A mixed-methods exploration of the contraceptive experiences of female teens with epilepsy

PURPOSE

We explored the contraceptive experiences of female teens with epilepsy, including their knowledge and perceptions of interactions between antiepileptic drugs and hormonal contraception and contraceptive decision-making processes.

METHOD

From November 2012 to May 2013, we conducted one online survey (n=114) and 12 online focus group discussions (n=26) with female teens with epilepsy about their contraceptive experiences and unmet needs. Survey data were analyzed using descriptive statistics and focus group transcripts were analyzed thematically using modified grounded theory methods.

RESULTS

Both survey and focus group participants reported believing that interactions between epilepsy medications and hormonal contraceptives could lead to reductions in contraceptive efficacy and seizure control. However, their knowledge about these types of medication interactions was often incomplete. Many study participants viewed contraceptive decision making as a difficult process, and some participants reported avoiding hormonal contraceptives because of potential interactions with antiepileptic drugs. Study participants reported relying on health care providers and parents for contraceptive decision-making support. Focus group participants also reported they wanted health care providers to provide more in-depth and comprehensive counseling about contraception, and that they desired peer support with contraceptive decisions.

CONCLUSION

The ability to make informed contraceptive decisions is important for teens with epilepsy as interactions between anti-epileptic drugs and hormonal contraceptives can impact seizure occurrence and lead to an increased risk of unplanned pregnancy. Guidance for providers offering contraceptive care to this population is needed, as well as a contraceptive support tool that empowers teens with epilepsy to advocate for desired health care.

MAPK kinase 3 is a tumor suppressor with reduced copy number in breast cancer

Cancers are initiated as a result of changes that occur in the genome. Identification of gains and losses in the structure and expression of tumor-suppressor genes and oncogenes lies at the root of the understanding of cancer cell biology. Here, we show that the mitogen-activated protein kinase (MAPK) MKK3 suppresses the growth of breast cancer, in which it varies in copy number. A pervasive loss of MKK3 gene copy number in patients with breast cancer is associated with an impairment of MKK3 expression and protein level in malignant tissues. To assess the functional role of MKK3 in breast cancer, we showed in an animal model that MKK3 activity is required for suppression of tumor growth. Active MKK3 enhanced expression of the cyclin-dependent kinase inhibitors p21(Cip1/Waf1) and p27(Kip1), leading to increased cell-cycle arrest in G1 phase of the cell cycle. Our results reveal the functional significance of MKK3 as a tumor suppressor and improve understanding of the dynamic role of the MAPK pathway in tumor progression.

What happens to the women who fall through the cracks of health care reform? Lessons from Massachusetts

We investigated the impact of Massachusetts health care reform on low-income women's experiences accessing insurance and health services, specifically reproductive health services such as contraception. Our findings suggest that concentrated efforts are needed to make sure that health services are available and accessible to populations who fall through the cracks of health care reform, including immigrants, minors and young adults, and women living outside urban areas. In addition, systems changes are needed to ensure that women going through common life transitions, such as pregnancy, marriage, moving, or graduating from school, have continuous access to insurance, and therefore health services, as their lives change. These groups face barriers enrolling in and maintaining their insurance coverage as well as obtaining timely health care benefits they are eligible for through their insurance benefits or public health programs. Without intervention, many in these groups may delay or avoid seeking health care altogether, which may increase health care disparities in the long term. Family planning providers in Massachusetts have played a critical role in mitigating barriers to insurance and health care. However, recent threats to defund family planning providers call into question the ability of these providers to continue providing much-needed services.

Fasting blood glucose predicts response to extended-release metformin in gestational diabetes mellitus

BACKGROUND

Metformin is increasingly accepted as an alternative to insulin therapy in gestational diabetes mellitus (GDM). The Metformin in Gestational Diabetes (MiG) trial reported similar pregnancy outcomes for metformin versus insulin; however, supplemental insulin was required in 46% of women on metformin.

AIMS

We aimed to identify predictors of response to metformin monotherapy in women with GDM attending a general hospital antenatal clinic.

METHODS

We offered extended-release metformin to women diagnosed with GDM (ADIPS 1998 criteria) at ≥24 weeks of gestation. If glucose targets were not achieved (≤5.0 mmol/L fasting, ≤6.7 mmol/L two-h post-meal), women were changed to insulin. We carried out an audit to determine characteristics of metformin responders versus nonresponders.

RESULTS

Twenty-five women chose initial metformin therapy; 16 (64%) achieved satisfactory glycaemic control (responders). Nine women (36%) were changed to insulin: seven due to inadequate control (nonresponders) and two had metformin intolerance. Fasting glucose at oral glucose tolerance test (OGTT) was significantly lower in metformin responders versus nonresponders; two-h glucose and BMI did not differ. Ninety-three percent of women with fasting glucose ≤5.2 mmol/L responded to metformin: conversely, at fasting glucose >5.2 mmol/L, 33% responded (P = 0.005). Neonatal outcomes were similar in metformin responders and nonresponders, women who chose initial insulin therapy (n = 25), or were diet-controlled (n = 21).

CONCLUSIONS

In women with GDM, fasting glucose on OGTT predicted response to metformin: at fasting glucose ≤5.2 mmol/L, the probability of response was 93%. Antenatal clinics should determine locally relevant predictors of response to metformin in women with GDM.

Abortion providers' experiences with Medicaid abortion coverage policies: a qualitative multistate study

OBJECTIVE

To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers.

DATA SOURCE

From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states.

STUDY DESIGN

In-depth interviews focused on abortion providers' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment.

DATA EXTRACTION

Data were transcribed verbatim before being coded.

PRINCIPAL FINDINGS

In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates.

CONCLUSIONS

Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women's health.

Barriers to contraception and interest in over-the-counter access among low-income women: a qualitative study

CONTEXT

Barriers to contraceptive access encourage nonuse and gaps in use, which contribute to the high prevalence of unintended pregnancy in the United States. One strategy to improve access to oral contraceptives is to make them available without a prescription.

METHODS

From March 2007 to January 2009, focus group discussions and in-depth interviews were conducted with 45 low-income women in the Boston area to explore how they obtain contraceptives and their opinions about making oral contraceptives available over the counter. Transcripts of the discussions and interviews were deductively and inductively coded. Data were analyzed thematically, and illustrative quotes were extracted.

RESULTS

Overall, participants reported ease in obtaining contraceptives, which were available at multiple accessible locations throughout Boston. However, various barriers-unaffordable copays and clinic visits, the time required for clinic visits, restrictions on the number of packs of prescription contraceptives (e.g., the ring, the pill) purchased monthly and the limited time frame in which to purchase them-deterred consistent use of preferred methods. Most participants supported over-the-counter access to oral contraceptives; however, they raised concerns about cost, as well as the safety of such access for minors, first-time users and women with medical conditions.

CONCLUSION

Women's concerns about over-the-counter access to contraceptives must be addressed if this approach is to improve use and potentially help reduce the unintended pregnancy rate.

Ability of non-invasive intermittent blood pressure monitoring and a continuous non-invasive arterial pressure monitor (CNAP™) to provide new readings in each 1-min interval during elective caesarean section under spinal anaesthesia

We compared the ability of automated non-invasive intermittent oscillometric blood pressure monitoring with a new device, CNAP(TM) (continuous non-invasive arterial pressure) to provide a new blood pressure reading in each 1-min interval between spinal anaesthesia and delivery during caesarean section. We also compared the accuracy of continuous non-invasive arterial pressure readings with non-invasive blood pressure measurements before spinal anaesthesia. Fifty-nine women participated. The non-invasive and continuous non-invasive monitors displayed new blood pressure readings in a mean of 82% (11%) and 83% (13%) (p = 0.97) of the one-minute intervals between spinal anaesthesia and delivery, respectively. Continuous non-invasive arterial pressure was more likely to fail on two or more consecutive minutes (p=0.001). From the pre-spinal readings, the mean bias, defined as non-invasive-continuous non-invasive arterial pressure, and limits of agreement (±2SD mean bias) for systolic, diastolic and mean blood pressure respectively were +1.3 (±26.0), -2.9 (±21.8) and +2.6 (±20.4) mmHg. The new monitor has disadvantages compared with conventional non-invasive intermittent blood pressure monitoring.

A qualitative study of obstacles to diaphragm and condom use in an HIV prevention trial in sub-Saharan Africa

Consistent condom use and the substitution of condoms with potential HIV prevention methods of lower or unknown effectiveness are important concerns in the development of new prevention technologies. This qualitative study explored obstacles to consistent condom use with the diaphragm in MIRA, an HIV prevention trial in South Africa and Zimbabwe. We conducted 26 focus group discussions (FGDs) with 206 women and 7 FGDs and 10 in-depth interviews with 41 male partners of intervention-arm women. The belief that the diaphragm/gel prevented HIV, women's difficulties negotiating condom use, and men's unawareness that using the products together was recommended were obstacles to consistent condom use with the diaphragm/gel. Concerns about protection from HIV and pregnancy, recognition that the diaphragm was not yet proven to prevent HIV or sexually transmitted infections, and the trial context were facilitators. Understanding selective study product use in HIV prevention trials may inform improved adherence counseling and male involvement strategies.

Strategies for securing funding for abortion under the Hyde Amendment: a multistate study of abortion providers' experiences managing Medicaid

OBJECTIVES

We investigated systematic barriers, identified by previous research, that prevent women from obtaining Medicaid coverage for an abortion even when it should legally be available: when the pregnancy resulted from rape or incest or threatens the mother's life. We also aimed to document strategies to improve access to federal Medicaid funding in qualifying cases.

METHODS

We conducted in-depth interviews from 2007 to 2009 with representatives of 49 facilities that provided abortions in 11 states. Interviews focused on participants' experiences and strategies in seeking federal Medicaid funding for abortions. We coded data both inductively and deductively and analyzed them thematically.

RESULTS

Common strategies described by the few participants who secured Medicaid funding for abortions in cases of rape, incest, and life endangerment were facility-level interventions, such as developing relationships with Medicaid staff, building savvy billing departments, and encouraging clients to advocate for themselves, as well as broader legal and collaborative strategies.

CONCLUSIONS

Multipronged state-level interventions that combine advocacy, legal, and on-the-ground resources show the most promise of increasing access to federal Medicaid funding for abortion care.