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Madden N, Trawick E, Watson K, Yee LM. Post- Dobbs Abortion Restrictions and the Families They Leave Behind. Am J Public Health 2024; 114:1043-1050. [PMID: 39231409 PMCID: PMC11375356 DOI: 10.2105/ajph.2024.307792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
The June 24, 2022 US Supreme Court decision in Dobbs v Jackson Women's Health Organization resulted in an expansive restriction on abortion access that had been constitutionally guaranteed for nearly half a century. Currently, 14 states have implemented complete bans on abortion with very limited exceptions, and an additional 7 states have implemented abortion bans at 6 to 18 weeks' gestation. It has been well demonstrated that restrictive policies disproportionately limit abortion access for minoritized people and people of low socioeconomic status; the financial and geographic barriers of these post-Dobbs restrictions will only exacerbate this disparity. Proponents of abortion restrictions, who identify as pro-life, assert that these policies are essential to protect children, women, and families. We examine whether the protection of these groups extends past conception by evaluating the association between state abortion legislation and state-based policies and programs designed to provide medical and social support for children, women, and families. We found that states with the most restrictive post-Dobbs abortion policies in fact have the least comprehensive and inclusive public infrastructure to support these groups. We suggest further opportunities for advocacy. (Am J Public Health. 2024;114(10):1043-1050. https://doi.org/10.2105/AJPH.2024.307792).
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Affiliation(s)
- Nigel Madden
- At the time of this study, all authors were with the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Katie Watson is also with Medical Social Sciences, Northwestern University Feinberg School of Medicine
| | - Emma Trawick
- At the time of this study, all authors were with the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Katie Watson is also with Medical Social Sciences, Northwestern University Feinberg School of Medicine
| | - Katie Watson
- At the time of this study, all authors were with the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Katie Watson is also with Medical Social Sciences, Northwestern University Feinberg School of Medicine
| | - Lynn M Yee
- At the time of this study, all authors were with the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Katie Watson is also with Medical Social Sciences, Northwestern University Feinberg School of Medicine
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McNamara M, Barondeau J, Brown J. Mental Health, Climate Change, and Bodily Autonomy: An Analysis of Adolescent Health Policy in the Post-Pandemic Climate. Pediatr Clin North Am 2024; 71:729-744. [PMID: 39003013 DOI: 10.1016/j.pcl.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2024]
Abstract
The COVID-19 pandemic exacerbated the vulnerability of adolescents and young adults (AYAs) who face economic disadvantage, depend on social safety net resources, have politically targeted identities, are geopolitically displaced, and/or are racially or ethnically marginalized. A rapid change in social safety net policies has impacts that reverberate throughout interrelated domains of AYA health, especially for vulnerable AYAs. The authors analyze policy-related changes in mental health, climate change, and bodily autonomy to offer a paradigm for an equitable path forward.
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Affiliation(s)
| | - Jesse Barondeau
- University of Nebraska Medical Center, Children's Nebraska, 8200 Dodge Street, Omaha, NE 68114, USA
| | - Joanna Brown
- Boston Children's Hospital, 333 Longwood Avenue, Boston, MA 02115, USA
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Gifford K, McColl R, McDuffie MJ, Boudreaux M. Postpartum long-acting reversible contraceptive adoption after a statewide initiative. Health Serv Res 2024; 59:e14300. [PMID: 38491794 PMCID: PMC11063091 DOI: 10.1111/1475-6773.14300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Abstract
OBJECTIVES To examine the effects of a comprehensive, multiyear (2015-2020) statewide contraceptive access intervention in Delaware on the contraceptive initiation of postpartum Medicaid patients. The program aimed to increase access to all contraceptives, including long-acting reversible contraceptives (LARC). The program included interventions specifically targeting postpartum patients (Medicaid payment reform and hospital-based immediate postpartum (IPP) LARC training) and interventions in outpatient settings (provider training and operational supports). DATA SOURCES AND STUDY SETTING We used Medicaid claims data between 2012 and 2019, from Delaware and Maryland (a comparison state), to identify births and postpartum contraceptive methods up to 60 days postpartum among patients aged 15-44 years who were covered in a full-benefit eligibility category. STUDY DESIGN Using difference-in-differences, we assessed changes in LARC, tubal ligation, and short-acting methods (oral contraceptive, injectable, patch/ring). LARC rates were assessed at 60 days after delivery and on an immediate postpartum basis. Other methods were only assessed at 60 days. Analyses were conducted separately for an early-adopting high-capacity hospital (that delivers approximately half of all Medicaid financed births) and for all other later-adopting hospitals in the state. DATA COLLECTION/EXTRACTION METHODS Data were extracted from administrative claims. PRINCIPAL FINDINGS The program increased postpartum LARC insertions by 60 days after delivery by 11.7 percentage points (95% CI: 10.7, 12.8) in the early-adopting hospital and 6.9 percentage points (95% CI: 4.8, 5.9) in later-adopting hospitals. Increases in IPP versus outpatient LARC drove the change, but we did not find evidence that IPP crowded-out outpatient LARC services. We observed decreases in short-acting methods, suggesting substitution between methods, but the share of patients with any method increased at the early-adopting hospital (5.2 percentage points; 95% CI: 3.5, 6.9) and was not statistically significantly different at the later-adopting hospitals. CONCLUSIONS Direct reimbursement for IPP LARC, in combination with provider training, had a meaningful impact on the share of Medicaid-enrolled postpartum women with LARC claims.
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Affiliation(s)
- Katie Gifford
- Biden School of Public Policy & AdministrationUniversity of DelawareNewarkDelawareUSA
| | - Rebecca McColl
- Biden School of Public Policy & AdministrationUniversity of DelawareNewarkDelawareUSA
| | - Mary Joan McDuffie
- Biden School of Public Policy & AdministrationUniversity of DelawareNewarkDelawareUSA
| | - Michel Boudreaux
- Department of Health Policy and ManagementUniversity of Maryland School of Public HealthCollege ParkMarylandUSA
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Costanzo MA, Magnuson KA, Gennetian LA, Halpern-Meekin S, Noble KG, Yoshikawa H. Contraception use and satisfaction among mothers with low income: Evidence from the Baby's First Years study. Contraception 2024; 129:110297. [PMID: 37806470 PMCID: PMC10843149 DOI: 10.1016/j.contraception.2023.110297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 09/19/2023] [Accepted: 10/01/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Low income can lead to limited choice of and access to contraception. We examine whether an unconditional cash transfer (UCT) impacts contraceptive use, including increased satisfaction with and reduced barriers to preferred methods, for individuals with low income. STUDY DESIGN Baby's First Years is a randomized control study of a monthly UCT to families with low incomes. The study enrolled 1000 mothers at the time of childbirth across four US sites in 2018-2019; 400 were randomized to receive a UCT of $333/mo and 600 were randomized to receive $20/mo for the first years of their child's life. We use intent-to-treat analyses to estimate the impact of the cash transfer on contraception use, satisfaction with contraception method, and barriers to using methods of choice. RESULTS Over 65% of mothers reported using some type of contraception, and three-quarters reported using the method of their choice. We find no impact of the UCT on mothers' choice of, satisfaction with, or barriers to contraception. However, the cash transfer was associated with trends toward using multiple methods and greater use of short-term hormonal methods. CONCLUSIONS We find high levels of satisfaction with current contraceptive use among mothers of young children with low income. Receipt of monthly UCTs did not impact contraception methods, perceived barriers to use, or satisfaction. Yet, 25% were not using the method of their choice, despite the provision of cash, indicating that this cash amount alone may not be sufficient to impact contraceptive use or increase satisfaction. IMPLICATIONS Satisfaction with contraception use among low-income populations may be higher than previously documented. Nevertheless, provision of modest financial resources alone may not sufficiently address access, availability, and satisfaction for individuals with low-incomes of childbearing age. This suggests the importance of exploring how other nonfinancial factors influence reproductive autonomy, including contraceptive use.
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Affiliation(s)
- Molly A Costanzo
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, United States.
| | - Katherine A Magnuson
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, United States; Sandra Rosenbaum School of Social Work, University of Wisconsin-Madison, Madison, WI, United States
| | - Lisa A Gennetian
- Sanford School of Public Policy, Duke University, Durham, NC, United States
| | - Sarah Halpern-Meekin
- School of Human Ecology, University of Wisconsin-Madison, Madison, WI, United States; LaFollette School of Public Affairs, University of Wisconsin-Madison, Madison, WI, United States
| | - Kimberly G Noble
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States; Department of Human Development, Teachers College, Columbia University, New York, NY, United States
| | - Hirokazu Yoshikawa
- Department of Applied Psychology at the Steinhardt School of Culture, Education and Human Development, New York University, New York, NY, United States
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Mitchell L, Vellanki B, Tang L, Hunter K, Finnegan A, Swartz JJ, Huchko M. Contraceptive Provision to Women With Intellectual and Developmental Disabilities Enrolled in Medicaid. Obstet Gynecol 2023; 142:1477-1485. [PMID: 38051293 PMCID: PMC10642699 DOI: 10.1097/aog.0000000000005421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/06/2023] [Accepted: 08/17/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE To compare contraceptive provision to women with and without intellectual and developmental disabilities enrolled in North Carolina Medicaid. METHODS Our retrospective cohort study used 2019 North Carolina Medicaid claims to identify women aged 15-44 years with and without intellectual and developmental disabilities at risk for pregnancy who were continuously enrolled during 2019 or had Family Planning Medicaid with at least one claim. We calculated the proportion in each cohort who received 1) most or moderately effective contraception, 2) long-acting reversible contraception, 3) short-acting contraception, and 4) individual methods. We classified contraceptive receipt by procedure type and disaggregated across sociodemographic characteristics. Adjusting for age, race, ethnicity, and urban or rural setting, we constructed logistic regression models to estimate most or moderately effective contraceptive provision odds by intellectual and developmental disability status and by level or type of intellectual and developmental disability. We performed subanalyses to estimate co-occurrence of provision and menstrual disorders. RESULTS Among 9,508 women with intellectual and developmental disabilities and 299,978 without, a significantly smaller proportion with intellectual and developmental disabilities received most or moderately effective contraception (30.1% vs 36.3%, P <.001). With the exception of injectable contraception, this trend was consistent across all measures and remained statistically significant after controlling for race, ethnicity, age, and urban or rural status (adjusted odds ratio 0.75, 95% CI 0.72-0.79; P <.001). Among those who received most or moderately effective contraception, a significantly greater proportion of women with intellectual and developmental disabilities had co-occurring menstrual disorders (31.3% vs 24.3%, P <.001). CONCLUSION These findings suggest disparities in contraceptive provision and potential differences in clinical indication by intellectual and developmental disability status. Future studies should investigate reasons for and barriers to contraceptive use among women with intellectual and developmental disabilities.
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Affiliation(s)
- Lauren Mitchell
- Duke Global Health Institute, the Sanford School of Public Policy, the Department of Political Science, Department of Obstetrics and Gynecology, and the Center for Global Reproductive Health, Duke University, Durham, and IntraHealth International, Chapel Hill, North Carolina
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Phillips-Bell G, Roque M, Romero L. Mapping Long-acting Reversible Contraceptive Interventions to the Social Ecological Model: A Scoping Review. Womens Health Issues 2023; 33:497-507. [PMID: 37500420 PMCID: PMC10522259 DOI: 10.1016/j.whi.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels. METHODS We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other. RESULTS Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n = 12) and cost support (n = 12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use. CONCLUSIONS Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.
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Affiliation(s)
- Ghasi Phillips-Bell
- Centers for Disease Control and Prevention, Chamblee Campus, Atlanta, Georgia.
| | - Maria Roque
- Texas A&M University, School of Public Health, College Station, Texas
| | - Lisa Romero
- Centers for Disease Control and Prevention, Chamblee Campus, Atlanta, Georgia
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Panchal VR, Rau AR, Mandelbaum RS, Violette CJ, Harris CA, Brueggmann D, Matsuzaki S, Ouzounian JG, Matsuo K. Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes. Am J Obstet Gynecol MFM 2023; 5:101056. [PMID: 37330009 DOI: 10.1016/j.ajogmf.2023.101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis. OBJECTIVE This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device. STUDY DESIGN This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device. RESULTS A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44). CONCLUSION This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.
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Affiliation(s)
- Viraj R Panchal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Panchal, Ms Rau, and Drs Violette, Harris, and Matsuo)
| | - Alesandra R Rau
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Panchal, Ms Rau, and Drs Violette, Harris, and Matsuo); Keck School of Medicine, University of Southern California, Los Angeles, CA (Ms Rau)
| | - Rachel S Mandelbaum
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Mandelbaum)
| | - Caroline J Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Panchal, Ms Rau, and Drs Violette, Harris, and Matsuo)
| | - Chelsy A Harris
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Panchal, Ms Rau, and Drs Violette, Harris, and Matsuo)
| | - Doerthe Brueggmann
- Department of Obstetrics and Gynecology, University of Frankfurt Faculty of Medicine, Frankfurt, Germany (Dr Brueggmann)
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan (Dr Matsuzaki)
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Ouzounian)
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Panchal, Ms Rau, and Drs Violette, Harris, and Matsuo); Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (Dr Matsuo).
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Darney BG, Biel FM, Oakley J, Coleman-Minahan K, Cottrell EK. Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016-2021. Obstet Gynecol 2023; 142:669-678. [PMID: 37535965 PMCID: PMC10424816 DOI: 10.1097/aog.0000000000005277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/28/2023] [Accepted: 05/11/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To describe patterns of contraceptive method switching and long-acting reversible contraception (LARC) removal in a large network of community health centers. METHODS We conducted a retrospective cohort study using individual-level electronic health record data from 489 clinics in 20 states from 2016 to 2021. We used logistic regression models, including individual-, clinic-, and state-level covariates, to calculate adjusted odds ratios and predicted probabilities of any observed contraceptive method switching and LARC removal among those with baseline incident LARC, both over 4-year time periods. RESULTS Among 151,786 patients with 513,753 contraceptive encounters, 22.1% switched to another method at least once over the 4-year observation period, and switching patterns were varied. In patients with baseline LARC, the adjusted predicted probability of switching was 19.0% (95% CI 18.0-20.0%) compared with patients with baseline moderately effective methods (16.2%, 95% CI 15.1-17.3%). The adjusted predicted probability of switching was highest among the youngest group (28.6%, 95% CI 25.8-31.6% in patients aged 12-14 years) and decreased in a dose-response relationship by age to 8.4% (95% CI 7.4-9.4%) among patients aged 45-49 years. Latina and Black race and ethnicity, public or no insurance, and baseline Title X clinic status were all associated with higher odds of switching at least once. Among baseline LARC users, 19.4% had a removal (to switch or discontinue) within 1 year and 30.1% within 4 years; 97.6% of clinics that provided LARC also had evidence of a removal. CONCLUSION Community health centers provide access to method switching and LARC removal. Contraceptive switching and LARC removal are common, and clinicians should normalize switching and LARC removal among patients.
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Affiliation(s)
- Blair G Darney
- Oregon Health & Science University, the OHSU-PSU School of Public Health, and OCHIN, Portland, Oregon; the National Institute of Public Health, Center for Population Health, Cuernavaca, Morelos, Mexico; and the College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, and the University of Colorado Population Center and the Population Program and Geography Department, University of Colorado Boulder, Boulder, Colorado
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Galvin AM, Garg A, Akpan IN, Spence EE, Thompson EL. Contraception-related knowledge, attitude, belief contexts among US women experiencing homelessness: A scoping review. Nurs Health Sci 2023; 25:290-301. [PMID: 37529965 DOI: 10.1111/nhs.13039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 06/29/2023] [Accepted: 07/13/2023] [Indexed: 08/03/2023]
Abstract
Contraception provision may help reduce undesired pregnancies, but women experiencing homelessness may have low health literacy, specific attitudes, and certain beliefs that influence contraception uptake. This scoping review identifies what is known about pregnancy prevention and contraception knowledge, attitudes, and beliefs among US women experiencing homelessness. This review examined English articles that measured the context of knowledge, attitudes, and beliefs related to contraceptive use for avoiding pregnancy among US women experiencing homelessness. Using PRISMA-ScR guidelines, articles published before May 2022 were located via PubMed, EBSCOhost, and Embase. The initial search identified 1204 articles, and 10 met the inclusion criteria. There were five quantitative, four qualitative, and one mixed-methods study, published between 2000 and 2022, with samples of 15-764 women ranging from ages 15-51. Contraception knowledge, attitudes, and beliefs related to pregnancy prevention suggested several knowledge gaps (e.g., contraception efficacy), contraception preferences and past experiences, interpersonal relationship influences, and vulnerability to clinic and shelter-specific barriers. These findings may ultimately inform contraception interventions in partnership with the community of US women who experience homelessness and the health care and social service organizations who serve them.
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Affiliation(s)
- Annalynn M Galvin
- Department of Research, Cizik School of Nursing, University of Texas Health Science Center (UTHealth) Houston, Houston, Texas, USA
| | - Ashvita Garg
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Idara N Akpan
- Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Emily E Spence
- Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Erika L Thompson
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, USA
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Wesevich A, Jiao MG, Santanam TS, Chung RJ, Uchitel J, Zhang Q, Brindis CD, Ford CA, Counts NZ, Wong CA. Adolescent and Young Adult Perspectives on Quality and Value in Health Care. Acad Pediatr 2023; 23:782-789. [PMID: 36288750 DOI: 10.1016/j.acap.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/12/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe adolescent and young adult (AYA) perspectives on defining quality and value in health care and to gain understanding of their knowledge of value-based payment. METHODS A text message-based survey was sent to a convenience sample of AYAs aged 14 to 24 in 2019. Participants were asked 4 open-ended questions: 1) how they would define "good health care," 2) what factors to consider in rating doctors, 3) whose opinions should matter most when rating doctors, and 4) the best ways to collect AYA opinions on doctors, and one yes/no question on their awareness of value-based payment. Analyses included descriptive demographic statistics and an inductive thematic approach with multivariable models comparing adolescent (14-18) and young adult (19-24) responses. RESULTS Response rate was 61.0% (782/1283). Most participants were White (63.3%), female (53.3%), and adolescents (55.6%). Common themes from the first 2 questions included accessibility (specifically affordability), coverage benefits, and care experience (including compassion, respect, and clinical competence). Young adults more commonly mentioned affordability than adolescents (54.4% vs 43.3%, P = .001) and more commonly felt their opinion should matter more than their parents when rating doctors (80.6% vs 62.0%, P < .001). Only 21.0% of AYAs were familiar with the potential value-based link between physician payment and care quality. CONCLUSIONS When considering quality and value in health care, AYAs expressed their desired agency in rating the quality of their care and clinicians. AYAs' perspectives on health care quality, including the importance of care accessibility and affordability, should be considered when designing youth-centered care delivery and value-based payment models.
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Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago (A Wesevich), Chicago, Ill; Department of Medicine, Department of Pediatrics, Duke University School of Medicine (A Wesevich and RJ Chung), Durham, NC
| | - Megan G Jiao
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Taruni S Santanam
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Richard J Chung
- Department of Medicine, Department of Pediatrics, Duke University School of Medicine (A Wesevich and RJ Chung), Durham, NC
| | - Julie Uchitel
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Qintian Zhang
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC
| | - Claire D Brindis
- Adolescent and Young Adult National Health Information Center and Philip R. Lee Institute for Health Policy Studies, University of California (CD Brindis), San Francisco, Calif
| | - Carol A Ford
- Division of Adolescent Medicine, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and the Children's Hospital of Philadelphia (CA Ford), Philadelphia, Pa
| | | | - Charlene A Wong
- Duke-Margolis Center for Health Policy, Duke University (MG Jiao, TS Santanam, J Uchitel, Q Zhang, and CA Wong), Durham, NC.
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Constantin J, Wehby GL. Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity. Am J Prev Med 2023; 64:377-384. [PMID: 36481185 DOI: 10.1016/j.amepre.2022.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The purpose of this study is to examine year-by-year effects of the 2014 Affordable Care Act Medicaid expansion on infant mortality by race and ethnicity over the first 6 years. METHODS Publicly available 2011-2019 Multiple Cause of Death data were extracted in October and analyzed by November 2021. A difference-in-differences event-study design compared infant mortality changes in states that expanded in 2014 to nonexpansion states. RESULTS In the main model, the 2014 Medicaid expansions were associated with a statistically significant decline in Black infants' mortality in 2018 and 2019 by 1.19 (95% CI= -2.27, -0.12) and 1.35 (95% CI= -2.45, -0.26) deaths per 1,000 live births, respectively. There was also a decline in mortality for Hispanic infants in 2015-2019, including by 0.8 (95% CI= -1.25, -0.36) and 1.28 (95% CI= -1.88, -0.68) deaths per 1,000 live births in 2015 and 2019, respectively. Overall, infant mortality declined by 0.37 (95% CI= -0.70, -0.05) deaths per 1,000 live births in 2019. CONCLUSIONS The study adds evidence on the association of the Affordable Care Act Medicaid expansions with a decline in mortality of Black and Hispanic infants. The findings shed light on the importance of examining year-by-year effects over multiple years.
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Affiliation(s)
- Joanne Constantin
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa.
| | - George L Wehby
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa
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Masoumirad M, Harvey SM, Bui LN, Yoon J. Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion. J Womens Health (Larchmt) 2023; 32:300-310. [PMID: 36716274 DOI: 10.1089/jwh.2022.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.
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Affiliation(s)
- Mandana Masoumirad
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - S Marie Harvey
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Linh N Bui
- School of Natural Sciences, Mathematics, and Engineering, California State University, Bakersfield, Bakersfield, California, USA
| | - Jangho Yoon
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA.,School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023. [DOI: 10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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Swan LET. Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023; 40:5. [DOI: https:/doi.org/10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 06/22/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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Bruce K, Stefanescu A, Romero L, Okoroh E, Cox S, Kieltyka L, Kroelinger C. Trends in Postpartum Contraceptive Use in 20 U.S. States and Jurisdictions: The Pregnancy Risk Assessment Monitoring System, 2015-2018. Womens Health Issues 2023; 33:133-141. [PMID: 36464580 DOI: 10.1016/j.whi.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION In the last decade, state and national programs and policies aimed to increase access to postpartum contraception; however, recent data on population-based estimates of postpartum contraception is limited. METHODS Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted multivariable-adjusted weighted multinomial regression to assess variation in method use by insurance status and geographic setting (urban/rural) among people with a recent live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018 overall and within subgroups using weighted multinomial logistic regression. RESULTS In 2018, those without insurance had lower odds of using permanent methods (adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53-0.98), long-acting reversible contraception (LARC) (AOR, 0.67; 95% CI, 0.51-0.89), and short-acting reversible contraception (SARC) (AOR, 0.61; 95% CI, 0.47-0.81) than those with private insurance. There were no significant differences in these method categories between public and private insurance. Rural respondents had greater odds than urban respondents of using all method categories: permanent (AOR, 2.15; 95% CI, 1.67-2.77), LARC (AOR, 1.31; 95% CI, 1.04-1.65), SARC (AOR, 1.42; 95% CI, 1.15-1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11-1.72). From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI, 1.01-1.05) and use of no method (OR, 1.05; 95% CI, 1.02-1.07) and a decrease in SARC use (OR, 0.97; 95% CI, 0.95-0.99). LARC use increased among those with private insurance (OR, 1.05; 95% CI, 1.02-1.08) and in urban settings (OR, 1.04; 95% CI, 1.02-1.07), but not in other subgroups. CONCLUSIONS We found that those without insurance had lower odds of using effective contraception and that LARC use increased among those who had private insurance and lived in urban areas. Strategies to increase access to contraception, including increasing insurance coverage and investigating whether effectiveness of existing initiatives varies by geographic setting, may increase postpartum contraceptive use and address these differences.
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Affiliation(s)
- Katharine Bruce
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina; Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana.
| | - Andrei Stefanescu
- Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ekwutosi Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyn Kieltyka
- Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charlan Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Congy J, Bouyer J, de La Rochebrochard E. Low-income women and use of prescribed contraceptives in the context of full health insurance coverage in France, 2019. Contraception 2023; 121:109976. [PMID: 36758736 DOI: 10.1016/j.contraception.2023.109976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Major socioeconomic differences in contraceptive use are observed in high-income countries. Cost is often cited as a main factor to explain these differences but other barriers may also exist. Our aim was to compare prescribed contraceptive use among low-income and non-low-income women in a national context of full health insurance coverage. STUDY DESIGN In the French national health insurance database, we selected all women (14.8 million) aged 15-49 years living in France in 2019. We compared the prevalence of use of each prescribed contraceptive between low-income and non-low-income women: oral contraceptives, copper intrauterine devices (IUDs), the levonorgestrel intrauterine system (LNG-IUS), and implants. RESULTS In the study population, 11% had a low income. Fewer low-income women used prescribed contraceptives than non-low-income women (36% vs. 46%, p < 0.001). When using a contraceptive, low-income women used a different method: at 20-24 years old, they used less oral contraceptives (60% vs. 77%, p < 0.001) and more implants (22% vs. 9%, p < 0.001), while at 40-44 years, they used less levonorgestrel intrauterine systems (18% vs. 30%, p < 0.001). CONCLUSIONS Even in a national context of free access to medical care for low-income women, they use less and different prescribed contraceptives than non-low-income women. These results could reflect barriers other than financial cost to the use of prescribed contraceptives by low-income women. IMPLICATIONS Financial barriers need to be removed in order to increase contraceptive use. However, this may not be sufficient and further research should explore barriers that low-income women may encounter in accessing and choosing their contraception.
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Affiliation(s)
- Juliette Congy
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France.
| | - Jean Bouyer
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France; Université Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
| | - Elise de La Rochebrochard
- Institut National d'Etudes Démographiques, Ined, Sexual and Reproductive Health and Rights Unit - UR14, 9 cours des Humanités, Aubervilliers, France; Université Paris-Saclay, UVSQ, Inserm, CESP, 16 avenue Paul Vaillant Couturier, Villejuif, France
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Madison AM, Powers D, Maslowsky J, Goyal V. Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015. Obstet Gynecol 2023; 141:361-370. [PMID: 36649327 PMCID: PMC9858333 DOI: 10.1097/aog.0000000000005057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/20/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013. METHODS In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders. RESULTS Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served. CONCLUSION Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.
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Affiliation(s)
- Anita M Madison
- Department of Obstetrics and Gynecology, Louisiana State University Health Science Center, Baton Rouge, Louisiana; the Population Research Center, University of Texas at Austin, Austin, Texas; and the School of Public Health, University of Illinois Chicago, Chicago, Illinois
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Quiñones AR, Valenzuela SH, Huguet N, Ukhanova M, Marino M, Lucas JA, O'Malley J, Schmidt TD, Voss R, Peak K, Warren NT, Heintzman J. Prevalent Multimorbidity Combinations Among Middle-Aged and Older Adults Seen in Community Health Centers. J Gen Intern Med 2022; 37:3545-3553. [PMID: 35088201 PMCID: PMC9585110 DOI: 10.1007/s11606-021-07198-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multimorbidity (≥ 2 chronic diseases) is associated with greater disability and higher treatment burden, as well as difficulty coordinating self-management tasks for adults with complex multimorbidity patterns. Comparatively little work has focused on assessing multimorbidity patterns among patients seeking care in community health centers (CHCs). OBJECTIVE To identify and characterize prevalent multimorbidity patterns in a multi-state network of CHCs over a 5-year period. DESIGN A cohort study of the 2014-2019 ADVANCE multi-state CHC clinical data network. We identified the most prevalent multimorbidity combination patterns and assessed the frequency of patterns throughout a 5-year period as well as the demographic characteristics of patient panels by prevalent patterns. PARTICIPANTS The study included data from 838,642 patients aged ≥ 45 years who were seen in 337 CHCs across 22 states between 2014 and 2019. MAIN MEASURES Prevalent multimorbidity patterns of somatic, mental health, and mental-somatic combinations of 22 chronic diseases based on the U.S. Department of Health and Human Services Multiple Chronic Conditions framework: anxiety, arthritis, asthma, autism, cancer, cardiac arrhythmia, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, coronary artery disease, dementia, depression, diabetes, hepatitis, human immunodeficiency virus (HIV), hyperlipidemia, hypertension, osteoporosis, post-traumatic stress disorder (PTSD), schizophrenia, substance use disorder, and stroke. KEY RESULTS Multimorbidity is common among middle-aged and older patients seen in CHCs: 40% have somatic, 6% have mental health, and 24% have mental-somatic multimorbidity patterns. The most frequently occurring pattern across all years is hyperlipidemia-hypertension. The three most frequent patterns are various iterations of hyperlipidemia, hypertension, and diabetes and are consistent in rank of occurrence across all years. CKD-hyperlipidemia-hypertension and anxiety-depression are both more frequent in later study years. CONCLUSIONS CHCs are increasingly seeing more complex multimorbidity patterns over time; these most often involve mental health morbidity and advanced cardiometabolic-renal morbidity.
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Affiliation(s)
- Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA.
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | - Steele H Valenzuela
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Nathalie Huguet
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Maria Ukhanova
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | - Jean O'Malley
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- Research Department, OCHIN Inc., Portland, OR, USA
| | | | - Robert Voss
- Research Department, OCHIN Inc., Portland, OR, USA
| | - Katherine Peak
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
| | | | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail code: FM, Portland, OR, 97239, USA
- Research Department, OCHIN Inc., Portland, OR, USA
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Kilmer G, Leon-Nguyen M, Smith-Grant J, Brittain AW, Rico A, Adkins SH, Lim C, Szucs LE. Medicaid Expansion and Contraceptive Use Among Female High-School Students. Am J Prev Med 2022; 63:592-602. [PMID: 35688721 PMCID: PMC10926112 DOI: 10.1016/j.amepre.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Access to effective contraception prevents unintended pregnancies among sexually active female youth. Potentially impacted by the Affordable Care Act's Medicaid-related policies, contraception use increased among sexually active high-school students from 2013 to 2019. METHODS Analyses conducted in 2021 assessed state-level Youth Risk Behavior Survey data among female students in grades 9-12 who reported being sexually active. States that expanded Medicaid were compared with other states in 2013 (baseline) and 2019 (after expansion). Measured outcomes included self-reported use of moderately effective or highly effective, long-acting reversible contraception at last sex. Long-acting reversible contraception included intrauterine devices and implants. Moderately effective contraception included birth control pills, injectables, patches, or rings. Results were weighted and adjusted for age and race/ethnicity. RESULTS Students in Medicaid expansion states (n=27,564) did not differ significantly from those in nonexpansion states (n=6,048) at baseline or after expansion with respect to age, age at first sex, or the number of sexual partners in the past 3 months; however, race/ethnicity population characteristics changed over time. Postexpansion increased use of intrauterine devices/implants was greater in Medicaid expansion states than in nonexpansion states (238.1% increase vs 120.0% increase, adjusted p=0.047). For those aged 16-17 years, Medicaid expansion states had a 283.3% increase in intrauterine device/implant use compared with an increase of 69.7% in nonexpansion states (adjusted p=0.004). CONCLUSIONS Medicaid expansion was associated with a greater population-level increase in intrauterine device/implant use among sexually active female high-school students aged 16-17 years. These findings point to the possibility that the Affordable Care Act's Medicaid-related policies played a role in young women's use of intrauterine devices/implants.
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Affiliation(s)
- Greta Kilmer
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Michelle Leon-Nguyen
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jennifer Smith-Grant
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anna W Brittain
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adriana Rico
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan H Adkins
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Connie Lim
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Leigh E Szucs
- Division of Adolescent and School Health, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hansen K, Boniface ER, Darney BG. Association of Title X clinic status with receipt of person-centered contraceptive counseling: a population-based study. Contraception 2022; 115:36-43. [PMID: 35995325 DOI: 10.1016/j.contraception.2022.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/02/2022] [Accepted: 08/11/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe receipt of person-centered contraceptive counseling among reproductive-aged women in the United States who sought contraceptive care at Title X clinics, non-Title X public clinics, and private clinics. STUDY DESIGN We conducted a secondary analysis of the 2017-2019 wave of the National Survey of Family Growth (NSFG). The sample included female respondents ages 15-49 who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling (PCCC) measure, a quality metric evaluating interpersonal quality of the care received. We used multivariable logistic regression to estimate the predicted probability of receiving person-centered contraceptive counseling by source of care, adjusted for individual-level characteristics. RESULTS Of 2,225 (weighted N=26,599,620) eligible respondents, 6.9% received care at a Title X clinic, 8.2% at a non-Title X public clinic, and 84.9% at a private clinic. The adjusted predicted probability of receiving person-centered contraceptive counseling among respondents attending private clinics was 50.6% (95% CI 46.3-54.8%) compared with 51.3% (95% CI 40.4-62.3%) at Title X clinics and 52.4% (95% CI 44.0-60.7%) at other public clinics. Respondents with incomes ≥300% above the federal poverty level (FPL) had higher odds of reporting receipt of person-centered counseling compared to those with incomes below 100% of the FPL (aOR = 2.12; 95% CI 1.47-3.06). Non-Latina Black respondents had lower odds of receiving person-centered contraceptive counseling (aOR = 0.69; 95% CI 0.51-0.94), compared to non-Latina white respondents. CONCLUSION Title X clinics perform as well as the private sector in delivering person-centered contraceptive counseling. IMPLICATIONS Title X clinics provide quality person-centered contraceptive counseling on par with the private sector, despite serving populations that are often less likely to report high quality care. Broad implementation of the PCCC measure will permit tracking person-centered contraceptive care across diverse practice settings and populations.
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Affiliation(s)
- Katie Hansen
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon, 97239, United States.
| | - Emily R Boniface
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon, 97239, United States
| | - Blair G Darney
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, Oregon, 97239, United States; OHSU-Portland State University School of Public Health, 1810 SW 5(th) Avenue, Portland, Oregon, 97201, United States; Centro de Investigación en Salud Poblacional (CISP), Instituto Nacional de Salud Pública (INSP), Cuernavaca, México
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Boudreaux M, Gifford K, McDuffie MJ, McColl R, Kim T, Knight EK. Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020. Am J Public Health 2022; 112:S537-S540. [PMID: 35767779 PMCID: PMC10490315 DOI: 10.2105/ajph.2022.306938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/04/2022]
Abstract
Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).
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Affiliation(s)
- Michel Boudreaux
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Katie Gifford
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Mary Joan McDuffie
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Rebecca McColl
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Taehyun Kim
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
| | - Erin K Knight
- Michel Boudreaux and Taehyun Kim are with the Department of Health Policy and Management at the University of Maryland, College Park. Katie Gifford, Mary Joan McDuffie, and Rebecca McColl are with the Center for Community Research and Service at the Biden School of Public Policy and Administration, University of Delaware, Newark. Erin K. Knight is with the Department of Health at West Chester University, West Chester, PA
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22
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Darney BG, Biel FM, Oakley J, Rodriguez MI, Cottrell EK. US "Safety Net" Clinics Provide Access to Effective Contraception for Adolescents and Young Women, 2017-2019. Am J Public Health 2022; 112:S555-S562. [PMID: 35767786 PMCID: PMC9725103 DOI: 10.2105/ajph.2022.306913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/04/2022]
Abstract
Objectives. To describe patterns of providing moderately effective versus the most effective contraception and of providing implants versus intrauterine devices in US community health centers. Methods. We conducted a historical cohort study (2017-2019). Outcomes were woman-level receipt of most effective contraception (long-acting reversible contraception; implants and intrauterine devices) or moderately effective contraception. We used logistic regression to identify patient and clinic factors associated with providing (1) most versus moderately effective methods, and (2) implants versus intrauterine devices. We calculated adjusted probabilities for both outcomes by age group. Results. We included 199 652 events of providing contraception to 114 280 women in 410 community health centers. Adjusted probabilities were similar across age groups for moderately versus most effective methods. However, the adjusted marginal means for receiving an implant compared with an intrauterine device were highest for adolescents (15-17 years: 78.2% [95% confidence interval (CI) = 75.6%, 80.6%]; 18-19 years: 69.5% [95% CI = 66.7%, 72.3%]). Women's health specialists were more likely to provide most versus moderately effective contraception. Conclusions. Community health centers are an important access point for most effective contraception for women of all ages. Adolescents are more likely to use implants than intrauterine devices. (Am J Public Health. 2022;112(S5):S555-S562. https://doi.org/10.2105/AJPH.2022.306913).
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Affiliation(s)
- Blair G Darney
- Blair G. Darney and Maria I. Rodriguez are with the Department of Obstetrics and Gynecology, Oregon Health & Science University (OHSU), Portland. Blair G. Darney is also with Health Systems & Policy, OHSU-Portland State University joint School of Public Health. Frances M. Biel, Jee Oakley, and Erika K. Cottrell are with the Oregon Community Health Information Network, Inc., Portland. Erika K. Cottrell is also with the School of Medicine, OHSU
| | - Frances M Biel
- Blair G. Darney and Maria I. Rodriguez are with the Department of Obstetrics and Gynecology, Oregon Health & Science University (OHSU), Portland. Blair G. Darney is also with Health Systems & Policy, OHSU-Portland State University joint School of Public Health. Frances M. Biel, Jee Oakley, and Erika K. Cottrell are with the Oregon Community Health Information Network, Inc., Portland. Erika K. Cottrell is also with the School of Medicine, OHSU
| | - Jee Oakley
- Blair G. Darney and Maria I. Rodriguez are with the Department of Obstetrics and Gynecology, Oregon Health & Science University (OHSU), Portland. Blair G. Darney is also with Health Systems & Policy, OHSU-Portland State University joint School of Public Health. Frances M. Biel, Jee Oakley, and Erika K. Cottrell are with the Oregon Community Health Information Network, Inc., Portland. Erika K. Cottrell is also with the School of Medicine, OHSU
| | - Maria I Rodriguez
- Blair G. Darney and Maria I. Rodriguez are with the Department of Obstetrics and Gynecology, Oregon Health & Science University (OHSU), Portland. Blair G. Darney is also with Health Systems & Policy, OHSU-Portland State University joint School of Public Health. Frances M. Biel, Jee Oakley, and Erika K. Cottrell are with the Oregon Community Health Information Network, Inc., Portland. Erika K. Cottrell is also with the School of Medicine, OHSU
| | - Erika K Cottrell
- Blair G. Darney and Maria I. Rodriguez are with the Department of Obstetrics and Gynecology, Oregon Health & Science University (OHSU), Portland. Blair G. Darney is also with Health Systems & Policy, OHSU-Portland State University joint School of Public Health. Frances M. Biel, Jee Oakley, and Erika K. Cottrell are with the Oregon Community Health Information Network, Inc., Portland. Erika K. Cottrell is also with the School of Medicine, OHSU
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23
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Johnson ER. Health care access and contraceptive use among adult women in the United States in 2017. Contraception 2022; 110:30-35. [PMID: 35248570 DOI: 10.1016/j.contraception.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the relationship between insurance status and contraceptive use, with health care access as a mediating variable. STUDY DESIGN This study uses data from the 2017 Behavioral Risk Factor Surveillance Survey to determine whether having a personal healthcare provider and experiencing cost as a barrier to care mediate the relationship between health insurance status and contraceptive use among women at risk of unintended pregnancy. Contraceptive use is measured 3 ways: as a binary variable (use vs non-use), by prescription status, and by tiered effectiveness. RESULTS Having insurance increases the odds of using all categories of contraception. Having a personal health care provider mediates this relationship, with having a personal health care provider increasing the odds of using any contraceptive, using a prescription method, and using a tier I or tier II method. Experiencing cost as a barrier to care is not associated with contraceptive use in weighted multivariable models but does mediate the relationship between having insurance and using tier-II methods. CONCLUSIONS These findings suggest that having health insurance and an ongoing relationship with a health care provider are key to ensuring consistent access to the full range of contraceptive options. This is particularly relevant in light of the ongoing policy debates regarding laws intended to increase health insurance access and decrease barriers to contraceptive use. IMPLICATIONS This paper updates and extends previous findings to show that the relationship between healthcare access and contraceptive use persists after the implementation of the Affordable Care Act and that having a personal provider partially explains this relationship.
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Affiliation(s)
- Erin R Johnson
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, United States.
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Gartner DR, Kaestner R, Margerison CE. Impacts of the Affordable Care Act's Medicaid Expansion on Live Births. Epidemiology 2022; 33:406-414. [PMID: 35067567 PMCID: PMC9040191 DOI: 10.1097/ede.0000000000001462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We hypothesize that the Affordable Care Act's (ACA) Medicaid expansion, which extended health insurance coverage to preconception, between-conception, and postconception periods for women meeting income eligibility guidelines, impacted the number of live births in the United States by increasing access to contraception and financial well-being. These impacts may differ by maternal socioeconomic and demographic characteristics. METHODS Using data from birth certificates aggregated to the state-year level and a difference-in-differences design, we estimated the association between Medicaid expansion and count of live births. We also examined whether associations differed by socioeconomic and demographic characteristics. RESULTS Overall, Medicaid expansion was not meaningfully associated with the count of births (difference-in-differences ß = 0.002; 95% confidence interval [CI] = -0.010, 0.015). However, among certain groups, Medicaid expansion was associated with meaningful changes in the count of live births, though all confidence intervals included the null value. The estimate of the relation between Medicaid expansion and the count of live births was -0.025 (95% CI = -0.052, 0.001) for those ages 18-24 years; -0.078 (95% CI = -0.231, 0.075) for those who were married, and -0.035 (95% CI = -0.104, 0.034) for those who were unmarried. CONCLUSIONS Despite its potential to impact live births, our results indicate that the ACA's Medicaid expansion was not, in general, associated with live births of US residents of reproductive age. However, for younger, married, and unmarried women, the magnitude of estimates supports the hypothesis of a potentially meaningful effect of Medicaid expansions on live births.
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Affiliation(s)
- Danielle R. Gartner
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert Kaestner
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
| | - Claire E. Margerison
- Department of Epidemiology & Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
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25
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Impact of Medicaid Expansion on Interpregnancy Interval. Womens Health Issues 2022; 32:226-234. [PMID: 35016841 DOI: 10.1016/j.whi.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 11/28/2021] [Accepted: 12/10/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Medicaid expansion under the Affordable Care Act (ACA) improved access to reproductive health care for low-income women and birthing people who were previously ineligible for Medicaid. We aimed to evaluate if the expansion affected the risk of having a short interpregnancy interval (IPI), a preventable risk factor for adverse pregnancy outcomes. METHODS We evaluated parous singleton births to mothers aged 19 or older from U.S. birth certificate data 2009-2018. We estimated the effect of residing in a state that expanded Medicaid access (expansion status determined at 60 days after the prior live birth) on the risk of having a short IPI (<12 months) using difference-in-differences (DID) methods in linear probability models. We stratified the analyses by maternal characteristics and county-level reproductive health care access. RESULTS Overall risk of short IPI was 14.9% in expansion states and 16.3% in non-expansion states. The expansion was not associated with a significant change in risk of having a short IPI (adjusted mean percentage point change 1.24 [-1.64, 4.12]). Stratified results also did not provide support for an association. CONCLUSIONS ACA Medicaid expansion did not have an impact on risk of short IPI. Preventing short IPI may require more comprehensive policy interventions in addition to health care access.
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Darney BG, Biel FM, Hoopes M, Rodriguez MI, Hatch B, Marino M, Templeton A, Oakley J, Schmidt T, Cottrell EK. Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016-18. Health Aff (Millwood) 2022; 41:497-506. [PMID: 35377749 PMCID: PMC10033226 DOI: 10.1377/hlthaff.2021.01483] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.
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Affiliation(s)
- Blair G Darney
- Blair G. Darney , Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Brigit Hatch
- Brigit Hatch, Oregon Health & Science University
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Eliason EL, Daw JR, Allen HL. Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age. J Womens Health (Larchmt) 2022; 31:949-956. [PMID: 35180356 DOI: 10.1089/jwh.2021.0451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.
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Affiliation(s)
- Erica L Eliason
- Columbia University School of Social Work, New York, New York, USA
| | - Jamie R Daw
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Heidi L Allen
- Columbia University School of Social Work, New York, New York, USA
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Hale N, Tatro K, Orimaye SO, Smith M, Meit M, Beatty KE, Khoury A. Changes in Adolescent Birth Rates within Appalachian Subregions and Non-Appalachian Counties in the United States, 2012-2018. JOURNAL OF APPALACHIAN HEALTH 2022; 4:31-50. [PMID: 35769510 PMCID: PMC9200451 DOI: 10.13023/jah.0401.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Adolescent births are associated with numerous challenges. While adolescent birth rates have declined across the U.S., disparities persist, and little is known about the extent to which broader declines are seen within Appalachia. Purpose The purpose of this study was to examine the extent to which adolescent birth rates have declined across the subregions of Appalachia relative to non-Appalachia. Methods We conducted a retrospective study of adolescent birth rates between 2012 and 2018 using county-level vital records data. Differences were examined across the subregions of Appalachia and among non-Appalachian counties. Multiple regression models were used to examine changes in the rate of decline over time, adjusting for additional covariates of relevance. Results About 13.4% of all counties in the U.S. are within the Appalachian region. The rate of adolescent births decreased by 12.6 adolescent births per 1,000 females between 2012 and 2018 across the U.S. While all regions experienced declines in the rate of adolescent births, Central Appalachia had the largest reduction in adolescent births (18.5 per 1,000 females), which was also noted in the adjusted models when compared to the counties of non-Appalachia (b= -5.78, CI: -9.58, -1.97). Rates of adolescent birth were markedly higher in counties considered among the most socially and economically vulnerable. Implications This study demonstrates that the rates of adolescent births vary across the subregions of Appalachia but have declined proportional to rates in non-Appalachia. While adolescent birth rates remain higher in select subregions of Appalachia compared to non-Appalachia, the gap has narrowed considerably.
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Pace LE, Saran I, Hawkins SS. Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine. Med Care 2022; 60:119-124. [PMID: 34908011 DOI: 10.1097/mlr.0000000000001666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use. STUDY DESIGN We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states. RESULTS In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17). CONCLUSIONS Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.
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Affiliation(s)
| | - Indrani Saran
- Boston College, School of Social Work, Chestnut Hill, MA
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Boniface ER, Rodriguez MI, Heintzman J, Knipper SH, Jacobs R, Darney BG. A comparison of contraceptive services for adolescents at school-based versus community health centers in Oregon. Health Serv Res 2022; 57:145-151. [PMID: 34624140 PMCID: PMC8763291 DOI: 10.1111/1475-6773.13889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare Oregon school-based health centers (SBHCs) with community health centers (CHCs) as sources of adolescent contraceptive services. DATA SOURCES Oregon electronic health record data, 2012-2016. STUDY DESIGN We compared clinic-level counseling rates and long-acting reversible contraception (LARC) provision, adolescent populations served, and visit-level LARC provision time trends. We evaluated adjusted associations between LARC provision and Title X participation by clinic type. DATA COLLECTION/EXTRACTION METHODS We used diagnosis and procedure codes to identify contraceptive counseling and provision visits, excluding visits for adolescents not at risk of pregnancy. PRINCIPAL FINDINGS CHCs were more likely to provide LARC on-site than SBHCs (67.2% vs. 36.4%, respectively). LARC provision increased more at SBHCs (5.8-fold) than CHCs (2-fold) over time. SBHCs provided more counseling visits per clinic (255 vs. 142) and served more young and non-White adolescents than CHCs. The adjusted probability of LARC provision at Title X SBHCs was higher than non-Title X SBHCs (4.4% [3.9-4.9] vs. 1.7% [1.4-2.0]), but there was no significant association at CHCs. CONCLUSIONS In Oregon, CHCs and SBHCs are both important sources of adolescent contraceptive services, and Title X plays a crucial role in SBHCs. Compared with CHCs, SBHCs provided more counseling, showed a larger increase in LARC provision over time, and served more younger and non-White adolescents.
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Affiliation(s)
- Emily R. Boniface
- Department of Obstetrics & GynecologyOregon Health & Science UniversityPortlandOregonUSA
| | - Maria I. Rodriguez
- Department of Obstetrics & GynecologyOregon Health & Science UniversityPortlandOregonUSA
| | - John Heintzman
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | | | - Rebecca Jacobs
- Public Health DivisionOregon Health AuthorityPortlandOregonUSA
| | - Blair G. Darney
- Department of Obstetrics & GynecologyOregon Health & Science UniversityPortlandOregonUSA
- OHSU‐Portland State University School of Public HealthPortlandOregonUSA
- Center for Population Health ResearchNational Institute of Public HealthCuernavacaMexico
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Contraceptive Provision and Quality Care Measures for Insured Individuals in Massachusetts Who Are Deaf or Hard of Hearing. Obstet Gynecol 2021; 138:398-408. [PMID: 34352855 DOI: 10.1097/aog.0000000000004505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate contraceptive provision and contraceptive care quality measures for individuals who are deaf or hard of hearing and compare these outcomes to those individuals who are not. METHODS We conducted a claims analysis with data from the 2014 Massachusetts All-Payer Claims Database. Among premenopausal enrollees aged 15-44, we determined provision of any contraception (yes or no) and provision by contraception type: prescription contraception (pills, patch, ring, injectables, or diaphragm), long-acting reversible contraceptive (LARC) devices, and permanent contraception (tubal sterilization). We compared these outcomes by deaf or hard-of-hearing status (yes or no). The odds of contraceptive provision were calculated with regression models adjusted for age, Medicaid insurance, a preventive health visit, and deaf or hard-of-hearing status. We calculated contraceptive care quality measures, per the U.S. Office of Population Health, as the percentage of enrollees who used: 1) LARC methods or 2) most effective or moderately effective methods (tubal sterilization, pills, patch, ring, injectables, or diaphragm). RESULTS We identified 1,171,838 enrollees at risk for pregnancy; 13,400 (1.1%) were deaf or hard of hearing. Among individuals who were deaf or hard of hearing, 31.4% were provided contraception (23.5% prescription contraception, 5.4% LARC, 0.7% tubal sterilization). Individuals who were deaf or hard of hearing were less likely to receive prescription contraception (adjusted odds ratio 0.92, 95% CI 0.88-0.96) than individuals who were not deaf or hard of hearing. The percentage of individuals who were deaf or hard of hearing who received most effective or moderately effective methods was less than that for individuals who were not (24.2% vs 26.3%, P<.001). There were no differences in provision of LARC or permanent contraception by deaf and hard-of-hearing status. CONCLUSION Individuals who were deaf or hard of hearing were less likely to receive prescription contraception than individuals who were not; factors underlying this pattern need to be examined. Provision of LARC or permanent contraception did not differ by deaf or hard-of-hearing status. These findings should be monitored and compared with data from states with different requirements for contraceptive coverage.
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Gifford K, McDuffie MJ, Rashid H, Knight EK, McColl R, Boudreaux M, Rendall MS. Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population. Contraception 2021; 104:284-288. [PMID: 34023380 DOI: 10.1016/j.contraception.2021.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type. STUDY DESIGN We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status. RESULTS Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI. CONCLUSIONS In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth. IMPLICATIONS Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.
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Affiliation(s)
- Katie Gifford
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States.
| | - Mary Joan McDuffie
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Hira Rashid
- Office of Health Affairs, West Virginia University
| | - Erin K Knight
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Rebecca McColl
- Biden School of Public Policy & Administration, University of Delaware, Newark, DE, United States
| | - Michel Boudreaux
- University of Maryland School of Public Health, University of Maryland, College Park, MD, United States
| | - Michael S Rendall
- Maryland Population Research Center, University of Maryland, College Park, MD, United States
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Gibbs SE, Harvey SM. Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon. J Womens Health (Larchmt) 2021; 31:55-62. [PMID: 33970712 DOI: 10.1089/jwh.2020.8941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.
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Affiliation(s)
- Susannah E Gibbs
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
| | - S Marie Harvey
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA
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Dehlendorf C, Fox E, Silverstein IA, Hoffman A, Campora Pérez MP, Holt K, Reed R, Hessler D. Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale. Contraception 2021; 103:310-315. [PMID: 33508252 DOI: 10.1016/j.contraception.2021.01.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Person-centeredness is a critical component of quality in family planning. We previously validated an 11-item Interpersonal Quality of Family Planning (IQFP) scale. We sought to create a parsimonious version of the scale in preparation for testing its appropriateness as a patient-reported outcome performance measure. STUDY DESIGN To explore clarity and importance of each of the 11 items, we conducted English and Spanish cognitive interviews with patients who received contraceptive counseling (n = 33) at 3 publicly funded California clinics. We triangulated these results with psychometric analysis of previously collected IQFP data (n = 1097) to assess validity and reliability of selected item combinations. RESULTS The 11-item IQFP scale was reduced to a 4-item scale (the Person-Centered Contraceptive Counseling scale, or PCCC) that includes items evaluating provider performance regarding respect for patients, information provision, and eliciting and honoring patient preferences for birth control. Interview participants deemed the items included in the 4-item PCCC important and clear in both English and Spanish versions of the instrument. The 4-item PCCC retained the 11-item IQFP's psychometric properties, including internal consistency (Cronbach's alpha = 0.92 vs 0.97 for the PCCC and IQFP, respectively) and a consistent single factor analysis solution (factor loadings = 0.86-0.92 and 0.81-0.91). The 4-item PCCC additionally retained the construct and predictive validity of the IQFP. CONCLUSIONS The 4-item PCCC is a valid and reliable as a measure of person-centered contraceptive counseling that reflects patients' perspectives on contraceptive counseling. IMPLICATIONS Person-centered measures such as the 4-item PCCC can help inform efforts to improve health care quality. Future work will investigate the validity and reliability of the 4-item PCCC as a performance measure to determine the appropriateness of its use in the quality improvement context.
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Affiliation(s)
- Christine Dehlendorf
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States; Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, United States.
| | - Edith Fox
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Ilana A Silverstein
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Alexis Hoffman
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - María Paula Campora Pérez
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Kelsey Holt
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Reiley Reed
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California, San Francisco, CA, United States
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Sumarsono A, Segar MW, Xie L, Atem F, Messiah SE, Francis JK, Keshvani N. Medicaid expansion and provision of prescription contraception to Medicaid beneficiaries. Contraception 2020; 103:199-202. [PMID: 33212032 DOI: 10.1016/j.contraception.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Medicaid expansion increased access to care, but longitudinal patterns of contraception use after the Medicaid expansion have not been described. METHODS We evaluated the effects of Medicaid expansion on the amount and type of contraceptive prescriptions using the Medicaid State Utilization Dataset. RESULTS Overall long-acting reversible contraception (LARC) use increased in both expansion and non-expansion states. In a difference-in-differences analysis, states that expanded Medicaid had no appreciable increase in per-capita prescription rates of LARC (p = 0.26) or short-acting hormonal contraception (p = 0.09) when compared to nonexpansion states. DISCUSSION The Medicaid expansion was not associated with a change in per-capita LARC or short-acting hormonal contraception use.
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Affiliation(s)
- Andrew Sumarsono
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA; Division of Hospital Medicine, Parkland Memorial Hospital, Dallas TX, USA.
| | - Matthew W Segar
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
| | - Luyu Xie
- University of Texas School of Public Health, Health Science Center at Houston, Dallas TX, USA; Center for Pediatric Population Health, Children's Health System of Texas and University of Texas Health Science Center, Dallas TX, USA
| | - Folefac Atem
- University of Texas School of Public Health, Health Science Center at Houston, Dallas TX, USA; Center for Pediatric Population Health, Children's Health System of Texas and University of Texas Health Science Center, Dallas TX, USA
| | - Sarah E Messiah
- University of Texas School of Public Health, Health Science Center at Houston, Dallas TX, USA; Center for Pediatric Population Health, Children's Health System of Texas and University of Texas Health Science Center, Dallas TX, USA
| | - Jenny Kr Francis
- Department of Pediatrics, UT Southwestern Medical Center, Dallas TX, USA; Children's Health, Dallas, TX, USA
| | - Neil Keshvani
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
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Moniz MH, Becker N, Dalton VK. Medicaid Expansion, Safety Net Clinics, and Opportunities to Improve Contraceptive Care. JAMA Netw Open 2020; 3:e207136. [PMID: 32496564 DOI: 10.1001/jamanetworkopen.2020.7136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Program on Women's Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | - Nora Becker
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Program on Women's Healthcare Effectiveness Research, University of Michigan, Ann Arbor
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