Dr Melissa Harris

CONTEXT: Ineffective use or nonuse of contraceptives following an unplanned birth can contribute to the risk of a subsequent unintended pregnancy; however, the literature on the relationship between unintended pregnancy and postpartum contraceptive use is sparse, especially in low-and middle-income countries. METHODS: Data on 4,493 women from the 2014 Bangladesh Demographic and Health Survey were analyzed; the subjects of the analysis had had a live birth in the three years prior to the survey and were currently at risk of pregnancy. Multilevel logistic regression analysis was used to examine associations between the intendedness of a woman¿s last pregnancy resulting in a live birth and her current modern contraceptive use adjusting for individual, household and community-level variables. RESULTS: Twenty-six percent of women reported that their last pregnancy resulting in a live birth had been unintended (15% mistimed and 11% unwanted); 61% reported current use of a modern contraceptive method. Compared with women who reported the pregnancy as having been wanted, those who reported the pregnancy as mistimed had greater odds of current modern contraceptive use (odds ratio, 1.6); no association was found between having had an unwanted pregnancy and subsequent modern contraceptive use. Other important correlates of modern contraceptive use included women¿s autonomy and desire for children, time since last birth and community-level poverty. CONCLUSIONS: Bangladeshi women who experience an unwanted pregnancy may have an elevated risk of subsequent unintended pregnancy. Broader coverage of family planning services, and integration of family planning with maternal health care, may increase modern contraceptive use following an unplanned birth.

Skilled delivery care has been targeted in the Sustainable Development Goals to reduce preventable maternal and newborn deaths, which mostly occur because of birthing complications. Birthing complications are more frequent in women with unintended than intended pregnancies, and around 43% of total pregnancies in low-A nd middle-income countries are unintended. This study quantified the impact of unintended pregnancy on skilled birth attendance and delivery in health care facilities in Bangladesh. Data from 4493 women participating in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Multilevel logistic regression models were used to assess the association of unintended pregnancy with skilled birth attendance and delivery in a health care facility through skilled providers while adjusting for individual-, household-A nd community-level factors identified using a directed acyclic graph. Around 26% of women reported that their last pregnancy (occurring within the previous 3 years) that ended with a live birth was unintended at conception. Only 42% reported having a skilled birth attendant present at their last birth and 38% gave birth in a health care facility. Significant differences were found across pregnancy intention. Lower odds of skilled birth attendance (OR, 0.70, 95% CI, 0.52-0.93) and delivery in a health care facility through skilled providers (OR, 0.65, 95% CI, 0.48-0.89) were found among women who had an unwanted pregnancy relative to women who had a wanted pregnancy. However, a mistimed pregnancy was not found to be associated with skilled birth attendance or delivery in health care facility through skilled providers. Increased availability of health care facilities at the community level is required in Bangladesh to ensure skilled delivery care for women with an unwanted pregnancy. Policies are also required to integrate women with an unwanted pregnancy into mainstream health care services through earlier detection and increased awareness in order to reduce the adverse maternal and fetal outcomes associated with lack of quality birthing care.

Background Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality. Methods A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes -namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality -were present together in a single article analysing the same sample at the same time. Results Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality. Conclusion Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies.

CONTEXT: Unintended pregnancy is common among young women. Understanding how such women use contraceptives¿ including method combinations¿is essential to providing high-quality contraceptive care. METHODS: Data were from a representative cohort of 2,965 Australian women aged 18¿23 who participated in the 2012¿2013 Contraceptive Use, Pregnancy Intention and Decisions baseline survey, had been heterosexually active in the previous six months, and were not pregnant or trying to conceive. Latent class analysis was employed to characterize women's contraceptive choices; multinomial logistic regression was used to evaluate correlates of membership in the identified classes. RESULTS: The vast majority of women (96%) reported using one or more contraceptives, most commonly short-acting hormonal methods (60%), barrier methods (38%), long-acting contraceptives (16%) and withdrawal (15%). In total, 32 combinations were reported. Four latent classes of method use were identified: no contraception (4% of women); short-acting hormonal methods with supplementation (59%, mostly the pill); high-efficacy contraceptives with supplementation (15%, all long-acting reversible contraceptive users); and low-efficacy contraceptive combinations (21%); supplementation usually involved barrier methods or withdrawal. Class membership differed according to women's characteristics; for example, women who had ever been pregnant were more likely than other women to be in the no-contraception, high-efficacy contraceptive or low-efficacy contraceptive combination classes than in the short-acting hormonal contraceptive class (odds ratios, 2.0-3.0). CONCLUSIONS: The complexity of women's contraceptive choices and the associations between latent classes and such characteristics as pregnancy history highlight the need for individualized approaches to pregnancy prevention and contraceptive care.

Objective: To identify factors associated with incidence of medication reviews (MRs), particularly in women with dementia and in residential aged care (RAC). Methods: Data from 10¿359 women in the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health were linked to Medicare Benefits Schedule data to identify MRs for each year from 2003 to 2015. Results: Incidence of MR increased from 2003 to 2013 (age 87-92¿years) when 37.1% of women with dementia had a MR compared to 19.8% of women without dementia. Adjusting for time and other factors, the odds of having a MR were higher for women with dementia (AOR¿=¿1.18, 95% CI: 1.06-1.32) and women in RAC (AOR¿=¿3.61, 95% CI: 3.28-3.98). Conclusions: Although higher in women with dementia and those in RAC, utilisation of MR was modest. System-level interventions may be required to ensure the use and benefits of MRs.

Objective: To synthesise primary research regarding the facilitators and barriers to smoking cessation amongst Aboriginal and/or Torres Strait Islander women during pregnancy. Design: An integrative review. Review methods: A systematic search of peer-reviewed literature from five databases published from January 2008 to April 2018. Articles were reviewed using the approach outlined by Whittemore and Knafl, with the identified themes collated and synthesised according to study characteristics and barriers and facilitators of smoking cessation. Findings: Of the 310 papers retrieved, nine studies were included within the review (five quantitative and four qualitative). The quality of the studies were ascertained via Joanna Briggs Institute checklists for cross sectional analysis, randomized controlled trials, and qualitative research. The overall quality of the research was deemed acceptable. Two facilitators to smoking cessation within the studied population were identified: ¿support to quit¿ and ¿information and advice¿ while four barriers to smoking cessation within pregnant Aboriginal and/or Torres Strait Islander women were identified: ¿smoking prevalence¿ ¿high daily stress¿ ¿ambivalence regarding adverse effects of smoking¿ and ¿attitudes, knowledge and training of the healthcare professional¿. Conclusions: Social and familial influences and daily stress have a strong impact on whether a woman feels she can quit smoking during pregnancy. However, in this study, information and advice regarding potential adverse effects of smoking on the foetus, or lack thereof, from health professionals either facilitated cessation of smoking in pregnancy or was a barrier to quitting. Likewise, a lack of awareness from midwives and doctors on smoking cessation strategies, such as nicotine replacement therapy, was a barrier for women. Implications for practice: The findings indicate that education regarding the adverse effects of smoking in pregnancy, as well as strategies on smoking cessation from midwives, doctors, and Aboriginal Health Workers within the antenatal period may have a positive effect on current smoking rates among pregnant Aboriginal and/or Torres Strait Islander women. Involving the partner/support person and family of the woman in this education may have a greater impact on smoking cessation rates through the woman gaining social and familial support in her decision to quit. Thus, healthcare workers require additional professional development to provide information and knowledge within a culturally competent manner. Successful smoking cessation programs for Aboriginal and Torres Strait Islander women during pregnancy could have measurable impacts on mortality rates for Indigenous infants and significantly contribute to ¿Closing the Gap¿.

Aims: To assess the impact of diabetes on the survival of older women, adjusted for other all-cause mortality predictors. Methods: Data were used from the 1921¿26 cohort of the Australian Longitudinal Study on Women's Health, when the women were aged 76¿81 years at baseline, with linkage to the National Death Index. Survival curves were plotted to compare the survival of women with no diabetes, incident diabetes and prevalent diabetes over 15 years. Cox proportional hazards models were used to examine the association between diabetes and all-cause mortality risks. Results: A total of 972 (11.7%) of 8296 eligible women reported either incident, 522 (6.3%) or prevalent, 450 (5.4%) diabetes. The median survival times were 10.1, 11.4 and 12.7 years among women with prevalent, incident and no diabetes, respectively. The risks of death were 30% [HR: 1.30 (95% CI: 1.16¿1.45)] and 73% [HR: 1.73 (CI: 1.57¿1.92)] higher for women with incident and prevalent diabetes compared to women without diabetes. These associations were sustained after controlling for demographics, body mass index, smoking status, comorbidities and health care use. Conclusions: This study revealed that diabetes is associated with reduced survival probabilities for older women with minimal moderation after adjustment for other predictors. Our findings suggest that diabetes management guidelines for older women need to integrate factors such as comorbidities, smoking and being underweight to reduce the risk of mortality.

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Objectives: Explore characteristics of hospital use for adults aged 85 and over in their last year of life and examine factors associated with cumulative overnight length of stay (LOS). Data source/study setting: NSW 45 and Up Study linked with hospital data. Study design: Longitudinal cohort study. Methods: Quantile regression models were performed for men and women (N = 3145)to examine heterogeneity in predictors of overnight hospital admissions. Coefficients were estimated at the 25th, 50th, 75th and 90th percentiles of the LOS distribution. Principal findings: 86% had at least one hospitalisation in their last year of life, with 60% dying in hospital. For men, first admission for organ failure was associated with a 26 day increase at the 90th LOS percentile, and a 0.22 day increase at the 10th percentile compared to men with cancer. Women admitted with influenza had decreased LOS of 20.5 days at the 75th percentile and 6 to 8 fewer days at the lower percentiles compared to those women with cancer. Conclusions: Poor health behaviours were a major driver of highest LOS among older men, pointing to opportunities to achieve health care savings through prevention. For older women, influenza was associated with shorter LOS, which could be an indicator of the high and rapid mortality rates at older ages, and may be easily prevented. Other factors associated with LOS among women, included where they lived before they were admitted, and discharge destination.

Objectives: To examine the association between unintended pregnancy and maternal healthcare services utilization in low- and lower-middle-income countries. Methods: A systematic literature search of Medline, Cinahl, Embase, PsycINFO, Cochrane Library, Popline, Maternity and Infant Care, and Scopus databases published since the beginning of the Millennium Development Goals (i.e. January 2000) to June 2018 was performed. We estimated the pooled odds ratios using random effect models and performed subgroup analysis by participants and study characteristics. Results: A total of 38 studies were included in the meta-analysis. Our study found the occurrence of unintended pregnancy was associated with a 25¿39% reduction in the use of antenatal, delivery, and postnatal healthcare services. Stratified analysis found the differences of healthcare services utilization across types of pregnancy unintendedness (e.g. mistimed, unwanted). Conclusions: Integrating family planning and maternal healthcare services should be considered to encourage women with unintended pregnancies to access maternal healthcare services.

Objective: To develop a greater understanding of the motivators of contraceptive method change over time for young Australian women, with a particular interest in long-acting reversible contraception (LARC) use. Method: Free-text comments from the Contraceptive Use, Pregnancy Intention and Decisions (CUPID) Study were used to explore the reasons for contraceptive method change among women who reported one or more contraceptive changes across the three CUPID surveys. Results: 512 women reported making at least one contraceptive method change, with 740 comments explaining these changes between them. Participants reported a multitude of reasons motivating their contraceptive change. Five key themes were developed to explain these motivators: the natural, sexual and fertile body, specific contraceptive characteristics and other important people. Findings suggest that women's decisions to switch or discontinue a contraceptive depended largely on her ability (and desire) to juggle its impact on her sexual, fertile and natural body. Importantly, the transient and fluid nature of contraceptive practices were demonstrated, as the women adjusted their method to suit their needs at the time. Conclusion: Regarding LARC use, these findings suggest that rather than being appealing, the ¿temporarily permanent¿ nature of these methods may be unappealing and incongruent with the needs of some women.

Background Although it is known that pregnancy intention impacts contraceptive use, there has been little exploration into the relationship between pregnancy intention and long-acting reversible contraception (LARC) non-use in the Australian context. Methods Semi-structured telephone interviews with a sample of participants from the Contraceptive Use, Pregnancy Intention and Decisions (CUPID) Study were conducted in 2016. Results Of the 59 women contacted, 15 participated in an interview. One theme arising from these interviews is reported here. Results from the analysis suggest that women with ambivalent or unclear plans toward pregnancy were less likely to perceive LARC as a suitable method for them. Conversely, women who clearly intended to avoid pregnancy and who had clear plans for future pregnancy valued these methods, and often framed their future plans for pregnancy within the context of their chosen LARC. Conclusions Findings presented demonstrated the complex relationship between pregnancy intention and contraceptive use. In particular, this study provided insight into the complex notion of pregnancy ambivalence. Dichotomous definitions of pregnancy as intended or unintended were found to be inadequate in encapsulating actual reproductive experiences.

Background: By 2050, adults aged 80 years and over will represent around 20% of the global population. Little is known about how adults surviving into very old age use hospital services over time. Objective: The objective of the study was to examine patterns of hospital usage over a 10-year period for women who were aged 84 to 89 in 2010 and examine factors associated with increased use. Methods: Survey data from 1936 women from the 1921 to 1926 cohort of the Australian Longitudinal Study on Women's Health were matched with the state-based Admitted Patients Data Collection. Hospital use profiles were determined using repeated measures latent class analysis. Results: Four latent class trajectories were identified. One-quarter of the sample were at low risk of hospitalization, while 20.6% demonstrated increased risk of hospitalization and a further 38.1% had moderate hospitalization risk over time. Only 16.8% of the sample was classified as having high hospitalization risk. Correlates of hospital use for very old women differed according to hospital use class and were contingent on the timing of exposure (ie, short-term or long-term). Conclusions: Despite the perception that older adults place a significant burden on health care systems, the majority of women demonstrated relatively low hospital use over an extended period, even in the presence of chronic health conditions. High hospitalization risk was found to be concentrated among a small minority of these long-term survivors. The findings suggest the importance of service planning and treatment regimes that take account of the diverse trajectories of hospital use into and through advanced old age.

Objective To explore the characteristics of long-acting reversible contraception (LARC) users in a nationally representative cohort of young Australian women aged 18¿23. Methods Data from 3155 women who responded to a question about their contraceptive use in the previous six months at the baseline Contraceptive Use, Pregnancy Intention and Decisions (CUPID) survey were included. Results 726 (19.1%) women reported LARC use, with the Implanon being the most popular method (n¿=¿478; 65.8%). A history of pregnancy was strongly associated with increased odds of LARC use in the multivariate model (OR¿=¿2.67, 95% CI¿=¿2.11, 3.34, p¿=¿0.001). Comparatively, using contraception for reasons other than pregnancy prevention was associated with decreased odds of LARC use in the multivariate model (period management: OR¿=¿0.74, 95% CI¿=¿0.60, 0.91, p¿=¿0.004, body management: OR¿=¿0.53, 95% CI¿=¿0.37, 0.77, p¿=¿0.001, medical condition: OR¿=¿0.25, 95% CI¿=¿0.09, 0.66, p¿=¿0.005). Highest education and Medicare card status also contributed to the final multivariate model, and were associated with decreased odds of LARC use. Conclusion Reproductive history and reasons for contraceptive use are strong indications of method choice. Promoting LARC as highly effective may not be a sufficient incentive for young women to take up the method when pregnancy prevention may be equal or secondary to their desired non-contraceptive effects.

There are increasing concerns regarding high hospital use among older adults and the capacity to manage the economic impact of the ageing population trend on healthcare systems. First hospitalisation in old age may act as a catalyst for ongoing intensification of health problems and acute care use. This study examined factors associated with first incident hospitalisation in women aged over 70, accounting for the health inequalities associated with geographic location. Survey data from 3780 women from the 1921 to 1926 cohort of the Australian Longitudinal Study on Women's Health were matched with the Admitted Patients Data Collection and National Death Index. Days to first event (hospitalisation or death) were modelled using competing risks methods. A total of 3065 (80.3%) women had at least one hospital admission. More than half of the top 15 reasons for first hospitalisation were related to cardiovascular disease, with atrial fibrillation the most common. Proportional subdistribution hazards models showed that first hospital admission was driven by enabling and need factors including asthma/bronchitis diagnosis (HR = 1.16; p = 0.047), private health insurance (HR = 1.16; p = 0.004) more than two prescribed medications in previous month (HR = 1.31; p = 0.001), more than four general practitioner visits in previous year (HR = 1.50; p = 0.034), lower physical functioning (HR = 0.99; p < 0.001) and living in an inner regional area (HR = 1.17; p = 0.003). First overnight hospitalisation was primarily related with potentially preventable and treatable chronic diseases. Primary and secondary strategies aimed at chronic disease generally, and better chronic disease management particularly for cardiovascular and respiratory diseases, may play a vital role in disease prevention or delay in readmissions among this population.

New developments in female contraceptives allow women increased options for preventing pregnancy, while men¿s options for reversible contraception have not advanced beyond the condom. There has been little discursive exploration of how neoliberal and postfeminist discourses shape women¿s accounts of choosing whether or not to use contraception. Our thematic discourse analysis of 760 free-text responses to a question about contraceptive choice considers the social and political climate that promotes the self-governed woman who freely chooses contraception. We examine the ways in which women formulated and defended their accounts of choice, focusing on the theme of free contraceptive choice that constructed women¿s choices as unconstrained by material, social and political forces. We identify two discursive strategies that underpinned this theme: a woman¿s body, a woman¿s choice and planning parenthood, and explore the ways in which choice was understood as a gendered entitlement and how contraceptive choices were shaped (and constrained) by women¿s plans for parenthood. We discuss the implications of these discursive strategies, and neoliberal and postfeminist discourses, in terms of the disallowance of any contextual, social and structural factors, including the absence of men in the ¿contraceptive economy¿.

Little research examining qualities of contraception that make them attractive or unattractive to users, particularly young women, exists. The aim of this study is to systemically review the evidence regarding desirable and undesirable qualities of long-acting reversible contraception (LARC), including intrauterine devices, the implant and the injection, as perceived by women. Five electronic databases were searched in May 2015 using terms related to LARC and method preference or decision-making. Studies were included if they concerned women aged 18-23 years from developed countries and reported on perceived positive or negative qualities of LARC. Thirty articles were deemed relevant. Five key themes emerged under which qualities were categorised; including: (1) impact on bleeding; (2) impact on the body; (3) device-specific characteristics; (4) general characteristics; and (5) perceptions and misbeliefs. Fit and forget, high efficacy and long-term protection were considered the top desirable qualities of LARC. Undesirable qualities varied among the LARC methods; however, irregular bleeding, painful insertion and removal procedure, weight gain and location in the body were among those most commonly reported. The contraceptive benefits of LARC, including their high efficacy and longevity, are generally considered to be positive qualities by women, while the potential impact of side-effects on the body are considered as negative qualities. This information is crucial in the clinical setting as it provides practitioners with a greater understanding of the qualities women do and do not like about LARC methods. Discussion about these qualities, positive and negative, during consultations about contraception may increase rates of uptake.

Recruitment of young people for epidemiologic research remains challenging, with marked decreases in the effectiveness of face-to-face, mail, and telephone recruitment methods. We report on the implementation and feasibility of an innovative and flexible approach used to recruit participants for a longitudinal cohort study about contraceptive use and pregnancy (the Contraceptive Use, Pregnancy Intention, and Decisions (CUPID) Study). Australian women aged 18-23 years were recruited using a range of online, networking, and offline methods, including social media (primarily Facebook (Facebook Inc., Menlo Park, California; http://www.facebook.com)), face-to-face events, distribution of promotional material, and media releases. Over the course of the 1-year recruitment period (beginning in September 2012), a total of 3,795 eligible women were recruited to complete the online survey, at a cost of approximately A$11 per participant. This sample was found to be broadly representative of the Australian population of women aged 18-23 years in terms of demographic characteristics, with the exception of an overrepresentation of tertiary-educated women (88.7% compared with 72.6%). This study demonstrated that although current recruitment strategies are required to be innovative and flexible in order to engage young people in epidemiologic research, representative samples can be achieved online at reasonable cost.

Objective: To qualify the psychosocial burden of osteoarthritis for older women and identify factors perceived to assist with psychological adjustment to the disease. Methods: Women who indicated being diagnosed/treated for osteoarthritis in the previous three years in the fifth survey of the Australian Longitudinal Study on Women's Health provided the sampling frame. Participants were randomly sampled until saturation was reached using a systematic process. Thematic content analysis was applied to the 19 semi-structured telephone interviews using a realist framework. Results: The findings indicate that the emotional burden of osteoarthritis is considerable, and the process of psychological adjustment complex. Older women with osteoarthritis have psychological difficulties associated with increasing pain and functional impairment. Psychological adjustment over time was attributed primarily to cognitive and attitudinal factors (e.g. stoicism, making downward comparisons and possessing specific notions about the cause of arthritis). This was a dynamic 'day to day' process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management. Conclusion: The findings of this study add to the current understanding of the complex processes involved in psychological adjustment over time. Targeted interventions focused on assisting women with arthritis redefine self-concepts outside the confines of caring responsibilities, coupled with public health education programs around understanding the destructive nature of arthritis are required. Understanding the destructive and (potentially) preventable nature of arthritis may facilitate early detection and increased uptake of appropriate treatment options for osteoarthritis that have the ability to modify disease trajectories.