James Trussell


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    Fatal flaws in a recent meta-analysis on
    termination of pregnancy and mental health
    Steinberg, J; Trussell, J; Hall, K; Guthrie, K
    Office of Population Research, Princeton University, USA
    Similar to other reviews within the last 4 years, a thorough review
    by the Royal College of Psychiatrists, published in December 2011,
    found that compared to delivery of an unintended pregnancy,
    termination of pregnancy (TOP) does not increase women’s risk
    of mental health problems. In contrast, a meta-analysis published
    by Coleman in September 2011 in the British Journal of
    Psychiatry claimed to find that TOP increases women’s risk of
    mental health problems by 81% and that 10% of mental health
    problems are attributable to TOP. Like others, we strongly
    question the quality of this meta-analysis and its conclusions.
    Here we detail seven errors in this meta-analysis and three
    significant shortcomings of the included studies because policy,
    practice, and the public have been badly misinformed. These
    errors and shortcomings render the meta-analysis’ conclusions
    invalid. In this case there was a complete failure of the peer-
    review process and editorial oversight.

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    Lessons from the Contraceptive CHOICE Project: The Hull LARC Initiative

    James Trussell1 ,2, Katherine Guthrie3 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK, 3City Health Care Partnership Hull, Hull, UK - trussell@princeton.edu

    Objective: To discover whether a hand-out explaining the benefits of intrauterine contraceptives (IUCs) and implants could increase their uptake in Hull, England. Methods: We developed a simple double-sided A4 hand-out. On one side was a script with pictures of copper and levonorgestrel IUCs beside a 20-pence coin and of an implant beside a hair grip. On the other side was the three-tiered effectiveness chart from Contraceptive Technology. The receptionist would give the hand-out to every woman and ask her to read it before seeing a clinician. Then the clinician would ask the woman if she had read it and if she had any questions. Although we implemented the project in family planning (FP), abortion, and antenatal clinics and GP practices, we evaluated it only in FP clinics and GP practices because electronic records are available. Results: There was no impact in GP practices. There was no overall impact in FP clinics. However, only one, the service hub (Conifer House) is open daily (except Sunday) and has permanent sexual health staff on the reception desk. In Conifer House there was an increase in the proportion of women receiving IUCs or implants of 15.2% from October 2011-April 2012 to May 2012-November 2012 (from 31.0% to 35.7%, p=0.0002). The proportion returned to baseline in December 2012-November 2013, when there was a change at reception to reduce waiting times. Conclusion: This was not a formal study, so there was no research coordinator to monitor the project. We think there was no impact among GPs or among peripheral FP clinics because the project was never implemented. And we think the change at reception at Conifer House caused an already overworked staff to stop dispensing hand-outs. This simple, extremely low-cost LARC intervention at Conifer House was highly effective, by far the most cost-effective on record.

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    Beyond unmet need: desired versus actual use of contraception

    James Trussell
    Princeton University, Princeton NJ, USA

    Two studies have examined what method of contraception women were using and what method they preferred to use. One was among postpartum women in Texas and the other was among women attending an antenatal clinic or an abortion clinic in Hull, England. In Texas, 800 postpartum women who wanted to delay childbearing for at least two years were followed prospectively.  At 6 months postpartum, 13% of women were using an IUD or implant, and 17% were sterilised or had a partner who had had a vasectomy. Twenty-four percent used hormonal methods and 43% relied on less effective methods such as condoms and withdrawal. However, 78% reported that they would like to be using either a long-acting reversible contraceptive method (LARC) or sterilisation. In Hull 76% and 6% of pregnancies among women in the abortion and antenatal clinics were unplanned, respectively. In this group, among those not using contraception, 31% were unable to obtain the method they wanted. Among those using a method 33% stated it was not the method they wanted; of these 75% would have preferred sterilisation, the implant, injectable or intrauterine contraceptive.

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    Contraception: why it fails

    James Trussell1,2 1Princeton University, Princeton NJ, USA, 2The Hull York Medical School, Hull, UK - trussell@princeton.edu

    In this presentation, I discuss the difference between contraceptive failure rates during perfect use and during typical use. I examine the logical error that many investigators make when computing failure rates during perfect use. I then highlight the impact of simultaneous use of two methods. I next explore the reasons for observed differences in correctly computed failure rates during perfect use and during typical use. Next I discuss reasons for the “creeping Pearl” (Pearl indexes for oral contraceptives approved by the FDA have increased over time). Finally, I report on the results of clinical trials of two new contraceptive patches and the stark implications for pharma and regulatory agencies.