with multiple contraindications or unusual situations. The US MEC is a guideline, not a mandate. Situations may arise in which specialists recommend an MEC category 3 or 4 method because the alternative to the contraceptive method, pregnancy, places the patient at even greater risk. 32 The US MEC does not include conditions for which there is insufficient evidence to make recommendations, such as aortic aneurysms, Marfan syndrome, or chronic marijuana use. For these patients, clinicians should consider referral to a complex family planning specialist. If the patient needs a method immediately, a progestin-only pill should be considered as a “bridging” method, because these can be used safely by most patients 32 and are more effective than barrier methods such as condoms.

The US MEC addresses common drug interactions with hormonal contraceptives. 32 Contraceptive steroid hormones are metabolized via the hepatic cytochrome P450 pathway. 51 , 52 Drugs that induce this pathway, such as rifampin and barbiturates, or chronic alcohol can impair contraceptive efficacy and drugs that inhibit the pathway, such as valproic acid, cimetidine, or fluconazole, may increase adverse effects. The FDA recognizes a drug-drug interaction as clinically significant if it causes at least a 20% difference in drug levels 53 but an interaction does not necessarily affect contraceptive failure rates. Adherence, continuation, fecundity, and frequency of intercourse also contribute to contraceptive effectiveness. Additionally, most pharmacokinetic studies do not have sufficient statistical power to determine differences in pregnancy rates. The most common drug classes that may interact with hormonal contraceptives are antiretroviral drugs (including efavirenz and ritonavir-boosted protease inhibitors) and anticonvulsant therapies (including carbamazepine, phenytoin, and others). 54 , 55 Evidence from both clinical and pharmacokinetic studies of routinely used antibiotics do not support impaired contraceptive efficacy with concomitant antibiotic prescription, 56 except for rifampin with which ethinylestradiol and progestin area under the curve levels are at least 40% lower. 57 Because the local progestin dose in the LNG IUD is so high, its efficacy is not reduced by drugs that may affect combined hormonal contraceptives, progestin-only contraceptive pills, or the progestin implant. While hormonal contraceptive use can change concentrations of some drugs, 58 this is rarely clinically relevant, except for the reduction in serum concentration of the anticonvulsant lamotrigine.

Another major guideline is the US Selected Practice Recommendations for Contraceptive Use 42 (US SPR, available online or via a smartphone app). The US SPR is organized by contraceptive method. It includes method-specific, up-to-date guidelines, such as how to initiate the method, how to manage bleeding irregularities, and recommended follow-up. For example, the guidelines on IUDs include evidence on medications to ease IUD insertion or IUD management if a pelvic infection occurs. Recommendations related to combined hormonal contraceptives include the number of pill packs that should be provided at initial and return visits or management of vomiting or severe diarrhea while using combined oral contraceptives.

Much of the data on noncontraceptive benefits of hormonal methods come from case-control studies or small comparative trials. However, fair evidence exists that methods that suppress ovulation can be effective in reducing benign ovarian tumors 59 and functional ovarian cysts. 60 Combined hormonal contraceptives diminish hormonally mediated premenstrual dysphoric disorder, with statistically significant mean differences in symptoms, such as headaches, bloating, and fatigue, and functionality scales. 61 The estrogen component of combined hormonal contraception increases hepatic sex hormone–binding globulin, which reduces free testosterone and improves androgen-sensitive conditions, such as acne and hirsutism. Cochrane systematic reviews of combined hormonal contraceptives and both conditions show significant associations with improvement in a variety of measures of acne and hirsutism. 62 , 63 All progestin-containing contraceptives cause endometrial atrophy and, thus, reduce menstrual blood loss and menstrual pain to varying extents. 64 - 66 While progestin-only methods can promote unscheduled or breakthrough bleeding, the total amount of blood loss is reduced and in those with heavy menstrual bleeding, hemoglobin levels can rise by 10 g/L in 12 months. 67 , 68 The LNG IUD has demonstrated efficacy in reduction of heavy menstrual bleeding 69 , 70 (including for women with anticoagulation, fibroids, 71 or hemostatic disorders), primary dysmenorrhea, 36 , 72 endometriosis, 73 adenomyosis, 74 and protection against pelvic infection. 75

Screening for pregnancy is important prior to prescribing contraception. According to the US SPR, clinicians should be “reasonably certain” that the patient is not pregnant. 42 A clinician can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any 1 of the following criteria: (1) is 7 days or less after the start of normal menses; (2) has not had sexual intercourse since the start of last normal menses; (3) has been correctly and consistently using a reliable method of contraception; (4) is 7 days or less after spontaneous or induced abortion; (5) is within 4 weeks’ postpartum; and (5) is fully or nearly fully breastfeeding (exclusively breastfeeding or most [≥85%] of feeds are breastfeeds), amenorrheic, and less than 6 months postpartum.

Quiz Ref ID These criteria have a negative predictive value of 99% to 100%. 76 - 78 A urine pregnancy test (UPT) alone is not sufficient to exclude pregnancy. UPT sensitivity is dependent on when the last act of intercourse occurred, the ovulatory cycle phase, and urine concentration. Sensitivity of UPTs is 90% at the time of a missed period, but only 40% in the week prior. 79 Additionally, a UPT can remain positive up to 4 weeks after delivery, miscarriage, or abortion. 80 , 81 Few other tests are required for safe and effective use of contraception.

Clinicians can offer other indicated preventive health tests at the contraceptive initiation visit, like screening for cervical cancer or STIs. However, these tests are not required for contraceptive use and should not prevent initiation of contraception.

Generally, all methods should be started immediately on prescription regardless of menstrual cycle day—known as the Quick Start protocol. 82 If a hormonal method is initiated within 5 days of the first day of menses, no additional backup method is needed. At other times in the cycle, or when switching from a nonhormonal to a hormonal method, a backup is necessary for 7 days to ensure ovulation suppression. If switching from one hormonal method to another, the switch can occur without a withdrawal bleed or backup.

If a woman reports unprotected intercourse within the 5 days before contraceptive initiation, most sources recommend giving emergency contraception, initiating her desired method, and repeating a UPT 2 to 3 weeks later. 82 - 85 Many studies have demonstrated that exposing an early pregnancy to hormonal contraception is not harmful 86 but delayed initiation increases the risk of undesired pregnancy.

Because comparative effectiveness studies to clearly identify the superiority of one contraceptive pill formulation over another are lacking, selecting a contraceptive pill often depends on patient experience. Monophasic regimens, in which each pill has the same hormone doses, have significant advantages over bi- and triphasic regimens. Cycles can be extended easily by skipping the placebo week and starting the next pack of active pills. If this is attempted with multiphasic regimens, the drop in progestin between phases typically results in breakthrough bleeding. In terms of ethinylestradiol, few patients require a pill containing more than 35 µg/d to prevent breakthrough bleeding. 87 Many clinicians advocate starting with the lowest ethinylestradiol dose to minimize risks. However, there are no data demonstrating that 10- to 20-µg/d ethinylestradiol doses are safer than 35 µg daily, and lower ethinylestradiol doses are associated with more unscheduled vaginal bleeding. 88 Thus, starting with a monophasic preparation containing 30 µg to 35 µg of ethinylestradiol provides the greatest likelihood of a regular bleeding pattern without increasing risk. Ethinylestradiol can be reduced if patients have estrogen-associated adverse effects, such as nausea or breast tenderness.

Many different progestins exist. Progestins differ in in vitro androgenicity, effects on surrogate metabolic markers, or similarity to testosterone. 89 While molecular structures differ, there is no evidence demonstrating that a particular progestin is superior to others. Traditionally, progestins were classified into “generations” by their parent compound and decade of development. This classification is not clinically useful and should be abandoned. 90 Patients sometimes prefer a pill that they used previously, and if no contraindications exist and the cost is acceptable to the patient, it is reasonable to prescribe it ( Figure 1 and Figure 2 ).

Combined hormonal contraceptives can be dosed in a cyclic or continuous fashion. Originally, birth control pills were dosed with 21 days of active drug and a 7-day placebo week to trigger a monthly withdrawal bleed, meant to mimic the natural menstrual cycle. However, many women prefer less frequent withdrawal bleeds. 91 Some women report significant adverse effects 92 during this placebo week, such as migraine, bloating, and pelvic pain, and extended use provides an easy way to manage or eliminate these problems. 61 During the placebo week, there is less suppression of the HPO axis. 93 - 95 For these reasons, many newer contraceptive pills have shorter (eg, 4-day) placebo periods. Further, most monophasic combined hormonal contraceptives can be used as extended use (fewer withdrawal bleeds) by having a 4-day placebo period quarterly or continuously (no withdrawal bleed) by eliminating the placebo altogether. Extended and continuous use are associated with improved typical use efficacy, likely because greater overall HPO axis suppression is achieved, which may offset lapses in user adherence. 96 A new vaginal ring (segesterone acetate/ethinyl estradiol vaginal system) is also available, which is prescribed for 1 year, with the patient removing the ring each month for 7 days. 97

This review has several limitations. First, relatively few randomized clinical trials that directly compared contraceptive methods were available. Therefore, contraceptive methods are typically evaluated by their individual efficacy (pregnancies per person-cycles) and not typically by their relative effectiveness compared with another method. Second, the quality of summarized evidence was not evaluated. Third, some aspects of contraception, such as counseling, noncontraceptive health benefits, ongoing contraceptive innovations, and the effect of cultural values, and patient preferences were not covered in this review.

Oral contraceptive pills are the most commonly used reversible contraceptives, IUDs and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Corresponding Author: Stephanie Teal, MD, MPH, Department of OB/GYN, University Hospitals Medical Center and Case Western Reserve University, 11100 Euclid Ave, MAC-5304 Cleveland, OH 44106 ( [email protected] ).

Accepted for Publication: November 10, 2021.

Author Contributions: Drs Teal and Edelman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Both authors.

Acquisition, analysis, or interpretation of data : Both authors.

Drafting of the manuscript : Both authors.

Critical revision of the manuscript for important intellectual content : Edelman.

Administrative, technical, or material support : Both authors.

Supervision : Both authors.

Conflict of Interest Disclosures: Dr Teal reported receiving grants from Merck & Co, Bayer Healthcare, Sebela, and Medicines360, and personal fees from Merck & Co and Bayer Healthcare outside the submitted work. Dr Edelman reported receiving grants from Merck, research funds from HRA Pharma, and royalties from UpToDate outside the submitted work.

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Evidence on factors influencing contraceptive use and sexual behavior among women in South Africa

A scoping review.

Editor(s): Desapriya., Ediriweera

Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.

∗Correspondence: Mbuzeleni Hlongwa, Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Howard College Campus, Glenwood, Durban, 4041, South Africa (e-mail: [email protected] ).

Abbreviations: AACODS = Authority, Accuracy, Coverage, Objectivity, Date, Significance, AIDS = acquired immunodeficiency syndrome, DMPA = depot medroxyprogesterone acetate, HIV = human immunodeficiency virus, HSRC = Human Sciences Research Council, IUCD = intrauterine contraceptive device, LMIC = low and middle-income countries, LNG-IUS = levonorgestrel releasing intrauterine system, MeSH = Medical Subject Headings, MMAT = Mixed Method Appraisal Tool, MRC = Medical Research Council, PCC = Population, Concept, and Context, SA = South Africa, SDGs = Sustainable Development Goals, SSA = Sub-Saharan Africa, STI = sexually transmitted infections, UCTD = Union Catalogue of Theses and Dissertations, WHO = World Health Organization.

How to cite this article: Hlongwa M, Mashamba-Thompson T, Makhunga S, Hlongwana K. Evidence on factors influencing contraceptive use and sexual behavior among women in South Africa: A scoping review. Medicine . 2020;99:12(e19490).

This study does not include any animal or human participants. Ethics approval and consent to participate are not applicable.

The work reported herein was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development under the BONGANI MAYOSI NATIONAL HEALTH SCHOLARS PROGRAM from funding received from the South African National Treasury. The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the SAMRC or the funders.

All the data analyzed and reported in this paper was from published literature, which is already in the public domain.

The datasets generated during and/or analyzed during the current study are publicly available.

The authors have no conflicts of interest to disclose.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

Introduction: 

Contraceptive use and sexual health behavior remain a prominent public health concern in South Africa (SA). Despite many government interventions, unintended pregnancies and termination of pregnancies remain relatively high. This review aimed to map evidence on factors influencing contraceptive use and sexual behavior in SA.

Methods: 

We conducted a scoping review guided by Arksey and O’Malley's framework. We searched for articles from the following databases: PubMed/MEDLINE, American Doctoral Dissertations via EBSCO host, Union Catalogue of Theses and Dissertations (UCTD) and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. Studies published from January 1990 to March 2018 were included. We used the Population, Concept, and Context (PCC) framework and the PRISMA chart to report the screening of results. The Mixed Method Appraisal Tool (MMAT) version 11 and ACCODS tools were used to determine the quality of the included studies.

Results: 

A total of 2030 articles were identified by our search criteria for title screening. Only 21 studies met our inclusion criteria and were included in quality assessment stage. We found that knowledge of a contraceptive method, length of a relationship, sexual debut, age difference between partners availability of a contraceptive method, long waiting hours, and nurse's attitudes toward human immunodeficiency virus (HIV) positive or younger clients predict whether or not women use a contraceptive method or improve sexual behavior.

Conclusion: 

There remains a necessity for improving educational programs aimed at transferring knowledge on contraceptives and sexual behavior to both women and their male counterparts, alongside the public health systems’ improvements.

1 Introduction

Access to safe and effective contraceptive methods is one of the cornerstones of reproductive health. [1] However, the degree to which women manage various aspects of their sexual and reproductive health, including the prevention of unintended pregnancies, maternal mortality, and exposure to human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), raises questions of health promotion concern. [2] The sub-Saharan African (SSA) region experiences more than 14 million abortions each year. [3] Almost half of the pregnancies are happening among women aged 15 to 24 years. [4] More than 13% and 16% of these pregnancies end in abortions and miscarriages, respectively. [5] As a result of maternal-related complications, one in 26 women of reproductive age die in Africa, compared to one in 9400 in European counterparts. [6]

Almost all of the deaths affecting the low and middle-income countries (LMIC) account for 99% of maternal mortality among women aged 15 to 49 years, globally. [7] In response to this reproductive health challenge, the South African (SA) government joined the global community in adopting the Sustainable Development Goals (SDGs), which aim to ensure universal access to sexual and reproductive health for all women by the year 2030. [8] Some of the main objectives of the department of health in SA is to reduce the maternal mortality in facility ratio to 100 (or less) per 100,000 live births and increase the rate of contraceptive use to 75% by 2030. [8]

Many plans and policies have been introduced by the SA government towards improving contraceptive use, including

• (a) the National Health Act (61 of 2003);
• (b) the new National Adolescent Sexual and Reproductive Health and Rights Framework Strategy (2014–2019);
• (c) the Strategic Plan for Maternal, Newborn, Child, and Women's Health and Nutrition in South Africa (2012–2016);
• (d) the 2012 National Contraception and Fertility Planning Policy;
• (e) the Strategic Plan for Maternal, Newborn, Child, and Women's Health; and
• (f) the Campaign for Accelerated Reduction of Maternal and Child Mortality. [9–12]

The National Health Act (61 of 2003) acknowledges the health needs of vulnerable groups, such as women, and makes provisions for free health care for pregnant women, including women undergoing termination of pregnancy. [11]

All these plans and policies acknowledge the importance of improving contraception and sexual behavior and they are largely supportive of women's rights and access to health care services. [12] However, unintended pregnancies are persistently high. While the contraceptive rate among sexually active women had a marginal decline from 68% to 64% between 1998 and 2016, there remains high termination of pregnancy due to the high numbers of undesirable and unintended pregnancies. This is a serious public health concern, especially in the context of high HIV/AIDS infection rates. [13]

The following contraceptive methods should be available for use by the South African general public at public health facilities based on national guidelines: female sterilization (tubal ligation), male sterilization (vasectomy), levonorgestrel releasing intrauterine system (LNG-IUS), copper intrauterine contraceptive device (IUCD), subdermal implants (Implanon), low-dose combined-oral contraceptive pills, progestogen-only injectables, progestogen-only pills, emergency contraceptive pills, male condoms, female condoms, and depot medroxyprogesterone acetate (DMPA/Depo) and Net-EN – norethisterone enanthate. [14]

Despite the growing number of HIV positive populations in SA, people continue to engage in unsafe sexual behavior. The 2016 South African Demographic and Health survey revealed that little progress had been made by the country with regards to improving contraceptive prevalence rate. [13] Although more than 97% of sexually active SA women had knowledge of at least one contraceptive method in 2003, only half of the SA youth were using contraceptives in 2007. [15]

Even HIV positive women seem to have poor sexual behavior in South Africa, resulting in 220,000 unintended pregnancies in 2010. [16] While studies have been conducted on contraceptive use and sexual behavior, there seem to be changes to what is generally known regarding sexual behavior patterns of South African citizens. Despite the country's implementation of various intervention programs, there remains the unmet need for contraceptive use in South Africa, given the high number of unintended pregnancies. [17] For instance, there is less likelihood of contraceptive use among HIV positive women, those with multiple sexual partners, as well as those who were diagnosed with sexually transmitted infections (STI) in the past 12 months. [17] Issues related to poor access for HIV positive women have also been found to act as barriers to contraceptive use, leading to high unintended pregnancies. [18] This controversy is testament to the challenges faced by government efforts to improving contraceptive use and promoting responsible sexual behavior in South Africa, hence the study investigating factors influencing contraceptive use and sexual behavior in South Africa, is both timely and appropriate.

Most of the published systematic review articles mainly focus on adolescents and their choices of contraceptive use in SSA. [19–21] There is limited scoping reviews conducted with a specific focus on contraceptive use and sexual behavior in general population and with specific focus to SA. The main objective of this review was to map evidence on factors influencing contraceptive use and sexual behavior in SA over a period spanning from 1990 to 2018.

We conducted a scoping review of published peer-reviewed and gray literature articles on the factors influencing contraceptive use and sexual behavior in SA. The protocol for this review was published apriori. [22] Scoping review studies allow researchers to review existing evidence of published, peer-reviewed journal articles and gray literature related to a specific research phenomenon to understand the current status of the knowledge related to a topic of interest. This scoping review included studies published between the years 1990 and 2018 because studies published prior to 1990 are unlikely to reflect the key aspects and changes pertaining to contraceptive use and sexual health behavior. More studies were conducted after 1990 after many interventions were implemented to address these public health challenges in the era of HIV/AIDS. These years were critical components of South African response to HIV/AIDS epidemic, contraception as well as sexual behavior. This study was guided by Arksey and O’Malley's (2005) scoping review framework. [23] We also followed the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. [24] This review also included the quality appraisal of included studies, which was recommended by Levac et al (2010) for scoping review projects. [25] The Population, Concept, and Context (PCC) framework was employed in this review to determine the eligibility of research question ( Table 1 ). Studies were eligible if they reported evidence on one of the primary outcomes: knowledge and availability, relationship status, sexual debut, age difference, waiting hours, and nurse's attitudes measured at individual, partner's, household, community, and healthcare levels. Secondary outcomes were also extracted when they were reported in the included studies: pregnancy (unintended pregnancy), termination of pregnancy, sexually transmitted diseases, or infections.

2.2 Identification of the research question

Research question: what are the factors that influence contraceptive use and sexual behavior among women of reproductive age in SA?

2.3 Search strategy

This review utilized articles published as primary studies and gray literature presenting evidence on factors that influence contraceptive use and sexual behavior in women of reproductive age in SA. We searched for articles from the following databases: PubMed, American Doctoral Dissertations via EBSCO host, Union Catalogue of Theses and Dissertations (UCTD) and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. We also searched the Medical Research Council (MRC) and Human Sciences Research Council (HSRC) databases. We searched the World Health Organization (WHO) and governmental websites and statistics institutions for policies and guidelines on contraceptive use and sexual behavior. We included studies published from January 1990 to March 2018. We searched for eligible literature from the citations of the selected studies. We conducted databases search using the following keywords: contraceptive use, family planning, sexual behavior, HIV/AIDS, South Africa, pregnancy, abortions, maternal mortality. We used Boolean terms, such as “AND” and “OR” to separate keywords. We included the Medical Subject Headings (MeSH) terms in the keyword search. We conducted title screening from the databases and exported eligible articles to the Endnote library. The eligibility criteria for abstracts and full articles screening were conducted by the two independent reviewers (MH and SM).

2.4 Eligibility criteria

2.4.1 inclusion criteria.

These principles were used to determine the studies presenting evidence of the following criteria:

• Studies presenting evidence published between January 1990 and March 2018.
• Studies presenting evidence that were published in SA.
• Studies presenting evidence on women aged 15 to 49 years.
• Studies presenting evidence on contraceptive use.
• Studies presenting evidence on sexual behavior.

2.4.2 Exclusion criteria

Studies with the following characteristics were excluded.

• Studies published before 1990.
• Studies with no evidence on contraceptive use or sexual behavior.

2.5 Quality of evidence

To determine the quality of the selected studies, a Mixed Method Appraisal Tool (MMAT) version 2011, was adopted and piloted by the two independent reviewers (MH and SM). The MMAT tool was utilized to scrutinize the relevance of study aim, adequacy and methodology, study design, data collection, study selection, data analysis, presentation of findings, author's discussions, and conclusions. Each study was assigned an overall grade of high, moderate, or low risk of bias. The following criteria were followed: for qualitative and quantitative studies the score was a number of criteria met by each study divided by 4, with 25% indicating that at least one criterion was met by the study while 100% indicates that all criteria were met. [26] For the mixed methods studies, the score was 25% when one criterion was met, 50% when two criteria were met for a domain, 75% when three criteria were met for a domain, and 100% when all criteria were met for all domains. [26] Domains comprise of qualitative, quantitative, and mixed methods components. The gray literature articles were appraised using the Authority, Accuracy, Coverage, Objectivity, Date, Significance (AACODS) checklist form which is designed to enable evaluation and critical appraisal of gray literature. [27] An overall quality percentage score for each of the included studies was calculated and scores interpreted as low quality (≤50%), average quality (51–75%), and high-quality (76–100%).

2.6 Charting the data

In this review, we sorted the information of the selected studies according to the following categories: author and date, journal full reference, aims or research questions, study population, age, gender, percentage of women (i.e., participants), percentage of men (i.e., participants), geographic setting (i.e., rural/urban/semi-urban), study design (i.e., survey type), data analysis (i.e., methodological approach used in data analysis) and intervention, type of contraceptive. Information obtained from studies were further summarized as

• (a) most relevant finding (i.e., benefits of contraceptive use or better sexual behavior versus perceived risks),
• (b) most significant finding (i.e., reasons or factors for contraceptive use or vice versa), and
• (c) conclusions pertaining to the study.

All extracted information was mapped in data charting forms by the first author. Study types, such as quantitative, qualitative, mixed methods, and prospective studies were reflected in the charting form. Data charting form was continually updated with the latest information and it included the highlighting of the key aspects which were designed and piloted. Updating of the data charting form was conducted continuously.

2.7 Collating and summarizing the findings

For coding and analyzing of data from the selected articles, content analysis of the extracted data was conducted. We first compared across all quantitative studies how frequently different explanatory variables for contraceptive use and sexual behavior were used and how often these variables were found to represent a significant determinant. Qualitative information was organized in the form of the main themes identified and explored across the selected qualitative studies. The pathways framework suggested by Shaikh et al (2010) to differentiate between different levels to predictor variables was adopted for reporting findings. [28] This framework looks at levels, such as individual level (i.e., woman as a user), partner level, couple level, household and community level, and healthcare service level. [28]

2.8 Patient and public involvement

No patients and/or animal participants were involved in this review. Ethics approval and consent to participate was not applicable.

As shown in Figure 1 , a total of 2030 articles were identified by our search criteria for title screening. After the title screening exercise, 52 articles were exported to Endnote library for further screening, while five articles were retrieved from other sources. This left us with 57 articles in our Endnote library. As many as 1979 articles were removed at title screening stage because they formed part of our exclusion criteria (i.e., those with no evidence on contraceptive use or sexual behavior, those published before 1990 and those conducted outside of SA). After removing duplicates, 51 articles remained and these articles were screened for abstracts, while 24 were excluded. Of the remaining 27 articles, six were excluded for the following reasons: three studies were conducted outside of SA, one study was an opinion paper, and another study was conducted only among male participants. The last excluded study was conducted among the minors below the age of 15 years. Only 21 studies met our inclusion criteria and were included in content analyses and quality assessment stage.

3.1 Characteristics of included studies

The PCC framework is presented in Table 1 . The detailed characteristics of the included studies are shown in Table 2   . All the eligible studies were published between the year January 1990 and March 2018. Fourteen studies were quantitative, [14,29–41] four were qualitative, [42–45] two were mixed methods, [46,47] and only one was a prospective study [48] ( Fig. 2 ). At least eight provinces of SA had one or more studies conducted in each, with KwaZulu-Natal having the highest number (n = 6) of studies. The other provinces comprised of Western Cape (n = 2), Eastern Cape (n = 2), Gauteng (n = 2), and nationally representative studies (n = 5). Provinces such as Limpopo, North West, Mpumalanga, and Free State had one each study. The total sample size from the included studies was 38,073 participants. The female participants were dominant (N = 35,641) as compared to male (N = 2432) participants. The majority of studies (81%) were published from 2010 onwards. Regarding geographical distribution, eight studies were conducted in rural areas, five in urban areas, and the remainder (n = 8) in mixed settings.

3.2 Quality of evidence from included studies

Of the 21 included studies which underwent methodological quality assessment, 13 scored the highest quality score of 100%. [29,30,33–35,37–41,45–47] Four studies scored a quality score of between 83% and 94%. [14,32,43,44] The remaining 4 studies scored a quality score between 67% and 71%. [31,36,42,48] The overall evidence was considered to have minimal risk of bias.

3.3 Study findings

The following sections report on the combined evidence gathered from the included studies, in a pathways framework to differentiate along with the following levels: individual woman level (user), partner's involvement, household and community involvement, and healthcare involvement level.

3.3.1 Individual woman level

Age of the woman was explored in five studies. [28,31,40,44,48] Two of these studies were conducted in rural settings, one in an urban setting and another two in both rural and urban settings. Four of these studies were quantitative, while one was qualitative. Some studies revealed age as a strong determinant of contraceptive use and sexual behavior. Some studies showed low levels of knowledge of modern contraceptive method among adolescents. [29,49] Only half of the adolescent girls surveyed could list at least one modern contraceptive. [29] The sexual debut for the majority of adolescent women has been found to be at 15 years, with the average ages of pregnancy being 19 years in other studies. [32,41] The majority of the migrant youth; however, debut at age 18 years due to higher educational aspirations. [45] Only about a quarter (24%) of sexually experienced women in the adolescent age group had ever used contraceptives, while just half had ever heard of emergency contraception. [29] Buga's (1996) article further revealed that, despite the poor knowledge of modern contraceptive methods among adolescent women in SA, the fear of attending family clinic services and disapproval by male partners also contribute to this age group's poor contraceptive use. [29] In general, more adolescents heard about contraception for the first time at school rather than at home. [32]

Knowledge of a contraceptive method was explored in six studies. [31,35,39,43,45,47] Two-each of these studies were conducted in rural, urban, and mixed settings. Four of these studies were quantitative, one-each was mixed methods, and a prospective study. These studies revealed knowledge of a contraceptive method as a strong determinant of contraceptive use. Despite the lack of adequate knowledge of all contraceptive method among adolescent girls, women in general, have high knowledge of at least one contraceptive method available in SA. The injectable contraceptive method and the condom appeared to be the most used form of contraception. At least six studies found injectable contraceptives to be the most commonly used method of contraception. [32,36,40,44,48,50] As high as 95%, 88%, and 76% of respondents knew condoms, the contraceptive pills and the injectable contraceptives, respectively. [32] However, injectable contraceptive method was reported to have side effects by some women, including spotting or heavy bleeding. [36]

Despite the high knowledge of a contraceptive method among women of reproductive age in SA a study by De Klerk (2015) revealed that there remains poor knowledge of intrauterine contraceptive device (IUD) and the emergency contraceptive pill. [32] A study conducted at the KwaZulu-Natal tertiary institution also revealed that the majority of students were not familiar with the most effective time-frames for taking emergency contraceptive pills nor with the side effects associated with its use. [46]

3.3.2 Partner's involvement

The partner's contribution to contraceptive use and sexual behavior was examined in eight studies. [27,32,33,35–37,44,46] Four of these studies were conducted in rural settings, two in urban settings, and two in mixed settings. Five of these studies were quantitative, one qualitative, one mixed methods, and one was a prospective study. In terms of sexual health behavior among women of reproductive age, condom use peaks at the beginning of relationships or with casual multiple partners; however, this trend decreases with an increase in relationships duration. [45] Women who do not use condoms are usually in a long term relationship. [45] This study further indicated that inconsistent use of condoms was highlighted by most participants and was based on relationship status, pregnancy prevention, and trust dynamics in the partnership. [45]

However, the use of condoms at first sexual debut was very low among adolescents due to being inexperienced and unplanned moments of sexual intercourse. [45] The decision-making process in the first sexual activity is largely made by the male partner. [45] This was supported by two quantitative, one qualitative, and one mixed method studies, of which two were conducted in mixed settings (i.e., both rural and urban) and one in each setting. [34,36,45,47] These studies revealed that partners are often opposed to condom use and this can negatively impact on a woman's ability to negotiate sex and condom use because it is assumed to lessen the pleasure of sex, intimacy, and trust. [34,36,45,47]

Male partners are usually reported as perpetrators of physical partner violence, psychological distress, and having concurrent partners, which in turn is associated with sexual risk behavior. [27] The age difference as a determinant for both sexual behavior and non-contraceptive use was also revealed in a quantitative study conducted in a rural setting. [33] This study revealed that women who had sex with a partner whose age difference was at least 10 years or more, were less likely to use a condom. [33] Alcohol use was found to be associated with multiple sexual partners in another rural-based quantitative study. [37] The situation becomes worse because not knowing partner's HIV status remained associated with significantly lower odds of condom use at last sex. [38]

Further findings from Seutlwadi et al (2012) indicated that having talked with the partner about condoms in the past 12 months were strong determinants of contraceptive use, while not having been pregnant, being HIV negative, not having had an STI in the past 12 months and not having had early sexual debut (below 15 years of age) were associated with current contraceptive use. [38] Timely notification of HIV status coupled with prevention messages can contribute to reductions in sexual risk behaviors. This study further revealed that although 79.1% of females reported having had unintended pregnancies, they were not motivated to use contraceptives. Contrary to what is generally known, being HIV positive, having been diagnosed with an STI in the past 12 months, having concurrent sexual partners and early sexual debut have been strongly associated with low contraceptive use. [38]

3.3.3 Household and community involvement

Determinants grouped at a household or community level such as education and employment were examined in five studies. [32,38,39,43,46] Three of these studies were conducted in rural areas, one in an urban setting, and another one was conducted in mixed settings (i.e., both urban and rural areas). Three of these studies were conducted using a quantitative research method, while one-each was qualitative and a mixed method, respectively. These studies found level of education and employment status to be significant predictors of contraceptive use. [32,38,39,43,46] A study by Osuafor et al (2017) revealed that employed women were three times more likely to report dual contraceptive methods use compared to those who were unemployed. [43] Poor socioeconomic status limits women's access to family planning services (e.g., transport costs). Due to poor socioeconomic status, some women end up depending on their partners for financial support. This, combined with other aspects of gender inequality weakens women's bargaining power when it comes to negotiating condom use. [47] However, women who worked outside the home were more likely than those who were not employed to be using the pill instead of the injection, while women living in wealthier households were less likely than those in poorer households to be using a more permanent method in lieu of the injection. [39]

Educated women are known to possess better bargaining powers as far as contraceptive use is concerned. The level of education and employment status have been shown to influence contraceptive use. [46] Peer pressure and living away from family support structures may also contribute to increased sexual activity, especially among younger women. [46]

3.3.4 Healthcare involvement

Determinants grouped at a healthcare level such as availability of contraceptives, long waiting hours, and nurses’ attitudes were examined in five studies. [14,34,36,42,49] Three of these studies were conducted in urban areas, one in urban, and another one was conducted in both urban and a rural area. [14,34,36,42,49] Three of these studies were conducted using a quantitative research method and one-each was qualitative, and mixed methods. Some of these studies found non-availability of contraceptives, long waiting hours, and nurses’ attitudes at clinics to be negatively associated with contraceptive use. [42,49] A study by Hoque et al (2012) found that more than 60% of women reported the unavailability of contraceptives as the reason for poor usage of contraception. [34] The SA public health clinics are known for being understaffed and overloaded with patients. This was evident in another study which revealed that due to overcrowding and long queues in clinics, patients are forced to wait for long periods of time (hours) and this sometimes lead to women being afraid to ask the nurses family planning-related questions due to many patients needing services. [36] Nonetheless, when women do find a rare opportunity of asking questions related to family planning, nurses usually promote hormonal contraceptives for family planning and condoms for STI prevention. [36]

Nurses can also influence method choice and/or continuation of methods – intentionally or otherwise – through sub-standard or biased counseling. [14] Another quantitative study conducted in both urban and rural settings found that counseling is often limited to few contraceptive methods (usually one or two), instead of the entire methods available at the facility. [14] This may also be due to the limited available contraceptive methods or nurses pushing the queue, hence limiting the time spent with each patient. At least two studies from both urban and rural settings (one qualitative and another one conducted using the quantitative method) reiterated that women generally encounter negative attitudes from nurses. [14,42] Such discrimination by healthcare providers is usually targeted to patients that are either younger (i.e., adolescents) or those that are infected with HIV. [14]

4 Discussion

This study aimed at mapping evidence on the factors affecting contraceptive use and sexual behavior among women of reproductive age in SA, over a period spanning from 1990 to 2018. Free access to contraception and safe sexual behavior has become a key priority for the SA government.

This review showed that healthcare workers’ negative attitude creates a barrier to adolescent girls accessing contraceptive services. [51] Younger women may likely be discouraged from seeking family planning services in public health clinics, for fear of being judged and/or discouraged from receiving their preferred contraceptive services. Similar findings were also shown in other settings where healthcare providers were found to be advising adolescents to abstain from sex in studies conducted in South Africa, Kenya, and Zambia. [52,53]

As found in this review, health systems challenges, such as poor working conditions and contraceptives stock-outs may compromise the provision of quality healthcare services. It is known in South Africa, that public health clinics are understaffed and overloaded with patients, thereby leading to long queues. These challenges may likely discourage women from seeking detailed family planning-related information as well limiting healthcare workers from communicating effectively with their patients. [54] While this is the case, lack of training among some nurses in public health clinics remain an obvious barrier to the provision of quality family planning services. [55,56]

Many women largely depend on their male partners for financial support due to poor socioeconomic status in SA. Such dependency is connected to weakened women's bargaining power for using condoms during sexual intercourse. The situation becomes even worse when women are less educated, unemployed, and residing in traditional rural areas. This also exposes women to new HIV infections given the poor HIV testing uptake among men. [57,58]

The findings of this study are consistent with the findings of other studies conducted elsewhere in Africa. [59,60] Similar findings indicated that demographic and socioeconomic factors, such as age, race, employment status, education, and geographical location are associated with contraceptive use. [39,61] The dominance of men over their women partners remain a strong predictor of contraceptive use. [62] While this is the case, the situation becomes even worse when women are uneducated, unemployed, and come from traditional rural settings. This is precisely because they possess very little bargaining power when it comes to negotiating safe sex with their partners and very few have control over their partner's sexual behavior. [63]

The knowledge of a contraceptive method is high among women in general. This review showed that the injectable contraceptive method was mostly used by women of reproductive age. There also remains a gap in knowledge particularly with regards to appreciating the benefits against the side effects. [46] Further studies have shown that the main reasons for implant removal were side effects, such as intolerable bleeding for two-thirds of removers as well as headaches in almost a half, [64] while nurses’ low confidence in providing implant services effectively, [65] may also act as a barrier toward women accessing this contraceptive method. It has also been revealed that a condom usually lessens the pleasure of sex, intimacy, and trust, while concerns over the pains resulting from using a condom during sexual intercourse were also raised. [66]

4.1 Strengths

We maintained quality measures by conducting quality appraisals of the peer-reviewed journal articles and gray literature. We further applied the eligibility criteria rigorously as part of extracting only the relevant information. The quality of the included studies was conducted for both peer-reviewed and gray articles. All included studies underwent quality appraisal using an approved tool, the MMAT, [67] and the ACCODS tool for gray literature studies to assess for bias. [27] Our full article screening tool was piloted to ensure the reliability of included studies.

4.2 Limitations

There is a likelihood that this scoping review did not identify all relevant studies despite all the efforts to do so. Despite the generally relevant keywords/terms used while searching for relevant articles in different databases, other terms may also exist as a reference to contraceptive use and sexual behavior. As such, those may have been missed. Although our title screening included a wide range of databases, the overall search strategy may have been biased toward public health and social sciences. Searching other bibliographic databases may have yielded additional published scoping reviews. While our review included any article published in any language, our search was conducted using only English terms. Despite these limitations, we believe that our search strategy was comprehensive in reviewing the public health and social sciences literature on contraceptive use and sexual behavior in SA. Furthermore, we believe that we managed to address the study aim, which was to determine factors that influence contraceptive use and sexual behavior among women of reproductive age in SA.

4.3 Recommendations for future research

More primary studies are necessary to further investigate factors related to contraceptive use and sexual behavior, particularly among key populations, mainly due to high HIV infection rates. With the possible introduction of male contraceptive pills, it would be important to determine the levels of male contraceptive users while investigating the effects on users as well as factors contributing to continuity or lack thereof. The question also remains whether or not the sexual behavior of South Africans is becoming riskier over time.

4.4 Implications for practice

Integrating family planning services with the delivery of other general services within a clinic would play a positive role in reducing the stigma experienced by younger women and those who are HIV positive, as well as reducing long queues. Government interventions aimed at educating youth about the benefits of contraceptive use and the risks involved when one is exposed to unprotected sexual activities should be integrated with school-health programs to improve knowledge and uptake of contraception among school-going sexually active women. School-based programs should be designed not only to be driven by teachers but also by parents as well. Peer educators should also be used as pioneers to promote reproductive health education among adolescents and school-going children.

5 Conclusion

This review revealed a gap which affects the uptake of contraceptive methods in SA. The factors associated with poor contraceptive use and sexual behavior and the reasons provided by women to explain their challenges regarding contraceptive use and sexual behavior appear to be largely similar across different settings and provinces in SA. Therefore, there is a need for improving educational programs aimed at transferring knowledge to both women and their male counterparts, while improving public health systems. We, therefore, conclude that contraceptive use and sexual health behavior leave room for improvement in SA. Programs aimed at improving contraceptive use and sexual behavior should mainly focus on adolescents, uneducated women, those who reside in rural areas, as well as those who are unemployed. This review further revealed that partners can either support or hamper women's decisions on sexual activity and contraceptive use, hence they also need to be included in the interventions.

Acknowledgments

The authors would like to thank the School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.

Author contributions

MH conceptualized and designed the study, as well as prepared the initial draft. KH and TPM-T reviewed the study. SM contributed to the abstract and full article screening. All the authors reviewed the draft and approved the final version of the manuscript.

Mbuzeleni Hlongwa orcid: 0000-0002-5352-5658.

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Level of knowledge, attitude, and practice on modern contraceptive method and its associated factors among housemaids living in Debre Tabor town, northwest Ethiopia: a community-based cross-sectional study

• Gebrehiwot Ayalew Tiruneh 1 ,
• Besfat Berihun Erega 1 ,
• Awgichew Behaile T/mariam 2 ,
• Endeshaw Chekol Abebe 2 ,
• Teklie Mengie Ayele 3 ,
• Nega Dagnaw Baye 2 ,
• Zelalem Tilahun 2 ,
• Alebachew Taye 4 &
• Bekalu Getnet Kassa 1  

BMC Women's Health volume  23 , Article number:  632 ( 2023 ) Cite this article

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Contraception is widely recognized as an effective technique for avoiding unplanned pregnancies and sexually transmitted diseases. Promoting contemporary contraceptive methods would minimize the number of unplanned pregnancies and the high number of maternal fatalities connected with unsafe abortions.

This study aims to assess the level of knowledge, attitude, and practice of modern contraceptive methods and its associated factors among housemaid residents of Debre Tabor Town, northwest Ethiopia:

A structured questionnaire supplemented with face-to-face interviews was used to conduct a community-based cross-sectional study with 423 housemaids’ women of reproductive age in Debre Tabor City. The data were analyzed using descriptive analysis, binary analysis, and multivariable logistic regression.

A 12.8% of respondents in this study used modern contraceptive methods. A 44.68% of study participants had good knowledge of modern contraceptive methods, and 36.40% had a positive attitude towards them. Housemaids’ older age, urban location, educational status, work experience, and family situation were found to be positive predictors of a good understanding of current contraceptive techniques. Housemaids’ older age, urban residence, educational level, work experience, family situation, and first sex before now are all positive predictors of a positive attitude and good practices.

Conclusions

Housemaids’ knowledge, attitude, and practice of modern contraceptive methods were influenced by a variety of socio-demographic factors. As a result, housemaids should be educated about modern contraceptive methods by the health sector and other stakeholders to improve their knowledge, attitude, and practices.

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Introduction

Family planning is the use of various methods and strategies to enable men and women to make educated decisions regarding childbearing [ 1 , 2 ]. It refers to the methods used by men and women to space their pregnancies and limit the number of children they plan to have [ 3 , 4 ]. It encompasses the services, policies, information, attitudes, practices, and commodities, such as contraceptives that allow women, men, couples, and adolescents to avoid unintended pregnancy or decide when to have a child [ 5 ]. Family planning is concerned with the mother’s reproductive health, adequate birth spacing, avoiding unwanted pregnancies and abortions, preventing sexually transmitted diseases, and increasing the mother’s quality of life, as well as the children’s and families’ in general [ 2 ]. Short-term modern family planning methods are currently available at all levels of governmental and private healthcare units, while long-term options are offered in health centers, hospitals, and certain private clinics [ 5 , 6 ].

The International Birth Spacing Policy encourages women to use reversible contraception such as oral contraceptives, depo-provera, condoms, and Intra Uterine Devices (IUDs). By expanding the spectrum of reversible and cheap contraceptives, this program promotes reproductive-age women to access the complete range of contraceptive services [ 7 ].

Contraception is regarded as an important preventive measure for unintended pregnancies and sexually transmitted diseases, such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), among adolescents [ 8 ].

Unintended pregnancies, maternal and child mortality, and induced abortions are all reduced when people practise family planning. Contraception has also been shown to increase woman’s sense of autonomy and ability to make decisions in other areas of her life. Contraception could save at least 25% of all maternal deaths by preventing unplanned pregnancies and unsafe abortions, as well as sexually transmitted diseases like HIV, Chlamydia, and Syphilis. In developing countries including Ethiopia, the major barriers to family planning adoption are a lack of knowledge about contraceptive methods, their source of supply, cost, or inadequate accessibility [ 6 , 9 ]. According to a study conducted in Jimma, Ethiopia, good contraceptive knowledge does not always equate with high contraceptive use. According to many studies, high contraceptive awareness but low contraceptive use makes the condition of family planning services a severe concern. It is critical to ensure that all pregnancies are wanted or intended on a global and national basis [ 6 , 10 ].

In India, however, universal adoption of the small-family norm remains a pipe dream. Only approximately 54% of currently married women aged 15–49 years or their husbands used a contraceptive technique to control their fertility in 2007-08, and the contraceptive prevalence rate appears to have plateaued after 2004. Furthermore, India’s contraceptive practice is reported to be strongly skewed toward terminal 11 techniques, implying that contraception is used mostly for birth limitation rather than birth planning in the country [ 4 , 8 ]. According to the World Health Organization (WHO), 94% of the world’s population resides in nations with policies that encourage the use of family planning. Despite these policies, a significant proportion of couples of reproductive ages do not use adequate fertility control strategies [ 9 , 11 ].

As a result, initiatives aimed at improving reproductive health by increasing the use of modern contraceptives must expressly target adolescent females at all levels of the program. As a result males should be actively involved at the knowledge level (the concept of family planning), the supporting level (being supportive of others who use contraception), and the acceptor level (accepting contraception) as the contraceptive user. To promote contraceptive use, males’ decision-making roles should be considered [ 6 , 10 , 11 ]. Despite several modern contraceptives being available worldwide, the problem of unwanted births persists, which may be attributed to a lack of information and a misunderstanding of contraception. Understanding community contraceptive use is critical to understanding variations in fertility and reproductive health in various parts of the world. Acceptance of children as God’s plan, attitudes toward avoiding conception, awareness of different methods, and comprehension of the adverse effects of different methods are all characteristics linked to contraceptive use, according to previous studies [ 7 , 11 , 12 , 13 ].

In developing countries, vulnerable and marginalized adolescents receive more research and programmatic attention. In terms of background, working habits, self-esteem and social ties, and exposure to HIV and adolescent programs, a descriptive analysis done to compare female domestic workers with other adolescent girls and boys revealed that they constituted 15% of the female adolescent population, the majority of whom had come from rural areas [ 9 , 10 , 14 ]. Housemaids were less likely than other adolescent groups to be educated or to live with their parents. They worked extraordinarily long hours for very little payment, with a monthly average salary of US$6. Domestic workers had worse self-esteem and fewer friends than other teens, and less HIV knowledge and engagement in existing adolescent programs. Despite their vast numbers in some urban areas, adolescent domestic workers are particularly vulnerable and usually unseen. These greater, at-risk groups of adolescent girls require more programmatic attention and awareness-raising [ 10 , 13 , 15 ].

However, there is limited data on female adolescent housemaids in Ethiopia, who may make up a significant fraction of urban girls in some areas. Most notably, in Debre Tabor, Ethiopia, there are no previous studies conducted among female domestic workers in the reproductive age group with the goal of determining their knowledge, attitude, and practice on family planning. Most reproductive-age women, particularly female domestic workers, have limited or erroneous understanding of family planning options. Moreover, despite the fact that some contraceptives are named, female domestic workers have no idea where to buy them or how to use them. In addition, these females have a negative attitude toward family planning, and some have heard erroneous and misleading information. Therefore, the current study aimed to analyze the knowledge, attitude, and practice (KAP) of FP among female domestic workers in the reproductive age range residing in Debre Tabor town, Ethiopia.

Study design and period

A community-based cross-sectional study design was employed in Debre Tabor town from April 4 to 30, 2022.

Study setting

The research was conducted in Debre Tabor Town Administration, the capital city of the South Gondar Administrative Zone of Amhara National Regional State in Northwest Ethiopia. The town is 666 km far from Ethiopia’s capital city, Addis Ababa. The source population consisted of all housemaids’ reproduction-aged women and up living in Debre Tabor. The town is divided into six kebeles.

Participants

All housemaid’s female found in the Debre Tabor town administration were used as the source population. While the study population was housemaids who live at least for a month during the study period. All systematically selected female housemaid’s reproductive-aged women and up who lived in the study area for at least a month during the study period were included in the study. But non-residential workers (not living together with the employer) and housemaid females who had a serious illness during the study period were excluded from the study.

Dependent variables

Knowledge, Attitude and practice of modern contraceptive methods.

Independent variables

socio-demographic characteristics (Age of housemaid, Previous residence of housemaids, Marital status of housemaids, Educational status of housemaid, Housemaid religion, Family situation of housemaids, Frist sex before now, Salary of housemaid, Working experience, Age of female employer, Age of male employer, Employer’s marital status, Employer’s religion, Educational status of female employer’s, Educational status of male employer’s, Khat-chewing history, smoking cigarrate and alcohol consumption history); Knowledge of modern contraceptive, attitude of modern contraceptive and practice of modern contraceptive methods, health facility related factors etc.

Operational definitions

The girl or woman who is a servant employed to do housework.

Knowledge of modern contraceptives methods

Thirty questions about modern contraceptive methods were asked to test the participants’ knowledge. The responses to each question were coded as “1” for “yes” and “0” for “no.“

Attitude towards modern contraceptive methods

Seven attitude-related questions were used to assess participants’ attitudes toward modern contraceptive methods. A likert scale was used to answer the questions.

Modern contraceptive practices

When a woman of reproductive age is reported using any method of modern contraceptives (e.g., injectable, regular pills, emergency pills, Implanon, intrauterine device, condom, and surgical methods) [ 1 ].

Good practice

Those housemaids utilized at least one in life until kwon by given questions.

Measurement

The respondents’ knowledge was evaluated using 30 questions, and the correct answers of each respondent for all questions were added together to determine whether the respondent had poor or good knowledge. Attitude questionnaires have seven questions that can be answered yes or no. Modern contraceptive method questionnaires also include 9 yes/no questions. To determine knowledge, attitude, and practice of modern contraceptive methods, the mean value of each variable for each respondent and the overall mean was determined.

Sample size determination

The sample size was calculated using the single population proportion formula, and the required sample size for this study was determined using the following assumptions: desired precision (d) = 5%, confidence level = 95% (Za/2 = 1.96 value), and 50% (no study conducted) of the prevalence of KAP in female housemaids.

As a result, adding 10% non-response rate the minimum sample size of the study was 423.

Sampling procedures

There are six kebeles in the study area; to start collecting data, the number of households with female housemaids in each kebele was determined using the kebele registration book. The study households were then chosen using a simple random sampling technique based on the proportion of households in each kebeles, with the first household chosen by lottery. When two or more eligible female housemaids are found in the same household, the lottery method is used to interview only one.

Data collection instrument and procedures

Data collection tools comprised structured questionnaires that were prepared after a thorough literature review and the study area’s local situation, and the study’s purpose was considered to design of the questionnaire. Questionnaires were prepared first in English and then translated into Amharic which is the vernacular language of the respondents by language experts for ease of understanding the respondents. Data were collected via face-to-face interview techniques using structured questionnaires.

Nine BSc-educated midwives were chosen and trained for data collection and supervision, respectively. They had prior experience with data collection. Data on socio-demographics, knowledge, attitude, and practice of family planning were gathered. Before collecting final data, questionnaires were pretested on 29 (5%) women from Woreta Town in South Gondar Zone. After the pre-test, the investigators and research assistants were involved in incorporating changes to the questionnaires. Only completed questionnaires were used to ensure internal validity.

Stastical analysis

Data were cleaned, coded, and entered into Epidata version 4.2 before being exported to SPSS version 25 for analysis. To summarize the data, a descriptive analysis was performed. A binary logistic regression analysis was performed to determine the association of predictors and outcome variables. All predictor variables with p  ≤ 0.2 were entered into multivariable logistic regression analysis; a significant association based on p  ≤ 0.05, and an adjusted odd ratio (AOR) with 95% CI were identified. The results were presented in the form of texts, figures and tables.

Socio-demographic characteristics of participants

Of the study participants, almost half the study of participants, 193 (45.6%) were in the age of 19 years. 174 (58.9%) of the 423 study participants had previously lived in a rural area. About 19.9% were illiterate, while 40.7% had completed college education or higher. The average age of the participants was 24.54 ( ±  6.25 SD). About 296 housemaids (70%) were orthodox Christians. 381 (90.1%) of all participants were single housemaids. Regarding the family situation of housemaids, approximately 55 (13%) of them have both their father and mother dead, and the average salary for housemaids was 706.62(± 134.69) ETB (see Table  1 ).

The majority, 306 (72.3%) employers were orthodox Christians. Regarding the educational status of employers, almost 110 (26%) employers are illiterate. The majority, 274 (64.8%), of employers were married. Of all participants employers 18 (4.3%) of the employers had a smoking cigarettes, and 48 (11.3%) employers had a chewing chat (see Table  2 ).

Knowledge status of participants on modern contraceptive methods

Almost half of participants ever heard about modern contraceptive methods. The major sources of information were from family (45.60%) and news media (44.7%). Among study participants knowing injectable contraceptive 53%% (see Fig.  1 ). Regarding the overall knowledge of study participants, 189 (44.69%) had good knowledge towards modern contraceptive methods (see Table  3 ) and (see Fig.  2 ).

Source of information about modern contraceptive method in Debre-Tabor Town, northwest Ethiopia, 2022

The respondents ‘level of knowledge Attitude, and Practice of Housemaids on modern contraceptive methods in Debre-Tabor Town, northwest Ethiopia, 2022

Attitude status of participants on modern contraceptive methods

Almost of the study participants 141 (33.4%) ever discussed on about contraceptive methods issues with their empowers. About 35.9% of the participants reported that they believe modern contraceptive methods exposes to infertility. Almost 192 (43.5%) of study participants reported that using modern contraceptive methods affect daily activities (see Table  4 ). Regarding the overall attitude, 154 (36.40%) of the participants had good attitude towards modern contraceptive methods (see Fig.  2 ).

Practice status of participants on modern contraceptive methods

One fourth (23.2%) of study participants ever used contraceptive methods (see Table  5 ). The main types were Oral contraceptive pills 47 (29.56%) and injecTable 44 (27.67) (see Fig.  3 ). Almost 54 (12.8%) of study participants had good practice and the rest 87.2% had poor practice (see Fig.  2 ).

Type of modern contraceptive method in Debre-Tabor Town, northwest Ethiopia, 2022

Factors associated with knowledge, attitude, and practice of housemaids on modern contraceptive methods

In the multivariable logistic regression analysis; respondent’s current age of housemaids, previous residence of housemaids, educational status of housemaids, Work experience of housemaids, the family situation of housemaids, and first sex before now, remained statistically significantly associated with housemaid knowledge, attitude, and practice of the modern contraceptive method.

Hence, the increased age of housemaids was 7. 78 times less likely to have housemaid knowledge about the use of modern contraceptive methods (AOR = 7.78; 95%CI: 4.70, 9.87). In addition, Hence, the increase housemaids’ current age was 2.19 times less likely to have a housemaid attitude to use the modern contraceptive method (AOR = 2.19; 95%CI: 2.01, 3.88 ) ( see Table  6 ).

Discussions

This study was done to assess the level of knowledge, attitude, and practice on modern contraceptive methods and their associated factors among housemaids living in Debre-Tabor Town, and there was a lack of similar studies, even in other countries. Given these constraints, the findings of this study are discussed below. This study found that the prevalence of knowledge, attitude, and practice about modern contraceptive methods was low, with 44.68%, 36.4%, and 12.80%, respectively. The research revealed that a significant number of housemaids of reproductive age were not aware of contraceptive methods, unfortunately, there is very limited data and unclear understanding of the knowledge has been problematic, this was insufficient, with reported (44.68% of the total housemaids). The injectable method of modern contraception was the one with the highest awareness rate (53%) while sterilization had the lowest awareness rate (9.2%).

According to the findings of this study, as housemaids’ ages increased, so did their knowledge, attitude, and practice of modern contraceptive methods. Furthermore, urban housemaids were approximately 2.19 times more likely to have good knowledge, 9.04 times more likely to have a positive attitude, and 3.21 times more likely to practice modern contraceptive methods. The reason could be because women in urban areas are more likely to be more educated, and they have better access to information, education, and health facilities than rural women. Furthermore, the availability of major sources of family planning information, such as privet health facility and newspapers, are still limited in rural areas.

Furthermore, having a positive attitude towards modern contraceptive methods was 2.01 times more likely among housemaids with college and above educational levels compared to no education, and having practise with modern contraceptive methods was 8.91 times more likely among housemaids with college and above educational levels compared to no education. This is explained by the idea that housemaids with higher educational levels have better access to health care information, more independence to make their own and informed decisions, and a greater ability to use health care services. The positive effect of education assists housemaids in increasing their understanding of reproductive health issues as well as understanding and using the various contraceptive methods that best suit their health condition. It also improves housemaids’ overall status in terms of knowledge, attitude, and practice of modern contraceptive methods.

According to this study, knowledge, attitude, and practice of modern contraceptive methods increased with age in housemaids with work experience. Possible explanations include improved access to health-care information and increased independence to make their own informed decisions. Generally, Modern contraceptive method information is not freely available but rather flows through hidden informal or “underground” channels. Women who have previously used the method or who have been close to women in a similar situation, women’s health organizations, health professionals, pharmacies, and internet sites are the ones who provide information or help to identify sources of information, such as female relatives, friends, neighbors, and the sexual partner.

Overall, the use of contraceptive methods among housemaids of reproductive age women in this study is positive, with the majority of housemaids believing that contraceptives are beneficial.

Strength and limitation of the study

This study has focused on a marginalized group of people who are highly vulnerable to unintended pregnancy due to the lack of the contraceptive method where adequate information and studies are lacking. This might certainly serve as baseline information and fill some of the knowledge gaps for further studies.

Limitation of the study

As the data were collected using face-to-face interview, study participants might not feel free and the reported KAP might be overestimated or underestimated. We do not used qualitative method of data collection to gather study participant’s internal feeling about modern contraceptive methods, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

A significant number of housemaids have inadequate knowledge, attitudes, and practices regarding modern contraceptive methods. Housemaids’ knowledge, attitude, and practice of modern contraceptive methods were influenced by a variety of socio-demographic factors.

As a result, housemaids should be educated about modern contraceptive methods by the health sector and other stakeholders to improve their knowledge, attitude, and practices. Increasing programmed coverage and access to modern contraceptive methods will not suffice unless all eligible women understand the importance of maintaining a positive attitude and practicing when necessary.

Data Availability

The datasets used and/or analyzed in this study can be obtained from the corresponding author on request.

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Acknowledgements

The author would like to acknowledge Debre Tabor University for ethical clearance and technical support as well as the study participants and data collectors and supervisors.

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Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Gebrehiwot Ayalew Tiruneh, Besfat Berihun Erega & Bekalu Getnet Kassa

Department of Biomedical Sciences, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Awgichew Behaile T/mariam, Endeshaw Chekol Abebe, Nega Dagnaw Baye & Zelalem Tilahun

Department of pharmacy, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Teklie Mengie Ayele

Department of statistics, College of natural and computational Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Alebachew Taye

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Contributions

BGK and GAT: conceived and designed the study, conducted statistical analysis and result interpretation, edition, prepared manuscript, assisted with data analysis and interpretation; BBE, ABT, ECA and TMA: participated with data collection, assisted with data analysis and interpretation, edition and revised the manuscript; NDB, ZT, and AT: conducted statistical analysis and result interpretation and revised the manuscript. All authors read and approved the manuscript.

Corresponding author

Correspondence to Bekalu Getnet Kassa .

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Ethical approval and consent to participant.

Ethical approval was obtained from Debre Tabor University, Ethical Review Committee with reference number (IRB reference number: DTU/CHS/12/03/2014). An official letter was obtained from the Debre Tabor town administration mayor’s office. Verbal informed consent was obtained from participants whose age was 18 years and above. For participants whose age was less than 17 years and those illiterate, informed consent was obtained from their employers, parents, and/or their legal guardian(s) after describing the purpose, benefit, and risk of the study and their right to the decision to participate in the study. Their names were omitted to ensure confidentiality and privacy. The interview was performed at a suitable and secure place. Finally, the questionnaire was cleaned, stored, and analyzed at a secured place. The authors confirmed that all methods were carried out in accordance with the relevant guidelines and regulations of Helsinki declarations.

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Tiruneh, G.A., Erega, B.B., T/mariam, A.B. et al. Level of knowledge, attitude, and practice on modern contraceptive method and its associated factors among housemaids living in Debre Tabor town, northwest Ethiopia: a community-based cross-sectional study. BMC Women's Health 23 , 632 (2023). https://doi.org/10.1186/s12905-023-02783-5

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DOI : https://doi.org/10.1186/s12905-023-02783-5

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A LITERATURE REVIEW ON CONTRACEPTIVE PRACTICES, BARRIERS AND MEASURES TO IMPROVE USE AMONG POSTPARTUM WOMEN

• Ochala Ejura Jennifer , Syed Ali Gulab Jan , S. Mat
• Published 2021
• Medicine, Sociology

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Barriers to Contraceptive Uptake among Women of Reproductive Age in a Semi-Urban Community of Ekiti State, Southwest Nigeria

Factors influencing utilization of contraception among women in port said city, scaling up family planning to reduce maternal and child mortality: the potential costs and benefits of modern contraceptive use in south africa, contraceptive practice in sub-saharan africa., prevalence, perceptions and factors contributing to long acting reversible contraception use among family planning clients, jimma town, oromiya region, south-west ethiopia, evaluate use and barriers to accessing family planning services among reproductive age women in the white nile, rural districts, sudan, timely initiation of postpartum contraceptive utilization and associated factors among women of child bearing age in aroressa district, southern ethiopia: a community based cross-sectional study, barriers to family planning acceptance in abakaliki, nigeria, family planning use among women attending a health care facility in rural ghana, related papers.

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• Prevention and care of adult enterostomy with high output: a scoping review protocol
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• http://orcid.org/0009-0008-0113-2984 Ying Che 1 ,
• Tianming Wang 2 ,
• Caifeng Gao 3 ,
• Fei Sun 1 ,
• Shangke Li 4 ,
• Zhanlin Luo 5
• 1 Research Ward , Gansu Provincial Hospital , Lanzhou , China
• 2 Gansu University Of Chinese Medicine , Lanzhou , China
• 3 Department of radiotherapy , Gansu Provincial People's Hospital , Lanzhou , China
• 4 Gansu Provincial Hospital , Lanzhou , Gansu , China
• 5 Department of radiotherapy , Gansu Provincial Hospital , Lanzhou , Gansu , China
• Correspondence to Professor Zhanlin Luo; lzl120606{at}126.com

Introduction The purpose of this protocol is to investigate the risk factors, critical evaluation contents and preventive measures of high-output enterostomy.

Methods and analysis This scoping review will follow the Joanna Briggs Institute guidelines for scoping reviews. PubMed, EMBASE, CINAHL, the Chinese Biological Literature Database and the Cochrane Library will be searched for relevant literature published from January 2015 to January 2024. The Grading of Recommendations, Assessment, Development and Evaluation and the Risk Of Bias In Non-randomised Studies of Interventions will be used to assess the reliability of the evidence.

Ethics and dissemination As this scoping review involves database searches for literature analysis, informed consent and ethical approval from patients will not be required. The findings will provide essential decision-making information for researchers, clinicians and ostomy nursing staff. The results of the review will be presented at a scientific conference and published in a peer-reviewed journal.

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This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-078602

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STRENGTHS AND LIMITATIONS OF THIS STUDY

This protocol will strictly adhere to the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews.

The literature search will include only English and Chinese literature from the past 10 years, potentially limiting the comprehensiveness of the search. However, researchers will broaden the search scope based on the included literature and supplement it by searching grey literature.

The Grading of Recommendations, Assessment, Development and Evaluation and Risk Of Bias In Non-randomised Studies of Interventions tools will be used to grade the quality of the evidence obtained after quality evaluation, ensuring the scientific rigour of the research design and the appropriateness of evidence classification.

To reduce the risk of bias, researchers will triple-check the input data during the process of literature quality evaluation and evidence summarisation.

Introduction

In recent years, with the rapid development of living standards, people’s eating habits and lifestyles have undergone major changes, leading to a continuously increasing trend in the incidence and mortality of malignant tumours such as gastric cancer and colorectal cancer. 1 The treatment of colorectal cancer predominantly involves surgery, and the number of patients undergoing enterostomy is on the rise. 2 Enterostomy requires the removal of the cancerous end of the intestine, extraction of a section of the intestine through the abdominal incision, and its attachment to the abdominal wall skin to form a stoma. 3 As the anal sphincter loses its normal excretion function, patients must use a stoma bag to collect excreta postsurgery. In the USA, approximately 100 000 patients undergo enterostomy annually, with a current total of 1 million enterostomy patients. 4 Despite rapid advancements in surgical techniques, the incidence of high output in enterostomy patients ranges from 23.8% to 31.1% compared with other common surgical procedures. 5 6

Postoperative complications of enterostomy can be categorised into early and advanced complications based on the time of occurrence. Early complications refer to those occurring within the first 30 days postoperation. High output is a prevalent early complication of enterostomy. 7 Typically, the output from an enterostomy ranges from 500 to 2000 mL but varies based on the type of stoma, enteral feedings and other factors. A review of extensive literature reveals ambiguity in the normal output for different types of enterostomies; however, it is widely accepted that an output exceeding 1500 mL per day from a small bowel enterostomy is considered high. 8 Fluid losses postsurgery usually resolve within a few weeks due to adaptive changes in the remaining small intestine. In some patients, high-output enterostomy results from inadequate adaptation or other causes of diarrhoea, such as indigestible food intake, leading to significant water and electrolyte loss, and potentially causing complications like kidney function injury. 9 High output is also the most common reason affecting readmissions of enterostomy patients. 10 Moreover, the quality of life for patients with enterostomy is poor in the early stages due to insufficient knowledge about stoma care and influences such as psychological emotions. 11 Overall, the risk of postoperative complications after enterostomy is lifelong, with high output being a frequent complication. Specialist stoma nurses should proactively focus on complication prevention and provide guidance.

Currently, the literature on preventing high output has not received adequate attention, and there is no consensus to guide precise and effective nursing interventions for preventing high output in enterostomy patients. Monitoring of enterostomy discharge is also often overlooked by patients and clinical ostomy nurses. Additionally, the variable quality of relevant literature can waste medical resources and lead to misleading clinical practices.

Given these issues, it is urgent to determine a comprehensive and effective prevention programme for high output. The scoping review, based on evidence-based concepts, aims to help researchers understand the scope and characteristics of existing evidence and identify gaps in the evidence. Thus, the methods employed in this study were designed to retrieve, summarise and analyse relevant evidence on high output in enterostomy patients, providing an evidence-based foundation for clinical nurses, patients and caregivers to implement enterostomy care and reduce the incidence of high output.

Review questions

What are the risk factors for high output enterostomy?

What are the critical evaluation contents of high-output enterostomy?

What are the main interventions that can effectively prevent high-output enterostomy?

This scoping review will follow the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. 12 13 The study is scheduled to commence in April 2024 and conclude in August 2024. This protocol has been registered with the OSF ( https://doi.org/10.17605/OSF.IO/UF9B7 ).

Patient and public involvement

No patients and the public were involved.

Inclusion criteria

The subjects are patients who have undergone enterostomy (including colostomy, ileostomy, cecostomy, jejunostomy, etc) after a pathological diagnosis of malignant diseases such as stomach and colorectal cancer. The patients are 18 years or older. Enterostomy in children is excluded due to factors such as the thin cuticle of the skin, crying and different ostomy bag management needs. Additionally, children undergoing enterostomy often have various congenital diseases, such as anal absence and Hirschsprung’s disease, which differ significantly from adult enterostomy. Finally, the rehabilitation outcomes for minor enterostomy patients depend on the effectiveness of care provided by primary caregivers, which is a further reason for their exclusion from this study.

Exclusion criteria

The subjects are patients undergoing urostomy.

Conference abstracts, animal experiments or preclinical trial studies and studies without specifying the type of stoma.

Studies where the full text is not available.

Studies with incomplete data and unsuccessful attempts to contact the original authors.

The objective of this scoping review is to search, select and extract evidence for the prevention and care of high-output enterostomy patients. According to the requirements of different databases, appropriate search strategies will be developed, and a literature search will be conducted. The data that meet the inclusion criteria will be analysed. The main contents include (1) risk factors for high-output enterostomy patients; (2) critical evaluation contents of high-output enterostomy, such as symptoms and signs of high output in enterostomy patients and (3) interventions that can effectively prevent and improve high output.

Types of studies

The literature types included in this study encompass randomised controlled trials (RCTs), non-RCTs, cohort studies, case–control studies, cross-sectional studies, observational studies and descriptive studies. Qualitative studies and systematic reviews will also be considered and published in either English or Chinese, from January 2015 to January 2024. This review will include studies on high-output enterostomy conducted in any country or region.

Search strategy

The search for studies related to the prevention of high output in adult enterostomy patients will be conducted through PubMed, EMBASE, CINAHL, the Chinese Biological Literature Database and the Cochrane Library. We will employ the following MeSH terms and/or free-text terms: surgical stomas, enterostomy, ostomy, stoma, ileostomy, jejunostomy, colostomy, high output, fast transit, diarrhoea, risk factor, association, relative risk, factor, influence, correlation, management, treatment, therapy and care.

Additionally, grey literature sources, such as Google Scholar, will be searched to ensure comprehensive evidence incorporation. Grey literature includes materials published by government departments, academic institutions and commercial industries that are non-profit, helping to avoid publication bias. The flow chart of the study diagram is presented in figure 1 , and the detailed search strategy is outlined in online supplemental appendix S1 .

Supplemental material

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The flow diagram of the study selection.

Literature screening

The literature screening will be conducted independently and cross-checked by two reviewers (Che Y and Luo ZL). In the event of disagreements, decisions will be discussed in a group meeting. The reviewers will independently use EndNote V.X9 software to remove duplicate entries and initially exclude irrelevant literature by reviewing titles and abstracts. For literature retained after this initial screening, further exclusions will be made by reading the full text to ensure alignment with the study theme, such as research object consistency and intervention plans.

Data extraction and presentation

Two reviewers (Che Y and Luo ZL) will independently extract data, including (1) research design, title, author, year of publication, types of literature, country or region of publication, and publication languages; (2) baseline characteristics of participants: sample size, gender, age, type of enterostomy, characteristics of the research population; (3) intervention details: intervention measures, observation period and (4) primary outcomes: the incidence of high-output enterostomy, enterostomy output volume, the change of output and the factors contributing to high-output enterostomy. There will be no secondary outcome measures.

Strategy for data synthesis

The study design, baseline characteristics of participants and intervention details of this scoping review will be quantitatively summarised in table format. For the incidence of high output in enterostomy, enterostomy output volume, changes in output and factors contributing to high-output enterostomy will be presented in the form of frequency, percentage and descriptive summary.

Quality of evidence

The quality of evidence for outcome indicators will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. 14 The GRADE evaluation criteria include five grading factors: research limitations, inconsistency, indirectness, imprecision and publication bias. The evidence quality will be rated across four levels: high, moderate, low and very low. The default evidence quality for RCTs is high, with one grade reduction to moderate, two reductions to low and three to very low.

For cohort studies, case–control studies and other non-RCTs included in this review, the risk of bias will be assessed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. 15 ROBINS-I tool divides bias into 7 domains with a total of 33 items: (1) confounding bias; (2) subject selection bias; (3) intervention classification bias; (4) intentional intervention deviation bias; (5) loss of data bias; (6) outcome measurement bias and (7) selective reporting bias. According to the evaluation results of each item, the researcher will make yes (Y), probably yes (PY), no (N), probably no (PN) and no information (NI) answers. ROBINS-I divided the evaluation results into five levels: low risk of bias, moderate risk of bias, high risk of bias, critical risk of bias and no information.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Since the literature related to the research topic will be obtained by searching the database for analysis in this scoping review, informed consent and ethical approval of patients will not be required. The results of this study will provide decision-making information for researchers, clinicians, and other ostomy nursing staff. The results of the review will be presented at a scientific conference and published in a peer-reviewed journal.

• Li H , et al
• Fu L , et al
• Takahashi H ,
• Haraguchi N , et al
• Sakamoto Y , et al
• Babakhanlou R ,
• Hita AG , et al
• Lederhuber H ,
• Massey LH ,
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• Shinkwin M ,
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Contributors All authors in the manuscript contributed substantially to the idea or design of the study and agreed to the manuscript’s publication; YC and SL: literature search and data extraction; YC and FS: quality assessment of systematic reviews and writing of papers; ZL: search literature and quality assessment of systematic reviews; TW and CG: search literature and quality assessment of systematic reviews; YC: design study and data extraction.

Funding This scoping review protocol was supported by Natural Science Foundation of Gansu Province, China (22JR5RA697).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Case Report
• Open access
• Published: 28 August 2024

Migration of an intrauterine contraceptive device into the bladder complicated by stone formation an exceptional complication: case report and literature review

• Hanane Houmaid   ORCID: orcid.org/0000-0001-5985-4340 1 ,
• Karam Harou 1 ,
• Bouchra Fakhir 1 ,
• Ahlam Bassir 1 ,
• Lahcen Boukhanni 1 ,
• Abderrahim Aboulfalah 1 ,
• Hamid Asmouki 1 &
• Abderraouf Soummani 1  

Contraception and Reproductive Medicine volume  9 , Article number:  42 ( 2024 ) Cite this article

Metrics details

We report a rare and unusual case of intravesical migration of an intrauterine device with stone formation. The intrauterine device (IUD) is the most common method of reversible contraception in women. However, its insertion is not without risk, it can cause early or late complications. IUD can perforate the uterus wall and migrate into adjacent structures.

Case presentation

A 35 year-old female 5 gravid, 4 para has been benefited from intrauterine contraceptive device (IUCD) 5 years ago, she was presented to gynecological consultation for chronic pelvic pain with urinary symptoms. There was history of a good IUD insertion 5 years ago, considered expelled after one month of its pose. Physical examination was normal, but a pelvic ultrasound and a plain abdominal radiography allowed the detection of an IUD outside the uterine cavity, but inside bladder. A diagnostic and therapeutic cystoscopy was performed, and the IUD with calculus was successfully removed. There were no postoperative complications.

This case is reported to highlight and to reiterate the need to think about one of the rare complication of IUD insertion, which every practitioner must know, it’s the transuterovesical migration, before concluding wrongly to its expulsion. It’s a consequence of, non-compliance with the rules for inserting an IUD and poor monitoring. The evolution towards calcification is a certain consequence; its screening involves rigorous clinical monitoring.

Introduction

The intrauterine device (IUD), is an effective, safe and practical contraceptive choice for many women with some 100 million users, it is currently the most popular reversible contraceptive method in the world [ 1 ].

Inserting the IUD is a simple medical procedure. However, it is not devoid of risk, especially when insertion techniques are not followed up. It can cause early or late complications, such as bleeding, gynecological infections, expulsion or perforation with migration to adjacent structures, which is both rare and serious [ 2 ]. Approximately 1–3 of 1000 IUD insertions result in migration, and the bladder remains the most common destination of IUD migration. Various localization are reported in the literature such omentum, the broad ligament, pouch of Douglas (45%), colon, mesentery and sigmoid [ 1 , 3 ].

We report a new case of bladder migration of IUD complicated by calculus formation.

Mrs. K.B, 35 year old of rural origin, illiterate, 5 gravida, 4 para (3 vaginal deliveries and one cesarean section), one spontaneous abortion and 4 living children, presented to a gynecological consultation for chronic pelvic pain with burning micturition, pollakiuria, dysuria but without hematuria, resistant to usual therapies for 5 years ago.

The careful questioning of Mrs. K.B discerned in her medical history the notion of contraception by IUD, implemented 5 years ago on day 40th postpartum by a nurse known as a certified and trained health care provider.

The preinsertion counseling have been carried out, the patient didn’t have any contraindication to using IUD. The vaginal examination didn’t show any abnormalities, the uterus was in an anteversed and anteflexed position with normal size,

There was no doubt at the time of insertion, and the immediately check up after insertion was good; the IUD strings was visible in the vagina, and the IUD was at the right place in the uterus after ultrasound control.

The patient reported a pelvic pain for three days after the IUD insertion which subsided with simple analgesic treatment, without abnormal bleeding or urinary complaints. One month later, in the routine control, the nurse did not find any intravaginal IUD strings. Thus, the diagnosis of IUD expulsion was accepted and oral contraception was newly prescribed.

Since that time, the patient complained of pelvic pain with burning micturition, exacerbated in the 3rd trimester of the last pregnancy (delivery by cesarean section) but which was attributed to the pregnancy. Specialized urogenital examination is completely normal, but pelvic ultrasound allowed the detection of an IUD outside the uterine cavity, but inside bladder (Fig.  1 ).

Pelvic Ultrasound showing the IUCD with calculs in the bladder

Additionally, Plain abdominal radiography showed the IUD projecting onto the bladder area (Fig.  2 ). The notion of expulsion of the IUD wrongly retained 5 years ago is eliminated and the diagnosis of secondary perforation of the uterus with migration of the IUD is admitted. The cytobacteriological examination of urine was negative and removal of the IUD under cystoscopy was indicated.

Plain abdominal radiography showed A mislocated IUD projecting in the lower left quadrant of the abdomen

Cystoscopic exploration reveals the IUD firmly embedded in the bladder wall with calcifications (Fig.  3 ). Its removal was carried out without any incident and the post-operative follow up was simple.

IUD removed from bladder with stone formation after 5 years of migration

The follow-up gynecological consultation, carried out 1 month after the removal of the IUD, noted the disappearance of the aforementioned symptoms. However, the patient was willing to use contraception such as tubal ligation.

The IUD is one of the highly effective reversible methods of contraception. There are two types of products available: copper-coated IUDs or levonorgestrel-releasing IUDs. In the absence of contraindications, the IUD can be used in all women seeking a reliable reversible method of contraception with long-term contraceptive effectiveness that is less demanding in terms of compliance [ 2 ].

Patients with contraindications to estrogen or those are breastfeeding may be good candidates. The IUD is also used as morning-after contraception in women who have had unprotected sex for up to 7 days.

The intrauterine device has multiple mechanisms of action; it prevents both fertilization and implantation. The biochemical and morphological modifications produced by the IUD, and more particularly its inflammatory action on the endometrium, lead to a significant accumulation of lysosomal enzymes promoting endometrial destruction and migration [ 4 ].

Despite the wide use of IUD in recent years, there are still limitations for adolescents and nulliparous, but recent studies show that the IUD is safe for both of them to use [ 5 ].

Untrained Healthcare providers may constitute a danger for women wishing to use IUD. These women are significantly more likely to experience complications, which in turn can decrease demand for IUD services [ 6 ]. Therefore, it is imperative to stay up-to-date on guidelines for improving the quality of IUD services. Clinical follow-up is recommended after 4 to 12 weeks, if the IUD threads are not visible or in cases of atypical symptoms, an ultrasound examination should be performed. It can easily confirm whether the IUD is correctly positioned and often to highlight if there is any complications related to the IUD. Moreover, performing an ultrasound before placement to check up uterus measures and position can help for a successful placement [ 2 ]. A preinsertion informed consent is mandatory and requires that women understand benefits, technique, and possible complications.

Uterine perforation is a complication rarely observed following IUD insertion; its incidence varies from 1/350 to 1/2,500 insertions [ 7 ]. This incidence may be largely underestimated taking into account asymptomatic forms.

Uterine perforation ; partial or complete; usually occurs in the insertion moment of the IUD, Migration to the bladder and development of symptoms are long processes, its real etiology remains unknown. The risk factors for this perforation are essentially the insertion of an IUD in the postpartum or post abortum period, an inexperienced practitioner, multiparity, nulliparirty, scarred and immobile uterus and extremely anteverted or extremely retroverted uterus, the relationship between the size of the IUD and that of the uterine cavity, insertion technique, the use of force more than necessary, atrophic uterus [ 2 , 7 ]. In our case, it seems that uterine perforation was probably happened at the time of forced insertion, as evidenced by the pain felt by the patient after insertion.

Therefore, it seems important after insertion of an IUD to check its correct positioning with a control ultrasound.

The transuterine migration of the IUD can take several directions to locate anywhere in the abdomen, a recent review illustrates that the bowel is the most affected organ in cases of perforated and migrated IUD (intestine 32%, colon 4%, appendix 1%, ileum 5%, rectum 12%, sigmoid 9%), the second most affected organ is the bladder (24%), often associated with lithiasis formation and urinary complaints [ 2 ].Vascular damage is exceptional; However, Ibghi described stenosis of the external iliac vein by an IUD [ 8 ].

The bladder location of an IUD is not always synonymous with trans utero-bladder migration. In some patients, a technical fault in the insertion of the IUD has been blamed, which can be accidentally placed in bladder via the transurethral route by inexperienced medical or paramedical profesionnals [ 9 ].

Uterine perforation by the IUD is often asymptomatic; most authors do not report any noisy symptoms during these perforations [ 3 ]. The disappearance of the reference threads is the first sign of migration (35%) [ 8 ], which must always be present in mind, before concluding in an unknown expulsion. It is only at the complication stage that the symptoms appear. Abdominal pain is the second revelatory signe (30%), followed by the occurrence of pregnancy (25%) and self-detection of IUD migration (11%) [ 10 ].

The bladder location of the IUD may be responsible for urinary symptoms consisting of Pollakiuria, burning micturition and dysuria, or even terminal hematuria, wrongly suggesting banal cystitis, as the case of our patient. The diagnosis is often mentioned on the plain abdominal radiography which shows the IUD with its metallic tone encompassed in an opacity of calcium tone because the stones are often radiopaque [ 11 ], but this is not constant. The diagnosis remains difficult if the IUD is not associated with bladder calculus.

Abdominal ultrasound confirms the bladder location of the IUD with or without stone formation. However, endovaginal ultrasound is more effective for studying the uterus (emptiness and/or possible partial perforation of the uterine wall by one of the arms of the IUD). This examination is more useful before insertion of the IUD because it allows the uterine anatomy to be clarified (anteverted or retroverted, dimensions, submucosal leiomyoma, congenital uterine anomalies). It must be repeated immediately afterwards and 4 to 12 weeks later to ensure the absence of uterine perforation [ 2 ].

Cystoscopy examination remains the most reliable diagnosis method, it’s the first stage of an endoscopic treatment. The use of computed tomography (CT), or even pelvic magnetic resonance imaging (MRI), is indicated in some cases, for better topographical characterization, and particularly in the case of associated pregnancy [ 12 ].

The IUD perforation of the uterine wall as well as its migration can be responsible in 0.1 to 0.9% of cases for serious complications such as pelvic abscesses, intestinal perforation and vesicoureteral fistula [ 7 ]. Furthermore, pelvic actinomycosis can develop, but the formation of bladder stones remains the most common possibility [ 13 ]. Indeed, bladder calculus in women is not common; it is 7 to 10 times less common than in men [ 14 ]. This is for anatomical and hormonal reasons. The formation of bladder calculus in women is favored by a local cause, a foreign body which may be an IUD.

The urinary infection and chronic inflammation which are almost always associated, plays a large part in calculus formation through ureolysis and the formation of struvite crystals. The migrated device act like foreign body over years and provides a bed for stone formatio n [ 11 , 15 ].

Stone formation would be independent of the duration of presence of the IUD as a foreign body in the bladder. Vecsey reported the formation of a stone very early in 6 months after migration [ 16 ], while Kiilholma reported the non-formation of a stone on a Nova T type IUD that had migrated into the bladder for 3 years ago [ 17 ].

Extraction of the IUD can be done either endoscopically as we did in our case, or via laparotomy and bladder section. [ 18 ]. In the event of partial perforation of the bladder wall, laparoscopic extraction was described [ 19 ]. In cases of vesicouterine fistula, surgical treatment is often the rule. Conservative treatment by prolonged bladder drainage is rarely effective. In the case of associated actinomycosis, treatment is often dual, combining surgical excision and prolonged antibiotic therapy based on penicillin. The duration of treatment varies from 3 to 12 months. The outcome is often favorable without recurrence [ 9 , 20 ].

This case is reported to highlight and to reiterate the need to think about one of the rare complication of IUD insertion, wich every practitioner must know, it’s transuterovesical migration, before concluding wrongly to its expulsion. It’s a consequence of, non-compliance with the rules for inserting an IUD and poor monitoring. The evolution towards calcification is a certain consequence; its screening involves rigorous clinical monitoring.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Intrauterine device

Intrauterine contraceptive device

Magnetic resonance imaging

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Hanane Houmaid, Karam Harou, Bouchra Fakhir, Ahlam Bassir, Lahcen Boukhanni, Abderrahim Aboulfalah, Hamid Asmouki & Abderraouf Soummani

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H.H. conceptualized the case study and took the lead in drafting the manuscript. K.H. and B.F. provided the clinical details of the case study, conducted a literature review and participated in drafting the manuscript. A.B, L.B, A.A. and H.A. reviewed the literature and critically reviewed the manuscript. A.S. conceptualized the case study, provided supervision, participated in the literature review and in drafting the manuscript. All authors read and approved the final manuscript.

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Houmaid, H., Harou, K., Fakhir, B. et al. Migration of an intrauterine contraceptive device into the bladder complicated by stone formation an exceptional complication: case report and literature review. Contracept Reprod Med 9 , 42 (2024). https://doi.org/10.1186/s40834-024-00302-x

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The Association Between Menstrual Cycle Phase, Menstrual Irregularities, Contraceptive Use and Musculoskeletal Injury Among Female Athletes: A Scoping Review

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• Published: 31 August 2024

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• Candice MacMillan   ORCID: orcid.org/0000-0002-5284-3208 1 , 2 ,
• Benita Olivier 3 , 4 ,
• Carel Viljoen 5 ,
• Dina Christa Janse van Rensburg 6 &
• Nicola Sewry 2 , 7  

3 Altmetric

The influence of menstrual cycle phases (MCPs), menstrual irregularities (MI) and hormonal contraceptive (HC) use on injury among female athletes has been scrutinised. Existing systematic reviews investigating the effect of exposures affecting the endogenous reproductive hormone status on sporting injuries are limited in terms of the types of studies included and injuries investigated.

This scoping review aims to summarise the coverage of the literature related to the extent, nature and characteristics of the influence of MCP, MI and HC use on musculoskeletal injuries among athletes. It also aims to summarise key concepts and definitions in the relevant literature. Observational and experimental studies investigating the effect of MCP, MI, and HC on musculoskeletal injuries among female individuals of reproductive age were included. Studies specifically stating pregnant women, perimenopausal/postmenopausal athletes, or those using medication (other than HC) that affects reproductive hormone profiles or the musculoskeletal system were excluded.

This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping reviews and JBI scoping review guidelines. Published and unpublished studies were sourced from several databases and resources. Initial keywords used included terms related to “menstrual cycle”, “hormonal contraception” and “injury.” Titles and abstracts of identified citations were screened independently and assessed for eligibility by two independent reviewers. Data from the included studies were extracted using a standard data extraction form.

The search yielded 10,696 articles, of which 96 met the eligibility criteria. Most studies investigated MI (77%), and 49% included MCP as a contributing injury risk factor. Publications have increased over the last two decades. Collectively, only 16% of research has been conducted in Africa, Asia and Oceania. There were no studies from South America. Seventy-five percent of the studies investigated individual versus team (25%) sport athletes. Most studies only investigated elite or professional ( n  = 24; 25%) level athletes. The definitions of injury, eumenorrhea and MI differ vastly among studies. Regarding MI, most studies (69%) investigated secondary amenorrhea, followed by oligomenorrhea (51%) and primary amenorrhea (43%). Concerning HC, the influence of oral contraceptive pills was mainly investigated.

Conclusions

Research related to MCP, MI and HC as contributing musculoskeletal injury risk factors is increasing; however, several gaps have been identified, including research from countries other than North America and Europe, the study population being non-professional/elite level athletes, athletes participating in team sports and specific injuries related to MCP, MI and HC, respectively. Differences in methodology and terminology of injury, MCP and MI hinder comparative summative research, and future research should consider current published guidelines during the study design. Identifying barriers to following standard guidelines or research investigating the most practical yet accurate methods to investigate the influence of MCP on musculoskeletal health might yield valuable insights for future research designs.

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1 Introduction

Injury rates in gender-comparable sports are higher among female athletes participating at different levels of play [ 1 , 2 , 3 ]. Acknowledgement of gender-based differences in injury presentation is necessary for holistic injury prevention, assessment, and treatment to allow for a successful return to play and a reduced risk of re-injury [ 4 , 5 ]. The influence of the menstrual cycle phases (MCPs) on injury among female athletes has been a subject of scrutiny [ 6 , 7 , 8 ]. Continuous hormonal fluctuations throughout the MCP seem to affect the material structure and mechanical properties of muscle [ 3 ], tendon [ 2 ], bone [ 6 ] and ligaments [ 1 , 9 ]. The use of hormonal contraceptives (HCs) and menstrual irregularities (MI) influences the fluctuation of reproductive hormones on athletes’ injury risk and it therefore, also warrants investigation [ 5 , 6 ].

1.1 Menstrual Cycle Phases (MCPs) and Injury Risk

A normal MCP consists of the follicular phase that precedes ovulation, followed by the luteal phase [ 10 , 11 , 12 ]. The fluctuation of reproductive hormones throughout the MCP is associated with an increased risk for acute [ 1 , 9 , 13 , 14 ] and overuse [ 2 , 3 , 15 ] injuries. Female footballers’ injury incidence rates are greater in the late follicular phase (47%) compared with the early follicular and luteal phases (32%) [ 14 ]. Studies also suggest an increased risk of muscle and tendon injuries [ 3 , 14 ], as well as anterior cruciate ligament (ACL) injuries [ 9 ] during the late follicular phase compared with the luteal phase. A recent systematic review [ 16 ] suggests that peak oestradiol in the ovulatory phase is associated with laxity, strength and poor neuromuscular control, which, in turn, can predispose athletes to injury. Data have, however, not been consistent, and a direct causal relationship to injury has not yet been established.

1.2 Menstrual Irregularity (MI) and Injury Risk

Menstrual irregularity is characterised by oligomenorrhoea, polymenorrhoea, amenorrhoea, anovulatory or luteal-phase deficient cycles [ 6 , 8 , 17 ] and is prevalent among athletes participating in different sports and is associated with an increased injury risk [ 6 , 17 ]. High school athletes with MI sustain more severe injuries in terms of time loss than athletes with regular menses [ 17 ]. The female athlete triad (FAT) refers to the interrelatedness of MI, low energy availability and diminished bone mineral density [ 6 , 17 ]. More recently, the FAT is called relative energy deficiency syndrome (RED-S); a condition resulting from insufficient energy intake relative to the energy expended, leading to impaired physiological functioning, including but not limited to metabolic rate, menstrual function, bone health, immunity and cardiovascular health. It is crucial for both male and female athletes, particularly emphasising the significant health and performance implications for female athletes [ 18 , 19 ]. Several studies have investigated the association between MI and bone injuries and found that adolescent [ 13 , 17 ] and adult [ 6 ] athletes with current or past menstrual dysfunction are particularly prone to bone stress injuries.

1.3 Hormonal Contraceptive (HC) Use and Injury Risk

Hormonal contraceptives are used by approximately half of female athletes [ 20 ]. There are many types of HCs including oral contraceptive pills (OCPs), intrauterine devices (IUDs), injections, transdermal patches, implants and vaginal rings [ 20 ]. Exogenous hormones inhibit endogenous hormone production, eliminating normal hormonal fluctuations throughout the normal menstrual cycle [ 6 , 21 ]. Considering the effects of natural MCP hormonal fluctuations on injury risk, several studies propose that the use of OCPs may, therefore, be protective against injury [ 1 ] . Among the general population, combined HCs are not protective against musculoskeletal (MSK) injuries [ 22 ]. Among female athletes, using OCPs in combination with [ 1 ] or without [ 23 ] neuromuscular training may increase the dynamic stability of the knee joint and decrease ACL injury risk.

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted. Systematic reviews investigating the effects of the MCP on athletes’ performance [ 24 ], ACL injuries [ 1 , 8 , 9 ] and tendinopathies [ 1 , 9 ] have been published. The most recent review [ 16 ] exploring the MCP and sports injuries only included eight studies. One review appraised the literature regarding the association between combined HC and MSK injuries and conditions but included all female individuals and not only female athletes [ 22 ]. True to their nature, systematic reviews delve into the particulars of evidence related to the specific topic, and the literature summarised and appraised is often limited by stringent eligibility criteria [ 25 ].

As the number of female athletes grows, the number of publications related to female-specific injury risk factors is increasing. While systematic reviews on the effect of MCP, MI and HC use have been published, studies on these topics that are not included because of minor deviations from the eligibility criteria might be overlooked. Therefore, the primary aim of this scoping review is to determine the scope of the literature related to the association between MCP, MI and HC use and MSK injury among female athletes and identify gaps to aid the planning and commissioning of future research. The heterogeneity in the methodology and definitions of MCPs and MIs has been highlighted as a limitation to conducting meta-analyses and comparing findings [ 22 , 26 , 27 ]. An additional aim of this scoping review is to summarise key concepts and definitions in the relevant literature. A scoping review was deemed most appropriate for these outcomes because it is exploratory and incorporates a variety of research designs, focusing on coverage rather than the depth of a topic.

2 Review Questions

The following broad research questions were proposed following preliminary literature searches and multidisciplinary discussions within the group.

What research is available regarding the association between MCP, MI and HC use on MSK injuries among female athletes?

How are MCP, MIs and injuries defined in research investigating the association between MCP, MI and HC use on MSK injuries among female athletes?

Which methods are used to confirm different MCPs in research investigating the MC–injury association?

Which types of MIs and HCs have been included in research investigating the influence of MI on injury risk?

What are the evidence gaps in these fields?

3 Eligibility Criteria

A detailed description of the eligibility criteria is summarised in Table 1 of the Electronic Supplementary Material (ESM) according to population, concept, context and study design. In short, studies investigating the effect of MCP, MI and HC on MSK sporting injuries among female athletes were included. Female athletes [ 28 ] and exercisers [ 29 ], participating in structured individual or team sports, regardless of the level of participation, who are of reproductive age, were considered. All menstruating women, regardless of regularity, and HC users (regardless of form) were included. Pregnant, perimenopausal and menopausal women or women using medications (other than HCs) that affect reproductive hormone profiles or the MSK system were excluded. All observational and experimental studies were considered. Studies published in languages other than English were not considered.

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) [ 30 ] and JBI guidelines [ 31 ] and registered on the Open Science Framework (identifier: https://doi.org/10.17605/OSF.IO/5GWBV ).

4.1 Search Strategy and Information Sources

The search strategy was developed with input from CM, NS and BO using the Peer Review of Electronic Search Strategies standard [ 32 ]. In addition, the search strategy was peer reviewed by a research librarian with expertise in systematic review searching and is not otherwise associated with the project [ 32 ]. A sequential three-step search strategy was utilised to find both published and unpublished studies before 30 November, 2023. First, a restricted search of the MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases was conducted, followed by an analysis of the text words contained in the title and abstract and of the index terms used to describe the article. Thereafter, a second search was undertaken across all the identified keywords and index terms across all included databases. Last, the reference lists of all identified studies was perused to identify any other relevant studies. Studies published in English were considered.

Databases searched included MEDLINE via PubMed, CINAHL, the Cochrane Controlled Trials Register in the Cochrane Library, Physiotherapy Evidence Database (PEDro), ProQuest 5000 International, ProQuest Health and Medical Complete, EBSCO MegaFile Premier, Science Direct, SPORTDiscus with Full Text and SCOPUS. The search for unpublished studies included EBSCO Masterfile Premier, OpenGrey (SIGLE), Worldwidescience.org, Google Scholar, Mednar and WiredSpace. Initial keywords used were terms related to “menstrual cycle”, “contraception” and “injury”. The filter function “humans” was applied where possible. A full search strategy for the PubMed database is detailed in Fig.  1 of the ESM. The one with the longest follow-up was selected for studies with multiple publications of the same outcome(s) reported. If older publications refer to articles, those included were accessed to clarify methods where necessary. When in doubt regarding a study’s eligibility criteria, the reviewers contacted the authors with a maximum of three attempts, two e-mails and one phone call (if possible), over 4 weeks.

4.2 Sources of Evidence

All search results were uploaded and stored in a systematic review management platform (Covidence systematic review software; Veritas Health Innovation, Melbourne, VIC, Australia) and were accessible to all reviewers. Covidence automatically removed duplicates by reviewing the following fields: titles, year, volume and authorship. Two reviewers (CM and NS) independently checked the duplicates removed by Covidence and verified their accuracy. Two independent reviewers (CM and NS) screened all records’ titles, abstracts and full texts (where indicated) for inclusion. Reasons for excluding sources of evidence in the full text that did not meet the inclusion criteria were recorded and reported in the scoping review. Any disagreements with the reviewers were resolved through discussion or the use of a third reviewer (BO). All three reviewers have previous experience in evidence synthesis.

4.3 Data Extraction and Charting Process

Four independent reviewers (CM, NS, BO and CV) extracted data from papers included in the scoping review. The data extracted included specific details about the study characteristics (i.e. design, location, study aim), (b) participant characteristics (i.e. eligibility criteria, age, training status), (c) context characteristics (i.e. type of sport, level of participation), (d) exposure characteristics (i.e. MCP, definitions and methods of determining participants’ MCP, type of MI, type, dosage and duration of HC use) and (e) injury incidence and characteristics (injury mechanism, body area/structure injured, type of the injury, primary or recurrent injury, injury definition) and key findings relevant to the review questions. Any reviewer disagreements were resolved through discussion or with an additional reviewer (CJR). Where appropriate, authors of papers were contacted to request missing or additional data.

4.4 Data Analysis and Presentation

The results are presented numerically and thematically. A numerical analysis maps the data in a tabular and diagrammatic form, showing the distribution of studies by theme (MCP, MI, HC use or a combination of MCP, MI and/or HC), publication period, country of origin and study method. The charting of the results was based on an iterative approach. A descriptive analysis pertaining to themes and key concepts relevant to the research questions accompanies the tabulated results and describes how the results relate to the review objective and questions.

5.1 Search Results

An initial search was performed in December 2022 and updated in December 2023. A total of 10,696 articles were found. After duplicate removal and screening, 96 articles (listed in Tables 2a–2g of the ESM) met the eligibility criteria and were included in this scoping review. The search results and the study inclusion process are reported in full in the PRISMA-ScR flow diagram (Fig.  1 ) [ 30 ].

Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) flow diagram

Figure  2 depicts the number of studies investigating the association between MSK injury and MCP, MI or HC, respectively, and those investigating two or all of the themes. Although summarising the findings of the studies was not the primary purpose of this review, a summary of the aims and findings of each included study is included in Tables 2a–2g of the ESM. The high number of citations associated with some statements in the results section may reduce the reader’s experience, therefore, references to studies referred to in the results section are available in Tables 2a–2g of the ESM.

Percentage of studies investigating the relationship between injury and menstrual cycle phase (MCP), menstrual irregularity (MI) and hormonal contraceptives (HC), respectively or combined

5.3 Study Characteristics

5.3.1 study design.

Study design by count and frequency were cross-sectional (43/96;45%), cohort (21/96;22%), case control (12/96;14%), case series (11/96;11%), case study (7/96;7%) and randomised controlled trial (1/96;1%).

5.3.2 Year of Publication of Articles Included

The year of publication of the included publications ranged from 1986 to 2023. Figure  3 illustrates the distribution of publications per decade since 1980. Publications increased over time, with most ( n  = 28; 29%) published between 2010 and 2019. Notably, 23 (24%) publications have been published in the last 4 years. Furthermore, the number of publications related to the MCP as an MSK injury risk factor is increasing.

Year of publication reported by theme and decade. Themes: menstrual cycle phase (MCP); menstrual irregularity (MI); and hormonal contraceptive (HC)

5.3.3 Geographical Location of Included Articles

Figure  4 demonstrates the distribution of studies included by continent and country. Most studies’ data collections ( n  = 51; 53%) were performed in North America, specifically the USA ( n  = 46; 43%), while no research emerged from South America. Only two studies included participants from more than one country [ 33 ], one of which was conducted across continents [ 34 ].

Geographic distribution of studies included by continent ( n ;%) and country ( n )

5.3.4 Sports Investigated

Tables 2a–2g of the ESM indicate the sports investigated in each study. Six (6%) studies [ 35 , 36 , 37 , 38 , 39 , 40 ] investigated female individuals in the military. Thirty (31%) studies included athletes from multiple different team and/or individual sports. However, seven of these studies did not specify the sports considered. Most ( n  = 48; 75%) studies investigating one sport were individual athlete sports compared to team ( n  = 16; 25%) sports. Endurance runners ( n  = 37; 39%) were mostly included, followed by track and field athletes ( n  = 24; 25%). Noteworthy, however, is that only 3/23 studies [ 41 , 42 , 43 ] investigating the MCP with or without HC and MI as contributing factors to injury included endurance runners and track and field athletes. Most of these studies (22/23; 96%) included athletes participating in sports that require multi-directional movements. Conversely, most studies (52/76; 68%) investigating MI with or without MCP and/or HC included endurance running track and field athletes and (18/76; 24%) athletes participating in multi-directional sports. All four studies only related to HC use investigated multi-directional type sports. When HC and MI were investigated, most studies included endurance and track and field athletes.

5.4 Participant Characteristics

The age range for most studies was 13–45 years. Four [ 44 , 45 , 46 , 47 ] studies included participants aged younger than 13 years and seven [ 48 , 49 , 50 , 51 , 52 , 53 , 54 ] aged older than 45 years. Half of the studies ( n  = 40) [excluding case studies and case series] did not specify an age range in the inclusion criteria and only reported a mean age or range in the results. None of the studies explicitly stated that peri-menopausal or menopausal female individuals was excluded. None of the studies that included female individuals aged older than 40 years described methods to confirm that the female individuals were not peri-menopausal or menopausal.

Most studies only investigated elite or professional ( n  = 24; 25%) level athletes. Other studies investigated recreational/amateur ( n  = 19; 20%), high school ( n  = 16; 17%), collegiate ( n  = 14; 15%) or a combination of different level ( n  = 15; 16%) athletes. Eight (8%) of the studies did not specify the athletes’ level of participation.

5.5 Injury Definition and Injuries Investigated

No study only considered contact injuries. Most studies (44/96;46%) only included non-contact injuries. Forty-two (44%) did not specify a mechanism of injury in the injury definition, and 10/96 (10%) considered both contact and non-contact injuries. Forty-seven (49%) included time loss as a severity measure, and three (3%) included both time-loss and non-time-loss injuries. Still, almost half (46/96,48%) did not include a time-loss component in the injury definition. According to the International Olympic Committee (IOC) consensus statement, a “time-loss injury” is defined as any injury that results in a player being unable to participate in training or competition for at least 1 day following the day of injury [ 55 ]. Seventy studies included multiple injury surveillance methods, while 26/96 (27%) did not report the method of injury data collection or whether the diagnosis was confirmed. Of the 70 studies that specified how injury data were collected or diagnosis confirmed, 52 required diagnosis or confirmation of the injury by medical professionals or medical records, and 45 by imaging. Twenty-seven accepted self-reporting by athletes.

Most studies included upper and lower limb injuries (52/96; 54%). Forty-three (45%) only considered lower limb injuries and only one case study exclusively reported an upper limb injury [ 56 ]. Fifty-four (56%) of the studies only included bone or stress fractures. Only one of these studies was not related to MI. Eighteen (19%) of the studies specifically investigated ligament injuries, of which only three included ligaments other than the ACL. Fourteen (15%) studies investigating ligament injuries were related to the MCP. While muscle and tendon injuries might have been included in studies that considered injuries to multiple tissue types, only one study specified the inclusion of muscle or tendon injuries.

5.6 MCP Characteristics

Twenty-five (25/96; 26%) studies investigated MCP with or without MI and HC. Most (18/25; 72%) did not report the definition of eumenorrhea. The remaining studies’ definitions of eumenorrhea varied and were based on one or more parameters, as summarised in Table  1 . Similarly, the division of MCP differed, as summarised in Table  2 .

The division of the menstrual cycle in its sub-phases differed between studies and is summarised in Table  2 .

Six (6/24; 25%) studies did not report how MCPs were confirmed. Of the remaining studies, 11 [ 44 , 46 , 58 , 59 , 60 , 61 , 62 , 63 , 66 , 68 , 74 ] relied on participant self-reporting. Two of the studies relied on more than one more than one medical test (i.e. blood, saliva or urinary) testing method. Three, two and one studies confirmed MCP by blood, saliva and urinary testing, respectively.

5.7 MI Characteristics

Seventy-four (74/96; 77%) studies investigated MI with or without MCP and/or HC. Several studies included more than one type of MI. Nine (9/74;12%) studies stated MIs were investigated but did not specify the type of MI, while another study [ 6 ] pooled amenorrhea, oligomenorrhea and delayed-onset menarche as MI but did not report the definitions of each. Most studies (50/74; 69%) investigated secondary amenorrhea, followed by oligomenorrhea (38/74; 51%), primary amenorrhea (32/74; 43%), luteal-phase deficit (1/74;1%) and one anovulation (1/74;1%). Twenty studies investigated the age of menarche, of which two [ 47 , 75 ] (10%) considered early-onset menarche and 18 (90%) considered delayed-onset menarche. The definition for early-onset menarche in both studies was a first period younger than 12 years. However, the definition of delayed-onset menarche differed, with studies considering ages ≥ 16 years [ 76 , 77 , 78 ], ≥ 15 years [ 79 ], and > 14 years respectively as “delayed”.

5.8 HC Characteristics

Fifty-three studies investigated HC use as a contributor to injury risk. Eleven (11/53; 21%) did not specify the type of HC investigated. Three studies included more than one type of HC. Oral contraceptive pills were most commonly investigated (42/53; 79%), followed by injections (4/53; 9%), intrauterine devices (2/53; 37.7%) and one (6%) vaginal ring. Only eight (8/53;19%) of the studies investigating OCPs specified the type or composition of OCP used by athletes. None of the studies considered the different phases of multi-phase contraceptives.

6 Discussion

More research is being published on the influence of endogenous and exogenous hormonal fluctuations on female athletes’ injury risk [ 80 ]. This scoping review aimed to summarise the characteristics of the literature related to the association between MCP, MI and HC use and MSK injury among female athletes and identify gaps to aid the planning and commissioning of future research.

Almost half (48%) of the studies included in this review investigated more than one theme (i.e. MI, CMP and or HC use). Including more than one female hormone-related contributing risk factor acknowledges and reflects the diversity in endogenous and exogenous hormone profiles in female sports teams or training groups. Authors should consider sample sizes that are large enough for a meaningful thematic subgroup analysis. Of the three main themes, the MCP was investigated least (23% of studies). This might be because of the challenges related to MCP research including feasible methods verifying MCPs [ 27 ] and athlete barriers to communication about their menstrual cycles. Investigations to identify and address methodological challenges associated with MCP research might result in more MCP-related research in all female athlete domains.

6.2 Study Characteristics

Research about the MCP, HC use and injury in female athletes has increased in the last 5 years. Considering the increase in the popularity of women’s sport (both participation and media coverage), it is fitting that research regarding the MCP and HC use has also increased [ 80 , 81 , 82 , 83 ]. Whilst the number of articles published in the domain has increased, there is a noticeable lack of research from certain countries across the world. High-income countries such as North America and Europe account for most of the research, with no research from South America and minimal research from Africa, Oceania and Asia. This lack of evidence from low-income to middle-income countries is a common thread among many sports medicine and sports science research areas [ 84 ]. Further, only a few articles included data from multiple countries. This lack of multi-national collaboration and multi-site projects is an area for improvement that could aid in pooling research data and potentially increase cohort numbers, thereby accelerating our learning on the topic and reducing research waste [ 85 , 86 ]. Additionally, consortium-type research will increase the impact of the research and enhance researchers’ understanding of the differences between regions.

Of the included articles, 18% were case studies/case series, which add minimal value to understanding the effect of the MC/HC on MSK injuries, as most of these studies include fewer than ten athletes and simply describe the menstrual function or HC use of these injured athletes. As expected, most studies included cross-sectional/cohort designs, with only one randomised controlled trial. These descriptive studies provide the initial evidence for the associations between MC/HC and MSK injuries. Few studies confirmed MCP by using objective laboratory measures. Most studies used self-reported questionnaires, and it would be useful to understand how accurate the data received from questionnaires are compared to laboratory measures. Future research could investigate interventions to better understand the associations and potential causes [ 87 ] relating to MCP and/or HC use and MSK injuries (both all and specific).

More individual than team sports were investigated, and sports such as endurance running, dancing and gymnastics predominated. One explanation for this is that these articles mainly aimed to investigate the FAT or RED-S and did not specifically seek to understand the MCP and HC contribution to MSK injuries. The sports investigated are assumed to have a higher prevalence of RED-S (particularly in female individuals) [ 88 ] compared with team sports such as soccer and football. The inclusion of these studies still provides insight into hormonal fluctuation or adjustments in MSK injuries. However, it should be interpreted with caution, as this was not their primary aim.

6.3 Participant Characteristics

Forty studies did not specify an age range in the inclusion criteria and only reported a mean age or range in the results. It is vital to include an age range in research related to ovarian hormone fluctuations as these fluctuations are age dependent. For example, when collecting data using self-reporting questionnaires, women aged older than 45 years might not recognise that they are peri-menopausal and report irregular menstrual cycles that might not be related to training. In cases where studies specified age ranges (< 35 years) or populations, for example high-school or collegiate athletes, in the inclusion criteria, the authors reasonably assumed that the female athletes investigated were not peri-menopausal or menopausal. For clarity, it is however recommended that in future studies that include age ranges that might include early-onset, perimenopausal or menopausal female individuals, authors should specify if and how the athletes’ menopausal status was confirmed.

Most studies only investigated elite or professional (25%) level athletes. A likely explanation is that these athletes operate in more controlled environments, with support staff and resources that can assist with and monitor data collection, making research among this cohort easier. Similar research among adolescent and high school athletes requires more logistical considerations, including obtaining consent from guardians and governing bodies, but is nevertheless essential.

6.4 Injury Definition

Consensus statements on uniform reporting of sports-related injury research have been published in various sports [ 89 , 90 , 91 , 92 , 93 ]. More recently, the IOC consensus statement promotes consistency in defining injury to allow for a comparison of injury-related data in sports [ 55 ]. Moore et al. [ 94 ], however, highlighted that little of the IOC consensus statement focussed on female athletes specifically and provided further recommendations on methods for recording and reporting epidemiological data on injury in female sports.

In the current literature, large inconsistencies in defining injury exist across studies. Most studies defined injury as “non-contact” injuries (46%), and only 3% of studies reported on time-loss and non-time-loss injuries. These definitions narrow the scope of included injuries and potentially result in underreporting of injury in the current literature. Furthermore, the true association between MCP, MI and HC use on MSK injuries among female athletes could be misrepresented as a result of inconsistent injury definitions used across studies. Studies specifically defining the severity of injuries according to the duration of time lost should use and report a uniform calculation for time lost. For example, is time loss calculated when athletes return to training or competition. The lack of uniform guidelines across sporting codes for collecting and reporting sports injury-related data could explain the variety of injury definitions. Most studies in this review (76%) were published before the guidance provided in the 2020 IOC [ 55 ] and 2023 Female Athlete Health Domain [ 94 ] consensus statements. Even under uniform reporting guidelines, injury definitions can still be affected by limited resources available to research teams. For example, self-reported injury data should ideally be verified through a clinical assessment or radiological imaging. However, such verifications require more funding and specialised skills and could, therefore, be impractical in most cases. Finally, a lack of awareness of appropriate consensus guidelines regarding the recording and reporting of injury data could result in continued inconsistencies in injury definitions in future studies.

The definition of eumenorrhea, the division of MCPs and methods to confirm MCP varied between studies included in the review. The heterogeneity in definitions and methodology limits the possibility of conducting meta-analyses, resulting in confusion and possible misinterpretation of results [ 26 , 27 ]. Two recent publications [ 26 , 27 ] proposed standardised guidelines and methods for studying the MCP as an independent variable in an attempt to catalyse the accumulation of knowledge on the physiological and psychological effects of the menstrual cycle. Most of the MCP studies in this review were published before these guidelines were published. As might be the case with applying standard injury definitions, standard MCP definitions and methods might be affected by financial resources, technology and skills available to research teams. Confirming MCP using blood tests for example might be the gold standard but impractical in most settings. The importance of evaluating the ecological validity of methods used to verify the MCP should be considered in future research endeavours. Researchers should rely on accurate measurement rather than estimation to reach valid and significant conclusions in a topic that is characterised by substantial controversy and conflicting findings [ 95 ]. We suggest, in agreement with a recent editorial’s authors [ 95 ], that if measurements were not taken, authors should provide a justification for this decision, alongside a transparent explanation of the limitations in their study design, and a comprehensive disclosure of the effects of their assumptions and estimates on the research quality, and the ability to make scientific inferences, and the specific clinical risks associated with these assumptions and estimates. In situations where financial and administrative constraints hinder the availability of ample resources, it may be prudent to opt for a classification system that simply relies on the distinction between bleeding and non-bleeding phases, as this may be the most straightforward and accurate approach. Research investigating the most practical yet accurate methods to explore the influence of MCP on MSK health or reasons for not implementing currently published guidelines might yield valuable insights for future research designs.

While the role of MCPs in injury risk is gaining more recognition, the distribution of research across different types of injuries and sports is unbalanced. For example, the association between MCPs and ACL injury and laxity has been investigated extensively [ 1 , 8 , 9 ]. However, ankle ligament injuries are more or equally prevalent compared to knee injuries among female netball [ 96 , 97 ], basketball [ 98 ] and football [ 99 ] players. Additionally, instability-type injuries of the shoulder [ 100 ] and ankle [ 15 ] are higher among female than male athletes competing in gender-comparable sports. Still, studies investigating the association between ankle and shoulder injuries and MCPs are scarce compared to ACL-related studies.

Like MCPs, the definition of MI could have been more consistent among studies. Some studies, for example, pooled amenorrhoea, oligomenorrhea and delayed-onset menarche as “MI”, while others analysed and reported them as individual MIs. The definition of delayed-onset menarche also varied. A possible explanation might be that “normal” ages of menarche differ between countries, races and ethnicities [ 101 ].

Most of the research investigated the association between MI (as an individual risk factor or as part of FAT/RED-S) and bone injuries. Evidence related to the association between MI and soft-tissue injuries remains scarce. Additionally, MI is characterised by oligomenorrhoea, polymenorrhoea, amenorrhoea, anovulatory or luteal-phase deficient cycles [ 6 , 8 , 17 ]. While some studies include all of these conditions in the definition of MI, others only include, for example, amenorrhea and oligomenorrhea. This could be due to the practicality and costs of methods required to confirm luteal-phase deficiency and anovulation. A feasibility study to establish if luteal-phase deficiency or anovulation affects injury risk before conducting full-scale studies might be valuable.

The potential impact of HC on the MSK system in athletes is an area of ongoing research with varied findings [ 22 , 102 ]. Most of the studies included in this review (79%) investigated the effect of OCP on injury risk but the influence of other forms of HCs, including patches, intrauterine devices and vaginal rings, are less prevalent. As mentioned, most research in this review has been conducted in North America and Europe. Hormonal contraceptive prescription practices and subsequent athlete use in other countries might be different. Therefore, future research related to athletes’ HC use characteristics in other countries and the effect of HC other than OCPs on MSK injury risk is warranted.

Some studies (21%) did not specify the type of HC investigated while others investigated more than one type of HC, but pooled them for a statistical analysis. Hormonal contraceptives have different exogenous hormone compositions, are processed via different physiological systems, and can have local or systemic effects [ 103 ]. Their effect on athletes’ bone [ 104 ] and soft-tissue structures and function [ 21 , 105 ] and, in turn, injury risk could be different. Therefore, it is important to specify the type of HC investigated when reporting on the effect of HC on injury risk.

In this review, HC research mainly focussed on bone/stress fractures. Research investigating the effect of OCP on soft-tissue injuries is scarce. While HC may theoretically influence bone density [ 104 ], connective tissue health [ 21 ], and muscle physiology and function [ 102 , 105 ], the direct impact on MSK injury risk remains uncertain. Factors such as age, individual hormonal profiles, type of contraceptive and lifestyle factors (including exercise habits) can all contribute to variations in how HCs may affect MSK health [ 21 , 106 , 107 ]. Further research is needed to understand these complex interactions better (Table 3 ).

7 Strength and Limitations

This scoping review is not without limitations. Scoping reviews commonly do not include a quality appraisal of the individual studies and this was not the main purpose of this review. Knowing the quality of individual studies is important when assessing and comparing the rigour of specific studies or groups of studies. The findings of this scoping review will inform future systematic reviews with narrower inclusion criteria that assess the risk of bias and study quality can significantly enhance researchers’ and practitioners’ understanding of the topic by providing more precise and reliable insights.

It is possible that we may have missed available data because of excluding studies published in languages other than English, which, in turn, might have impacted the geographical location of the results presented. While we can comment on the lack of studies that use recommended surveillance strategies, in alignment with scoping review methodology we did not evaluate the risk of bias or assess the methodological quality of the included studies, and thus cannot directly comment on low-quality research.

8 Conclusions

Research related to MCP, MI and HC as contributing MSK injury risk factors is increasing. However, several gaps have been identified, including research from countries other than North America and Europe, among non-professional/elite-level athletes, in team sports and specific injuries related to MCP, MI and HC, respectively. Differences in the methodology and terminology of injury, MCP and MI hinder comparative and summative research, and future research should consider current published guidelines during the study design. Identifying barriers to following standard guidelines or research investigating the most practical yet accurate methods to investigating the influence of MCP on MSK health might yield valuable insights for future research designs. Collaborative international multi-site projects could be used to pool research talent, enterprise, and data and potentially increase cohort numbers, thereby accelerating our learning on the topic.

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MacMillan, C., Olivier, B., Viljoen, C. et al. The Association Between Menstrual Cycle Phase, Menstrual Irregularities, Contraceptive Use and Musculoskeletal Injury Among Female Athletes: A Scoping Review. Sports Med (2024). https://doi.org/10.1007/s40279-024-02074-5

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Barriers and motivators of contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies

Luchuo Engelbert Bain

1 Lincoln International Institute for Rural Health (LIIRH), College of Social Science, University of Lincoln, Lincoln, Lincolnshire, United Kingdom

2 Global South Health Research and Services, GSHS, Amsterdam, The Netherlands

3 Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana

Elvis Enowbeyang Tarkang

Associated data.

All relevant data are in the paper and its Supporting Information files.

In sub-Saharan Africa, about 80% of young women either use a traditional method or do not use any form of contraception at all. The objectives of this review were to ascertain the barriers and motivators of contraceptive use among young people in Sub–Saharan Africa.

Materials and methods

We conducted electronic literature searches in PubMed, EMBASE, Ebsco/PsycINFO and Scopus. We identified a total of 4,457 publications and initially screened 2626 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 13 qualitative studies were retained for the final analysis based on the Joanna Briggs criteria for assessing qualitative studies. The systematic review is registered on PROSPERO with identifier CRD42018081877.

Supportive social networks, respect for privacy and confidentiality, ready availability, affordability and accessibility of contraceptives, as well as the desire to prevent unintended pregnancy and sexually transmitted infections were the motivators of contraceptive use among young people in sub-Saharan Africa. Despite these motivators, myriad of personal, societal, and health systems-based barriers including myths and misconceptions, known side effects of contraceptives, prohibitive social norms, and negative attitude of health professionals were the major barriers to contraceptive use among young people.

Sub-Saharan African countries with widespread barriers to contraceptive use among young people may not be able to achieve the Sustainable Development Goal 3.8 target of achieving health for all by the year 2030. Interventions intended to improve contraceptive use need to be intersectoral and multi-layered, and designed to carefully integrate the personal, cultural, organizational and political dimensions of contraception.

Introduction

Pregnancy and childbirth among young women remain major public health concerns worldwide [ 1 ]. In low- and middle-income countries (LMICs), about 16 million girls aged 15 to 19 years give birth every year, with about 2.5 million being under the age of 16 years [ 1 ]. In sub-Saharan Africa (SSA), about 13% of pregnancies end up in abortions and 97% of these are unsafe [ 2 ]. Optimal contraceptive use alone has the capacity of reducing the burden of unintended pregnancies and abortions by one third [ 3 , 4 ]. High levels of contraceptive failure or discontinuation are accrued predominantly to the use of traditional methods (coitus interruptus [withdrawal method], lactational amenorrhea method, calendar/rhythm method, cervical mucus method, and abstinence), and consequently increase the overall burden of unintended pregnancies and abortions in SSA [ 4 ].

With many SSA countries still having challenges the provision of optimal access to safe abortion care, non–use or inconsistent use of contraceptives account for most of the unsafe abortions. The effects are high maternal mortality and morbidity rates, especially among young people [ 1 ]. The contraceptive challenges and their resultant morbidities and mortalities occur at the backdrop that SSA countries have signed up to meeting the Sustainable Development Goal (SDG) 3.8 target of achieving health for all by the year 2030 [ 5 , 6 ]. Achieving health for all, therefore, implies that the countries have to, among other things increase the level of contraceptive use among their populace especially young people. Young people according to the World Health Organisation [ 7 ] are people 10–24 years old. Intrauterine devices and contraceptive implants, also called Long-Acting Reversible Contraceptives (LARC) are the most effective reversible contraceptive methods [ 8 ] and are highly recommended for young people [ 9 , 10 ].

Despite high levels of awareness that have been reported in the literature regarding contraceptives in SSA, utilisation has been overwhelmingly sup-optimal [ 11 – 16 ]. In SSA, however, about 80% of young people use traditional methods or do not use any form of contraception at all [ 8 ]. This review was, therefore, guided by two objectives which were to ascertain the barriers to contraceptive use and explore the motivators of contraceptive use among young people in SSA. Findings from this review could be potentially relevant in adequately planning and implementing public health interventions among this target group.

A comprehensive search was performed in the bibliographic databases: PubMed, Embase.com, Ebsco/PsycINFO and Scopus in collaboration with the medical librarian of the Vrije Universiteit, Amsterdam. A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-statement ( www.prisma-statement.org ). Databases were searched from inception up to 10th September 2019. The following terms were used (including synonyms and closely related words) as index terms or free-text words: “Africa South of the Sahara”, “sub-Saharan Africa” “Adolescent”, “Young women”, “young people” “Family Planning”, “Contraception”, (contraceptives) “Birth Control”, “young female”, “teen”, “family planning”, “barrier”, “factor”, “enablers”, “facilitators”, “predictor”, “determinant”. The search was performed without date, language or publication status restriction. Duplicate articles were excluded. The full search strategies for all databases can be found in the Supplementary Information. The systematic review is registered on PROSPERO with identifier CRD42018081877.

Only qualitative studies were retained for the final review. Our decision to include only qualitative studies was informed by the paucity of qualitative analyses especially in terms of reviews in SSA. We thus sought to bridge this gap by providing a deeper and more holistic appreciation of the barriers and motivators of young people’s contraceptive use. To ensure the trustworthiness of the themes and sub-themes generated, two independent researchers were involved in the selection of articles. The reviewers compared and decided upon the articles to be retained for final review after discussing and coming to a consensus. In addition to these, two reviewers assessed clear reporting of aims and objectives of the study, adequate description of the context in which the research was carried out, adequate description of the sample and the methods by which the sample was identified and recruited, adequate description of the methods used to collect data, and adequate description of the methods used to analyse data. A third reviewer was on standby to be involved if disagreement happens between the two reviewers. The Joanna Briggs criteria for assessing qualitative studies were used [ 17 ] with a particular focus on the critical appraisal checklist for qualitative research, to determine the eligibility of studies included in the final review. Methodological insights reported by Uman (2011) were applied in the data interpretation and discussion phases of the study [ 18 ]. We used conceptual thematic analysis to re-categorise the barriers and motivators reported by the studies into major themes, sub-themes, and their respective codes. These were then organised in the form of tables.

Background of studies included in the review

Electronic search through relevant databases yielded a total of 4,457 publications. Out of this, 2,626 articles were screened based on article title and abstracts. At this stage, 2,475 were excluded due to unfit title and abstract. The remaining 151 full-text articles were further screened for eligibility and 134 were expunged. A total of 13 studies were finally retained. Fig 1 presents the PRISMA flow diagram of the literature selection. The studies spanned the period 2000 to 2018 (See Table 1 ). Four were conducted in Ghana and two in South Africa. Mali, Nigeria, Uganda, Kenya, Tanzania, Mozambique, and Senegal each recorded one study. While 12 of the studies generally targeted young people, one focused on young people with disabilities. Concerning methods of data collection, seven of the studies used only in-depth interviews, three studies used only focus group discussions, and one adopted IDI and FGD. Of the remaining two studies, one added responses of young people in a general discussion to FGDs while the other one added informal conversation and observation to IDI and FGD. For 12 of the studies, sample sizes used ranged from 15 to 149. Ten of the studies focused on all contraceptives while one focused on condoms. The remaining two also focused on emergency contraceptives and modern contraceptives respectively (See Table 1 ).

Motivators of contraceptive use

Eight out of the 13 studies reported on motivators of contraceptive use. Table 2 presents the motivators of contraceptive use as reported by the eight studies. Five main themes were realised from the review. These were: social support, protection of identity, ready availability, affordability and access, effectiveness in preventing unintended pregnancy and Sexually Transmitted Infections (STIs), and other motivations. The "other" theme was labelled as such because the motivations under the theme were mentioned by just one study in each case.

Concerning social support, three sub-themes were realised. These were: support from friends and peers, support from family, and support from other people who are neither friends nor family. Two studies reported on friends being major motivators of their contraceptive use [ 23 , 29 ]. Burke et al. [ 29 ] and Hall et al. [ 30 ] also reported on the family being an important motivation for young people’s contraceptive use. Tabane and Peu [ 23 ] also indicated that apart from friends, there were "significant others" who motivate young people to utilise contraceptives.

Two sub-themes were realised from the theme on the protection of identity. These were anonymity and confidentiality. These two issues were made one theme because they both deal with concealing the identity of the young people regarding their utilization of contraceptives. Two studies made findings on anonymity [ 19 , 29 ] where the study participants, for instance, indicated that the use of purchase points which were mainly vending machines offered acceptable levels of anonymity and thus, motivated them to purchase and use the contraceptives. Confidentiality was also associated with patent medicine stores in 2 studies [ 20 , 29 ]. Lack of confidence in sellers of modern contraceptives was a major hindrance for young people’s utilization of contraceptives [ 20 , 29 ].

Three studies also mentioned ready availability, affordability, and access to contraceptives as a major motivation for their utilization of contraceptives. Accessibility was for instance found by Patient and Orr [ 1 ] and Burke et al. [ 29 ] while availability and affordability were both found in Castle’s [ 21 ] study. According to the young people in these studies, condoms for instance were cheap and this made it possible to afford and use them. The condoms were also readily available at various points of sale for easy purchase whenever needed.

The effectiveness of contraceptives in preventing unintended pregnancy and STIs was also reported as a motivation for their utilisation. Castle [ 21 ], Tabane and Peu [ 23 ], and Rokicki and Merten [ 31 ] all made findings on the effectiveness of contraceptives in preventing unintended pregnancy. Castle [ 21 ] also reported that a major motivation for using condoms among young people was the fact that it made it possible for them to avoid contracting STIs. Other motivations mentioned by the studies comprised the need to maximise fertility in future (to gain status through childbearing) [ 21 ], service providers being of the same sex as the young people [ 22 ], and perceived quality of pharmacy shops [ 29 ].

Barriers to contraceptive use

Table 3 presents the barriers to contraceptive use which were reported by all the 13 studies included in our analyses. Three main themes were identified from the review. These were personal, societal, and health systems-based barriers. With personal barriers, five sub-themes were observed. They were: myths and misconceptions, lack/inadequate knowledge, negative attitude towards contraceptive use, known side effects of contraceptives, and financial challenges. Myths and misconceptions were the most reported personal barriers to contraceptive use. The sub-themes reported under myths and perceptions were lack of trust in contraceptives (especially condoms), colour and size of available condoms considered unsuitable, contraceptive use encourages promiscuity and straying (cheating), contraceptive use reduces sexual pleasure, risk of future infertility with contraceptive use, and perceived ineffectiveness of contraceptives in preventing conception. Five studies also reported the known side effects of contraceptives including weight gain, bleeding, high blood pressure, headache, and disruption of the menstrual cycle as personal barriers to contraceptive use among the young people.

Societal-based barriers were reported by nine studies, comprising two sub-themes which were social consequences of contraceptive use and social norms. The specific societal based barriers to contraceptive use were: divorce, accusations of witchcraft, stigma, the tag of being promiscuous, disproval of contraceptive use by friends and colleagues as well as family and the larger society, societal prohibition of discussions on issues concerning contraception, contraception being considered an issue only for females, and religious prohibitions.

Health systems-based barriers which were reported by 7 of the studies comprised five sub-themes; lack of privacy and confidentiality at health facilities, negative attitude of health professionals, long waiting time, poor communication between health professionals and young people, and physical inaccessibility of buildings by the persons with disability as the sub-themes. The most-reported sub-theme was the negative attitude of health professionals which comprised being treated disrespectfully, being entirely refused contraceptive services, being denied teaching about contraceptives, and discrimination.

In this review, we explored the barriers and motivators of contraceptive use among younger people in SSA using 13 qualitative publications. The motivators were re-categorised into social support, protection of identity, ready availability, affordability and access, effectiveness in preventing unintended pregnancy and STIs, and other motivators. The barriers were also re-categorised into personal, societal, and health systems-based barriers.

Social support was realised in our review as an important motivator of contraceptive use. Tabane and Peu [ 23 ] for instance posited that approval from friends and positive peer influence from peers greatly encourage young people to utilise contraceptives. Burke et al. [ 29 ] and Hall et al. [ 30 ] also noted that family support is an instrumental protective factor for young people’s utilisation of contraceptives. We also realised from our review that when anonymity and confidentially are assured and there is ready availability, affordability, and access, young people are highly motivated to patronise contraceptives and contraceptive services. This is an issue of importance because, young people in SSA have been known to have grave unmet needs for contraceptive use which stems from their inability to access, afford, and/or be guaranteed confidentiality when they make efforts to utilise contraceptives [ 32 , 33 ].

Despite the motivators realised in our review, we observed that myriad of barriers also inhibit young people from utilising contraceptives and this has negative implications for SSA countries towards the attainment of health for all by the year 2030. Key among these challenges are myths and misconceptions. Young people according to Otoide et al. [ 20 ], Hokororo et al. [ 26 ], Capurchande et al. [ 27 ], and Rokicki and Merten [ 31 ] for instance, erroneously perceived that contraceptives were ineffective in preventing conception. They also believed that contraceptive use posed risks of future infertility [ 20 – 22 , 24 ]. The myth and misconceptions realised in our review could have been due to lack of knowledge which Otoide et al. [ 20 ], Flaherty et al. [ 22 ], Tabane and Peu [ 23 ], Hokororo et al. [ 26 ], Capurchande et al. [ 27 ], Burke et al. [ 29 ] and Rokicki and Merten [ 31 ] found as comprising poor knowledge on the mechanism of action of contraceptives and on how to utilise them and lack of reliable, trusted and non-judgmental sources of information on contraceptives was also reported by seven of the studies. The findings of our review regarding knowledge point to its essential role in the reproductive health decision making of young people including contraception [ 34 – 37 ].

Our review showed that the known side effects of contraception such as weight gain, bleeding, headaches, high blood pressure, and disruption of the menstrual cycle were personal barriers to contraceptive use among the young people. If such fears are not effectively managed through innovative approaches which reassure them of the important reasons for utilisation, such young people would continue to shy away from contraceptive use and this would not auger well for the achievement of universal health coverage by countries in SSA. Besides, financial challenges which were mainly about the unaffordability of contraceptives and contraceptive services remained major barriers to the young people in their quest to utilise the contraceptives according to Burke et al. [ 29 ] and Rokicki and Merten [ 31 ]. This finding, however, contradicts arguments by Castle [ 21 ] that young people in her study felt contraceptives were affordable and this served as a motivation for them in utilizing such contraceptives.

Attitude of health professionals towards clients is an important determinant of health care utilisation [ 38 – 40 ]. The negative attitude of health professionals towards young people was reported by Flaherty et al. [ 22 ], Tabane and Peu [ 23 ], Hokororo et al. [ 26 ], Burke et al. [ 29 ], and Hall et al. [ 30 ] as a health systems-based barrier to contraceptive use among young people and this manifested in being treated disrespectfully, being entirely refused contraceptive services, being denied teaching about contraceptives, and discrimination. Our finding of physical inaccessibility of buildings as reported by Burke et al. [ 29 ] where staircases were unfriendly and the physically challenged young people needing to be accompanied by someone, points to the general neglect of the rights of persons with physical disabilities to these buildings [ 41 ]. Our finding thus justifies calls for the physical environment to be designed and equipped to meet the needs of persons with disabilities (PWDs) and prioritization of their needs through national planning, budgeting and other national programmes.

Social norms are powerful societal factors which predict the health-seeking behaviour of people. In our review, we realised that these norms militated against the utilisation of contraceptives among young people in the form of disproval of contraceptive use by friends and colleagues, disproval of contraceptive use by family and the larger society, societal prohibition of discussions on issues concerning contraception, and contraception being considered an issue only for females. The continuous prevalence of such inhibitive social norms in SSA would only continue to preclude young people in these countries from utilizing contraceptives and thus making it impossible for the countries to achieve universal levels of contraceptive use.

In most SSA countries, major contraceptive interventions have included the promotion and delivery of contraceptives during the postpartum period, expansion of long-acting contraceptive options, and community-based contraceptive outreach and service delivery [ 42 , 43 ]. The effectiveness of these interventions has, however, been a major challenge as they mainly do not yield the expected results for which they are implemented which warrant the adoption of alternative interventions proven to be effective [ 43 , 44 ].

Conclusions

Our review revealed social support, protection of identity, ready availability, affordability and access, effectiveness in preventing unintended pregnancy and STIs as motivators of young people’s utilization of contraceptives in SSA. Despite the availability of these motivators, myriad of personal, societal, and health systems-based barriers prevail and prevent the young people from utilizing the contraceptives. These barriers include myths and misconceptions, lack/inadequate knowledge on contraceptives, known side effects of contraceptives, financial challenges, prohibitive social norms, negative attitude of health professionals, physical inaccessibility of buildings, and poor communication between health professionals and young people. The perpetuation of these barriers implies that many SSA countries, especially those from which the barriers where identified may not be able to achieve the SDG target of health for all by the year 2030.

Recommendations

To ameliorate the barriers to contraceptive use and accelerate the progress of SSA countries towards the achievement of health for all by the year 2030, we proffer these policy recommendations:

• There is a need for community engagements to improve prohibitive social norms to make them more receptive towards contraceptive use and discussions regarding contraception.
• Contraceptive service provision should be made friendly in countries which are not already implementing such young people-friendly contraceptive services. In such countries, there should, for instance, be a re-conscientization of health professionals to improve their attitudes towards young people in the provision of contraceptive services to them. Privacy and confidentiality should be afforded the young people in their utilisation of services.
• Efforts should be made by respective SSA countries to make public health facilities accessible for persons living with disabilities.
• To reduce financial barriers, voucher schemes which have been implemented in some countries, could be adopted by other countries for young people to access subsidised or free contraceptive services.

Strengths and limitations

Our study is the first effort at exploring the barriers and motivations for contraception among young people using purely qualitative studies. The fact that we reviewed only qualitative studies, however, meant that other relevant papers reporting barriers and motivations for contraceptive use among young people were expunged. It is, however, noteworthy that such studies could have contributed to a better understanding of the totality of the barriers and motivators for young people’s contraceptive use.

Supporting information

Abbreviations.

Funding Statement

The authors received no specific funding for this work.

Data Availability

• PLoS One. 2021; 16(6): e0252745.

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Barriers to and motivations for contraceptive use among adolescents and young women in Sub-Saharan Africa: A systematic review of qualitative studies

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Reviewer #2: Yes

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Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #2: No

5. Review Comments to the Author

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Reviewer #1: Authors need to go through the PDF document of the manuscript where reviewer comments are included.

The objective/question of the review was on three areas but only two of the questions were answered with the review. One question remains to be answered.

Reviewer #2: This is a systematic review on Barriers to and motivations for contraceptive use among adolescents and young women in Sub-Saharan Africa. Since low contraceptive usage is a challenge African countries are grabbling with, synthesising knowledge to identify gaps is important for public health.

Introduction: Pg3 The age range for young people includes adolescents. So why separate adolescents and young people in your population of interest?

Methods: Pg 4 "the reviewers met" does not connote an objective process. Why was it not done independently and if necessary a third person adjudicates in the event of indecision?

Policy recommendations: There is no indication from your write up on what policies countries have in place with regards to contraceptive usage for readers to appreciate if your policy recommendations are necessary. As it is no one knows what the countries within the review are doing.

General comments:

1. There are so many recommendations authors could give. For instance taking a look at Table 1, the age groups of included studies indicate a gap. As indicated in the introduction the age group is 10-24 years but the selected studies lack on age group 10-13 who are also sexually active.

2. One would have expected that as what is known is being synthesised authors will identify gaps that need closing with research to win the low contraceptive battle. Because, bringing together what is available in the articles is not enough. This is concluded like a research based on a primary data. Gaps must be identified. Therefore as it is, a major revision is needed.

3. There's the need for editing to correct typographical errors

4. Authors failed to indicate why the focus is on qualitative studies

6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1:  Yes:  Hailemariam Segni A. (MD, MPH, Gyn/Obs)

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Submitted filename: PONE-D-20-10773_reviewer.pdf

Author response to Decision Letter 0

Response to Reviewers

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

Response: This study did not receive any funding.

b. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Response: No funding was received for this study

c. If any authors received a salary from any of your funders, please state which authors and which funders.

Response: No salaries were received from funders.

d. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Response: “The authors received no specific funding for this work.”

Reviewer #1:

Authors need to go through the PDF document of the manuscript where reviewer comments are included.

Response: this has been done and all issues raised by the reviewer have been pasted in the “response to reviewers” document and duly addressed

1. Search was conducted from a small number of data bases were searched.

Response: Thank you for this comment. Based on previous studies including those published in Plos One, we believe that the number of databases searched were exhaustive enough to ensure we retrieve all relevant publications. We actually searched PubMed, EMBASE, Ebsco/PsycINFO and Scopus. Searching other sources may only create further duplication of papers as these are the most popular databases available.

2. Too many papers (4457) were retrieved from which only 13 were eligible. Maybe the search terms used were not refined enough?

Response: Our study focused only on qualitative studies which was the reason for the rather small number of papers included in the final review. We have also detailed the search tersm in the methods section and believe that the terms used were exhaustive enough to produce the expected results.

3. The review has not answered one of the questions, Prevalence and usage.

Response: The focus of this systematic review was only on the barriers and motivations for contraceptive uptake among young people.

4. The protocol mentioned Prevalence and usage as one of the questions to be answered.

Response: The main review has focused only on the barriers and motivations

5. Enough number of data bases were not searched from.

6. This maybe one of the reasons why you had too many non-eligible studies during the search. Restriction of time of study and/or publication is one thing to seriously consider.

Response: We agree with the reviewer that this is a plausible explanation of the high number of non – eligible studies we had. However, empirical qualitative research on the subject was not very rampant, and we wanted to be an inclusive as possible.

7. What about during a situation of failure to reach at consensus between the two reviewers? You need to have a third tie breaker reviewer in the team.

Response: Even though a third reviewer was on standby, no such disagreements emerged between the two reviewers which required his inputs. That is why it has not been mentioned in the manuscript.

8. Prevalence and usage?

Response: This has not been explored in our current review even though contained in the registered protocol.

9. Physical inaccessibility of buildings by the persons with disability" should be discussed here as one of the major barriers.

Response: This has been done. See page 11.

10. "Physical inaccessibility of buildings by the persons with disability" should be part of the conclusion section as a major barrier.

Response: This has been done. See page 12.

11. It is very difficult to reach at this type of conclusion based on this systematic review.

Response: We have refined the statement to indicate that some countries, especially the ones from which the studies were reviewed, may not be able to achieve the SDG target with the persistence of the barriers identified. See page 12.

Reviewer #2:

This is a systematic review on Barriers to and motivations for contraceptive use among adolescents and young women in Sub-Saharan Africa. Since low contraceptive usage is a challenge African countries are grabbling with, synthesising knowledge to identify gaps is important for public health.

Response: We have revised the manuscript to focus only on young people.

Response: the phrased has been revised accordingly (See page 5). Also, while a third reviewer was actually on standby, no serious disagreements in terms of what to include in the final review emerged and so that reviewer did not intervene.

Response: A writ-up has now been included in the discussion in this regard. See page 12.

Response: A recommendation has been provided in this regard. See page 14.

Response: This has been done. An English language expert has proof-read the manuscript.

4. Authors failed to indicate why the focus is on qualitative studies.

Response: This has been done. See page 5.

Submitted filename: Response to Reviwers CommentsA-Reviewplosone.doc

Decision Letter 1

12 Jan 2021

PONE-D-20-10773R1

Barriers to and motivations for contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies

Kindly address the minor comments of the reviewers.

Please submit your revised manuscript by 11th March 2021 If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: Reviewer’s comments 2

• Title: it is better if written as “Barriers and motivators of contraceptive use among young people in Sub Saharan Africa: a systematic review of qualitative studies”.

• Key words: replace “Motivation” with “Motivators”.

• Methods: you need to include in methods section that a third reviewer was standby to be involved if disagreement happens between the two reviewers but there was need for it.

• Some editorial work is still needed.

Reviewer #2: Please I do not see the response authors indicated to be on page 12 of the manuscript to be a response to the request to provide existing policies on the various countries from where studies have been included. This is to contextualise and make relevant the policy recommendations.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #1:  Yes:  Hailemariam Segni Abawollo, MD/OB-GYN, MPH

Submitted filename: Reviewers second round comments.docx

Author response to Decision Letter 1

17 Jan 2021

RESPONSE TO REVIEWERS

Reviewer #1: Reviewer’s comments 2

Response: The title has been revised as recommended by the reviewer. See page 1

Response: The change has been made as the reviewer recommended. See page 3

Response: The addition has been made. See page 6

Response: Some more editing has been done on the manuscript

Reviewer #2: Please I do not see the response authors indicated to be on page 12 of the manuscript to be a response to the request to provide existing policies on the various countries from where studies have been included. This is to contextualise and make relevant the policy recommendations.

Response: Please see page 13, lines 271-276

Decision Letter 2

11 Apr 2021

PONE-D-20-10773R2

Barriers and motivators of contraceptive use among young people in Sub Saharan Africa: a systematic review of qualitative studies

You are requested to revise the manuscript focusing on the recommendations. Ensure that the recommendations are reason and doable.  

Please submit your revised manuscript by 10th May, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewer #2: Materials and methods

1. Please correct the sentence in line #101-103

1. Line #275: There is an omission in the sentence

2. Recommendation 1(line #273-276): but literature showed knowledge does not always translate to action, so authors should be recommending something other than increasing knowledge

3. Recommendation 3 (line #279-282): I know a country included in the review that is already practicing this, so you can’t box them together to still do this. Unless the country is facing implementation challenges. Then you suggest a separate recommendation to that effect.

4. Recommendation 5 (line#285-286): a country in your review has begun implementing free FP in pockets of places and not scaled up nationwide though. But your suggestion implies all countries should implement without considering what others are doing.

5. It is for these reasons I suggested you provide a context on the countries (i.e. policy) from which studies are included for your audience to appreciate things better.

Author response to Decision Letter 2

19 Apr 2021

Reviewer #2: Materials and methods

Response: The correction has been made as the reviewer suggested (See page 6)

Response: The entire sentence has been deleted in response to a subsequent comment made by the reviewer. See page 14.

Response: The recommendation has been deleted based on the reviewer’s comments.

Response: We have reviewed the suggestion to focus on countries which are not already implementing friendly contraceptive services for young people. See page 15.

Response: We have revised the recommendation to focus on countries which are not already implementing the voucher schemes.

5. It is for these reasons I suggested you provide a context on the countries (i.e. policy) from which studies are included for your audience to appreciate things better

Response: We have deleted the recommendation. See page 15.

Decision Letter 3

24 May 2021

PONE-D-20-10773R3

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact gro.solp@sserpeno .

Additional Editor Comments (optional):

Reviewer #2: All comments have been addressed

Acceptance letter

27 May 2021

Dear Dr. Engelbert Bain:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno .

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How contraceptive use affects birth intervals: results of a literature review

Affiliation.

• 1 Population Reference Bureau, 1875 Connecticut Avenue, NW, Suite 520, Washington, DC 20009, USA. [email protected]
• PMID: 19852410
• DOI: 10.1111/j.1728-4465.2009.00203.x

Short birth intervals can have adverse consequences for maternal and infant outcomes. Optimal birth spacing is often presumed to be achieved through the practice of family planning and use of contraceptives, yet most of the available research does not address explicitly the contribution of contraceptive-method use to birth spacing or maternal and infant survival. We conducted a systematic literature review to assess the body of evidence linking contraceptive use to birth-interval length. Fourteen studies published in English between 1980 and 2008 met our eligibility criteria for inclusion. The findings from these studies are mixed but suggest that the use of contraceptives is protective against short birth intervals. Although results are favorable, many of the studies and methodologies employed are dated. More current research is needed to determine the impact of contraceptive-method use on birth-interval length in order to inform the promotion of family planning for reducing maternal and infant morbidity and mortality through birth spacing.

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Contraceptive Practices in Nigeria:Literature Review and Recommendation for Future Policy Decisions

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• U.S. Department of Health and Human Services
• National Institutes of Health

Acupuncture: Effectiveness and Safety

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Acupuncture is a technique in which practitioners insert fine needles into the skin to treat health problems. The needles may be manipulated manually or stimulated with small electrical currents (electroacupuncture). Acupuncture has been in use in some form for at least 2,500 years. It originated from  traditional Chinese medicine but has gained popularity worldwide since the 1970s.

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According to the World Health Organization, acupuncture is used in 103 of 129 countries that reported data.

In the United States, data from the National Health Interview Survey show that the use of acupuncture by U.S. adults more than doubled between 2002 and 2022. In 2002, 1.0 percent of U.S. adults used acupuncture; in 2022, 2.2 percent used it. 

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National survey data indicate that in the United States, acupuncture is most commonly used for pain, such as back, joint, or neck pain.

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How acupuncture works is not fully understood. However, there’s evidence that acupuncture may have effects on the nervous system, effects on other body tissues, and nonspecific (placebo) effects. 

• Studies in animals and people, including studies that used imaging methods to see what’s happening in the brain, have shown that acupuncture may affect nervous system function.
• Acupuncture may have direct effects on the tissues where the needles are inserted. This type of effect has been seen in connective tissue.
• Acupuncture has nonspecific effects (effects due to incidental aspects of a treatment rather than its main mechanism of action). Nonspecific effects may be due to the patient’s belief in the treatment, the relationship between the practitioner and the patient, or other factors not directly caused by the insertion of needles. In many studies, the benefit of acupuncture has been greater when it was compared with no treatment than when it was compared with sham (simulated or fake) acupuncture procedures, such as the use of a device that pokes the skin but does not penetrate it. These findings suggest that nonspecific effects contribute to the beneficial effect of acupuncture on pain or other symptoms. 
• In recent research, a nonspecific effect was demonstrated in a unique way: Patients who had experienced pain relief during a previous acupuncture session were shown a video of that session and asked to imagine the treatment happening again. This video-guided imagery technique had a significant pain-relieving effect.

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Research has shown that acupuncture may be helpful for several pain conditions, including back or neck pain, knee pain associated with osteoarthritis, and postoperative pain. It may also help relieve joint pain associated with the use of aromatase inhibitors, which are drugs used in people with breast cancer. 

An analysis of data from 20 studies (6,376 participants) of people with painful conditions (back pain, osteoarthritis, neck pain, or headaches) showed that the beneficial effects of acupuncture continued for a year after the end of treatment for all conditions except neck pain.

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• In a 2018 review, data from 12 studies (8,003 participants) showed acupuncture was more effective than no treatment for back or neck pain, and data from 10 studies (1,963 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. The pain-relieving effect of acupuncture was comparable to that of nonsteroidal anti-inflammatory drugs (NSAIDs).
• A 2017 clinical practice guideline from the American College of Physicians included acupuncture among the nondrug options recommended as first-line treatment for chronic low-back pain. Acupuncture is also one of the treatment options recommended for acute low-back pain. The evidence favoring acupuncture for acute low-back pain was judged to be of low quality, and the evidence for chronic low-back pain was judged to be of moderate quality.

For more information, see the  NCCIH webpage on low-back pain .

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• In a 2018 review, data from 10 studies (2,413 participants) showed acupuncture was more effective than no treatment for osteoarthritis pain, and data from 9 studies (2,376 participants) showed acupuncture was more effective than sham acupuncture. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. Most of the participants in these studies had knee osteoarthritis, but some had hip osteoarthritis. The pain-relieving effect of acupuncture was comparable to that of NSAIDs.
• A 2018 review evaluated 6 studies (413 participants) of acupuncture for hip osteoarthritis. Two of the studies compared acupuncture with sham acupuncture and found little or no difference between them in terms of effects on pain. The other four studies compared acupuncture with a variety of other treatments and could not easily be compared with one another. However, one of the trials indicated that the addition of acupuncture to routine care by a physician may improve pain and function in patients with hip osteoarthritis.
• A 2019 clinical practice guideline from the American College of Rheumatology and the Arthritis Foundation conditionally recommends acupuncture for osteoarthritis of the knee, hip, or hand. The guideline states that the greatest number of studies showing benefits have been for knee osteoarthritis.

For more information, see the  NCCIH webpage on osteoarthritis .

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• A 2020   review of nine studies that compared acupuncture with various drugs for preventing migraine found that acupuncture was slightly more effective, and study participants who received acupuncture were much less likely than those receiving drugs to drop out of studies because of side effects.
• There’s moderate-quality evidence that acupuncture may reduce the frequency of migraines (from a 2016 evaluation of 22 studies with almost 5,000 people). The evidence from these studies also suggests that acupuncture may be better than sham acupuncture, but the difference is small. There is moderate- to low-quality evidence that acupuncture may reduce the frequency of tension headaches (from a 2016 evaluation of 12 studies with about 2,350 people).

For more information, see the  NCCIH webpage on headache .

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• Myofascial pain syndrome is a common form of pain derived from muscles and their related connective tissue (fascia). It involves tender nodules called “trigger points.” Pressing on these nodules reproduces the patient’s pattern of pain.
• A combined analysis of a small number of studies of acupuncture for myofascial pain syndrome showed that acupuncture applied to trigger points had a favorable effect on pain intensity (5 studies, 215 participants), but acupuncture applied to traditional acupuncture points did not (4 studies, 80 participants).  

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• Sciatica involves pain, weakness, numbness, or tingling in the leg, usually on one side of the body, caused by damage to or pressure on the sciatic nerve—a nerve that starts in the lower back and runs down the back of each leg.
• Two 2015 evaluations of the evidence, one including 12 studies with 1,842 total participants and the other including 11 studies with 962 total participants, concluded that acupuncture may be helpful for sciatica pain, but the quality of the research is not good enough to allow definite conclusions to be reached.

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• A 2016 evaluation of 11 studies of pain after surgery (with a total of 682 participants) found that patients treated with acupuncture or related techniques 1 day after surgery had less pain and used less opioid pain medicine after the operation.

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• A 2016 review of 20 studies (1,639 participants) indicated that acupuncture was not more effective in relieving cancer pain than conventional drug therapy. However, there was some evidence that acupuncture plus drug therapy might be better than drug therapy alone.
• A 2017 review of 5 studies (181 participants) of acupuncture for aromatase inhibitor-induced joint pain in breast cancer patients concluded that 6 to 8 weeks of acupuncture treatment may help reduce the pain. However, the individual studies only included small numbers of women and used a variety of acupuncture techniques and measurement methods, so they were difficult to compare.
• A larger 2018 study included 226 women with early-stage breast cancer who were taking aromatase inhibitors. The study found that the women who received 6 weeks of acupuncture treatment, given twice each week, reported less joint pain than the participants who received sham or no acupuncture.

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• Chronic prostatitis/chronic pelvic pain syndrome is a condition in men that involves inflammation of or near the prostate gland; its cause is uncertain.
• A review of 3 studies (204 total participants) suggested that acupuncture may reduce prostatitis symptoms, compared with a sham procedure. Because follow-up of the study participants was relatively brief and the numbers of studies and participants were small, a definite conclusion cannot be reached about acupuncture’s effects.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Irritable Bowel Syndrome

• A 2019 review of 41 studies (3,440 participants) showed that acupuncture was no more effective than sham acupuncture for symptoms of irritable bowel syndrome, but there was some evidence that acupuncture could be helpful when used in addition to other forms of treatment.

For more information, see the  NCCIH webpage on irritable bowel syndrome .

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• A 2019 review of 12 studies (824 participants) of people with fibromyalgia indicated that acupuncture was significantly better than sham acupuncture for relieving pain, but the evidence was of low-to-moderate quality.

For more information, see the  NCCIH webpage on fibromyalgia . 

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In addition to pain conditions, acupuncture has also been studied for at least 50 other health problems. There is evidence that acupuncture may help relieve seasonal allergy symptoms, stress incontinence in women, and nausea and vomiting associated with cancer treatment. It may also help relieve symptoms and improve the quality of life in people with asthma, but it has not been shown to improve lung function.

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• A 2015 evaluation of 13 studies of acupuncture for allergic rhinitis, involving a total of 2,365 participants, found evidence that acupuncture may help relieve nasal symptoms. The study participants who received acupuncture also had lower medication scores (meaning that they used less medication to treat their symptoms) and lower blood levels of immunoglobulin E (IgE), a type of antibody associated with allergies.
• A 2014 clinical practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery included acupuncture among the options health care providers may offer to patients with allergic rhinitis.

For more information, see the  NCCIH webpage on seasonal allergies .

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• Stress incontinence is a bladder control problem in which movement—coughing, sneezing, laughing, or physical activity—puts pressure on the bladder and causes urine to leak.
• In a 2017 study of about 500 women with stress incontinence, participants who received electroacupuncture treatment (18 sessions over 6 weeks) had reduced urine leakage, with about two-thirds of the women having a decrease in leakage of 50 percent or more. This was a rigorous study that met current standards for avoiding bias.

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• Experts generally agree that acupuncture is helpful for treatment-related nausea and vomiting in cancer patients, but this conclusion is based primarily on research conducted before current guidelines for treating these symptoms were adopted. It’s uncertain whether acupuncture is beneficial when used in combination with current standard treatments for nausea and vomiting.

For more information, see the  NCCIH webpage on cancer .

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• In a study conducted in Germany in 2017, 357 participants receiving routine asthma care were randomly assigned to receive or not receive acupuncture, and an additional 1,088 people who received acupuncture for asthma were also studied. Adding acupuncture to routine care was associated with better quality of life compared to routine care alone.
• A review of 9 earlier studies (777 participants) showed that adding acupuncture to conventional asthma treatment improved symptoms but not lung function.

For more information, see the  NCCIH webpage on asthma .

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• A 2018 review of 64 studies (7,104 participants) of acupuncture for depression indicated that acupuncture may result in a moderate reduction in the severity of depression when compared with treatment as usual or no treatment. However, these findings should be interpreted with caution because most of the studies were of low or very low quality.

For more information, see the  NCCIH webpage on depression .

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• In recommendations on smoking cessation treatment issued in 2021, the U.S. Preventive Services Task Force, a panel of experts that makes evidence-based recommendations about disease prevention, did not make a recommendation about the use of acupuncture as a stop-smoking treatment because only limited evidence was available. This decision was based on a 2014 review of 9 studies (1,892 participants) that looked at the effect of acupuncture on smoking cessation results for 6 months or more and found no significant benefit. Some studies included in that review showed evidence of a possible small benefit of acupuncture on quitting smoking for shorter periods of time.

For more information, see the  NCCIH webpage on quitting smoking .

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• A 2021 review evaluated 6 studies (2,507 participants) that compared the effects of acupuncture versus sham acupuncture on the success of in vitro fertilization as a treatment for infertility. No difference was found between the acupuncture and sham acupuncture groups in rates of pregnancy or live birth.
• A 2020 review evaluated 12 studies (1,088 participants) on the use of acupuncture to improve sperm quality in men who had low sperm numbers and low sperm motility. The reviewers concluded that the evidence was inadequate for firm conclusions to be drawn because of the varied design of the studies and the poor quality of some of them. 

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• A 2018 review of 12 studies with 869 participants concluded that acupuncture and laser acupuncture (a treatment that uses lasers instead of needles) may have little or no effect on carpal tunnel syndrome symptoms in comparison with sham acupuncture. It’s uncertain how the effects of acupuncture compare with those of other treatments for this condition.    
• In a 2017 study not included in the review described above, 80 participants with carpal tunnel syndrome were randomly assigned to one of three interventions: (1) electroacupuncture to the more affected hand; (2) electroacupuncture at “distal” body sites, near the ankle opposite to the more affected hand; and (3) local sham electroacupuncture using nonpenetrating placebo needles. All three interventions reduced symptom severity, but local and distal acupuncture were better than sham acupuncture at producing desirable changes in the wrist and the brain.

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• A 2018 review of studies of acupuncture for vasomotor symptoms associated with menopause (hot flashes and related symptoms such as night sweats) analyzed combined evidence from an earlier review of 15 studies (1,127 participants) and 4 newer studies (696 additional participants). The analysis showed that acupuncture was better than no acupuncture at reducing the frequency and severity of symptoms. However, acupuncture was not shown to be better than sham acupuncture.

For more information, see the  NCCIH webpage on menopause .

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• Auricular acupuncture is a type of acupuncture that involves stimulating specific areas of the ear. 
• In a 2019 review of 15 studies (930 participants) of auricular acupuncture or auricular acupressure (a form of auricular therapy that does not involve penetration with needles), the treatment significantly reduced pain intensity, and 80 percent of the individual studies showed favorable effects on various measures related to pain.
• A 2020 review of 9 studies (783 participants) of auricular acupuncture for cancer pain showed that auricular acupuncture produced better pain relief than sham auricular acupuncture. Also, pain relief was better with a combination of auricular acupuncture and drug therapy than with drug therapy alone.
• An inexpensive, easily learned form of auricular acupuncture called “battlefield acupuncture” has been used by the U.S. Department of Defense and Department of Veterans Affairs to treat pain. However, a 2021 review of 9 studies (692 participants) of battlefield acupuncture for pain in adults did not find any significant improvement in pain when this technique was compared with no treatment, usual care, delayed treatment, or sham battlefield acupuncture.

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• Relatively few complications from using acupuncture have been reported. However, complications have resulted from use of nonsterile needles and improper delivery of treatments.
• When not delivered properly, acupuncture can cause serious adverse effects, including infections, punctured organs, and injury to the central nervous system.
• The U.S. Food and Drug Administration (FDA) regulates acupuncture needles as medical devices and requires that they be sterile and labeled for single use only.

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• Some health insurance policies cover acupuncture, but others don’t. Coverage is often limited based on the condition being treated.
• An analysis of data from the Medical Expenditure Panel Survey, a nationally representative U.S. survey, showed that the share of adult acupuncturist visits with any insurance coverage increased from 41.1 percent in 2010–2011 to 50.2 percent in 2018–2019.
• Medicare covers acupuncture only for the treatment of chronic low-back pain. Coverage began in 2020. Up to 12 acupuncture visits are covered, with an additional 8 visits available if the first 12 result in improvement. Medicaid coverage of acupuncture varies from state to state.

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• Most states license acupuncturists, but the requirements for licensing vary from state to state. To find out more about licensing of acupuncturists and other complementary health practitioners, visit the NCCIH webpage  Credentialing, Licensing, and Education . 

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NCCIH funds research to evaluate acupuncture’s effectiveness for various kinds of pain and other conditions and to further understand how the body responds to acupuncture and how acupuncture might work. Some recent NCCIH-supported studies involve:

• Evaluating the feasibility of using acupuncture in hospital emergency departments.
• Testing whether the effect of acupuncture on chronic low-back pain can be enhanced by combining it with transcranial direct current stimulation.
• Evaluating a portable acupuncture-based nerve stimulation treatment for anxiety disorders.

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• Don’t use acupuncture to postpone seeing a health care provider about a health problem.
• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

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Nccih clearinghouse.

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: [email protected] (link sends email)

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: How To Make Sense of a Scientific Journal Article

Understanding Clinical Studies (NIH)

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed .

Website: https://pubmed.ncbi.nlm.nih.gov/

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Website: https://www.nih.gov/health-information/nih-clinical-research-trials-you

Research Portfolio Online Reporting Tools Expenditures & Results (RePORTER)

RePORTER is a database of information on federally funded scientific and medical research projects being conducted at research institutions.

Website: https://reporter.nih.gov

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• Befus D, Coeytaux RR, Goldstein KM, et al.  Management of menopause symptoms with acupuncture: an umbrella systematic review and meta-analysis . Journal of Alternative and Complementary Medicine. 2018;24(4):314-323.
• Bleck   R, Marquez E, Gold MA, et al.  A scoping review of acupuncture insurance coverage in the United States . Acupuncture in Medicine. 2020;964528420964214.
• Briggs JP, Shurtleff D.  Acupuncture and the complex connections between the mind and the body. JAMA. 2017;317(24):2489-2490.
• Brinkhaus B, Roll S, Jena S, et al.  Acupuncture in patients with allergic asthma: a randomized pragmatic trial. Journal of Alternative and Complementary Medicine. 2017;23(4):268-277.
• Chan MWC, Wu XY, Wu JCY, et al.  Safety of acupuncture: overview of systematic reviews. Scientific Reports. 2017;7(1):3369.
• Coyle ME, Stupans I, Abdel-Nour K, et al.  Acupuncture versus placebo acupuncture for in vitro fertilisation: a systematic review and meta-analysis. Acupuncture in Medicine. 2021;39(1):20-29.
• Hershman DL, Unger JM, Greenlee H, et al.  Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial. JAMA. 2018;320(2):167-176.
• Linde K, Allais G, Brinkhaus B, et al.  Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews. 2016;(6):CD001218. Accessed at  cochranelibrary.com on February 12, 2021.
• Linde K, Allais G, Brinkhaus B, et al.  Acupuncture for the prevention of tension-type headache. Cochrane Database of Systematic Reviews. 2016;(4):CD007587. Accessed at  cochranelibrary.com on February 12, 2021.
• MacPherson H, Vertosick EA, Foster NE, et al. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain . Pain. 2017;158(5):784-793.
• Qaseem A, Wilt TJ, McLean RM, et al.  Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514-530.
• Seidman MD, Gurgel RK, Lin SY, et al.  Clinical practice guideline: allergic rhinitis. Otolaryngology—Head and Neck Surgery. 2015;152(suppl 1):S1-S43.
• Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis . The Journal of Pain. 2018;19(5):455-474.
• White AR, Rampes H, Liu JP, et al.  Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews. 2014;(1):CD000009. Accessed at  cochranelibrary.com on February 17, 2021.
• Zia FZ, Olaku O, Bao T, et al.  The National Cancer Institute’s conference on acupuncture for symptom management in oncology: state of the science, evidence, and research gaps. Journal of the National Cancer Institute. Monographs. 2017;2017(52):lgx005.

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• Adams D, Cheng F, Jou H, et al. The safety of pediatric acupuncture: a systematic review. Pediatrics. 2011;128(6):e1575-1587.
• Candon M, Nielsen A, Dusek JA. Trends in insurance coverage for acupuncture, 2010-2019. JAMA Network Open. 2022;5(1):e2142509.
• Cao J, Tu Y, Orr SP, et al. Analgesic effects evoked by real and imagined acupuncture: a neuroimaging study. Cerebral Cortex. 2019;29(8):3220-3231.
• Centers for Medicare & Medicaid Services. Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). Accessed at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295 on June 25, 2021.
• Chen L, Lin C-C, Huang T-W, et al. Effect of acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer: a meta-analysis of randomized controlled trials . The Breast. 2017;33:132-138. 
• Choi G-H, Wieland LS, Lee H, et al. Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome. Cochrane Database of Systematic Reviews. 2018;(12):CD011215. Accessed at cochranelibrary.com on January 28, 2021.
• Cui J, Wang S, Ren J, et al. Use of acupuncture in the USA: changes over a decade (2002–2012). Acupuncture in Medicine. 2017;35(3):200-207.
• Federman DG, Zeliadt SB, Thomas ER, et al. Battlefield acupuncture in the Veterans Health Administration: effectiveness in individual and group settings for pain and pain comorbidities. Medical Acupuncture. 2018;30(5):273-278.
• Feng S, Han M, Fan Y, et al. Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis. American Journal of Rhinology & Allergy. 2015;29(1):57-62.
• Franco JV, Turk T, Jung JH, et al. Non-pharmacological interventions for treating chronic prostatitis/chronic pelvic pain syndrome. Cochrane Database of Systematic Reviews. 2018;(5):CD012551. Accessed at cochranelibrary.com on January 28, 2021.
• Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association task force report. The Journal of Clinical Psychiatry . 2010;71(6):669-681.
• Giovanardi CM, Cinquini M, Aguggia M, et al. Acupuncture vs. pharmacological prophylaxis of migraine: a systematic review of randomized controlled trials. Frontiers in Neurology. 2020;11:576272.
• Hu C, Zhang H, Wu W, et al. Acupuncture for pain management in cancer: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2016;2016;1720239.
• Jiang C, Jiang L, Qin Q. Conventional treatments plus acupuncture for asthma in adults and adolescent: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine . 2019;2019:9580670.
• Ji M, Wang X, Chen M, et al. The efficacy of acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine.  2015;2015:192808.
• Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Annals of Internal Medicine . 2002;136(5):374-383.
• Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research. 2020;72(2):149-162. 
• Langevin H. Fascia mobility, proprioception, and myofascial pain. Life. 2021;11(7):668. 
• Liu Z, Liu Y, Xu H, et al. Effect of electroacupuncture on urinary leakage among women with stress urinary incontinence: a randomized clinical trial. JAMA. 2017;317(24):2493-2501.
• MacPherson H, Hammerschlag R, Coeytaux RR, et al. Unanticipated insights into biomedicine from the study of acupuncture. Journal of Alternative and Complementary Medicine. 2016;22(2):101-107.
• Maeda Y, Kim H, Kettner N, et al. Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture. Brain. 2017;140(4):914-927.
• Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip osteoarthritis. Cochrane Database of Systematic Reviews. 2018;(5):CD013010. Accessed at cochranelibrary.com on February 17, 2021. 
• Moura CC, Chaves ECL, Cardoso ACLR, et al. Auricular acupuncture for chronic back pain in adults: a systematic review and metanalysis. Revista da Escola de Enfermagem da U S P. 2019;53:e03461.
• Nahin RL, Rhee A, Stussman B. Use of complementary health approaches overall and for pain management by US adults. JAMA. 2024;331(7):613-615.
• Napadow V. Neuroimaging somatosensory and therapeutic alliance mechanisms supporting acupuncture. Medical Acupuncture. 2020;32(6):400-402.
• Patnode CD, Henderson JT, Coppola EL, et al. Interventions for tobacco cessation in adults, including pregnant persons: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(3):280-298.
• Qin Z, Liu X, Wu J, et al. Effectiveness of acupuncture for treating sciatica: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2015;2015;425108.
• Smith CA, Armour M, Lee MS, et al. Acupuncture for depression. Cochrane Database of Systematic Reviews. 2018;(3):CD004046. Accessed at cochranelibrary.com on January 20, 2021.
• US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons. US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
• Vase L, Baram S, Takakura N, et al. Specifying the nonspecific components of acupuncture analgesia. Pain. 2013;154(9):1659-1667.
• Wang R, Li X, Zhou S, et al. Manual acupuncture for myofascial pain syndrome: a systematic review and meta-analysis. Acupuncture in Medicine. 2017;35(4):241-250.
• World Health Organization. WHO Traditional Medicine Strategy: 2014–2023. Geneva, Switzerland: World Health Organization, 2013. Accessed at https://www.who.int/publications/i/item/9789241506096 on February 2, 2021.
• Wu M-S, Chen K-H, Chen I-F, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367.
• Xu S, Wang L, Cooper E, et al. Adverse events of acupuncture: a systematic review of case reports. Evidence-Based Complementary and Alternative Medicine. 2013;2013:581203.
• Yang J, Ganesh R, Wu Q, et al. Battlefield acupuncture for adult pain: a systematic review and meta-analysis of randomized controlled trials. The American Journal of Chinese Medicine. 2021;49(1):25-40.
• Yang Y, Wen J, Hong J. The effects of auricular therapy for cancer pain: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine. 2020;2020:1618767.  
• Yeh CH, Morone NE, Chien L-C, et al. Auricular point acupressure to manage chronic low back pain in older adults: a randomized controlled pilot study. Evidence-Based Complementary and Alternative Medicine. 2014;2014;375173.
• You F, Ruan L, Zeng L, et al. Efficacy and safety of acupuncture for the treatment of oligoasthenozoospermia: a systematic review. Andrologia. 2020;52(1):e13415.
• Zhang X-C, Chen H, Xu W-T, et al. Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. Journal of Pain Research. 2019;12:527-542.
• Zheng H, Chen R, Zhao X, et al. Comparison between the effects of acupuncture relative to other controls on irritable bowel syndrome: a meta-analysis. Pain Research and Management. 2019;2019:2871505.

Acknowledgments

NCCIH thanks Pete Murray, Ph.D., David Shurtleff, Ph.D., and Helene M. Langevin, M.D., NCCIH for their review of the 2022 update of this fact sheet. 

This publication is not copyrighted and is in the public domain. Duplication is encouraged.

NCCIH has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCIH.

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