Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States

BACKGROUND

Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings.

METHODS AND FINDINGS

Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences.

CONCLUSION

Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

Association of the National Dependent Coverage Expansion With Insurance Use for Sexual and Reproductive Health Services by Female Young Adults

IMPORTANCE

Sexual and reproductive health services are a primary reason for care seeking by female young adults, but the association of the 2010 Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE) with insurance use for these services has not been studied to our knowledge. Insurer billing practices may compromise dependent confidentiality, potentially discouraging dependents from using insurance or obtaining care.

OBJECTIVE

To evaluate the association between implementation of ACA-DCE and insurance use for confidential sexual and reproductive health services by female young adults newly eligible for parental coverage.

DESIGN, SETTING, AND PARTICIPANTS

For this cross-sectional study, a difference-in-differences analysis of a US national sample of commercial claims from January 1, 2007, to December 31, 2009, and January 1, 2011, to December 31, 2016, captured insurance use before and after policy implementation among female young adults aged 23 to 25 years (treatment group) who were eligible for dependent coverage compared with those aged 27 to 29 years (comparison group) who were ineligible for dependent coverage. Data were analyzed from January 2019 to February 2020.

EXPOSURES

Eligibility for parental coverage under the ACA-DCE as of 2010.

MAIN OUTCOMES AND MEASURES

Probability of insurance use for contraception and Papanicolaou testing. Emergency department and well visits were included as control outcomes not sensitive to confidentiality concerns. Linear probability models adjusted for age, plan type, annual deductible, comorbidities, and state and year fixed effects, with SEs clustered at the state level.

RESULTS

The study sample included 4 690 699 individuals (7 268 372 person-years), with 2 898 275 in the treatment group (mean [SD] age, 23.7 [0.8] years) and 1 792 424 in the comparison group (mean [SD] age; 27.9 [0.8] years). Enrollees in the treatment group were less likely to have a comorbidity (77.3% vs 72.9%) and more likely to have a high deductible plan (14.6% vs 10.1%) than enrollees in the comparison group. Implementation of the ACA-DCE was associated with a -2.9 (95% CI, -3.4 to -2.4) percentage point relative reduction in insurance use for contraception and a -3.4 (95% CI, -3.9 to -3.0) percentage point relative reduction in Papanicolaou testing in the treatment vs comparison groups. Emergency department and well visits increased 0.4 (95% CI, 0.2-0.7) and 1.7 (95% CI, 1.3-2.1) percentage points, respectively.

CONCLUSIONS AND RELEVANCE

The findings suggest that implementation of the ACA-DCE was associated with a reduction in insurance use for sexual and reproductive health services and an increase in emergency department and well health visits by female young adults newly eligible for parental coverage. Some young people who gained coverage under the expansion may not be using essential, confidential services.

Distribution and predictors associated with the use of breast cancer screening services among women in 14 low-resource countries

BACKGROUND

Breast cancer is one of the leading public health problem globally, especially in low-resource countries (LRCs). Breast cancer screening (BCS) services are an effective strategy for early determining of breast cancer. Hence, it is imperative to understand the utilisation of BCS services and their correlated predictors in LRCs. This study aims to determine the distribution of predictors that significantly influence the utilisation of BCS services among women in LRCs.

METHODS

The present study used data on 140,974 women aged 40 years or over from 14 LRCs. The data came from country Demographic and Health Surveys (DHS) between 2008 and 2016. Multivariate logistic regression analysis was employed to investigate the significant predictors that influence the use of BCS services.

RESULTS

The utilisation of BCS services was 15.41%, varying from 81.10% (95% CI: 76.85-84.73%) in one European country, to 18.61% (95% CI: 18.16 to 19.06%) in Asian countries, 14.30% (95% CI: 13.67-14.96%) in American countries, and 14.29% (95% CI: 13.87-14.74%). Factors that were significantly associated to increase the use of BCS services include a higher level of education (OR = 2.48), advanced age at first birth (> 25 years) (OR = 1.65), female-headed households (OR = 1.65), access to mass media communication (OR = 1.84), health insurance coverage (OR = 1.09), urban residence (OR = 1.20) and highest socio-economic status (OR = 2.01). However, obese women shown a significantly 11% (OR = 0.89) lower use of BSC services compared to health weight women.

CONCLUSION

The utilisation of BCS services is low in many LRCs. The findings of this study will assist policymakers in identifying the factors that influence the use of BCS services. To increase the national BCS rate, more attention should be essential to under-represented clusters; in particular women who have a poor socioeconomic clusters, live in a rural community, have limited access to mass media communication, and are have a low level educational background. These factors highlight the necessity for a new country-specific emphasis of promotional campaigns, health education, and policy targeting these underrepresented groups in LRCs.

Availability, practices and acceptance of postabortion contraceptive services in health facilities: A study in six states of India

OBJECTIVE

To assess the availability of and practices around postabortion contraceptive services in health facilities, and document women's acceptance of postabortion contraception in six Indian states.

STUDY DESIGN

We conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women.

RESULTS

Although some contraceptive methods and information were available at a majority of facilities (75-97%), the range of methods was lacking and the information provided to women varied considerably by state. 8-26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method.

CONCLUSION

The limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed.

IMPLICATIONS

Some 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies.

Seeking culturally safe care: a qualitative systematic review of the healthcare experiences of women and girls who have undergone female genital mutilation/cutting

OBJECTIVE

To explore the experiences of accessing and receiving healthcare related to female genital mutilation/cutting (FGM/C) across the life course from the perspective of women and girls who have undergone FGM/C.

DESIGN

A systematic review of qualitative research studies using a thematic synthesis approach.

METHODS

Inclusion criteria were qualitative studies (including grey literature) of any design, from Organisation for Economic Co-operation and Development (OECD) countries, of any date and any language. Sixteen electronic databases were searched from inception to December 2017, supplemented by reference list searching. Papers were screened, selected and quality-appraised by two reviewers using established tools from the Joanna Briggs Institute. NVivo software was used to extract study characteristics and code study findings. An inductive thematic synthesis approach was undertaken to identify descriptive themes and interpret these into higher order analytical constructs. Confidence in the review findings was assessed using Grading of Recommendations, Assessment, Development and Evaluations-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

Fifty-seven papers (from 55 distinct studies) from 14 different OECD countries were included (50% published within the last 8 years). One-third of studies focused exclusively on maternity care experiences, whereas others covered a range of foci. No studies reported explicitly on girls' experiences or on experiences of health service-led safeguarding interventions. Only three studies addressed psychological care. The synthesis developed 17 descriptive themes, organised into 5 analytical constructs. These related to communication, access to care, experiences of cultural dissonance/integrity, disempowering care experiences and positive care encounters. The themes illuminate significant challenges to obtaining timely and holistic care (especially for deinfibulation), and highlight different ways in which women may experience care as disrespectful, unsafe and disempowering. Key elements of 'culturally safe care' are identified.

CONCLUSIONS

This review has highlighted key knowledge gaps, especially around (1) girls'/unmarried women's experiences and (2) the impact of recent safeguarding interventions. There is an ongoing need for community engagement, service development and staff training.

PROSPERO REGISTRATION NUMBER

CRD420150300012015.

Variable participation of knowledge users in cancer health services research: results of a multiple case study

BACKGROUND

Integrated knowledge translation (IKT) is a research approach in which knowledge users (KUs) co-produce research. The rationale for IKT is that it leads to research that is more relevant and useful to KUs, thereby accelerating uptake of findings. The aim of the current study was to evaluate IKT activities within a cancer health services research network in Ontario, Canada.

METHODS

An embedded multiple case study design was used. The cases were 5 individual studies within an overarching cancer health services research network. These studies focused on one of the following topics: case costing of cancer treatment, lung cancer surgery policy analysis, patient and provider-reported outcomes, colorectal cancer screening, and a team approach to women's survivorship. We conducted document reviews and held semi-structured interviews with researchers, KUs, and other stakeholders within a cancer system organization. The analysis examined patterns across and within cases.

RESULTS

Researchers and their respective knowledge users from 4 of the 5 cases agreed to participate. Eighteen individuals from 4 cases were interviewed. In 3 of 4 cases, there were mismatched expectations between researchers and KUs regarding KU role; participants recommended that expectations be made explicit from the beginning of the collaboration. KUs perceived that frequent KU turnover may have affected both KU engagement and the uptake of study results within the organization. Researchers and KUs found that sharing research results was challenging because the organization lacked a framework for knowledge translation. Uptake of research findings appeared to be related to the researcher having an embedded role in the cancer system organization and/or close alignment of the study with organizational priorities. Document reviews found evidence of planned IKT strategies in 3 of 4 cases; however, actual KU role/engagement on research teams was variable.

CONCLUSIONS

Barriers to KU co-production of cancer health services research include mismatched expectations of KU role and frequent KU turnover. When a research study directly aligns with organizational priorities, it appears more likely that results will be considered in programming. Research teams that take an IKT approach should consider specific strategies to address barriers to KU engagement.

Immigrant Women's Access to Sexual and Reproductive Health Coverage and Care in the United States

ISSUE

Immigrant women of reproductive age in the U.S. face significant challenges obtaining comprehensive and affordable health insurance coverage and care--including sexual and reproductive health services--compared with U.S.-born women, because of myriad policy and systemic factors.

GOALS

Synthesize recent evidence on immigrant women’s access to sexual and reproductive health coverage and care and provide recommendations for policymaking and research.

METHODS

A rapid literature review to identify and summarize evidence from peer-reviewed and select grey literature published since 2011 on health insurance coverage and sexual and reproductive health care services use among immigrant women in the U.S. Where available, evidence is compared to U.S.-born women.

FINDINGS AND CONCLUSIONS

Immigrant women are less likely to have coverage and use sexual and reproductive health services than U.S.-born women, which may increase their risk of negative outcomes. Federal and state policymakers could take actions to advance immigrant women’s sexual and reproductive health, including expanding eligibility for coverage and shoring up the nation’s health care safety net. Further research is needed to understand the needs, use of services, and outcomes of immigrant women, as well as the factors that contribute to differences between immigrant and U.S.-born women, and among groups of immigrant women.

The Impact of a 72-hour Waiting Period on Women's Access to Abortion Care at a Hospital-Based Clinic in North Carolina

BACKGROUND In 2015, North Carolina became the 5th state to pass legislation requiring women to undergo state-mandated counseling 72 hours prior to abortion. Whether this legislation has changed the timing of abortion decision-making or receipt of care is not known.METHODS This is a cross-sectional study using anonymous survey data from women presenting for abortion at a hospital-based abortion clinic in North Carolina. Data were collected for 8 weeks immediately before and after implementation of the new waiting period.RESULTS 26/48 (54%) of eligible patients participated. More than half (56%) of women made their abortion decision relatively quickly (less than or equal to 3 days), but had a median time-to-care of almost a week.LIMITATIONS This small study is the 1st recent evaluation of abortion decision-making and receipt of care immediately before and after implementation of a 72-hour waiting period in a Southern state. Only women presenting for care at a single hospital-based clinic were surveyed. Data were self-reported.CONCLUSION In our clinical setting, most women decided to have an abortion quickly but still waited 10-15 days before receiving care. Extended waiting periods provide no medical benefits and the potential for harm and delay of care remains.

An equity analysis of health examination service utilization by women from underdeveloped areas in western China

OBJECTIVE

This study sought to examine the sources of inequity in health examination service utilization by women from underdeveloped areas in western China.

METHODS

Based on data from the 5th National Health Service Survey in Shaanxi province, women's utilization of health examination services was examined according to gynecological, cervical smear, and breast examination rates. The equity of health examination service utilization by 15- to 64-year-old women and the factors contributing to inequity were determined using the health concentration index, decomposition of the concentration index, and the horizontal inequity index.

RESULTS

The examination rates for gynecological, cervical smear, and breast exams for 15- to 64-year-old women in Shaanxi province were 40.61%, 27.08%, and 24.59%, respectively. The horizontal inequity indices of gynecological, cervical smear, and breast examination rates were 0.0480, 0.0423, and 0.0764, respectively, and each examination rate was higher for wealthy individuals. The contribution rates of economic status to the inequalities in gynecological, cervical smear, and breast examination rates were 65.80%, 74.31%, and 56.49%, respectively. The contribution rates of educational status to the inequalities in gynecological, cervical smear, and breast examination rates were 21.01%, 14.83% and 30.00%, respectively. The contribution rates of age to the inequalities in gynecological, cervical smear, and breast examination rates were 25.77%, 26.55%, and 18.40%, respectively.

CONCLUSIONS

Women's health examination rates differed between populations with different socio-demographic characteristics. There is pro-wealth inequality in each examination rate. This study found that financial status, age, and education level were the main reasons for the unequal utilization of health examination services.

Assessment in the primary care of the State of São Paulo, Brazil: incipient actions in sexual and reproductive health

OBJECTIVE

The objective of this study is to assess performance in sexual and reproductive health of primary health care services of the Brazilian Unified Health System, in the State of São Paulo, Brazil.

METHODS

An evaluative framework was built for sexual and reproductive health with the categorization of 99 indicators in three domains: sexual and reproductive health promotion (25), sexually transmitted infections/AIDS prevention and care (43), and reproductive health care (31). This framework was applied to assess the services responses to the questionnaire of Quality Evaluation of Primary Health Care in the Municipalities of São Paulo State (QualiAB), in 2010. Percentages were calculated for positive responses to indicators and performance in the sexual and reproductive health dimension, according to domains, and their contribution to the overall score in sexual and reproductive health (Friedman), relative participation (Dunn), and correlation (Spearman) was verified.

RESULTS

Overall, 2,735 services participated in the study. They were located in 586 municipalities (distributed throughout the 17 regional health departments of São Paulo), of which 70.6% had fewer than 100,000 inhabitants. The overall average performance of these services for sexual and reproductive health is 56.8%. The actions are characterized by: prenatal with adequate beginning and exams, better organization for immediate rather than for late postnatal care, and selective reproductive planning for some contraceptives; prevention based on specific protection, limitations in the prevention of congenital syphilis, in the treatment of sexually transmitted infections, and in the screening of cervical and breast cancer; specific educational activities, with a restricted vulnerability approach, focus on sexuality over reproduction. The domain of reproductive health has greater participation in the overall score, followed by prevention/care and promotion. The three domains are correlated; the domain of prevention/care has the highest correlation with the other ones.

CONCLUSIONS

The implementation of sexual and reproductive health in primary health care in the services studied is incipient. The revision of the purpose of the work, the dissemination of technologies, and the investing in permanent education are needed. The evaluative framework built can be used by the sexual and reproductive health program services and management in primary health care, thereby contributing to their actions.

OBJETIVO

Avaliar o desempenho em saúde sexual e reprodutiva de serviços de atenção primária à saúde do Sistema Único de Saúde, no estado de São Paulo.

MÉTODOS

Construiu-se quadro avaliativo para a saúde sexual e reprodutiva com a categorização de 99 indicadores em três domínios: promoção à saúde sexual e reprodutiva (25), prevenção e assistência às doenças sexualmente transmissíveis/aids (43), e atenção à saúde reprodutiva (31). Esse quadro foi aplicado para avaliar as respostas dos serviços ao questionário Avaliação da Qualidade da Atenção Básica em Municípios de São Paulo (QualiAB), em 2010. Calcularam-se as porcentagens de respostas positivas aos indicadores e o desempenho na dimensão saúde sexual e reprodutiva, segundo os domínios; e verificou-se sua contribuição para o escore geral em saúde sexual e reprodutiva (Friedman), participação relativa (Dunn) e correlação (Spearman).

RESULTADOS

Participaram 2.735 serviços, localizados em 586 municípios (distribuídos nos 17 departamentos regionais de saúde paulistas), dos quais 70,6% municípios com menos de 100.000 habitantes. A média geral do desempenho desses serviços para saúde sexual e reprodutiva é 56,8%. As ações são caracterizadas por: pré-natal com início e exames adequados, melhor organização para puerpério imediato do que tardio, e planejamento reprodutivo seletivo para alguns contraceptivos; prevenção baseada em proteção específica, limites na prevenção da sífilis congênita, no tratamento de doenças sexualmente transmissíveis, no rastreamento do câncer cervical e mamário; atividades educativas pontuais, com restrita abordagem das vulnerabilidades, predomínio do enfoque da sexualidade centrado na reprodução. O domínio saúde reprodutiva tem maior participação no escore geral, seguido de prevenção/assistência e promoção. Os três domínios estão correlacionados; o domínio prevenção/assistência apresenta as maiores correlações com os demais.

CONCLUSÕES

A implementação da saúde sexual e reprodutiva na atenção primária à saúde nos serviços estudados é incipiente. É necessário rever finalidades do trabalho, disseminar tecnologias e investir em educação permanente. O quadro avaliativo construído pode ser utilizado pelos serviços e pela gestão do programa de saúde sexual e reprodutiva na atenção primária à saúde e contribuir para suas ações.

Age at menopause, and knowledge of and attitudes to menopause, of women in Karachi, Pakistan

Objectives. The objectives of the study were to identify the average age at menopause in Karachi and to assess knowledge of and attitudes to the menopause among Pakistani women in different social strata.

Study design. A population-based cross-sectional study of 960 women aged over 35 years was conducted.

Results. As insufficient data were available for 35 women, 925 interviews were analysed. There were 287 menopausal women, whose mean (SD) age at menopause was 47.1 (4.7) years (95% CI 46.8 to 47.6). Of these 287 women, 135 (47%) wanted their menses to continue and 235 (82%) had consulted a physician after the menopause. Of all 925 women, 58% knew the correct definition of the menopause, all had consulted a physician for various symptoms related to the menopause and 53% said that women should consult a physician premenopausally. Symptoms experienced by premenopausal women included lack of sleep (25%), fear of infertility (13%) and urinary incontinence (18%). The majority of the overall sample (52%) were sexually active. Of the sexually active women, 16% had marital problems, compared with 44% of sexually inactive women, and this difference was statistically significant ( P < 0.0001). Source of knowledge about the menopause included relatives (35%), television (18%), neighbours (17%), friends (17%) and health-care providers (14%).

Conclusions. Evidence-based information about the menopause should be provided for Pakistani women.

Restraining Orders in California

The authors tabulated statewide administrative data for all types of restraining orders. On June 6, 2003, there were 227,941 active restraining orders against adults in California; most were for domestic violence. Rates of restraining orders (i.e., restrained persons) were highest for men, African Americans, and 25- to 34-year-olds. In 72.2% of the orders, a woman was to be protected and a man was to be restrained; in 19.3%, the restrained and protected persons were of the same sex. Although state law prohibits the purchase or possession of a firearm by persons against whom a restraining order is issued, 9.2% of the orders documented no firearm restrictions.

Cultural Beliefs and Service Utilization by Battered Arab Immigrant Women

This study examines the relationship between cultural beliefs and the utilization of services among Arab immigrant women. All participants ( N = 67) reported at least one act of partner abuse resulting in a consultation with various formal services. Significant correlations were found between the holding of traditional attitudes toward gender in general and wife battering in particular by the women and the utilization of formal mental ( r = .32, p = < .001), social ( r = .29, p < .05), and legal ( r = .38, p = < .001) services. The study's limitations, policy implications, and the impacts of 9/11 on the Arab immigrant community and on their use of services are discussed.

[The maternity and childhood care in penal executive system of Russia]

The Russian Federation pays particular attention to maternity and children care. During the last three years, slight decreasing of number of women held in detention together with children of tender age was marked. This tendency is related to policy of humanization of penalty determination and execution of punishment. At that, number of women with pregnancy at the moment of adjudgement of conviction of court increases. Annually, 3% of women residing in institutions of penal executive system are observed because of pregnancy that results with delivery in curative preventive institutions of the penal executive system in 35% and in medical institutions of municipal and state health care systems in 65% of cases. The newborns of women serving a sentence by way of deprivation of freedom enter Home of Child. The Federal penitentiary service of Russia comprise 13 Homes of Child in female correctional institutions where about 700 children are brought up. The article considers issues of development of organization of medical sanitary support of children of tender age in homes of Child of the penal executive system.

U.S. Women's Intended Sources for Reproductive Health Care

INTRODUCTION

The current sociopolitical climate and context of the Affordable Care Act have led some to question the future role of family planning clinics in reproductive health care. We explored where women plan to get their future contraception, pelvic exam/pap smears, and sexually transmitted infection testing, with a focus on the role of family planning clinics.

METHODS

Data were drawn from a study of United States adults conducted in January 2013 from a national online panel. We focused on English-literate women aged 18-45 years who answered items on intended sources of care (private office/health maintenance organization [HMO], family planning clinic, other, would not get care) for reproductive health services. We used Rao-Scott F tests to compare intended sources across sociodemographic groups, and logistic regression to model odds of intending to use family planning clinics. Probability weights were used to adjust for the complex sampling design.

RESULTS

The response rate was 61% (n = 2,182). Of the 723 respondents who met the inclusion criteria, approximately half intended to use private offices/HMOs. Among some subgroups, including less educated (less than high school), lower annual incomes (<$25,000) and uninsured women, the proportion intending to use family planning clinics was higher than the proportion intending to use private office/HMO in unadjusted analyses. Across all service types, unmarried and uninsured status were associated with intention to use family planning clinics in multivariable models.

CONCLUSIONS

While many women intend to use private offices/HMOs for their reproductive health care, family planning clinics continue to play an important role, particularly for socially disadvantaged women.

A population-based study of US women's preferred versus usual sources of reproductive health care

OBJECTIVE

We characterized US women's preferred and usual sources of reproductive health care.

STUDY DESIGN

Data were drawn from the Women's Health Care Experiences and Preferences Study, an Internet survey of 1078 women aged 18-55 years randomly sampled from a national probability panel. We described and compared women's preferred and usual sources of care (women's health specialists including obstetricians-gynecologists and family-planning clinics, primary care, other) for Papanicolaou/pelvic examination, contraception, and sexually transmitted infection (STI) services using χ(2), logistic regression, and kappa statistics.

RESULTS

Among women reporting health service utilization (n = 984, 92% overall; 77% Papanicolaou/pelvic; 33% contraception; 8% STI), women's health specialists were the most used sources of care for Papanicolaou/pelvic (68%), contraception (74%), and STI (75%) services. Women's health specialists were also the most preferred care sources for Papanicolaou/pelvic (68%), contraception (49%), and STI (35%) services, whereas the remainder of women preferred primary care/other sources or not to get care. Differences in preferred and usual care sources were noted across sociodemographic groups, including insurance status and income level (P < .05). Preference for women's health specialists was the strongest predictor of women's health specialist utilization for Papanicolaou/pelvic (adjusted odds ratio, 48.8; 95% confidence interval, 25.9-91.8; P < .001) and contraceptive (adjusted odds ratio, 194.5; 95% confidence interval, 42.3-894.6; P < .001) services. Agreement between preferred and usual-care sources was high for Papanicolaou/pelvic (85%, kappa, 0.63) and contraception (86%; kappa, 0.64) services; disagreement (range, 15-22%) was associated with insurance, employment, income, race, and religion (P < .05).

CONCLUSION

Women's preferences for and use of women's health specialists for reproductive health care has implications for efforts to define the role of obstetricians-gynecologists and family planning clinics in current health systems.

Pay Now or Pay Later: An Economic Rationale for State-Funded Helping Services to Assist Women Leaving an Abusive Relationship

There has been an increase in costing analysis of intimate partner violence in recent decades, including the monetary impact to government, society, and the individual. Using data collected in a Canadian longitudinal study, the empirical analysis in this article provides an economic rationale for mobilizing public resources that improve the well-being of women leaving an abusive relationship. I estimated six variants of a selection model and used a costing exercise to build an economic case for preventive and other helping services to support women over their healing journey. The removal of financial constraints suffered by abused women, in support of their training needs, as well as reduced barriers to preventive health care services, may potentially lead to fiscal resource savings in the long run.

Women's experiences seeking publicly funded family planning services in Texas

CONTEXT

Little is known about low-income women's and teenagers' experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services.

METHODS

Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July-October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Participants were recruited through organizations that serve low-income populations. At least two researchers independently coded the transcripts of the discussions and identified main themes.

RESULTS

Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care.

CONCLUSION

Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges.

State abortion context and U.S. women's contraceptive choices, 1995-2010

CONTEXT

The number of women in the United States exposed to restrictive abortion policies has increased substantially over the past decade. It is not well understood whether and how women adjust their contraceptive behavior when faced with restrictive abortion contexts.

METHODS

Data from 14,523 women aged 15-44 were drawn from the 1995 and 2010 cycles of the National Survey of Family Growth. A difference-in-differences approach was employed to examine the relationship between state-level changes in women's access to abortion and their contraceptive choices. Multinomial logistic regression analysis was used to determine the relative risk of using highly effective or less effective methods rather than no method for women exposed to varying levels of restrictive abortion contexts.

RESULTS

Women who lived in a state where abortion access was low were more likely than women living in a state with greater access to use highly effective contraceptives rather than no method (relative risk ratio, 1.4). Similarly, women in states characterized by high abortion hostility (i.e., states with four or more types of restrictive policies in place) were more likely to use highly effective methods than were women in states with less hostility (1.3). The transition to a more restrictive abortion context was not associated with women's contraceptive behavior, perhaps because states that introduced restrictive abortion legislation between 1995 and 2010 already had significant limitations in place.

CONCLUSION

To prevent unwanted pregnancies, it is important to ensure access to highly effective contraceptive methods when access to abortions is limited.

Experiences and unmet needs of women undergoing Pap smear cervical cancer screening: impact on uptake of cervical cancer screening in south eastern Nigeria

The burden of cervical cancer is on the increase in sub-Saharan Africa mainly due to inadequate provision and utilisation of cervical cancer prevention services. Several evidence-based strategies have been deployed to improve cervical cancer screening uptake without much success. However, patients' experiences and satisfaction with service provision has not been adequately studied. Inefficiencies in service delivery and less fulfilling experiences by women who attend cervical cancer screening could have considerable impact in future voluntary uptake of cervical cancer screening. Six hundred and eighty women who underwent Pap smear screening in three health care facilities in two states in south eastern Nigeria were interviewed to evaluate their satisfaction, willingness to undertake future voluntary screening, unmet needs and correlation between satisfaction level and willingness to undergo future screening. Satisfaction with Pap smear screening correlated positively with willingness to undertake future voluntary screening (Pearson's correlation coefficient = 0.78, P = 0.001). The mean satisfaction score was significantly higher among participants handled by nurses than those handled by the physicians (3.16 ± 0.94 vs 2.52 ± 0.77, P = 0.001). 'Scrapping discomfort' of the spatula was reported as the most dissatisfying aspect of Pap smear experience. The need for less invasive screening procedures was the most unmet need. It was concluded that improving the Pap smear screening experience of women and providing less invasive methods of cervical cancer screening with immediate results could improve uptake of cervical cancer screening in south eastern Nigeria.

Organization and functioning of primary care for women in Croatia: in relation to the health care reforms introduced between 1995 and 2012

The main aim of this study was to investigate trends in the organization and functioning of the HC service. The Croatian Health Service Yearbooks, from 1995 to 2012, served as the basis for the data. The results showed that the HC reforms aimed at the organization and functioning of primary care for women somehow compromised their accessibility. A general lack of around 100 gynecologists, the huge number of women on the lists, from 4, 350 to 8,061 women, and excessively heavy daily consultations, between 23.8 and 28.4, were all observed. The location of the majority of gynecological practices in the big cities also makes the service inaccessible to women from the rural areas. A flow of service away from the public to the private providers was also observed. Since, the results of this study can be viewed only in terms of trends and more detailed research will be needed in future.