The Need for Reproductive Justice in Pediatrics

The role (and limits) of developmental neuroscience in determining adolescents' autonomy rights: The case for reproductive and voting rights

Neuroscientific evidence documenting continued neural development throughout adolescence has been leveraged in advocacy for more lenient treatment of adolescents in the criminal justice system. In recent years, developmental science, including neuroscience, has progressed and enabled more nuanced interpretations of what continuing neural development in adolescence likely means functionally for adolescents' capabilities. However, oversimplified interpretations equating continuing neural development to overall "immaturity" are frequently used to make the case that adolescents should have fewer legal rights to make decisions on their own behalf, including regarding reproductive and voting rights. Here we address ongoing debates about adolescents' autonomy rights and whether such rights should be expanded or restricted. We review extant neuroscientific and developmental research that can inform these debates. We call for: (1) a more nuanced application of developmental neuroscience to specific rights issues in specific contexts; (2) additional research designed to inform our understanding of the developmental benefits or harms of rights-based policies on young people over time; and (3) the grounding of developmental neuroscientific research on adolescents within a human rights framework. We offer suggestions to developmental and neuroscience scholars on how to discuss the science of adolescent development with those seeking guidance in their design of law and policy.

Exploring primary care physician biases in adolescent contraceptive counseling

OBJECTIVE(S)

While previous literature has shown clinician bias in adult contraceptive counseling, less is known on the biases clinicians may exhibit when counseling adolescents about contraception. Our study aimed to describe long-acting reversible contraception (LARC) counseling and prescribing practices of adolescent-serving clinicians.

STUDY DESIGN

This study used a cross-sectional discrete choice experiment mixed methods design. We sent a survey containing vignettes and items pertaining to demographics and beliefs to a convenience sample of adolescent-serving clinicians across the United States.

RESULTS

Of 296 clinicians, 80% were in pediatrics, and had geographic, practice setting, gender, and racial diversity. Most clinicians reported being up-to-date with current literature regarding contraception. Sixty-eight percent of respondent's practices administer contraceptive injections, but only 17% place intrauterine devices (IUDs). Of those who do insert IUDs, nearly half inserted five or fewer within the last year. Patients' younger age and Hispanic ethnicity were associated with lower odds, and history of pregnancy was associated with higher odds, of clinicians' recommending LARC. Across all vignettes, the top five reasons clinicians chose their first-choice method for the patient were adherence or compliance, efficacy, side effects, patient age, and reversibility.

CONCLUSION(S)

Clinicians often recommend contraceptives based on adherence, efficacy, and age, and we found younger age, minoritized race or ethnicity, and history of pregnancy were all associated with LARC recommendations, indicating potential biases against teen parents and assumptions about adolescents' priorities. This may impede the provision of patient-centered contraceptive counseling for adolescents, and highlights the need for improved education and practice changes post-Dobbs.

IMPLICATIONS

We found that clinicians demonstrated several biases in how they provide contraceptive recommendations to adolescent patients. These biases were often associated with their personal beliefs and experiences. Our findings can guide the development of future interventions aimed at improving adolescent reproductive health counseling and care delivery in primary care settings.

Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid

PURPOSE

Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation.

METHODS

This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018.

RESULTS

Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001).

DISCUSSION

We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.

Medication abortion for adolescents in the United States: Strengthening the role of pediatric primary care providers

BACKGROUND

Recent legal changes have led to mounting abortion restrictions in the United States (US), disproportionately impacting adolescents, who already face multifaceted barriers to abortion care. Informed by the framework of reproductive justice, adolescents who become pregnant deserve comprehensive, unbiased, and non-judgmental pregnancy options counseling, inclusive of all choices for pregnancy continuation and termination. Pediatric primary care providers are at the front lines of caring for adolescent patients' reproductive health needs and frequently diagnose pregnancy, provide pregnancy options counseling, and assist patients in accessing abortion care. They are uniquely poised to provide this care given their trusted, ongoing relationships with adolescent patients and their families, and their values of deep respect for adolescents' individuality and autonomy.

METHODS

In this commentary, we aim to describe the medical and legal landscape of adolescent abortion access in the US and provide recommendations to support pediatric primary care providers' involvement in abortion care. We focus on medication abortion, as the provision of medication abortion has the potential to encompass a broad group of clinicians, including pediatric primary care providers.

RESULTS

We discuss the importance of providing options counseling to adolescents within the reproductive justice framework, improving abortion education for pediatric providers, and expanding access to abortion care by supporting providers at an institutional level if they opt to provide medication abortions.

CONCLUSION

In light of the current legal landscape, the role of pediatric primary care providers in ensuring adolescent access to abortion care is ever more critical. Although many pediatric and adolescent providers already provide this important care, we, a team of obstetricians/gynecologists and adolescent medicine physicians, echo prior calls for improved training and institutional support for pediatric providers to counsel about and provide abortion-related care. We hope that highlighting the role of pediatric providers in this sphere will help center the needs of adolescent patients and help them fulfill their family planning goals.

Sources of Contraception Among Adolescents and Young Adults

This cross-sectional study describes the nationwide pattern of contraception access by sociodemographic characteristics and health care settings among US youth aged 15 to 24 years.

Reproductive justice in pediatric health care: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify the barriers and facilitators of reproductive justice in pediatric health care.

INTRODUCTION

Reproductive justice is defined as the right to maintain personal bodily autonomy, to have or not have children, and to parent children in safe and sustainable communities. The reproductive justice framework is often applied to adult women in conventional care settings; however, the need for health care guided by the framework should extend to all females of reproductive age in all care settings, including pediatric settings.

INCLUSION CRITERIA

This review will consider studies from 1994 to the present that report on the barriers and facilitators of reproductive justice in pediatric health care. Studies from any setting or geographic location will be included. This scoping review will include pediatric patients up to 21 years of age of any gender identity or sexual orientation who may birth a child, and their health care providers.

METHODS

Database searches will include CINAHL (EBSCOhost), MEDLINE (PubMed), Embase (Elsevier), and Web of Science Core Collection. Sources of unpublished studies and gray literature to be searched include MedNar and ProQuest Dissertation and Theses Science and Engineering Collection (ProQuest). The JBI methodology for scoping reviews will be followed. Data extracted will include details about the title, authors, year of publication, type of evidence, participants, context, and concept. The extracted data will be presented in diagrammatic or tabular format in a manner that aligns with the objective and questions of the scoping review.

REVIEW REGISTRATION

Open Science Framework https://osf.io/d5vf9.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PURPOSE

Single-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic.

METHODS

This retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10-19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19.

RESULTS

One thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01).

DISCUSSION

Incidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Long-Acting Reversible Etonogestrel Subdermal Implant in Adolescents

Several effective contraceptive options are available for use by adolescents, including the long-acting reversible subdermal implant and intrauterine devices, which provide a high level of convenience, privacy, and effectiveness for an adolescent. Knowledge of all the effective birth control methods is essential for the pediatrician to be able to provide effective contraceptive counseling for an adolescent. An approach to counseling using a reproductive justice framework, which allows the provider and adolescent patient to engage in shared decision-making, is described. This article focuses on the long-acting reversible etonogestrel (ENG) subdermal implant for adolescents. The ENG implant is labeled for preventing pregnancy by suppressing ovulation. The ENG implant may also have a role in ameliorating dysmenorrhea and heavy menstrual bleeding. Postlabeling studies indicate that the ENG implant is effective for up to 5 years, although the device's labeling states effectivenessup to 3 years. The main contraindication to using the ENG implant is pregnancy itself. Safe initiation of the ENG implant is described, including an approach to determine whether an adolescent is pregnant. The main adverse effect of the ENG implant is an unpredictable bleeding pattern that is most often ameliorated by use of nonsteroidal anti-inflammatory medications, as well as estrogen, if not contraindicated for the patient. Details of the insertion and removal procedures, including potential complications, are described to enable the pediatrician to provide effective anticipatory guidance for the adolescent.

"The thing in my arm": Providing contraceptive services for adolescents in primary care

BACKGROUND

Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services.

OBJECTIVES

This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings.

DESIGN

This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative.

METHODS

In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data.

RESULTS

Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients.

CONCLUSION

Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.

Attitudes about the Provision of Sexual Health Services in an Inpatient Setting

OBJECTIVE

To examine the relationship between clinicians' attitudes about the appropriateness of providing sexual health services in the inpatient setting and confidence in providing services METHODS: An online survey was emailed to pediatric hospitalists, adolescent medicine, and pediatric and adolescent gynecology societies and directors. Confidence in managing 8 sexual health situations was measured on a 4-point Likert scale, summed, averaged, and dichotomized into confident and not so confident. Participants were asked to rate on a 5-point Likert scale their belief that providing sexual health services in the inpatient setting would be appropriate. An adjusted, multivariate logistic regression identified associations between participant demographic characteristics, professional characteristics, and confidence and attitudes about the appropriateness of providing inpatient sexual health services.

RESULTS

Among the 610 participants, the mean age was 40 years. Most were females (79%), non-Hispanic White (71%), and practiced pediatric hospital/general medicine (73%). Most (73%) were not so confident across all 8 confidence items. Overall, 61% "strongly agreed" that providing sexual health services in the inpatient setting was appropriate. Participants who reported younger age, being female, and confidence in providing services were significantly associated with strong agreement that it was appropriate to provide sexual health services in the inpatient setting. Those who identified as Christian non-Catholic were significantly less likely to report strong agreement.

CONCLUSION

Most providers strongly agreed that providing sexual health services in the inpatient setting was appropriate, yet most were not so confident in managing sexual health situations. Future studies should focus on addressing concerns and barriers to providing sexual health services.

Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado

CONTEXT

Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences.

METHODS

Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method.

RESULTS

Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods.

CONCLUSIONS

Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review

PURPOSE

Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH.

METHODS

We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible.

RESULTS

Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes.

DISCUSSION

This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.

A qualitative study of clinicians' perspectives on a law that allows for a 12-month supply of short-acting contraceptives in Massachusetts: Barriers and facilitators to implementation

OBJECTIVE

To explore clinicians' perspectives regarding the Massachusetts 2017 law, 'An Act Relative to Advancing Contraceptive Coverage and Economic Security in Our State' (ACCESS), including awareness of the law, perceived barriers and facilitators to successful implementation, and recommendations to improve uptake. ACCESS requires all insurers, except self-insured businesses, to cover short-acting reversible contraceptives (SARCs) at no cost to patients and for a 12-month supply to be prescribed/dispensed if desired after the completion of a three-month trial.

DATA SOURCES AND STUDY SETTING

We collected primary data from clinicians in Massachusetts from February 1 to July 31, 2021.

STUDY DESIGN

Semi-structured interviews of a purposeful sample of Massachusetts clinicians who provide primary and/or women's health care were conducted via Zoom.

DATA COLLECTION/EXTRACTION METHODS

Interview guide and codebook were created using the Theoretical Domains Framework. Interviews were analyzed using framework analysis, including deductive and inductive approaches. Major themes and subthemes were organized by a four-level model of the health care system: patient, care team (clinician), organization, and environment.

PRINCIPAL FINDINGS

Most (58.1%) of the 31 participants were not aware of the law. Perceived advantages of this law included decreasing burden on patients, unnecessary clinical visits, and administrative burden on staff for refill requests. Perceived disadvantages focused on concerns that patients would lose their medications or devices (patient-level) and decreased clinician contact with patients (provider-level). Perceived organization- and environmental-level barriers to implementation included lack of electronic medical record (EMR) prescription defaults and insurance coverage issues. Many felt EMR modifications and more training for clinicians and pharmacists could lead to a change in practice.

CONCLUSION

Our study identifies potentially modifiable barriers to the implementation of the ACCESS law. Massachusetts clinicians' lack of awareness of the law demonstrates the need for statewide education, which may allow more eligible patients to obtain a 12-month SARC supply.

Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action

OBJECTIVE (STUDY QUESTION)

To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States.

DATA SOURCES/STUDY SETTING

Data were collected from six groups of system actors via online focus groups.

STUDY DESIGN

This is a qualitative multilevel study using the iceberg systems thinking framework.

DATA COLLECTION/EXTRACTION METHODS

Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas.

PRINCIPAL FINDINGS

Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders.

CONCLUSIONS

By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Reproductive Health Care for Female Adolescents Prescribed Mycophenolate at a Children's Hospital: A 10-Year Retrospective Cohort Study

OBJECTIVES

To describe female adolescents' reproductive health needs and subspecialists' teratogenic counseling at initiation of mycophenolate as well as use of reproductive health care and contraception after mycophenolate initiation.

STUDY DESIGN

We searched health records for female patients aged 12-20 years prescribed mycophenolate from 2010 to 2019. We included 125 subjects, 72 with systemic lupus erythematosus, 27 with transplants, and 26 with other conditions. We reviewed all encounters with pediatric subspecialists and reproductive clinicians. We recorded counseling by subspecialists at mycophenolate initiation and compared rates pre- and post-Risk Evaluation and Mitigation Strategy (REMS). We recorded subjects' menstrual, sexual and pregnancy history, type of first highly effective contraceptive method used, and duration of use over the decade.

RESULTS

At mycophenolate initiation, mean age was 16.8 ± 2.6 years; 72% Hispanic/Latina or Black. In total, 80% were postmenarchal, 28% ever had sex, 18% ever had a reproductive health care visit, 14% used highly effective contraception, and 7% were ever pregnant. Post-REMS vs pre-REMS, we found greater rates of counseling for teratogenicity (68% vs 32%, P < .001) and contraception (62% vs 32%, P < .001) and pregnancy testing (51% vs 24%, P < .01). Over the mean 4.9 ± 3.3 years' follow-up, 56% ever had sex; 59% ever attended a reproductive health care visit; 38% used highly effective contraception; and 10% had a pregnancy.

CONCLUSIONS

Adolescents prescribed mycophenolate have ongoing unmet reproductive health care needs. Although many are sexually active, fewer use effective contraception. Teratogenicity counseling rates improved over the decade but not rates of referral for reproductive health care.