Recommendations for intrauterine contraception: a randomized trial of the effects of patients' race/ethnicity and socioeconomic status

Patient Preferences for Immediate Compared With Delayed Postpartum Intrauterine Device Placement

OBJECTIVE

To use choice-based conjoint survey methodology to evaluate patient values and decision making regarding immediate compared with delayed placement of postpartum intrauterine devices (IUDs).

METHODS

We conducted a cross-sectional study in which we surveyed 200 nonpregnant, parous patients. Participants chose between hypothetical postpartum IUDs varying in multiple attributes (hormonal or nonhormonal IUD type, placement timing, 1-year efficacy, expulsion risk, risk of lost strings, and malposition risk). The primary outcome was preference for immediate compared with delayed postpartum IUD placement and importance of placement timing relative to other attributes. Secondarily, we evaluated whether demographic and neighborhood characteristics were associated with timing preference and attribute importance.

RESULTS

We included 190 participants for analysis. Most participants (62.6%) preferred delayed placement. There was no significant difference in timing preference by race ( P =.28) or block-level Area Deprivation Index score ( P =.27). Patients who preferred immediate placement were more likely to have public insurance than private insurance (70.4% vs 29.6%, P =.04); however, the majority of patients (55.1%) with public insurance still preferred delayed placement. Attributes of IUD type, malposition risk, 1-year efficacy, and expulsion risk all had greater effects on patient decision making than placement timing. There was no difference in attribute importance by race ( P =.30), Area Deprivation Index score ( P =.88), or insurance type ( P =.22).

CONCLUSION

Patients preferred the higher efficacy and lower complication rates of delayed postpartum IUD placement over the convenience of immediate placement. Insurance considerations may affect these timing preferences. There was no difference in attribute importance between demographic groups or based on neighborhood-level factors, indicating that, although both immediate and delayed postpartum IUD placement should be offered, counseling should not vary according to individual demographic characteristics.

ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology

Disparate health outcomes and unequal access to care have long plagued many communities in the United States. Individual demographic characteristics, such as geography, income, education, and race, have been identified as critical factors when seeking to address inequitable health outcomes. To provide the best care possible, obstetrician-gynecologists should be keenly aware of the existence of and contributors to health inequities and be engaged in the work needed to eliminate racial and ethnic health inequities. Obstetrician-gynecologists should improve their understanding of the etiologies of health inequities by participating in lifelong learning to understand the roles clinician bias and personally mediated, systemic, and structural racism play in creating and perpetuating adverse health outcomes and health care experiences.

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.

Attitudes Toward Implicit Bias Among Athletic Trainers

Implicit biases are attitudes, emotions, or stereotypes that occur in an unconscious manner and have the potential to negatively affect behaviors, actions, and decisions. Recent studies have suggested that even when certain factors are controlled for, health care workers do not provide equitable care to patients from different demographics. When patients are not receiving equitable health care, there is a potential for disparities in patient-related outcomes. The purpose of this study was to determine attitudes toward implicit bias among athletic trainers. A secondary purpose of this study was to assess differences and correlations between attitudes toward implicit bias and demographic factors including age, years of experience, gender identity, sexual orientation, and race. Participants were recruited for this study by emailing athletic trainers from publicly available staff directories at institutions of higher education and high schools, and athletic training education program directors. The survey consisted of questions gathering demographic information and questions taken from the Attitudes Toward Implicit Bias Instrument. A total of 218 athletic trainers (age = 38 [11] y, years of certified experience = 14 [11] y) opened and completed the survey. On average, participants scored 71.0 [11.2] on the Attitudes Toward Implicit Bias Instrument. This mean score indicated that the average participant felt that implicit bias had the potential to negatively impact patient care and needed to be addressed through education. There was a significant, negligible negative correlation between age and attitudes toward implicit bias (r[216] = -.157, P = .02). Examining implicit bias among athletic trainers warrants further research to understand how implicit bias can negatively affect access to equitable health care opportunities. The development of high-quality interventions for identifying and addressing implicit bias is crucial to ensuring optimal patient outcomes in athletic training and all medical settings.

Long-Acting but Reversible: Opportunities to Address Provider Bias in Contraceptive Care

Jasmine is an 18-year-old Black female bringing her infant to the pediatrician for a newborn weight check. She asks her pediatrician's opinion about hormonal contraceptive injections, sharing that they were strongly recommended after she gave birth. The recommending health care provider told her, "We don't want you to end up back here any time soon." Rosita, a 16-year-old Latina female, visits her pediatrician for a well check. She reports a history of vaginal sex with 2 male partners and agrees to have a hormonal subcutaneous implant placed to avoid pregnancy. After 4 months of bothersome spotting, Rosita returns to have the implant removed. Rosita's provider strongly counsels against removal. Jasmine and Rosita are members of populations that have been systematically marginalized throughout American history. Their stories are derived from real cases and reveal how structural racism impacts modern contraceptive care. Specifically, their cases are examples of statistical discrimination, wherein the tendency to disproportionately recommend long-acting reversible contraception to historically marginalized communities does not follow the central tenants of sexual and reproductive justice, including acknowledging historical harms in health care and honoring bodily autonomy for all people. By sharing Jasmine and Rosita's stories, we use a reproductive justice lens to (1) examine the historical roots of disproportional prescription of long-acting reversible contraception to historically marginalized individuals, (2) discuss provider bias related to sexual and reproductive health care, and (3) illustrate how trauma-informed care with a recognition of historical trauma and the use of individuation can facilitate positive and equitable health outcomes.

"It Means Being Safe, Having Power over One's Body": Black Female Adolescent Experiences with Reproductive Health Counseling in Primary Care

STUDY OBJECTIVE

There is limited research examining the sexual and reproductive health (SRH) care needs and experiences of Black adolescents who are assigned female at birth (AFAB). This study aimed to understand the perspectives of Black AFAB adolescents in their receipt of SRH counseling in primary care and elicit preferences for SRH-related communication with clinicians.

METHODS

We interviewed English-speaking Black AFAB adolescents, ages 13-17, living in North Carolina between February and June 2022 about their SRH care experiences. The interviews were conducted via video conferencing, audio-recorded, professionally transcribed, and analyzed using a thematic approach.

RESULTS

We interviewed 23 adolescents (mean age 15.8 years) across 10 geographically diverse counties in North Carolina. Most conveyed positive perceptions of clinicians regarding trust and comfort. However, many expressed concerns about clinicians not doing enough to ensure patient confidentiality, provide them with enough information to make informed and autonomous decisions, and destigmatize discussing SRH issues during the clinical encounter. Suggested improvements include sociodemographic congruence between patients and clinicians (eg, younger Black women), ensuring time alone with clinicians across adolescence, and proactively sharing information to promote respect and autonomy.

CONCLUSION

Although Black AFAB adolescents had positive perceptions of their health care providers regarding relational components of care, many participants shared significant gaps and areas for improvement in the quality of care received to better align services with their preferences for SRH care. These findings can inform the development of SRH counseling best practices and clinician education to support respect and autonomy, which are routinely denied to Black AFAB adolescents.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Social Determinants of Health and Patient-Reported Difficult Discontinuation of Long-Acting Reversible Contraception

Background: Some individuals who receive long-acting reversible contraception (LARC) face barriers to discontinuation. The inability to discontinue a contraceptive method when desired negatively impacts a person's reproductive autonomy. Persons impacted by social determinants of health (SDH) may be disproportionately affected. The objective of this study is to evaluate the association of SDH with patient-reported difficult LARC discontinuation. Methods: A retrospective cross-sectional analysis of data from the 2017-2019 cycle of the National Survey of Family Growth was conducted. The main outcome was patient-reported difficulty discontinuing a LARC method (intrauterine device or implant) in the last 10 years. Descriptive statistics were used to identify demographic characteristics and SDH domains. Multivariable logistic regression models were used to estimate associations across SDH domains with difficult LARC removal. Results: A total of 754 respondents reported wanting to have their LARC removed, and 105 (11%) reported difficulty discontinuing LARC methods. One-third of respondents experienced one or more SDH, notably food insecurity (26%) or transportation barriers (30%). After adjusting for age, race, education, geographic location, parity, and body mass index (BMI), persons with one or more SDH had an increased adjusted odds ratio (aOR) for difficultly discontinuing LARCs compared with respondents without any SDH (2.11; 95% confidence interval [CI]: 1.21, 3.69). Transportation barriers demonstrated the largest aOR of 2.90 (95% CI: 1.07, 7.87). Conclusions: SDH are associated with challenges to LARC discontinuation. SDH are unique risk factors that can impact one's entire contraceptive experience. A nuanced discussion of SDH at the time of contraceptive counseling may be a critical step in addressing the intersectionality of method selection and reproductive agency.

Contraceptive Attitudes and Beliefs of Women With Sickle Cell Disease: A Qualitative Study

OBJECTIVES

We aimed to qualitatively explore factors influencing contraceptive use in women living with sickle cell disease (SCD).

STUDY DESIGN

We conducted a semi-structured qualitative study using data from interviews with reproductive-aged women with SCD. The Theory of Planned Behavior, which describes an individual's attitudes, subjective norms, and perceived behavioral control as drivers of a health behavior, served as a framework for data collection and thematic analysis.

RESULTS

We analyzed interviews from 20 participants. Attitudes toward contraception showed skepticism regarding hormonal contraception and concern about adverse effects of contraception related to SCD. The role of subjective norms in contraceptive choice depended on whether participants possessed trusted sources of information, such as health care providers, family, and friends, or whether they relied on themselves alone in their contraceptive decision-making. The influence of health care providers was complicated by inconsistent and sometimes conflicting counseling. Finally, with regard to participants' perceived control in their contraceptive choices, some were motivated to alleviate menstrual pain or prevent SCD-related pregnancy risks, but many reported feeling disempowered in contraceptive decision-making settings because of ways that healthcare providers exerted pressure or responded to participants' demographic characteristics.

CONCLUSIONS

Women living with SCD are influenced by many factors similar to those documented for other populations when making decisions about contraception. However, SCD amplifies both the importance and risks of contraception and may also complicate individuals' autonomy and contraceptive access. Hematology and reproductive health providers should recognize the risk of coercion, maximize patients' reproductive agency, and coordinate reproductive health counseling for patients with SCD.

Influence of Pregnancy Intention on Postpartum Contraceptive Choice at an Urban Academic Medical Center

OBJECTIVE

 This study aimed to describe postpartum contraception preferences in the context of pregnancy intention (PI).

STUDY DESIGN

 A prospective cohort study analyzing postpartum contraceptive choice (PCC) in 431 postpartum women who delivered at a single academic medical center. PCC in women with an unintended or mistimed pregnancy was compared to contraceptive choice in women with an intended pregnancy using the adapted National Survey of Family Growth categorization. Mistimed and unintended pregnancies were grouped for analysis. Generalized linear modeling estimated the relative influence of PI on PCC adjusting for maternal age, race, and parity.

RESULTS

 Nearly three out of four (71.9%) pregnancies were mistimed or unintended. These pregnancies were more likely in women who were non-Hispanic Black (62.3%), unmarried (86.3%), 18 to 24 years (51.3%), and insured by Medicaid or Medicare (82.1%), compared to women with an intended pregnancy, p-value <0.001. Women with mistimed or unintended pregnancy were 83% more likely to choose highly effective, user-independent methods compared to any other or no method, adjusted relative risk (aRR) = 1.83 (95% confidence interval [CI]: 1.36, 2.47), and more likely to desire voluntary sterilization, aRR = 2.70 (95% CI: 1.58, 4.59). Additionally, women with these pregnancies were 56% more likely to use user-independent methods compared to user-dependent methods, aRR = 1.56 (95% CI: 1.18, 2.06).

CONCLUSION

 Women with mistimed or unintended pregnancies are 83% more likely to choose highly effective postpartum contraception or voluntary sterilization, and thus initiatives are necessary to increase access and affordability to these methods before hospital discharge after delivery.

KEY POINTS

· Nearly three out of four pregnancies in this study were mistimed or unintended.. · Women with mistimed or unintended pregnancies are more likely to choose highly effective postpartum contraception or voluntary sterilization.. · Public health initiatives to improve access to family planning services and postpartum contraception, including surgery for bilateral tubal ligation before discharge from the hospital postdelivery, are important areas of focus to help attenuate the rates of unintended pregnancy in the United States..

Contraceptive Use Among Women Experiencing Intimate Partner Violence and Reproductive Coercion: The Moderating Role of PTSD and Depression

Women experiencing reproductive coercion (RC) report more unintended pregnancies and mental health symptoms that can influence contraceptive use patterns. We examined associations between RC and contraceptive use among intimate partner violence (IPV) exposed women aged 18-35 (N = 283). We tested depression, post-traumatic stress disorder (PTSD), and co-morbid depression and PTSD as effect modifiers. Though no association was found between RC and contraception, PTSD significantly modified this relationship. Among Black women (n = 112), those reporting RC and either PTSD or comorbid PTSD and depression were less likely to use partner-independent contraception compared to those reporting RC without mental health symptoms. PTSD could be a barrier to contraceptive choice among this population.

Claims for Contraceptive Services and Chlamydia and Gonorrhea Testing Among Insured Adolescent and Young Adult Females in the United States

Objective: To examine claims for reversible prescription contraceptives and chlamydia and gonorrhea testing among commercially and Medicaid-insured adolescent and young adult (AYA) females in the United States. Methods: Using IBM MarketScan Research Databases, we identified sexually active, nonpregnant AYA (15- to 24-year-old) females enrolled in 2018. We examined claims for reversible prescription contraceptives and chlamydia and gonorrhea testing, using drug names and diagnosis/procedure codes, by age-group in commercially and Medicaid-insured separately and by race/ethnicity in Medicaid-insured. Results: Among 15- to 19-year-old and 20- to 24-year-old females, 67.2% and 67.9% of commercially insured and 57.3% and 54.0% of Medicaid-insured, respectively, had claims for reversible prescription contraceptives in 2018. Across insurance types among both age-groups, the most common claim for contraceptives was prescription for combined oral contraceptives. Among Medicaid-insured 15- to 19-year-olds, claims for contraceptives ranged from 42.6% for Hispanic females to 63.4% for non-Hispanic White females; among Medicaid-insured 20- to 24-year-olds, claims ranged from 50.4% for non-Hispanic Black females to 57.0% for non-Hispanic White females. Approximately half of the commercially and Medicaid-insured females had claims for chlamydia and gonorrhea testing. Non-Hispanic Black females had the highest percentages of claims for chlamydia testing (56.3% among 15- to 19-year-olds and 61.1% among 20- to 24-year-olds) and gonorrhea testing (61.6% among 15- to 19-year-olds and 64.9% among 20- to 24-year-olds). Conclusion: Approximately, two-thirds of commercially insured and more than half of Medicaid-insured, sexually active, nonpregnant AYA females had claims for reversible prescription contraceptives. Race/ethnicity data were available for Medicaid-insured females, and there were differences in claims for contraceptives and chlamydia and gonorrhea testing by race/ethnicity. Half of the AYA females had claims for chlamydia and gonorrhea testing suggesting missed opportunities.

Factors associated with unintended pregnancy and contraceptive practices in justice-involved adolescent girls in Australia

INTRODUCTION

Despite a decline in unintended teenage pregnancy in Australia, rates remain higher amongst justice-involved adolescent girls, who are more likely to be from disadvantaged socio-economic backgrounds, have histories of abuse, substance use and/or mental health issues. Furthermore, exposure to the criminal justice system may alter access to education and employment and opportunities, potentially resulting in distinct risk-factor profiles. We examine factors associated with unintended pregnancy, non-contraceptive use and Long-Acting Reversible Contraception (LARC) in a sample of sexually active, justice-involved adolescent girls from Western Australia and Queensland.

METHODS

Data from the Mental Health, Sexual Health and Reproductive Health of Young People in Contact with the Criminal Justice System (MeH-JOSH) Study was analysed on 118 sexually active adolescent girls. Participants were aged between 14 and 17 years, purposefully sampled based on justice-system involvement and completed an anonymous telephone survey. We constructed two multivariate models taking reproductive outcomes as the dependent variables.

RESULTS

Over one quarter (26%, 30/118) reported a past unintended pregnancy, 54 did not use any contraception at their last sexual encounter, and 17 reported LARC use. Following adjustments in the multivariate analysis, lifetime ecstasy use was associated with both unintended pregnancy (aOR 3.795, p = 0.022) and non-contraception use (aOR 4.562, p = 0.004). A history of physical abuse was also associated with both any contraception (aOR 3.024, p = 0.041) and LARC use (aOR 4.892, p = 0.050). Identifying as Aboriginal & Torres Strait Islander, education/employment status and geographic location appeared to have no association.

CONCLUSION

Our findings suggest that justice-involved adolescent girls have distinct risk factors associated with unplanned pregnancy and contraception use compared to the general population, but more research is required to understand the mechanisms and contexts underlying these risk factors. How exposure to physical violence may encourage contraception and LARC use, in particular, warrants further attention as does the association with ecstasy use.

Pain experiences during intrauterine device procedures: a thematic analysis of tweets

INTRODUCTION

In June 2021, high-profile testimonials in the media about pain during intrauterine device (IUD) procedures in the UK prompted significant discussion across platforms including Twitter (subsequently renamed X). We examined a sample of Twitter postings (tweets) to gain insight into public perspectives and experiences.

METHODS

We harvested tweets posted or retweeted on 21-22 June 2021 which contained the search terms coil, intrauterine system, IUD or intrauterine. We analysed the dataset thematically and selected illustrative tweets with the authors' consent for publication.

RESULTS

Following deduplication and screening, we included 1431 tweets in our analysis. We identified testimonials with descriptions of varied pain experiences. Twitter users reported that clinicians had not warned them that pain could be severe or explained the options for pain relief. Some raised concerns about pain being minimised or dismissed and linked this to the management of women's pain in medicine more broadly. Twitter users described connecting to an online community with shared experiences as validating and used this as a springboard for collective action.

CONCLUSIONS

While we acknowledge the limitations of our sample, this study highlights important perspectives and accounts relating to pain during IUD procedures. Our findings attest to the need for strategies to improve the patient experience for those opting for IUD as a clinical priority. Further research should explore IUD users' experiences, expectations and wishes around pain management.

Social determinants of choosing telemedicine for contraceptive care: A retrospective cohort study

OBJECTIVES

Compare demographic characteristics and contraception choices among individuals seeking contraception care via telemedicine versus in-person.

STUDY DESIGN

Retrospective cohort study of contraception visits from June-September 2021 at Planned Parenthood of the Pacific Southwest. We assessed demographics and contraception choices. We used multivariable logistic regression to evaluate effect of language, age, income, having children, and insurance type on choosing telemedicine.

RESULTS

We included 16,855 patients: 2383 (14.1%) telemedicine visits and 14,472 (85.9%) in-person visits; 149/2383 (6.3%) non-English speakers used telemedicine compared to 1194/14,472 (8.3%) who used in-person care. A higher proportion of the telemedicine cohort had public insurance compared to the in-person cohort (2312/2383 [97.0%] telemedicine vs 11,646/14,472 [80.5%] in-person). Among the telemedicine cohort, a higher proportion of patients chose a barrier method (691/2363 [29.2%] telemedicine vs 1564/14,215 [11.0%] in-person) and short-acting method (1248/2363 [52.8%] telemedicine vs 5834/14,215 [41.0%] in-person) compared to in-person. A higher proportion of in-person patients chose long-acting reversible contraception (2681/14,215 [18.9%] in-person vs 179/2363 [7.6%] telemedicine) and injection (3779/14,215 [26.6%] in-person vs 115/2363 [4.9%] telemedicine) compared to telemedicine. Speaking Spanish was associated with decreased odds of choosing telemedicine after adjusting for covariates (aOR 0.53 [95% CI 0.44-0.64], p < 0.001). Older age, having children, lower income, and public insurance were associated with increased odds of choosing telemedicine.

CONCLUSIONS

Telemedicine for contraception visits was associated with language, age, parity, income, and insurance. Despite small absolute difference in the proportion of patients that speak Spanish, in adjusted multivariate analysis speaking Spanish was associated with lower odds of choosing telemedicine.

IMPLICATIONS

Increasing access for people with limited technology as well as those who prefer non-English languages is essential to promote equitable reproductive care. Prospective research that focuses on patient experience and preferences is needed to better guide access to equitable, person-centered contraception care.

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section

OBJECTIVES

While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization.

STUDY DESIGN

We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders.

RESULTS

Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8 vs. 5.3%, p < 0.01), bleeding disorders (3.9 vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9 vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4 vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75).

CONCLUSION

Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions.

KEY POINTS

· Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: A retrospective survey of HER Salt Lake participants

OBJECTIVES

In an established cohort of HER Salt Lake Contraceptive Initiative participants with a prior intrauterine device (IUD) placement, we sought to (1) define the proportion of participants who reported a negative Patient Acceptable Symptom State (PASS) response, (2) explore factors associated with an unacceptable PASS response, and (3) identify pain management preferences for IUD placement.

STUDY DESIGN

A retrospective survey was sent to 1440 HER Salt Lake IUD users. A PASS question queried IUD placement pain experience acceptability. We explored associations between an unacceptable PASS response and sociodemographic, reproductive and other individual characteristics using t-tests, chi-square tests, and multivariable logistic regression.

RESULTS

Of those surveyed, 620 responded (43%), and 41.6% reported an unacceptable PASS response. Those with an unacceptable PASS response reported a significantly higher experienced pain level (79.2 mm vs 51.8 mm; p < 0.01) than those with an acceptable response, were more likely to have an anxiety diagnosis (47.7% vs 37.1%; p < 0.01), and have a trauma history (33.7% vs 25.1%; p = 0.02). Most patients were not offered pain control options, but 29.4% used ibuprofen and 25.3% had a support person. Regardless of PASS response, if offered, 59.0% desired numbing medication, 56.8% ibuprofen, 51% heating pad, 33.2% support person, and 31.8% anti-anxiety medication, among others. In our multivariable logistic regression model, higher pain was associated with unacceptable PASS response (OR 1.07, 95% CI 1.05-1.08; p < 0.01).

CONCLUSIONS

The common finding of unacceptable pain experiences with IUD placement may cause negative perceptions of an otherwise desirable method. Incorporation of the PASS response into IUD pain management studies could expand our pain experience understanding.

IMPLICATIONS

IUD placement resulted in unacceptable pain experiences for 41.6% of respondents. Screening for anxiety and trauma history could identify at-risk patients to individualize pain management strategies. Incorporation of the PASS into future IUD pain management studies could result in a more comprehensive, patient-centered measure of patient experiences.

Achieving Reproductive Justice Within Family Planning

There is a long-standing history of reproductive oppression in the United States which impacts how patients, particularly those from marginalized communities, receive reproductive health services today. The reproductive justice (RJ) framework is a tool to support people to become pregnant, to not become pregnant, and to parent in safe communities. In this review, the authors provide essential background about this history and how those in reproductive health care can use the RJ framework through an intersectional lens to achieve inclusive reproductive goals and advocate for comprehensive access to family planning care, including contraceptive and abortion care.

Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8

Permanent contraception is the most used method of contraception among women aged 15-49 years and is one of the most straightforward surgical procedures an obstetrician-gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician-gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician-gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.

Patient Barriers to Discontinuing Long-Acting Reversible Contraception

OBJECTIVES

To describe how frequently a national sample of patients with experience discontinuing or desiring discontinuation of long-acting reversible contraception (LARC) experienced barriers to discontinuation.

METHODS

We conducted an online survey of individuals ages 18 to 50 in the United States who had previously used and discontinued or attempted to discontinue LARC. We recruited respondents using the Amazon platform MTurk. Respondents provided demographic information and answered questions regarding their experience discontinuing LARC, including reasons removal was deferred or denied. We analyzed frequency of types of barriers encountered and compared these by demographic factors.

RESULTS

Of the 376 surveys analyzed, 99 (26%) described experiencing at least one barrier to removal. Barriers were disproportionately reported by those who had public health insurance, a history of abortion, and a history of birth compared to those who did not report barriers to removal. They also more frequently identified as Latinx, Asian, or Middle Eastern. Most barriers were provider-driven and potentially modifiable.

CONCLUSIONS FOR PRACTICE

Barriers to LARC discontinuation are common and may be provider- or systems-driven. Providers should be mindful of biases in their counseling and practices to avoid contributing to these barriers.

Removal of long-acting reversible contraceptive methods and quality of care in Dar es Salaam, Tanzania: Client and provider perspectives from a secondary analysis of cross-sectional survey data from a randomized controlled trial

Access to removal of long-acting reversible contraception (LARCs) (e.g., implants and intrauterine devices (IUDs)) is an essential part of contraceptive care. We conducted a secondary analysis of cross-sectional survey data from a randomized controlled trial. We analyzed 5,930 client surveys and 259 provider surveys from 73 public sector facilities in Tanzania to examine the receipt of desired LARC removal services among clients and the association between receipt of desired LARC removal and person-centered care. We used provider survey data to contextualize these findings, describing provider attitudes and training related to LARC removals. All facilities took part in a larger randomized controlled trial to assess the Beyond Bias intervention, a provider-focused intervention to reduce provider bias on the basis of age, marital status, and parity. Thirteen percent of clients did not receive a desired LARC removal during their visit. Clients who were young, had lower perceived socioeconomic status, and visited facilities that did not take part in the Beyond Bias intervention were less likely to receive a desired removal. Clients who received a desired LARC removal reported higher levels of person-centered care (β = .07, CI: .02 - .11, p = < .01). Half of providers reported not being comfortable removing a LARC before its expiration (51%) or if they disagreed with the client's decision (49%). Attention is needed to ensure clients can get their LARCs removed when they want to ensure patient-centered care and protect client autonomy and rights. Interventions like the Beyond Bias intervention, may work to address provider-imposed barriers to LARC removals.

Patient-centered or population-centered? How epistemic discrepancies cause harm and sow mistrust

Medical distrust is often conceived of as a problem of misinformation or ignorance. In this paper, I depart from this framework, attributing distrust instead to epistemic divergence between lay people and experts. Using data from a contraceptive side effects Facebook group and in-depth physician interviews, I find that providers employ a "body-as-subject" lens informed by population-health goals, while group members employ a "body-as-agent" lens that privileges individuality and bodily autonomy. Provider epistemologies are privileged, creating epistemic injustice and harm for patients. Ultimately, this erodes trust in providers and the medical community more broadly.

Characteristics Associated With Physician Bias in Contraceptive Recommendations

OBJECTIVE

We aimed to examine associations between obstetrician-gynecologist (OBGYN) contraceptive recommendations and sociodemographic characteristics of patients and recommending physicians.

METHODS

OBGYNs affiliated with residency programs across the United States were recruited via email to participate in an online exploratory survey depicting scenarios of reproductive-age women of differing race and socioeconomic status, all other factors identical, and were asked to provide contraceptive recommendations. The χ2 test, Fisher's exact tests, and logistic regression were used to analyze recommendation differences based on physician and patient characteristics.

RESULTS

Of 172 physician respondents, large proportions self-identified as white (74%) and attending physicians (56%) from the Mid-Atlantic (42%). In multivariate logistic regression, self-administered methods (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.2-0.8) and condoms (OR, 0.5; 95% CI, 0.3-0.9) were recommended significantly less to Black high SES patients compared with white high SES patients. Non-white physicians recommended tubal ligation (OR, 0.7; 95% confidence interval [CI], 0.5-0.9) significantly less than white physicians, and recommended long-acting reversible contraception (OR, 3.3, CI 2.2-5.2) and condoms (OR, 1.4; 95% CI, 1.1-1.9) significantly more. Trainee physicians recommended self-administered methods (OR, 0.3; 95% CI, 0.2-0.4), condoms (OR, 0.2; 95% CI, 0.2-0.3), and tubal ligation (OR, 0.4; 95% CI, 0.3-0.6) significantly less than attending physicians.

CONCLUSIONS

OBGYN contraceptive recommendations differed based on patients' perceived race and SES. Recommendations also differed based on race, training level, and geographic location of the recommending physician. Results suggest that physician bias contributes to contraceptive recommendations. OBGYNs should receive education about contraceptive coercion and patient-centered decision-making so that they provide high-quality counseling to all patients.

"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.

Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits

INTRODUCTION

Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics.

METHODS

Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects.

RESULTS

The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services.

CONCLUSIONS

Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.

Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care

OBJECTIVES

This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting.

STUDY DESIGN

Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit.

RESULTS

Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%).

CONCLUSIONS

Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study.

IMPLICATIONS

Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.

Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016-2021

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.

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample

CONTEXT

The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care.

METHODS

Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores.

RESULTS

PCCC scores were high (x ¯ : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]).

CONCLUSIONS

The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Who gets to decide? Assessing contraceptive coercion in health care settings

See related article by Swan et al .

Preferences and Experiences Regarding Pregnancy Options Counseling in Adolescence and Young Adulthood: A Qualitative Study

PURPOSE

Perspectives of adolescents and young adults (AYAs) experiencing pregnancy options counseling (POC) are absent from the literature. This study explores AYA experiences and preferences related to POC to inform best practice guidelines.

METHODS

We conducted semistructured phone interviews in 2020-2021 among US-based individuals, 18-35 years old, who experienced a pregnancy less than 20 years of age. We performed qualitative descriptive analysis of positive and negative attributes of AYA's experiences with POC.

RESULTS

Fifty participants reported 59 pregnancies (16 parenting, 19 abortions, 18 adoptions, three miscarriages) between the ages of 13 and 19 years. Positive attributes of POC experienced included: (1) provider communication that was compassionate, respectful, supportive, and attentive to nonverbal cues; (2) provider neutrality; (3) discussion of all pregnancy options; (4) asking about feelings, choice, life plans, and additional supports; (5) provision of informational materials; and (6) warm handoffs/follow-up facilitation. Negative attributes of POC experienced included: (1) judgmental, impersonal, or absent communication; (2) lack of counseling on all options and/or coercive/directive counseling; (3) insufficient time and supportive resources; and (4) confidentiality concerns. We identified no differences in these perspectives across pregnancy outcomes reported. Participants generally desired counseling about all options, with rare exceptions of ambivalence.

DISCUSSION

Individuals who experienced an adolescent pregnancy described similar positive and negative attributes of POC regardless of preferred pregnancy outcome. Their perspectives highlight how crucial interpersonal communication skills are for effective POC for AYA. POC training across health care specialties should emphasize confidential, compassionate, and nonjudgmental care for AYA patients.

"She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California

INTRODUCTION

Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.

METHODOLOGY

We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.

RESULTS

The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.

DISCUSSION

Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Racial Inequities in Adolescent Contraceptive Care Delivery: A Reproductive Justice Issue

STUDY OBJECTIVE

The objective of this study was to examine racial/ethnic disparities in contraceptive delivery for adolescent patients within an adolescent medicine subspecialty clinical system before and during the COVID-19 pandemic. Secondarily, we aimed to assess the relationship between race and contraceptive delivery by telehealth.

DESIGN

Retrospective cohort study using electronic health record data SETTING: Three adolescent medicine subspecialty clinics in a large academic hospital system, including an urban location and 2 suburban locations PARTICIPANTS: Patients assigned female sex at birth prescribed hormonal contraception between January 1st, 2018, and May 31st, 2021.

MAIN OUTCOME MEASURES

Method and type of contraceptive prescribed (short-acting, medium-acting, long-acting reversible contraception [LARC]) RESULTS: There were 2453 patients in the study; 47.5% were White, 36.0% were Black, and 8.1% identified as Hispanic. After controlling for insurance and age, Black patients, compared with non-Black patients, had twofold higher odds of receiving LARC compared with a short-acting method across the study period (aOR = 2.0; 95% CI, 1.52-2.62). We identified effect modification with significant interaction between Black race and the pandemic period, with evidence of a higher marginal probability of Black patients receiving LARCs during the pandemic. Additionally, during the pandemic, patients receiving new contraceptive prescriptions via telehealth were less likely to be Black (aOR = 0.63; 95% CI, 0.41-0.94) or publicly insured (aOR = 0.56; 95% CI, 0.38-0.81).

CONCLUSION

Our data show significantly higher prescribing of LARCs to Black adolescents by clinicians, which could suggest differences in physician contraceptive counseling with a bias toward preferentially counseling Black patients toward LARCs. Our data also show that Black and publicly insured patients had decreased utilization of contraceptive care by telehealth during the pandemic.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Reproductive justice in post-Roe America: Impact of restricted abortion access on patients seeking permanent contraception

Anecdotally, clinicians have reported an increase in demand for permanent contraception procedures since the Dobbs v. Jackson Women’s Health Organization (Dobbs) decision, which may reflect patients’ fear of losing reproductive autonomy. In this commentary we rely upon the history of bias and discrimination in permanent contraception access in the United States to interpret and predict potential outcomes following the Dobbs decision. These findings can shape clinical practice as clinicians aim to balance meeting a patient’s contraceptive goals while upholding a commitment to avoid reproductive coercion. We provide recommendations for clinicians’ contraceptive counseling to ensure equitable access to permanent contraception for all patients.

Reproductive Autonomy in Appalachia: An Investigation into Perceived Contraceptive Pressure

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants (N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent's partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

Exploratory study of race- or ethnicity-based discrimination among patients receiving procedural abortion care

OBJECTIVE

Explore relationships of race and ethnicity with experiences of race- or ethnicity-based discrimination during abortion care.

STUDY DESIGN

English- or Spanish-speaking individuals aged 18 to 50 completed cross-sectional, self-administered online surveys within 30 days of procedural abortion at 5 Northeastern U.S. reproductive health clinics from June 2020 toFebruary 2021. We considered any affirmative response on the Discrimination in Medical Settings (DMS) scale evidence of race- or ethnicity-based discrimination. We performed bivariate analyses and logistic regression examining discrimination among Black non-Latinx, Latinx any race, Other race non-Latinx compared to White non-Latinx participants. We assessed associations between discrimination and healthcare quality and satisfaction.

RESULTS

Participants (n = 163) averaged 27(±6) years and self-identified as Black non-Latinx (36.2%), White non-Latinx (28.8%), Latinx of any race (27.0%), and Other non-Latinx (8.0%). Most were publicly insured (52.8%) and <14 weeks gestation (90.8%).Overall, 15.3% reported race- or ethnicity-based discrimination during abortion care with Black non-Latinx more likely to report discrimination (23.7%; OR 7.00, 95% CI 1.50-32.59), while Latinx any race (15.9%, OR 4.26, 95% CI 0.83-21.74) and Other race non-Latinx participants (15.4%, OR 4.09, 95% CI 0.52-32.35) demonstrated statistically nonsignificant trend toward increased odds of discrimination compared to White non-Latinx (4.3%). Discrimination was associated with negative perceptions of: time with physician (p = 0.03), patient care involvement (p < 0.05), physician communication (p = 0.01), care quality (p = 0.02), and care satisfaction (p < 0.01).

CONCLUSION

Racially minoritized participants were more likely to report race- or ethnicity-based discrimination during abortion care; Black non-Latinx reported highest odds of discrimination compared to White non-Latinx. Discrimination was associated with unfavorable healthcare quality measures.

IMPLICATIONS

Race- or ethnicity-based discrimination during abortion care is disproportionately reported by racially minoritized populations, especially Black individuals, compared to White non-Latinx individuals. Discrimination is significantly associated with negative experiences of care. Future work should verify findings in different regions and larger studies, and design and test discrimination-reduction interventions.

Provider perspectives on patient-centered contraceptive counseling for Latinas in Baltimore, MD

OBJECTIVES

To explore: 1) provider narratives of their contraceptive counseling practices with Latina patients within the context of patient-centered care (PCC); and 2) provider perceptions about the barriers to the provision of patient-centered contraceptive counseling in general and more specifically, with Latina patients in Baltimore, MD.

STUDY DESIGN

We conducted 25 semistructured qualitative interviews with physicians  and nurse practitioners from four specialties who provide contraceptive care to Latinas in Baltimore, MD. We analyzed data using directed content analysis. We discuss findings with attention to major constructs of PCC, applying a reproductive justice framework.

RESULTS

Providers described a contraceptive counseling approach focused on pregnancy prevention as the primary goal. Most respondents used a tiered-effectiveness approach, even while noting the importance of PCC. Providers noted health system barriers to PCC, including time constraints and insurance status. Provider-reported patient-attributed barriers included low patient education/health literacy, culturally-attributed misconceptions about contraception, and language discordance.

CONCLUSION

Providers described knowledge of and intention to practice PCC but had limited integration of it in their own counseling with Latinas. Responses suggest tension between an expressed desire to provide PCC and paternalistic counseling paradigms that prioritize pregnancy prevention over patient preferences. Inequitable health system barriers also interfere with true implementation of contraceptive PCC.

IMPLICATIONS

Translating contraceptive PCC into practice, especially for marginalized communities, is paramount. Training should teach clinicians to recognize systems of structural inequity and discrimination that have informed approaches to counseling but are not reflective of PCC. Institutional policies must address health system barriers that also hamper PCC.

Is enhanced, structured prenatal counseling in third trimester associated with postpartum contraceptive uptake?

INTRODUCTION

Contraception is key for maternal well-being in the postpartum period. This study aims to evaluate the impact of prenatal counseling on postpartum contraception uptake.

METHODS

This cohort study assessed pregnant patients who received their prenatal care at our outpatient obstetrics clinic in 2021-2022. The intervention group received counseling at their 28- and 36-week prenatal visits with a language-congruent paper handout and a review of methods by the provider. The non-intervention group was seen in the outpatient clinic prior to implementation. Intervention patients were surveyed on postpartum days 1-3 to evaluate recollection of counseling and intent to start contraception. Data on uptake and type of contraception chosen was collected for both groups at 6- and 12-weeks postpartum. Our primary outcome was uptake of any type of contraception at the 6-week postpartum visit.

RESULTS

A total of 126 patients over two five-month intervals (64 intervention and 62 non-intervention) were included in analysis. Baseline patient characteristics were similar between the groups, including predominance of public insurance. Groups differed by race/ethnicity, with higher rates of Hispanic patients in the intervention group. Patients in the intervention group had higher contraception uptake within six weeks of delivery (OR 2.61, p = 0.0287). Forty-three patients in the intervention group desired postpartum contraception (including permanent methods, such as tubal ligation), although only 21 (48.8 %) received their desired method. There were no differences in method chosen between the non-intervention and intervention groups (p = 0.15).

CONCLUSIONS

Structured prenatal counseling regarding contraceptive options can improve the timely initiation of contraception.

Factors associated with never-use of long-acting reversible contraception among adult reproductive-aged women in Ohio

BACKGROUND

The number of women using long-acting reversible contraception (LARC)-intrauterine devices (IUDs) and implants-is increasing and 14% of contraceptive users in the United States adopt LARC. We examined correlates of LARC never-use in a population-based survey of reproductive-aged women in Ohio.

METHODS

We analyzed data from the 2018-19 Ohio Survey of Women. We examined the prevalence of LARC never-use and reasons for never-use among ever users of contraception (N = 2388). Using Poisson regression to generate prevalence ratios (PRs), we examined associations between selected correlates (demographic factors, healthcare access/quality measures, and religious/political views) and LARC never-use.

RESULTS

Most Ohio women (74%) had never used LARC. Commonly reported reasons for not using an IUD or an implant were preferring a different method (46% and 45%, respectively), not wanting an object inside their body (45% and 43%), side effect concerns (39% and 33%), insertion/removal concerns (31% and 25%), and unfamiliarity (13% and 20%). Conservative political views (PR: 1.12, 95% confidence interval [CI]: 1.04-1.22), pro-life affiliation (PR: 1.11, 95% CI: 1.02-1.20), placing high importance on religion in daily life (PR: 1.15, 95% CI: 1.06-1.26), and being non-Hispanic white as compared to non-Hispanic Black (PR: 1.20, 95% CI: 1.02-1.41) were significantly associated with LARC never-use. Findings were generally similar for models analyzing IUD and implant never-use separately.

CONCLUSIONS

Among ever-users of contraception, LARC never-use was associated with having conservative political views, being religious, and having a pro-life affiliation. Except for race/ethnicity, demographic and healthcare measures were not associated with LARC never-use among women in Ohio.

Elevating the patient voice in contraceptive care quality improvement: A qualitative study of patient preferences for peripastum contraceptive care

OBJECTIVE

Patient-centeredness is an important indicator of peripartum contraceptive care quality. Prior work demonstrates how care fragmentation, provider biases, and other factors sometimes undermine the patient-centeredness and quality of this care. To guide the design of future quality improvement interventions, we explored patient preferences for peripartum contraceptive care.

STUDY DESIGN

For this qualitative study, we recruited a convenience sample of individuals receiving prenatal care at the study site and participating in an online survey about their experience of peripartum contraceptive care during February-July 2020. We conducted individual, in-depth, semistructured interviews to assess patients' preferences for peripartum contraceptive care. Using inductive and deductive qualitative content analysis, we evaluated interview data for patient preferences for peripartum contraceptive counseling and organized preferences into domains to inform future quality measurement.

RESULTS

Interviews (lasting 7-26 min) included 21 postpartum individuals, who were largely White with high levels of formal education. Many participants described suboptimal care experiences characterized by insufficient information, inadequate centering of patient values, and, occasionally, disrespectful care. We identified four key themes describing patients' desire for (1) comprehensive, anticipatory information from one's peripartum provider; (2) counseling and decision-making that (a) prioritize patient preferences and values and (b) avoid pressure; (3) care that respects patient feelings and wishes; and (4) provider responsiveness to individual patient preferences regarding timing and frequency of counseling.

CONCLUSIONS

We newly identify four key domains of patient preferences for peripartum contraceptive care. Additional research is needed to understand peripartum contraceptive care preferences among diverse patient populations. Future research should develop validated measures for evaluating the patient experience of peripartum contraceptive care at scale, as part of ongoing efforts to improve the quality and respectfulness of peripartum care.

IMPLICATIONS

Patients want peripartum contraceptive care to provide comprehensive, anticipatory information; elicit and respond to their counseling and decision-making preferences; and demonstrate respect for their wishes.

Critiquing the Unintended Pregnancy Framework

The unintended pregnancy framework, a central tenet of sexual and reproductive health care delivery and research, has been depicted as an adverse outcome that should be prevented. There is growing criticism of the inadequacies of this framework, although little modification in public health guidelines, measurement, or clinical practice has been seen. This article critically reviews the literature on unintended pregnancy to encourage reflection on how this framework has negatively influenced practice and to inspire the advancement of more patient-centered care approaches. We begin by outlining the historical origins of the unintended pregnancy framework and review how this framework mischaracterizes patients' lived experiences, fails to account for structural inequities, contributes to stigma, and is built upon weakly supported claims of a negative impact on health outcomes. We close with a discussion of the relationship between health care provision and unintended pregnancy care and the implications and recommendations for realigning clinical practice, research, and policy goals.

Uptake of postplacental intrauterine device placement at cesarean delivery

BACKGROUND

Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States.

OBJECTIVE

This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery.

STUDY DESIGN

This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics.

RESULTS

Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (P<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all P<.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score-matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66-1.69; P=.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67-2.14; P=.554).

CONCLUSION

The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

"It Just Depends on Their Stability": A Qualitative Examination of Patient Factors Influencing Providers' Contraceptive Counseling Approaches for Persons With Substance Use Disorders

OBJECTIVES

This qualitative study examined how patient-related factors influence providers' contraceptive counseling for persons with substance use disorders (SUDs). Specifically, we explored individual behavior and social factors that contribute to providers modifying their contraceptive counseling approaches and described how providers alter their counseling recommendations and communication strategies in the presence of such factors.

METHODS

In 2019, we purposively recruited a national sample of contraceptive providers (N = 24) and conducted semistructured phone interviews to inquire about their contraceptive counseling practices for women with SUDs. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis with inductive codes.

RESULTS

Participants included 10 medical doctors, 8 nurse practitioners, and 6 certified nurse-midwives. We found that providers modify their contraceptive counseling provision when their patients are actively using substances or have unstable living conditions, such as intimate partner violence or homelessness. With patients experiencing these instabilities, providers reported postponing contraceptive discussions until patients are stabilized in treatment, recommending long-active reversible contraceptive methods, and varying communication styles according to their own perceptions of patients' communication needs. Providers perceived that individuals in long-term recovery have increased stability and fewer barriers to contraceptive access and adherence and therefore reported increased willingness to provide greater autonomy during contraceptive decision making and shift the counseling focus to short-acting contraceptive methods.

CONCLUSIONS

This study highlights that substance use and social "stability" of patients contributes to how providers approach their contraceptive counseling and make methods recommendations for their patients with SUDs. More research is needed to understand strategies that individuals with SUDs use to overcome barriers to contraceptive access and adherence in the context of active substance use and social instability.

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

BACKGROUND

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear.

OBJECTIVE

This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes.

STUDY DESIGN

This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery.

RESULTS

Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated.

CONCLUSION

Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

"Post-Roe" Abortion Policy Context Heightens the Imperative for Multilevel, Comprehensive, Integrated Health Education

The exceptionalism of abortion in public health education, due to social stigma, politicization, and lack of training, contributes to misinformation, policies unjustified by rigorous science, lack of access to person-centered health care, and systemic pregnancy-related inequities. Now that abortion access has vanished for large portions of the United States, following the Supreme Court decision in Dobbs v. Jackson Women's Health Organization (JWHO), health educators must work to eliminate abortion-related silos, destigmatize abortion education, and bring comprehensive sexual and reproductive health information and evidence to the many audiences that will require it. We discuss consequences of abortion exceptionalism in health education for the public, health care providers, pregnant people, and health professionals in training-and opportunities to better and more accessibly provide sexual and reproductive health education to these audiences.

Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US

Importance

Little is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity.

Objectives

To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity.

Design, Settings, and Participants

This cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022.

Exposures

Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups).

Main Outcomes and Measures

Receipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences.

Results

Among the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, -2.1 to -0.3), rural residents (1.3 pp lower than urban; 95% CI, -2.2 to -0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, -1.6 to -0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%).

Conclusions and Relevance

The findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss

OBJECTIVES

To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss.

METHODS

We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression.

RESULTS

We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005).

CONCLUSIONS

Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping.

PRACTICE IMPLICATIONS

Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.